Traumatic Brain Injury in the Elderly

Traumatic Brain Injury in the Elderly Felicity Bright Clinical Supervisor Speech Language Therapy Rehab Plus Auckland District Health Board Why the Interest?  Mark    SDH after fall while intoxicated Lived with daughter and grandchildren Rehab: Appropriateness of environment  Staff want early discharge  Needs of families  Why the Interest?  Kate      Car accident – multi-trauma and TBI Lives alone Complicated acute stay Cognitive deficits ++ Discharge planning: Recommendation for discharge home with home based rehab in May  Discharge occurred in October  Why the Interest?  Patrick     Multiple falls and SDH Lives with wife Team meeting – “probably got a TBI” Discharged 2 days later; no assessment or education completed TBI and the Elderly  Two peaks in TBI rates:   15 – 24 years 70 years +    Equal rates men and women In US – TBI most likely in white Americans Common causes:   Falls  TBI 3rd most common type of injury after fall MVA What Makes the Elderly Different?  There are going to be more!   2004: 18/100 >65 2051: 45/100 >65  13% will be >85  Pre-existing conditions place at risk for TBI  Gait impairment, dizziness, history of stroke, postural hypotension, poor visual acuity, multiple medications, depression, cognitive impairment What Make the Elderly Different?  Older brains:   Changes in brain structures ↑ risk of bleeding Medications ↑ risk of bleeding  Older bodies:   Body systems not 100% pre-injury Medications affect patients differently What Makes the Elderly Different?  Different outcomes:  As age increases, increased likelihood of: Complications  Increased length of stay  Discharge to care  Severe disability  Increased mortality, regardless of severity   Can get good outcomes, but they take longer and cost more Mortality      Falls main cause of death Over 1990s, 21% increase in mortality in elderly Severe TBI (GCS 3-5) – 90-100% death rate Moderate TBI – elderly 9%; young 1% Mild TBI – few deaths Rehabilitation    US has seen reduction in length of stay in rehab centres – NZ has similar pressures Older people make smaller gains on a slower basis Length of stay    Acute – Rehab Cost - 16.3 22.0 $124K 18.8 27.2 $135K Rehab Outcomes* Young Admission Discharge Change 64 101 37 Older 53 87 34 * FIM Morbidity Young Elderly 28% to rehab Discharge FIM 10.4 68% totally (I) FIM 6/12 11.0/12 57% good outcome or mod disability 10% good outcome or mod disability Mild TBI 16% to rehab Discharge FIM 11.4 89% totally (I) FIM 6/12 11.4/12 86% good outcome or mod disability 53% discharge to community; average FIM 53 Moderate TBI Severe TBI Discharge Locations  Older patients who came from home are more likely to be discharged into care  94% young; 80% elderly  Issues with discharge home:   Needs of carers Access to support Psychiatric and Cognitive Effects  TBI and Alzheimers Sleep disorders   Cognitive changes Relational Effects     Communication changes Increased dependence and interdependence after TBI Social change Relationship persistence We don’t know much about older people and TBI Specifics      Patterns of rehab – young vs. old Best place of rehab for the elderly Outcomes Co-ordination of care when moving from rehab to home/placement Experiences of carers in NZ