Three Cases of Traumatic Brain Injury

1. Three Cases of Traumatic Brain Injury Rigo Van MeerCairns Base Hospital 30 April 2014

2. TBI • 2004-2005: 22,000 hospitalizations for TBI in Australia • 40% fall • 30% MVA • 16% assault • Lasting disabilities & more • memory problems • poor concentration • slowed responses • poor planning and problem solving • lack of initiative • Inflexibility • impulsivity • irritability • socially inappropriate behavior • decrease of communication skills • self-centeredness • dependency on others • emotionally labile • depression. • 25% aggressive behaviours (Baguley, 2006) • Alcohol abuse, drug abuse, homelessness, jail

3. TBI & Alcohol • High correlation TBI and alcohol abuse • Persons with alcohol abuse have more TBI • Falls, MVA, aggression • Persons with TBI exhibit more alcohol abuse

4. TBI & ADHD • Chronic symptoms of ABI overlap ADHD symptoms • Memory problems, poor concentration, slowed responses, poor planning and problem solving, lack of initiative, inflexibility, impulsivity, irritability, socially inappropriate behavior, decrease of communication skills, self-centeredness, dependency on others, emotional lability and depression. • Alcohol abuse, drug abuse, homelessness, jail • ADHD used to be called Minimal Brain Damage (MBD) • Children with TBI develop more often ADHD

5. Patient Mr A. 43 y, mechanic, 5 children, DSP • Did well in school. Finished year 10 and took apprenticeship. • At 23 assaulted. Closed head trauma. No loss of consciousness. • He clearly remembers the assault. Diagnosed with PTSD. • Personality changes: started to abuse alcohol, negative thinking, easily angry and aggressive. • Alprazolam 1mg prn, Fluoxetine 60mg, Sodium Valproate 500mg, Propanolol 40mg • 5 years ago BIBP intoxicated following siege at his home. Threatening suicide with a large knife. Disheveled, aggressive demeanour, shouting & swearing. Nil psychosis. • Next day regretted his actions

6. Mr A cont’d • 4 ½ years ago later walked into hospital brandishing a knife, threatening self harm and suicide • He admits afterwards it was stupid to do • Arrested, 2 months jail • On assessment after incarceration: irritable, negative thinking, ruminating about past injustices and harassment by the police. Racing scattered thoughts • 10 to 12 standard drinks daily • Smokes a “couple of cones”

7. Mr A presentation • Presents to local hospital, agitated, demanding medication. Referred to Mental Health. • Depressed, sleeping problems, racing negative thoughts • Lack of interest and motivation. • Stressed and on edge • Angry very easily • Drinks heavily before going to bed. • Concentration and focus very poor. • No psychosis or a major mood disorder. • Citalopram 20mg • Fits criteria for ADHD, apart from late onset

8. Mr A treatment outcomes • Treatment trial on dexamphetamine • Thinking clearer, more organized • Mood improved • More relaxed, more in control • Much less irritable and angry • Drinking reduced • Deals with stress without aggressive explosions • Sees goal in life again • Maintenance dose dexamphetamine 75mg daily • Citalopram 20mg

9. Mr A interview

10. Mr B, 30y, DSP • Did well in school. Worked as labourer. Adventurous, fit, sporty and outgoing person from a caring family. • MVA at 19y under the influence of alcohol. Skull fracture, coma, 18 months rehabilitation • After the accident he had changed dramatically. • He suffered from severe mood swings and took to heavy drinking. • Three years after the accident he overdosed on Disulfiram. • Two years later he intended hanging himself, took an overdose and attempted to cut his wrist. • He participated in a 3 months residential program for alcohol abuse. • A year later he was found heavily intoxicated, knocking on people’s doors to ask them to take care of his infant baby, so he could kill himself. • Two years later there was an incident in which he smashed a window and a glass table whilst intoxicated. • He lost his drivers license due to driving under influence.

11. Mr B, presentation to Mental Health • He asks for treatment of his bipolar disorder. The diagnosis of bipolar disorder was made shortly after his accident, but years later questioned on good grounds. • Disheveled and very bad neglected dentition. • Low mood. More desperate than depressed. • Sleeps about 3 hours per night. Can’t “switch off his brain”. • Short-term memory problems, visual memory intact. • Concentration and focus severely diminished. • Procrastinates a lot and does not finish chores. • Often irritable. • Fits DSM5 criteria for adult ADHD apart from late onset.

12. Mr. B, alcohol & drugs • He had abstained from alcohol for 3 months, with help of the alcohol service, but was struggling with considerable craving. • No marijuana or other drugs. • Tried speed in the past, after his accident. Calmed him somewhat and made him go and do things. “I had everything, now I have nothing”

13. Mr. B, treatment outcome • Trial of dexamphetamine. • After 10 days feeling much better. He had actually fixed a mower, something he has been putting off for a long time. • Three weeks later the positive changes are even clearer • At 3 months the improvements were maintained. • 40mg Dexamphetamine daily (8 tablets) • Concentration and focus much improved. • Motivated and able to do things now. • Finished all kinds of chores that he had been putting of over the past years. • Mood is much improved. • Sleep much improved. • Decrease in appetite in the first days of treatment, now returned to normal. • Alcohol craving practically disappeared. • Less irritable, which he says is very pleasant for his children. • He says he is 95% normal again. • Positive and optimistic, he has a future again. • He feels the treatment has changed his life.

14. Mr.B interview

15. Mrs. C, 51, recently unemployed • Long Hx of severe alcohol abuse • Started drinking after MVA and later death of partner 20 years ago • Drinks 2 liters wine a day. Wants to stop. • Worked in childcare. Well organized. • 6 Months ago bumped her head when getting up, leading to subarachnoidal hematoma left • Hematoma operated, 3 burr holes • Seizures since head trauma. Cognitive & emotional symptoms. • Fluoxetine 20mg, Levetiracecam 250mg

16. Mrs C, presentation • Referred by ATODS for suicidal ideation, depressed mood, severe agitation, possible epilepsy • One week later seen in hospital for OD • Well dressed and kempt • Agitated, can’t sit still. Cries most of the time • Very tangential, scattered. Difficult to interview. • Feels stressed all the time, out of control of her emotions. • She feels very angry for no reason • Memory problems, severe concentration problems • Word finding problems. Spelling problems • Sleep very bad

17. Mrs. C, treatment • First Quetiapine for sleep an relaxation • After a week cautiously started on low dose (10 to 20mg) dexamphetamine (Lower seizure threshold?) • Next week: could do crossword again since 6 months • No recurrence of seizures. • Dexamphetamine trial continued • New stressful events, stops dexamphetamine, relapses in drinking • Regains herself. Reduces alcohol. Restarts dexamphetamine

18. Mrs. C, 2 weeks on dexamphetamine again • Says she is coping well • Calmer and less emotional • Can spell and do crosswords again • Memory in general improved • Concentration and focus improved, but still far worse than before the trauma • Alcohol craving reduced but not disappeared • Finds medication helpful and wants to continue

19. Lessons learned • The effects of stimulants in brain injury can be dramatic and life changing • There is a strong overlap between chronic symptoms of brain injury and adhd. • In patient with brain injury and cognitive and emotional disabilities a trial with stimulants is very worth its while. • The effectiveness of stimulants on symptoms of brain injury is severely under reported in the literature. • The effectiveness of stimulants is virtually unknown to psychiatrists.

20. Questions • Why is the effect of stimulants on symptoms of brain injury severely under reported in the literature? Possibly because… • Use of objective measures instead of subjective; changes may be big but hard to prove objectively • For instance, there are no objective tests for ADHD • There is a wide array of different symptoms of traumatic brain injury. This makes it very difficult to do randomized controlled trials. • In trials the dose of stimulants used is often quite low, probably too low • In trials standard doses are used instead of individually adjusted doses • The last 20 years there is no interest in research with stimulants (with one important exception)

21. Question • A trial with stimulants (methylphenidate or dexamphetamine) costs $12 on a private script for 100 tablets • What would be your reason to deny a brain injured patient a trial on stimulants?