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Assisting Patients with Traumatic Brain Injury: A Brief Guide for Primary Care Physicians Margaret A. Struchen, Ph.D. 1,2 Lynne C. Davis, Ph.D. 1,2 Stephen.

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Presentation on theme: "Assisting Patients with Traumatic Brain Injury: A Brief Guide for Primary Care Physicians Margaret A. Struchen, Ph.D. 1,2 Lynne C. Davis, Ph.D. 1,2 Stephen."— Presentation transcript:

1 Assisting Patients with Traumatic 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 Scale 5 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/aggression 23 Substance use 25  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 stressors 34  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

51 Impaired Self-Awareness (ISA)  Major challenge to healthcare professionals and family members is impaired self-awareness.  As direct result of TBI, some individuals have difficulty seeing themselves and their abilities and behaviors accurately.  Nearly 45% of those with moderate to severe TBI may experience a significant degree of ISA. 39  Problems with ISA are associated with: Poor treatment compliance Longer rehabilitation stays Increased caregiver distress Poorer vocational outcomes 40 © Baylor College of Medicine, 2009

52 Impaired Self-Awareness (ISA)  ISA is different than denial. Denial: person is aware at some level that problem exists but uses defense mechanisms to deny the problem ISA: person does not realize that a problem is present or is unaware of how problems might impact their ability to perform daily tasks. © Baylor College of Medicine, 2009

53 Impaired Self-Awareness (ISA)  ISA may pose challenges to physicians as patient may not fully understand the reasons for a referral or may not be able to provide accurate history regarding symptom and presenting problem.  ISA often noted more with more general questions (do you have problems with memory?), rather than specific ones (can you remember to go to scheduled appointments?). 21  ISA also more pronounced with nonphysical functioning (cognitive and affective issues) than with physical functioning. 21  You may need to use more specific questions to elicit information and/or may need assistance of a family member or close other to help provide clinical history. © Baylor College of Medicine, 2009

54 Impaired Self-Awareness (ISA)  Presence of ISA may vary from person to person and over time after injury.  Patients may or may not be able to report presence of symptom, report how such symptoms affect functioning, or anticipate when such symptoms are likely to affect functioning in future situations.  For many with ISA, improvements are noted over time.  However, post-acute brain injury rehabilitation programs may be helpful for increasing awareness.  Consultation with physiatrist or neuropsychologist may be helpful, particularly if awareness problems are interfering with your ability to treat your patient or are contributing to family distress. © Baylor College of Medicine, 2009

55 Sexual Dysfunction  Problems with sexual functioning and/or intimacy issues are not uncommon among persons with TBI.  Although typically not addressed during medical appointments, including a standard question or questions about sexual functioning may be important (especially if other factors such as prescription medications or depression may impact sexual functioning). © Baylor College of Medicine, 2009

56 Sexual Dysfunction  More common problems after TBI include: 41 Diminished libido Decreased frequency of intercourse Difficulty achieving/maintaining erection Difficulty reaching orgasm  Much less commonly reported include: Hypersexuality Problem sexual behaviors (e.g. exhibitionism, public or frequent masturbation, promiscuity, sexual aggressiveness).  Sexual problems not limited to those with moderate/severe TBI, but may occur in those with mild TBI as well. 42 © Baylor College of Medicine, 2009

57 Alcohol and Substance Use/Abuse  Likelihood of confronting issues related to alcohol or other substance use is high. 43-46  May be a pre-injury issue and often related to cause of injury.  Can also be a post-injury issue.  Alcohol and substance use/abuse associated with poorer outcomes. 47-50 © Baylor College of Medicine, 2009

58 Alcohol and Substance Use/Abuse  Pre-injury abuse in patients with TBI is common. 45, 51  Pre-injury history of alcohol abuse related to: Higher mortality Greater frequency of mass lesions Poorer neuropsychological functioning acutely and at 1- year follow-up Poorer global outcome 45, 52-53  If TBI occurred as result of alcohol intoxication, patient has a 4-fold increased risk of sustaining a second TBI. 54 © Baylor College of Medicine, 2009

59 Alcohol and Substance Use/Abuse  Post-injury substance use also carries significant morbidity after injury (particularly for those with greater TBI severity).  Substance use may have greater effect on cognition and judgment than may have been the case prior to injury.  Highly problematic for patients with poor insight, reasoning, and judgment who become even more impaired while drinking or using illegal drugs. © Baylor College of Medicine, 2009

60 Alcohol and Substance Use/Abuse  Although alcohol and substance use/abuse often declines in the near-term following TBI, longer-term follow-up studies suggest that use (of alcohol in particular) increases to pre-injury levels over time.  Approximately 15-25% of persons with TBI who were abstinent or light drinkers prior to injury may become heavy drinkers after injury. 55 © Baylor College of Medicine, 2009

61 References  1. Levin HS, Mattis S, Ruff RM, et al. Neurobehavioral outcome following minor head injury: a three-center study. Journal of Neurosurgery. Feb 1987;66(2):234-243.  2. Ruff RM, Camenzuli L, Mueller J. Miserable minority: Emotional risk factors that influence the outcome of a mild traumatic brain injury. Brain Injury. Aug 1996;10(8):551- 565.  3. McCauley SR, Boake C, Pedroza C, et al. Correlates of persistent postconcussional disorder: DSM-IV criteria versus ICD-10. J Clin Exp Neuropsychol. Jul 25 2007:1-20.  4. Binder LM, Rohling ML. Money matters: a meta-analytic review of the effects of financial incentives on recovery after closed-head injury. The American journal of psychiatry. Jan 1996;153(1):7-10.  5. Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of depression in traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2004; 85:1457-1464.  6. Fann J, Katon W, Uomoto J, Esselman P. Psychiatric disorders and functional disability in outpatients with traumatic brain injury. American Journal of Psychology 1995; 152:1493- 1499.  7. Federoff JP, Starkstein SE, Forrester AW, et al. Depression in patients with acute traumatic brain injury. American Journal of Psychiatry 1992; 149:918-923.  8. Jorge RE, Robinson RG, Moser D. Tateno A, Crespo-Facorro B, Arndt S. Major depression following traumatic brain injury. Archives of General Psychiatry 2004; 61:42-50. © Baylor College of Medicine, 2009

62 References  9. Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of depression after traumatic brain injury: A comprehensive examination. Brain Injury 2001; 15:563-576.  10. Seel RT, Kreutzer JS. Depression assessment after traumatic brain injury: An empirically-based classification method. Archives of Physical Medicine and Rehabilitation 2003; 84:1621-1628.  11. Seel RT, Kreutzer JS, Rosenthal M, Hammond FM, Corrigan JD, Black K. Depression after traumatic brain injury: A National Institute on Disability and Rehabilitation Research model systems multicenter investigation. Archives of Physical Medicine and Rehabilitation 2003; 84:177-184.  12. Underhill AT, Lobello SG, Stroud TP, Terry KS, Devivo MJ, Fine PR. Depression and life satisfaction in patients with traumatic brain injury: A longitudinal study. Brain Injury 2003; 17:973-982.  13. Rappoport MJ, McCullagh S, Shammi P, Feinstein A. Cognitive impairment associated with major depression following mild and moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. Winter 2005;17(1):61-65.  14. Keiski MA, Shore DL, Hamilton JM. The role of depression in verbal memory following traumatic brain injury. Clin Neuropsychol. Sep 2007;21(5):744-761.  15. Farrin L, Hull L, Unwin C, Wykes T, David A. Effects of depressed mood on objective and subjective measures of attention. J Neuropsychiatry Clin Neurosci. Winter 2003;15(1):98- 104.  16. Chamelian L, Feinstein A. The effect of major depression on subjective and objective cognitive deficits in mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. Winter 2006;18(1):33-38. © Baylor College of Medicine, 2009

63 References  17. Jorge RE, Robinson RG, Starkstein SE, Arndt SV. Influence of major depression on 1-year outcome in patients with traumatic brain injury. J Neurosurg. Nov 1994;81(5):726-733.  18. McCleary C, Satz P, Forney D, et al. Depression after traumatic brain injury as a function of Glasgow Outcome Score. J Clin Exp Neuropsychol. Apr 1998;20(2):270-279.  19. Robinson RG, Jorge RE. Mood disorders. In: Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of traumatic brain injury. Washington, D.C.: American Psychiatric Publishing, Inc. ; 2005:201-212.  20. Sherer M, Bergloff P, Boake C, High W, Jr., Levin E. The Awareness Questionnaire: factor structure and internal consistency. Brain Inj. Jan 1998;12(1):63-68.  21. Sherer M, Boake C, Levin E, Silver BV, Ringholz G, High WM, Jr. Characteristics of impaired awareness after traumatic brain injury. J Int Neuropsychol Soc. Jul 1998;4(4):380-387.  22. Bay E, Hagerty BM, Williams RA. Depressive symptomatology after mild-to-moderate traumatic brain injury: a comparison of three measures. Arch Psychiatr Nurs. Feb 2007;21(1):2- 11.  23. Oquendo MA, Friedman JH, Grunebaum MF, Burke A, Silver JM, Mann JJ. Suicidal behavior and mild traumatic brain injury in major depression. J Nerv Ment Dis. Jun 2004;192(6):430- 434.  24. Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study. Brain Inj. Nov 2001;15(11):935-945. © Baylor College of Medicine, 2009

64 References  25. Teasdale TW, Engberg AW. Suicide after traumatic brain injury: a population study. J Neurol Neurosurg Psychiatry. Oct 2001;71(4):436-440.  26. Simpson G, Tate R. Clinical features of suicide attempts after traumatic brain injury. J Nerv Ment Dis. Oct 2005;193(10):680-685.  27. Bryant RA, Harvey AG. Relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. Am J Psychiatry. May 1998;155(5):625-629.  28. Bryant RA, Marosszeky JE, Crooks J, Gurka JA. Posttraumatic stress disorder after severe traumatic brain injury. Am J Psychiatry. Apr 2000;157(4):629-631.  29. Levin HS, Brown SA, Song JX, et al. Depression and posttraumatic stress disorder at three months after mild to moderate traumatic brain injury. J Clin Exp Neuropsychol. Dec 2001;23(6):754-769.  30. van Reekum R, Bolago I, Finlayson MA, Garner S, Links PS. Psychiatric disorders after traumatic brain injury. Brain Inj. May 1996;10(5):319-327  31. Hiott DW, Labbate L. Anxiety disorders associated with traumatic brain injuries. NeuroRehabilitation. 2002;17(4):345-355.  32. Rogers JM, Read CA. Psychiatric comorbidity following traumatic brain injury. Brain Injury. 2007;21(13-14):1321-1333.  33. Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis I disorders. Arch Phys Med Rehabil. Apr 2004;85(4 Suppl 2):S36-42. © Baylor College of Medicine, 2009

65 References  34. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. Jan 2003;129(1):52-73.  35. McMillan TM. Post-traumatic stress disorder following minor and severe closed head injury: 10 single cases. Brain Inj. Oct 1996;10(10):749-758.  36. Levin HS, Grossman RG. Behavioral sequelae of closed head injury. A quantitative study. Arch Neurol. Nov 1978;35(11):720-727.  37. Hibbard MR, Uysal S, Kepler K, Bogdany J, Silver J. Axis I psychopathology in individuals with traumatic brain injury. J Head Trauma Rehabil. Aug 1998;13(4):24-39.  38.Tateno A, Jorge RE, Robinson RG. Clinical correlates of aggressive behavior after traumatic brain injury. J Neuropsychiatry Clin Neurosci. Spring 2003;15(2):155-160.  39. Freeland J. Awareness of deficits: A complex interplay of neurological, personality, social and rehabilitation factors. Magazine. 1996;4:32-34.  40. Sherer M. Rehabilitation of impaired awareness. In: High WM, Jr., Sander AM, Struchen MA, Hart KA, eds. Rehabilitation for traumatic brain injury. New York: Oxford University Press; 2005:31-46.  41. Kreutzer JS, Zasler ND. Psychosexual consequences of traumatic brain injury: methodology and preliminary findings. Brain Inj. Apr-Jun 1989;3(2):177-186.  42. Kosteljanetz M, Jensen TS, Nørgård B, Lunde I, Jensen PB, Johnsen SG. Sexual and hypothalamic dysfunction in the postconcussional syndrome. Acta Neurol Scand. Mar 1981;63(3):169-180. © Baylor College of Medicine, 2009

66 References  43. Sherer M, Bergloff P, High W, Jr., Nick TG. Contribution of functional ratings to prediction of longterm employment outcome after traumatic brain injury. Brain Inj. Dec 1999;13(12):973-981.  44. Bogner JA, Corrigan JD, Mysiw WJ, Clinchot D, Fugate L. A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury. Arch Phys Med Rehabil. May 2001;82(5):571-577.  45. Corrigan JD. Substance abuse as a mediating factor in outcome from traumatic brain injury. Arch Phys Med Rehabil. Apr 1995;76(4):302-309.  46. Corrigan JD, Bogner JA, Mysiw WJ, Clinchot D, Fugate L. Life satisfaction after traumatic brain injury. J Head Trauma Rehabil. Dec 2001;16(6):543-555.  47. Kreutzer JS, Marwitz JH, Witol AD. Interrelationships between crime, substance abuse, and aggressive behaviours among persons with traumatic brain injury. Brain Inj. Nov-Dec 1995;9(8):757-768.  48. Brooks N, Symington C, Beattie A, Campsie L, Bryden J, McKinlay W. Alcohol and other predictors of cognitive recovery after severe head injury. Brain Inj. Jul-Sep 1989;3(3):235- 246.  49. Hall KM, Karzmark P, Stevens M, Englander J, O'Hare P, Wright J. Family stressors in traumatic brain injury: a two-year follow-up. Arch Phys Med Rehabil. Aug 1994;75(8):876- 884.  50. Kreutzer JS, Wehman PH, Harris JA, Burns CT, Young HF. Substance abuse and crime patterns among persons with traumatic brain injury referred for supported employment. Brain Inj. Apr-Jun 1991;5(2):177-187. © Baylor College of Medicine, 2009

67 References  51.Corrigan JD, Bogner J, Lamb-Hart G. Problematic substance use identified in the TBI Model Systems national database: The Center for Outcome Measurement in Brain Injury. Center for Outcome Measurement in Brain Injury (COMBI) website: 2003. Accessed March 20, 2008.  52. Dikmen SS, Donovan DM, Loberg T, Machamer JE, Temkin NR. Alcohol use and its effects on neuropsychological outcome in head injury. Neuropsychology. 1993;7(3):296-305.  53. Ruff RM, Marshall LF, Klauber MR, et al. Alcohol abuse and neurological outcome of the severely head injured. Journal of Head Trauma Rehabilitation. 1990;5(3):21-31.  54. Winqvist S, Luukinen H, Jokelainen J, Lehtilahti M, Nayha S, Hillbom M. Recurrent traumatic brain injury is predicted by the index injury occurring under the influence of alcohol. Brain Inj. Sep 2008;22(10):780-785.  55. Corrigan JD, Rust E, Lamb-Hart GL. The nature and extent of substance abuse problems among persons with traumatic brain injuries. J Head Trauma Rehabil. 1995;11(5):58-69. © Baylor College of Medicine, 2009

68 Module 4 Modifying Clinical Practice and Suggestions Regarding Resources © Baylor College of Medicine, 2009

69 Modifications to Clinical Practice  Patients with TBI may experience sensory, motor, cognitive, behavioral, and emotional difficulties that can impact the ability to provide accurate history and to comply with treatment.  This section provides selected examples of tips to assist you in working with patients with TBI. © Baylor College of Medicine, 2009

70 Modifications to Clinical Practice  Patient with learning/memory problems: Provide all important information in writing. Repeat important information many times. Ask patient to repeat back important information. Depending on severity of the impairment, consultation with family or close others may be needed. Patients should be encourage to write down important information in an organized fashion (like a planner or memory notebook). Patients may need reminder calls the day before their appointments, and in some cases, on the day of the appointment as well. © Baylor College of Medicine, 2009

71 Modifications to Clinical Practice  Patient with attention problems: Conduct session in a quiet environment with minimal distraction Focus on one topic at a time Ask patient to repeat back important information If patient is getting off-topic, provide redirection and cueing to return to topic at hand. © Baylor College of Medicine, 2009

72 Modifications to Clinical Practice  Patients with slowed speed of processing: Allow extra time for patient to process your statements and to respond. Present information at a slower rate of speed, and focus on one issue at a time. Encourage the patient to ask others to slow down or repeat information as needed. © Baylor College of Medicine, 2009

73 Modifications to Clinical Practice  You may wish to consider staff training for all support staff to ensure that all patients are treated with courtesy and flexibility.  Training should include all staff members who might interact with patients, including receptionists, administrative assistants, and others.  Increasing staff knowledge about potential difficulties that patients with TBI may experience can prevent negative interactions from occurring.  Increased staff knowledge may also enhance the clinical experience for both patients and staff members. © Baylor College of Medicine, 2009

74 Modifications to Clinical Practice  Examples of issues that can present challenges to the staff/patient interaction: Dysarthria: some patients with TBI may have slurred speech, which can be misinterpreted as intoxication with patients being misperceived as being “drunk.” Increased staff awareness of this issue can prevent a negative interaction from occurring. In addition, such patients may require staff to pay close attention to patients to understand information. It may be necessary for staff to request that information be written down to ensure that they are receiving the correct interpretation of the patient’s communication. © Baylor College of Medicine, 2009

75 Modifications to Clinical Practice Slowed speed of processing/response: Patients may take longer to respond to questions or to get their ideas out. Encourage staff to be patient and wait for the patient to complete the statement. Bypassing the patient by speaking only to family can be upsetting to the patient with TBI. If clarification of the patient’s statement is needed, staff can then ask the patient or family to clarify. © Baylor College of Medicine, 2009

76 Modifications to Clinical Practice Memory problems: Patients with such problems are likely to have difficulty remembering appointments. To facilitate attendance, staff should be encouraged to: Provide appointment date/time in writing. Call patient with reminder the day before appointment. Consider calling on day of appointment for reminder. Provide any additional instructions needed for appointment in writing. © Baylor College of Medicine, 2009

77 Modifications to Clinical Practice  Take time to let staff members know if there are any modifications that you would recommend in interacting with specific patients to facilitate a good clinical experience.  Encourage staff to use courtesy with all patients and to come to you if they are having any particular challenge in interacting with a specific patient. © Baylor College of Medicine, 2009

78 Resources - Referrals  Your patient with TBI may benefit from referral to specialized healthcare providers and/or TBI- related resources. Here are some resources that you may find helpful in working with your patient with TBI: Physiatrist: physician specializing in rehabilitation of neurological conditions like TBI, stroke, and spinal cord injury. Such physicians also treat musculoskeletal injuries, pain syndromes, and sports injuries. Other physician specialists who may be helpful for your patient with TBI include: behavioral neurologists, neurorehabilitation specialists, and neuropsychiatrists/ © Baylor College of Medicine, 2009

79 Resources - Referrals Neuropsychologists: clinical psychologists with advanced training in brain-behavior relationships. They specialize in the assessment of cognitive functioning and may provide specification of your patient’s cognitive strengths and weaknesses, along with recommendations for interventions and referrals. Speech language pathologists: specialize in assessment, diagnosis, and treatment of language and cognitive communication disorders. They also evaluate and treat swallowing problems. Occupational therapists: work with patients to maximize performance of activities of daily living (e.g., dressing, grooming, bathing, feeding, etc.) Physical therapists: work with patients to improve their ability to move and function within their environment and to restore fitness and health. © Baylor College of Medicine, 2009

80 Resources - Referrals Clinical and counseling psychologists: provide psychotherapy to patients with TBI and their family members. Rehabilitation counselors: specialize in working with patients with disabilities, providing personal and vocational counseling, coordination of vocational training and job placement services. © Baylor College of Medicine, 2009

81 Resources - Referrals  Your patient with TBI and his or her family may also benefit from referral to state and nationally- run resources that may provide information and assistance. Examples include: Brain Injury Association of America: leading organization servicing and advocating for persons with TBI and their families. A network of 40 state affiliates and hundreds of local chapters provide information, education, and support. North American Brain Injury Society: organization composed of professionals involved in care of those with brain injury. Provides educational programs and scientific updates to all those interested. Vocational Services: Each state agency provides funding to assist patients in searching for employment, obtaining job training, and providing support for services to facilitate return to work. © Baylor College of Medicine, 2009

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