Traumatic Brain Injury 101: Causes, Consequences & Strategies

1. Traumatic Brain Injury 101:Causes, Consequences & Strategies February 28, 2008

2. Brain Injury Association of Ohio • State Office-Columbus + • CSN 1, Toledo: Christine Veronie • CSN 3, Cleveland: Lori Surtman • CSN 5, Lima: Jennie Horner • CSN 8, New Philadelphia: Chris Curtiss • CSN 11, Columbus: Rich Haddix • CSN 12, Caldwell: Jenny Rucker • CSN 13, Cincinnati: Peggy O’Neill • CSN 15, Marietta: Cindy Auker

3. Objectives • Increase knowledge of demographics & scope of brain injury • Gain understanding of common consequences and challenges following brain injury • Better understand the impact on the individual and his or her family • Learn about available sources of information & assistance + the lack of a “home” agency. • Identify skills and strategies to assist individuals with brain injury

4. What is a Brain Injury? • Acquired Brain Injury (ABI) • Traumatic Brain Injury (TBI)

5. Acquired Brain Injury • Any injury to the brain that occurs after birth as a result of: • Physical force (due to an accident) • Tumors • Strokes • Violent Acts (e.g., gun shot wound) • Infectious Diseases (e.g., encephalitis) • ABI is the broadest category and includes all brain injuries that occur after birth.

6. Traumatic Brain Injury • A brain injury from an external force • Vehicle accidents • Violent Acts (e.g., gun shot wound) • Falls • Physical Abuse • Sports Injuries

7. Severity Continuum Things to Consider • Symptomology • Pre-injury functioning • Symptoms vary Mild Moderate Severe

8. 15% of all TBIs are considered moderate to severe • 85% of all TBIs are considered mild

9. Mild Brain Injury • Traumatically induced physiological disruption of brain function as manifested by at least one of the following: • Loss of consciousness (often measured by the Glasgow Coma Scale • Loss of memory for events immediately before or after the accident (not longer than 24 hours) • Alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and/or • Focal neurological deficits that may or may not be transient. • (Glascow Coma Scale score 13-15)

10. Moderate Brain Injury • A loss of consciousness that lasts from a few minutes to a few hours; • Confusion lasts from days to weeks; • Physical, cognitive, and/or behavioral impairments last for months or are permanent; and/or • Persons with moderate traumatic brain injury generally make a good recovery with treatment or successfully learn to compensate for their deficits. • (Glascow Coma Scale score 9-12)

11. Severe Brain Injury • Severe Brain Injury (Glascow Coma Scale score 8 or less) • Almost always results in prolonged unconsciousness or coma, brain contusions, hematomas, damage to nerve fibers and axons, and/or anoxia • Often results in permanent physical, behavioral, and/or cognitive impairments • Significant improvements are generally made during the first year and continue thereafter • (Glascow Coma Scale score 3-8)

12. Every 23 seconds, one person in the United States sustains a brain injury.

13. Epidemiology • An estimated 5.3 million Americans have a long-term or life long need for help with activities of daily living as a result of TBI (est. 227,000 Ohioans) • An estimated 1.4 million people will sustain a TBI each year in the United States. • Of these: • 50,000 die; • 235,000 are hospitalized • 1.1 million are treated and released from an ER *The number of people with TBI who are not seen in an ER or who receive no treatment is unknown.

14. Disability Prevalence Rates 400,000 with Spinal Cord Injuries 500,000with Cerebral Palsy 2 million Americans with Epilepsy 3 million with Stroke disabilities 4 million with Alzheimer’s Disease 5 millionwith persistent mental illness 5.3 MILLION WITH TBI DISABILITY 7.3 million Americans with mental retardation National organizations’ web sites, 4/00; Slide source: Brain Injury Association of America 227,000 Ohioans - Estimate of adults living w/disability due to TBI - source CDC

15. Leading Causes of TBI 1st Falls (among elderly and very young) 2nd Vehicle accidents, bicycle, or pedestrian-vehicle incidents (account for most hospitalizations) 3rd Violent acts 4th Sports accidents – An estimated 90% are mild and go unreported (BIA of America Fact Sheet) & (109 Rehabilitation of Persons with TBI)

16. If you have a brain injury, you are 3 times more likely to get another. After the second injury, the risk for the third injury is 8 times greater.

17. Who experiences brain injuries? • Extremely Diverse • Highest risk 0-4 years, 15-24, and 75 years and older • Males are 1.5 times more likely than females to experience TBI • 70% of people who incur TBI recover “completely” • 15% remain symptomatic for the remainder of their lives • Alcohol is reported to be associated with 50% of all TBI

18. TBI is the leading cause of death and disability for children, adolescents, and young adults in the United States. 90,000 of those injured will sustain permanent injuries. (www.biausa.org)

19. Neuroanatomy and Physiology of the Brain Deficits vary depending upon location and severity of brain injury • Major Brain Areas • Frontal Lobe • Parietal Lobe • Temporal Lobes • Occipital Lobe • Cerebellum • Brain Stem

20. Frontal Lobe(Almost always sustains injury due to coup-contra-coup & boney undersurface of skull) • Motor output • Problem Solving • Self-monitoring • Expressive language organization (i.e., speech) • Personality • Emotions • Inhibition of Behavior

21. Parietal Lobe • Sense of touch • Sensory integration • Spatial perception • Visual perception • Identification of size, shape, color

22. Temporal Lobe • Auditory projection (interpretation of speech)/Receptive language • Memory of new information • Sequencing • Hearing

23. Occipital Lobe • Vision

24. Cerebellum • Balance • Coordination • Skilled motor activity

25. Brain Stem • Breathing • Arousal and consciousness • Sleep/wake cycles • Attention and concentration • Heart rate

26. Living with a Brain Injury: The Impact on the Individual • Physical • Cognitive • Social • Behavioral & Emotional

27. Physical Disabilities • Headaches • Dizziness • Chronic pain • Seizures • Decreased coordination • Loss of limbs or use of limbs • Nerve Damage (i.e., optic nerve, facial palsy) • Sensory limitations (visual disturbances, hearing loss, decreased taste and smell, increased sensitivity to noise and light)

28. Cognition • Broad range of symptoms that occur independently or in combination • Memory impairment • Impaired attention • Inability to remain on task • Difficulty focusing on thoughts, words, events • Deficits in language use • Deficits in visual perception

29. Cognition-Deficits in Executive Skills – the “thumbprint” of brain injury • Inability to self-monitor and inhibit responses • Poor initiation • Difficulty sequencing steps and completing activities • Poor judgment

30. Social • Difficulty attending to social cues • Relearning appropriate social skills • Loss of friends • Loss of familiar activities • Loss of self • Personality changes • Problems with emotional control • Susceptible to mood and anxiety disorders • Increased risk of suicide • Egocentric

31. Behavioral and Emotional • Frustration • Irritability • Restlessness • Anxiety • Low motivation • Depression

32. Behavioral and Emotional – Cont. • Aggression- reactive, triggered by modest or trivial stimuli, non-reflective, not pre-meditated, non purposeful, explosive and periodic, impulsive • Exhibits socially inappropriate behavior • Disinhibition * Cognitive fatigue and/or physical fatigue can significantly impact all areas of functioning

33. Medications Presently, there are no FDA approved treatments for cognitive, emotional, or behavioral impairments due to TBI.

34. Medications • Often on multiple medications • SSRIs (e.g., Prozac) often prescribed for anxiety and depression • Anticonvulsants (e.g., Tegretol) often prescribed to prevent seizure activity or to treat behavioral problems • Sleep medications (e.g., Melatonin) often prescribed for sleep disturbances • Neuroleptics (e.g., Risperdal) prescribed for psychosis and/or aggression • Need for continued re-assessment

35. Substance Abuse • Higher rates of substance abuse • Effects 28%-32% of individuals with TBI

36. Cognition- Reasoning and Problem-Solving • Difficulty analyzing situations • Inability to draw conclusions and make decisions • Lack of logical thinking

37. Living with Brain Injury:The Impact on Support Systems (e.g., family, friends, employer) • Grieving • Stress • Survival Adaptations

38. Grieving • Denial • Anger • Bargaining • Depression • Acceptance

39. Stress • Economic Strain • Estimates for average lifetime cost of care for a person with severe TBI exceed $4 million • Changed Family goals and roles

40. Practical Adaptations/Accommodations

41. Signs in Loss of Attention/Concentration • Confusion • Rambling Conversations • Staring • Unable to finish a task • Difficulty attending to more than one thing at a time

42. Strategies to Help with Attention/Concentration • Get individual’s attention before beginning a discussion • Reduce unnecessary noise or unneeded materials on desk • Limit the amount of information presented • Pace the work with short work periods followed by brief breaks

43. Signs of Memory Loss • Confusion regarding appointments or daily schedule • Unable to remember tasks from day to day • Unable to remember new information • Confabulates (makes up stories to fill memory gaps; this is not lying)

44. Strategies to Help with Memory Loss • Establish consistent schedule • Structure tasks • Provide written cues (memory book, chart, etc.) • Provide verbal cues (initial sounds, choices) • Use compensatory tools (alarm, watches, calculators) • Link new information with old information

45. Signs in Loss ofReasoning/Problem Solving • Ineffective problem solving • Inappropriate and potentially harmful decisions • Unable to make inferences • Disorganized thinking • Difficulty drawing conclusions • Rigidity in changing plans

46. Strategies to Help inReasoning/Problem Solving • Instruct and post note for “Stop and Think” • Help identify the problem and possible solutions • Help predict consequences • Break the task down into several easier steps • Write steps in notebook/planner

47. Signs in Loss of Impulsivity/Poor Self Control • Acts or speaks without considering the consequences • Inappropriate comments to or about others • Lower tolerance for frustrating situations • Inappropriate laughing or crying • Get stuck on one idea or thought

48. Strategies to Help in Impulsivity, Poor Self Control • Encourage the person to slow down and work through task • Provide verbal and/or nonverbal feedback in a supportive way • Respond to inappropriate ideas, but maintain focus on original discussion • Expect the unexpected • Provide alternatives for inappropriate or perseverative behavior • Give frequent and consistent positive reinforcement • Remove the individual from a frustrating task or environment

49. Signs of Impaired Self-awareness, Difficulty with Social Situations • Lack of awareness of deficits and limitations • Inaccurate self-image/self perception

50. Strategies to Help withImpaired Self-awareness, Difficulty with Social Situations • Anticipate lack of insight • Prompt accurate self-statements • Use feedback generously in a positive way • Give realistic feedback as you observe behavior