Presentation Texas Veterans Commission by jolinmilioncherie

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									Meeting Special Needs of Individuals
         with Brain Injury




                Presented by
            Joanne McGee, Ph.D.
     Clinical Director, ResCare Premier
        Types of Brain Injury
• There are many types of injuries and
  illnesses that can cause injury to the brain.

• At times, eligibility for services will depend
  on whether the disability is due to a
  traumatic brain injury (TBI) vs. other
  causes.
Types of Brain Injuries

    • Congenital Disorder

• Acquired Brain Injury (ABI)
           Congenital Disorders
• A disorder that is present at
  birth
• May occur as a result of birth
  trauma or during the
  development of the fetus
• Examples include mental
  retardation, learning disability,
  ADHD, fetal alcohol syndrome,
  etc.
     Acquired Brain Injury

• An injury to the brain that has occurred
  after birth as a result of an illness or
  injury
  Acquired Brain Injury, Cont’d.
             Examples include:

• TBI (most common)     • Infectious diseases
• Stroke (2nd most      • Brain tumor
  common)               • Metabolic disorders
• Anoxia (shortage of     (e.g., diabetic coma)
  oxygen)               • Seizure disorders
• Brain surgery         • Toxic exposure
           What causes TBI?

The leading causes of TBI are:
• Falls (28%);
• Motor vehicle-traffic crashes (20%);
• Struck by/against (19%); and
• Assaults (11%).
• Bullets, fragments, & blasts are a leading cause of
  TBI for military personnel in war zones.
                     FACT
• TBI is the leading cause of death and disability
  among children and young adults.

• Males are about 1.5 times as likely as females to
  sustain a TBI.

• Military duty increases the risk of sustaining a TBI.

      (CDC National Center for Injury Prevention & Control, 1999; 2004;
                                DVBIC, 2007)
                 FACT
In the U.S., the annual
   incidence of TBI is
 more than that of MS,
    spinal cord injury,
 HIV/AIDS, and breast
          cancer
     COMBINED.
                FACT
  64% of Soldiers recently wounded in action in OIF
                sustained brain injuries.

Mild & undiagnosed TBI may be the signature challenge
            from the Global War On Terror.

  TBI is experienced by a higher percentage of Texas
     military personnel than any previous conflict.

              (DVBIC, 2007; TexVet Initiative, 2007)
          Basic Brain
• Brainstem

• Cerebellum

• Cerebrum
             Brain Stem

•   Cardiac
•   Respiratory
•   Arousal
•   Movement & touch
    sensation in body
         Cerebellum

• Balance of the
  body
• Coordination of
  body movement
          Cerebrum
Four lobes in each
   hemisphere:
    Frontal
   Temporal
   Occipital
    Parietal
Frontal Lobe Syndromes
          Executive functioning

          Problems with:
          •Speaking
          •Muscle weakness & paralysis
          •Attention
          •Impulse control/inhibition
          •Problem solving/flexibility
Frontal Lobe Syndromes, Cont’d.

               •   Lack of motivation
               •   Inability to plan ahead
               •   Poor judgment
               •   “Intellect without
                   social and emotional
                   guidance”
 Frontal Lobe Syndromes, Cont’d.
    PREFRONTAL CORTEX
• Goal formation
• Plan of action to
  reach goals
• The “CEO” of the
  brain
• “The best connected
  part of the brain”
Frontal Lobe Syndromes, Cont’d.
   PREFRONTAL CORTEX
                       DORSOLATERAL
                          SYNDROME
                •   Inertia/apathy
                •   Flat affect
                •   Appears indifferent
                •   Distractible
                •   Lack mental flexibility
                    with reverse inertia
                •   Irritability (short-lived)
    Frontal Lobe Syndromes, Cont’d.
       PREFRONTAL CORTEX
       ORBITOFRONTAL
          SYNDROME
•   Disinhibited behavior
•   Lack concern for social
    taboos
•   Emotions fluctuate from
    euphoria to rage
•   Some engage in criminal
    acts
•   Some “loose but harmless”
•   Confabulation
Frontal Lobe Syndromes, Cont’d.

• Perseveration       • Utilization or field-
• Derailment of         dependent behavior
  thought processes   • Echolalia/echopraxia
• Tangentiality       • Anosagnosia
Temporal Lobe
      • Hearing
      • Understanding Speech
      • Memory
      • Music/ Sound
         Comprehension
Occipital Lobe

       • Located at the rear
          of the brain
       • Interpretation of
          visual information
Parietal Lobe
      •Located at the top of brain
      •Perception of touch/body
          orientation
      •Face and shape
         recognition
      • Awareness of spatial
         relationships
      • Arithmetic calculations
  How the Brain is Hurt: TBI
PRIMARY INJURY:
• Skull fracture
• Contusion (Coup/Contracoup injury)
• Diffuse axonal injury (DAI)
• Focal Shear Injury
PRIMARY INJURIES

Coup-Contra Coup
Diffuse Axonal Injury (DAI)
Rotational forces on the brain cause stretching and
                snapping of axons.




                    Image courtesy of Centre for Neuroskills
Focal Shear Injury




        Image courtesy of Centre for Neuroskills
 How the Brain is Hurt: TBI,
          Cont’d.

SECONDARY INJURY:
• Cerebral edema
• Hydrocephalus
• Hematomas
• Chemical Cascade
           Secondary Injuries




     Edema               Hydrocephalus
(swollen brain tissue)   (enlarged ventricles)
Hematoma




   Image courtesy of Centre for Neuroskills
                FACT
                                         More than
                                       442,000 Texans
                                       are living with a
                                        disability from
                                       TBI (about 2%
                                             of the
                                         population).
(Thurman, Alverson, Dunn, Guerrero, & Sniezek, 1999)
 TOP TEN CHANGES
AFTER BRAIN INJURY
1.   Mobility             6. Problem
2.   Communication            solving/planning
3.   Memory               7. Fatigue
4.   Attention            8. Judgment
5.   Speed of thought &   9. Emotional/behavioral
     action                   control
                          10. Initiation/Inhibition
                                                                                                        Psychosocial
                                                                                                 •   Imbalance in family
    Changes After                                          •
                                                               Emotional/Behavioral
                                                                Agitation (excessive
                                                                restlessness)
                                                                                                 •
                                                                                                 •
                                                                                                     relationships
                                                                                                     Peer relationships lost
                                                                                                     Decreased or lack of
                                                           •    Lack of cooperation                  independence
     Brain Injury                                          •
                                                           •
                                                                Frustration tolerance
                                                                Irritability, aggression
                                                                                                 •
                                                                                                 •
                                                                                                     Emotional disturbances
                                                                                                     Alteration of self / identity
                                                           •    Inappropriate sexual behavior    •   Alteration of career & life
        Physical                   Cognitive               •    Emotional lability                   goals
                                                           •    Distortions of reality           •   Drugs & alcohol
•   Hemiplegia/ hemiparesis   •   Level of                 •    Paranoia                         •   Sexuality
•   Spasticity                    consciousness            •    Depression/Anxiety
•   Tremors                   •   Attention/concen-        •    Judgment                                    Family
•                                 tration
    Medical complications                                  •    Obsessions or compulsions        •   Emotional reactions (anger,
•                             •   Memory
    Swallowing                                             •    Overeating/overdrinking              denial, depression, guilt)
•                             •   Expressive language                                            •
    Hearing loss                  (spoken and/or           •    Anorexia                             No final stage of acceptance
•   Seizures                                               •    Confusional behavior                 (brain injury is forever deal)
                                  written)
•   Double vision                                          •                                     •   No “empty nest” for parents
                              •   Receptive language            Wandering
•   Visual field cuts                                      •                                     •   No time to work
                              •   Constructional                Neglect of hygiene
•   Changes in sensory            ability                  •    Loose associations               •   Attachment/emotional
    perception                                                                                       conflicts (injured member is
                              •   Orientation              •    Tangentiality                        changed; not the same
•   Fatigue                   •   Abstract thought         •    Echolalia/echopraxia                 person)
•   Ataxia (problems with     •   Planning/goal            •    Egocentrism                      •   Financial loss
    balance/coordination          formation                •    Decreased social skills          •   Loss of friends
•   Dysphagia                 •   Organizing               •    Lack of initiation /motivation   •   Role changes
•   Dysarthria                •   Insight                  •    Apathy                           •   Children compete with
•   Autonomic dysfunction     •   Generalization                                                     injured member for parent’s
                                                           •    Utilization behavior
•   Apraxia                   •   Flexibility                                                        attention
                                                           •    Misidentification
•   Left neglect              •   Problem solving                                                •   Non-injured parent devotes
                                                           •    Perseveration
                              •   Speed of mental                                                    all: no time
                                                           •    Disinhibition
                                  processing                                                     •   Social roles non-existant or
                                                           •    Impulsivity                          significantly decreased
                              •   Academic skills
                                                           •    Inappropriate affect             •   Children/siblings neglected/
                              •   Right-left orientation
                                                           •    Tolerance for stimulation            increased
                              •   Self-awareness
                                                           •    Response to social cues              responsibilities
                                                           •    Confabulation
   Severity of Injury: MILD
• 75-90% of all brain injuries
• LOC less than 20-30 minutes
• A concussion is a mild brain injury
• Most recover within hours or days
• May have problems over time (e.g.,
  headache, attention, memory, fatigue,
  emotional problems)
Severity of Injury: MODERATE
• 8-10% of all brain injuries
• LOC less than about 6 hours
• 3 months post-injury 2/3 have not returned
  to work
• 33-50% have residual problems (e.g.,
  initiation including sexual, memory, temper,
  poor planning)
 Severity of Injury: SEVERE
• Less than 10% of all brain injuries
• LOC more than 6 hours
• Cognitive, emotional/behavioral, physical
  problems
• Socially isolated/psychiatric problems
• Likely greater long-term impairment
                 3 Question DVBIC TBI
                     Screening Tool
1. Did you have any injury(ies) during your deployment from any of
   the following? (check all that apply):

A. ���� Fragment
B. ���� Bullet
C. ���� Vehicular (any type of vehicle, including airplane)
D. ���� Fall
E. ���� Blast (Improvised Explosive Device, RPG, Land mine,
      Grenade, etc.)
F. ���� Other
    Specify:_______________________________
                          3 Question DVBIC TBI
                              Screening Tool
2. Did any injury received while you were deployed result in any of the
   following? (check all that apply):

A. ���� Being dazed, confused or “seeing stars”
B. ���� Not remembering the injury
C. ���� Losing consciousness (knocked out) for less than a minute
D. ���� Losing consciousness for 1-20 minutes
E. ���� Losing consciousness for longer than 20 minutes
F. ����   Having any symptoms of concussion afterward
     (such as headache, dizziness, irritability, etc.)
G. ���� Head Injury
H. ���� None of the above

NOTE: Confirm F and G through clinical interview

NOTE: Endorsement of A-E meets criteria for positive TBI Screen
                  3 Question DVBIC TBI
                      Screening Tool
3. Are you currently experiencing any of the following problems that
   you think might be related to a possible head injury or concussion?
   (check all that apply):

A. ���� Headaches                           E. ���� Ringing in the ears
B. ���� Dizziness                  F. ���� Irritability
C. ���� Memory problems            G. ���� Sleep problems
D. ���� Balance problems           H. ���� Other
                                 specify:___________
     What are the costs of TBI?

Direct medical costs and indirect costs such as
 lost productivity of TBI totaled an estimated
    $60 billion in the United States in 1995.

               …in Texas,
   approximately $1.08 billion each year.
        Myths About Brain Injury

                                REALITY
        MYTH                   The cognitive and
Visible, physical recovery    behavioral effects of a
   is a sign that the brain    brain injury can last
         is healed.            long after the person
                              heals “on the outside.”
       Myths About Brain Injury,
               Cont’d.
       MYTH                      REALITY

Younger children are more   It may just take longer for
     resilient and can          the effects of a brain
  therefore “bounce back”      injury to show up in a
  easier and more quickly
                                    growing and
    from a brain injury.
                                 developing brain.
      Myths About Brain Injury,
              Cont’d.

                               REALITY
       MYTH
                           Even a 60 second loss of
Mild brain injury has no
                               consciousness has
    long term effects.
                            resulted in DAI (as seen

                                  on autopsy).
Myths About Brain Injury,
        Cont’d.

MYTH             REALITY

Time heals.   There is no cure for a

                   brain injury.
Arizona Governor’s Council on Spinal & Head Injuries. Adapted with permission.
Continuum of Treatment for TBI
   ACUTE REHABILITATION
          SETTING:
          Military Treatment Facilities (MTFs): Walter Reed
             Army Medical Center, Wilford Hall US Air Force
             Medical Center, Brooke Army Medical Center, Fort
             Sam Houston/Lackland Air Force Base, Naval
             Medical Center-San Diego
          Rehabilitation Hospital
          Home/Community-Based Rehabilitation Programs

          • Typically transferred from acute care
            hospital/trauma center
          • After medical stabilization
          • Begin rehabilitation & therapies
 ACUTE REHABILITATION
     RESOURCES                   BARRIERS (Civilian)
                                 • Limited length-of-stay
• Funding for services
   – DOD, Insurance for active   • May be discharged
     duty military                 without adequate
   – Public: DARS (CRS             information
     Program), Medicaid (for     • Lack of coordination of
     children), Crime Victim’s
     Fund
                                   community services (Case
   – Private insurance
                                   Management) at discharge
                                 • Cultural/language issues
    Continuum of Treatment for TBI
      POST-ACUTE REHABILITATION
SETTINGS:
   Active Duty Military: MTFs, Concussion
    Clinics (Ft. Bragg, Camp Pendleton)
    Veterans: VA Polytrauma Rehabilitation Centers
        (Minneapolis, Palo Alto, Richmond, Tampa,
        [San Antonio]), Polytrauma Network Sites
        (1 in each VISN), Lakeview Virginia Neurocare,
        Laurel Highlands Neuro-Rehabilitation Center
    Outpatient
    Day therapy
    Residential
    Vocational
    Home/Community-Based

• Comprehensive rehabilitation
• Focused on functional
   independence and/or vocational rehabilitation
           POST-ACUTE
         REHABILITATION
     RESOURCES               BARRIERS (Civilian)
• DOD & VA, Insurance for    • Limited length-of-stay
  active duty military and   • Eligibility
  veterans                   • May be waiting lists for
• Publicly funded programs     public services
  through DARS (CRS          • Limited access to supports
  Program)                     and services
                             • Lack of coordination of
• Some private insurance
                               community services (Case
  provides benefits            Management) at discharge
                             • Cultural/language issues
Continuum of Treatment for TBI
      LONG-TERM CARE
                                            SETTINGS:
                     Day programs at VA Medical Centers
                                            Family home
                               Supervised living facilities
                                  Assisted living settings
                                         Nursing homes
                                           Group homes
                                         Mental hospital
                                                   Prison
                                                    Street



         • Depends on severity of injury
      • Depends on individual’s support system
       • May require lifetime supervised living
         LONG-TERM CARE
RESOURCES                     BARRIERS
                  • VERY FEW publicly funded placements
• VA nursing      • Eligibility requirements based on age,
  homes             diagnosis, and geography preclude
                    access
• Some publicly
                  • Limited funds relative to costs
  funded
                  • Long waiting lists
  programs        • Lack of case management
  through DADS,   • May be inappropriate setting
  DARS            • May unduly restrict freedom
                  • Limited access to supports and services
                  • Services and supports are inappropriate
                    to people with TBI
                  • Lack of services
        Supports and Services:
            Final Notes
• Not everyone with TBI needs every service
• Lack of a needed intervention can worsen
  condition
• Effects of TBI may not be visible
• Psycho-social deficits often most impairing
• Needs are unique based upon unique
  neurological involvement
                 The Family
• Emotional Reactions: Anger,
  Denial, Depression, Guilt
• There is no final stage of
  acceptance… “Brain injury is
  a forever deal.”
• There is no empty nest for
  parents.
• No time to work
• Attachment/emotional
  conflicts (injured member is
  changed—not the same
  person)
          The Family, Cont’d.
NEEDS
• Information
• Counseling (adjustment
  in roles, loss, etc.)
• $
• Time
• Respite
• Social Support
• Communication
The Family, Cont’d.
         ROLE CHANGES
         • Spouse as caretaker
         • Mother devotes all: no time
         • Injured older child reverts to
           earlier developmental stage
         • Child competes with father for
           mother’s attention
         • Children/siblings increased
           responsibility
         • Social roles non-existent or
           significantly decreased
          QUESTION:
“What problems are you having?”




               REASON:
    To identify needs as they relate to
           available services.
          QUESTION:
 “Is there someone who helps you
that you would want me to talk to?”



                REASON:
       Individual may have problems
       communicating their needs or
               following up.
                FACT
TBI accounts for more years of lost
    productivity than any other
              injury.


  (CDC National Center for Injury Prevention & Control, 1999)
              FACT
 More than 5,700 Texans are
 permanently disabled by TBI
         each year.


(CDC National Center for Injury Prevention & Control, 2004)
The End of the Line:
Additional Resources
• Defense & Veterans Brain
  Injury Center (DVBIC)
• 2-1-1 Texas/TexVet
• Brain Injury Association of
  Texas (www.BIATX.org)
• Texas TBI Advisory Council
  (www.dshs.state.tx.us/braininjury)
• Support groups:
   – long-term help
   – free
   – available in many areas
     where other services are
     limited
• Natural supports (e.g., community, churches, charity
                    organizations)
           TBI: PREVENTION
• Common sense
• Seatbelts
• Use child safety seats
• Helmets
• Education
• Home Safety Check
• Lock up firearms
• Don’t drive under influence
  of any substance
• Don’t drink to excess
• No drugs of abuse

								
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