Guidelines Quick Access

Cognitive Difficulties

Symptoms of cognitive dysfunction are common after mTBI and include changes in speed of thinking and responses, attention, memory and learning, and aspects of executive functions.74, 342-344

Cognitive impairment may be directly related to the pathology of the brain injury but may also reflect secondary effects of other symptoms (e.g. ongoing headache pain, fatigue/low energy, sleep disturbance, visual disturbance, anxiety and/or depression) that may produce a disruption in cognitive processing345. Neuropsychological evaluations that also consider these factors can assist in determining the aetiology of cognitive impairment and directing treatment.344

Pre-injury factors such as ADHD, learning difficulties and PTSD may exacerbate symptoms. 

It is important to document cognitive symptoms to characterise the nature of these symptoms and to track progress over time.

Assessment and Diagnosis

CBR 344

Qualified health care professionals should attempt to determine the aetiology of cognitive dysfunction within the context of other mTBI symptoms. (Children and adults)

Practice Points for Elderly Adults

Cognitive change in an older person could be a symptom of dementia. An early assessment to exclude intracranial pathology is recommended in older people with mTBI/concussion. After exclusion of other organic pathology, consider referral of older people with cognitive difficulties for further assessment (e.g. to a geriatrician, neurologist).

Education

While return to school and work are encouraged, cognitive symptoms may limit successful return. The aim is to return to school or work with appropriate restrictions and accommodations (e.g. part-time attendance) in place to optimise reintegration. Individual workplaces and academic institutions may have resources available to facilitate reintegration.

Many people will recover from mTBI/concussion-related symptoms within the first few weeks following injury; however, a smaller percentage of individuals will experience prolonged symptoms. Providing early education about concussion symptoms and recovery to people with mTBI/concussion (and their families/significant others) has been demonstrated to positively influence recovery.28, 118 Education should be offered in multiple formats to ensure information is accessible and comprehensible. 

EBR (Conditional) 201,210,283,317,346-357

People with pre-existing conditions and comorbid symptoms (e.g. anxiety, mood disorders, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, sleep disturbances, fatigue, pain) should be provided with education highlighting that these pre-existing conditions may contribute to having an increased risk of more severe and prolonged cognitive symptoms. (Children and adults)

Treatment

Manage factors that interfere with cognitive symptoms. Compensatory strategies can help people with symptoms of cognitive impairments following mTBI/concussion. These may include internal strategies, comprising of instructional (e.g. repeated practice, retrieval practice) and metacognitive methods (e.g. self-awareness and regulation).358, 359 Additionally, external compensatory strategies such as the use of environmental supports and reminders (e.g. mobile/smartphones, notebooks) may also be employed.334

EBR (Conditional) 305,334,358,360-365

Manage factors that interfere with cognitive symptoms that interfere with daily functioning which may include self-directed compensatory strategies (i.e. internal, external, environmental). If disabling cognitive difficulties persist for more than 4 weeks, consider specialist assessment, preferably by a neuropsychologist or interdisciplinary concussion team. (Children and adults)

Follow-Up and Referral

For people with prolonged cognitive symptoms, it may be challenging to identify the contribution of multiple conditions and their impact on cognitive function. Psychological distress often plays a significant role in the subjective cognitive difficulties.308 Specialised cognitive assessment may assist in clarifying diagnoses and appropriate treatment options based on individual characteristics and conditions. While neuropsychological assessment is the current gold standard for cognitive assessment, there are often barriers (i.e. financial or limited resource issues) preventing access to this type of assessment. Referral should only be considered after other comorbidities potentially impacting cognition have been managed.

CBR 

Referral for specialised cognitive assessment (e.g. neuropsychological assessment) may be considered in the following circumstances (Children and adults):   

  • There is functionally limiting cognitive impairment   
  • Comorbidities potentially impacting cognition have been optimally managed  
  • There is no ongoing cognitive symptom improvement   
  • Cognitive symptoms are prolonged (i.e. beyond 4 weeks). 

CBR 

Older people (see Glossary) with cognitive symptoms should be referred to a geriatrician, neurologist, memory clinic or cognitive medical specialist for evaluation. (elderly adults)

CBR 178

If cognitive symptoms are persisting beyond 3 months, then review, modify, and extend work/school accommodations as appropriate. These accommodations must be assessed and reviewed by the medical team and adjusted to individual needs as required. (Children and adults)