Traumatic Brain Injury and Alzheimer’s Disease

Traumatic head injury increases effect of Alzheimer disease which disrupts activity of neurotransmitters and electrical charges travel within cells. Alzheimer disease is characterized by synaptic loss and neuronal death with gross brain atrophy. Falls are common in older population which lead to prolong hospital stay and serious medical complications such as traumatic brain injury. Traumatic head injury cause brain tissue to swell which prevent fluids from leaving brain and broken pieces of skull can rupture blood vessels in head. Effect of traumatic brain injury is crucial due to the association of cognitive impairment, decrease motor function, and neuroinflammation with Alzheimer's disease, especially in women with the APOE genotype. Reducing the onset with preventative measures including diet modification, physical activities, and continuous intellectual stimulation constituting a medical management and care plan.

Neuroinflammation and Cognitive Impairment

Neuroinflammation and cognitive impairment role on the brain is critical to traumatic brain injury with Alzheimer disease. Brains immune cells play an important role in healing process, removal of dead, and damaged neurons which doesn't occur cause of the traumatic brain injury. Amnesia is memory loss and different types include retrograde amnesia and anterograde amnesia. Retrograde amnesia hinders ability to retrieve memories that were already stored in brain and limited to period before head injury or before Alzheimer disease develops. Anterograde amnesia lose capacity to make new memories and present for events that occur or information that is present after brain injury or Alzheimer disease. Aphasia is impaired communication and apraxia is deficit involuntary motor skills.

Neuroinflammation is cellular damage and loss of neuronal functions occurring when brain or spinal cord become inflamed cause by irritation and swelling of brain tissue or blood vessels. Brain swelling cause increased intracranial pressure (ICP) which prevent blood flow to brain and deprived it of oxygen need to function. Brain fog occurs due to decrease communication between neurons leading to damaged brain cells and brain decelerating. Inflammation cause deficits such as memory loss, decrease alertness, change in concentration and behavior, confusion, mood swings, and distortions in thought. Chronic cerebral inflammation associated with increased proinflammatory cytokines capable of mediating neural protection and regeneration. Traumatic brain injury follows by oxidative stress and hypoxia which stimulate microglia and astrocytes. Continuing neuroinflammation and oxidative stress occur in existence of brain damage and functional impairments (O'Brien, 2015).

Cognitive impairment is act of knowing, thinking, ability to choose, understand, remember information. Problems include attention and concentration, speech and language, learning and memory, problem-solving, decision-making, and judgment. First, unable to pay attention and concentration resulting in restless, distraction, difficulty working on more than one task at a time, problem carrying on long conversation or sitting still for long period of time. Second, problem with processing and understanding information slow down and result in taking longer to grasp what other say, more time to understand and follow direction, trouble following tv, take longer to read and interpret written information, slow to reaction such as driving, slow to carry out physical task like getting dress or cooking. Third, language and communication problems include difficulty thinking of right words, trouble starting or following conversation, rambling, misunderstanding jokes, difficult with more complex language, trouble communicating thoughts and feelings using facial expression, tone of voice and body language, reading others' emotions. Fourth, problem learning and remember new information that occur recently but remember information from long time ago. Fifth, problem with problem-solving, decision-making, and judgment include difficult recognizing problem, trouble analyzing information, or change way of thinking, difficult deciding best solution, and quick decision without thinking about consequences. Sixth, inappropriate, embarrassing or impulsive behavior occur with lack of self-control and self-awareness including denying cognitive problems, say hurtful or insensitive things, act out of place and behave in inconsiderate way and lack awareness of social boundaries and others' feeling. Adrenal cortex produces the hormone cortisol and shows a high level in people affective by mild cognitive impairment (Battino, 2016

APOE Genotype

The sex difference varies by APOE genotype which regulate aggregation and clearance in brain, neuronal signaling, and neuroinflammation. Traumatic brain injury reduce ability to repair and remodel synapses or protect neurons with APOE gene. Patient carrying APOE gene have high tau level, low cerebral spinal fluid (CSF) and great brain atrophy particularly in hippocampal area cause loss in cortical thinness and hippocampal value leading to decrease cognitive performance. APOE- µ4 gene more common in Alzheimer disease patient associated with increased risk for cerebral amyloid. Amyloid-related decline with presence of APOE- ?µ4 by assessing memory, cognitive, and executive function in participants with Alzheimer pathology and no pathology. (Donohue, 2014) Amyloid-b (A) peptides becomes accumulate and aggression causing injury to synapse and neurodegeneration. Microtubule-associated protein tau appear as neurofibrillary tangles in Alzheimer disease brain caused by overproduction of A.

Low level of gonadal sex hormones is associated with decline in neurogenesis with memory decline and executive function difficulties. Female sex-linked to decrease longitudinal cognitive, advance hippocampal atrophy, and lower cognitive testing. Women with APOE- µ4 have more pronounced brain pathology than men showing more buildup of sticky plaques called amyloid beta protein. APOE- µ4 in women cause worse performance, greater brain atrophy and lower brain metabolism due to higher level of biological markers. Women with low CSF have greater left hippocampal atrophy, quicker decline in memory, and function performance while women with higher CSF have decrease in function performance and advance right hippocampal atrophy (Koran, 2016). Estrogen important for hippocampal memory consolidation, hippocampal-dependent spatial navigation memory, object recognition, and object placement which decrease with age and associated with cognitive decline.

Preventive Measure

Diet modification, physical activities, intellectual stimulation to help decrease cognitive impairment, neuroinflammation, and increase motor function. Research has showed that wearing a seat belt while in an automobile can reduce injury from occurring during accidents. Secure rugs and loose electrical cord to minimize risk of tripping over them which could lead to falls. Brain cells critical for memory is lose as brain shrink with age, and large brain volume association include diet rich in fruits, vegetables, whole grains, dairy, nuts, fish, and low in sugary beverage.

Diet modification include nutrition which is an environmental factor, and proper nutrition can change biomarker level. Decrease oxidation in the brain cause decrease deacetylase activity (Athanasopoulos, 2016). Vitamin D has neuroprotector properties such as antioxidative, calcium homeostasis, neurotrophic regulation and anti-inflammatory action which regulate DNA methylation and modulate gene expression leading to decrease risk for developing Alzheimer disease. Vitamins A, C, and E has antioxidant properties which can reduce abnormal histone acetylation modification. Vitamin A group include retinol, retinoic acid, and b-carotene which have beneficial effect on memory. Vitamin C group require for recycling ?±-tocopherol radical which acts as a reducing agent and induces epigenetic changes to protect against Alzheimer disease. Vitamin E group include tocopherols and tocotrienols associated with decreased risk for Alzheimer disease. Omega-3 fatty acids reduce cognitive decline in older adults by increasing the specialized pro-resolving mediators produce by peripheral blood mononuclear cells. Omega-3 fatty acids benefit heart and blood vessels, anti-inflammatory effects, and protect nerve cell membranes. Inflammation and cognitive decline can be physical reduced with alpha-lipoic acid, curcumin, fish oil, ginger, resveratrol, and spirulina.

Physical activities help brain cells increase blood and oxygen flow in brain encouraging new cell growth which stimulate brains ability to maintain old connection as well as make new ones. Muscle, joints, balance, and heart help maintain higher level of functioning and reducing risk of falls. Adequate exercise reduces restlessness and prevent wandering and cognitive decline improve with supporting cardiac function. Improve sleeping habits by maintaining a good sleep-wake cycle and facilitate sound sleep at night. Walking shows improvement with memory and weight training show improvement in selective attention, memory, and conflict resolution. Yoga decrease blood pressure and decrease risk of cardiovascular which improve brain function and decrease risk of Alzheimer disease. Overall quality of life improves with yoga with increase processing speed, executive function, attention, memory, and mood.

Stimulating Activities

Certain stimulating activities can reduce risk of mild cognitive impairment and show improvement in complex thinking and memory skills by staying engage and alert while enjoying vigorous memory workout. People with APOE ?µ4 genotype engage in intellectual activities show reduced risk of mild cognitive impairment and higher cognitive reserve is associated with cerebrospinal biomarker. Reduce risk of mild cognitive impairment by playing brain games, reading, using computer, and social activities. Puzzles or sorting object use hand-eye coordination to exercise problem-solving ability and make sense of shapes to complete pictures which help maintain neural connection of brain. Game encouraging verbal articulation of ideas strengthen mental capacity through word related activities, mental exercises, or question by stimulating mind to sharpen cognitive awareness. Reading stimulate both memories and emotion and more neurobiological demanding require vision, language, and associate learning all connection. Tackling new technologies is a way to learn new things. Remain interested, active and engage in life by staying social will keep brain active.

Learn something new to challenge mind and stimulate brain stem growth such as new language, musical instrument, and painting which provide novelty, complexity, and challenge by disrupting brain's habit and routines. Artistic hobbies such as drawing, and paint keeps senses fine-tuned by work part of the brain that might not have been utilized in past. Music stimulates specific part of the brain and has power to stir memories and elicit emotion. Practice memorization by creating rhymes and patterns to strength memory connection. Practice the 5 W's. Who, What, Where, When, and Why by observing and reporting to capture visual details to keep neurons firing. Things already know how to do, try in new ways to create new brain pathways such as eating or styling hair with non-dominant hand and placing watch on opposite wrist.

Medical Management and Care Plan

Medical management and care plan help communicate and organize action needed for individual's needs. Neurological examination includes blood test, spinal tap, nerve function, electroencephalogram (EEG), and imaging test CT scan and MRI. Cognitive evaluated by neuropsychologist since many factors affect how cognitive can be improve and challenging to predict recovery. Cognitive rehabilitation focus on remediation focus on improving skills that have been lost or impaired and compensate learning new ways to achieve goal. Speech therapist to identify areas that need work

Treatment

Medication can't stop the damage Alzheimer disease cause brain cell but can lessen or stabilize symptoms by affecting certain chemicals involving with brain nerve cells. Neuroinflammation treatment include controlling inflammation with immunosuppressant. Cholinesterase inhibitors and memantine to treat cognitive symptoms such as confusion, problem with thinking and reasoning, and memory loss. Cholinesterase inhibitors prevent breakdown of chemical called acetylcholine essential for learning, memory, and support communication among nerve cells by increasing acetylcholine. Memantine regulates activity of a chemical called glutamate improved mental function and ability to perform daily activities. Oxygen therapy provide oxygen to help blood have enough oxygen and reduce amount of swelling. PROG treatment shows improved long-term cognitive and motor outcome with decrease brain damage (O'Brien, 2015). MW 151 treatment Selective proinflammatory cytokine prevent cognitive impairment (Bachstetter, 2015).

Cognitive rehabilitation focuses on remediation by developing skills that have been lost or impaired and compensate for learning new ways to achieve goal. Ventriculostomy by drilling small hole in skull to drain cerebrospinal fluid from inside brain. Surgery to remove part of skull to relieve intracranial pressure or repair damaged artery or vein.

Care Plan

Cognition-focused evaluation is a comprehensive and interview with family member to obtain description of current issue, accurate patient history, exams, medication, and medical. Functional assessment includes activities of daily living, decision-making capacity, evaluation of safety and advances care planning with palliative care. Reminiscing will help with long-term memories and intellectual activities to keep cognitive skills active. Early detection can assist with more time to prepare for future, better chance of treatment such as increased chance of participating in clinical drug trials, participate in decision about care, transportation, living option, financial, and legal matters. Evaluation of safety and advance care planning with palliative care.

Plans to help improve different changes that are occurring in mind and body. Attention and concentration problems improved by decreasing distraction, focus on one task at a time, practice attention skills, and take breaks when tired. Problem with processing and understanding improved with placing full attention on trying to understand, more time to think about information, re-read information, and ask to repeat themselves. Language and communication improved with using gentle tone of voice, don't speak quickly, limit conversation to one person at a time. Problems learning and remembering new information improved by putting together a structured routine of daily task and activities, be organized, review and practice new information, well rested and reduce anxiety, learn memory aids such as memory notebooks, calendars, daily schedules, and daily task list. Problem with problem-solving, decision-making, and judgment include teaching organized approach such as step-by-step problem-solving strategy, define problems, possible solution, pros and cons of solutions, pick solution, and evaluate success of solution. Inappropriate, embarrassing or impulsive behavior include think ahead about situation, clear expectation for desirable behavior, plan and rehearse social interaction, verbal and non-verbal cues.

Conclusion

Alzheimer disease is a complex neurodegenerative disorder which progressive due to traumatic brain injury. Effect of traumatic brain injury can be reduced by understanding neuroinflammation, cognitive impairment, APOE genotype, and sex hormones. Diet modification. Physical activities improve blood flow to brain and stimulate nerve cells growth. Ongoing intellectual stimulation improves complex thinking, memory, communication, and interaction.

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