Neuropsychological Disorders & Traumatic Brain Injury: Causes, Symptoms & Consequences, Exams of Nursing

Download Neuropsychological Disorders & Traumatic Brain Injury: Causes, Symptoms & Consequences and more Exams Nursing in PDF only on Docsity! CBIS 2024-2025 UPDATE ACTUAL EXAM ALL QUESTIONS AND VERIFIED ANSWERS ALREADY GRADED A+/ 100% PASS SOLUTION * Glasgow Coma Scale (GCS) 3-8 Severe TBI; normal or abnormal structural imaging. LOC over 24 hours, post traumatic amnesia over 7 days -12 * Glasgow Coma Scale 9 Moderate TBI; LOC over 30 minutes but less than 24 hours; alteration of consciousness over 24 hours, post traumatic amnesia more than 1 day but less than 7 days * Glasgow Coma Scale 13-15 Mild TBI; normal imaging; LOC 0-30 minutes, alteration of consciousness up to 24 hours, post traumatic amnesia up to 1 day * 3 parts of neuron Cell body Axon Dendrites * 2.5 million TBIs 53,000 deaths (2%) 284,000 hospitalizations (11%) 2,214,000 ED visits (87%) * Coup-contrecoup When the brain accelerates in one directions, it rebounds in the opposite direction * Acquired Brain Injury An injury to the brain that is not hereditary, congenital, degenerative or induced by birth trauma * Traumatic Brain Injury An alteration of brain function or other evidence of brain pathology caused by an external force * Incidence Rate or range of occurrence * Prevalence Number of people with a given condition at a specific point in time * What determines the effects of brain injury? Injury severity Age at injury Alcohol misuse Domestic violence Service in military Participation in sports * Concussion Mild TBI caused by bump, blow or jolt to head that can change the way the brain works (or a fall) Can occur in any sport or recreation activity Memory loss May or may not lose consciousness 00:0201:18 * 2.5 million people sustained TBI in 2010 ... * Brain Stem Top of spinal column Central point for all incoming and outgoing information and basic life functions * Limbic System Emotions and basic feelings * Frontal Lobe Damage Executive function/personality Lack of control of behaviors, poor short term memory and working memory * Broca's Area Located in lower portion of motor cortex (left frontal-temporal lobe) Expression- production of speech * Wernicke's Area Located in left temporal parietal area Receptive- understanding of speech * Risk of TBI after first injury 3x greater for 2nd injury * Risk of TBI after second injury 8x greater for 3rd injury * Alcohol and TBI 37%-51% of brain injuries 22% of drivers aged 15-20 involved in fatal MVAs had been drinking 56% not wearing seat belts * Neurons Communicating cells * Frontal Lobe Primary motor cortex and prefrontal cortex Planning, organizing, problem solving, judgment, impulse control, decision Bilateral head pain; tight hat or vice clamping around head Tx with NSAIDs and low load craniocervical mobilization Cervicogenic Headache Head pain generated from cervical spine Can provoke headache through movement or manipulation of neck Tx with manual therapies or nerve injections Post-traumatic Migraine Episodes of headaches with different phases Prodrome-> aura -> headache -> post drome Typically unilateral, throbbing, stabbing or sharp pain Tx with triptans, NSAIDs, dark room, quiet environment Neuralgia Pain caused by damage to nerve or structural change in nerve Standard Precautions Hand hygiene, PPE, respiratory hygiene, safe injection and disposal of sharps, cleansing of equipment, isiolation Awareness An individual's ability to receive and process information and use that information to relate to an intentional way to the outside world Regulated by higher cortical areas in cerebrum Costs of Brain Injury Lost productivity Insufficient or inappropriate diagnosis, treatment and care CDC Centers for Disease Control Carries out projects to reduce the incidence of TBI Brain Injury is a silent epidemic Person looks normal Under diagnoses, unreported Problems at work/school, changes in personal relationships, legal problems, homelessness Public Funding of TBI Medicaid Medicare Patient Protection and Affordable Care Act 2010 Axon Transmits signals electrochemically from one cell body to another Dendrite Receives information at the synapse from other neurons Synaptic Gap Between axon and other neuron's dendrite (neurotransmitters come here) 2 parts of diencephalon Thalamus Hypothalamus Excitotoxicity Neuron is no longer able to maintain resting potential as a result of impairment of sodium and potassium pump in combination with large scale increases in extracellular excitatory neurotransmitters Neurons fire repeatedly Apoptosis Programmed cell death; increases of free radical production mTBI (mild) 75% of TBIs (1.1 million persons) Traumatically induced physiologic disruption of brain function.. any period of loss of consciousness, any loss of memory, any alteration in mental state at time of incident Normal brain structure on CT or MRI GCS 13-15 Anticoagulants Clotting, stroke risk Coumadin, heparin, lovenox Fall risk and skin integrity issues Coma No arousal/eye opening No behavioral signs of awareness Impaired spontaneous breathing Impaired brainstem reflexes No vocalizations > 1 hour 2-4 weeks Vegetative State Months to years long Arousal/spontaneous or stimulus induced eye opening No behavioral signs of awareness Preserved spontaneous breathing Preserved brainstem reflexes No purposeful behaviors No language production/comprehension Preservation (partial or complete) of hypothalamic and brainstem autonomic functions May grimace to pain, localize to sounds inconsistently Disinhibition Engaging in behaviors on impulse without reflecting on potential future consequences Increased lability, social inappropriateness, depression, apathy Fatigue mTBI Common symptom Mental exertion not physical Altered sleep pattern Limit overall activity for 2-4 weeks Vision Changes mTBI Impaired motor control-> blurred vision Convergence insufficiency -> cannot focus Orthostatic Hypotension Drop in blood pressure upon standing Change in balance Benign Paroxysmal Positional Vertigo (BPPV) Vestibular disorder Inner ear and visual/spatial and proprioceptive centers Nystagmus Epley maneuver to correct Sleep Disturbance Management Sleep hygiene education: proper sleep ritual, bedroom environment, diet Neuropsychologists Assess cognitive and psychological functioning EI: education and reassurance Make recommendations for therapies for improved tx Monitor return to work or school Treat emotional problems The management and treatment of mTBI is a serious matter that requires a well rounded diagnostic and treatment approach. A concussion creates changes to the chemical and physical structures of brain which should be monitored to ensure full recovery. Review any lingering symptoms. ... Intrathecal Baclofen (ITB) Severe spasticity Used only when there is a poor response to oral meds Works at level of spine to inhibit excitatory activity at spinal reflexes Pump considered after 1 year Botox Injected into muscles and used to treat increased muscle stiffness (elbow, wrist, fingers typically) Contractures Dizziness, loss of balance Rarely exists in isolation: visual, perceptual, vestibular, and somatosensory symptoms combined Concomitant SCI Cooccurring SCI with brain injury 60% Complete SCI No motor or sensory function below level of injury Incomplete SCI Functioning of sensory and possibly some or much motor sensation below level of injury Pressure Sores Impaired sensation Decreased ability to reposition Perform skin checks frequently-especially bony prominences Hyperreflexia Involuntary increase in muscle tone and exaggerated deep tendon reflexes Osteoporosis Diminished levels of estrogen and testosterone Vulnerable to falls and injuries Incontinence Presence of bilateral central lesions Damage to pedundal nerve and sacral nerve roots UTI Occur early and late post injury Cognitive or behavioral changes Maintain hydration, timed voiding Dysphagia Impaired motor control, weakness of facial, masticatory, pharyngeal or laryngoesphogeal muscles, dyscoordination with breathing and muscle function and changes in sensation MBS ordered Frazier Free Water Protocol Dysphagia patients Use of water with minimal risk of aspiration Requires stringent oral care and oral suction Dysphagia Food Levels Pureed Mechanically altered Advanced Regular diet Dysphagia Liquid Levels Thin Nectar Honey Spoon/pudding Complications of Reproductive System Changes in libido, arousal and sexual performance Hormonal changes Limited ability to utilize oral contraceptives Reasons for Skin Breakdown Dependence for repositioning Physical restlessness and associated shearing Bowel and bladder incontinence Splint pressure Bowel/Bladder Dysfunction Incontinence Constipation Bowel irregularities Discomfort Infections with stool or UTIs Hygiene and skin issues Goal Setting of Persons with Disorders of Consciousness Based on responses to stimuli, tolerance for stimuli/activity, risk management, caregiver development Person unable to participate in goal setting and passive participate in therapeutic activity Person does not have volitional control over responses or functioning Goals for Physical Management ROM Orthotics Upright positioning: maintain bone density, normalize body function, increase alertness Bed positioning Fatigue The awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and/or restoration of resources needed to perform activity Physical: muscle weakness or other changes or injuries in peripheral nervous system Physiological: depletion of energy, hormones, neurotransmitters or a reduced number of neural connections Anxiety, depression, pain Sleep Disturbance Following TBI 30-80% of individuals with TBI Changes in REM sleep Excessive day time sleepiness Circadian rhythm disorders Treatment of Sleep Disturbances Regulate lifestyle (decreased work, modify demands, rest breaks) Physical conditioning programs Sleep hygiene techniques Pharmacological interventions (not longterm tx) Narcolepsy Repeated episodes of naps or lapses into sleep of short duration usually less than one hour Post-traumatic Hypersomnia Excessive sleepiness that occurs as a result of a traumatic event involving CNS Headache Post traumatic headache: within 14 days of loss of consciousness Primary headache: no specific cause Secondary headache: identifiable cause Chronic headache: occurs at least 14 days/month for at least 3 months Craniomandibular Headache Subtype of tension headache Difficulty eating/talking Tx with bite blocks, dietary changes, surgery Neuroma Nerve becomes entrapped in scar tissue CNS Stimulants Attention Ritalin, adderall, provigil Irritability, mania, agitation, seizures, weight loss SSRIs, SNRIs, Tricyclics Depression Zoloft, paxil, prozac, cymabital, elavil, wellbutrin Headache, altered mental state, sweating, fever Anti-cholingerics and Cholingerics Bladder Enablex, ditripan, urecholine Increased urgency, falls, confusion, constipation Alpha blockers, Infection suppressant, laxatives, stool softeners, suppositories and enemas UTI prevention and bowel Flomax, cranberry tablets, miralax, colace Fall risk, constipation, bowel obstruction GI meds (motility) Promotes motility, slows motility Reglan, lomodil, pepito bismol Tardive dyskinesia, movement disorders GI meds (appetite stimulant/acid production) GI Nexium, pepcid, prilosec, marinol, megace Tardive dyskinsia, movement disorder Behavioral/Emotional Symptoms mTBI Depression, anxiety, agitation, irritability, aggression, impulsivity Headaches mTBI Typically worsen with increased physical and mental exertion Meds commonly used are avoided secondary to restricting blood flow (prevents healing) Chronic Traumatic Encephalopathy (CTE) Rare, progressive, degenerative condition of CNS Seen in repetitive brain trauma (multiple concussions) Can develop ALS Diffuse axonal injury-relase of Tau proteins creating a chronic inflammatory statue Deterioration in concentration, attention, memory, judgment, insight Dizziness and headaches Apathy, impulsiveness, suicidal thoughts Cardiopulmonary and Vascular Complications of Brain Injury Direct damage to organ, complications from trauma or trauma care, damage to parts of brain that control function Tracheostomy, risk of aspiration, BP issues Cranial Nerve Dysfunction Visual disturbances Facial drooping Postural instability Dysphagia Autonomic dysregulation Neuropathy Weakness resulting from injury to peripheral nerve Nutritional Management of TBI Metabolic needs increase as body works to heal brain At least 40% more calories Infections Invasion of body tissues by disease causing microorganisms Open wounds, indwelling devices, immuno-suppressed Meningitis, respiratory infections, UTIs, surgical sites, cellulitis Periodic Limb Movement Disorder Periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep (usually leg) Minimally Conscious State Months to years long Arousal/spontaneous eye opening Fluctuating but re-produceable behavioral signs of awareness Response to verbal directive Environmentally contingent smiling or crying Object localization/manipulation Sustained visual function and pursuit Verbalization Intentional but unreliable communication Emergence: functional communication, functional object use Respiratory Concerns Tracheostomy tube Sleep apnea (decreased muscle tone or nervous system injury) Tracheal aspiration Neurobehavioral Assessment Designed to capture a broad range of responses to sensory input and to provide rater with quantifiable findings (establish level of consciousness, caregiver education, outcome prediction, identify most effective targets for treatment) Measurement of Fatigue Quantify fatigue levels, assess subjective distress and measure impact on performance of daily activities Primary fatigue Results directly from injury or disease Secondary Fatigue Factors that exacerbate fatigue (pain, sleep disturbance, stress) Not common post TBI Cognitive Behavior Therapy may be useful Post traumatic Stress Disorder A group of symptoms following a traumatic event that may include re-experiencing the traumatic event, avoidance of stimuli, increased arousal, flashbacks Reduced awareness/amnesia following event may decrease risk of development Can be incapacitating Substance Misuse Consumption of alcohol and illegal drugs and use of prescription drugs exceeding the prescribed amount or the use of another's prescription Substance Use Disorder Involves continued use despite health, psychological or social consequences * TBI is a contributing factor to 1/3 of all injury related deaths ... * 75% of TBIs are concussions or other forms of mild TBI ... * Domestic Violence and TBI 67% of women victims of domestic violence had symptoms associated with brain injury * 5% of persons with severe brain injuries have adequate funding for long term treatment and supports ... The Olmstead Decision Supreme Court States must administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities * TBI Act of 1996 To expand efforts to identify methods of preventing TBI, to expand biomedical research efforts or minimize the severity of dysfunction as a result of such an injury HRSA TBI state grant program Improve integration of services Establishment of policy Procurement of financial support TBI and Mortality 2x likely to die Life expectancy reduction of 7 years 37x more likely to die from seizures 12x from septicemia 4x from pneumonia 3x from respiratory conditions Traumatic Impact Contact Injury Closed Focal or diffuse Brain contusions, brain lacerations, intracerebral hemorrhage, diffuse axonal injury Blast related, assaults, vehicular accidents, sports accidents Traumatic Impact Contact Injury Open Primarily focal Epidural hematomas, subdural hematoma, intracerebral hemorrhage, infections Gun shot, stabbing falls, vehicular accidents, sports accidents Skull fracture Traumatic Inertial Noncontact Injury Rotational/Angular Forces Primarily diffuse (multifocal) Diffuse axonal injury, white matter lesions, hemorrhage Falls, vehicular accidents, sports accidents Non traumatic internal insult Severe reduction in blood flow or hemorrhage due to clotting Focal or diffuse White matter lesions, hemorrhage CVA, neurotoxic poisoning, hypoxia/anoxia, ischemia, infection, tumors The Rehabilitation Act of 1973 A federal/state supported system of services which assists persons with disabilities who are pursuing meaningful careers Prohibits discrimination on disabilities in programs run by government agencies Evaluation services Job development, job placement, job coaching Glial Cells Non communicating cells which support and nourish neurons Vesicles Sacs filled with neurotransmitters Medulla Brainstem base Reflex center controlling breathing, heart rate, blood pressure, swallowing, vomiting, sneezing Injury here is life threatening Pons Brainstem Facial movements, facial sensation, hearing, coordinating eye movements Connects cerebellum and cerebral cortex Midbrain Brainstem Seeing, hearing, alertness, arousal Smallest part of brainstem Temporal Lobe Functions Memory Language Hearing Parietal Lobes Primary sensory cortex (somatosensory cortex) Sensation, perception (touch, temp, pain) Damage to Parietal Lobe Lack of awareness of impairment of body on affected side Difficulty identifying sensation (location, type) Anterior Cord Syndrome Loss of muscle control, pain + temp, sensation Maintain proprioception and touch sensation Posterior Cord Syndrome Maintain strength, loss of proprioception Intraoperative complications, cell death Brown Squared Syndrome One side of spinal cord is damaged Ipsilateral paralysis, loss of light touch sensation on side of lesion, loss of pain + temp on contralateral side Magnesium Trial of neuroprotective agent for TBI Involved in cellular processes (cellular respiration, protein synthesis, membrane stability, regulation of vascular tone) Progesterone Trial of neuroprotective agent for TBI Decreased cerebral edema Lower dose Nicotinomide Trial of neuroprotective agent for TBI Soluble B group vitamin Reduced injury volume, decreased glial activation, reduced blood brain barrier breach, improved motor performance, reduced behavioral impairments 6-24 hours post TBI Axonal Sprouting and Synaptogenesis When a subset of neural projections to a brain region is lost, remaining ones sprout and form new synaptic connections onto partially denervated neurons Osmolarity Edema caused with imbalances Contributes to intracranial pressures and apoptosis Implications of Seizure Increased mortality Increased morbidity Risk of injury Can lead to disability Impacts employment Impacts driving Alzheimer's Meds Cognition Donepizil, rivastigmine May cause seizures, GI bleeds, difficulty voiding, HR changes Antiparkinsonian Meds Arousal Synnemet, cogentin Neuroleptic malignant syndrome (increased temp, altered consciousness, autonomic instability, muscle rigidity) Anxiolytics and Beta Blockers Anxiety Xanax, ativan Used cautiously with substance abuse Anticonvulsants, Mood Stabilizers, Anti-psychotics Behavioral control and mood stability Depakote, neurontin, lithium, lyrica, respiradol, seroquel Changes in neurologic status and motor function, dyskinesias 4,200 individuals are classified in a vegetative state each year 315,000 people present with a disorder of consciousness (35,000 vegetative state and 280,000 minimally conscious state) ... Arousal Primitive, involuntary responsiveness to the world Responses to internal and external stimuli Reticular activation system (RAS) pathways in brain responsible for maintaining arousal Physical/Somatic Symptoms mTBI Headache, fatigue, seizure, nausea, numbness, poor sleep, light sensitivity, noise sensitivity, impaired hearing, blurred vision, dizziness/LOB, neurologic abnormalities Cognitive Symptoms mTBI Inattentiveness, diminished concentration, poor memory, impaired judgment, slowed processing speed, executive dysfunction Persistent Post-concussive Symptoms (PPCS) Risk factors: older than 40, female, traumatically injured, low socioeconomic status Headache, dizziness, nausea, post traumatic amnesia + 1 hour, GCS 13-14 Requires thorough neuropsych assessment Motor Learning A set of internal processes associated with practice or experience leading to relatively permanent changes in the capability for skilled behavior Basic Principles to Enhance Neuroplasticity Use it or lose it Use it and improve it Be specific Repetition is essential Intensity matters Salience is important Age must be addressed Transference Interference Patient expectation Reward or feedback Environment Fun Helping others Obstructive or non communicating hydrocephalus Obstruction of flow of CFS around brain after trauma Tx: to prevent any ventricular enlargement Hydrocephalus ex vacuo After TBI Brain tissue that has been injured will cause neuronal loss and shrinking of brain tissue which will lead to look of ventricular enlargement on scans Vascular Thrombus/Emboli Anticoagulants Signs: redness, swelling, fever Occurs due to immobility Thrombus Mass of platelets and/or fibrin that forms in a blood vessel Blood clot Embolus A piece of thrombus that has broken free and circulates within the bloodstream Pain following TBI Chronic pain in 58% of persons with brain injury More prevalent with mTBI Affect mood, concentration, sleep Somatosensory Issues Proprioception, tactile sensation, thermal sensation, pressure and pain Assess for safety Ballisms Quick flailing movements Choreiform Golas for Sensory Stimulation and Regulation Increase level of arousal and awareness through stimulation of the reticular activating system Prevent sensory deprivation Facilitate increase response frequency and consistency through structured sensory input Facilitate ability of follow commands and communicate meaningfully Present stimuli one at a time, allow time for response, vary stimuli to reduce habituation, regulate environment to reduce over stimulation The Coping Hypothesis Fatigue may result from the compensatory effort necessary to meet the demands of every day life in the presence of cognitive deficits Increased psychophysiological costs (higher BP) Growth Hormone Deficiency and Fatigue Common following TBI Neuroendocrine abnormalities Hypocretin Wake promoting neurotransmitter Decrease in levels may increase daytime sleepiness (fatigue) There are over 5.3 million Americans living with long term disabilities secondary to brain injury ... Cognitive Impairments Difficulties with attention, memory, problem solving, decision making Impacts independence, educational or vocational engagement, social interaction, familial interaction, life satisfaction Cognition A complex collection of conscious mental activity such as attention, perception, comprehension, remembering or using language Sensory input is transformed, reduced, elaborated, stored, recovered and used Cognitive Skills and Processes Alertness, association, attention, attention span, awareness, categorizing, comprehension, decision making, insight, learning, goal directed behavior, memory, organizing, planning, problem solving, reasoning, retention, selective attention, stimuli recognition, stimuli discrimination, synthesis of info, thinking Focused Attention Perceive and respond to internal and external stimuli Sensory Memory Registers iconic, echoic, haptic, olfactory and gustatory information Executive Functions Planning, reasoning, judgment, initiation, abstract thinking, problem solving, decision making TBI exhibit impulsivity, disinhibition, hyper verbosity, poor control of emotions Attention Deficits Intervention Recognize and control conditions Sharpen ability to focus attention Retraining -> Attention Process Training (APT) cognitive rehab The Categorization Program Remediation of deficits in object categorization and decision making Starts with basic attribute identification and progress to higher concepts Executive functions have been conceptualized as "cognitive directors" since they assist in the interaction between other cognitive processes. Metacognitive functions are viewed as "awareness directors" since they oversee thinking processes. ... * Parietal Lobe Academic skills Eye hand coordination Object naming Spatial orientation Tactile perception Visual Attention * Temporal Lobe Emotional response Face recognition Language comprehension Memory Object categorization Object location Receptive language Selective attention Interference with Cognitive Rehabilitation Hearing Vision Communicative function Medical stability Emotional and behavioral control Emotional and Behavioral Control Difficulty adjusting to functional deficits, pre-existing psychological factors Depression, aggression, irritability, noncompliance, emotional lability Cognitive Rehabilitation Tx must be hierarchical in nature OT, ST, neuropsych Increase task complexity Isolated settings may not allow for generalization of skills 1. environmental stimulus (quiet to distracting) 2. task complexity (simple to complex) 3. cognitive distance (concrete to abstract) Cognitive Skill Memory Procedures necessary to win a game or solve a problem Long term implicit memory Focuses on real world improvements in daily functioning Factors that play a role in developing neuropsychiatric symptoms after TBI age, gender, premorbid symptoms, injury location, injury severity, individual factors: marital discord, poor relationships, hx of work problems, financial instability Psych problems as rehab barriers Agitation, confusion, combative May be inappropriately placed or D/C early Often unable to engage in traditional counseling Psych meds may exacerbate aspects of TBI Caregiver stress Playing with meds Long term outcome of TBI/psych Integrate psychiatric and psychological services Return to community can add stress (may intensify deficits related to daily life) Limited providers Special attention: community reintegration, peer relationships, caregiver burden, loss of independence, economic stress Depression Anxiety and depression linked to poorer outcomes Severe injuries-lower depression (self awareness) Major depression disorder, avoidant, paranoid and schizoid personality disorders most common Factors related to development of depression Pre existing difficulties in social functioning, job dissatisfaction, low economic status, less education, lack of close personal relationships Alcoholism and anxiety Can lead to isolation (restricted socialization) Major Depressive Episode At least 2 weeks in which individual experiences loss of interest or depressed mood accompanied by 4 symptoms (change in appetite, weight gain, decreased energy, feelings of worthlessness, suicidal ideation) Risks: socioeconomic status, premorbid psych Manic Episode 1 week of noticeably elevated, expansive, or irritable mood with 3 symptoms (extremely amplified self esteem, decreased desire for sleep, grandiose ideas, distractibility, risk activities) Increased aggression, irritability, activation and decreased euphoria and sleep Panic Disorder Repeated panic attacks followed by worry about future attacks or changes in behavior related to the panic attack 4 somatic symptoms: sweating, palpitations, trembling, nausea, chest pain, dizziness, chills, hot flashes Schizophrenia Disorder lasting 6 months with 1 month phase including delusions, hallucinations, incoherent speech, catatonia, or avolition Correlation between TBI and schizophrenia Lead to problems with independence, relationships, cognitive behavior and psych problems Personality Disorders Apathy, affective lability, uncontrolled emotions, aggression Most common: avoidant, paranoid, schizoid Frontal Lobe Syndrome Presents symptoms of psych disorders; depression, psychosis, mood disorders Increase risk for development of depression and anxiety Individual typically cannot recognize and acknowledge deficits EEG, neuropsych, MRI Rehab and Psych Rehab harder as person becomes more aware of deficits Family may distance to cope with stress Rehab to request neuropsych for helpful strategies and meds to aid in process May be lifelong process If an individual misused alcohol or other drugs prior to injury the risk to return to misuse is 10x higher ... TBI and Substance Misuse TBI = increased substance misuse Children with TBI before age 5 more likely to develop a substance use disorder Parental and childhood alcohol use increase risk of 1 TBI Higher rate of rein jury, suicide attempts, decreased life satisfaction Hazardous Use The use of substances in a manner that is associated with higher risk of physical, mental, or social consequences and represents a public health concern Psychoactive Substance Misuse The use of any psychoactive drug for non medical purposes High Risk Drinking The amount of alcohol use considered to be unhealthy for most of US population Men 4 drinks/day 14/week Women 3 drinks/day 7/week Assessment of Substance Misuse Clinical interview Open ended questions Reflective listening Standardized assessments: CAGE, AUDIT, CRAFFT, ASSIST * Models of Disability as Foundations for Rehab Biomedical Functional Environmental Sociopolitical * Biomedical Model of Disability Treatment methods are concerned with changing the individual Create diverse treatment areas Interpreters Longterm Consequences of TBI Seizures, premature death, dementia/alzheimer's, parkinson's, unemployment, diabetes, psychosis, suicide Cognitive Aging General phenomena occurs across all people Changes can be managed with assistive technology TBI is a chronic disease process. It is disease causative and disease accelerative. ... Elements of Successful Aging after TBI Exercise, brain health, heart health, advocate, nutrition, mental health, protect the brain, socialize, avoid drugs and alcohol, make more connections Males with TBI outnumbers females with TBI 2:1 ... Females were observed to have worse outcomes on 85% of 20 variables studies (mortality, poor outcomes, cognitive impairments) ... Males have a higher rate of return to work 23.6% males 4.4% females Domestic Violence and TBI 92% report a blow to head 40% report loss of consciousness Psychological symptoms: distress and worry, anxious arousal, depression, PTSD Women and TBI Psychological Sequela Higher rates of depression, PTSD, sexual difficulty Increased symptomology over time Body image concerns Lower rates of marriage Brain injury and Sex Reduced sex drive Reduced sensation/orgasm Problematic positioning/pain Changed body image/confidence Decreased ability to satisfy sexual partner Disinhibition/hypersexuality Issues with bowel and bladder equipment Capacity for sexual ideation Causes of Sexual Dysfunction Neuroendocrine changes Hypothalamus and pituitary changes Physical changes: spasticity, hemiparesis, ataxia, decreased balance, movement disorders, sensory deficits Cognitive impairments: attention, concentration, initiation, social communication abilities, impaired awareness, memory loss, executive dysfunction Emotional and behavioral changes: depression, dependency, self centeredness, apathy, disinhibition, low self esteem Isolation, meds, financial stress, role changes Sexuality is not fully addressed in rehab Person has difficulty talking about it Treatment team does not view as a goal LGBT and TBI Benign neglect: staff discomfort and inexperience Homophobia 4 Domains of Sexual Intimacy Psychological: self esteem, awareness, respect, loyalty Emotional: share emotional needs, communication affection, share empathy, listen Operational: share responsibilities, decisions and parenting Shared: activities, hobbies, traditions, friends, family and community Sexual Addiction Internet based sexual addiction Accessibility Affordability Anonymity Sexual competence includes... Overall cognitive function Safety skills Sexual knowledge Understanding of consequences Youth with TBI learn from parents and professionals regarding sexuality rather than peers ... Formal interventions for Sexuality Permission Affirmation: acceptance Limited Information: detailed info of TBI and sex Specific Suggestions: medical exams, modifications Intensive Therapy: individual, couple or family Traumatic brain injury is the leading cause of death and acquired disability in children and adolescents in US ... Children ages 0-4 TBI Falls Susceptible to abusive head trauma/shaken baby syndrome (AHT and SBS) Children ages 15-19 TBI Struck by something Falls Motor vehicle accidents Age Effect Concussion symptoms will begin to dissipate within days or weeks of injury 10% will have persistent symptoms (problems with attention, memory, fatigue, sleep, headache, dizziness, irritability, change in mood/personality School Reintegration Process after Brain Injury Reintegrate part time or homebound instruction Family support Section 504 or IDEA with an IEP Around cognitive, psychosocial and sensorimotor Common Long term effects for Students Memory, attention and concentration, higher level problem solving, language skills, visuospatial skills, behavioral and emotional effects, motor impairment, physical effects, feeding disorders, sensory impairments, communication impairments, cognitive impairment, fatigue, medical issues, family difficulties Causes for changes in behavior Difficulty with STM, reduced behavior control, limited executive functioning, limited awareness of others expectations, misperception of interaction, limited awareness of social cues, communication deficits, inattention, impulsivity, disinhibition, inflexibility, emotional lability * Section 504 of the Rehabilitation Act of 1973 Requires schools receiving federal funding to provide reasonable acommodations to allow an individual with a disability to participate Quality if they have a "presumed" disability (physical or mental impairment that substantially limits one or more major activities, has a record of impairment or is regarded as having an impairment) Preschool -> employment * Individuals with Disabilities Education Act (IDEA) Federal education mandate to provide public education through special education and support services to children with eligible disabilities HAS DISABILITY Special education and services at no cost IEP starts with the assessment process to determine eligibility AT, SLP, PT, OT, psych, parent counseling, medical services Preparing for school re-entry Hospital and rehab staff inform school immediately Request school to begin eval process and release of medical records School based educators can visit in facility Assessment of student's present levels of academic and functional performance * 504 Plan Can establish eligibility for 504 plan with medical verification of brain injury before IEP is established Can be in place while waiting for more intensive IEP supports * IEP A "CONTRACT" between student's family and school system designating kinds and extent of services student needs based on assessment Healthcare facility, school and family Identify skills, strategies and behaviors student needs to learn and function Reviewed every 12 months ( or 2-4) Frequent re-eval during 6-12 months post injury Services for children in charter and private schools Charter school considered public Private schools: public school in district provides assessment (child may then attend public, may remain at private school with private school service (limited services)) School Transitions Recognize need for transition planning Begin planning early Assess new environment and determine needs Prepare receiving teachers with specific info Monitor progress Transition to post secondary education Likely to need special assistance Institution determines accommodations High school is responsible with assisting to find appropriate college Transition to work and community Be aware of vocational services Many assessments should be done prior to return to work Link to adult service providers Programs may have waiting list Military Population Incidence TBI is signature injury sustains in modern warfare Penetrating gun shot wounds and explosive attacks Issues: mechanism of injury, co-occuring effects of deployment, military culture 22% TBI and concussion 8% persistent symptoms mTBI and PTSD Most injuries are mild or concussive Rate of persistent symptoms low at 8% Most battlefield injuries are closed head injuries mTBI only 56% mTBI and PTSD 44% With overlap of symptoms, diagnosis is difficult Cause and Types of Injury to Military Personnel Combat Related Blast events, falls, gunshot wounds, MVA Can be closed head injury Can be open head injury due to penetrating through dura mater (foreign objects, munition fragment, bone) Cause and Types of Injury to Military Personnel Peacetime related Injuries MVA, falls, sports related, training accidents, working in closed surfaces (tanks and submarines), high risk behaviors after returning from duty Four Levels of Blast Related Injuries Primary injury: direct impact from over pressure wave, compresses air filled organs, catapults body backwards Secondary injury: energized debris or explosive fragments impacts head/body Tertiary injury: body impacts wall, ground or object Quarternary injury: inhalation of toxic gases or substances TBI Screening Tests used by first responders and medics for triage to higher level of care Military Acute Concussion Evaluation (MACE) provides gross measure of cognitive domains: orientation, immediate memory, concentration, memory recall TBI diagnoses made whenever alteration in consciousness exists "Showing your wounds" Neuropsychological Testing DOD does not prescribe specific batteries of tests Prior to deployment each service member completes a 20 minute computerized neuropsychological battery Effects of concussion better determined by comparing pre and post injury performance Compared if suspicion of head injury Helps determine return to duty Initial Treatment Considerations for Concussion and mTBI Symptom management (headache, vision, cognition, sleep) Education: signs and symptoms, strategies, rest guidelines Therapy Implementation of duty restrictions Return to Duty Considerations Concussion and mTBI Clinical practice guidelines provide recommendations for care Rest and return to duty are very important No one is returned until symptom free at rest and exertion Mission responsibilities may take precedence over recuperation and final decision made by commander Cascading Effects of mTBI Symptoms Chronic pain, PTSD, depression, anxiety, substance misuse Comorbidities provide diagnostic challenge Problems associated with TBI are aggravated by other symptoms Treatment focuses on symptom relief Medical Discharge Process involves 2 boards: medical and physical evaluation Standard used by PEB is whether the medical condition precludes the member from reasonably performing the duties of his/her rank or office Uses VA schedule for rating disabilities 0-100% Encompasses skill set: belief system, family organization, effective communication Couples after TBI Support intimate relationship by providing accurate info and instill hope Spouses report depression, decreased marital satisfaction and impacted family functioning Lower rate of relationship breakdown Challenges include relationship satisfaction, sexual satisfaction, parenting difficulties Parents of Adults with Brain Injuries Parents must return to their early life role of authority Parents become social outlet as peers pull away Increased stress As parents age, increased difficulty providing care = institutions No respite program available for brain injury survivors Sibling Relationships Siblings struggle to cope with changes, may feel resentment Siblings needs may be overlooked Provide support, guidance, maintain normalcy and devote special time Cultural Considerations Elicit family stories Tailor communication to fit family Special consideration for military Brain Injury Family Interventions (BIFI) Target psychological support, education, problem solving and skills training Fact sheets, guides and readings (90-120 minute sessions) Considerations for Professionals Working with Families BI has dramatic impact on family People do best when well informed Respect Active listening Normalizing Positive reframing Resource referral Support group Case Management A method to manage unique and high risk conditions Needed if self care capacity diminished Collaborative process of assessment, planning, facilitating, care coordination, evaluation and advocacy Case Management Domain I: Processes and Services Allows for navigation of patient and family through continuum of care Case Management Domain II: Resource Utilization and Management Develop strategies to oversee and protect the limited health care dollars available Continually evaluate medical necessity of procedures Case Management Domain III: Psychosocial and Economic Support Education of pt. and family regarding services Facilitate access to services and funding sources Identify resources and supports Assess social support systems and caregiver burden Ensure caregivers are capable Case Management Domain IV: Rehabilitation Clear emphasis on vocational aspects of rehab Environmental modification, specialized services (work hardening), facilitate return to work Case Management Domain V: Outcomes Collection, analysis, reporting Assess quality and effectiveness of outcomes (clinical, financial, quality of life) Case Management Domain VI: Legal and ethical practices Duty to adhere to: pertinent regulatory requirements (ADA), accrediting standards, legal requirements, ethical standards, confidentiality (HIPAA) Case Management and Advocacy Educate and listen to pt. Care coordination Communicate among team members Resolve disagreements Obtain consent Appeal denials Establish relationships Advocacy Elements of a life care plan Utilize evidence based standards of care and recognize clinical practice guidelines Identify details to deal with catastrophic injury through expected lifespan Plan should provide blueprint for family to assist in management and care Must be specific to individual Consider comorbidities Short and long term needs Special Needs Trusts (SNTs) Start process with attorney and determine trustee Life Care Plan Checklist Projected evals Projected therapeutic modalities Diagnostic testing W/C needs, accessories Aids of independent functioning Orthotics/prosthetics Home furnishings Drugs/supplies Home care/facility care Future medical care Transportation Health and strength maintenance Architectural renovations Future care Intervention and aggressive tx. Vocational and educational plan Orthopedic equipment needs Potential complications Advocacy Person/organization that speaks/writes in support or defense of an individual or cause Self advocate Public Policy Combination of enacted legislation, regulations and judicial interpretations of federal, state, local laws Advocates work to improve access to healthcare, education, housing, transportations, employment and income Social Security Act Provides cash benefits and healthcare plans for those who are aged, disabled and low income SSDI needs sufficient prior work experience SSI prior work not needed State Children's Health Insurance Program Known as CHIP Covers uninsured children in families with income too high to quality for medicaid Each state has flexibility in design program Medicaid Joint state and federal funding May be eligible for medicaid if not medicare Provides healthcare coverage for individuals with low income, chronic illness and disabilities who do not have private insurance at no cost Medicare Federal funding Established 1965 Part A (no cost) hospitalization, SNF, outpatient Who to notify if guardian is not performing as expected Act on best interest of person Power of Attorney Competent person appoints other person to act for him/her in legal and financial issues Can be immediate or when something happens Durable means it's not changed when person becomes disabled or incompetent Living Will Document provides written instructions by a competent adult to a physician providing, withholding or withdrawing life sustaining procedures when in a terminal or permanently unconscious condition Confidentiality HIPAA 1996 Protect individually identifiable health info Cannot be used or disclosed without specific authorization other than for tx, payment of healthcare operations Informed Consent Pt's. right to consent to care after provider fully disclosed all risks and facts to make informed decision Done if legally competent or not Privilege The right of a patient to prevent disclosure of healthcare info unless consent is given State law may override pt. privilege without consent (abuse, communicable disease) Abuse The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish Neglect A failure to provide for the basic needs of a dependent individual Exploitation The use of a dependent individual's property illegally or without the consent of the individual (expenditure of funds) Advocate An individual or organization who serves on behalf of a pt. Can be legal or informal Americans With Disabilities Act Enacted in 1990 to prohibit discrimination of those with disabilities Employment, state/local government, public accommodations ADA Title I Employment Prohibits discrimination in recruitment, hiring, promotions, training, pay, social activities and other privileges of employments Employer must make reasonable accommodations as long as it doesn't constitute an undue hardship ADA Title II State and Local Government Covers state and local government services Give all individuals an equal opportunity to benefit from all programs, activities and services Provide services in most integrated setting ADA Title III Public Accommodations All businesses and nonprofit entities who provide service to the public Must comply with basic nondiscrimination requirements that prohibit exclusion, segregation and unequal treatment Private clubs, religious organizations and private residences are exempt ADA Title IV Telecommunications Addresses telephone and TV access for those with hearing and speech disabilities Use of devices for the deaf Closed captioning of federally funded public service announcements ADA Title V Misc. Provisions Addresses relationship of the law to other laws and jurisdictions Includes info on insurance providers, attorneys' fees and conditions not defined as disabilities Measurement The assignment of numbers to objects or events Accurately record change and tx effectiveness Measurement drives best practice * Some measures predict outcomes Drive reimbursement and length of stay Researchers require measurement to develop best practice "Home grown" Measures Measurements specific to brain injury are lacking Not consistent across facilities or settings Not reliable or valid Psychometrics Branch of psychology which studies the design, qualities, administration and interpretation of tests for the measurement of psychological concepts such as intelligence, emotions/personality traits Includes reliability and validity of tests Ensures the use of quality measures Standardized Assessment A test given in the same way to all individuals Allows for comparison of scores Functional (measurement) Refers to daily activities, occupations of daily life such as dressing, eating, cooking etc. Likert Scale Commonly used for questionnaires Scored on how much the individual agrees with each statement Considerations when Choosing a Measure Reliability Validity Timing Cost (time, cost of materials, location) Expertise and training Common data elements Reliability A measurement consistency Used for different individuals across facilities and with different providers Validity Measures what it claims to measure Floor Affect Assessment is too challenging and many will receive lowest score possible Ceiling