Traumatic Brain Injury in the Elderly

1. Traumatic Brain Injury in the Elderly Focus on Research Opportunities in Older Populations

2. Traumatic Brain Injury (TBI) • Insult to the brain, caused by an external physical force (not of degenerative or congenital nature) • May produce mild to severe impairment of cognitiveor physicalabilities

3. Facts and Figures Each Year in the U.S. • 1 million are treated and released from ERs with TBI • 80,000 experience the onset of long term disability with TBI • 50,000 die from TBI • 2% of the population currently live with disabilities from TBI

4. Facts and Figures

5. Facts and Figures

6. Why Study TBI in Older Adults? • Research has focused on younger populations • Little is known about TBI in an aging population • 65+ is growing • Different health concerns than younger age adults • Longer, more costly stays on rehabilitation units than younger adults • Recovery post TBI is slower than in younger adults

9. Census Projections of Centenarian Population of U.S. YearNumber of Centenarians 2000 61,000 2010 213,000 2020 505,000 2030 1,048,000 2040 1,842,000 2050 4,057,000 Total population in 2050 = N 400,000,000

10. Chronic Health Conditions

11. Memory Impairment

12. Estimated Percentage of Adults with Daily Activity Limitations, by Age Group and Type of Limitation (2006)

13. Challenge • Increase Research of TBI in older populations • Need to explore areas of opportunity

15. About NIA • Overview • NIA, one of the 27 Institutes and Centers of NIH, leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life. In 1974, Congress granted authority to form NIA to provide leadership in aging research, training, health information dissemination, and other programs relevant to aging and older people. • Mission • NIA’s mission is to improve the health and well-being of older Americans through research, and specifically related to: • Aging processes • Age-related diseases • Special problems and needs of the aged

16. NIA Research Programs

18. Research: Develop strategies to reduce falls and their consequences

21. Tai Chi, Balance, Strength Vision, Fall hazards Polypharmacy, Behavioral

22. Research: TBI and linkages with Dementia

23. Cognition • Known as neurogenesis, studies suggests that medical and behavioral approaches could be found to stimulate the formation of new neurons to compensate for the loss and functional decline of neurons with aging, disease, or traumatic injury

25. Older persons who exercised ≥ 3 times per week were more likely to be dementia-free than those who exercised fewer < 3 times per week (N=1740)

26. Research: Resiliency and recovery post TBI

27. A Model of the Enabling-Disabling Process Pathology Impairments Functional LimitationsDisability • TBI • Dysfunction and structural abnormalities in specific body systems (musculoskeletal, cardiovascular, etc.) • Restrictions in basic physical and mental actions (ambulate, reach, grasp, climb stairs, speak, see standard print) • Difficulty doing activities of daily life (personal care, household management, hobbies) Verbrugge LM and Jette AM. Soc Sci Med. 1994;38:1-4.

28. Objective Performance Measures of Functioning • Assessment instruments in which an individual is asked to perform a specific task and is evaluated in an objective, standardized manner • Assessment may include counting of repetitions or timing of the activity

29. Examples of Objective Performance Tests used to Evaluate Functional Limitations • Grip Strength • Picking up object • Lifting 10 pounds • Gait speed • Chair rise – single and repeated • Stair climb • Test of balance

30. Short Physical Performance Battery • Developed at the National Institute on Aging (NIA) for use in the Established Population for the Epidemiologic Studies of the Elderly (EPESE) • Timed standing balance (up to 10 seconds) • Side-by-side stand • Semi-tandem stand • Tandem stand • Timed 4-meter walk (or 8-foot walk) • Chair rise • Single • Timed multiple (5) chair rises

31. 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Test Category 5 23 25 26 22 22 19 20 20 19 10 15 13 14 49 % Distribution Death Rates According to Individual Performance Tests—age and sex adjusted Walk Chair Stands Standing Balance

32. Death Rates According to Performance Test Summary Score–age and sex adjusted Deaths per 100 Person–Years Performance Test Summary Score

36. Potential Applications of Physical Performance Measures in TBI Research • Identifying levels of functioning • Identifying resilient and vulnerable persons • Clinical “vital sign” • Evaluating change • Intervention studies

37. Psychological Health: 1996 – 2005 Worry (1.5%) Psychological Health (7.8%) Anxiety (30.5%) Anger (3.2%) Depression (50.0%) Psychological Well-Being Significance: “NIH to invest significant new resources in advancing knowledge of positive health. Such a program builds on emerging studies of resilience and resistance to adverse health outcomes as well as current work on recovery from illness.” National Research Council

38. Psychological Well-Being Individuals with high psychological well-being • Like themselves • Good inter-personal relationships • Creative at work / problem solving • Cognition (memory, abstract thinking) • Increased motivation to accomplish tasks

39. H O Patient Characteristics Age, Ethnicity Gender, Marital Status, & Education & Cognition Behavioral Factors Smoking, Alcohol, Exercise Attitudes Functional Status S P Impairments (e.g., Muscle Weakness) I Social Networks T Psychological Well-Being A L Functional Limitations (e.g., Ability to perform walking speed task) I Appraisal & Coping Z A T Clinical Measures Admitting Diagnosis, Pain Level, Length of Stay, Depression, Comorbidities Physiological Measures Cortisol, IL-6, CR-P & Hemoglobin Disability (e.g., Basic activities required for daily living) I O N Conceptual Model Illustrating the Potential Pathways of Association between Psychological Well-Being and Functional Status among Older Patients.

40. ADL Recovery 1-yr. Post Stroke by Positive Emotion Score

42. Research: Understand how demographic characteristics of cohorts reaching old age with TBI affect health and well-being Develop a research plan to understand the dynamic changes that occur across the life course and plan appropriate interventions

43. Research: Examine ethnic disparities in recovery post TBI

45. Infrastructure Goals Develop a Translational Research program to provide the necessary infrastructure to support TBI research efforts • Develop a plan to recognize co-investigators • Train funded faculty for working in teams • Increase # of investigators engaged in TBI research Create Strategic Partnerships with key investigators • Maximize interschool partnership • Establish mechanism to enhance multi-institutional grants

46. Summary • Most of our knowledge about TBI comes from studies involving younger age groups • With the aging of the population there is a critical need to undertake TBI research in the older adult

47. Summary Areas of potential multidisciplinary research • Falls risk / assessment • Cognition / Dementia • Functional limitations and disability • Psychological well-being

48. NIA strategic directions available at:www.nia.nih.gov/AboutNIA/StrategicDirections Other Helpful Web Sites: National Institute on Aging Home Page – www.nia.nih.gov Current Funding Opportunities for Research and Training – www.nia.nih.gov/GrantsAndTraining NIA Extramural Research Programs – www.nia.nih.gov/ResearchInformation/ExtramuralPrograms Biology of Aging Program – www.nia.nih.gov/bap Behavioral and Social Research Program – www.nia.nih.gov/bsr Neuroscience and Neuropsychology of Aging Program – www.nia.nih.gov/nna Geriatrics and Clinical Gerontology Program – www.nia.nih.gov/gcg NIA Intramural Research Programs – www.grc.nia.nih.gov National Institutes of Health Home Page – www.nih.gov NIH Roadmap for Medical Research – nihroadmap.nih.gov NIH Blueprint for Neuroscience Research – neuroscienceblueprint.nih.gov