Neuropsychology of Traumatic Brain Injury

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Neuropsychology of Traumatic Brain Injury

• Resent Findings on Signs, Symptoms, Diagnosis,
  Treatment, and Prognosis
• Martin L. Rohling, Ph.D.
• Assistant Professor
• Department of Psychology
• University of South Alabama

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Epidemiology of TBI Data From TBI Model Systems

• Mean age in years 36
• Gender 75 male
• Race 57 white 31 African-American
• Marital status 71 unmarried
• Education 12.0 36 without HS degree
• Average GCS score upon admission 7

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Epidemiology of TBI Data From Rohling et al.
(2001)

• Incidence prevalence
• 1.3 million Americans experience TBI yearly
• Severity defined by LOC 88 experience LOC
• Average LOC 3.8 days However,
• 40 LOC lt 1 hr
• 21 LOC 1-23 hrs
• 15 LOC 1-6 days
• 10 LOC 7-13 days
• 8 LOC 14-28 days
• 6 LOC gt 28days

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Epidemiology of TBI More Data CDC TBIMS

• 5.3 million Americans currently living with this
  condition
• 60 employed at time of injury
• Only 25 employed 1-year post injury

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Epidemiology of TBI More TBIMS Data

• TBI resulting in hospitalizations or death was 95
  per 100,000.
• 22 of TBI resulted in death.
• 80,000 Americans incur significant disability
  consequent to TBI each year.
• Best predictors of pediatric TBI outcome is
  family functioning premorbidly.

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Etiology of Injury

• 57 due to motor vehicle accidents
• 29 due to violence
• 56 of these blunt (closed head injury)
• 23 of these penetrating (open head injury)
• 11 due to falls
• 3 other causes

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Visual Aid for TBI Explanation
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TBI Alcohol Use at Injury

• Persons with TBI tested positive for alcohol at
  time of injury in 49 of cases.
• Of these, blood alcohol levels of 100mg/ml (i.E.,
  Common legal limit for DUI) were detected in 62
  of cases.

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Violence and TBI

• 44 of death due to TBI due to gunshot
• 9 of non-fatal TBI due to violence
• Who suffers TBI due to violence
• Older than other types of TBI (modal age 40)
• 3 times more likely to be a minority
• More likely single/divorced living alone
• Lower educational levels more unemployment

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Violence Induced TBI Recovery Results

• Higher ETOH at admission than nonviolent.
• Less severe injuries (GCS 9.6 vs. 8.3).
• Shorter lengths of stay both acute rehab.
• Payor is Medicaid in 58 of cases, which is 3X
  that of the non-violently injured.
• No difference on FIM at admission or d/c.
• Higher rates of unemployment and ETOH use
  post-injury than non-violently injured.

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TBI Treatment Cost of Care

• Average acute care costs for treating TBI
  patients in 1999 were 96,606. Mean costs for
  inpatient rehab care for these individuals was
  43,435

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Epidemiology of TBI More TBIMS Data

• Inpatient length of stay (LOS) going down
• LOS data from 1994
• 22 days acute care
• 39 days rehab unit
• LOS data from 1999
• 19 days acute care
• 27 days rehab unit

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TBIMS in Alabama

• University of Alabama at Birminghamtraumatic
  brain injury care system contact Dr. Tom Novack,
  project director, Spain rehabilitation center,
  1717 6th Ave. S., Birmingham, AL 35233-7330.
  Phone [phone]. Fax [phone]. E-mail
  novack_at_sun.rehabm.uab.edu.

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TBIMS at UAB Studies Currently Underway

• (1) the utility of utilizing routine D-DIMER
  measurement as a screen for proximal deep vein
  thrombosis will be examined in collaboration with
  the model center in Mississippi
• (2) the use of constraint induced therapy, which
  has proven effective for people having
  hemiparesis after CVA, will be examined in people
  with TBI
• (3) competency to make medical and financial
  decisions will be examined twice in the course of
  recovery after TBI
• (4) A home-based cognitive remediation program
  that can be implemented by family members will be
  developed in cooperation with ADRS

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TBIMS at UAB Studies Currently Underway

• (5) the utility of the useful field of view test,
  which has proved very effective with older
  drivers, will be examined for people with TBI,
  specifically as a means of screening before an
  the on-the-road driving evaluation takes place
• (6) impact of an intentional injury, such as an
  assault or through a self-inflicted trauma, will
  be examined as compared unintentional injury,
  such as occurs in a motor vehicle crash
• (7) outcomes as a result of diffuse axonal injury
  as compared to focal TBI will be examined
• (8) in collaboration with the model center in
  Mississippi, UAB will be participating in a study
  evaluating self-awareness of deficits after TBI
  and specifically the correlation with depression
  and impact on outcome a year after trauma.

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Cohort Outcome Measures
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Factors Affecting Rate of Neurological Recovery

• Recovery following TBI is multifaceted
• 1 yr post TBI significant individual differences
• Important factors premorbidly are
• Age, education, and injury severity
• Cognitive recovery past 1 year minimal and only
  in measures of complex attention
• Rate of recovery dependent on cognitive domain
  and location of injury

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Impact of TBI Severity on Cognition 1-yr Post TBI
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Effects of Financial (2nd Gain) on TBI Recovery

• Binder Rohling (1996) found the effect size of
  litigation/compensation .60 sd units.
• Binder, Rohling, Larrabee (1997) found the
  effect of Mild TBI to be non-significant (ES is
  between .07-.10 sd units).
• For Mild TBI w/ financial incentives, impairment
  is 6 to 9 times more likely to be caused by
  incentives than neurological factors.

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Symptom Validity or Suboptimal Performance

• Base rate of exaggeration estimated to be 27 all
  TBI cases (Rohling et al., 2000).
• Base rate for symptom exaggeration higher in
  patients with mild TBI versus severe TBI (54
  versus 21).
• Impairment equals 1.2 to 1.5 sd units.
• For LOC lt 1 hr, deficit 14-28 days LOC.

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Pediatric TBI Differences Between Kids and Adults

• Developmental stage at time of injury is much
  more important in determining outcome.
• Family and school support much more relevant in
  improving long-term outcome.
• Delayed effects of TBI can be expected.
• ADHD, LD, behavioral disorders.