Category: Blog Post

What is traumatic brain injury?

Traumatic brain injury (TBI) results from a sudden, external, violent blow to the head that damages the brain, disrupting normal brain functioning. TBI is a broad term that refers to a wide range of brain injuries. It can affect an individual’s cognitive abilities, including memory, thinking, and learning.

Experts classify TBI as mild, moderate, or severe based on whether the injury induces unconsciousness, the duration of unconsciousness, and the severity of symptoms. Since most brain injuries are non-fatal, they display mild symptoms. However, even minor traumatic brain injuries can have catastrophic and long-term consequences.

According to statistics, most of the TBI cases (about 40%) are due to falls followed by unintentional blunt trauma (15%) and motor vehicle accidents (14%).

What are the types of TBI?

There are two types of traumatic brain injuries.

• Closed brain injury occurs due to non-penetrating injury with no skull breakage. Rapid forward or backward movement or indirect violent jolts to the brain within the skull can cause this type of TBI due to the tearing and bruising of brain tissues and blood vessels. Falls, car accidents, and sports head injuries are the leading causes of closed brain injury.
• Penetrating brain injury (also known as open head injury) results when there is a break in the skull, for instance, when a bullet pierces the skull and brain.

How can TBI impact cognitive health?

Traumatic brain injury, which occurs as a result of a blow to the head and affects normal brain function, endangers cognitive health in two ways:

• The direct effects of TBI might include unconsciousness, disorientation, inability to recollect traumatic events, trouble learning and retaining new information, difficulty speaking, lack of coordination, and visual or hearing problems. These can be long-lasting or even permanent.
• Some forms of TBI may raise the likelihood of acquiring Alzheimer’s or another type of dementia years later.

Is there any connection between Traumatic Brain Injury and Dementia?

Over the last three decades, research has connected moderate and severe traumatic brain injury to an increased risk of getting Alzheimer’s disease or another dementia years later. According to a study, the higher the severity of the head injury, the higher the Alzheimer’s risk. Seniors with a history of moderate brain injury had a 2.3 times greater risk of developing Alzheimer’s than seniors with no TBI history. Furthermore, those with a history of severe brain injury had an even higher (about 4.5 times) risk. Some other studies (but not all) have also suggested a similar connection between moderate and severe TBI and increased risk.

Increased Risk of TES/CTE

There is no proof that a single moderate TBI raises the risk of dementia. However, the emerging evidence does demonstrate that the chance of developing traumatic encephalopathy syndrome (TES) or specific brain alterations linked to chronic traumatic encephalopathy (CTE) may increase with repeated mild traumatic brain injuries, such as those that can occur in sports like American football, hockey, boxing, and soccer.

Symptoms of TES/CTE include memory loss, disorientation, impaired judgment, anger, depression, anxiety, suicidality, parkinsonism, and progressive dementia. These symptoms may manifest years or even decades later after the last brain injury.

Previous studies have demonstrated that boxers are more likely to experience particular brain alterations linked to CTE and may also experience impairments in cognition. The likelihood of the specific CTE-associated brain changes in boxers appears to correspond with the number of rounds boxed rather than the number of knockouts. It implies that even repeated mild traumatic brain injuries that do not render a person unconscious may increase the risk of dementia. CTE-associated brain changes CTE can occur after a small number of severe TBIs, a large number of mild or very TBIs, or some other pattern of head trauma.

TBI is a risk factor for dementia

Researchers in Sweden have also reported that TBI is a risk factor for dementia, revealing that the likelihood of receiving a dementia diagnosis was highest in the first year following the injury. During this time, dementia diagnoses were four to six times more likely to occur in TBI patients than in the general population. The study also concluded that there might be a risk of dementia even 30 years after a concussion or other TBI.

Having a history of TBI may accelerate dementia

According to a study published in 2016, a history of TBI may cause cognitive impairment to appear two or more years earlier than it would otherwise. These findings were commensurate with other studies that found TBI to be a substantial risk factor for cognitive decline in older adults and associated with the beginning of moderate cognitive impairment and Alzheimer’s disease at a younger age.

Similar brain changes in Alzheimer’s and mild TBI

A recent study revealed similarities in the brain changes in people with Alzheimer’s disease and mild TBI. The brains of Alzheimer’s and TBI individuals exhibited a reduced cortical thickness in comparison with healthy individuals. Experts frequently associate cortical thinning with a decline in memory, verbal fluency, the ability to integrate new knowledge, and the capacity to make judgments.

The link between TBI and APOE ε4 gene

The APOE ε4 gene is associated with the onset of Alzheimer’s disease. Some studies have indicated that in individuals with an APOE ε4 variant of the apolipoprotein E (APOE) gene, TBI may be more likely to increase the risk of Alzheimer’s. However, more research is required to fully understand the association between APOE ε4 and dementia risk in people who have experienced a traumatic brain injury.

More research is needed to understand the connection between TBI and dementia

More research is required to fully comprehend the connection between TBI and dementia and why people who have experienced moderate, severe, or repeated mild traumatic brain injuries are more likely to experience alterations in their memory, thinking, and reasoning later in life.

What are the symptoms of TBI?

Whether the injury is mild, moderate, or severe will determine how severe the symptoms are. Among all forms of TBI, cognitive changes are the most prevalent, disabling, and persistent effects of the injury. It also frequently impacts the ability to learn and remember new information, pay attention, organize thoughts, develop efficient strategies for completing tasks and activities and make sound judgments. Years after the damage and the person seems to have recovered from its initial consequences, more severe cognitive abnormalities (which are a hallmark of dementia) may arise.

Mild TBI or concussion may or may not cause unconsciousness. Its symptoms may include headache, dizziness, confusion, disorientation, blurry vision, nausea and vomiting, problem finding words, sensitivity to light or sound, trouble speaking clearly, and changes in energy, emotions, or sleep patterns. Unconsciousness may last for 30 minutes or less, and a person may be unable to remember the circumstances leading up to the injury or those that happened within 24 hours.

In moderate TBI, unconsciousness lasts more than 30 minutes but less than 24 hours, while in severe TBI, it lasts more than 24 hours. Their symptoms are similar to mild TBI but are graver and longer-lasting.

How to prevent traumatic brain injury?

Falls are the most common cause of TBI. The following measures can help prevent falls:

• Utilize a walker or other aid to compensate for muscle weakness, poor balance, or mobility issues.
• Get your vision examined regularly and use contact lenses or glasses for correcting changes.
• Prevent domestic dangers like clutter, loose rugs, and poor lighting.

You can also take other precautions to prevent traumatic brain injury, such as wearing a helmet or other protective gear to protect your head while biking or playing contact sports,
maintaining your vehicle to keep it in good condition, following road and traffic rules, and fastening your seat belt.

References

1. Dementia in Head Injury. https://www.webmd.com/alzheimers/dementia-head-injury

2. Gottlieb, S., 2000. Head injury doubles the risk of Alzheimer’s disease. BMJ, 321(7269), p.1100. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1173459/

3. McCrory, P., Zazryn, T. and Cameron, P., 2007. The evidence for chronic traumatic encephalopathy in boxing. Sports medicine, 37(6), pp.467-476. https://pubmed.ncbi.nlm.nih.gov/17503873/

4. Nordström, A. and Nordström, P., 2018. Traumatic brain injury and the risk of dementia diagnosis: A nationwide cohort study. PLoS medicine, 15(1), p.e1002496. https://pubmed.ncbi.nlm.nih.gov/29381704/

5. Li, W., Risacher, S.L., McAllister, T.W. and Saykin, A.J., 2016. Traumatic brain injury and age at onset of cognitive impairment in older adults. Journal of neurology, 263(7), pp.1280-1285. https://pubmed.ncbi.nlm.nih.gov/27007484/

6. Rostowsky, K.A. and Irimia, A., 2021. Acute cognitive impairment after traumatic brain injury predicts the occurrence of brain atrophy patterns similar to those observed in Alzheimer’s disease. GeroScience, 43(4), pp.2015-2039. https://pubmed.ncbi.nlm.nih.gov/33900530/

Diabetes mellitus (DM) is a health condition in which the body does not produce enough insulin (a hormone responsible for blood sugar regulation in the body) or cannot effectively use it, resulting in abnormally high blood sugar (glucose) levels. Generally, three types of diabetes are known:

1. Type 1 diabetes (T1DM) is an autoimmune disorder in which the body attacks its insulin-producing beta cells in the endocrine part of the pancreas, causing them to lose the ability to make insulin. Consequently, the blood sugar level becomes too high.
2. Type 2 diabetes (T2DM) is a chronic condition in which the body cells become resistant to insulin and do not use it well or the pancreas cannot produce it adequately to keep up with the demand.
3. Gestational diabetes (GDM) occurs during pregnancy, and blood sugar levels are abnormally high during this period.

Some researchers have proposed the term “type 3 diabetes” for describing Alzheimer’s disease. According to them, a type of insulin resistance and insulin-growth factor dysfunction that occurs specifically in the brain cause amyloid plaques, inflammation, and oxidative stress in the brain triggering the disease. Some scientists also use this term when people with type 2 diabetes are diagnosed with Alzheimer’s.

“Type 3 Diabetes” is not universally acknowledged by the medical community as a clinical diagnosis. Its classification is highly controversial, and the American Diabetes Association and other major health organizations do not consider it a type of diabetes.

This condition is not to be confused with type 3c diabetes mellitus (also known as T3cDM and pancreatogenic diabetes). Type 3c may result due to pancreatitis and is entirely different from Alzheimer’s.

Causes of type 3 diabetes

In a review published in 2008, the authors conclude that “type 3 diabetes” precisely describes Alzheimer’s disease as a form of diabetes that impacts the brain. According to them, Alzheimer’s is a neuroendocrine disorder characterized by decreased insulin and insulin-like growth factor (IGF) signaling. It can also cause oxidative stress and inflammation in the brain. Besides, the authors note that while obesity and type 2 diabetes may contribute to the development of dementia, they are not sufficient causes in and of themselves.

A more recent study, however, reveals that an insulin-degrading enzyme may cause type 2 diabetes to progress to type 3 diabetes by shifting metabolic pathways. This mechanism may result in oxidative stress and beta-amyloid buildup in the brain, both of which are symptoms of Alzheimer’s.

Another study stated that people with type 2 diabetes might be about 60% more likely to develop Alzheimer’s or any other type of dementia, suggesting type 2 to be one of the risk factors.

Potential risk factors for type 3 diabetes, as mentioned in a recent study, include:

• Family history
• Genetics
• Birth weight
• Ethnicity and race
• Lack of physical activity
• Stress
• A diet high in calories, sugars, and fats and low in fiber

Inheritance of the APOE-ε4 gene is one of the most substantial risk factors for Alzheimer’s disease. Research has also suggested a stronger association between diabetes and Alzheimer’s-associated amyloid pathology among the carriers of the APOE-ε4 gene, implying that this gene can increase an individual’s risk of the condition.

Symptoms of type 3 diabetes

Since “type 3 diabetes” is not officially classified as diabetes, medical practitioners do not use it as a diagnostic term. Its symptoms are similar to dementia which include:

• Memory loss that impacts daily lives
• Trouble carrying out familiar tasks
• Frequently misplacing things
• Changes in mood and personality
• Confusion about time or location
• Poor judgment
• Withdrawal from work or social activities

Diagnosis and treatment

No specific test can diagnose type 3 diabetes. However, doctors can diagnose Alzheimer’s via brain imaging, neurophysiological tests, and neurological examination.

There is no specific treatment for type 3 diabetes, but distinct treatment options are available for people with pre-type 2 diabetes, type 2 diabetes, and Alzheimer’s.

Currently, Alzheimer’s has no treatment, and the available medication can temporarily treat its symptoms or slow its progression. In case a person has both Alzheimer’s disease and type 2 diabetes, treating the latter is essential to help slow dementia progression.

References

1. De la Monte, S.M. and Wands, J.R., 2008. Alzheimer’s disease is type 3 diabetes—evidence reviewed. Journal of diabetes science and technology, 2(6), pp.1101-1113. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769828/

2. Mittal, K., Mani, R.J. and Katare, D.P., 2016. Type 3 diabetes: cross talk between differentially regulated proteins of type 2 diabetes mellitus and Alzheimer’s disease. Scientific reports, 6(1), pp.1-8. https://www.nature.com/articles/srep25589

3. Chatterjee, Saion, Sanne AE Peters, Mark Woodward, Silvia Mejia Arango, G. David Batty, Nigel Beckett, Alexa Beiser et al. “Type 2 diabetes as a risk factor for dementia in women compared with men: a pooled analysis of 2.3 million people comprising more than 100,000 cases of dementia.” Diabetes care 39, no. 2 (2016): 300-307. https://diabetesjournals.org/care/article/39/2/300/37175/Type-2-Diabetes-as-a-Risk-Factor-for-Dementia-in

4. Nguyen, T.T., Ta, Q.T.H., Nguyen, T.K.O., Nguyen, T.T.D. and Van Giau, V., 2020. Type 3 diabetes and its role implications in Alzheimer’s disease. International journal of molecular sciences, 21(9), p.3165. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246646/

5. Zhao, N., Liu, C.C., Van Ingelgom, A.J., Martens, Y.A., Linares, C., Knight, J.A., Painter, M.M., Sullivan, P.M. and Bu, G., 2017. Apolipoprotein E4 impairs neuronal insulin signaling by trapping insulin receptor in the endosomes. Neuron, 96(1), pp.115-129. https://www.cell.com/neuron/fulltext/S0896-6273(17)30791-2

People with dementia usually spend a lot of time sleeping both during the day and night, especially in the late stages of the disease. The sleep pattern typically changes as a person ages. However, these changes are more complex in people with Alzheimer’s disease or other forms of dementia.

As the disease advances, brain damage becomes widespread. The person also becomes weaker over time and, as a result, may feel exhausted after performing the simple routine tasks such as eating, communicating, or trying to comprehend their surroundings can exhaust them. As the symptoms worsen, they may need to sleep more during the day. Some drugs, including antidepressants, antipsychotics, antihistamines, and sleeping pills, may also cause sleepiness.

Why does Alzheimer’s disease or dementia affect sleep?

Although sleep disorders are common for people with dementia, how the disease affects sleep is still not clearly understood. Sleep disturbances may foreshadow the cognitive decline that occurs in dementia patients. Commonly occurring sleep problems include:

• sleeping during the day and being awake and agitated at night
• waking up more frequently and staying awake longer at night
• experiencing disorientation in the dark if the person wakes up to use the toilet
• unable to distinguish between day and night
• waking up in earlier hours and mistakenly believing that it is daytime.

Experts believe that Alzheimer’s disease and other types of dementia cause cellular changes in the brain that can disturb the sleep-wake cycle. In some people, the damage to their internal biological clocks (that judge the time) may lead to sleepiness at the wrong time of the day. Furthermore, malfunctioning of some other parts of the brain (that control whether we stay awake or not) due to damage may also result in sleep disturbances.

A person with dementia may occasionally entirely reverse their sleep pattern, staying awake all night and sleeping all day.

What to do if the person with dementia is sleeping a lot?

Dementia progression is likely the cause if your late-stage dementia patient has gradually started to sleep a lot. However, if it has suddenly started, or the person does not feel well in other ways, it may be due to some other reason.

In the latter case, you should consult a doctor to rule out any infection or condition that could be causing sleep disturbances in the patient. It would also be helpful to ask the doctor or the pharmacist about the side effects of the medication that your patient might be using.

If the person does not seem distressed or uncomfortable, there is no reason to be worried about sleeping more during the day. However, lying down and sleeping most of the time may cause health problems. Therefore, it is essential to check on your patient to ensure they do not develop any physical health issues.

Sleep disturbances in people with Lewy body dementia and Parkinson’s disease dementia

The type of dementia may affect the sleep pattern of dementia patients. People with Lewy body dementia (LBD) or Parkinson’s disease dementia often experience sleepiness during the day but feel very agitated and disturbed at night. They may hallucinate, feel confused, and have nightmares. Furthermore, they usually exhibit symptoms like insomnia, sleep apnea (breathing problems), and restless legs.

People with these types of dementia also manifest rapid eye movement (REM) sleep disorder at the earliest stages of the disease and onwards. This disorder causes them to mistakenly act out their dreams by shouting or moving in bed and can injure themselves or their sleeping partners. As a result, the person feels like they have not slept at
all, making them exhausted and sleepy during the day.

It might be difficult to stay awake throughout the day following a bad night’s sleep. However, if feasible, try to limit daytime sleep to tiny bursts or ‘catnaps.’ Otherwise, a person’s biological clock might become quite confused, making sleeping soundly at night even more difficult.

Brain proteins and sleep changes in Alzheimer’s disease

Recent research has shown a link between beta-amyloid protein, the hallmark of Alzheimer’s disease, and sleep changes. The brain removes excess beta-amyloid protein when a person sleeps. Sleep deprivation can cause an increase in beta-amyloid, as indicated in the mice model. In another study (performed on human subjects), the researchers found an increase in beta-amyloid levels increased up to 5% following a sleep deprivation of about 31 hours.

Scientists have also found a link between tau protein and sleep disturbances. According to a study, sleep deprivation of as little as one night can increase tau levels up to 50% in cerebrospinal fluid.

The link between beta-amyloid, tau, and Alzheimer’s disease is complicated, but researchers agree that getting quality sleep assists the brain in removing extra proteins. They are still uncertain if sleep disturbance causes Alzheimer’s, aggravates symptoms, and accelerates disease development or if it is a consequence of a disease.

References

1. National Institutes of Health, 2018. Sleep deprivation increases Alzheimer’s protein. NIH Research Matters, April, 24. https://www.nih.gov/news-events/nih-research-matters/sleep-deprivation-increases-alzheimers-protein

2. Shokri-Kojori, E., Wang, G.J., Wiers, C.E., Demiral, S.B., Guo, M., Kim, S.W., Lindgren, E., Ramirez, V., Zehra, A., Freeman, C. and Miller, G., 2018. β-Amyloid accumulation in the human brain after one night of sleep deprivation. Proceedings of the National Academy of Sciences, 115(17), pp.4483-4488. https://www.pnas.org/doi/10.1073/pnas.1721694115

3. Holth, J.K., Fritschi, S.K., Wang, C., Pedersen, N.P., Cirrito, J.R., Mahan, T.E., Finn, M.B., Manis, M., Geerling, J.C., Fuller, P.M. and Lucey, B.P., 2019. The sleep-wake cycle regulates brain interstitial fluid tau in mice and CSF tau in humans. Science, 363(6429), pp.880-884. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6410369/

Staying in a hospital can be an unpleasant experience for anyone, but it may specifically be hazardous for people with Alzheimer’s disease and other forms of dementia. Situations such as changed routine, unfamiliar people poking, an entirely different environment, etc., can make the stay a challenging experience for them.

According to studies, people with dementia have an increased risk of experiencing adverse outcomes¹ following hospitalization. Even a brief stay can exacerbate the dementia symptoms and augment the risk of complications, including falls, dehydration, malnourishment, delirium, and hospital-acquired infections.

Due to the mentioned reasons, caring for your loved one with Alzheimer’s or dementia in a hospital can be a daunting task. However, some tips can help you make their hospital stay a bit convenient.

Prepare Beforehand

Whether your patient has a scheduled treatment or unexpectedly ends up in the emergency department, it is critical to have a few essential items on hand. An already prepared and packed hospital kit can come in handy in emergencies. You should include the current insurance information and relevant health information, such as a comprehensive list of medications, a brief medical history, and a copy of the medical power of attorney document.

While planning for the stay, think of the things that can make your patient’s hospital stay easier. Take along items such as a cherished photograph album, a favorite book or puzzle, or a prepaid topped-up mobile phone with easy-to-locate contact numbers to keep them engaged.

Before your arrival, it will be helpful to call the hospital ward to know what services they can provide to dementia patients.

Provide Comfort And Reassurance To Your Dementia Patient

Hospitals may appear loud and unfamiliar to dementia patients, making them confused and agitated. They may not know where they are or why they are there. Therefore, it is essential to explain to them the place and why they are there in a calm manner. Try to be gentle and reassuring to make your patient feel at ease.

Since the noise at the hospital can scare the patient and add to their anxiety, check that their hearing aids are on and adjusted as per new surroundings. Ask the staff if there is a day room for the patient to take a break from the ward, especially at the peak times (such as visiting hours or ward rounds).

Another way to provide reassurance is to talk to them, read to them, and support them emotionally since familiar faces can bring comfort to dementia patients in such situations.

Share Information About Your Dementia Patient With Staff

It is helpful to discuss your loved one’s behavior and dementia symptoms they exhibit with the hospital staff because the staff might not know that the patient has dementia or may not have experience dealing with dementia patients. Sharing information about the person will help the staff to understand and respond to them more effectively.

You can give details of the person’s daily routine, the food they like or dislike, difficulties they have during mealtimes or while communicating, sleeping patterns, or any other information that can help staff build a good relationship with the patient. It is also necessary to let the staff know if your loved one needs reminders or assistance with activities such as eating, drinking, dressing, taking medication, or going to the toilet.

Support Your Loved One With Dementia To Eat And Drink

Hospital stays can considerably impact the mealtimes of dementia patients, who can become stressed, dehydrated, and malnourished. If ward mealtimes occur outside of visiting hours, you can ask the staff if you can stay after these timings. As hospital staff is often busy at mealtimes, they may be grateful for any assistance you can provide. So, it will be helpful to be there for mealtime or bring extra food if you can.

Since you may not always be around for assistance, it would be better to let the staff know about any difficulties your patient has at mealtimes.

You can make your patient’s mealtimes easier by having a drink or snack with them. If they do not seem to eat, do not presume that they are not hungry. Instead, try engaging them in different ways and making food seem more appealing.

Support Your Patient If They Are Walking About

A person with Alzheimer’s disease or other types of dementia might attempt to get up and roam around the ward. As the patient must be safe, this behavior can make the staff worried. However, walking can be a great activity to stay active in the hospital.

If the patient wants to walk around the ward, and it is safe and possible, ask the staff to assist them. Some dementia patients may become stiff if they do not move around, increasing the risk of falls. So, explain to the staff why it is important for your patient to walk around.

Sometimes, the person may feel angry, threatened, or agitated if they are prevented from walking around. In such cases, you can ask the staff to make any adjustments to help them. For instance, they can let them walk when they have visitors.

Stay By Your Loved One’s Side

When it comes to keeping a senior calm in the hospital, a familiar face may do wonders. Make every effort to spend as much time as possible with your loved one, especially in the evenings, during meals, and while medical tests and procedures like IV insertions and vital sign checks are carried out. If you are unable to visit the hospital regularly, attempt to arrange for other family members to do so.

Alzheimer’s Research Association is committed to helping caregivers of Alzheimer’s disease and dementia by providing the latest news and research on Alzheimer’s, useful tips, and grants. For more information, contact us!

References

1. Fogg, C., Griffiths, P., Meredith, P. and Bridges, J., 2018. Hospital outcomes of older people with cognitive impairment: an integrative review. International journal of geriatric psychiatry, 33(9), pp.1177-1197. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099229/