Traumatic Brain Injury 149pres ent with symptoms of classic aphasia, apraxia of speech, and dysarthria typically seen in stroke
patients. Aphasia caused by focalized ce re bral lesions occurs in approximately 6% of cases of trau-
matic brain injury (Petit, 2001). In some cases, although patients suffer brain damage, the major
speech and language centers are spared. They do not have the classic symptoms of aphasia, apraxia
of speech, and the dysarthrias. These patients may have language of confusion. The brain damage
causes reduced or impaired consciousness, and their speech and language ref lect the confusion.
In many patients with traumatic brain injuries, the neurogenic communication disorders are
complicated by reduced or impaired consciousness. They have the slurred, indistinct speech of
dysarthria, the motor speech programming prob lems of apraxia of speech, and the aphasic word
finding and naming deficits occurring in the cloud of confusion. The confusion results in unusual
and sometimes bizarre symptoms. They make random naming errors or produce unintelligible
utterances and sometimes act as if the listeners should understand their “perfectly normal” speech.
Their communication is not only disrupted by the damaged speech and language centers of the
brain, but also affected by the global confusion.
Coma
Not all patients who have serious traumatic brain injuries become comatose, and coma can
happen in other neurological events such as stroke. However, many patients who suffer traumatic
brain injuries become comatose, and their awareness of self and the environment is reduced or
impaired to varying degrees— stupor, delirium, and clouding of consciousness. The patient in stu-
por requires continued stimulation to be aroused. Delirium is associated with confusion, and the
patient is agitated. In clouding of consciousness, the mildest level of reduced awareness, the patient
is mildly confused and may at times appear normal.
The Glasgow Coma Scale (Teasdale & Jennett, 1974) is a test widely used to mea sure the degree
of coma. It assesses the patient’s eye opening, motor response, and speech; scores range from 3 to
- The Rancho Los Amigos Scale (Malkmus, Booth, & Kodimer, 1980), another widely used test
of cognitive and behavioral functioning, can be used to help family members understand the pro-
cess of recovery (Mackay, Chapman, & Morgan, 1997). This test has eight cognitive levels (e.g., “no
response,” “confused, agitated,” “automatic, appropriate”) and a description of be hav iors; it also
gives suggestions for patient management.
Traumatic Brain Injury, Disorientation, and Amnesia
Amnesia and disorientation go hand in hand in many patients with traumatic brain injuries.
Amnesia is memory loss, and the time of the accident is the dividing line for detecting the loss of
memories for past events (retrograde amnesia) and the inability to acquire new memories (antero-
grade amnesia). Retrograde amnesia can be as brief as a few hours or as long as several years and
even de cades. It is related to disorientation because memory of past events is necessary for orienta-
tion to time, people, places, and situations.
Many patients with serious traumatic brain injuries are disoriented at some time during the
recovery period. Such patients have lost their bearing. The most common type of disorientation
involves time. Disorientation to time includes the time of events and the passage of time. For
patients completely disoriented to time, these concepts are lost. These patients may also have
forgotten one or several of the persons in their lives. Disorientation to relationship can include
family and friends. Patients may even lose their sense of identity. Confusion about what hap-
pened and the cause of the hospitalization is called disorientation to situation or predicament.
Disorientation to place is not knowing one or more physical locations. Usually, patients are dis-
oriented about several aspects of real ity, but some are only disoriented about one. A patient dis-
oriented to one aspect of real ity is said to be disoriented times one; disorientation to two aspects
of real ity is called disorientation times two, and so forth. A person who is completely disoriented
is said to be disoriented times four: time, place, person, and situation (predicament).