Assisting Patients with Traumatic Brain Injury: A Brief Guide for Primary Care Physicians

1. Assisting Patients withTraumatic Brain Injury:A Brief Guide for Primary Care Physicians Margaret A. Struchen, Ph.D.1,2 Lynne C. Davis, Ph.D.1,2 Stephen R. McCauley, Ph.D.1 1 Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 2 Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX

2. Module 1 General Information on Traumatic Brain Injury © Baylor College of Medicine, 2009

3. Definition • A TBI occurs when an outside mechanical force is applied to the head and affects brain functioning. • The physical force can consist of a blow to the head (such as from an assault, a fall, or when an individual strikes his/her head during a motor vehicle accident) or a rapid acceleration-deceleration event (like a motor vehicle accident). • It is possible for the brain to become injured even if the head has not directly struck or been struck by another object. • The brain can become injured whether or not the skull is fractured. © Baylor College of Medicine, 2009

4. Causes of Injury • The most common causes of TBI: • Falls (28%) • Motor vehicle-traffic crashes (20%) • Being struck by or against an object (19%) • Assaults (11%).1 • Blasts are a leading cause of TBI for active duty military personnel in war zones.2

5. Overview: Pathology/Pathophysiology of TBI • Primary brain injury secondary to trauma: • Cerebral contusions • Lacerations • Hemorrhage (sometimes considered secondary) • Diffuse axonal injury • Secondary injury to brain tissue: • Intracranial hypertension • Brain shift and herniation • Biochemical processes • Swelling • Cerebral ischemia © Baylor College of Medicine, 2009

6. Overview: Pathology/Pathophysiology of TBI • Cerebral contusions: typically in tips/bases of frontal lobes and tips/bases/lateral surfaces of temporal lobes. • Lacerations: less frequent but associated with penetrating TBI • Hemorrhage: may be epidural, subdural, subarachnoid, intraparenchymal, and/or intraventricular. • Diffuse axonal injury (DAI): occurs due to widespread shearing and stretching of axons and myelin sheaths in white matter. DAI is best correlate with prolonged coma after TBI.3 © Baylor College of Medicine, 2009

7. Overview: Pathology/Pathophysiology of TBI • Intracranial hypertension: most common cause of death from TBI from those surviving initial injury due to brainstem herniation compromising vital functions.4 Compression effects and/or ischemic injury secondary to intracranial hypertension can cause further impairment for those who survive. • Brain shift: Pressure effects from bleeds, edema can cause mass effect or brain shift leading to additional damage to brain tissue. • Biochemical processes: that occur as part of the body’s response to injury can cause additional cell death and therefore, poorer functional outcome. © Baylor College of Medicine, 2009

8. Overview: Pathology/Pathophysiology of TBI • Brain swelling: can occur due to increased cerebral blood volume or cerebral edema. Swelling may be localized adjacent to contusions, diffuse within a cerebral hemisphere, or diffuse throughout both hemispheres. • Cerebral ischemia: can occur even without increased intracranial pressure and may relate to vascular disruption and vasospasm. • Most acute hospital care is focused on limiting or eliminating secondary injury to the brain by: • Keeping open airway • Providing appropriate seizure control • Relieving intracranial hypertension • Aggressively treating intracranial hematomas © Baylor College of Medicine, 2009

9. Grading of Injury Severity • Level of severity can be related to many variables, including the amount of force involved and the speed at which the head or object was moving at the time of injury. • Injury severity classification labels refer to the initial injury, not to the eventual outcome (i.e., a person with a severe injury may have a good outcome, a person with a mild injury may have a poor outcome). • Typically, initial injuries with greater severity are associated with poorer outcomes. • Injury severity classification assist with initial triaging. © Baylor College of Medicine, 2009

10. Grading of Injury Severity • Duration of Loss of Consciousness: • In acute hospital settings, tracked hourly/daily often with GCS score (detailed below). • Longer duration of LOC, more severe the injury. • Glasgow Coma Scale5 score: • Scale to assess responsiveness widely used. • Evaluates eye opening (score 1-4), motor responses (1-6), and verbal responses (1-5). • Total scores range from 3-15 and are sum of 3 subcomponent scores. • 3-8 Severe; 9-12 Moderate; 13-15 Mild injury severity • Scale values available in website supplementary materials. © Baylor College of Medicine, 2009

11. Grading of Injury Severity • Duration of Post-traumatic Confusion: • After TBI, common for persons to be confused or disoriented for a period of time after injury. The ability to remember information during this time is affected. In general, the longer the period of post-traumatic confusion, the more severe the injury. © Baylor College of Medicine, 2009

12. Common Sequelae following Mild TBI • Every brain injury is different, with heterogeneity of sequelae being a hallmark of TBI. • Most common sequelae of a mild TBI (in order of frequency) include: • Headache • Fatigue • Dizziness • Irritability • Other fairly common sequelae after mild TBI include: • Sensitivity to light/noise; attention/concentration problems; memory problems; slowed information processing; depression; and less often blurred/double vision. © Baylor College of Medicine, 2009

13. Sequelae after Moderate to Severe TBI • All of the following problems may be seen after TBI, although some are more common than others. • Somatosensory: • Headaches, fatigue, dizziness, blurred vision, visual field cuts, sensitivity to light/noise, anosmia, aguesia • Motor: • Hemiparesis, spasticity; slowed performance; poor coordination; dysarthria • Cognitive: • Attention/concentration problems; memory problems; slowed information processing; visuospatial difficulties; executive functioning impairments • Emotional/Behavioral: • Decreased initiation; impaired self-awareness; impulsivity; inappropriate or embarrassing behaviors; depression; irritability/anger; emotional lability; anxiety © Baylor College of Medicine, 2009

14. Sequelae of TBI • Every brain injury is different. • Experiences vary due to factors such as: • Severity of injury • Localization of injury to brain • Mechanism of injury • Other factors: • Pre-injury functioning • Use of compensatory strategies • Material supports (e.g. financial resources, access to transportation) • Social supports (e.g., family members, friends) • Awareness of patient’s ongoing symptoms important to your clinical interactions and treatment. © Baylor College of Medicine, 2009

15. Typical Course of Recovery after Mild TBI • Majority with mild TBI experience symptoms in initial weeks and months after injury. • “Postconcussion syndrome” often termed to describe symptoms experienced after mild TBI. • Most will feel close to “normal” within the first three months after a single, uncomplicated mild TBI. • Different people have different rates of recovery. • Recovery can be slower for: • Persons with one or more previous brain injury. • Older-age adults. © Baylor College of Medicine, 2009

16. Course of Recovery after Mild TBI • Symptoms usually worse acutely. • Sometimes patients may not notice problems until they attempt to resume normal daily activities (e.g., discovering concentration problems after return to work). • Symptoms tend to get better over time for most people. • Small subset of individuals with mild TBI experience continuing problems. • Presence of persisting symptoms likely due to multiple factors, such as: • Biomechanics of injury • Personal characteristics of injury person (and brain) • Severity of injury • Symptom presentation • Reactions to symptoms • Availability of material/social resources to address issues after injury. © Baylor College of Medicine, 2009

17. Typical Course of Recovery after more Severe Injury • Recovery course longer than for mild TBI. • Most rapid improvements in functioning occur in first six months. • Continued improvement between six months and one year after injury, although not as rapid or dramatic as in first six-month period. • Between 1-2 years post-injury, recovery may differ with some showing continued slow and gradual improvement while others plateau. • Those with more severe injury show little change 2 or more years post-injury, although possible to see functional changes with implementation of compensatory strategies. © Baylor College of Medicine, 2009

18. Typical Course of Recovery after more Severe Injury • Patients with moderate to severe injuries are more likely to have longer-lasting sequelae post-injury. • Likelihood increases with severity of injury and degree of initial impairments related to such injury. • Longer durations of coma and/or post-traumatic confusion associated with more severe impairments post-injury. © Baylor College of Medicine, 2009

19. References • 1. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths 2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. • 2. Defense and Veterans Brain Injury Center (DVBIC). [unpublished]. Washington (DC): U.S. Department of Defense; 2005. • 3. Gennarelli TA, Thibault LE, Adams JH, Graham DI, Thompson CJ, Marcincin RP. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1982; 12(6): 564-74. • 4. Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977; 47:491-502. • 5. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81-84. © Baylor College of Medicine, 2009

20. Module 2 Clarifying Diagnosis and Utilization of the Neuropsychological Report © Baylor College of Medicine, 2009

21. Clarifying Diagnosis • General practitioners may not be aware that a new patient has experienced a traumatic brain injury. • Patient may present to you for other medical reason. • Patient may not spontaneously report history of TBI. • Not reported because presenting symptom complaint unrelated to TBI. • Not reported because patient unaware of importance of injury to your care. • Not reported due to patient’s cognitive deficits which may interfere with accurate self-reporting of medical history information. • Important as part of your initial patient history to inquire as to history of significant head injury to ascertain presence of TBI. © Baylor College of Medicine, 2009

22. Clarifying Diagnosis • Questions to include: • Ever had injury to head? • If so, accompanied by loss of consciousness (LOC), confusion, or memory disturbance? • Obtain details of any hospital treatment, neuroimaging studies, brain-injury related surgeries, and rehabilitation services. • If patient has had head injury but no LOC, confusion, or memory problems, it is unlikely that a TBI has occurred. If head injury is accompanied by these problems, it is likely that a TBI has occurred. Query to determine severity of injury. © Baylor College of Medicine, 2009

23. Clarifying Diagnosis • Patients with cognitive problems may have difficulty answering these questions or providing an accurate history. • Keep in mind that persons with TBI may have few obvious physical problems, yet have significant cognitive, emotional, or behavioral difficulties. • When encountering patients with severe cognitive impairments, obtaining permission from the patient to talk with other family members may be critical to your management of the patient’s care. © Baylor College of Medicine, 2009

24. Clarifying Diagnosis • Obtaining medical records is important to understanding history of your patient with TBI. • Variables to look for: • Date and severity of injury • Physical, cognitive, emotional, and behavioral changes related to injury • Therapies received • Assistive devices used to help with daily functioning • Social and material resources • Functional limitations • Recommendations • Attend to the various dates when information was gathered, as information that was gathered early in recovery may not accurately reflect current functioning. • The closer in time that data collected in relation to your visit, the more accurate findings will be towards depicting your patient’s status. © Baylor College of Medicine, 2009

25. The Neuropsychological (NP) Report • A good source of information about the patient’s physical, cognitive, emotional, and behavioral status in the NP report. • NP evaluation uses the following types of measures to assess the domains of interest: • Interview • Observation • Behavioral measures • Patients often referred for NP evaluation if have or suspected to have neurological disorder or dysfunction. • Patients with moderate to severe TBI often will have had NP evaluation, although those with limited healthcare resources may not have had such an assessment. • Few with mild TBI will have had such an evaluation, especially for those who were not hospitalized as a result of the injury. © Baylor College of Medicine, 2009

26. The Neuropsychological (NP) Report:Why can it be helpful? • Describes areas of cognitive weakness and strength, which may help determine what modifications to your treatment approach may be needed in caring for your patient. • Describes emotional functioning which may assist with consideration of medication management and/or referral to a psychologist or psychiatrist. • NP report will provide recommendations which may be helpful in determining what might be your patient’s current needs. © Baylor College of Medicine, 2009

27. The Neuropsychological (NP) Report:Areas Typically Evaluated • Orientation • Attention • Memory • Language • Visuospatial Functioning • Processing Speed • Problem-Solving • Conceptual Reasoning • Self-awareness • Emotional Functioning: • Depression • Anxiety • Anger/irritability © Baylor College of Medicine, 2009

28. The Neuropsychological (NP) Report:When should you refer your patient? • If your patient never had a NP assessment and he or she is experiencing cognitive problems as indicated by self-report, family report, or clinical observation. • If the patient had a NP evaluation, but findings are outdated and you need an update on current patient functioning. © Baylor College of Medicine, 2009

29. The Neuropsychological (NP) Report: Maximizing Utility • Be sure to provide your medical records on the patient to the neuropsychologist. • Be clear in communicating you referral question(s). • Specific questions will yield more fruitful information than a non-specific referral. • Be sure to include all questions you wish to be addressed. • Be sure to specify the time by which you need to receive the evaluation results, especially if critical clinical decisions are pending receipt of the results. • Contact the neuropsychologist to talk over report if you have any questions. © Baylor College of Medicine, 2009

30. Module 3 Common Comorbid Emotional and Behavioral Disorders for Persons with TBI © Baylor College of Medicine, 2009

31. Emotional/Behavioral Disorders commonly associated with TBI • Postconcussion syndrome • Depression • Post-traumatic stress disorder • Anger, agitation, aggression • Problems with behavioral regulation • Impaired self-awareness • Sexual dysfunction • Alcohol and substance abuse issues © Baylor College of Medicine, 2009

32. Postconcussion syndrome (PCS) • Set of symptoms occurring in loose cluster following mild (sometimes moderate) TBI: • Headache • Dizziness • Irritability • Difficulty concentrating • Impairment of memory • Insomnia • Reduced tolerance for stress, emotional excitement, and alcohol © Baylor College of Medicine, 2009

33. Postconcussion syndrome (PCS) • Estimated 80-100% of patients with uncomplicated mild TBI experience at least one PCS symptom in first month post-injury.1 • Symptoms often accompanied with feelings of depression, anxiety, fear of permanent brain damage. • Most recover completely within 1-3 months after injury, but minority (roughly 10-20%) experience more persistent symptoms.2 © Baylor College of Medicine, 2009

34. Postconcussion syndrome (PCS) • Although secondary gain (e.g., participation in litigation or receiving insurance or other compensation after injury) is often a concern, studies have found that a large percentage of those with persisting PCS symptoms have no such incentive – so do not automatically assume that secondary gain is the root cause of your patient’s symptoms.3-4 • Chronic symptom presentation in patients with an initial uncomplicated mild TBI is likely multifactorial (physical, psychological and environmental). • Careful identification of factors and referral to those experienced in these issues (e.g., physiatrists, neuropsychologists, and the like) will be important to the management of these patients. © Baylor College of Medicine, 2009

35. Depression • Depression is the most common affective disturbance after TBI and incidence rates far exceed those of community base rates.5-12 • Depression after TBI can exacerbate TBI-related cognitive impairments (e.g., attention, memory, etc.).8, 13-16 • Depression also contributes to functional impairment and quality of life for those with TBI.17-18 © Baylor College of Medicine, 2009

36. Depression • Diagnosis of depression post-TBI can be complicated as sequelae of TBI can lead to overdiagnosis or underdiagnosis. • Changes in sleep, libido, fatigue, concentration, and memory may be direct result of injury and not a symptom of depression but overlap can lead to overdiagnosis.19 • Poor self-awareness after TBI can lead to underreporting of symptoms contributing to underdiagnosis.20-21 © Baylor College of Medicine, 2009

37. Depression • Carefully assess your patient’s symptoms to determine if depression is present. • Use of the Centers for Epidemiologic Studies Depression Scale (CES-D)22 as a good screening instrument for detecting depression (available as a downloadable file on our website). © Baylor College of Medicine, 2009

38. Depression • Assessment of suicidality in patients with TBI is important as regular part of your evaluation of mood in these patients. Persons with TBI and depression are at greater risk for suicide relative to those with depression and no history of TBI.23-25 • Strongest predictors of suicide attempts in patients with TBI are: • Young age • Male gender • Increased feelings of hostility/aggression23 • Substance use25 • Patients who are post-TBI with co-morbid diagnoses of mood disorder and substance abuse were at 21 times higher odds of suicide attempts than persons without TBI.26 © Baylor College of Medicine, 2009

39. Post-traumatic stress disorder (PTSD) • Diagnosis of PTSD in patients with TBI is controversial since concern over whether patients with no memory of circumstances around the traumatic event could develop features and meet criteria for PTSD (frequent re-experiencing of event unlikely to occur). • Discussion of these is beyond scope of this podcast, but convincing evidence that PTSD can develop in patient with TBI severe enough to result in period of amnesia surrounding traumatic event. © Baylor College of Medicine, 2009

40. Post-traumatic stress disorder (PTSD) • Prevalence rates vary from 12-24% in those with mild TBI and 27% in those with severe TBI.27-30 • One study found rate of PTSD in patients with TBI to be 5.8 time the relative risk observed in the general population.30 • Note: Generalized anxiety disorder is possibly the most common type of anxiety disorder diagnosed following TBI.31-32 © Baylor College of Medicine, 2009

41. Post-traumatic stress disorder (PTSD) • Keep in mind that features of PTSD overlap with postconcussion syndrome. Overlapping features include: • Feeling of anxiety • Disordered sleep • Concentration difficulties • Irritability/anger outbursts • Trouble recalling important details of traumatic event • Diminished interest or participation in significant activities • Feelings of detachment from others © Baylor College of Medicine, 2009

42. Post-traumatic stress disorder (PTSD) • Good screening instrument to help detect PTSD following TBI is the Posttraumatic Checklist-Civilian form (PCL-C), available as a downloadable file from our website. • Post-TBI PTSD is sometimes associated with pre-injury psychiatric history.33-34 Other factors associated with PTSD include: • Trauma severity • Poor social support networks • High number of life stressors34 • Specific features of PTSD for patients with TBI include: • PTSD more common in patients who deny loss of consciousness.29 • Women are over-represented among those with TBI and PTSD.29, 35 • Patients with TBI are less likely to report re-experiencing phenomena.33,35 © Baylor College of Medicine, 2009

43. Anger, Agitation, and Aggression • People often report having a “shorter fuse” after TBI. • Increased irritability noted for persons with all levels of injury severity. • Violent behavior is rare, but can occur. • More commonly, verbal and sometimes physical outbursts occur. © Baylor College of Medicine, 2009

44. Anger, Agitation, and Aggression • During acute recovery from severe TBI, patients may experience agitated behavior and as much as 33% may exhibit aggression and/or agitation at 6 months post-injury.36 • A high percentage of patients with severe TBI (anywhere from 31-71%) report increased irritability, aggression, or agitated behavior over the long term. Also occurs in those with mild and moderate TBI, however.37 • Pre-injury history of poor social functioning, substance abuse, and presence of major depression significantly correlated with aggressive behavior in persons with TBI.38 © Baylor College of Medicine, 2009

45. Problems with Behavioral Regulation • After TBI, poor behavioral regulation may be present including: • Impulsivity • Poor initiation • Inappropriate behavior • Personality changes • Emotional dysregulation • These behavioral issues can greatly affect the ability to resume community activities (work, school, independent living) and can interfere with relationships. © Baylor College of Medicine, 2009

46. Problems with Behavioral Regulation • Impulsivity, or the difficulty inhibiting actions, can occur after TBI. • Neural mechanisms that help us “stop and think” prior to acting have been affected. © Baylor College of Medicine, 2009

47. Problems with Behavioral Regulation • Patients may experience impaired initiation after TBI, having trouble getting started with things even if expressing an interest in engaging in activities. • Often misinterpreted as “laziness” or “noncompliance” by family members or caregivers, can be a significant source of stress. • However, initiation difficulties can occur as a result of damage to neural systems involved in activating motor sequences and are not a deficit of motivation. © Baylor College of Medicine, 2009

48. Problems with Behavioral Regulation • Inappropriate behaviors may occur, often due to disinhibition. • Examples include: • Asking casual acquaintances or strangers overly personal questions (e.g., about finances or sexual issues). • Disclosing overly personal information to others. • Engaging in inappropriate activities (e.g., childlike behaviors or sexual behaviors) • Such problems are often very stressful for family members, friends, and caregivers. © Baylor College of Medicine, 2009

49. Problems with Behavioral Regulation • Personality and social skill changes can occur, including: • Impaired social perceptiveness • Poor self-monitoring • Verbosity • Perseveration on topic • Difficulty maintaining topic or idea • Inability to benefit from previous social experiences © Baylor College of Medicine, 2009

50. Problems with Behavioral Regulation • For some with TBI, emotional regulation can be affected. • Emotions may shift quickly from one extreme to another. • Control of emotions may be difficult with patients more easily crying or laughing in situations. • In some cases, emotional reactions may be inappropriate to the context (e.g., laughing when someone is hurt or dies) due to difficulty controlling the emotional display. © Baylor College of Medicine, 2009