TBI & Older Adults: Special Considerations for Behavioral Health Professionals, Caregivers and

Community Providers

Heartwarming yes, but what is wrong with these

pictures?

What do These Individuals Have in

Common ?• Katherine Graham-publisher

Washington Post

• Robert Atkins-Diet doctor

• Kurt Vonnegut-author

• Ed McMahon- former Tonight Show host & TV personality

They were all vibrant older adults who died from traumatic brain injury

incurred via falls.

Agenda

• The incidence and prevalence of TBI

• What is brain injury?

• What are the types of brain injury?

• Brain Injury and Older Adults

• Strategies to support

• Resources

Incidence of TBI

Centers for Disease Control (CDC) 2010, 2002-2006 data

In the United States, at least

1.7 million sustain a TBI each year…

275,000 are hospitalized

Incidence of TBI CDC 2010

Of those 1.7 million.. 52,000 die of their injuries

This equals the approximate number of people needed to fill

Yankee Stadium

CDC DATA 2010

• 1,365,000 million are treated an released from an emergency department

• TBI is a contributing factor to a third (30.5%) of all injury related deaths

• The majority of TBIs that occur each year are concussions or other forms of mild TBI

Maryland 2007-2011 Hospitalization Data

updated November 2013, DHMH • After a 3 year trend of declining TBI

related hospitalizations, rates increased 21% between 20010-2011

• 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

Maryland 2007-2011 ED Visit Data

updated November 2013, DHMH • TBI related ED visits increased by 7%

between 2010-2011

• The age groups with the highest rate of ED visits are 5-14, and 65-74

• Most common cause of TBI related ED visits are MVAs, followed by falls

Causes of TBI CDC 2010

Analyzing Falls- Simon Fraser, University of Vancouverhttp://www.youtube.com/watch?v=Z3e1Xvnj8Wo• Analyzed video from two assisted living

facilities and cross referenced with staff reports

• 70% of the falls occurred during attempts to perform daily living activities (e.g walking, playing catch during recreation)

• The rest occurred attempting to make contact with an external object (e.g.chair)

Anthony J. DiPasquale OD, 4.13.13 Lecture on Trauma & The

ElderlyNew Jersey Institute for Successful Aging

http://www.youtube.com/watch?v=5K67IAjEiag• Low force = substantial injury• In elderly falls = 50% of traumatic injuries HIGH

risk for repeats• Adults 65 years of age and older are greater risk

by being hit by a car as a pedestrian than children• Many older adults cannot navigate crossing the

street at a crosswalk at the expected rate of 4 feet per second

Why are Older Individuals Vulnerable to Falls Leading to Brain Injury?

Adapted from BrainInjuryEducation.org & The Centers for Disease Control & Prevention

• Reduced balance, strength, and reaction time• Medications with side effects such as

dizziness, balance impairment, fatigue, blood thinners such as Coumadin

• Age related structural changes in the brain• Visual impairments such as glaucoma• Substance use can be an issue

Skull AnatomyThe skull is a rounded layer of bone designed to protect the brain from penetrating injuries.

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.

Bony ridges

Lobes of the Cerebrum

Frontal lobe

Parietal lobe

Temporal lobe

Temporal lobe

Adults age 75 years or older have a high rate of TBI

related hospitalization and death (599 per 100,000)

CDC 2010

Falls are the Leading Cause of Traumatic Brain Injury

CDC Website 2012

Why are Older Individuals Vulnerable to Falls Leading to Brain Injury?

Adapted from Brain Injuryeducation.org & The Centers for Disease Control

• Reduced balance, strength, and reaction time

• Medications with side effects such as dizziness, balance impairment, fatigue, blood thinners such as Coumadin

• Age related structural changes in the brain

• Visual impairments such as glaucoma

• Substance use can be an issue/**

Rehabilitation Works!Researchers New

Jersey found that after mild TBI, “functional outcome is good to

excellent for both elderly and younger patients. Older patients required more

inpatient rehabilitation and lagged behind their younger counterparts but continued to recover and improve after

discharge”

Types of TBI• Distribution of Severity:

– Mild injuries = 80% (Loss of Consciousness) < 30 min, PTA ,1 hour)

– Moderate = 10 - 13% (LOC 30 min-24 hours, PTA 1-24 hours)

– Severe = 7 - 10% (LOC >24 hours, PTA >24 hours)

Impact of Brain Injury

• Physical; balance, coordination, headaches, fatigue, visual problems

• Cognitive; memory, attention, concentration, processing, receptive and expressive language difficulties, new learning difficulties

• Emotional/Behavioral; depression, impulse control, mood swings, irritability and emotional lability

Aging With A Traumatic Brain Injury, Some Risk Factors

adapted from TBI Research Brief~Western Oregon University 7.12

• The injury is incurred later in life, with the impact worsening as the individual ages

• The injury is more severe

• There are repeated injuries

• There are genetic markers (ApoE4 genotype)

• The individual is a male

Aging With A Traumatic Brain Injury, Other Issuesadapted from TBI Research Brief~Western Oregon

University 7.12

• Medication issues (individuals with TBI may respond differently then individuals w/out TBI to medications/dosages)

• Increased risk of falls due to TBI balance issues

• Seizures, chronic pain, hearing loss, headaches…..

“TBI Accelerates Aging”

Brain Injury and Dementia & Alzheimer’s Disease

• Taiwanese researchers reported an increase risk of dementia among individuals with TBI (2012)

• A study in Finland suggests that fall related TBI predicts an earlier onset of dementia and the effect was higher among those who carry the ApoE epsilon4 allele

• At the University of Pittsburgh researchers discovered that following severe TBI, plaques and early evidence of neuronal degenerative changes can develop rapidly after brain injury, increasing the risk of developing the pathological and clinical symptoms of Alzheimer’s Disease

NFL, Concussion & Alzheimer’s Disease (Guskiewicz

et. al. 2005)• 61% of the former players sustained at least

one concussion in their career• 24% sustained 3 or more concussions

• Retired players with 3 or more concussions had a fivefold prevalence of reported significant memory problems compared to players with no hx of concussion

• Researchers also observed an earlier onset of Alzheimer's disease in retirees than in general male population.

Boston University’s Ann McKee and others are exploring the link between repetitive

head injury and Chronic Traumatic Encephalophy

• Derek Boogaard- “enforcer” for the NFL Rangers• Chris Henry-Cincinnati Bengals• Chris Benoit-professional wrestler• Justin Strzelczyk-Pittsburgh Steelers• Mike Webster-Pittsburgh Steelers• Owen Thomas-Lineman-University of Pennsylvania • John Grimsley-Houston Oilers

Sources: Jeffery Kluger, Time Magazine 12.6.11 & Ann C. McKee, MD in written testimony presented to the House Judiciary Committee hearing on Legal Issues Relating to Football Head Injuries 8.28.09

What can older adults, professionals and family

members do?Preventive measures

Screen for a history of brain injury

Strategies to support

Resource and Referral

Prevention Tips from the Centers for Disease Control• Exercise: activities that address balance

and coordination are especially helpful

• Review medicines with health care provider

• Have vision checked

• Fall proof homes and facilities

Screen for a History of Brain Injury

• Review medical records

• Take a detailed history

• Use the HELPS Screening

• Observe, does the individual have difficulty learning new routines, information, retaining names, difficulty communicating thoughts either verbally or in writing?

The HELPS Brain Injury Screening Tool

(see handout)

The original HELPS tool developed by M. Picard, D. Scarisbrick, R.

Paluck, 9.1991Updated by the Michigan Department

of Community Health

Strategies

• Use of a journal/calendar

• Create a daily schedule

• “To do” lists and shopping lists

• Labeling items

• Learning to break tasks into small manageable steps

• Use of a digital recorder

Strategies

• Encourage use of rest and low activity periods

• Work on accepting feedback or coaching from others

• Work on generalizing strategies to new situations

• Use of a high lighter• Alarm watch

Strategies

• Review schedule each day

• Post signs on the wall etc.

• Try to “routinize” the day as much as possible

Strategies

• Safety checklist (e.g. for use of stove)reinforces attention

• Checklists- “things to do before leaving the house” (turn off all the appliances?, lock all the doors?, did I take my morning medications? turn down the heat/turn off the air conditioner?, do I have money or keys?, where am I going?, how will I get there? What time should I leave? Etc.) Very good for routine tasks, reinforces memory

• Place visual cues in the environment (cupboard labels, written directions, calendars, list of emergency phone numbers) reinforces memory

Even for individuals with poor new learning capacity due to a brain

injury, keep in mind the three R’s Review

Rehearse&

Repeat Can lead to mastery of tasks as

they eventually enter into memory

References, Resources&

Referral Information

References

• The Brain Injury Guide & Resources, a Collaboration of the Missouri Department of Health and Senior services and the MU Department of Health Psychology www.braininjuryeducation.org

• The Centers for Disease Control and Prevention, www.cdc.gov/BrainInjuryInSeniors

• The Fact of the Matter, Evidence-based practices in traumatic brain injury. A Publication of the Center on Brain Injury Research and Training~Teaching Research Institute~Western Oregon University, TBI Research Brief No. 11. July 2012 www.cbirt.org

References• Mosenthal AC, Livingston DH, Lavery RF, Knudson

MM, Lee S, Morabito D, Manley GT, Nathens A, Jurkovich G, Hoyt DB, Coimbra R. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. Journal of Trauma. 2004; May;56(5): 1042-8.

• Luukinen H, Viramo P, Herala M, Kervinen K, Kesaniemi YA, Savola O, Winqvist S, Jokelainen J, Hillborn M. Fall-related brain injuries and the risk of dementia in elderly people: a population-based study. European Journal of Neurology. 2005; Feb; 12(2):86-92.

References• Wang HK, Lin SH, Sung PS, Wu MH, Hung KW,

Wang LC, Huang CY, Lu K, Chen HJ, Tsai KJ. Population based study on patients with traumatic brain injury suggests increased risk of dementia. Journal of Neurological Neurosurgery & Psychiatry 2012 Nov; 83(11): 1080-5. doi: 10.1136/jnnp-2012-302633. Epub 2012 Jul. 27

• Ikonomovic MD, Uryu K, Abrahamson EE, Ciallella JR, Trojanowski JQ, Lee VM, Clark RS, Marion DW, Wisniewski SR, DeKosky ST. Alzheimer’s pathology in human temporal cortex surgically excised after severe brain injury. Experimental Neurology 2004. Nov; 190(1): 192-203

References

• Slides 16 & 17 adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

Resources• Brain Injury Association of America 703-236-

6000, www.biausa.org• Brain Injury Association of Maryland 410-448-

2924, www.biamd.org• Ohio Valley Center For Brain Injury

Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org.

• www.headinjury.com. Good resource for memory aides and tips

Resources• Centers for Disease Control www.cdc.gov/injury. 770-

488-1506• Http://www.neuro.pmr.vcu.edu/ National Resource

Center for Traumatic Brain Injury, developed by the Medical College of Virginia and Virginia Commonwealth University. Offers useful articles that are very user friendly, and a catalogue of nicely priced resources for working with people with brain injury

Resources

• www.cdc.gov/traumaticbraininjury/pdf/PreventingBrainInjury_Factsheet_508_080227.pdf

• www.brainline.org/content/2009/06/aging-with-a-brain-injury.html

Resources• The University of Alabama Traumatic Brain Injury Model

System has created the UAB Home Stimulation Program. This program offers many activities for use by individuals with brain injuries, their families and the professionals who work with them. The activities are designed to help support cognitive skills and can be done in the home setting. The Home Stimulation Program can be accessed from the Internet at htt://main.uab.edu/show.asp?durki=49377. For further information contact: Research Services, Dept. of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, 619 19th St. S SRC 529, Birmingham, AL 35249-7330/ 206-934-3283. Tbi@uab.edu.

The Michigan Department of Community Health

Web-Based Brain Injury Training for Professionals

www.mitbitraining.orgThis free training consists of 4 module that

take an estimated 30 minutes each to complete. The purpose of the training is

twofold, to “ensure service providers understand the range of outcomes” following

brain injury and to “improve the ability of service providers to identify and deliver

appropriate services for persons with TBI”

Anastasia EdmonstonTBI Trainer

Mental Hygiene Administration

anastasia.edmonston@maryland.gov

410-402-8478