How To Treat Cognitive Impairment From Traumatic Brain Injury

Traumatic Brain Injury (TBI) is a preventable and treatable condition that, if left unchecked, can predispose a person to cognitive impairment/dementia.  This article describes the following:

Mechanisms: Why and how TBI can favor the development of dementia

Integrative treatment: Holistic approaches you can incorporate in your life to treat TBI if it has already occurred. In my direct clinical experience, these approaches can minimize the impact that these conditions will have on cognition, and moreover, they can even reverse some of the functional losses that may have already taken place.

Prevention: Steps you can take to prevent TBI from occurring in the first place

MECHANISMS BY WHICH DEMENTIA DEVELOPS IN TBI

When the skull is hit hard (referred to as blunt force trauma, e.g. from a fall, or from a blow to the head): For a fraction of a second, millions of miniscule bubbles will form in the solid matter of the brain, and will then quickly dissipate. But like Sherman marching through Atlanta, a swath of destruction is left in the wake of this swarm of nano-bubbles. Specifically, the bubbles trigger the release of glutamate, a “normal” neurotransmitter that, when released in excessive amounts, acts like shrapnel on nearby neurons (a process called “neurotoxicity”).

Whatever the mechanism by which the physical trauma works, there are downstream consequences that manifest themselves in what we call “pathologies,” typically a disruption of anatomical structures, or a disruption of function, or both. Some of these pathologies are of academic interest only, due to the fact that they don’t (yet) translate into something we can easily address and remedy. However, there are other pathologies that do offer hints, to the inquiring mind, of steps we can take to improve the outcome. We call this “translational medicine.”

One of the important pathologies of TBI, and also of Alzheimer’s disease (AD) as well, is that large numbers of neurons can no longer get glucose to enter the cell. So they are starved for “fuel,” that fuel being glucose. It’s not that there’s a shortage of glucose, or a shortage of insulin. These are in abundance. Rather, the trauma to the brain has disrupted the insulin receptors on the neurons, so that these receptors can no longer activate a portal (think of it as a turnstile) that is needed to transport glucose into the cell. It’s like someone plugging up your car’s gas tank with rags – the fuel can’t get in.

With little or no glucose getting in, these neurons falter. The clinical result is slow thinking, difficulty taking initiative, problems following through, dysregulation of affect, and the like. In other words, all the major aspects of executive function have taken a hit.

Extract of ginseng root

INTEGRATIVE TREATMENT FOR TBI

KETONES

It is important to note that in Alzheimer’s Disease there is a very similar disruption of the insulin receptors on neurons. And this is why both conditions – TBI and AD – respond so well to foods and “medical foods” that provide ketones, such as coconut oil.

Ketones are the final breakdown product of fat metabolism. When you ingest coconut oil, the liver converts it into “ketone bodies” that passively diffuse into the neurons (no receptor needed, no turnstile involved). These ketones thereby provide an “alternative fuel” for the brain.

The brain is thus a hybrid engine. If it cannot get glucose, it can utilize ketones. This is important for species survival in the face of famine: We will break fat down into ketones that will keep us alive in the face of starvation. I and many other of my functional/integrative colleagues have seen coconut oil produce huge gains in people with dementia, TBI, and/or Parkinson’s disease (yes there are problems with neuronal insulin receptors in Parkinson patients).

Some skeptical physicians are critical of all the hype around coconut oil. They don’t understand the metabolic strategy underlying this approach, and therefore, in their minds, “it can’t work.” It can, and it does. Numerous scholarly articles have been published on the subject, and one of the most compelling facts is that, gram for gram (actually more per mole), each molecule of ketone produces vastly more energy (as a high-energy molecule called ATP) than does each molecule of glucose.  [1]

[1] Henderson ST1Vogel JLBarr LJGarvin FJones JJCostantini LC. Study of the ketogenic agent AC-1202 in mild to moderate Alzheimer’s disease: a randomized, double-blind, placebo-controlled, multicenter trial. Nutr Metab (Lond). 2009 Aug 10;6:31.

If you have had a head injury or accident of any kind, seek medical attention.  The recommendations made in this issue are for educational purposes only, and do not constitute medical advice, nor are they meant to prescribe a treatment.

There are some side effects of coconut oil that we need to be aware of. Specifically, it can cause loosening of stools and even frank diarrhea. So start with a low dose of coconut oil, e.g. ¼ teaspoon once per day, and build slowly, perhaps to one full tablespoon twice a day.

If you are administering coconut oil or other ketone strategies to someone who is profoundly demented, watch out: they can suddenly become much more active, and can then injure themselves because they don’t yet have full awareness. I have seen this in my own practice. It’s like the movie “Awakenings.” You may have to “baby-proof” the house to prevent injuries.

 

OTHER TREATMENTS

It is intriguing that many of the medications and nutraceuticals that help patients who have dementia are also helpful for patients who have TBI. An excellent compilation of sound ideas for treating TBI can be found in Textbook of Traumatic Brain Injury, edited by Jonathan Silver et al.

Prescription medications

In that book there is a useful chapter called “Psychopharmacology”. Some of the medications they list as being useful for the cognitive impairments seen in TBI include stimulants (methylphenidate and dextroamphetamine), amantadine, bromocriptine, Sinemet (levodopa/carbidopa), modafanil, and donepezil. These may be worth trying, particularly if the nutraceuticals in the next section do not work sufficiently well.

Nutraceuticals

Another very helpful chapter in Dr. Silver’s textbook is the one entitled “Alternative Treatments”, by Drs. Richard Brown and Patricia Gerbarg. On page 683 of the 2005 edition of the book, the authors provide a table listing a number of nutraceuticals. We will list them here, without commentary as it goes beyond the scope of this article. It is very worthwhile to know about these, that they are available and that they work. You can then consult that chapter, and/or do a literature search, to delve more deeply. In the list below, the items that I have put in bold are ones that I universally recommend to patients with TBI and/or dementia. The others on the list are probably very good, but I have had little or no experience with them.

  • Galantamine
  • Huperzine
  • Centrophenoxine
  • Acetyl-L-carnitine
  • Citicholine
  • S-adenosylmethionine (SAMe)
  • Picamilon
  • Pyritinol
  • Idebenone
  • Vinpocetine
  • Rhodiola rosae
  • Ginkgo biloba
  • Ginseng
  • Racetams (e.g. piracetam)
  • L-Deprenyl
  • B vitamins

Neurofeedback

(“NF”): NF is a type of biofeedback where the “signal” you are trying to train is the amount of abnormal neuronal activity in various regions of the brain. Some regions are underactive, as will be seen visually on a computer-based analysis of brain activity that is called a quantitative EEG (qEEG). These underactive regions can be “tuned up” through biofeedback. For example, when the underactive region in question happens to show more activity, you are “rewarded” by being able to continue to watch a video that you have been set up to watch. The video will stop running if you slip out of that zone of activity. The cumulative effect of this training (over many sessions) is a meaningful improvement in executive function. I don’t do NF in my own practice, but I do work very closely with a colleague who has helped scores of TBI patients. If you are interested, contact me at rcarltonmd@gmail.com, with the word NEUROFEEDBACK in all caps in the Subject heading, and I’ll get you a link to a directory or some contacts in your part of the world.

Yoga

This can help in several ways. One is that you need to come into your body, to allow breathing to take place and find a way to “live” with the disability you’ve suffered. Another benefit is that yoga teaches us to be less judgmental, meaning more accepting of the limitations from which you are suffering. We all have a tendency (that we have to over-rule) to be critical of what is “wrong.” People with TBI can wind up hating their brains, and hating themselves, and this sends them into a vicious downward spiral.

Important to know: “Accepting” does not mean that it’s OK with you if this loss from which you are suffering goes on forever. Rather, it means that it is here now; you cannot make it go away; and if you are confrontational with it (if your own dialog inside your head is nasty), you are punishing yourself. You don’t scowl at your dog when it limps from arthritis, do you? No, you love it and extend your empathy.

Learn to accept and to let go, and you may heal. This does not mean that you stop looking for help. It means that you stop hating yourself, along the way.

The February/March 2020 issue of Brain & Life (“Neurology for Everyday Living”), published by the American Academy of Neurology, has a wonderful article entitled “How Yoga Can Help People with Traumatic Brain Injury”. The author recommends a TBI-specific yoga program you can get online, at loveyourbrain.com/yoga. If you try it, please let me know at the above email address if you find it helpful.

PREVENTING TBI

Many of the ideas about prevention presented here may seem obvious, and you have probably heard many of them already. But if even one or two of these ideas stick, so that you remember them while engaging in an activity in which you are vulnerable, then your quality of life will be protected and it will have been worthwhile to consider once again these sensible ideas.

Fasten your seat belt

Don’t drive even “just one block” without putting your belt on. Most auto accidents occur within a mile or so of the home. You don’t have to go through the window to suffer a devastating TBI. Just a solid tap of your head against the glass, at a decent speed, can severely affect your life.

Look up!

Overhanging objects: Make a mental note that they are there. If you are about to bend down under an open cupboard door, or underneath a stairwell, remind yourself of the danger before you do it. Otherwise, when you absent-mindedly stand back up you will get a whack.

Don’t put objects down in the path where you or others will be walking.

Instead, put things down along the wall, or in a corner. A neighbor of mine was hospitalized for a fall after she put her shoes down in the middle of the hallway, turned around to get something, and then walked forward and tripped on one of the shoes.

”Watch where you’re going.”

There’s a less judgmental variant that I prefer: “Go where you’re watching.” If you can’t see the path clearly, don’t go. It could be that the path (e.g. through a room) is dark. It could be that you’re carrying objects that partially obscure your field of vision. It could be that you’re looking at your cell phone or tablet as you walk. Murphy’s Law tells us that if there is an object along that path, and if you don’t see it, your foot will somehow manage to find it. Whether the ensuing fall smashes your head, or fractures your hip, is just a matter of chance – a chance you don’t want to take.

Look down!

Consistent with “Go where you’re watching,” be mindful and observant for (a) cracks in the sidewalk (see the Case History below), (b) sidewalks pushed up by the roots of a tree, (c) rough patches of macadam, and of course (d) icy patches (especially on grates and on those metal gates one opens to gain entrance to store basements).

Never walk with your hands in your pockets.

A friend of mine tripped on a rough patch of macadam and couldn’t get her arms out in time to break the fall. She hit her sternum on the curb and was in excruciating pain for a month. If she had landed on her head instead, she’d have TBI for sure and would be seeing neurologists.

Balance training

Take classes that improve your balance. This could be yoga, Tai Chi, balance classes at the Y or the health club or at your local medical center. These classes can prevent falls, and can teach you skills to land more safely if you do fall.

TBI CAE STUDY: AN INTEGRATIVE APPROACH

At intake, “Nancy” (not her real name) was a 73-year-old bipolar woman with a Ph.D. in Psychology. Prior to her TBI, she had been a high-functioning scholar, author, and international speaker. The TBI had occurred two years earlier when she tripped on an uneven sidewalk and landed flat on her face. There was no loss of consciousness. She was treated at a nearby urgent-care center, with a gash at the left temple and a black eye. In the days that followed the injury she became dizzy, and had trouble walking straight. Each step she took seemed to “rattle” her brain. Ever since, she has shown many of the signs and symptoms of TBI. For example, she becomes exhausted very easily; has profoundly lost her ability to focus on tasks; has great difficulty taking initiative; and feels depressed and demoralized. She now has tremendous difficulty completing the writing tasks she has undertaken and teaching and supervising postdoctoral candidates. At intake she was getting neurofeedback training, with some improvements, but the NF practitioner referred her to me for metabolic/nutritional support.

I started this bright and engaging lady on Rhodiola, DopaMind (an herbal product that increases synthesis of dopamine and is neuroprotective), bacopa, gingko, and saffron extract (which can help treat depression). All of these improved her cognition and mood to a decent extent, but it was still difficult to complete the articles she had to write. She felt tortured by this disorganization. So we added in the prescription drug amantadine, which counteracts excess glutamate toxicity while increasing dopamine and acetylcholine. The drug produced huge improvements in executive functioning and in self-esteem; unfortunately, it had to be discontinued because (even at fractional doses) it provoked double vision, a fairly common side-effect. We can’t use any of the stimulant medications that normally help TBI, because they are contraindicated in people who are bipolar. In her case, even the nutraceutical SAMe (see above), which we had tried early-on, induced hypomanic mood and had to be discontinued. We are still working our way through the list of prescription meds and nutraceuticals.

At two points in the course of treatment she had to stop all of the nutrients completely, to avoid the potential side effect of bleeding after dermatological surgery procedure that was scheduled. Both times, within days of stopping the nutraceuticals her executive functioning plummeted back towards baseline, and her depression worsened profoundly; and both times when she resumed the nutraceuticals, within days the cognitive gains returned sharply, and the depression was greatly reduced.

This was not a controlled study, as there was never any time on placebo. But it is crystal clear to her from the “crossovers” (when she came on and off the nutraceuticals), that she is enjoying robust improvements from the nutraceuticals. Further improvement is needed, as executive functioning is still severely hobbled. But the gains the nutraceuticals have produced, in terms of cognition and mood, are huge and unmistakable to her.

This case is very typical of the kinds of gains that I see in treating people suffering from TBI. I am reporting this to give hope to people suffering from the condition, to their family members, and to health practitioners who are searching for complementary and alternative (“CAM”) approaches to treating this devastating disorder.

Dr. Richard Carlton is an integrative psychiatrist and pioneer in the rational use of nutrition-based treatment approaches when treating “mental” issues (such as depression, anxiety, ADHD), or “physical” problems (such as cognitive impairment or dementia, migraines, PMS, and IBS). He practices in Port Washington, NY.