Brain Injury

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Brain Injury
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Objectives

• Identify acquired brain injury (ABI) and
  traumatic brain injury (TBI)
• Identify and describe how brain injury impacts an
  individual
• Describe how brain injury impacts the support
  system of the individual
• Identify at least 8 strategies to more
  effectively support an individual with brain
  injury
• Describe where to find at least 3 additional
  resources regarding brain injury

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Meet Andrea
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What is a Brain Injury?

• Acquired Brain Injury (ABI)
• Traumatic Brain Injury (TBI)

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Acquired Brain Injury

• Any injury to the brain that occurs after birth
  as a result of
• Physical force (due to an accident)
• Tumors
• Strokes
• Violent Acts (e.g., gun shot wound)
• Infectious Diseases (e.g., encephalitis)
• ABI is the broadest category and includes all
  brain injuries that occur after birth.

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Traumatic Brain Injury

• A brain injury from an external force
• Vehicle accidents
• Violent Acts (e.g., gun shot wound)
• Falls
• Physical Abuse
• Sports Injuries

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All TBI is ABI, but not all ABI is TBI
Infectious Diseases
Stroke
Tumors
Falls
Gun Shot Wounds
ABI
Vehicle Accidents
Physical Abuse
Sports Injuries
TBI
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Severity Continuum

• Things to Consider
• Symptomology
• Pre-injury functioning
• Symptoms vary

Mild
Severe
Moderate
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• 15 of all TBI are considered moderate to severe
• 85 of all TBI are considered mild

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Mild Brain Injury

• Traumatically induced physiological disruption of
  brain function as manifested by at least one of
  the following
• Loss of consciousness (often measured by the
  Glasgow Coma Scale, see Appendix A)
• Loss of memory for events immediately before or
  after the accident (not longer than 24 hours)
• Alteration in mental state at the time of the
  accident (e.g., feeling dazed, disoriented, or
  confused) and/or
• Focal neurological deficits that may or may not
  be transient.
• (Glascow Coma Scale score 13-15)

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Moderate Brain Injury

• A loss of consciousness that lasts from a few
  minutes to a few hours
• Confusion lasts from days to weeks
• Physical, cognitive, and/or behavioral
  impairments last for months or are permanent
  and/or
• Persons with moderate traumatic brain injury
  generally make a good recovery with treatment or
  successfully learn to compensate for their
  deficits.
• (Glascow Coma Scale score 9-12)

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Severe Brain Injury

• Severe Brain Injury (Glascow Coma Scale score 8
  or less)
• Almost always results in prolonged
  unconsciousness or coma, brain contusions,
  hematomas, damage to nerve fibers and axons,
  and/or anoxia
• Often results in permanent physical, behavioral,
  and/or cognitive impairments
• Significant improvements are generally made
  during the first year and continue thereafter
• (Glascow Coma Scale score 3-8)

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• Every 23 seconds, one person in the United States
  sustains a brain injury.

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Epidemiology

• An estimated 5.3 million Americans have a
  long-term or life long need for help with
  activities of daily living as a result of TBI
• An estimated 1.4 million people will sustain a
  TBI each year in the United States.
• Of these
• 50,000 die
• 235,000 are hospitalized
• 1.1 million are treated and released from an ER
• The number of people with TBI who are not seen
  in an ER or who receive no treatment is unknown.

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Leading Causes of TBI

• 1st Falls (among elderly and very young)
• 2nd Vehicle accidents, bicycle, or
  pedestrian-vehicle incidents (account for most
  hospitalizations)
• 3rd Violent acts
• 4th Sports accidents An estimated 90 are mild
• and go unreported
• (BIA of America Fact Sheet)
• (109 Rehabilitation of Persons with TBI)

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• If you have a brain injury, you are 3 times more
  likely to get another. After the second injury,
  the risk for the third injury is 8 times greater.

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Who experiences brain injuries?

• Extremely Diverse
• Highest risk 0-4 years, 15-24, and 75 years and
  older
• Males are 1.5 times more likely than females to
  experience TBI
• 70 of people who incur TBI recover completely
• 15 remain symptomatic for the remainder of their
  lives
• Alcohol is reported to be associated with 50 of
  all TBI

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• TBI is the leading cause of death and disability
  for children, adolescents, and young adults in
  the United States. 90,000 of those injured will
  sustain permanent injuries.
• (www.biausa.org)

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Utah Brain Injury Statistics

• 5,533 incidents of TBI in 1997-1999 resulting in
  acute care hospitalization and/or death (i.e.,
  approximately five incidents per day)
• On average, 23.1 of individuals requiring acute
  care hospitalization died as a result of the TBI

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Neuroanatomy and Physiology of the Brain

• Deficits vary depending upon location and
  severity of brain injury
• Major Brain Areas
• Frontal Lobe
• Parietal Lobe
• Temporal Lobes
• Occipital Lobe
• Cerebellum
• Brain Stem

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Frontal Lobe

• Motor output
• Problem Solving
• Self-monitoring
• Expressive language organization (i.e., speech)
• Personality
• Emotions
• Inhibition of Behavior

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Parietal Lobe

• Sense of touch
• Sensory integration
• Spatial perception
• Visual perception
• Identification of size,
• shape, color

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Temporal Lobe

• Auditory projection (interpretation of
  speech)/Receptive language
• Memory of new information
• Sequencing
• Hearing

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Occipital Lobe

• Vision

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Cerebellum

• Balance
• Coordination
• Skilled motor activity

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Brain Stem

• Breathing
• Arousal and consciousness
• Sleep/wake cycles
• Attention and concentration
• Heart rate

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Living with a Brain Injury The Impact on the
Individual

• Physical
• Cognitive
• Social
• Behavioral Emotional

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Physical Disabilities

• Headaches
• Dizziness
• Chronic pain
• Seizures
• Decreased coordination
• Loss of limbs or use of limbs
• Nerve Damage (i.e., optic nerve, facial palsy)
• Sensory limitations (visual disturbances, hearing
  loss, decreased taste and smell, increased
  sensitivity to noise and light)

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Cognition

• Broad range of symptoms that occur independently
  or in combination
• Memory impairment
• Impaired attention
• Inability to remain on task
• Difficulty focusing on thoughts, words, events
• Deficits in language use
• Deficits in visual perception

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Cognition-Deficits in Executive Skills

• Inability to self-monitor and inhibit responses
• Poor initiation
• Difficulty sequencing steps and completing
  activities

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Cognition- Reasoning and Problem-Solving

• Difficulty analyzing situations
• Inability to draw conclusions and make decisions
• Lack of logical thinking

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Social

• Difficulty attending to social cues
• Relearning appropriate social skills
• Loss of friends
• Loss of familiar activities
• Loss of self
• Personality changes
• Problems with emotional control
• Susceptible to mood and anxiety disorders
• Increased risk of suicide
• Egocentric

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Behavioral and Emotional

• Frustration
• Irritability
• Restlessness
• Anxiety
• Low motivation
• Depression

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Behavioral and Emotional Cont.

• Aggression- reactive, triggered by modest or
  trivial stimuli, non-reflective, not
  pre-meditated, non purposeful, explosive and
  periodic, impulsive
• Exhibits socially inappropriate behavior
• Disinhibition
• Cognitive fatigue and/or physical fatigue can
  significantly impact all areas of functioning

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Medications

• Presently, there are no FDA approved treatments
  for cognitive, emotional, or behavioral
  impairments due to TBI.

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Medications

• Often on multiple medications
• SSRIs (e.g., Prozac) often prescribed for anxiety
  and depression
• Anticonvulsants (e.g., Tegretol) often prescribed
  to prevent seizure activity or to treat
  behavioral problems
• Sleep medications (e.g., Melatonin) often
  prescribed for sleep disturbances
• Neuroleptics (e.g., Risperdal) prescribed for
  psychosis and/or aggression
• Need for continued re-assessment

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Substance Abuse

• Higher rates of substance abuse
• Effects 28-32 of individuals with TBI

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Lets Take a Break!
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Living with Brain InjuryThe Impact on Support
Systems (e.g., family, friends, employer)

• Grieving
• Stress
• Survival Adaptations

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Grieving

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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Stress

• Economic Strain
• Estimates for average lifetime cost of care for a
  person with severe TBI exceed 4 million
• Changed Family goals and roles

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Practical Adaptations/Accommodations
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Signs in Loss of Attention/Concentration

• Confusion
• Rambling Conversations
• Staring
• Unable to finish a task
• Difficulty attending to more than one thing at a
  time

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Strategies to Help with Attention/Concentration

• Get individuals attention before beginning a
  discussion
• Reduce unnecessary noise or unneeded materials on
  desk
• Limit the amount of information presented
• Pace the work with short work periods followed by
  brief breaks

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Signs of Memory Loss

• Confusion regarding appointments or daily
  schedule
• Unable to remember tasks from day to day
• Unable to remember new information
• Confabulates (makes up stories to fill memory
  gaps this is not lying)

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Strategies to Help with Memory Loss

• Establish consistent schedule
• Structure tasks
• Provide written cues (memory book, chart, etc.)
• Provide verbal cues (initial sounds, choices)
• Use compensatory tools (alarm, watches,
  calculators)
• Link new information with old information

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Signs in Loss ofReasoning/Problem Solving

• Ineffective problem solving
• Inappropriate and potentially harmful decisions
• Unable to make inferences
• Disorganized thinking
• Difficulty drawing conclusions
• Rigidity in changing plans

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Strategies to Help inReasoning/Problem Solving

• Instruct and post note for Stop and Think
• Help identify the problem and possible solutions
• Help predict consequences
• Break the task down into several easier steps
• Write steps in notebook/planner

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Signs in Loss of Impulsivity/Poor Self Control

• Acts or speaks without considering the
  consequences
• Inappropriate comments to or about others
• Lower tolerance for frustrating situations
• Inappropriate laughing or crying
• Get stuck on one idea or thought

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Strategies to Help in Impulsivity, Poor Self
Control

• Encourage the person to slow down and work
  through task
• Provide verbal and/or nonverbal feedback in a
  supportive way
• Respond to inappropriate ideas, but maintain
  focus on original discussion
• Expect the unexpected
• Provide alternatives for inappropriate or
  perseverative behavior
• Give frequent and consistent positive
  reinforcement
• Remove the individual from a frustrating task or
  environment

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Signs of Impaired Self-awareness, Difficulty with
Social Situations

• Lack of awareness of deficits and limitations
• Inaccurate self-image/self perception

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Strategies to Help withImpaired Self-awareness,
Difficulty with Social Situations

• Anticipate lack of insight
• Prompt accurate self-statements
• Use feedback generously in a positive way
• Give realistic feedback as you observe behavior

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Signs of Problems with Conversations

• Does not respond to another persons
  conversation, questions or comments
• Does not start, or is slow to start
  conversations, ask questions, or make comments
• Leaves long pauses
• Has difficulty explaining what he or she means

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Strategies to Help with Conversations

• Encourage the individual to participate, e.g.,
  ask What do you think about that?
• Ask open-ended questions Tell me about
• Give time to organize thoughts
• Give the individual your full attention and allow
  them to complete the thought
• Re-phrase what the person has said, Do you mean

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Signs of Non-verbal Communication

• Poor eye contact
• Does not understand non-verbal cues
• Stands to close
• Uncomfortable number/type of physical contacts
• Body language/facial expressions dont seem to
  match what is said (flat affect)

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Strategies to Help withNon-verbal Communication

• Ask the person to maintain a comfortable distance
• Politely ask the individual to modify their
  physical contacts explain that you are
  uncomfortable with such contact
• Tell the person you are confused by the
  difference in body language and spoken message
• Ask the person what he or she is feeling
• Politely ask the individual to stop distracting
  movements

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General Suggestions

• Structure the environment
• Break tasks into component parts
• Pace the work (consider headaches, fatigue, etc.)
• Help develop organizational systems
• BE CONSISTENT

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Remember the Fatigue Factor!

• Both cognitive and physical fatigue often impact
  multiple areas of functioning

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Additional State Resources

• Brain Injury Association of Utah www.biau.org
• Utah Medical Home
• http//medhome.med.utah.edu

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Additional Local Resources
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Additional National Resources

• TBI Technical Assistance Center at NASHIA
  (National Association of State Head Injury
  Administrators)
• Main Websites in the section on 'Who to contact
  for more information on TBI
• http//www.tbitac.nashia.org/tbics/
• Brain Injury Association of America (Their
  mission is to create a better future through
  brain injury prevention, research, education and
  advocacy) www.biausa.org

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Thats All Folks!
Thank You
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Logan

• Logan Regional Hospital
• Phone [phone]
• Deb Smith
•  
• Bear River Health Department
• Phone [phone]
• Sandra Hoggan
• TBI Support Group
• Options for Independence
• Phone [phone]
• Vicki Smith