Difficulties in Treating Patients with Traumatic Brain injury

James A. Young, M.D.

Objectives

1. Describe the different medical and non-medical treatments available to diagnose and treat TBI

2. Examine the newest evidence-based treatments for TBI

3. Explain the difficulty of discharging patients with TBI

Disclosures

None

Introduction Predictability is fair at best Ten stages/patients for one diagnosis Limitless personality outcomes All organ systems involved Late problems Physical, mental, and emotional

disabilities Most behavioral problems are not the

patient’s fault Discharge complications at every level

Introduction Occurs every 15 seconds with 500,000 requiring hospitalization It is the leading killer and cause of disability in children and young

adults Motor vehicle crashes are a leading cause of death in the U.S. More

than 2.5 million  drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle crashes in 2012. The economic impact is also notable: in a one-year period, the cost of medical care and productivity losses associated with injuries from motor vehicle crashes exceeded $80 billion. http://www.cdc.gov/injury/wisqars, 2010

An estimated 2.4 million children and adults in the U.S. sustain a traumatic brain injury (TBI) and another 795,000 individuals sustain an acquired brain injury (ABI) from non-traumatic causes each year.

Currently more than 5.3 million children and adults in the U.S. live with a lifelong disability as a result of TBI and an estimated 1.1 million have a disability due to stroke.  (Statistics courtesy of the Centers for Disease Control and the Stroke Fact Sheet

Misunderstandings Few professionals in Medicine outside of

Neurology, Rehabilitation, Neurosurgery are knowledgeable about TBI

Phases of recovery can be confusing (and permanent)

Medicines used are frequently off-label and paradoxical

Cause and effect from the environment plays a key role

Behavioral and Cognitive issues predominate at all levels of recovery

Patients often look better than they are

Misunderstandings If a disability exists, all problems are somehow

connected with that disability ‘Not in my backyard’ Basis for knowledge

Readings Internet TV medical reporters TV and Movies Friends Sports (‘getting his bell rung’)

Misunderstandings

Cognitive Difficulties Behavioral Difficulties Emotional complexities If you cannot see it, it doesn’t exist Head injury versus Brain injury Prior exposure to TBI “I (or someone else ) had an injury,

and I have no problems”

Mechanisms of Injury Primary Injury

Direct brain injury Acceleration, deceleration, rotational

components Shearing forces between tissue planes of

different densities Structural damage, disruptions in

membrane stability Intra-axonal cytoskeletal function

changes Axonal transport mechanism change

Mechanisms of Injury Secondary

Changes due to ▪ Changes in cerebral metabolism▪ Hypoxia▪ Ischemia

Types of Injury Focal Diffuse Axonal Injury Hypoxia Penetrating

Focal Any location Usually anterior and inferior surfaces

of frontal and temporal lobes Frequently acceleration/deceleration Sagittal plane of injury if after

movement Occipital areas usually not involved

unless a direct blow

Diffuse Axonal Injury The major type of diffuse traumatic

cerebral injury Shearing axotomy Lateral and oblique directional

movements Coma lasts 6 hours or more

Hypoxic Brain Injury Worst prognosis Seen with other types of TBI Oxygen sensitive areas include the

hippocampus, basal ganglia and cerebellum

Seen in about 1/3 of severe TBI Arterial hypotension in 15% of

severe TBI (<90mmHg)

Penetrating Brain injury Diffuse perivascular damage and

focal disruption No axonal injury Diffusion of energy and formation of

a cavity which opens a and closes in milliseconds

Changes in intracranial pressure

Phases of Recovery Coma Acute Post-Acute Community

Coma No specific treatment or medicine shown

effective On going monitoring to prevent primary

and secondary changes Many with normal BAER’s, with changes in

heart rate, ICP with auditory stimulation Talking to comatose patients

Not time consuming and humane Not doing, may promote inappropriate

care Those awakening from coma-comments

Acute Care Intermediate and developing medical and

surgical concerns Behavioral and medicine adjustments Ward/Rehab treatment goals

Physical Therapy Occupational Therapy Speech and language pathology Psychology Family Education Some Recreational and Cognitive

remediation

Post Acute Rehabilitation treatment goals

Independent living skills Cognitive therapies Recreational therapies Community skills Family education

Behavioral and medicine adjustments

Community Rehabilitation treatment goals

Community independence Vocational services Cognitive retraining Transportation independence

Behavioral and medicine adjustments Social reintegration Respite care

Traumatic Brain Injury Each level of injury and recovery has its own

idiosyncrasies and needs Tremendous variation in treatment styles and

approaches Important to differentiate PTSD from brain

injury Exaggeration and malingering are rare but

easier and easier to detect Lifetime disabilities. The majority of disabilities after brain injury

are cognitive and behavioral, not physical

Traumatic Brain Injury

Vegetative versus minimally conscious

Voluntary versus involuntary activity Role of psychiatry and

neuropsychology Dependency issues and residential

concerns Power of attorney Conclusive proof of injury Legal implications

Traumatic Brain Injury The goal is to systematically identify qualitative

and quantitative predictors of functional outcome Although not the majority of injury, most

mapping studies look at the sensory and motor regions

Cognitive, behavioral, and language skills are less precise in the their localization and more diffusely distributed to various parts of the brain

Structural and functional relationships are more difficult to identify

Traumatic Brain Injury

Which determines a “lesion” depends on the imaging technique

Most injuries are not seen with today’s instruments

Combining different techniques has potential

The neuropsychological evaluation, history, and those close to the patient are usually the most helpful to corroborate story

Traumatic Brain Injury Glasgow Coma Scale with Post Traumatic

Amnesia Scale and the Disability Rating Scale probably the most sensitive combination

CTs performed commonly in the emergency room grossly underestimates the injury

MRIs correlate reasonably well with neuropsychological evaluations.

PET scans one third more sensitive than MRIs Brainstem lesions very predictive of a

negative outcome

Traumatic Brain Injury Diffusion Tensor Imaging

Detecting diffusion of water molecules in the tissue Software using using magnetic resonance imaging Tractography (an extension of DTI)▪ Directional pattern of diffusion with colors representing

direction of white matter connectivitiy▪ Green is anterior posterior▪ Red represents left and right▪ Blue represents head to foot or dorsal–ventral

Potential for mild and moderate traumatic brain injury, along with other disorders

Behavioral Problems Unlimited causes for behavioral

disturbances At all levels, behavioral concerns more

disabling than physical ones Difficulty predicting behaviors

Right and left sided syndromes Frontal lobe syndromes rarely specific Neuroanatomy and psychology partly

help Cortical/subcortical connections

Behavioral Problems-Symptoms/Syndromes Agitation Anxiety Childishness Limited self-aware. Facetiousness Impatience Lability Phobias Social inappropriate Aggressiveness Apathy Denial

Disinhibition Helplessness/Depen. Impulsivity Misperceptions Restless Suspicious Anger Depression Euphoria Indifference Paranoid Sexual interests Withdrawal

Behavioral Problems-Aggravating conditions

Late neurological sequelae

Pain syndromes Iatrogenic (meds) Sleep/wake cycles Depression Situational conflicts Recurrent head injury

Secondary medical problems

Vestibular dysfunctions

Drug/Alcohol abuse Pre-morbid psycho

problems Learned maladaptive

behavior

Neurology and the Law No test can accurately depict the mental

state at a specific past action or crime, only provide the substrate that may have contributed

Present studies involve simple tasks and are done in isolation and in sterile, stress-free environments. Study numbers are also small

It is likely that the neurosciences will supplement not replace moral and legal domains (Baskin, 2007)

Discharge problems With the PPS system, and the growth of managed care,

there has been a steady outflow of the acute inpatient population and growth of the outpatient, residential, subacute levels of care

Continuation for inpatient care has changed because of High costs Few long-term effectiveness studies Few standards of performance among similar providers Industry influenced by negative press Few models of care and service

Discharge problems Other factors

Lack of education by the consumers in interpreting marketing and advertising material

Not knowing what to ask Limited sources of information for social

workers, even treaters Dependence on word of mouth Use of Internet to observe legal entanglements

by facilities

How to Choose Where to Go Opinions of the primary treaters on present

needs▪ Medical stability▪ Cognitive concerns▪ Behavioral problems▪ Anticipated problems requiring close follow-up care or

emergency attention▪ Botox▪ Baclofen fills▪ Frequent adjustments of meds▪ Seizures▪ Specialty follow up

How to Choose Where to Go Family concerns

Distances Visits Personal involvement Sleeping arrangements Transportation Conferencing Staffing numbers Gyms, smells, roommates Restraint use, medications employed commonly Types of patients (numbers treated of each category)

How to Choose Where to Go Financial concerns

Type of insurance dictates much▪ Services▪ Duration▪ After skilled services (i.e. after PT monies are used)▪ Next level of care ▪ Follow-up visits▪ Emergency visits or hospitalizations▪ Surgical options▪ ‘Experimental’ trials (ITB pumps)

Home

Usually with 3x a week of ▪ SP, PT, OT

Nursing frequency depends on the needs Advantages▪ Familiarity of surroundings▪ Orientation assistance for many▪ Own bed▪ Rehab Without Walls▪ Local services or hospitals▪ Insurance frequently covers

Home

Disadvantages▪ Frequency of therapeutic visits▪ Duration of visits▪ Disruption of family life▪ Dependency on family/caregiver to be around▪ Experience of the caregivers, therapists with

TBI▪ Behavioral correction▪ Supervision of therapists/nurses

Subacute/Skilled nursing

Advantages▪ Level of medical acuity can be higher▪ Insurance coverage▪ Therapeutic coverage frequently

adequate but with 0.6-2.2 hours per day▪ Rehabilitative milieu▪ 24 hour care

Subacute/Skilled nursing

Disadvantages▪ Nursing ratios can be as high as 14:1 for CNA:RN▪ Number of beds per room▪ Mixing of populations and ages▪ Experience of facility for TBI▪ May not accept patients with any behavioral problems▪ Frequency of medical visits▪ Interaction with a non-treater can be problematic▪ Follow-up in the specialist’s office▪ Programmatic limitations (possible)

Day Rehab services

Advantages▪ Less acute dollars spent due to earlier discharge▪ Picks the patient up from home▪ Allows the family ‘down time’▪ Intensity of services▪ 3-6 hours per day with routine set▪ Frequently involves all services▪ Nursing services usually available▪ Can be daily, not on weekends▪ Possibilities of therapeutic outings

▪ Facilities usually specialize

Day Rehab services

Disadvantages▪ Cost▪ Sites may not be close and the ride to the

facility long▪ Duration of services over time▪ Numbers involved in the program▪ May be too strenuous▪ Milieu is reduced or minimized▪ Privacy considerations

Residential

Advantages▪ 24 hour care▪ Personal choices▪ Room decor▪ Roommate or not▪ Home like

▪ Longer stays▪ Focused on certain diagnoses▪ Community events▪ Outings▪ Shopping▪ Consistent orientation in facility

Residential Advantages▪ Seven day a week structure (or not)▪ Variable supervision ▪ Variable sizes of the house, apartment▪ Vocational training▪ Taking public transportation▪ Socialization opportunities

Residential

Disadvantages▪ Cost▪ Availability▪ Openings in the facility▪ Paucity of programs

▪ Distance▪ Medical acuity issues▪ Appointments

Conclusion

Due to shorter lengths of stay in the acute rehab setting, multiple layers of post-acute programs are now available

Significant differences regarding Cost Availability Support and professional help

Conclusion Prior to considering any of the options

Visit the facilities Ask the treaters MSW Insurance agents Research▪ Brain Injury Association▪ CARF

Family groups have significant data A true understanding which level of care is best for what

type of injury, at what point in the injury, and service outcomes is yet unknown