UNM COC:  Your Healthcare Primer for Long Term Care

 
Traumatic Brain Injury

Alya Reeve, M.D. (Neuropsychiatrist)

Definition

Traumatic brain injury (TBI) is an insult to the brain caused by an external force that results in impairment of cognitive abilities and/or physical functioning and/or behavioral and emotional functioning. Often, TBI induces coma, a diminished state of consciousness, lasting from minutes to weeks/months. Mild TBI (MTBI) is defined by brief loss of consciousness and memory, with neither symptom lasting longer than 60 minutes.

Acquired brain injury (ABI) is any injury to the brain which is not hereditary (inherited), congenital (you're born with), or degenerative (progressive loss of function).

Introduction

In the United States approximately 2% of the population live with the disabilities resulting from brain injury.

Every year, about 80,000 Americans experience long-term disability due to TBI.

Vehicle crashes are the leading cause of TBI. The second leading cause is falling down -- elderly persons and young children are at especially high risk.

Risk for TBI is greatest between ages 15-30 and over 75 years. This corresponds to the ages of high risk-taking behavior and diminished motor coordination and speed of motor response, respectively.

The risk of re-injury increases over time: after one injury the risk for a second TBI is three times greater; after the second injury, the risk is eight times greater.

Diagnosis

A TBI requires that a person has been hurt by a blow directly or indirectly to his/her head, such as being hit by an object, being thrown into an unmoving surface (e.g. windshield), or being severely shaken (heading swinging back and forth). The history of the sequence of events is usually provided by an observer; the person who sustains the injury does not usually have memory for the immediate events. Because every person is unique, there is no one syndrome that applies to every person in a predictable way.

Physical symptoms: Persons with TBI can have long-standing problems in moving around; decreased sensation in parts of their bodies; weakness (even paralysis) and poor coordination; changes in speech; change in their ability to smell, to taste, to see; headaches or migraines; easy fatigue; pain; seizures; increased muscle tone. MTBI is often overlooked because a person may have nothing visibly wrong with her/him.

Cognitive symptoms: TBI may cause a person to have difficulty in concentration; in retaining and learning new information; in understanding multiple sources or types of information; slowed abilities to process information; difficulty in organizing altered sense of time; variable memory loss (short term and long term). The level of fatigue, and degree of being rested changes a person's ability to perform at their best. Any of these tasks tend to contribute to fatigue -- plowing through doesn't usually help them to perform better. Frequent breaks, pacing the effort, is often a much more effective method of tackling a task.

Emotional symptoms: The symptoms vary a lot from person to person, depending upon their previous personality and the location(s) of the injury to their brain. There may be difficulties with initiating things and in finishing tasks without reminders -- this is not a laziness response. Depression and rapid mood swings are common, as is anxiety. The person has experience a sudden and devastating change in their sense of themselves and the world around them. Anxiety is a frequent component -- because of not being sure what they are experiencing, and because of having difficulty in dealing with new information. Impulsivity, difficulty in anticipating consequences of actions, and difficulty in seeing how their behavior affects others are some of the most problematical behaviors after TBI.

Most people with TBI are very aware, even if impaired in their abilities to respond verbally. A frequent feature is an increased responsiveness to their immediate environment -- activities and noises that used to be tolerated as background noise to be ignored, may now be perceived as loud and intrusive, or they may mimic whatever attitude is presented (as an example, when threatened, they may immediately posture with a threatening attitude).

Treatment

Acute: This treatment involves immediate stabilization at the scene of the injury and in the emergency room. Steroid medications are used to decrease swelling of brain tissues. Fluid replacement, support for breathing and circulation (including increases and decreases in blood pressure), replacement of loss of blood, and repairs of fractures or other structural damage is all essential medical supports.

Post-Acute: During this early phase of recovery, rehabilitation efforts are started, often involving speech and language pathology (working on language, eating and swallowing, speaking), occupational therapy (skills in getting around), physical therapy (getting limbs to move properly, improving balance), and psychology (cognitive evaluations, emotional support, tests of memory and initial strategies to improve memory). As sedating medications are reduced, the survivor may experience depression, rage, changes in personality and perceptions, seizures, and a lot of confusion.

Long-term: There are continued needs for treatment and rehabilitation during the 6 months to 5-10 year period after severe brain injury. Neurological and psychiatric disorders declare themselves. Recovery of memory function, adaptive behavior and increased independence continues, if supported and adequate opportunity for practice is available.

Prevention

Safety measures: Basic safety measures must be relearned, and maintained scrupulously, such as seat belts in vehicles, helmets when riding motorcycles, bicycles, horses, skate boards, etc. Practicing safe judgment in complex situations is a skill that must be relearned -- crossing streets, being in crowds, getting out of closed spaces (movie theaters), how to drive, cooking on one's own. Ability to maintain personal hygiene is also a measure of safety, from brushing teeth regularly to completing all the steps in getting dressed (for example, no shoe laces left untied to trip on while walking).

Risk assessment: During the rehabilitation the treatment team must evaluate an individual's abilities to maintain personal and public safety. Assessment of a person's capability must be comprehensive and tailored to the individual's needs and abilities: to remember to test water for taking showers or baths, to turn off the burner after boiling water/cooking, to lock doors appropriately to their residence, to look both ways in a timely way when crossing the street, to keep track of bills and money spent, etc.

Secondary conditions: There is growing awareness that complications from having a brain injury put the individual at direct and indirect risk of having a second brain injury and of developing other medical conditions. These are called secondary conditions. For example, inattentiveness and poor attention to time overall may contribute to a person not noticing that he/she isn't taking all their prescribed medication, and as a result they start to have more frequent seizures and injure themselves. Or, lack of brushing teeth leads to inflammation of gums, loss of teeth and progressively poorer nutrition. In some people, a lack of initiation leads to sitting watching TV, with loss of socialization, loss of physical movement and general conditioning.

The common theme in this section is that of assisting the person with TBI to prevent further health complications as a result of their brain injury. The assessments and supports needed to prevent greater illness changes over time, as the individual regains and develops capabilities and new learning over months and years. Prevention continues to be a lifelong concern.

How to Help a Person with TBI

Interactions: It is very important to recognize that the identity of the person with a TBI is often not lost -- especially with adults, it is important not to be patronizing or to act as if they are decades younger than their chronological age. Attention to the rate at which a person can accept new information is also important. By conversing or doing things at a pace that the patient with TBI can maintain, he or she can better understand your input and can communicate more effectively in response to you.

Structure: As a general rule, most people with TBI will experience greatest comfort when daily activities follow a predictable pattern. This entails having the same staff present during the day, meals or therapy sessions to follow a regular schedule, regular rest periods (early on it may require a rest every 30 minutes), maintaining predictable physical distance from the individual, speaking in calm voices at a moderate rate of speed (in order to give the person the time to understand all that is being said). Structure in behavior and in the environment is designed to assist the person to organize their perceptions of the world, not to limit their efforts or creativity -- so it also important that it not become a jail.

Nonverbal attentiveness: Carefully noticing what slight body movements (facial expressions, for example) occur in response to different activities, sounds, and level of interaction will help you a lot. As you notice the person with TBI tiring, or becoming overwhelmed, you can initiate a change that will help to reduce the fatigue or anxiety, and then a short time later, you can encourage the person to try the activity again. In this sensitive way you can assist the person with TBI to learn how to tackle and tolerate new experiences while keeping themselves intact. By watching body language with attentiveness, you will pick up on changes in mood and interest. This will help you to increase the psychological comfort level of the person with TBI and will build his/her sense of trust in you and in himself/herself.

Alya Reeve, M.D. (Neuropsychiatrist)