Meeting Special Needs of Individuals with Brain Injury

1. Meeting Special Needs of Individuals with Brain Injury Presented by Joanne McGee, Ph.D. Clinical Director, ResCare Premier

2. Types of Brain Injury • There are many types of injuries and illnesses that can cause injury to the brain. • At times, eligibility for services will depend on whether the disability is due to a traumatic brain injury (TBI) vs. other causes.

3. Types of Brain Injuries • Congenital Disorder • Acquired Brain Injury (ABI)

4. Congenital Disorders • A disorder that is present at birth • May occur as a result of birth trauma or during the development of the fetus • Examples include mental retardation, learning disability, ADHD, fetal alcohol syndrome, etc.

5. Acquired Brain Injury • Aninjury to the brain that has occurred after birth as a result of an illness or injury

6. TBI (most common) Stroke (2nd most common) Anoxia (shortage of oxygen) Brain surgery Infectious diseases Brain tumor Metabolic disorders (e.g., diabetic coma) Seizure disorders Toxic exposure Acquired Brain Injury, Cont’d.Examples include:

7. What causes TBI? The leading causes of TBI are: • Falls (28%); • Motor vehicle-traffic crashes (20%); • Struck by/against (19%); and • Assaults (11%). • Bullets, fragments, & blasts are a leading cause of TBI for military personnel in war zones.

8. FACT • TBI is the leading cause of death and disability among children and young adults. • Males are about 1.5 times as likely as females to sustain a TBI. • Military duty increases the risk of sustaining a TBI. (CDC National Center for Injury Prevention & Control, 1999; 2004; DVBIC, 2007)

9. FACT In the U.S., the annual incidence of TBI is more than that of MS, spinal cord injury, HIV/AIDS, and breast cancer COMBINED.

10. FACT 64% of Soldiers recently wounded in action in OIF sustained brain injuries. Mild & undiagnosed TBI may be the signature challenge from the Global War On Terror. TBI is experienced by a higher percentage of Texas military personnel than any previous conflict. (DVBIC, 2007; TexVet Initiative, 2007)

11. Basic Brain • Brainstem • Cerebellum • Cerebrum

12. Cardiac Respiratory Arousal Movement & touch sensation in body Brain Stem

13. Balance of the body Coordination of body movement Cerebellum

14. Cerebrum Four lobes in each hemisphere: Frontal Temporal Occipital Parietal

15. Frontal Lobe Syndromes • Executive functioning • Problems with: • Speaking • Muscle weakness & paralysis • Attention • Impulse control/inhibition • Problem solving/flexibility

16. Frontal Lobe Syndromes, Cont’d. • Lack of motivation • Inability to plan ahead • Poor judgment • “Intellect without social and emotional guidance”

17. Frontal Lobe Syndromes, Cont’d.PREFRONTAL CORTEX • Goal formation • Plan of action to reach goals • The “CEO” of the brain • “The best connected part of the brain”

18. Frontal Lobe Syndromes, Cont’d.PREFRONTAL CORTEX DORSOLATERAL SYNDROME • Inertia/apathy • Flat affect • Appears indifferent • Distractible • Lack mental flexibility with reverse inertia • Irritability (short-lived)

19. Frontal Lobe Syndromes, Cont’d.PREFRONTAL CORTEX ORBITOFRONTAL SYNDROME • Disinhibited behavior • Lack concern for social taboos • Emotions fluctuate from euphoria to rage • Some engage in criminal acts • Some “loose but harmless” • Confabulation

20. Perseveration Derailment of thought processes Tangentiality Utilization or field-dependent behavior Echolalia/echopraxia Anosagnosia Frontal Lobe Syndromes, Cont’d.

21. Temporal Lobe • Hearing • Understanding Speech • Memory • Music/ Sound • Comprehension

22. Occipital Lobe • Located at the rear • of the brain • Interpretation of • visual information

23. Parietal Lobe • Located at the top of brain • Perception of touch/body • orientation • Face and shape • recognition • Awareness of spatial • relationships • Arithmetic calculations

24. How the Brain is Hurt: TBI PRIMARY INJURY: • Skull fracture • Contusion (Coup/Contracoup injury) • Diffuse axonal injury (DAI) • Focal Shear Injury

26. Diffuse Axonal Injury (DAI)Rotational forces on the brain cause stretching and snapping of axons. Image courtesy of Centre for Neuroskills

27. Focal Shear Injury Image courtesy of Centre for Neuroskills

28. How the Brain is Hurt: TBI, Cont’d. SECONDARY INJURY: • Cerebral edema • Hydrocephalus • Hematomas • Chemical Cascade

29. Secondary Injuries Edema (swollen brain tissue) Hydrocephalus (enlarged ventricles)

30. Hematoma Image courtesy of Centre for Neuroskills

31. FACT More than 442,000 Texans are living with a disability from TBI (about 2% of the population). (Thurman, Alverson, Dunn, Guerrero, & Sniezek, 1999)

32. Mobility Communication Memory Attention Speed of thought & action Problem solving/planning Fatigue Judgment Emotional/behavioral control Initiation/Inhibition TOP TEN CHANGESAFTER BRAIN INJURY

33. Physical Hemiplegia/ hemiparesis Spasticity Tremors Medical complications Swallowing Hearing loss Seizures Double vision Visual field cuts Changes in sensory perception Fatigue Ataxia (problems with balance/coordination Dysphagia Dysarthria Autonomic dysfunction Apraxia Left neglect Emotional/Behavioral Agitation (excessive restlessness) Lack of cooperation Frustration tolerance Irritability, aggression Inappropriate sexual behavior Emotional lability Distortions of reality Paranoia Depression/Anxiety Judgment Obsessions or compulsions Overeating/overdrinking Anorexia Confusional behavior Wandering Neglect of hygiene Loose associations Tangentiality Echolalia/echopraxia Egocentrism Decreased social skills Lack of initiation /motivation Apathy Utilization behavior Misidentification Perseveration Disinhibition Impulsivity Inappropriate affect Tolerance for stimulation Response to social cues Confabulation Psychosocial • Imbalance in family relationships • Peer relationships lost • Decreased or lack of independence • Emotional disturbances • Alteration of self / identity • Alteration of career & life goals • Drugs & alcohol • Sexuality Changes After Brain Injury Cognitive • Level of consciousness • Attention/concen-tration • Memory • Expressive language (spoken and/or written) • Receptive language • Constructional ability • Orientation • Abstract thought • Planning/goal formation • Organizing • Insight • Generalization • Flexibility • Problem solving • Speed of mental processing • Academic skills • Right-left orientation • Self-awareness Family • Emotional reactions (anger, denial, depression, guilt) • No final stage of acceptance (brain injury is forever deal) • No “empty nest” for parents • No time to work • Attachment/emotional conflicts (injured member is changed; not the same person) • Financial loss • Loss of friends • Role changes • Children compete with injured member for parent’s attention • Non-injured parent devotes all: no time • Social roles non-existant or significantly decreased • Children/siblings neglected/ increased responsibilities

34. Severity of Injury: MILD • 75-90% of all brain injuries • LOC less than 20-30 minutes • A concussion is a mild brain injury • Most recover within hours or days • May have problems over time (e.g., headache, attention, memory, fatigue, emotional problems)

35. Severity of Injury: MODERATE • 8-10% of all brain injuries • LOC less than about 6 hours • 3 months post-injury 2/3 have not returned to work • 33-50% have residual problems (e.g., initiation including sexual, memory, temper, poor planning)

36. Severity of Injury: SEVERE • Less than 10% of all brain injuries • LOC more than 6 hours • Cognitive, emotional/behavioral, physical problems • Socially isolated/psychiatric problems • Likely greater long-term impairment

37. 3 Question DVBIC TBI Screening Tool 1. Did you have any injury(ies) during your deployment from any of the following? (check all that apply): A. 􀀀 Fragment B. 􀀀 Bullet C. 􀀀 Vehicular (any type of vehicle, including airplane) D. 􀀀 Fall E. 􀀀 Blast (Improvised Explosive Device, RPG, Land mine, Grenade, etc.) F. 􀀀 Other Specify:_______________________________

38. 3 Question DVBIC TBI Screening Tool 2. Did any injury received while you were deployed result in any of the following? (check all that apply): A. 􀀀 Being dazed, confused or “seeing stars” B. 􀀀 Not remembering the injury C. 􀀀 Losing consciousness (knocked out) for less than a minute D. 􀀀 Losing consciousness for 1-20 minutes E. 􀀀 Losing consciousness for longer than 20 minutes F. 􀀀 Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) G. 􀀀 Head Injury H. 􀀀 None of the above NOTE: Confirm F and G through clinical interview NOTE: Endorsement of A-E meets criteria for positive TBI Screen

39. 3 Question DVBIC TBI Screening Tool 3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? (check all that apply): A. 􀀀 Headaches E. 􀀀 Ringing in the ears B. 􀀀 Dizziness F. 􀀀 Irritability C. 􀀀Memory problems G. 􀀀 Sleep problems D. 􀀀 Balance problems H. 􀀀 Other specify:___________

40. What are the costs of TBI? Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $60 billion in the United States in 1995. …in Texas, approximately $1.08 billion each year.

41. Myths About Brain Injury REALITY The cognitive and behavioral effects of a brain injury can last long after the person heals “on the outside.” MYTH Visible, physical recovery is a sign that the brain is healed.

42. Myths About Brain Injury, Cont’d. REALITY It may just take longer for the effects of a brain injury to show up in a growing and developing brain. MYTH Younger children are more resilient and can therefore “bounce back” easier and more quickly from a brain injury.

43. Myths About Brain Injury, Cont’d. REALITY Even a 60 second loss of consciousness has resulted in DAI (as seen on autopsy). MYTH Mild brain injury has no long term effects.

44. Myths About Brain Injury, Cont’d. REALITY There is no cure for a brain injury. MYTH Time heals.

45. Arizona Governor’s Council on Spinal & Head Injuries. Adapted with permission.

46. Continuum of Treatment for TBIACUTE REHABILITATION SETTING: Military Treatment Facilities (MTFs): Walter Reed Army Medical Center, Wilford Hall US Air Force Medical Center, Brooke Army Medical Center, Fort Sam Houston/Lackland Air Force Base, Naval Medical Center-San Diego Rehabilitation Hospital Home/Community-Based Rehabilitation Programs • Typically transferred from acute care hospital/trauma center • After medical stabilization • Begin rehabilitation & therapies

47. RESOURCES Funding for services DOD, Insurance for active duty military Public: DARS (CRS Program), Medicaid (for children), Crime Victim’s Fund Private insurance BARRIERS (Civilian) Limited length-of-stay May be discharged without adequate information Lack of coordination of community services (Case Management) at discharge Cultural/language issues ACUTE REHABILITATION

48. Continuum of Treatment for TBIPOST-ACUTE REHABILITATION SETTINGS: Active Duty Military:MTFs, Concussion Clinics (Ft. Bragg, Camp Pendleton) Veterans:VA Polytrauma Rehabilitation Centers (Minneapolis, Palo Alto, Richmond, Tampa, [San Antonio]), Polytrauma Network Sites (1 in each VISN), Lakeview Virginia Neurocare, Laurel Highlands Neuro-Rehabilitation Center Outpatient Day therapy Residential Vocational Home/Community-Based • Comprehensive rehabilitation • Focused on functional independence and/or vocational rehabilitation

49. RESOURCES DOD & VA, Insurance for active duty military and veterans Publicly funded programs through DARS (CRS Program) Some private insurance provides benefits BARRIERS (Civilian) Limited length-of-stay Eligibility May be waiting lists for public services Limited access to supports and services Lack of coordination of community services (Case Management) at discharge Cultural/language issues POST-ACUTE REHABILITATION

50. Continuum of Treatment for TBILONG-TERM CARE SETTINGS: Day programs at VA Medical Centers Family home Supervised living facilities Assisted living settings Nursing homes Group homes Mental hospital Prison Street • Depends on severity of injury • Depends on individual’s support system • May require lifetime supervised living