FALLS-RELATED TRAUMATIC BRAIN INJURY IN OLDER AUSTRALIANS New South Wales Council of Social Service; NSW Aged Care Alliance - October 22, 2009 Fast digest of policy paper recently completed for the policy paper paper on falls-related Traumatic Brain Injury prepared for the Australian Government's Department of Families, Housing, Community Services and Indigenous Affairs. do 3 things quickly – 1) provide a brief introduction to ABI/ TBI; 2) evidence on falls; 3) prevention… Restating the bleeding obvious…teaching you how to suck eggs…don’t mean to ”problematise” PWABI; awareness in this room may not necessarily be any higher than other parts of the community with regular dealings with disability – numbers are small, their participation, relative to other disability groups/ types, low. Glass-bottom boat tour of this landscape…slow me down, stop me if I’m going too fast…. FALLS-RELATED TRAUMATIC BRAIN INJURY IN OLDER AUSTRALIANS Nick Rushworth Executive Officer Brain Injury Australia

“…peak of peaks” …what Brain Injury Australia is is (relatively) unimportant. Govt. funded pyramidic structure, vertically integrated? In every state – associate member in the NT.

“…Brain Injury Australia works to ensure that all people living with an ABI have access to supports and resources each person needs to optimise their social and economic participation…” “…advocacy for Australian Government program allocations and policies that reflect the needs and priorities of people with an ABI and their families…” ….like all mission statements, lofty goals. The latter 2 really relate to the terms of our funding agreement. In the “good old days” governments were confident enough to fund organisations to criticise them, nowadays more like hush money. 99% of my work externally-directed, basic awareness-raising… The history of advocacy, lobbying around ABI probably mirrors that for other disability groups – family members carers, PWD themselves (the absence of the standard issue paternalistic approach – the able-bodied, the sound-minded speaking “on behalf” of – has both its pluses and minuses, PWABI – if they’re representative [a whole other issue] less/ least able to advance their own cause… “…the provision of effective and timely input into policy, legislation and program development through active contact with Australian Government ministers, parliamentary representatives, Australian Government departments and agencies, and national disability organisations…”

ACQUIRED BRAIN INJURY (ABI) any damage to the brain that occurs after birth stroke brain infection alcohol or other drug abuse neurological diseases (Huntington's disease etc.) accident or trauma …Australian Bureau of Statistics’ 2003 Survey of Disability, Ageing and Carers radically underestimates the real number of Australians with an ABI. …Sample: “14,000 private dwellings and 300 non-private dwelling units”, covering “people in both urban and rural areas in all states and territories, except for those living in remote and sparsely settled parts of Australia. The exclusion of these people will have only a minor impact on any aggregate estimates that are produced for individual states and territories, with the exception of the Northern Territory where they account for over 20% of the population.” Estimates of the prevalence of ABI in Indigenous communities generally, and in the Northern Territory specifically (where Indigenous Australians comprise 30% of the population) indicate rates up to three times that of non-Indigenous communities. …no capture of the criminal justice system or the homeless where estimates of the prevalence of ABI range between 40%-80% and 10%-30% respectively. …survey’s results were “based, wherever possible, on the personal response given by the respondent. However, in cases where information was provided by another person, some answers may differ from those the selected person would have provided….A number of people may not have reported certain conditions because of: the sensitive nature of the condition…[and] a lack of awareness of the presence of the condition on the part of the person reporting…” …July, 2008 Community and Disability Services Ministers’ Conference agreed to inject $6.5 million to enhance the next iteration of ABS Survey of Disability, Ageing and Carers, including doubling the sample size. over 500,000 Australians have an Acquired Brain Injury

1 in every 5 strokes happens to a person aged less than 55 STROKE/ “CVA” 2003; 347,000 reported stroke 60,000 new strokes occur every year median age for stroke is around 80 years leading cause of Acquired Brain Injury is stroke – sometimes referred to as a cerebrovascular accident, or “CVA” where blood supply to the brain is stopped by a clot or bleeding. It often results in physical disability as well as changes in a person’s cognitive and emotional functioning. 60,000 new strokes occur every year - a number that’s growing as Australia’s population ages. Strokes normally occur in older age groups. 1 in every 5 strokes happens to a person aged less than 55

results from external force applied to the head TRAUMATIC BRAIN INJURY (TBI) results from external force applied to the head motor vehicle accidents falls assaults …no surprises here, except that falls are now not only the leading cause of all injury hospitalisations throughout the developed world, but also the leading cause of TBI - due to populations ageing.

“tri-modal age structure”, 1996-97 TRAUMATIC BRAIN INJURY (TBI) …quite dramatic changes, as injury surveillance has caught up with population change …no surprises here, except that falls are now not only the leading cause of all injury hospitalisations throughout the developed world, but also the leading cause of TBI - due to populations ageing.

“tri-modal age structure”, 2001-02(?) TRAUMATIC BRAIN INJURY (TBI) …Liverpool Hospital Brain Injury Unit - training package on TBI in 2006, graph undated.

“tri-modal age structure”, 2004-05 TRAUMATIC BRAIN INJURY (TBI) …Australian Institute of Health and Welfare – 22,000 TBIs (as Principal Diagnosis).

falls… leading cause of Traumatic Brain Injury in Australia - 42% of TBI hospitalisations in 2004-2005 leading cause of injury hospitalisations overall - 1 in every 3 (126,800) injury admissions in 2003-2004 of all causes of TBI, falls are the most fatal. 63% resulted in death in 2004-2005 …I don’t want to blind you with figures…advocacy organisation, concerned with people. It is never just about the numbers – 99.9% raising awareness from ground, you have to make the case…. under-recognised of the title, “under-researched”…just in case you thought I was cheerleading from the sidelines of injury, of disability in the aged…for some boutique interest… …falls most fatal? – from heights in younger age groups + frail aged (“old old”)

falls injuries in older people… 65+ accounted for 62% of all TBI deaths in hospital in 2004-2005 - 1 in every 6 the result of a fall 3,272 TBIs the result of a fall in people aged 65+ = 1 in every 7 TBI hospitalizations in 2004-2005 “Head injury” was the second most common falls-related injury (after those to the hip and thigh) in 65+ during 2005-2006 (17% of cases) Why have I hammered on hospitalisations…the vast majority of TBIs, 75%-90%, are mild-to-moderate. If they end up in hospital, if the TBI is picked up in the elderly…I’ll come back to the centrality of neurological observations… “Head injury” - In general, Brain Injury Australia considers the descriptor “head injury” to be so non-specific as to be unhelpful in fostering understanding of TBI: it includes everything from abrasions to the face to an “open” head injury (where an object penetrates the skull and enters the brain). “Head injury” is not always associated with loss of consciousness, let alone TBI…

falls injuries in older people… 70,000 aged 65 + admitted to hospital in 2005-2006 for a falls injury = an increase of 10% over 2003-2004 admission numbers falls injuries to the hip and thigh decreasing, rates of head injury increasing – to 1 in every 5 admissions ….age-adjusted hip fracture ↓, “head injury” ↑. Curiosity – falls prevention programs/ practitioners….credit for reduction in hip#, responsibility for ↑ in TBI? …calcium supplementation, “active ageing” strategies…falls from greater heights, involving physical activity…

falls injuries in older people… 2003-2004; costs of hospitalised falls in people aged 65+ estimated at $566 million by 2051; total fall-related injury health costs for older people to triple to $1.375 billion per annum = an additional 886,000 hospital bed days and 3,320 extra residential aged care places …Jerry Moller’s research for the Commonwealth – some reservations on some of the estimates…Global nature of injury – complexity and multiplicity of disability; PricewaterhouseCoopers estimates @ $110,000 per year

falls injuries in older Americans… 2003: direct costs of treating a principal diagnosis of TBI in patients aged 65+ “exceeded $2.2 billion… “…If, as expected, the older population in the United States doubles from the current 35 million to 70 million by 2030, Understand differences between US-style “managed care”…Brain Injury Australia understands how the differences between “managed [health] care” in the United States and Australia’s system of majority publicly-funded acute and sub-acute care might result in their higher TBI incidence rates, it also believes the experience of the United States - which has a younger demographic profile than Australia – is highly relevant to Australia’s future. …also seeing increase in TBI combined with decrease in hip fracture… …the costs of caring for older adults with TBI in monetary and human terms will be staggering.”

PHYSICAL DISABILITY paralysis poor balance and coordination chronic pain fatigue seizures (1 in 6) vision and hearing disturbance speech impairment loss of sense of taste or smell With all of these sequelae, consequences…many of them aren’t necessarily related to TBI but to ageing generally. paralysis poor balance and coordination – drive, operate heavy machinery, lifting, physical, labouring work… chronic pain fatigue – cognitive as well as physical seizures (1 in 6) – epilepsy plan/ management, medication vision and hearing disturbance speech impairment loss of sense of taste or smell – emergency management

COGNITIVE DISABILITY poor memory and concentration (2 in 3) reduced ability - to learn - to plan and - to solve problems Brain Injury Australia is under no illusion that the effects of TBI in the elderly may not be readily distinguishable from other age-related brain failure, especially in the time-poor and resource-constrained context of acute care. This is especially the case when the majority of hospitalised falls-related TBIs in the elderly tend towards the “mild” end of the spectrum and where other falls injuries may demand more urgent attention…

“CHALLENGING BEHAVIOUR” (for 2 out of 3, the most disabling) increased irritability poor impulse control verbal and physical aggression disinhibition

OUTCOMES 1 AIHW – recent “Injury deaths, Australia 2004-05” Around double the number of people (3,000) died from falls as from MVAs…Overall, the most common cause of injury-related deaths was unintentional falls, which accounted for 29% of all injury deaths that occurred in 2004–05. People aged 70 years and over accounted for almost 90% of all deaths in this group.

OUTCOMES 1 (cont.) 85 plus: highest age-specific falls injury, falls deaths, TBI and TBI death rates (“100% mortality”) Age = strongest clinical predictor of recovery from TBI (after measures of injury severity): every 10 years of age increases “odds on poor outcome” 40% - 50%; “optimal change points” in age at TBI were 60 years (mortality), 29 years (“unfavorable outcome“). Of all deaths due to falls, 83% were in people aged 70 years or more. The median age at death due to falls in 2007 was 85 years. Both local and overseas surveys report “100% mortality” from TBI in the “old old” – all 15 patients aged 85 and over admitted to Victorian trauma units with a severe TBI between July 2001 and September 2005 died in hospital. …these numbers do not include TBI deaths prior to hospitalisation or after discharge – it excludes those who don’t make it there (the “long lie”) as well as those who may die directly or indirectly as a consequence of their TBI 6 days, 6 months, 6 years after discharge… ? Evidence Based Review of Moderate to Severe Brain Injury - Ontario Neurotrauma Foundation - reviewed 13,640 articles, selected 1,312 for more careful assessment The majority of hospitalised TBIs are in the mild-to-moderate category – anywhere between 75% and 90%. But for those, between 10-15% will experience ongoing post-concussion symptoms… The point is: what might be a mild TBI for an 18 year-old where problems in cognition and in behaviour especially resolve within 6 months…are much more likely to be permanent in an 80 year-old. Also, what might be a mild disability for mild initial impact of injury in the young – measured by GCS score or length of PTA – is much more likely to be severe disability in the old.

OUTCOMES 2 …death rates for persons aged 65 years and over fell by 13% from 1997–98 to 2004–05. …a marked increase of 16% in the number of fall-related deaths (3,830 to 4,446) for persons aged 65 years and over, between 2000–01 and 2004–05, the age-adjusted rates did not change much, reflecting Australia’s ageing population.

OUTCOMES 2 (cont.) 3X risk of intracranial bleeding than younger TBI 2X length of hospital stay longer periods of Post-Traumatic Amnesia (PTA) increased risk of developing Alzheimer’s Disease only 30%-50% returned directly home increased risk of residential aged care placement higher incidence of general brain deterioration reduced psychosocial and financial support "lowered expectations for recovery by staff and patient" …No local “outcomes” research in TBI in older people – apart from small Victorian study. US “meta-study”

“…it is worth noting that many TBIs in older people occur among those who already have a measure of neurodegenerative disease and especially among those in resicare – the majority already have disabling dementia…” …quickly; two perspectives from geriatricians. [READ] …Brain Injury Australia is not trying to be precious about this…under no, or few, illusions about the “population” here. Moreover, in terms that initial impact of injury (LOC, GCS etc.) most falls in older people are in the mild category. But I wonder whether seeing TBI as a complication of or as an addition to (“…already has”) other aged-related cognitive decline gives it the…attention it deserves.

“…you are probably correct in stating that TBI in the elderly[sic] tends to get mixed in with dementia and mild cognitive impairment… Of course a significant proportion of the falls that occur in the elderly[sic] happen in persons with dementia and any added TBI is seen as a dementia complication…” …correct usage – “older Australians”.

TBI PREVENTION falls “from heights” 65+ men - ladders, “DIY” (up 25%, 1999-2005) women – (outlive men), home hazards “old old” – residential aged care (5X rate at home) “hit head” or no? neurological observations (72 hours+?) anti-thrombotics use, intracranial bleeding (…2005- 06 - 21,000 scripts for warfarin issued to 80 yrs+)

US CDC falls prevention program…and they are talking TBI…

falls prevention programs – why? NAME RECOGNITION falls prevention programs – why? “head injury” second to hip fracture in falls injury ageing population + increased life expectancy “baby boomers” …will cut it for the current generation of “older persons” (more Stoical, more enduring/ endurant) – ageing baby boomers…won’t cut it – lack of TBI-specific rehabilitation for people aged 65 plus (67???)…enormous service infrastructure built around whether you are aged around one’s 65th birthday…appropriate vehicle for argument about the artificiality of strict age-based cut-offs to service access. Neither does Brain Injury Australia have any direct evidence that cost constraints in State and Territory Government-funded health services have resulted in people with a TBI aged over 65 years – most of whose injuries would be non-compensable - being shifted to Australian Government-funded aged care services, except to note the perverse incentives therein. But, in the context of the shifting ground in policy on government health, aged care and disability services responsibility, Brain Injury Australia notes the following: firstly, Australians’ increasing life expectancy – by 2047 men and women aged 65 can expect to live a further 3.7 years and 2.8 years, respectively, than their counterparts born in 2007; secondly, Australia’s aged dependency ratio (the proportion of people aged over 65 to those of traditional “working age” - 15-64) is projected to increase from almost 20 per cent in 2007 to over 42 per cent by 2047) and resulted in a strong public policy emphasis on encouraging older workers to remain in paid employment for as long as possible (for example, the introduction of age discrimination legislation at federal, state and territory levels, the gradual increase in the age at which women can access the Age Pension, the introduction of a Pension Bonus Scheme etc.) thus; thirdly, between 2001 and 2006 labour force participation rates for people aged 65 and over have risen by 2.7%, to 8.2%. While Brain Injury Australia accepts that an enormous service infrastructure has been built around the mark of 65 years, such social change suggests it is overdue for overhaul.

www.braininjuryaustralia.org.au …training – general ABI awareness etc. available…? …donations?