Fragmented Cognitive Continuity: A Hidden Neurocognitive Consequence of Polypharmacy in Disabled Veterans

Disabled Veterans are frequently prescribed complex medication regimens spanning psychiatric, neurologic, pain, gastrointestinal, and autonomic indications. While polypharmacy is widely associated with sedation, delirium, and measurable cognitive impairment, an under-recognized pattern persists in which intellectual capacity appears preserved while sustained cognitive reliability is impaired. This pre-analysis research prospectus proposes a short clinical and policy primer introducing fragmented cognitive continuity as a descriptive construct to explain why heavily medicated Veterans may perform adequately on standardized cognitive testing yet experience profound real-world functional impairment. The phenomenon is characterized by intermittent, unpredictable disruptions in sustained cognition that impair prolonged reading, extended conversation, task persistence, and occupational reliability—domains not adequately captured by conventional neuropsychological assessment paradigms. The proposed primer will synthesize existing medical literature on polypharmacy, anticholinergic burden, central nervous system depressant stacking, and pharmacogenomic variability, situating these mechanisms within a functional capacity and disability evaluation context relevant to U.S. Department of Veterans Affairs (VA) and Social Security Administration (SSA) adjudication frameworks. The work will also highlight mitigation strategies currently present within the VA system, including pharmacogenomic testing and Board-Certified Pharmacotherapy Specialist (BCPS) oversight, while identifying gaps in recognition and evaluation. This prospectus serves as the foundation for a subsequent comprehensive white paper examining polypharmacy-related cognitive impairment and its implications for disability evaluation, communication, and adjudicative accuracy.