2008 Galveston Brain Injury Conference

1. Group Presentations 2008 Galveston Brain Injury Conference Moody Gardens Convention Center Galveston Texas

2. TRAUMATIC BRAIN INJURY, AGING AND COGNITIVE FUNCTIONING Presented by Wayne A. Gordon, PhD ABPP-CN, Amanda L. Sacks PhD, Angela S. Yi PhD (Group 2)

3. Purpose of Review To examine the literature on the impact of aging on Post-TBI cognitive function. Research Implications Examine current literature. Provide methodological recommendations for future research. Clinical Implications Provide prognostic information to patients on how aging will affect cognitive functioning after a TBI.

4. Research Questions 1. Are there changes in cognitive function in individuals with TBI as they get older? 2. If so, what are the specific changes in cognitive function in individuals with TBI as they get older?

5. Review ProcessKey Words used: word finding fluency pragmatics expressive language receptive language visuospatial visual perception visual construction neglect visual scanning orientation alertness arousal memory retrieval retention encoding concentration speed of information processing concept formation verbal abstraction nonverbal abstraction executive dysfunction intelligence

6. Review Process 450 Abstracts Reviewed 113 Articles Requested 102 Articles Rejected 11 Articles Reviewed 22 age not examined 5 Meta-analysis 72 Non-TBI 3 Case Study

7. Study Designs Longitudinal Designs - studies that measure cognitive functioning of the same individual at two or more time points. Question:What happens to my cognitive functioning over time? Cohort Design – studies that compare the cognitive performance between two groups at one time point. Age 1 vs. Age 2 (TBI) TBI vs. Controls (Age-matched) Question:How does my cognitive functioning compare to different age groups?

8. 2 Cohort Studies AAN ratings AAN Rating 3 = 1 AAN Rating 4 = 1 Strobe ratings Klein et al (1996) = 78% Ogden et al (1998) = 72%

9. 9 Longitudinal Studies AAN ratings summary (M = 3; Range = 2-4) AAN Rating 1 = 0 AAN Rating 2 = 3 AAN Rating 3 = 4 AAN Rating 4 = 2 Strobe ratings (M = 74%; Range = 57%-87%) 50% < = 1 Article 60-70% = 2 Articles 70%-80% = 4 Articles 80%-90% = 2 Articles

10. Cohort Studies Red=Similarities Yellow = Differences

11. Cohort Studies: Cognitive Domains

12. Cohort Studies TBI & Age Interaction Klein (1996): Middle age TBI group performance was similar to older controls on executive functioning task. Interpretation of authors: TBI accelerates aging. Ogden (1998): Younger TBI group does worse than age-matched controls. Middle aged TBI group does equal to or better than age-matched controls. (Memory and executive functioning)

13. TBI Accelerates Aging: ? Or! Visual Verbal Learning Test, Raw Scores Klein et al. (1996)

14. Longitudinal Studies: Cognition Improved Red = SimilaritiesYellow = Differences

15. Longitudinal Studies: Cognition Declined

16. Longitudinal Studies: Cognition Stable

17. Longitudinal Studies: Mixed Findings

18. Longitudinal Studies: Cognitive Domains

19. Longitudinal: Cognitive Conclusions

20. Longitudinal: Cognitive Conclusions

21. Overall Conclusions “What will happen to my cognitive functioning over time?” No definitive conclusions can be made regarding Post-TBI cognitive functioning over time.

22. Differences In Study Design = Varied Findings There was no pattern to variability among studies: Different tests Different samples Age Severity Time since injury Age at injury Different age at injury, time since injury and interval between assessments

23. Normal Aging: 2 Vectors TIME BETWEEN ASSESSMENTS SHORT LONG AGE AT INITIAL EVAL YOUNG OLD

24. Aging & TBI: 4 Vectors TIME BETWEEN ASSESSMENTS SHORT LONG TIME SINCE INJURY AT ASSESSMENT EARLY LATE AGE AT INITIAL EVAL YOUNG OLD AGE AT INJURY YOUNG OLD POTENTIAL CONFOUNDS -Re-injury - Onset of co-morbidity -Treatment - Change in psychosocial status

25. Additional Variability Across Studies Sampling issues Differences in demographics (i.e. education, ethnicity, gender) Differences in severity Variability of control group (i.e. matched control v. convenience sample) Variability of Tests used (i.e. self report vs. objective measures) Diversity of objective measures used= NO GOLD STANDARD for examining cognitive change over time

26. Recommendations for Future Research Take into account interactions between all 4 vectors: Age at injury Age at initial evaluation Time since injury at initial assessment Time between assessment. Assess a diverse range of cognitive abilities across as many domains as possible. Give same battery to all pts. at all assessment points. Use terminology that appropriately describes methodology used (i.e. “follow-up” should have two points of assessment).

27. Thank You!

28. Ageing with Traumatic Brain Injury: Medical Issues Steven Flanagan, M.D. Theodore Tsaousides, Ph.D. Dana W. Moore, Ph.D. Kenneth Ottenbacher Cindy Harrison-Felix, Ph.D. (Group 3)

29. Overarching Issue • What happens to individuals with TBI from a medical perspective as they age? • Are there differences from general population re: • Mortality/survival • Medical problems

30. Variation From Other Groups • Less concerned with age as opposed to ageing • No age cutoff • Assessments made years post-injury

31. Process • Initial research questions • What are the 10 leading causes of mortality > 10 years post injury? • What are the risk factors associated with mortality > 10 years post injury? • What are the most common long-term health problems >10 years post injury?

32. Process • Key words (multiple variations of) • Brain injuries • Risk, mortality, health • Age

33. Results to Those Specific Question • Little more than

34. Process Adaptation • Is risk of early mortality different from the general population and if so, how? • What risk factors are associated with premature mortality? • What are the causes of death beyond the acute (sub-acute) phase following TBI? • What long-term health problems afflict individuals post-TBI? • Self-reported • Diagnosed

35. Process Adaptation • Questions changed to include those ≥ 5 years post to increase “hit” rate.

36. Initial Search Results • 2709 abstracts screened • 350 selected for further review • 72 deemed appropriate for research questions • 71 located • 25 addressed research questions

37. AAN Grade • Most studies reviewed achieved a grade III-IV • 4 Received grade II*

38. 3 Broad Categories • Mortality/Survival • 15 studies • Self-Reported Health Symptoms • 9 studies • Endocrine/Pituitary Dysfunction • 1 Study

39. Mortality

40. Hospitalized

41. Hospitalized

42. Mortality in This Sample • Literature suggests • Increased likelihood of pre-mature death • Older age at injury more likely to die prematurely although younger age more likely to die compared to “age-matched” population • Increased risk associated with physical disability, premorbid social/personal problems, substance abuse, pre-morbid neurological illness • Seizures, sepsis, pneumonia, digestive, injuries causes of death greater than general population

43. Outpatient Services

44. Mortality • Literature suggests • Increased likelihood of premature mortality post-TBI, associated with residual disability • Causes of death choking, epilepsy, GU, respiratory, circulatory, digestive

45. War Veterans

46. Vegetative State

47. Mortality • 13 studies reported increased likelihood of premature death • Different populations • WWI, WWII, Vietnam vets, inpatient rehab, outpatient services, others • Cause of injury/Severity • Penetrating/varying severity • Time • Varying times post injury • Different levels and places of care

48. Risk Factors • 13 studies addressed risk factors • Age at injury • Employment status • Pre-morbid EtOH/social problems • Post-morbid functional skills • Epilepsy (in vet studies only).

49. Cause of Death • 7 studies assessed cause of death • Individuals with TBI more likely to die from • Meningitis, seizures, drowning, choking/suffocation, genitourinary, respiratory, circulatory, gastrointestinal related conditions, sepsis, injuries.

50. Mortality/Survival • Literature suggests that: • TBI increases likelihood of premature death beyond acute/subacute phase • Some reports suggest mortality rate decreased over time • Pre-morbid problems, post-morbid functional limitations, epilepsy and older age increase risk of early death • Premorbid EtOH abuse often reported as a risk factor