Traumatic Brain Injury: Physical, Cognitive and Behavioral Implications

1. Traumatic Brain Injury:Physical, Cognitive and Behavioral Implications Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

2. Training Agenda • The incidence and prevalence of TBI • What is brain injury? • What are the types of brain injury?

3. Training Agenda • Common cognitive, behavioral and physical sequela of TBI • Ideal rehabilitation pathways for mild, moderate and severe TBI • The TBI, mental health and substance abuse connection

4. Training Agenda • Why Screen? • How to Screen for a history of a TBI • Strategies to support individuals with TBI • Resources, medical, rehabilitation, community supports and employment

5. Incidence of TBI CDC 2006 Worldwide, an estimated 10 million people incur a TBI serious enough to result in death or hospitalization each year

6. Incidence of TBICDC 2004 In the United States, at least 1.6 million sustain a TBI each year

7. Incidence of TBI CDC 2004Of those 1.6 million.. • 51,000 die; • 290,000 are hospitalized; and • 1,224,000 million are treated an released from an emergency department

8. Annual Incidence of TBI with DisabilityAN ESTIMATED 124,000 American civilians Cited by Jean Langlois ScD,MPH NASHIA Conference 2007 Preliminary findings as analyzed by Selassie, et. al

9. Returning Veterans • As of 11.07 VA officials reported that of 61,285 veterans screened since April 14, 2007 19% screened positive Honolulu Star-Bulletin Nov. 4, 2007 • Pentagon reported as of September 20, 2007, 4,471 of 30,327 wounded troops sustained brain injuries. • A September 2007 article in USA Today by Gregg Zoroya looked at data from a variety of military sources put the number as at least 5 times that much. (20,000) • In that same USA Today article, Rep. Bill Pascrell is quoted as saying more than 150,000 troops may have suffered brain injury in combat

10. “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq”Hoge, McGurk, Thomas, et.alNEJM Volume 358:453-463 January 31, 2008 • 1 in 6 returning troops have had at least one concussion • 4.9% reported injuries with LOC of those, 43.9% met criteria for PTSD (3xs the rate found in those with other injuries) • 10.3% reported altered mental status, of those, 27.3% met criteria for PTSD • TBI with LOC also associated with major depression

11. Incidence of TBI Maryland 2000 CDC Surveillance • 5,229 Marylanders sustained a moderate to severe TBI • 13 people a day • 5% of all hospitalizations TBI related

12. Causes of TBICDC 2006

13. The Scope of the ProblemBy Age • Approximately 475,000 TBIs occur among children ages 0-14 • ED visits account for more than 90% of the TBIs in this age group • Adults age 75 years or older have the highest rates of TBI related hospitalization and death CDC 2004

14. Why are the Numbers so Big? • 30 years ago, 50% of individuals with TBI died, the number today is 22% • due to: • Improved medical technology and techniques • Safety features such as car seatbelts, child safety seats and airbags

15. What are the Costs of TBI?CDC 2006 Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated 60 billion in the United States in 2000. (That is equal to the cost of building the international space center or 60 times the net worth of Oprah Winfrey )Jean Langlois of the CDC

16. A Huge Public Health Issue…... With Very Little Public Awareness or Funding

17. According to a 2000 Harris Poll... • 1 in 3 Americans interviewed were not familiar with the term “brain injury” • 2 in 3 or 66% believe that TBI occurs less frequently then breast cancer • 50% believe brain injuries happen less frequently than AIDS BIAA, 2000

18. In Fact……. • TBI results in 1 1/2 times more deaths each year then AIDS • Each year 1.5 million people sustain a TBI, that is 8 times the number of individuals diagnosed with breast cancer

19. Public Funding for Brain InjuryOutlook Magazine 2005 • 900,000 living with HIV/AIDS, Per person federally allocated $ = $18,111 • 4,557,000 living with MR/DD, Per person federally allocated $ = $4,635 • 3,000,000 living with Breast Cancer, Per person federally allocated $ = $295 • 5,3000,000 living with TBI, Per person federally allocated $ = $2.55

20. What happens in a TBI? • Mechanism – Acceleration/Deceleration • Differential movement of partially tethered brain within the skull • Results in: • Bruising of the brain surface against rough areas of the skull • Stretching and twisting of nerve axons

21. Primary Injuries… Coup-Contra Coup

22. Chuck Durgin 2007

23. Primary Injuries… Rotational forces on the brain cause the stretching, snapping and shearing of axons Diffuse Axonal Injuries

24. Hematoma Dura Epidural Hematoma …Primary Injuries Dura Hematoma or Blood Clot forms on top of the dura

25. …Primary Injuries Subdural Hematoma Dura Hematoma or blood clot forms under the dura

26. Secondary Injuries Intracerebral Hemorrhage Edema (swollen brain tissue) Hydrocephalus (enlarged ventricles

27. Definitions: How brain injury may be defined in the Medical Record Traumatic Brain Injury is an insult to the brain caused by an external physical force Acquired Brain Injury is an insult to the brain that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia

28. Types of TBI • Distribution of Severity: • Mild injuries = 80%(LOC < 30 min, PTA ,1 hour) • Moderate = 10 - 13%(LOC 30 min-24 hours, PTA 1-24 hours) • Severe = 7 - 10% (LOC >24 hours, PTA >24 hours)

29. Using Post-Traumatic Amnesia(PTA) to Determine Severity of CHI Dr. Paul McClelland • When did you wake up from the head injury? Do you remember being transported to the hospital? Do you remember being in the trauma unit? Being transferred to the rehab unit? • PTA: period of time after the CHI for which the patient has no memory

30. Types of TBI-Mild • Most common, 75%-85% of all brain injuries are mild • Individuals experience a brief (<15 minutes)or NO loss of consciousness • Normal neurological exam • 90% of individuals recover within 6-8 weeks, often within hours or days

31. 2000 Epidemiological Study of Mild TBIJ. Silver of NYU, cited in WSJ by Thomas Burton 1.29.08 http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_ • 5,000 interviewed • 7.2% recalled a blow to the head w/unconsciousness or period of confusion • Follow up testing found; 2x rate of depression, drug and alcohol abuse • Elevated rates of panic and and obsessive-compulsive DO

32. “That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled” Ryan Church, NYT 3/10/08 “All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel NYT reporter

33. Types of TBI-Moderate • LOC/Coma between 20-30 minutes to 24 hours, followed by a few days or weeks of confusion • EEG/CAT/MRI are positive for brain injury • 33-50% of individuals with moderate brain injury have long term difficulties in one or more areas of functioning

34. Types of TBI-Severe • Almost always results in prolonged consciousness or coma of days,weeks, or longer • 80% of individuals with severe brain injury have multiple impairments in functioning

35. Simplified Brain Behavior Relationships Frontal Lobe• Initiation• Problem solving• Judgment• Inhibition of behavior• Planning/anticipation• Self-monitoring• Motor planning• Personality/emotions• Awareness of abilities/limitations• Organization• Attention/concentration• Mental flexibility• Speaking (expressive language) Parietal Lobe• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception Frontal Lobe Parietal Lobe Occipital Lobe• Vision Temporal Lobe Cerebellum•Balance• Coordination• Skilled motor activity Cerebellum Brain Stem Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing

36. Possible Changes-Physical • Motor skills/Balance • Hearing • Vision • Spasticity/Tremors • Speech • Fatigue/Weakness • Seizures • Taste/Smell

37. Memory Attention Concentration Processing Aphasia/receptive and expressive language Executive skills Problem solving Organization Self-Perception Perception Inflexibility Persistence Possible Changes-Thinking

38. Possible Changes-Personality and Behavioral • Depression • Social skills problems • Mood swings • Problems with emotional control • Inappropriate behavior • Inability to inhibit remarks • Inability to recognize social cues

39. Personality and Behavioral cont.. • Problems with initiation • Reduced self-esteem • Difficulty relating to others • Difficulty maintaining relationships • Difficulty forming new relationships • Stress/anxiety/frustration and reduced frustration tolerance

40. A memory deficit might look like trouble remembering or it might look like……(Capuco & Freeman-Woolpert) • She frequently misses appointments-avoidance, irresponsibility • He says he’ll do something but doesn’t get around to it • She talks about the same thing or asks the same question over and over-annoying perservation • He invents plausible sounding answers so you won’t know he doesn’t remember

41. An attention deficit might look like trouble paying attention or it might look like…(Capuco & Freeman-Woolpert) • He keeps changing the subject • She doesn’t complete tasks • He has a million things going on and none of them ever gets completed • When she tries to do two things at once she gets confused and upset

42. A deficit in executive skills might look like the inability to plan and organize or it might look like...(Capuco & Freeman-Woolpert) • Uncooperativeness, stubbornness • Lack of follow through • Laziness • Irresponsibility

43. Unawareness might look like…(Capuco & Freeman-Woolpert) • Insensitivity, rudeness • Overconfidence • Seems unconcerned about the extent of her problems • Doesn’t think she needs supports • Covering up problems (“everything’s fine…”) • Big difference in what he thinks and what everyone else thinks about his behavior • Blaming others for problems, making excuses

44. Lack of Awareness A common and difficult to remediate hallmark of a brain injury

45. Levels of AwarenessCrossen et.al (1989) J Head Trauma Rehabilitation • Intellectual Awareness-individual is able to understand at some level, that a particular function or functions is impaired. A greater level of intellectual awareness is required to recognize some common thread in the activities in which they have difficulty • Emergent Awareness-individual is able to recognize a problem when it is actually happening. To do so, they must recognize a problem exists (intellectual awareness), and realize when it occurs • Anticipatory Awareness-individual is able to anticipate a problem will occur and plan for the use of a particular strategy or compensation that will reduce the chances that a problem will occur, e.g. keep and refer to a calendar to support memory for daily schedule

46. Ideal Rehabilitation Pathway for Mild TBI • Diagnosed after injury and provided with education and follow-up • If they are of the approximately 10% of mild TBI sufferers who continue to experience difficulty functioning, there is evidence of appropriate rehabilitation, neurological/neuropsychiatric/neuropsychol-ogical treatment or consultation

47. Common and Less than Ideal Pathway-Mild TBI • Discharged and released from ER or not even seen in ER • Memory, emotional lability, visual, vertigo, headaches and or fatigue symptoms do not resolve after the first few weeks following injury • If subsequently seen by GP or in the ER often told to just”take it easy”

48. Common and Less than Ideal Pathway-Mild TBI, cont.. • Can’t function at work or home • Spiral into depression and anxiety • Family, friends and co-workers loose patience • If seen by a GP or neurologist may be viewed as having a psychosomatic reaction or be labeled a malinger-inappropriately medicated

49. Common and Less than Ideal Pathway-Mild TBI, cont.. • Job loss • Mental Health Problems • Relationships and supports erode • At risk for Substance Abuse • At risk for entry into the criminal justice system

50. Ideal Medical/Rehabilitation Pathway-Moderate to Severe TBI • Acute care delivered at a trauma center (Shock Trauma, Johns Hopkins) • Inpatient rehabilitation at a CARF accredited brain injury rehabilitation hospital(Sinai, Kernan, Maryland General) • Outpatient rehabilitation at a CARF accredited brain injury rehabilitation center offering a community re-entry program and individual therapies (Sinai, Kernan, Total Rehab Care,Treatment and Learning Centers)