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Alzheimer’s Disease Medications for Memory

Alzheimer’s Disease Medications for Memory

Dementia Treatments

Alzheimer’s Disease Medication

Introduction 

People are increasingly interested in the latest advancements in Alzheimer’s disease medications as they seek to safeguard their brain health through the most cutting-edge scientific developments. Alzheimer’s disease, a progressive neurodegenerative disorder characterized by memory loss, cognitive decline, and behavioral changes, poses significant challenges for both patients and their loved ones. As awareness of Alzheimer’s grows and its prevalence rises, there is a growing sense of urgency to explore all available options for prevention, treatment, and management.

Leqembi

+ Leqembi is an IV medication for early-stage Alzheimer’s, targeting and removing beta-amyloid from the brain.

+ While not a cure, it’s the first FDA-approved treatment addressing Alzheimer’s biology, aiming to slow down cognitive decline and maintain independence.

+ It’s only for those with confirmed elevated beta-amyloid levels and hasn’t been tested for advanced stages or those without symptoms.

Aduhelm

Aducanumab

+ Aducanumab (Aduhelm®) has gained accelerated FDA approval for treating early Alzheimer’s and Mild Cognitive Impairment (MCI) due to Alzheimer’s Disease.

+ It’s the first therapy to demonstrate that reducing beta-amyloid in the brain can slow cognitive and functional decline in early-stage Alzheimer’s by targeting and removing specific forms of beta-amyloid plaques.

+ Administered via intravenous infusion every 4 weeks, Aducanumab aims to reduce beta-amyloid accumulation, potentially aiding other brain functions in memory, thinking, learning, and behaviors.

Aricept

Donepezil

Donepezil (Aricept) : Approved to treat all stages of Alzheimer’s Disease. Its primary mechanism of action involves inhibiting an enzyme called acetylcholinesterase. This enzyme normally breaks down acetylcholine, a neurotransmitter involved in memory and learning. By inhibiting acetylcholinesterase, Aricept increases the levels of acetylcholine in the brain, temporarily improving communication between nerve cells.

Exelon

Rivastigmine

Rivastigmine (Exelon): Approved for mild-to-moderate Alzheimer’s disease and mild-to-moderate dementia associated with Parkinson’s disease. This is another medication used to treat Alzheimer’s disease. Its mechanism of action is similar to Aricept but extends to inhibiting both acetylcholinesterase and butyrylcholinesterase enzymes. By doing so, Rivastigmine increases the levels of acetylcholine in the brain, supporting improved communication between nerve cells. This helps alleviate cognitive symptoms in individuals with Alzheimer’s, providing symptomatic relief without modifying the underlying progression of the disease.

Razadyne

Galantamine

Galantamine (Razadyne): Approved for mild-to-moderate stages of Alzheimer’s disease. Its mechanism of action involves acting as a reversible acetylcholinesterase inhibitor, similar to Aricept and Rivastigmine. By inhibiting the breakdown of acetylcholine, a neurotransmitter crucial for memory and learning, Galantamine temporarily increases its levels in the brain. This enhancement of acetylcholine communication between nerve cells aims to alleviate cognitive symptoms associated with Alzheimer’s disease.

Namenda

Memantine

Memantine (Namenda): Approved for moderate-to-severe Alzheimer’s disease. Unlike acetylcholinesterase inhibitors, Memantine works by modulating the activity of glutamate, an excitatory neurotransmitter in the brain. It acts as an NMDA receptor antagonist, helping regulate the activity of glutamate and preventing excessive stimulation. This mechanism aims to protect nerve cells from damage caused by overstimulation, which is implicated in the progression of Alzheimer’s. Memantine provides symptomatic relief by addressing a different aspect of neurotransmission compared to acetylcholinesterase inhibitors, offering a complementary approach in the treatment of Alzheimer’s disease.

Namzaric

Donepezil and memantine (Namzaric): Approved for moderate-to-severe Alzheimer’s disease. Namzaric is a combination medication that includes both donepezil and memantine. Each component targets different aspects of Alzheimer’s disease to provide a comprehensive treatment approach. Together, the combination of donepezil and memantine in Namzaric aims to enhance cognitive function and provide symptomatic relief in individuals with moderate to severe Alzheimer’s disease. It represents a synergistic strategy by targeting both acetylcholine and glutamate to address different aspects of the disease’s underlying pathology.

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The Neurological Therapist – Interview your therapist

The Neurological Therapist – Interview your therapist

The Neurological Therapist – Interview your therapist

Neurological therapy is a specialized area requiring devoted time and training.

When looking for a neurological therapist, whether for hiring or collaborating, it’s crucial to consider several factors to ensure they possess the necessary knowledge and skills in neurological rehabilitation.

Qualifications and Credentials

  • Do they hold any additional certifications relevant to neurological rehabilitation, such as Certified Stroke Rehabilitation Specialist (CSRS), Certified Brain Injury Specialist (CBIS), or Neuro-Developmental Treatment (NDT) certification?
  • Have they pursued advanced training or completed post-professional education programs focused specifically on neurological rehabilitation?
  • Are they members of professional organizations related to neurological rehabilitation, such as the American Occupational Therapy Association (AOTA) or the American Physical Therapy Association (APTA)?
  • Have they participated in continuing education courses or workshops related to specific neurological conditions, assessment tools, or treatment approaches?
  • Can they provide evidence of ongoing professional development and commitment to staying abreast of advancements in neurological rehabilitation practice?

Experience

  • What is the extent of their experience specifically in neurological rehabilitation, including the number of years dedicated to this specialty area?
  • Have they worked with a diverse range of neurological conditions, including stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, Parkinson’s disease, etc.?
  • In what settings have they practiced neurological rehabilitation, such as acute care hospitals, inpatient rehabilitation facilities, outpatient clinics, community-based settings, or specialized neurological rehabilitation centers?
  • Can they demonstrate versatility in adapting their skills and expertise to different practice environments and patient populations?
  • Can they provide specific examples or case studies of patients they’ve treated for neurological conditions, highlighting successful outcomes achieved through their interventions?
  • Are they able to articulate their approach to managing complex neurological cases, including the development of individualized treatment plans, goal-setting strategies, and ongoing assessment and modification of interventions based on patient progress?
  • Have they encountered challenging cases or situations in neurological rehabilitation, and how did they approach and overcome these challenges to achieve positive results for their patients?

Knowledge of Neurological Conditions

  • Do they have a comprehensive understanding of different neurological conditions, such as stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, Parkinson’s disease, Alzheimer’s Disease, Dementia, etc.?
  • Are they familiar with the specific impairments and challenges associated with each condition?
  • Can they tailor treatment plans to address the unique needs of individual patients with neurological disorders?
  • Can they integrate the principles of neuroplasticity, motor learning, and task-specific training into their treatment approaches to promote recovery, maximize functional independence, and enhance quality of life for individuals with neurological disorders?

Evidence-Based Practice (EBP)

  • Do they stay updated on the latest research and evidence-based practices in neurological rehabilitation?
  • Are they able to integrate evidence-based interventions into their treatment plans?
  • Can they critically evaluate the effectiveness of different treatment approaches based on research findings?

Assessment and Evaluation Skills

  • How do they assess and evaluate the functional abilities and limitations of patients with neurological conditions?
  • Are they proficient in using standardized assessment tools commonly used in neurological rehabilitation?
  • Can they conduct comprehensive evaluations to identify specific impairments and set realistic goals for therapy?

Treatment Techniques and Modalities

  • What treatment techniques and modalities do they utilize in neurological rehabilitation?
  • Are they skilled in neurorehabilitation approaches such as neuroplasticity-based therapy, constraint-induced movement therapy, task-specific training, etc.?
  • Do they have experience with assistive devices, adaptive equipment, and technology used in neurological rehabilitation?

Interdisciplinary Collaboration

  • Are they accustomed to working collaboratively with other healthcare professionals, such as neurologists, physiatrists, speech therapists, etc.?
  • Do they ask you about your experience and your team at the time of your evaluation?
  • Do they seek to offer referrals and recommendations for other professionals at the time of your evaluation?
  • Can they effectively communicate and coordinate care plans with other team members to optimize patient outcomes?

Patient-Centered Care

  • Do they prioritize patient-centered care and actively involve patients in goal-setting and treatment planning?
  • Are they empathetic, compassionate, and able to establish rapport with patients and their families?

Bottom Line:

For anyone seeking neurological physical therapy or occupational therapy, it’s essential to do some research and be ready to ask questions when meeting with your therapist. Since health insurance often limits the number of sessions and out-of-pocket costs for neurological rehabilitation can be high, it’s crucial not to waste time with the wrong therapist. Take the time to research your provider before committing to treatment.

Stages of Alzheimer’s Disease

Stages of Alzheimer’s Disease

“Memories are the threads that weave the fabric of our lives, shaping who we are and who we become.” – Elizabeth Loftus

    Stages of Alzheimer’s Disease

    Alzheimer’s disease is a complex condition that affects millions of individuals worldwide, impacting not only those diagnosed but also their families and caregivers. Understanding the progression of Alzheimer’s is crucial for providing appropriate care and support at each stage of the disease. In this article, we’ll explore the seven stages of Alzheimer’s Disease, highlighting the areas of the brain affected, common symptoms experienced, and available treatments for each stage.

    Stage 1 – No Impairment

    Area of the Brain: No noticeable changes.

    Symptoms: No memory problems or cognitive decline.

    Treatments: Focus on maintaining a healthy lifestyle, including regular exercise, a balanced diet, and mental stimulation.

    Stage 2 – Very Mild Decline

    Working Memory

    Working Memory

    Do you find it challenging to remember things you just learned or heard? This could be a sign of dementia.

    Area of the Brain: Minimal changes, primarily in the hippocampus.

    Symptoms: Occasional forgetfulness, such as misplacing keys or forgetting names.

    Treatments: Continued emphasis on lifestyle factors, along with memory aids and cognitive exercises.

    Stage 3 – Mild Decline

    Slower Retrieval and Rapid Forgetting

    Slower Retrieval and Rapid Forgetting

    Finding it takes longer to recall information, and forgetting things more quickly.

    Immediate Recall Difficulty

    Immediate Recall Difficulty

    Struggling to remember information right after learning it.

    Area of the Brain: Further deterioration in the hippocampus and other regions involved in memory and learning.

    Symptoms: Noticeable memory lapses, difficulty finding the right words, and challenges with planning and organization.

    Treatments: Introduction of medications such as cholinesterase inhibitors to help manage cognitive symptoms, along with support from caregivers and memory care programs.

    Stage 4 – Moderate Decline

    Prospective Memory Challenges

    Prospective Memory Challenges

    Difficulty remembering to perform tasks in the future without external reminders.

    Episodic Memory

    Episodic Memory

    Trouble remembering specific events or experiences from your past.

    Area of the Brain: Significant damage in multiple brain regions, including the frontal and temporal lobes.

    Symptoms: Increased memory loss, difficulty performing tasks independently, mood swings, and confusion about time and place.

    Treatments: Additional medications, such as memantine, may be prescribed to manage cognitive symptoms. Occupational therapy and support services become more important for daily functioning.

    Stage 5 – Moderately Severe Decline

    Autobiographical Memory Changes

    Autobiographical Memory Changes

    Memories across your lifespan become less detailed and more vague.

    Area of the Brain: Extensive damage throughout the brain, affecting communication between neurons.

    Symptoms: Severe memory impairment, inability to recall personal details, challenges with basic activities of daily living, and behavioral changes.

    Treatments: Intensive support from caregivers, including assistance with personal care and supervision. Behavioral interventions and communication strategies are crucial.

    Stage 7 – Very Severe Decline

    Area of the Brain: Severe neuronal loss and widespread brain damage, resulting in complete dependence on others for care.

    Symptoms: Loss of verbal communication, minimal responsiveness, and severe physical impairment.

    Treatments: End-of-life care focuses on comfort and dignity, with a focus on pain management and emotional support for both the individual and their loved ones.

    Stage 6 – Severe Decline

    Area of the Brain: Severe atrophy and damage in all brain regions, leading to profound cognitive and physical decline.

    Symptoms: Loss of awareness of surroundings, difficulty recognizing familiar faces, incontinence, and limited mobility.

    Treatments: Palliative care focuses on maximizing comfort and quality of life. Supportive therapies, such as music and art therapy, can provide comfort and stimulation.

    Bottom Line:

    Understanding the stages of Alzheimer’s disease is essential for navigating the challenges and providing appropriate care and support throughout the journey. While there is currently no cure for Alzheimer’s, early diagnosis and intervention can help manage symptoms and improve quality of life for individuals and their families. With ongoing research and advancements in treatment, there is hope for a future where Alzheimer’s is more effectively managed and ultimately cured.

    Warning Signs of Dementia

    Warning Signs of Dementia

    “Memory is the diary that we all carry about with us.” – Oscar Wilde

    Warning Signs of Dementia

    Memory changes as we age can be unsettling, leaving many of us wondering if what we’re experiencing is just a normal part of getting older or something more serious, like dementia. It’s important to recognize that there’s a subtle overlap between age-related memory changes and the warning signs of dementia. In this article, we’ll explore these warning signs in a way that’s easy to understand.

    Consider the following symptoms of Dementia: 

    Working Memory

    Working Memory

    Do you find it challenging to remember things you just learned or heard? This could be a sign of dementia.

    Episodic Memory

    Episodic Memory

    Trouble remembering specific events or experiences from your past.

    Immediate Recall Difficulty

    Immediate Recall Difficulty

    Struggling to remember information right after learning it.

    Slower Retrieval and Rapid Forgetting

    Slower Retrieval and Rapid Forgetting

    Finding it takes longer to recall information, and forgetting things more quickly.

    Prospective Memory Challenges

    Prospective Memory Challenges

    Difficulty remembering to perform tasks in the future without external reminders.

    Autobiographical Memory Changes

    Autobiographical Memory Changes

    Memories across your lifespan become less detailed and more vague.

    What can ‘offset’ these changes or help you cope with them?

    Intelligence, expertise, and using compensatory strategies can help cope with memory changes.

    Examples: 

    • Using tools like calendars or setting reminders on your phone to help remember important dates or tasks.
    • Using mnemonic devices to remember important information.
    • Writing notes to yourself to remember tasks or appointments.
    • Creating a daily routine to help remember daily tasks and activities

    Note: Memory specialists are trained with information that greatly exceeds these very simple everyday strategies found on the internet. Clinical oversight is recommended if you feel some of these symptoms have described you. 

     

    Bottom Line:

    If you or a loved one are experiencing these warning signs of dementia, it’s essential to seek help from a local memory specialist. While it can be challenging to confront these changes, getting an evaluation and discussing options early on can lead to better outcomes and quality of life. Remember, you’re not alone, and there are resources available to support you through this journey.

    References

    Baddeley, A. D., Kopelman, M. D., & Wilson, B. A. (2004). The essential handbook of memory disorders for clinicians. Chichester, West Sussex, England ;: J. Wiley.

    Cohen, C., Culver, C., Gomberg, D., Magai, C., & Malatesta, C. (1996). Emotional Expression During Mid- to Late-Stage Dementia. International psychogeriatrics, 8(3), 383-395. doi:10.1017/S104161029600275X

    Early Signs of Dementia in Women

    Early Signs of Dementia in Women

    “Memory is the treasure house of the mind wherein the monuments thereof are kept and preserved”.  Thomas Fuller

    Early signs of dementia in women:

    Early: This refers to the beginning stages or the initial phase of something. In the context of “early signs of dementia,” it means recognizing symptoms at an early stage before they become more severe or noticeable.

    Signs: Signs are indications or signals that suggest something is happening or present. In this case, “early signs” of dementia are the first noticeable changes or behaviors that may indicate the presence of dementia.

    Dementia: Dementia is a general term used to describe a decline in cognitive function (thinking, memory, and reasoning) severe enough to interfere with daily life. It is not a specific disease but rather a set of symptoms associated with various underlying causes.

    Introduction

    You may have heard that more women than men show early signs of dementia, but let’s set the record straight. Recent studies suggest there’s not enough evidence to support this claim. So, if you’re a woman, don’t fret – your risk of dementia isn’t higher just because of your gender (Beam et al., 2018).

    Understanding early signs of dementia in women isn’t easy. Dementia affects everyone differently, no matter their gender, but let’s try to develop our understanding of it!

    The Facts:

    Let’s start by looking at what recent studies tell us about dementia and its risk factors.

    According to Neergaard et al. (2016), there are certain things we can’t change (non-modifiable risk factors), like getting older and genetics that might make us more likely to develop dementia.

    There are other things we can change (modifiable risk factors), like how much we exercise, nutrition, chronic stress, sleep, and whether we smoke that play a big role in whether or not we begin experiencing early signs of dementia. Norton et al. (2014) found that things like not exercising enough and smoking could make us more likely to get dementia.

    Surprisingly, Neergaard et al. (2016) discovered that being a bit overweight when we’re older might not matter as much as we thought! Being obese doesn’t seem to make much of a difference according to the evidence. So, it’s not just about being thin or fat – it’s more complicated than that!

    Sex Differences in Early Symptoms:

    Now, let’s talk about the early signs of dementia and whether they’re different for women and men.

    In a study by Edahiro et al. (2023), they found that women with early-onset dementia were more likely to have trouble with their memory. Men, on the other hand, were more likely to feel irritable.

    Mendez (2012) also discovered that the first signs of dementia might not always be about forgetting things. Sometimes, they can be about having trouble with things like seeing things around us and paying attention.

    The most common symptoms of early-onset dementia across gender are as follows:

      1. Loss of memory (Edahiro et al., 2023)
      2. Difficulty in word generation (Edahiro et al., 2023)
      3. Loss of motivation (Edahiro et al., 2023)
      4. Increased mistakes in the workplace or domestically (Edahiro et al., 2023)
      5. Unusual behaviors or attitudes (Edahiro et al., 2023)
      6. Visuo-spatial dysfunction (Mendez, 2012)
      7. Executive dysfunction (Mendez, 2012)
      8. Attention impairment (Mendez, 2012)

    What can you do?

    Stay physically active: Engage in regular physical activity, such as walking, swimming, or dancing, to promote brain health and reduce the risk of dementia

    Manage depression: Seek support and treatment for depression if needed, as depression has been identified as a potential risk factor for dementia

    Stay mentally active: Keep your brain stimulated by engaging in activities that challenge your cognitive abilities, such as puzzles, reading, learning new skills, or socializing with others

    Monitor and manage other health conditions: Take steps to manage other health conditions that may increase the risk of dementia, such as diabetes, hypertension, and smoking

    Be mindful of early signs: Pay attention to any changes in memory, cognition, or behavior, and seek medical advice if you notice any concerning symptoms. Early detection and intervention can be crucial in managing dementia

    Bottom Line:

    So, what’s the bottom line? Even though some studies say women might show early signs of dementia more than men, it’s not necessarily the case. That said, there are some gender differences like women being more likely to experience memory difficulties in the early stages of dementia than men.  Dementia is a complicated thing, and lots of factors can play a part in whether we get it or not.

    I will forever tell everyone I know that there is no harm in seeking functional oversight of your cognition! Find a board-certified medical professional trained in memory, cognition, and neurological-based pathologies to evaluate you. This will allow you to remain in control of your brain health and manage modifiable risk factors.

    References

    Beam, C. R., Kaneshiro, C., Jang, J. Y., Reynolds, C. A., Pedersen, N. L., & Gatz, M. (2018). Differences Between Women and Men in Incidence Rates of Dementia and Alzheimer’s Disease. J Alzheimers Dis, 64(4), 1077-1083. doi:10.3233/jad-180141

    Edahiro, A., Okamura, T., Arai, T., Ikeuchi, T., Ikeda, M., Utsumi, K., . . . Awata, S. (2023). Initial symptoms of early‐onset dementia in Japan: nationwide survey. Psychogeriatrics, 23(3), 422-433. doi:10.1111/psyg.12949

    Fitzpatrick, A. L., Kuller, L. H., Lopez, O. L., Diehr, P., O’Meara, E. S., Longstreth, W. T., Jr., & Luchsinger, J. A. (2009). Midlife and late-life obesity and the risk of dementia: cardiovascular health study. Arch Neurol, 66(3), 336-342. doi:10.1001/archneurol.2008.582

    Mendez, M. F. (2012). Early-onset Alzheimer’s disease: nonamnestic subtypes and type 2 AD. Arch Med Res, 43(8), 677-685. doi:10.1016/j.arcmed.2012.11.009

    Neergaard, J. S., Dragsbæk, K., Hansen, H. B., Henriksen, K., Christiansen, C., & Karsdal, M. A. (2016). Late-Life Risk Factors for All-Cause Dementia and Differential Dementia Diagnoses in Women: A Prospective Cohort Study. Medicine, 95(11). Retrieved from https://journals.lww.com/md-journal/fulltext/2016/03150/late_life_risk_factors_for_all_cause_dementia_and.64.aspx

    Norton, S., Matthews, F. E., Barnes, D. E., Yaffe, K., & Brayne, C. (2014). Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol, 13(8), 788-794. doi:10.1016/s1474-4422(14)70136-x

    Traumatic Brain Injury Rehabilitation TBI

    Traumatic Brain Injury Rehabilitation TBI

    Traumatic Brain Injury (TBI) Rehabilitation and Support Services

    TBI and Concussion in Teens

    Traumatic Brain Injury Treatment Buffalo NY - Blue Fill

    TBI and Concussion in Adults

    What is a Traumatic Brain Injury (TBI)

    A traumatic brain injury (TBI) can occur after a fall,  sport injury, motor vehicle accident, blunt force trauma, accident at work, or any other occurrence causing the brain to be jolted or damaged in some way. The severity of the injury can range from mild to severe, and you may experience symptoms lasting days, weeks, months, or even years. 

    Most people will begin the recovery process of a TBI in an inpatient hospitalization setting where you will regain physical, sensory, behavioral, and cognitive function. If you experienced a TBI resulting in concussion, but is not so severe that you require inpatient hospitalization, you should be immediately beginning community-based outpatient occupational therapy. In a more severe case, outpatient occupational therapy will be part of the continuum of care. Making sure you see a therapy team familiar with the symptoms and recovery process of a traumatic brain injury is crucial to maximizing your outcomes. 

    Symptoms of

    Traumatic Brain Injury (TBI)

    Physical Symptoms

    • Headaches and migraines
    • Impaired balance and dizziness
    • Neck and lower back pain
    • Upper body and lower body muscle weakness
    • Loss of coordination
    • Difficulty sleeping and staying asleep

    Emotional Symptoms

    • Mood changes
    • Personality changes
    • Increase volatility and short-tempered 
    • Unable to balance emotions 
    • Increased desire to be alone

    Cognitive Symptoms

    • Confusion
    • Decreased executive functioning 
    • Short attention span
    • Short term memory deficits
    • Impaired information processing speed
    • Impaired multi-tasking ability
    • Impaired working memory skills
    • Word finding difficulties

    Sensory Symptoms

    • Tremors in hands, legs, or feet
    • Neuropathy, paresthesia, numbness, or tingling in hands and feet
    • Depth perception difficulties
    • Visual perceptual deficits 
    • Sensitivity to light and sound
    • Ringing in your ears (tinnitus) 
    • Taste changes or lack of appetite

    For more information, check out the Brain Injury Association

    Meaningful Activities (Occupations) affected by a Traumatic Brain Injury (TBI) 

    ADLs 

    • Bed mobility 
    • Cleanliness and thoroughness while toileting
    • Showering and maintaining safety 
    • Dressing 
    • Mobility (standing tolerance, walking, getting up and down without dizziness)

    IADLs

    Other Occupations (meaningful activities)

    • Maintaining volunteer roles 
    • Participating in hobbies or extra-curricular activities
    • Going to church 
    • Exercising 

    Why is outpatient occupational therapy imperative for Traumatic Brain Injury 

    What are some problems an occupational therapy can help solve? 

    References

    Altman, I. M., Swick, S., Parrot, D., & Malec, J. F. (2010). Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged. Archives of Physical Medicine and Rehabilitation, 91, 1697–1704.

    Kim, H., & Colantonio, A. (2010). Effectiveness of rehabilitation in enhancing community integration after acute traumatic brain injury: a systematic review. American Journal of Occupational Therapy, 64, 709–719. https://dx.doi.org/10.5014/ajot.2010.09188

    Traumatic brain injury. (2019, March 29). Retrieved March 13, 2020, from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

    Traumatic brain injury. (2019, March 29). Retrieved March 13, 2020, from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557