1. Brain Injury and Older Adults A Product of the Maryland Traumatic Brain Injury Partnership Implementation Project 2006-2009

2. Agenda The incidence and prevalence of TBI What is brain injury? What are the types of brain injury? Brain Injury and Older Adults

3. Incidence of TBI CDC 2007 In the United States, at least 1.6 million sustain a TBI each year

4. Of Those 1.6 Million CDC2007 51,000 die; 290,000 are hospitalized; and 1,224,000 million are treated an released from an emergency department

5. Annual Incidence of TBI with Disability AN ESTIMATED 124,000 American civilians Cited by Jean Langlois ScD,MPH NASHIA Conference 2007 Preliminary findings as analyzed by Selassie, et. al

6. Causes of TBI CDC 2006

7. Adults age 75 years or older have the highest rates of TBI related hospitalization and death CDC 2004

8. In 2000, TBI Accounted for 46% of fatal falls among older adults (Stevens et. al. 2006) CDC Website 2007

9. Types of TBI Distribution of Severity: –Mild injuries = 80% (LOC < 30 min, PTA,1 hour) –Moderate = 10 - 13% (LOC 30 min-24 hours, PTA 1-24 hours) –Severe = 7 - 10% ( LOC >24 hours, PTA >24 hours)

10. The HELPS Brain Injury Screening Tool (see handout) The original HELPS tool developed by M. Picard, D. Scarisbrick, R. Paluck, 9.1991 Updated by the Michigan Department of Community Health

11. H ELPS Have you ever Hit your Head or been Hit on the Head? Prompt individual to think about; TBI at any age, MVAs. Assaults, Sports injuries, Service related injuries, Shaken baby and/or adult

12. H E LPS Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head? Explore the possibility of “unidentified traumatic brain injury” many do not present in medical settings

13. HE L PS Did you ever Lose consciousness or experience a period of being dazed and confused because of an injury to your head? Remember, a LOC isn’t required for someone to develop symptoms subsequent to a blow to the head. “alteration of consciousness” AKA post traumatic amnesia (PTA). At this point, the interviewer may consider asking the individual if they have had multiple mild TBI

14. HEL P S Do you experience any of these Problems in your daily life since you hit your head? You want to know when any problems began (or began to be noticed) Remember, lack of awareness is a hallmark of brain injury, you might ask if anyone close to the individual has made any observations regarding changes in function.

15. HEL P S Headaches Dizziness Anxiety Depression Difficulty concentrating Difficulty remembering Difficulty reading, writing, calculating Poor problem solving Difficulty performing your job/school work poor judgement (being fired from job, arrests, fights, relationships affected)

16. HELP S Any significant Sickness? Acquired Brain Injury (ABI) can result in many of the same functional impairments as traumatic brain injury (TBI). For example, brain tumor, meningitis, West Nile virus, stroke, seizures, toxic shock syndrome, aneurysm, AV malformation, any history of anoxic injury, e.g. heart attack, near drowning, carbon monoxide poisoning can all result in multiple deficits

17. Scoring the HELPS Positive for a possible Brain Injury when the following three are identified: An event the could have caused a brain injury (YES to H, E, or S), and A period of loss of consciousness or altered consciousness after the injury or another indication that the injury was severe (YES to L or E), and the presence of 2 or more chronic problems listed under P that were not present before the injury.

18. Scoring the HELPS A positive screening is not sufficient to diagnose TBI as the reason for current symptoms and difficulties-other possible possible reasons need to be ruled out Some individuals could present exceptions to the screening results, such as people who do have TBI- related problems but answered “no” to some questions Consider positive responses within the context of the person’s self-report and documentation of altered behavioral and/or cognitive functioning

19. Additional comments and observations of the interviewer Any visible scars? Walks with a limp? Uses a cane or walker? Has a foot brace? Limited use of one hand? Appears to have difficulty focusing vision? Difficulty answering questions? Answers are unorganized and/or rambling Becomes easily distracted, agitated or is emotionally labile

20. What you are looking for…..And Why Any reported or suspected functional difficulties that are interfering with home, work or community activities With the identification a history of brain injury, professionals can better support the individuals served and make informed referrals to brain injury specialists when appropriate

21. Brain Injury in the News Veterans: NFL Players Prominent Older Americans with fall related brain injuries

22. Impact of Brain Injury Physical; balance, coordination, headaches, fatigue, visual problems Cognitive; memory, attention, concentration, processing, receptive and expressive language difficulties, new learning difficulties Emotional/Behavioral; depression, impulse control, mood swings, irritability and emotional lability

23. Lack of Awareness A common and difficult to remediate hallmark of a brain injury

24. Brain Injury and Alzheimer’s Disease Some evidence to suggest that severe brain injury is a risk factor in development of Alzheimer’s especially in individuals lacking the ApoEepsilon4 genotype( Jellinger et. al. 2001) An earlier study by Schofield (1997) found that subjects who had a head injury with a loss of consciousness or amnesia exceeding 5 minutes were at significantly increased risk of developing Alzheimer’s Disease.

25. NFL, Concussion & Alzheimer’s Disease (Guskiewicz et. al. 2005) 61% of the former players sustained at least one concussion in their career 24% sustained 3 or more concussions Retired players with 3 or more concussions had a fivefold prevalence of reported significant memory problems compared to players with no hx of concussion Researchers also observed an earlier onset of Alzheimer's disease in retirees than in general male population.

26. What can older adults, professionals and family members do? Preventive measures Screen for a history of brain injury Strategies to support Resource and Referral

27. Prevention Tips from the Centers for Disease Control Exercise: activities that address balance and coordination are especially helpful Review medicines with health care provider Have vision checked Fall proof homes and facilities

28. Screen for a History of Brain Injury Review medical records Take a detailed history Use the HELPS Screening Observe, does the individual have difficulty learning new routines, information, retaining names, difficulty communicating thoughts either verbally or in writing?

29. Strategies Use of a journal/calendar Create a daily schedule “To do” lists and shopping lists Labeling items Learning to break tasks into small manageable steps Use of a tape recorder

30. Strategies Encourage use of rest and low activity periods Work on accepting feedback or coaching from others Work on generalizing strategies to new situations Use of a high lighter Alarm watch

31. Strategies Review schedule each day Post signs on the wall etc. Try to “routinize” the day as much as possible

32. Strategies Safety checklist (e.g. for use of stove)reinforces attention Checklists- “things to do before leaving the house” (turn off all the appliances?, lock all the doors?, did I take my morning medications? turn down the heat/turn off the air conditioner?, do I have money or keys?, where am I going?, how will I get there? What time should I leave? Etc.) Very good for routine tasks, reinforces memory Place visual cues in the environment (cupboard labels, written directions, calendars, list of emergency phone numbers) reinforces memory

33. Even for individuals with poor new learning capacity due to a brain injury,keep in mind the three R’s Review Rehearse & Repeat Can lead to mastery of tasks as they eventually enter into memory

34. Resource and Referral Information

35. Resource Coordination in Maryland Charlotte Wisner, Resource Coordinator for Frederick & Washington Counties, call 301-682-6017 Lauren Dorsey, Resource Coordinator for Baltimore & Howard Counties, call 301-529-1508 Catherine Reinhart, Resource Coordinator for Montgomery County, call 301-586-0900 Any questions regarding resource coordination or free trainings for professionals regarding brain injury, call Anastasia Edmonston, Project Director 410-402- 8478

36. Resources Brain Injury Association of America 703-236- 6000, www.biausa.org Brain Injury Association of Maryland 410-448- 2924, www.biamd.org Ohio Valley Center For Brain Injury Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org. www.headinjury.com. Good resource for memory aides and tips

37. Resources Centers for Disease Control www.cdc.gov/injury. 770- 488-1506 Http://www.neuro.pmr.vcu.edu/ National Resource Center for Traumatic Brain Injury, developed by the Medical College of Virginia and Virginia Commonwealth University. Offers useful articles that are very user friendly, and a catalogue of nicely priced resources for working with people with brain injury

38. Resources The University of Alabama Traumatic Brain Injury Model System has created the UAB Home Stimulation Program. This program offers many activities for use by individuals with brain injuries, their families and the professionals who work with them. The activities are designed to help support cognitive skills and can be done in the home setting. The Home Stimulation Program can be accessed from the Internet at htt://main.uab.edu/show.asp?durki=49377. For further information contact: Research Services, Dept. of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, 619 19 th St. S SRC 529, Birmingham, AL 35249- 7330/ 206-934-3283. Tbi@uab.edu. Tbi@uab.edu

39. Resources staff training…. http://www.webaim.org/simulations/cognitive - this is a site that can be used in staff training. It is a simulation of the effects of cognitive disabilities. You will be asked to complete simple tasks, but other tasks will get in the way.http://www.webaim.org/simulations/cognitive

40. Resources staff training…. http://www.biausa.org/Pages/related_articles.html - links to many online articles, written not for professionals in the field, but for people learning about brain injury. They cover all types of topics, from substance abuse and brain injury to cognition and brain injury. Written by various experts in the brain injury field.http://www.biausa.org/Pages/related_articles.html Certified Brain Injury Specialist (CBIS) Training offered through the American Academy for the Certification of Brain Injury Specialists, www.biausa.org

41. The Michigan Department of Community Health Web-Based Brain Injury Training for Professionals www.mitbitraining.org This free training consists of 4 module that take an estimated 30 minutes each to complete. The purpose of the training is twofold, to “ensure service providers understand the range of outcomes” following brain injury and to “improve the ability of service providers to identify and deliver appropriate services for persons with TBI”

42. Anastasia Edmonston TBI Projects Director Mental Hygiene Administration Aedmonston@dhmh.state.md.us 410-402-8478

43. A Product of the Maryland TBI Partnership Implementation Project, a collaborative effort between the Maryland Mental Hygiene Administration, the Mental Health Management Agency of Frederick County and the Howard County Mental Health Authority 2006-2009 Support is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Service Please use and distribute widely