Cognitive Reserve

By J. Thomas Anderson

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Traumatic brain injury is a lifelong disease and a dreadful one at that. Even mild traumatic brain injuries (TBI) reduce a brain's cognitive reserve, thereby reducing a person's resiliency following future insults, challenges, injuries, and exposing our clients to increased risk of dementing illnesses, such as Alzheimer's disease, at an earlier age. Cognitive reserve may be presented to the jury as a barrier against the loss of selfhood: in other words, the more brain you have and the more flexible that brain going into any future accident or old age, the better your outcome will be.  

Defense attorneys will argue that TBI is a momentary event, not a progressive disease, and will try to stop damages at the emergency evaluation. But with the loss of cognitive reserve, we know the downward pull on our clients will continue throughout their lifetimes, at an increased rate and intensity, due to their brain insult and its unending sequelae.  

The term cognitive reserve? was coined by Dr. Yaakov Stern at the Taub Institute for Research on Alzheimer's Disease at the College of Physicians and Surgeons of Columbia University, to describe the mind's resilience or resistance to damage as measured by behavior, blood-based markers, and imaging. The concept of cognitive reserve against brain damage arose from repeated observations that there is no straightforward relationship between the degree of brain pathology or brain damage and the clinical manifestation of brain damage. The theory of prophylactic cognitive reserve arose in 1989 after the autopsies of one hundred and thirty-seven Alzheimer's victims revealed far less pathology than expected. And then advanced Alzheimer's disease pathology was found in brains at the autopsies of cognitively normal people. The most common yard stick is Alzheimer's disease, closely followed by TBI.  

Cognitive reserve has been compared to software, as opposed to brain reserve which might be compared to hardware. The two are complementary. First, software: cognitive reserve compares to the capacity to reroute and/or perform tasks better through experimentation and practice. Cognitive reserve is the ability to learn new skills.  

Second, hardware: brain reserve compares to the actual neurons and synapses. An abundance of brain reserve (neurons and synapses) can be protective against damage and degeneration: if some are damaged, others may be recruited. Brain reserve is calculated in relatively easy physical measurements: head circumference, synaptic count, dendritic branching, and so forth.  

Active models of cognitive reserve work from the assumption that a brain actively attempts to heal brain damages. To some degree, this will-to-repair process is present in both healthy and damaged brains. The difference lies in flexibility, creativity, and ability-to-repair. Traumatic brain injuries reduce the amount of cognitive reserve available to a person, thereby reducing our client's ability to spring back from future injuries and exposing our clients to increased risk of mentally unbalanced diseases at an earlier point in life.  

With Alzheimer's, at autopsy, a grotesquely shriveled and cavernous brain, filled with plaques and tangles, a brain which has clearly been disintegrating for a decade, may have been culled from a patient who showed symptoms of dementia for only a couple years. In contrast, a dramatically more intact brain may be culled from a patient who has suffered from dementia for over a decade. Interestingly, people who accomplished higher levels of education are generally diagnosed at later stages of dementia, leading researchers to believe that education protects against disease manifestations when it may merely protect against traditional diagnosis methodologies. Similarly, more educated clients may suffer higher levels of brain dysfunction without detection because neuropsychologists are trained to hunt for the median fellow. 

For the same reason, the more highly educated victim of TBI or Alzheimer's disease, the faster their decline. The best theory today is that this is due to the delay in diagnosis due to the prophylactic effect of cognitive reserve which hid the effects of the damage. Your client was able to mediate TBI damages with cognitive reserve. He or she recruited alternative neurons, built new synapses, and used interchanging neural pathways to get-by for a long time and disguise his or her damages. Thus, your client was diagnosed with TBI at a later stage in the disease. And his or her decline will be alarmingly fast. By way of explanation, neuroscientists present functional brain imaging which shows that high functioning older adults recruit more of their brains and use more alternative brain strategies to so l have problems than lower functioning adults and lower functioning young people.  

Neuroscientists posit that high functioning older adults brains are more flexible as a result of expansive and varied early cognitive experience. Theoretically, intellectually stimulating activities and/or physical activities may increase capacity, efficiency, and resiliency of brain networks. In other words: the brain is plasticized (in a good way) by embracing challenge. The beneficial challenge may begin at any time, but researchers suggest that earlier intellectual activity is better. In an interesting aside, researchers generally stop defining intellectual activity at education and language, when the definition is, more likely than not, significantly broader.

Suggestions for cognitive reserve arguments for your closing argument: 

Diminished cognitive reserve makes your client more susceptible to oncoming dementia and/or Alzheimer's.

Diminished cognitive reserve makes your client subject to early onset dementia or Alzheimer's, like NFL football players, so your client has been involuntarily aged.

Diminished cognitive reserve exposes your client to increased risk of schizophrenia, adult depression, adult anxiety, all with longer persistence, and a future generally wide open to the horrors of mental illness.

Your client's lifetime of an active mind is lost due to the wreck.  

Your client's educational expectations are lost due to the wreck.

Your client's social expectations are lost due to the wreck.

Your client's career expectations are lost due to the wreck.

Your client's moral compass is lost and all the horrors that go with that. 

Your client's soul has been amputated.

 The enormous costs of attendant care for your client in the future must be borne by someone. Who will that be? An innocent family member? The government? But for this accident, this burden would not have occurred, so where should that burden be fairly placed? 

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