Traumatic Brain Injury: Overview

1. Traumatic Brain Injury:Overview

2. Anastasia Edmonston, TBI and Person Centered Planning Trainer-MHA&Dawn Roher, Clinical Resource Manager-BIAMD

3. MHA’s – Lead Agency in Maryland for Traumatic Brain Injury Programs and initiatives: • Home and Community Based Services Waiver for Individuals with Brain Injury. • Staff to the Maryland Traumatic Brain Injury Advisory Board. • Pilot program for transition age youth with brain injury. • Statewide TBI training to human service professionals. • MHA contracts with the Brain Injury Association of Maryland to provide TBI resources and referral information to Marylanders with brain injury. • Additional information about these programs and initiatives can be found at http://dhmh.maryland.gov/mha/SitePages/tbi.aspx

4. What We will Cover Today • The Basic Brain • Who is affected? • Types of Brain Injury • How are people affected by Brain Injury? • Resources

5. What might it feel like to be living with a brain injury? Writing and processing exercise

6. Incidence of TBICDC 2010, 2002-2006 data In the United States, at least1.7 million sustain a TBI each year…275,000 are hospitalized

7. TBI By Cause CDC 2010 • Falls-35.2% (young children & elderly) • Unknown/Others-21% • Motor Vehicle-Traffic-17.3% • Struck by/against-16.5% (unintentionally by object or another person) • Assault-10%

8. Maryland 2007-2011 Hospitalization Dataupdated November 2013, DHMH • After a 3 year trend of declining TBI related hospitalizations, rates increased 21% between 2010-2011 • Rates of hospitalization increase with age, for those 45-54 a 23% rate is noted, for those 75 and older, 46% • Most common cause of TBI related hospitalization are falls, followed by motor vehicle accidents

9. The Scope of the Problem • Distribution of Severity: • Mild injuries = 80%(Loss of consciousness < 30 min, Post traumatic amnesia < 1 hour) • Moderate = 10 - 13%(LOC 30 min-24 hours, PTA 1-24 hours) • Severe = 7 - 10%(LOC >24 hours, PTA >24 hours)

10. Skull Anatomy The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration. The skull is a rounded layer of bone designed to protect the brain from penetrating injuries. Bony ridges adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

11. The Developing Brain • Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old • The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties

12. The Developing Brain • Many of our adult thinking skills reside in the Frontal Lobe • The Frontal Lobe is very vulnerable to injury • If you have a frontal lobe injury as a child, you may “grow into your brain injury”

13. The Frontal Lobe • The frontal lobe is the area of the brain responsible for our “executive skills” - higher cognitive functions. • These include: • Problem solving • Spontaneity • Memory • Language • Motivation • Judgment • Impulse control • Social and sexual behavior. adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

14. Temporal Lobe The temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior. The temporal lobe also contains the language area of the brain. adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

15. Symptoms and functional manifestations individuals with brain injury or their family members may describe and MAPs Resource Specialists may detect

16. Physical Challenges They May Report • Dizziness, headaches • Sleep problems • Diminished taste/smell • Tremors/ataxia/poor coordination • Speech problems (reduced rate, slurring, stuttering) • Seizures • Hearing impairment • Double vision, visual field cut, tunnel vision • Fatigue • Hemiparisis

17. Cognitive/Thinking Challenges They May Report • Memory, especially for information recently read or heard • Trouble organizing themselves, their day, their household • Can’t multi-task anymore • Have difficulty in social/work situations following the conversation if more than one person is talking • Easily distracted (can’t read the paper if the TV is on)

18. Cognitive/Thinking Challenges You May Detect • Difficulty staying on topic • Vague, unclear language • Perservation (repeating themselves) • Confused • Memory lapses • Very concrete in their thinking (poor abstract thinking, doesn’t get jokes) • Talks too loud/too fast • No first hand memory of injury

19. Other Clues to Cognitive/Thinking Challenges • Difficulty following directions • Might have difficulty with simple orientation questions • Aggressive or hostile response to seemingly benign questions • Delayed response time to your questions • Tangential responses to your questions • Confabulation (hard to determine at first interaction)

20. Personality and Behavioral Challenges They May Report • Depression • Anxiety • Moody/Irritable • Loss of/or strained relationships • Insomnia • Substance use/abuse

21. Personality and Behavioral Challenges You May Detect • Impulsivity • Poor judgment • Flat affect (noticeable in speech pattern) • Sexually Disinhibited • Emotionally labile • Substance Use/Abuse • Aggression • Poor initiation

22. Lack of Awareness AKAAnosognosiaA common and difficult to remediate hallmark of a brain injury

23. “Emergence of Self Awareness is the Highest of all Integrated Activities of the Brain” Stuss & Benson 1986

24. Commonly seen Scenarios

25. Growing into Brain Injury • Great physical recovery, good initial cognitive recover • Returns to school, behind peers • Academically challenged • Acts out behaviorally, if the injury several grades back, not recognized as TBI related

26. Continued…. • Drifts after graduation from high school • Gets in with the “wrong” crowd • At risk for mental health issues, substance abuse, criminal activity, burn out families and supports

27. Lack of Awareness X Impulsivity + Substance Abuse = Crisis • Severe brain injury with excellent physical recovery • Rejects outpatient therapy • Impulse control, memory problems, work dries up • Drugs and Alcohol • Marriage on the rocks • Near tragic interaction with a state trooper • Resolution

28. “Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure”Wayne Gordon, Ph.D of the Brain Injury Research Center at Mount Sinai School of MedicineQuoted in the Wall Street Journal 1.29.08

29. Individuals with Brain Injury are Overrepresented in the Following Populations • Incarcerated individuals • Homeless individuals • Victims and perpetrators of domestic violence • Individuals with behavioral health disorders (mental health and/or substance abuse) • Service members returning from Iraq and Afghanistan

30. Treatment and Rehabilitation Typical Course of Treatment for a Severe Brain Injury • Treatment at a Trauma Center • ICU/Acute Care • Inpatient Rehabilitation • Outpatient Rehabilitation • Other Community Services

31. Treatment Plan can include therapy and services from the following…… • Physical Therapy • Occupational Therapy • Speech Therapy • Cognitive Therapy • Social Work • Psychology • Recreation Therapy • Case Management • Nursing • Physician (rehab medicine, neurology) • Neuropsychology

32. Important Things to Remember: • A person with a brain injury is a unique individual first • No two brain injuries are exactly the same • The effects of a brain injury are complex and vary greatly fromperson to person • The effects of a brain injury depend on such factors as cause, location and severity • THUS…each person’s recovery and treatment process is unique to them

33. Factors that can determine the course of treatment: • Family support • Finances • Insurance • Age • Co-occurring mental health and substance abuse issues • Level of Education • Geographical location • Other resources and supports in the community

34. When do people ask for help ? • When the person is initially injured • When they hit a “bump in the road” • Further down the recovery curve, when they are looking for services and never received them initially • When they know something isn’t right and they are reaching out for education, validation, and support • Aging parents with adult children with TBI

35. Who are the other sources of support and resources that complete this picture? • Specialty clinics, i.e.-concussion, mild TBI, sleep, etc. • Neuropsychologists • Medical specialists—headache, pain, neuro-opthamologists, physiatrists, neuropsychiatrists, neurologists, etc. • Vocational counselors • State vocational rehabilitation counselors (DORS) • Attorneys • Private case managers • Insurance case managers • Psychotherapists • Educators and school personnel • Addictions Specialists • Other advocacy agencies-C.I.L., MDLC, etc. • Pediatric resources • Developmental Disabilities Administration • Support groups

36. Please refer to the Brain Injury Resource Handout for a additional information and educational materials