Brain Injury and Older
Adults
A Product of the Maryland Traumatic
Brain Injury Partnership Implementation
Project
2006-2009
Agenda
• The incidence and prevalence of
TBI
• What is brain injury?
• What are the types of brain
injury?
• Brain Injury and Older Adults
Incidence of TBI
In the United States, at
least
1.6 million sustain
a TBI each year
CDC 2007
Of Those 1.6 Million
CDC2007
• 51,000 die;
• 290,000 are hospitalized; and
• 1,224,000 million are treated an
released from an emergency
department
Annual Incidence of TBI with
Disability
AN ESTIMATED 124,000
American civilians
Cited by Jean Langlois ScD,MPH
NASHIA Conference 2007
Preliminary findings as analyzed by
Selassie, et. al
Causes of TBI
Unknown,
9%
Suicide, 1%
Other Transport,
2%
Other, 7%
Falls, 28%
Pedal Cycle
(non MV), 3%
Assault, 11%
Motor VehicleTraffic, 20%
Struck
By/Against, 19%
CDC 2006
Adults age 75 years or older
have the highest rates of
TBI related hospitalization
and death CDC 2004
In 2000, TBI Accounted for
46% of fatal falls among
older adults
(Stevens et. al. 2006)
CDC Website 2007
Types of TBI
• Distribution of Severity:
– Mild injuries = 80%
(LOC < 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)
The HELPS Brain Injury
Screening Tool
(see handout)
The original HELPS tool developed by M. Picard, D.
Scarisbrick, R. Paluck, 9.1991
Updated by the Michigan Department of Community
Health
HELPS
• Have you ever Hit your Head or
been Hit on the Head?
• Prompt individual to think about;
TBI at any age, MVAs. Assaults,
Sports injuries, Service related
injuries, Shaken baby and/or adult
HELPS
• Were you ever seen in the
Emergency room, hospital, or by a
doctor because of an injury to your
head?
• Explore the possibility of
“unidentified traumatic brain injury”
many do not present in medical
settings
HELPS
• Did you ever Lose consciousness or
experience a period of being dazed and
confused because of an injury to your head?
• Remember, a LOC isn’t required for someone
to develop symptoms subsequent to a blow to
the head. “alteration of consciousness” AKA
post traumatic amnesia (PTA). At this point,
the interviewer may consider asking the
individual if they have had multiple mild TBI
HELPS
• Do you experience any of these Problems in
your daily life since you hit your head?
• You want to know when any problems began
(or began to be noticed) Remember, lack of
awareness is a hallmark of brain injury, you
might ask if anyone close to the individual
has made any observations regarding
changes in function.
HELPS
•
•
•
•
•
Headaches
Dizziness
Anxiety
Depression
Difficulty
concentrating
• Difficulty
remembering
• Difficulty reading,
writing, calculating
• Poor problem
solving
• Difficulty performing
your job/school work
• poor judgement
(being fired from job,
arrests, fights,
relationships
affected)
HELPS
• Any significant Sickness?
• Acquired Brain Injury (ABI) can result in many
of the same functional impairments as
traumatic brain injury (TBI). For example,
brain tumor, meningitis, West Nile virus,
stroke, seizures, toxic shock syndrome,
aneurysm, AV malformation, any history of
anoxic injury, e.g. heart attack, near
drowning, carbon monoxide poisoning can all
result in multiple deficits
Scoring the HELPS
Positive for a possible Brain Injury when the
following three are identified:
• An event the could have caused a brain
injury (YES to H, E, or S), and
• A period of loss of consciousness or
altered consciousness after the injury or
another indication that the injury was
severe (YES to L or E), and
• the presence of 2 or more chronic
problems listed under P that were not
present before the injury.
Scoring the HELPS
• A positive screening is not sufficient to diagnose
TBI as the reason for current symptoms and
difficulties-other possible possible reasons need to be
ruled out
• Some individuals could present exceptions to the
screening results, such as people who do have TBIrelated problems but answered “no” to some
questions
• Consider positive responses within the context of the
person’s self-report and documentation of altered
behavioral and/or cognitive functioning
Additional comments and
observations of the interviewer
•
•
•
•
•
•
•
•
•
Any visible scars?
Walks with a limp?
Uses a cane or walker?
Has a foot brace?
Limited use of one hand?
Appears to have difficulty focusing vision?
Difficulty answering questions?
Answers are unorganized and/or rambling
Becomes easily distracted, agitated or is
emotionally labile
What you are looking
for…..And Why
• Any reported or suspected functional
difficulties that are interfering with
home, work or community activities
• With the identification a history of
brain injury, professionals can better
support the individuals served and
make informed referrals to brain
injury specialists when appropriate
Brain Injury in the News
• Veterans:
• NFL Players
• Prominent Older Americans
with fall related brain injuries
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
Lack of Awareness
A common and difficult to remediate
hallmark of a brain injury
Brain Injury and Alzheimer’s
Disease
• Some evidence to suggest that severe brain
injury is a risk factor in development of
Alzheimer’s especially in individuals lacking
the ApoEepsilon4 genotype( Jellinger et. al.
2001)
• An earlier study by Schofield (1997) found that
subjects who had a head injury with a loss of
consciousness or amnesia exceeding 5
minutes were at significantly increased risk of
developing 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.
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?
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 tape 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
Resource and Referral
Information
Resource Coordination in
Maryland
• Charlotte Wisner, Resource Coordinator for Frederick
& Washington Counties, call 301-682-6017
• Lauren Dorsey, Resource Coordinator for Baltimore &
Howard Counties, call 301-529-1508
• Catherine Reinhart, Resource Coordinator for
Montgomery County, call 301-586-0900
• Any questions regarding resource coordination or
free trainings for professionals regarding brain injury,
call Anastasia Edmonston, Project Director 410-4028478
Resources
• Brain Injury Association of America 703-2366000, www.biausa.org
• Brain Injury Association of Maryland 410-4482924, 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. 770488-1506
• 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
•
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 352497330/ 206-934-3283. Tbi@uab.edu.
Resources staff training….
• http://www.webaim.org/simulations/cognitive - this is
a site that can be used in staff training. It is a
simulation of the effects of cognitive disabilities.
You will be asked to complete simple tasks, but other
tasks will get in the way.
Resources staff training….
• http://www.biausa.org/Pages/related_articles.html links to many online articles, written not for
professionals in the field, but for people learning
about brain injury. They cover all types of topics,
from substance abuse and brain injury to cognition
and brain injury. Written by various experts in the
brain injury field.
• Certified Brain Injury Specialist (CBIS) Training
offered through the American Academy for the
Certification of Brain Injury Specialists,
www.biausa.org
The Michigan Department of
Community Health
Web-Based Brain Injury Training
for Professionals
www.mitbitraining.org
This 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 Edmonston
TBI Projects Director
Mental Hygiene Administration
Aedmonston@dhmh.state.md.us
410-402-8478
A Product of the Maryland TBI
Partnership Implementation Project, a
collaborative effort between the Maryland
Mental Hygiene Administration, the
Mental Health Management
Agency of Frederick County and the
Howard County Mental Health Authority
2006-2009
Support is provided in part by project H21MC06759 from
the Maternal and Child Health Bureau (title V, Social
Security Act), Health Resources and Services
Administration, Department of Health and Human
Service
Please use and distribute widely