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.298-301
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 processing. Neuropsychological evaluations that also consider these factors can assist in determining the aetiology of cognitive impairment and directing treatment.301
Pre-injury factors such as ADHD, learning difficulties and PTSD may exacerbate symptoms.
Assessment has unique challenges in elderly and cultually diverse populations including Aboriginal and Torres Strait Islander groups. When assessing impairments, normative data may not be appropriate for all ages, cultures, and neurodevelopmental disorders.
It is important to document cognitive symptoms to characterise the nature of these symptoms and to track progress over time.
When cognitive dysfunction does not resolve with treatment of potentially contributing factors or if cognitive symptoms persist past 4–6 weeks, referral for further assessment should be considered.
CBR 4. Lumba-Brown A, Yeates Keith O, Sarmiento K, Breiding Matthew J, Haegerich Tamara M, Gioia Gerard A, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):1-13. doi: 10.1001/jamapediatrics.2018.2853. Adapted4 N/A New
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.27, 98 Education should be offered in multiple formats to ensure information is accessible and comprehensible.
Prolonged cognitive symptoms following mTBI/concussion (beyond 1 month) are often generated and exacerbated by other pre-existing and comorbid conditions such as headache, insomnia, visual disturbances and disturbances in mood. If a person presents with prolonged symptoms, they should be made aware that the presence of comorbidities may be interfering with recovery.157, 302 People should be encouraged to pursue targeted interventions geared towards these comorbid conditions with the aim of facilitating the resolution of their cognitive symptoms.
EBR (conditional)164, 173, 235, 272, 302-313 4. Lumba-Brown A, Yeates Keith O, Sarmiento K, Breiding Matthew J, Haegerich Tamara M, Gioia Gerard A, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):1-13. doi: 10.1001/jamapediatrics.2018.2853.
29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
164. Hromas GA, Houck ZM, Asken BM, Svingos AM, Greif SM, Heaton SC, et al. Making a Difference: Affective Distress Explains Discrepancy Between Objective and Subjective Cognitive Functioning After Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2021;36(3):186-95. doi: 10.1097/HTR.0000000000000618.
173. Anderson JFI. The association between pain type, cognition and complaint after mild traumatic brain injury in prospectively studied premorbidly healthy adults admitted to hospital. Neuropsychology. 2020;34(1):53-62. doi: 10.1037/neu0000585.
235. Anderson JFI, Jordan AS. An observational study of the association between sleep disturbance, fatigue and cognition in the post-acute period after mild traumatic brain injury in prospectively studied premorbidly healthy adults. Neuropsychol Rehabil. 2021;31(9):1444-65. doi: 10.1080/09602011.2020.1781665.
272. Karr JE, Iverson GL, Huang SJ, Silverberg ND, Yang CC. Perceived Change in Physical, Cognitive, and Emotional Symptoms after Mild Traumatic Brain Injury in Patients with Pre-Injury Anxiety or Depression. J Neurotrauma. 2020;37(10):1183-9. doi: 10.1089/neu.2019.6834.
302. Van Patten R, Iverson GL. Examining associations between concussion history, subjectively experienced memory problems, and general health factors in older men. Clin Neuropsychol. 2023;37(1):119-40. doi: 10.1080/13854046.2021.1991481.
303. Broggi M, Ready RE. Academic skills, self-perceptions, and grades in university students with a history of multiple concussions: The mediating roles of processing speed and psychological symptoms. Clin Neuropsychol. 2022;36(8):2188-204. doi: 10.1080/13854046.2021.1958924.
304. Crocker LD, Jurick SM, Thomas KR, Keller AV, Sanderson-Cimino M, Hoffman SN, et al. Mild traumatic brain injury characteristics do not negatively influence cognitive processing therapy attendance or outcomes. J Psychiatr Res. 2019;116:7-13. doi: 10.1016/j.jpsychires.2019.05.022.
305. Hwang PH, Nelson LD, Sharon JD, McCrea MA, Dikmen SS, Markowitz AJ, et al. Association between TBI-related hearing impairment and cognition: A TRACK-TBI study. J Head Trauma Rehabil. 2022;37(5):E327-E35. doi: 10.1097/HTR.0000000000000735.
306. Jurick SM, Crocker LD, Merritt VC, Sanderson-Cimino ME, Keller AV, Glassman LH, et al. Independent and synergistic associations between TBI characteristics and PTSD symptom clusters on cognitive performance and postconcussive symptoms in Iraq and Afghanistan veterans. J Neuropsychiatry Clin Neurosci. 2021;33(2):98-108. doi: 10.1176/appi.neuropsych.20050128.
307. Schneider ALC, Huie JR, Boscardin WJ, Nelson L, Barber JK, Yaffe K, et al. Cognitive outcome 1 year after mild traumatic brain injury: results from the TRACK-TBI study. Neurology. 2022;98(12):e1248-e61. doi: 10.1212/WNL.0000000000200041.
308. Stenberg J, Karr JE, Terry DP, Haberg AK, Vik A, Skandsen T, et al. Change in self-reported cognitive symptoms after mild traumatic brain injury is associated with changes in emotional and somatic symptoms and not changes in cognitive performance. Neuropsychology. 2020;34(5):560-8. doi: 10.1037/neu0000632.
309. Van Patten R, Keith C, Bertolin M, Wright JD. The effect of premorbid attention-deficit/hyperactivity disorder on neuropsychological functioning in individuals with acute mild traumatic brain injuries. J Clin Exp Neuropsychol. 2016;38(1):12-22. doi: 10.1080/13803395.2015.1091064.
310. Disner SG, Kramer MD, Nelson NW, Lipinski AJ, Christensen JM, Polusny MA, et al. Predictors of postdeployment functioning in combat-exposed U.S. military veterans. Clin Psychol Sci. 2017;5(4):650-63. doi: 10.1177/2167702617703436.
311. Terry DP, Brassil M, Iverson GL, Panenka WJ, Silverberg ND. Effect of depression on cognition after mild traumatic brain injury in adults. Clin Neuropsychol. 2019;33(1):124-36. doi: 10.1080/13854046.2018.1459853.
312. Saksvik SB, Smevik H, Stenberg J, Follestad T, Vik A, Haberg A, et al. Poor sleep quality is associated with greater negative consequences for cognitive control function and psychological health after mild traumatic brain injury than after orthopedic injury. Neuropsychology. 2021. doi: 10.1037/neu0000751.
313. Garcia A, Reljic T, Pogoda TK, Kenney K, Agyemang A, Troyanskaya M, et al. Obstructive sleep apnea risk is associated with cognitive impairment after controlling for mild traumatic brain injury history: a chronic effects of neurotrauma consortium study. J Neurotrauma. 2020;37(23):2517-27. doi: 10.1089/neu.2019.6916.Adapted4,29
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).314, 315 Additionally, external compensatory strategies such as the use of environmental supports and reminders (e.g. mobile/smartphones, notebooks) may also be employed.289
EBR (conditional)289, 290, 314, 316-321 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
289. Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, et al. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2019;90(3):333-41. doi: 10.1136/jnnp-2018-319315.
290. Acabchuk RL, Brisson JM, Park CL, Babbott-Bryan N, Parmelee OA, Johnson BT. Therapeutic effects of meditation, yoga, and mindfulness-based interventions for chronic symptoms of mild traumatic brain injury: A systematic review and meta-analysis. Appl Psychol Health Well Being. 2021;13(1):34-62. doi: 10.1111/aphw.12244.
314. Pagulayan KF, O’Neil M, Williams RM, Turner AP, Golshan S, Roost MS, et al. Mental health does not moderate compensatory cognitive training efficacy for veterans with a history of mild traumatic brain injury. Arch Phys Med Rehabil. 2017;98(9):1893-6 e2. doi: 10.1016/j.apmr.2017.04.009.
316. Cooper DB, Bunner AE, Kennedy JE, Balldin V, Tate DF, Eapen BC, et al. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging Behav. 2015;9(3):403-20. doi: 10.1007/s11682-015-9440-2.
317. Fure SCR, Howe EI, Andelic N, Brunborg C, Sveen U, Roe C, et al. Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial. Ann Phys Rehabil Med. 2021;64(5):101538. doi: 10.1016/j.rehab.2021.101538.
318. Samuelson KW, Engle K, Abadjian L, Jordan J, Bartel A, Talbot M, et al. Cognitive training for mild traumatic brain injury and posttraumatic stress disorder. Front Neurol. 2020;11:569005. doi: 10.3389/fneur.2020.569005.
319. Storzbach D, Twamley EW, Roost MS, Golshan S, Williams RM, O’Neil M, et al. Compensatory cognitive training for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with mild traumatic brain injury. J Head Trauma Rehabil. 2017;32(1):16-24. doi: 10.1097/HTR.0000000000000228.
320. Twamley EW, Jak AJ, Delis DC, Bondi MW, Lohr JB. Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) for veterans with traumatic brain injury: pilot randomized controlled trial. J Rehabil Res Dev. 2014;51(1):59-70. doi: 10.1682/JRRD.2013.01.0020.
321. Twamley EW, Thomas KR, Gregory AM, Jak AJ, Bondi MW, Delis DC, et al. CogSMART compensatory cognitive training for traumatic brain injury: effects over 1 year. J Head Trauma Rehabil. 2015;30(6):391-401. doi: 10.1097/HTR.0000000000000076.Adapted29
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.263 Specialized 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 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] Adapted29 CBR148 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
148. Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: A randomized controlled trial of emergency department discharge instructions. Acad Emerg Med. 2017;24(1):75-82. doi: 10.1111/acem.13073.Adpated29