BR A IN INJURY professional vol. 5 issue 3
The official publication of the North American Brain Injury Society
Aging and TBI T h e I n ter section o f A g i n g / A g e a n d T B I : S yst emat ic Review M et hodology T r a um atic B r ain In j u r y a n d D e m e n t i a : A Syst emat ic Review T h e C on sequences o f T B I O c c u r r i n g i n t h e Elderly: A Syst emat ic Review Post-TB I L i f e E x p e c t a n c y a n d H e a l t h : A Systematic Review Pos t-TBI A ging and C o g n i t i v e F u n c t i o n i n g : A Syst emat ic Review Pos t-TBI Emotional F u n c t i o n i n g a n d A g e : A Syst emat ic Review Pos t-TBI V ocationa l S t a t u s a n d A g e : A S yst emat ic Review C om mu nity Integr a t i o n a n d P o s t - T B I A g i n g : A Syst emat ic Review Pos t-TBI A ging and L i f e S a t i s f a c t i o n / Q u a l it y of Life: A Syst emat ic Review
BRAIN INJURY PROFESSIONAL
1
LAKEVIEW ...
It’s About Life!
From Coma To Community
Long-Term Acute Care Hospital Specializing in Coma Recovery Neurobehavioral Programs • Children • Adults Special Education Accredited School Grades 1 - 12 Rehabilitation and Transition Programs Community Integrated Residential Programs Supported Apartments and Home Programs Outpatient Clinics
The Lakeview AfÀliated Programs - now located in New Hampshire, Maine, Rhode Island, Wisconsin and Virginia.
Call 1-800-4-REHAB-1 For More Information or Visit our Web Site at: www.lakeviewsystem.com
contents
BRAIN INJURY professional vol. 5 issue 3, 2008
The official publication of the North American Brain Injury Society
north american brain injury society
departments 4 Executive Vice President’s Message 6 Guest Editor’s Message
chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes
30 bip expert Interview brain injury professional 32 Legislative Round-up 34 Non-profit News
publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legislative Issues Susan L. Vaughn founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker
EDITORIAL ADVISORY BOARD
features 8 The Intersection of Aging/Age and TBI: Systematic Review Methodology by Marcel Dijkers, PhD, Wayne A. Gordon, PhD, Beatriz Abreu, OTR, PhD, James Graham, PhD, Ann Charness, PT, MS 12 Traumatic Brain Injury and Dementia: A Systematic Review by Tina M. Trudel, PhD, Anna MacKay-Brandt, MA, Richard O. Temple, PhD 14 The Consequences of TBI Occurring in the Elderly:
A Systematic Review By Marcel Dijkers, PhD, Joshua Cantor, PhD, Mary Hibbard, PhD, Stacy Belkonen, PhD, Adam Warshowsky, PhD, David Layman, PhD 22 Post-TBI Life Expectancy and Health: A Systematic Review by Steven Flanagan, MD 24 Post-TBI Aging and Cognitive Functioning: A Systematic Review by Amanda Sacks, PhD, Angela Yi, PhD, Wayne A. Gordon, PhD 25 Post-TBI Emotional Functioning and Age: A Systematic Review by Teresa Ashman, PhD, Guido Mascialino, PhD 26 Post-TBI Vocational Status and Age: A Systematic Review by Margaret Brown, PhD 28 Community Integration and Post-TBI Aging: A Systematic Review by Timothy A. Reistetter, PhD 29 Post-TBI Aging and Life Satisfaction/Quality of Life: A Systematic Review by Gary A. Seale, MS, Beatriz Abreu, PhD
Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD
editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org
advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787
national office
North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2008 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com
BRAIN INJURY PROFESSIONAL
3
executive vice president’s message
Ronald Savage, EdD Said the little boy, “Sometimes I drop my spoon.” Said the old man, “I do that too.” The little boy whispered, “I wet my pants.” “I do that too,” laughed the old man.” Said the little boy, “I often cry.” The old man nodded, “So do I.” “But worst of all,” said the boy, “it seems Grown-ups don’t pay attention to me.” And he felt the warmth of a wrinkled old hand. “I know what you mean,” said the old man. - Shel Silverstein
We know that aging changes us in many ways, physically, cognitively and spiritually to name a few. None of us want the aging process speeded up in our adult years. We want our abilities and skills to continue as long as possible. Many of us entering our middle and later decades are already complaining about aching knees that were originally injured in high school sports and never really bothered us until we got “old”. (Think about it, how many friends do you know with knee replacements?) Humans get older despite all the good things we do for ourselves. And what about all those missing car keys or cell phones or lost names many of us confront on occasion? When we forget something it puts a little fear into all of us. Obviously, losing the functioning of one’s knee is one thing, but losing one’s mental faculties is even more frightening. Now we add a brain injury to the mix…what happens now? Does a brain injury sustained earlier in life accelerate the aging of the brain, just like our earlier knee injury worsens as we get older? Drs. Gordon, Dijkers, Abreu and Brown assembled a national team at the Spring 2008 Galveston Brain Injury Conference. The focus over this year and next will be to further investigate the relationship between brain injury and early dementia, as well as expanding our knowledge of brain injury in our ever growing
Erratum: In the last issue of Brain Injury Professional, the following acknowledgement was omitted from the article, “Mild Traumatic Brain Injury: Identification, the Key to Preventing Social Failure”, by Gordon and Brown: The preparation of this manuscript was supported in part by Grant Nos. H133A07033 and H133B040033 from the National 4
BRAIN INJURY PROFESSIONAL
older population. Each of the review articles in this issue addresses a particular topic and sets the agenda for further research. This topic is significant to all of us in multiple ways, not only for our patients, but also for ourselves. We need to look a brain injury through an aging telescope and see as far ahead as possible into the future. Might we need to develop specialized brain injury supports and services that parallels the good work in Alzheimer’s programs? Will we need to investigate newer cognitive enhancing medications as preventive treatment? Do we need to better prepare families about the aging issues commonly found after brain injury rather than take a “wait and see” approach? And what about our Boomer Generation – still active in sports, riding motorcycles (TBI on the increase!), and still thinking that “60 is the new 40”? It’s not just falls with TBI in the elderly that we need to think about. Aging is a whole new arena in brain injury treatment, services and supports. NABIS wants to particularly recognize Mr. Robert L. Moody who created and supports this tremendous opportunity for clinicians and scientists each year and to thank Dr. Brent Masel who orchestrates the meetings with his exemplary leadership and extraordinary intellect. Ronald Savage, EdD
Institute on Disability and Rehabilitation Research, United States Department of Education, and Grant No. 1R49CE00171-01 from the Centers for Disease Control and Prevention, as well as through the generosity of the John Blair Haldeman Fund. The publisher regrets this error.
Acquired Brain Injury Services x NeuroRehabilitation x NeuroBehavioral x Supported Living x Adolescent Integration x Host Home x Outpatient Services x Day Treatment x Respite Program Locations: CCS-Carbondale, IL, CCS-Florida, CCS-Kentucky, CCS-New England, CCS-Tennessee, REM IA, REM CO, REM MN, REM Health, IL MENTOR, SC MENTOR, NJ MENTOR Brain Injury Services & CareMeridian-CA.
www.mentorabi.com
800-203-5394
guest editor’s message
Wayne A. Gordon, PhD1, Beatriz Abreu, PhD1, Marcel Dijkers, PhD2,3, Margaret Brown, PhD1 (not pictured) The focus of this issue of Brain Injury Professional is on aging after TBI, TBI and dementia and TBI occurring in the elderly. The eight systematic reviews represent a massive effort of researchers at Mount Sinai School of Medicine in New York, and of the University of Texas Medical Branch and the Transitional Learning Center in Galveston. Why did we devote all this time and energy to a fine-toothcomb review of thousands of abstracts and hundreds of articles to see what evidence is available to describe the realities of TBI and age/aging? First, from the perspective of the person with TBI and family members, one of the areas reviewed – TBI and dementia – focuses on a key fear that often is expressed in clinical encounters: Do I face a higher probability of Alzheimer’s disease
because of my TBI? From the clinician’s perspective, the need is obvious for being fully acquainted with the state of the science at the intersection of dementia and TBI. Similarly, for clinicians, the importance of expanding their knowledge about brain injuries that occur in elderly people, a second area reviewed, is clear. Added to this is the reality that the aged population will expand (almost) exponentially over the coming decades. Another review team addressed questions consumers and clinicians have about life expectancy post TBI as well as longterm health problems after injury. The other five reviews looked at changes in functioning associated with aging after injury: cognitive, emotional and vocational functioning, as well as community inte-
Mount Sinai School of Medicine, New York NY The Transitional Learning Center, Galveston TX 3 University of Texas Medical Branch, Galveston TX 1 2
6
BRAIN INJURY PROFESSIONAL
gration and life satisfaction/quality of life. With each of these reviews, the goal was to expand our knowledge, in order to provide more insight into life after TBI and the dynamics of change. This important contribution to the field’s knowledge about TBI and aging was made possible through the efforts of many, whose input is recognized in each of the papers that follow. However, others have earned our immense gratitude and should not go unmentioned. First, and foremost we want to acknowledge and thank those who, each year, “produce” and select the topic for the Galveston TBI Conference, which supported the development of these reviews. This includes leadership from the Transitional Learning Center (Brent Masel, M.D., President and Medical Director) and from the University of Texas Medical Branch (UTMB) (Kenneth Ottenbacher, Ph.D., Senior Associate Dean for Graduate Research Education, and Elizabeth Protas P.T., Ph.D., FACSM, Dean Ad Interim of the School of Allied Health Sciences). Thanks also are due to the Moody Foundation and UTMB, which financially support the conference each year, including these reviews. Additionally, the work of many of the team members is supported in part by grant awards from the National Institute on Disability and Rehabilitation Research, the Centers for Disease Control and Prevention, and the National Institutes of Health.
Wayne A. Gordon, PhD1 Marcel Dijkers, PhD1 Beatriz Abreu, PhD2,3 Margaret Brown, PhD1
A C C E P T I N G A C C E P T I N G
R E S E R V A T I O N S R E S E R V A T I O N S
F O R F O R
O C T O B E R O C T O B E R
2 0 0 8 2 0 0 8
C L C R L NR N
DEVELOPED BY DR. ROBERT D. VOOGT DEVELOPED BY DR. ROBERT D. VOOGT
Call us for more information (757) 412 1180 or go to thememoryctr.com ~ Call us for more information (757) 412 1180 or go to thememoryctr.com
Living Living Room Room MAGNOLIA PLACEPLACE MAGNOLIA
General Store
Dining Dining Room Room
Dining Room
““
LibraryLibrary Kitchen Kitchen
CHESAPEAKE SHORES Dining Room
Worship Center
Patio Patio
General Worship Store Center
Reception Area Area Reception
CHESAPEAKE SHORES
Majestic Majestic Theater Theater
OCEAN SANDS
Beach Beach
Living Room Living Room
WE OFFER WE OFFER EVERY INCENTIVE EVERY INCENTIVE TO CELEBRATE LIFE AND FIND TO CELEBRATE LIFE AND FIND PURPOSE IN EACH DAY PURPOSE IN EACH DAY
~ Neurological Rehabilitation Rehabilitation Living Centers Centers Neurological Living 1853 OLD DONATION PARKWAY, VIRGINIA BEACH, VA 23454 1853 OLD DONATION PARKWAY, VIRGINIA BEACH, VA 23454
Living Room Living Room
TOWN CENTER TOWN CENTER
AT THE MEMORY CENTER, we believe the challenging conditions AT THE MEMORY CENTER, we believe the challenging conditions of an aging brain should be met with a caring, interactive community of an aging brain should be met with a caring, interactive community designed around the individual. The latest science, nutrition and designed around the individual. The latest science, nutrition and interactive therapies proven to extend life are part of our philosophy interactive therapies proven to extend life are part of our philosophy to extend the meaning of life. to extend the meaning of life.
Dining Room Dining Room OCEAN SANDS
Bank Bank
¢ ¢
TavernTavern
¢ ¢
Living Well with Dementia and Alzheimer’s Living Well with Dementia and Alzheimer’s
Living Living Room Room
TheMemoryCenter TheMemoryCenter
Hair Salon Hair Salon
¢ ¢
Interactive community featuring Interactive community featuring an experiential “Town Center” an experiential “Town Center” Four residential neighborhoods Four residentialthe neighborhoods encompassing stages of encompassing memory loss the stages of memory loss The latest in science, nutrition The in science, nutrition and latest interactive therapies and interactive therapies proven to extend the proven to and extend longevity thethe longevity quality ofand life the quality of life Natural & Natural peaceful& peaceful atmosphere atmosphere
HERON COVECOVE HERON
¢ ¢
Dining Dining Room Room
DESIGN, SERVICES & AMENITIES DESIGN, SERVICES & AMENITIES
””
C L C R L NR N
Neurological Rehabilitation Rehabilitation Living Living Centers Centers Neurological
PROFESSIONAL, FAMILY-ORIENTED, BRAIN INJURY REHABILITATION PROFESSIONAL, FAMILY-ORIENTED, BRAIN INJURY REHABILITATION
NRLC STARTS WHERE TRADITIONAL MEDICINE ENDS, using NRLC STARTS WHERE TRADITIONAL MEDICINE ENDS, using community-based environments to build individual dignity, respect community-based environments to build individual dignity, respect and esteem. Custom care plans and specially trained staff address all and esteem. Custom care plans and specially trained staff address all functional areas — physical, cognitive, social and behavioral — to create functional areas — physical, cognitive, social and behavioral — to create independence and build lives. NRLC rehabilitation programs are independence and build lives. NRLC rehabilitation programs are conducted in exquisite home-like facilities designed to incorporate conducted in exquisite home-like facilities designed to incorporate advanced therapies and clinical activities such as: advanced therapies and clinical activities such as: ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢
VIRGINIA BEACH CENTER VIRGINIA BEACH CENTERC.E.O. DR. ROBERT D. VOOGT,
DR. ROBERT D. VOOGT, C.E.O. Founder and Program Director Founder Program Director 1851 Oldand Donation Parkway 1851 OldBeach, Donation Parkway Virginia VA 23454 Virginia Beach, VA 23454 757.481.7565 757.481.7565 NRLC_TMC BIP ad.indd 1 NRLC_TMC BIP ad.indd 1
COMPREHENSIVE EVALUATIONS C OMPREHENSIVE EVALUATIONS PERSONALIZED CARE PLANS P CARE PLANS PERSONALIZED HYSICAL THERAPY P THERAPY SHYSICAL PEECH/COGNITIVE THERAPY SOPEECH /C OGNITIVE THERAPY CCUPATIONAL THERAPY O CCUPATIONAL THERAPY VOCATIONAL REHABILITATION VOCATIONAL REHABILITATION
¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢
NEUROPSYCHOLOGY N EUROPSYCHOLOGY BEHAVIOR MANAGEMENT B MANAGEMENT MEHAVIOR EDICATION MANAGEMENT M EDICATION MANAGEMENT SOCIAL SKILLS TRAINING SINTERNAL OCIAL SKILLS TRAINING CASE MANAGEMENT ICNTERNAL CASE MANAGEMENT OMMUNITY INTEGRATION COMMUNITY INTEGRATION
NEW ORLEANS CENTER NEW ORLEANS CENTERCBIT HECTOR GUTIERREZ,
HECTOR GUTIERREZ, CBIT Louisiana Executive Director Louisiana Executive 614 W. 18th Avenue Director 614 W. 18thLA Avenue Covington, 70433 Covington, LA 70433 985.875.3100 985.875.3100
9/17/08 10:48:26 PM 9/17/08 10:48:26 PM
The Intersection of Aging/Age and TBI: Systematic Review Methodology by Marcel Dijkers, PhD,1 Wayne Gordon, PhD,1 Beatriz Abreu, OTR, Phd, 2,3 James Graham, Phd, 3 Ann Charness, PT, MS 3 Many people with TBI raise questions when they get beyond the early period of adjustment to injury: Will the impact of TBI change over time, particularly when I get old? Will I get better or worse as I age? Am I more likely to get Alzheimer’s? Brain injury professionals may raise an additional question: Does TBI affect people differently if injury occurs in the later years, when the person is nearing or above retirement age, in comparison to injuries in earlier adulthood? Clearly, these questions are important for the individual with TBI and his/her family in preparing for challenges down the line. They are similarly important to brain injury professionals in the diagnosis and treatment of any challenges that are age-related. Because of these important implications, teams of researchers from Mount Sinai School of Medicine and the Transitional Learning Center and the University of Texas Medical Branch conducted systematic reviews of the literature to address questions about TBI and aging. These reviews were initiated in preparation for the 2008 Galveston TBI Conference, an annual event on a focused topic, to which research and clinical experts are invited. This issue of the Brain Injury Professional describes both the methods and findings of the 2008 Galveston Conference reviews. Mount Sinai School of Medicine, New York NY The Transitional Learning Center, Galveston TX 3 University of Texas Medical Branch, Galveston TX 1 2
8
BRAIN INJURY PROFESSIONAL
This first paper focuses on the methods used in conducting the reviews as well as suggestions for future research that emerged as a result of what was found (as well as what wasn’t found) by the review teams. The papers that follow briefly review the results of systematic reviews of the published literature relevant to the eight age-related topics selected as most important. One team focused on TBI and dementia, a second on TBI occurring in the elderly and a third on life expectancy and health issues post TBI. Other teams reviewed evidence on post-TBI changes associated with aging in five areas of functioning: (1) cognitive, (2) emotional, (3) vocational, (4) community integration, and (5) life satisfaction. It should be noted that the latter six reviews did not just focus on people at the older end of the age continuum, but instead also included studies relevant to aging across the full adult life span. Thus, when we use the word aging in these articles, we do not solely mean changes occurring just before or after the start of “old age.” We also mean long-term changes occurring well before the magical threshold of 65 years. The methods we adopted were similar to those used in many systematic reviews. The definition of a systematic review closest to the one we used is that of the National Health Service Center for Reviews and Dissemination, University of York1: “a review of
the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research, and to extract and analyze data from the studies included in the review.” Our process included the following steps: 1. Topic selection (see above) and specification of questions (presented in the papers that follow) 2. Specification of methods to be used in answering the questions (databases, search terms, inclusion/exclusion criteria, data abstracting methods, data synthesis methods) 3. Identification of the literature that is potentially relevant, review of abstracts of identified literature and acquisition of full publications of papers that appear to be possibly or probably relevant and fit inclusion criteria 4. Abstraction of data from these publications into evidence tables and evaluation of the quality of papers 5. Synthesis of the evidence relevant to each question and formulation of conclusions The selection criteria for the literature to be included were developed by a coordinating group (this article’s authors plus senior reviewers from each review team), although the eight groups were allowed leeway whenever they had good reason to vary from the general criteria. The criteria we defined for “longterm change” are of particular importance for understanding the reviews produced by the six groups focused on post-TBI, agerelated changes. While many studies assess participants immediately after injury and one or two years later, we decided that in order to explore the process of aging, in longitudinal studies the time between the first and later measurements ought to be at least 10 years, and in cross-sectional studies, at least 10 years should separate the youngest and oldest age groups. As it turned out, the number of studies that fit this criterion was quite small, so several of the teams included studies that varied from these guidelines. Other inclusion criteria are delineated below. In searching bibliographic databases to identify potentially relevant studies, we primarily relied upon MedLine, PsycINFO and CINAHL (the Cumulative Index of Nursing and Allied Health Literature). Two sets of search terms were used initially: variations on “TBI” and on “age”. TBI variations included terms such as brain contusion, brain injury, head trauma, cortical contusion, diffuse/focal brain injuries, TBI, traumatic brain injury, and the like. For age, terms included aged, age, aging and elderly. In subsequent searches, the “TBI” terms (and optionally the “age” terms) were combined with variations on whatever area of functioning comprised the topic of review (e.g., in the vocational review, “work,” “school” and “vocation” exemplify some of the topic-relevant terms entered). In addition, teams used review articles and bibliographies, if available, to find additional literature, as well as the list of references provided in the papers that they had ordered. Over 5,000 abstracts were reviewed independently by two readers (Charness and Graham), who made a preliminary and liberal decision regarding the relevance of each article to any or all of the eight review topics. Each group’s senior scientist read the assigned abstracts and decided whether the full text of the paper needed to be obtained for a final decision. In the next step, the full article was perused by group members, to validate the relevance of the study with respect to the review topic. The groups adhered to relevance criteria developed by the coordinating group, namely: (1) primarily people with TBI were sampled (>75%), or TBI data were reported separately
AAN criteria2 for prognostic articles (condensed)
Table 1
Class I
Prospective (i.e. cohort survey) study of a broad spectrum of persons at risk for developing the outcome. All patients have the predictor and outcome variables measured. Independent gold standard for case definition. Person evaluating predictor(s) is blinded to outcome; person evaluating outcome (caseness) is blinded to predictor(s).
Class II
Prospective study of a narrow spectrum of persons at risk for developing the outcome, or a retrospective study of a broad spectrum of persons with the condition compared to a broad spectrum of controls. Acceptable independent gold standard for case definition. Person evaluating predictor(s) is blinded to outcome (caseness)
Class III
Retrospective (i.e. case control) study where either the persons with the condition or the controls are of a narrow spectrum. Acceptable independent gold standard for case definition. The outcome, if it is not objective (i.e. unlikely to be affected by expectation bias), is determined by someone other than the person who measured the predictor.
Class IV
Any design where the predictor is not applied in an independent evaluation OR evidence provided by expert opinion or case series without controls.
Table 2
Elements of a paper reporting on a prognostic study evaluated in the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) checklist3
• • •
Title & abstract Background/rationale Objectives • Study design • Setting • Participants • Variables • Data sources/measurement • Bias • Study size • Qualitative variables • Statistical methods
•
•
•
Results Participants Descriptive data Outcome data Main results Other analyses Discussion • Key results • Limitations • Interpretation • Generalizability Other information • Funding • • • • •
if TBI and non-TBI cases were studied; (2) the report focused on a topic relevant to the team’s question; (3) time trends centered on adulthood (“pediatric only” articles were excluded), and (4) the paper was published in a peer-reviewed journal. Additional criteria were specified for longitudinal studies: (1) if at the first point of assessment (T1) the mean age was under 30, 10 years or more must elapse before the final point of assessment; but, (2) if at T1 the average subject was over age 30, at least five years must elapse between T1 and the last point of measurement. In crosssectional studies: (1) if the youngest group assessed was on average under 30, the oldest group must average 40 years or older; but, (2) if the youngest group is over 30, the oldest group must be 45 or older. In studies where the “aging” variable is “time since injury”, at least one group must be 10 years or more since injury. These latter criteria were relaxed in some groups, especially when few (if any) publications were found that met criteria. In the next step, team members completed evidence tables that allowed systematic comparison of studies on such elements as: • Study design and objective(s) • Subject characteristics (e.g., inclusion/exclusion criteria, demographics, injury severity indicators) • Main prognostic and outcome measures • Major findings • Conclusions • At the same time, the abstracters made three determinations of the quality of the study: • Assignment of an evidence grade, using criteria developed by the American Academy of Neurology (AAN)2 • An evaluation of research quality based on an existing checklist3 • A global rating of quality The AAN Clinical Practice Guideline Process Manual (2004 edition) offers standards for grading evidence into four classes that characterize evidence, from the strongest (class I) to the weakest (class IV) based on the basic study design, as well as secBRAIN INJURY PROFESSIONAL
9
ondary design elements. Because the groups primarily encountered articles of a prognostic or correlational nature, the AAN criteria for these types of studies were the only ones used; see Table 1 for a condensed listing of these criteria. The second approach to judging quality was based on our development and application of a checklist focusing primarily on elements of methodology; this was adapted from STROBE3, one of many existing checklists used to evaluate the reporting of research (for instance, CONSORT4,5 and STARD6,7). Our use is justified by the fairly strong link between the quality of a research report (the intended use for STROBE) and that of the underlying research itself (our use for STROBE). The form we adapted from STROBE (see Table 2) required that each of 30 elements were rated as: • 0: not done, not reported, done very poorly • 1: reported as done, and done at least “adequately” • NA: not applicable to this study Lastly, the abstracters gave a global subjective rating to each study on a 5-point scale (1=very poor, 5=exemplary). This rating was assigned considering the strengths and weaknesses of the study in question within its category of research design, e.g., a case-control or cohort study. This global rating could take into account the STROBE elements or anything else that the abstracter considered relevant to the quality of the evidence offered in the paper. The AAN, STROBE and global ratings were each seen as useful in encouraging scrutiny of the methodology of the studies reviewed, but the coordinating group did not require that they be used identically within each review. The AAN ratings, in particular, were not meant to be applied as they are in reviews designed to inform clinical practice, where they typically are used to dictate the strength of recommendations that are made (e.g., at least two level I studies are required for making a “should do” recommendation). Given that we did not set out to develop recommendations for practice, the fact that these scores were used “for information only” is not problematic. Before readers turn to the systematic reviews reported in this issue, they should be aware of the weaknesses of our procedures, of the literature used, as well as of the databases utilized to identify research. First, we excluded the “gray” literature, as well as reports written in languages not translatable by the members of the review teams (English, French, Spanish, German, Dutch). Also, because the AAN and STROBE standards were developed for application primarily to (bio)medical research, they are less appropriate when applied to most of the research included in the reviews (i.e., primarily using methods developed within social science research). Lastly, as noted above, STROBE is a checklist designed to evaluate reports of research, not to evaluate research methods adopted within a study. The bibliographic databases that we relied on to find research papers have their own shortcomings. First, they were poor or late in indexing terms related to traumatic brain injury. For instance, PubMed did not have the classification category “closed head injury” until 1992. Thus, for finding abstracts of earlier literature, one is dependent on searching for the precise textwords used by authors. A more important shortcoming was the poor indexing of age groups and the poor match between the concept of aging adopted in these systematic reviews and as used in the respective databases. Thus, “aging” is a key word or category in most, if not all, of the bibliographic databases, but only refers to time trends in people over 55-65 or the status of anyone called elderly or 10 BRAIN INJURY PROFESSIONAL
aged; “aging” in younger adults is not included. Weaknesses within the reviewed literature also are clear. First, from the results of these eight reviews, one could easily conclude that few studies addressing long-term development after TBI or TBI occurring to the elderly (>60) have been done. This conclusion may be inordinately pessimistic, as the abstracts that authors provide for their papers (except for longitudinal studies) almost never allow one to identify papers that shed light on adult development; we may have missed a number of them. Most importantly, the majority of studies that we did include in our reviews were designed, implemented and/or reported poorly, resulting in weak evidence in terms of AAN grade. In most of the reviews, something was learned, but in none was this as much as we would like or as much as we had expected. Several of the review teams, in their drafts, discussed the problems that led to the paucity of information and the inconsistent results, and they made several suggestions for improved research methods. Because these critiques and proposed solutions apply equally to most of the topics reviewed, we have taken the liberty to summarize their ideas here at the outset instead of repeating these suggestions several times over (topic-specific critiques remain within the respective reviews). First, it is clear that if we are to study post-TBI aging most appropriately we need longitudinal studies over lengthy periods that include a non-disabled control group. This would be optimal if, in addition, at least two points of assessment were undertaken after the first few years post injury, to better differentiate age-/aging-related changes from those associated with recovery from TBI. In reality, this approach is not likely to be implemented because extensive funding would be required and the commitment of researchers and funding agencies to “stick with it” over a lengthy time span is unlikely. Also, the number of subjects lost to attrition might be so large as to make such a study both inconclusive as well as expensive. Cross-sequential methods address some of these challenges. The following comprise some additional suggestions meant to improve and expand research output in this area: 1. More funding needs to be allocated to undertake such research. 2. More studies need to be implemented with age or aging as an explicit focus. Some of the methodological problems encountered in the studies reviewed arose because information about age-related changes was only a by-product, as the goals of the study were unrelated to age/aging. 3. As in most areas of research, definitions and approaches to measurement vary widely across studies focused, ostensibly, on “the same” topic. The optimal solution is for future work to be based on standard definitions and the adoption of standard measures. However, this is unlikely to happen. An approach that addresses part of this problem is for researchers to undertake more studies that seek to validate “the best” of what has been published, rather than reinventing the wheel with each new study of “the same” thing. 4. In cross-sectional and longitudinal studies (but particularly in the latter), too many investigations explicitly focusing on age/aging rely on data not particularly suited to that goal, but which simply are available. For example, studying what happens in the first 10 years after injury is possible using TBI Model System data, but these data are likely to reveal more about adjustment to and immediate changes after in-
jury than about aging after TBI per se. 5. Researchers should look beyond the TBI literature for guidance and models, accessing information available on aging, aging post stroke (as well as after onset of other neurological disorders), and the cognitive aging literature. Despite the caveats delineated above, these reviews are among the first to systematically collect, evaluate and synthesize the existing evidence regarding aging after TBI and TBI in the aged.* They set forth what TBI researchers and clinicians collectively know and what we do not yet know. The 2009 Galveston TBI Conference will continue the discussion on these topics and will contribute to a directive we all can agree upon: We need more and better research to provide the evidence desired by people with TBI, their families and the professionals who treat them on what happens long-term after TBI and how TBI affects elderly people. The eight articles that follow provide an introduction only, not a final summing up. We want to thank Renee Pearcy and Janet Burke for the immense help they provided in assisting all of the review teams; without their input, the work summarized in this issue of BIP would not have been accomplished. * The exceptions are two earlier reviews on the topic of TBI and Alzheimer’s disease, which are referenced herein by Trudel et al., as well as another review on depression in elderly people with TBI that was published after our eight systematic reviews had been completed.8
References
1. University of York, NHS Centre for Reviews and Dissemination. Undertaking systematic reviews of research on effectiveness: CRD’s guidance for those carrying out or commissioning reviews, 2001. http://www.york.ac.uk/inst/crd/report4.htm 2. Edlund W, Gronseth G, So Y, Franklin G. (2004). Clinical practice guidelines process manual - 2004 edition. St. Paul MN: American Academy of Neurology. 3. Fernandez E. Observational studies in Epidemiology (STROBE). Medicina Clinica, 2005;125(Supl.1):43-48. 4. Altman DG. Better reporting of randomised controlled trials: the CONSORT statement. BMJ (Clinical Research Ed.), 1996;313(7057):570-571. 5. Begg C, Cho M, Eastwood S, et al. Improving the quality of reporting of randomized controlled trials. The CONSORT statement. JAMA. 1996;276:637-639. 6. Bossuyt PM, Reitsma JB, Bruns DE, et al. (2003). Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Standards for Reporting of Diagnostic Accuracy. 2003a;Clin Chem:49:1-6. 7. Bossuyt PM, Reitsma JB, Bruns DE, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. 2003b;Clin Chem:49:7-18. 8. Menzel JC. Depression in the elderly after traumatic brain injury: a systematic review. Brain Inj. 2008;22:375-380.
Building futures…
Years of Making a Difference
For more information:
(800) 774-5516 425 Kings Highway East, P.O. Box 20 Haddonfield, NJ 08033-0018 USA www.bancroftneurohealth.org Bancroft NeuroHealth, a New Jersey Non-Profit Corporation
For more than 120 years, Bancroft NeuroHealth has helped people with brain injuries rebuild their lives, step by step. Our person-centered programs are based on the needs of each individual, with the goal of helping each person reach his or her maximum level of independence and lead the most fulfilling life possible. With a range of community-based and campus-based options, Bancroft provides a full continuum of life skills rehabilitation at several locations in New Jersey. These include a return to school, work, social and recreational activities. Our outcomes-oriented planning encourages personal achievement — leading to both greater independence and reduced costs.
More than
Traumatic Brain Injury Serving the community for two decades, Beechwood has expanded its TBI offering to encompass broad neurological services as well as new Behavioral Remediation and Late Adolescent programs. In addition to TBI, we serve individuals with brain damage due to: • Anoxia/Hypoxia due to drowning, heart attack, drug overdose, alcohol poisoning, anesthesia errors, etc.
• Electric shock/lightning strike • Degenerative diseases • Infectious diseases • Early stage moderate dementias • Tumors • Brain surgeries • Many neurological disorders
• Stroke For information and admissions, call 1-800-782-3299. Our facilities are adapted to accommodate all levels of accessibility.
REHABILITATION
SERVICES
A Community-Integrated Brain Injury Program An affiliated service of Woods Services, Inc. www.beechwoodrehab.org
Langhorne, PA • Bensalem, PA BRAIN INJURY PROFESSIONAL
11
Traumatic Brain Injury and Dementia: A Systematic Review by Tina M. Trudel, PhD,1,2 Anna MacKay-Brandt, MA,3 Richard O. Temple, PhD4
One of the most frequently expressed concerns of individuals with TBI and their families is the likelihood of developing dementia, particularly Alzheimer’s Disease (AD) – is this more likely as a consequence of TBI? Thus, this review focuses on literature studying the intersection of TBI and AD. While 182 TBI and AD research abstracts were identified, only 12 met the criteria of scientific evidence adopted by the American Academy of Neurology. The studies included are internationally representative and examine a broad spectrum of TBI, from mild to severe. Findings regarding the incidence and prevalence of AD in TBI were mixed. A number of studies suggest that the overall rate of AD in people with TBI is similar to that of the general population. For example, Guskiewicz and colleagues1, in a study of 2,552 National Football League retirees, found the rate of AD among older retirees (but not younger) who had experienced football-related TBI to be similar to the general population. The comparability of AD rates was also supported in larger population studies,2,3 in studies of people with mild TBI4,5 and in a study that controlled for genotype (ApoE4) and examined TBI as a sole cause of AD.6 In contrast to the prior studies suggesting a rate of AD in the TBI population consistent with the general population, an early meta-analysis of 8 small-sample-size, case-controlled studies and a similar meta-analysis of 15 studies of post-TBI AD demonstrate significantly higher odds of AD post TBI, but only for males.7,8 Higher rates of AD in TBI samples have also been noted in autopsy studies9 and for subpopulations, such as those with more severe or repeated injuries4,5 and younger NFL retirees with histories of TBI.1 These findings demonstrate that higher risk for AD after TBI is not a uniform phenomenon and that specific risk factors play a role. Although findings are not uniform in this area,4 the ApoE4 genotype appears to be, by itself, a risk factor for development of AD and to significantly increase risk for AD after TBI, particuLakeview Healthcare Systems University of Virginia School of Medicine, Charlottesville, VA 3 Washington University, Saint Louis, MO 4 CORE Health Care, Dripping Springs, TX 1 2
12 BRAIN INJURY PROFESSIONAL
larly when the genotype is homozygous (identical alleles for this genetic trait).5,6 Severity of injury also appears to play a role, with more severe injury increasing the risk.4,5 Findings regarding repeated injury are mixed, with no difference in the rate of AD after TBI noted in a study involving NFL retirees;1 while a trend for greater risk with repeated injury was noted in a large, prospective population study.4 Male gender also appears to increase the likelihood of AD after TBI. As noted above, meta-analytic reviews of AD post TBI7,8 demonstrate significantly higher odds ratios for males. A trend for a higher post-TBI ratio of AD for males is also noted in a large population study,3 and Isonniemi and colleagues10 reported that 100% of the ApoE4 TBI and AD subset (N=6) were male, in a 69% male sample (N=61). While this is a small sample, it does raise the question of possible complex interactions amongst gender, genetics and severity of TBI. Additional questions have been raised regarding the clinical presentation of AD post TBI and how this may differ from the appearance and patterns of AD in the general population. Unfortunately, only minimal data are available. The only issue substantively studied is that of time for onset of AD post TBI. While a study of 548 World War II veterans demonstrates no difference in time of onset of post-TBI dementia,5 large-sample studies of NFL retirees1 and population-based samples2 demonstrate reduced time to onset of AD, with the population-based study reporting a difference of eight years.2 The often contradictory and confusing findings regarding rates and risks for AD after TBI and the gross lack of information on the clinical presentation of AD in TBI raise the need for further study of these topics. Also, studies have not been done that examine treatment of AD after TBI. And, it is particularly critical to gain better understanding of risk factors by including analyses of injury severity, injury frequency, age at injury, gender, genotype and course of recovery wherever possible. Utilization
POTENTIAL TBI AND ALZHEIMER’S DISEASE RISK FACTORS • Severe TBI • Repeated TBI
• ApoE4 genetic allele • Male gender
of the detailed diagnostic guidelines for dementia provided in the Uniform Data Set of the National Alzheimer’s Coordinating Center is advised, as well as accessing existing longitudinal studies to identify population-based and clinical cohorts for comparisons and controls, as well as mining these sources for TBI data. Future research should also utilize state-of-the-art neuroimaging and other biomarker tools, taking advantage of advances that are reflected in the evolving body of general AD research, such as the quantification of high resolution structural MRI for volumetric and structural integrity measures, as well as more recent advances in beta amyloid imaging. Standardized assessment and protocols for functional measurement in AD also need to be implemented, such as commonly used rating tools (Clinical Dementia Rating, Neuropsychiatric Inventory, AD 8 Checklist); the Uniform Data Set Psychometric Battery and relevant telephonic instruments (e.g., TICS, BTACT). Lastly, inclusion in and collaboration of TBI researchers within the larger AD research community is essential. Collaboration with existing AD resources increases the opportunity for substantial sample sizes and grant opportunities. Institutional and regional overlapping already exists in Alzheimer’s Disease Centers and TBI Model Systems, in multiple sites across the country. The inclusion of TBI measures as variables within existing AD studies, particularly those assessing potential treatments, is a key to future interventions. Eventual treatments can only be developed by commencing AD treatment studies within postTBI populations. This includes representing TBI within new research protocols, in basic research and in animal models and through the eventual development of a network comparable to the Alzheimer’s Disease Center System, with centers possessing expertise in both clinical trials and TBI. Acknowledgements: The authors would like to thank Stacy Belkonen, Ph.D., Ramon Diaz-Arrastia, M.D., Felicia Goldstein, Ph.D., Amanda Sacks, Ph.D. and Angela Yi, Ph.D., for their contributions to this review.
LiveOakLiving.com
References
1. Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurg. 2005;57:719726. 2. Nemetz PN, Leibson C, Naessens JM, et al. Traumatic brain injury and time to onset of Alzheimer’s disease: a population based study. Am J Epidem. 1999;149:32-40. 3. Williams DB, Anneger JF, Kokmen E, et al. Brain injury and neurologic sequelae: A cohort study of dementia, parkinsonism, and amytrophic lateral sclerosis. Neurol. 1991;41:1554-1557. 4. Mehta KM, Ott A, Kalmijn S, et al. Head trauma and risk of dementia and Alzheimer’s disease. Neurol. 1999;53:1959-1962. 5. Plassman BL, Havlik RJ, Steffens DC, et al. Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurol. 2000;55:1158-1166. 6. Mayeux R, Ottman R, Maestre G, et al. Synergistic effects of traumatic head injury and apolipoprotein-e4 in patients with Alzheimer’s disease. Neurol. 1995;45:555-557. 7. Fleminger S, Oliver DL, Lovestone S, et al. Head injury as a risk factor for Alzheimer’s disease: the evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiat. 2003;74:857-862. 8. Mortimer JA, van Duijn CM, Chandra V, et al. Head trauma as a risk factor for Alzheimer’s disease: a collaborative re-analysis of case-control studies. EURODEM Risk factor Research Group. Int J Epidem. 1991;20:S28-S35. 9. Jellinger KA, Paulus W, Wrocklage C, Litvan I. Traumatic brain injury as a risk factor for Alzheimer’s disease. Comparison of two retrospective autopsy cohorts with evaluation of ApoE genotype. BMC Neurol. 2001 Dec 18;1:3. 10. Isonniemi H, Tenovuo O, Portin R, et al. Outcome of traumatic brain injury after three decades – relationship to ApoE genotype. J Neurotrauma. 2006;23:1600-1608.
LifeLong Living Programs for Adults with Cognitive Disabilities David Seaton, Owner/CEO • ds@tc-tx.com • 512.371.1078 P.O. Box 1410 • Manchaca, Texas 78652
Programs of BRAIN INJURY PROFESSIONAL
13
The Consequences of TBI Occurring in the Elderly: A Systematic Review By Marcel Dijkers, PhD,1 Joshua Cantor, PhD,1 Mary Hibbard, PhD,1 Stacy Belkonen, PhD,1 Adam Warshowsky, PhD,1 David Layman, PhD1 Projections from the U.S. Bureau of the Census1 and others predict that in the next few decades the elderly will be the fastest growing segment of the population. For instance, from 2000 to 2050, the population between 65 and 84 years will more than double, from 31 to 66 million, while the population as a whole will grow less than 50%. The oldest old group, those 85 and over, will grow even faster, from 4 to 21 million. When we consider TBI in the elderly, the most recent estimates from the Centers for Disease Control and Prevention (CDC) show that the incidence of TBI is highest among the youngest (age 0-4) and the oldest (75 and over) age groups.2 In both instances, the major cause of TBI is falls, while motor vehicle crashes and assaults play a minor role. A significant difference in the consequences of TBI is found, however, between young children and the elderly. While young children generally do not require much more care than an emergency room visit, among the elderly such visits very often are followed by a hospital admission (in 42% of elderly injured), and death is a not uncommon consequence (17% of hospitalizations). The changes that occur in the aging brain, in terms of anatomy and functioning, may explain the high risk for TBI in the elderly and the high risks of hospitalization and death for those with TBI. With aging: • The dura becomes more adherent to the skull • The bridging veins are more exposed • Synaptic density and neural plasticity decrease • Nerve growth factor production decreases • Cerebral perfusion decreases Mount Sinai School of Medicine, New York, NY
1
14 BRAIN INJURY PROFESSIONAL
These age-related changes may contribute to diminishing cognitive reserve, which in turn increases the risk for TBI within the aging population. The situation is worsened by the fact that many elderly people suffer chronic diseases and disorders, contributing to the risk of falls. Of the non-institutionalized elderly population in the U.S. (65 or older), 48% have arthritis, 35% hypertension, 27% coronary disease, 10% diabetes, 6% are post-stroke, and 2% have Parkinson’s. Because of these and other health conditions, polypharmacy is the rule among the elderly,3 further increasing the risk for falls and traffic mishaps, both of which are associated with undesirable drug-related side-effects and drug interactions. The high rates of chronic illness as well as of cognitive and physical disability in the 65+ population who incur a TBI make it unlikely that they can be sent home from the ED; the significant comorbidities suffered by the older population have variable and deleterious effects on their survival, length of stay, and acute care and rehabilitation outcomes. While these issues are generally well known, information is lacking on the burden exacted by TBI in elderly people surviving injury and the relative success (or failure) of treatment in returning them to pre-injury functioning. The systematic review of the existing literature presented here is intended to answer a number of specific questions and to make recommendations for future research. One of the first questions we needed to resolve in developing our systematic review methodology was: when does one become elderly? Traditionally 65 is used in the U.S., based on the age cutoff the Social Security Administration “set in stone” in the
1930s. However, “aging” is a gradual and life-long process, and it is unlikely that 65 is the point at which the pace of aging picks up, or the nature of aging changes qualitatively. In TBI studies, very often people of 55 are considered “aged”, sometimes those as young as 50. This may be due more to the fact that the 60+ or 65+ group in most studies is too small to analyze separately (statistical power issues), than because of an acceleration in the aging of the brain at 50 or 55. In this review, we rather arbitrarily decided to draw the line at 60. We focused on natural history, status after emergency/acute care, and the effects of rehabilitative treatments, rather than on epidemiology or emergency and neurosurgical treatment. We skipped the literature on TBI as a potential cause of Alzheimer’s or other dementias, as this was the focus of the Trudel et al. review. And, we excluded qualitative studies and those based on a sample size of nine or fewer cases. In total, 32 papers were selected as applicable and of acceptable quality. They all dealt with the natural history of TBI in the elderly (i.e., prognostic studies). On the STROBE-derived scale that we used, which generates a score between 0.00 (very poor) and 1.00 (exemplary),4 the average score of these papers was 0.62, with a standard deviation of 0.15. In terms of the AAN grades for “prognostic articles” they scored poorly: 96% fell into the two lowest categories. However, the global quality ratings of our reviewers were “kinder”, as only 34% of the studies were given the two lowest ratings. Several questions were addressed based on the evidence provided in the studies that were accepted as applicable to our topic: Question 1: Is a good outcome after TBI possible for the elderly, and how does severity of injury affect this? The evidence relevant to this question was mostly found in studies reporting on the status of individuals discharged from acute care hospitals. Outcome at discharge was primarily given in terms of the Glasgow Outcome Scale (GOS), a 5-point scale that ranges from 1 (dead) to 5 (good recovery). The fact that “good recovery” essentially means “able to return to work or school,”5 two activities not relevant to most elderly people, implies a basis for concern regarding use of the GOS to assess outcome in the elderly. The fact that in some studies this ability is judged at hospital discharge (rather than three or six months later) is even more worrisome, since at discharge typically it is too early to predict the person’s ability to return to productivity. Recovery rates were found to vary by severity of the brain injury (most studies we found reported severity in terms of Glasgow Coma Scale [GCS]6 scores): • • •
Severe (GCS under 9/10): For the elderly, “Good Recovery” is exceptional Moderate (GCS from 8/9-11): “Good Recovery” is reported for approximately 50% Mild (GCS 12-15): “Good Recovery” is found for 80+%
Question 2: Do elderly people have worse outcomes than younger age groups? The simple response to this is, Yes. In all GCS severity groups, elderly people fare worse in terms of GOS at hospital discharge and later post injury. However, insufficient comparability between the studies makes it impossible to determine whether the elderly are relatively worse off in one or another of the GCS
Help Seniors Live Better, Longer: Prevent Brain Injury Concern with the high rates of TBI among senior citizens has led the Centers for Disease Control and Prevention to develop an awareness and prevention campaign directed at the children, grandchildren and others who are caregivers of the elderly or simply concerned about their welfare. In “Help Seniors Live Better, Longer: Prevent Brain Injury” the CDC offers ways to prevent, recognize, and respond to TBI in adults 75 and older – the most vulnerable segment of our population, per CDC statistics. Available free for download (from www.cdc. gov/braininjuryinseniors/) are the following: • ‘Preventing Falls and TBI’ (podcast) • “Preventing Traumatic Brain Injury in Older Adults: Information for Family Members and Other Caregivers” (brochure) • “Preventing Traumatic Brain Injury in Older Adults: A Fact Sheet for Family Members and Other Caregivers” (fact sheet) • “Preventing Traumatic Brain Injury in Older Adults” (booklet for older adults) • “Facts about TBI in Older Adults Poster” (poster) • “TBI is a Special Health Concern or Older Adults” (E-card for caregivers) • “Fall-related TBI Prevention Steps” (E-card for caregivers) • “Signs and Symptoms of TBI” (poster) • Magnet • An “Event Planning Guide” that includes suggestions and tools for planning and organizing a community event, for enlisting partners, and for promoting and evaluating an event. • A “Media Access Guide” that includes tips and tools, such as talking points and templates for press releases and media advisories, to help one work with local media to get valuable news coverage for the activities planned in support of this national effort. Most of these materials are available in English and Spanish and use question-and-answer and other simple formats to provide information that older adults and their caregivers can use to take an active role in preventing, recognizing, and responding to TBI
severity categories. Question 3: How does recovery of the elderly compare to that of other adults, in terms of specific areas in which they may recover differently from others (e.g., domains where recovery occurs, speed of recovery)? No evidence, beyond that offered on differential GOS levels at fixed time points, suggests that, controlling for comorbidities, the elderly recover more slowly overall or recover slower in some areas but not in others. They may have a longer length of stay in acute care or inpatient rehabilitation, which would suggest (but not offer definitive evidence of ) slower recovery. Question 4: What factors determine outcomes for this group? Is the slope or level of recovery significantly affected by severity of injury, age, associated injuries, pre-injury health status or pre-injury cognitive and functional status? Evidence provided in Question 1 indicates that (as in other age groups) severity of injury strongly affects recovery among the elderly. Evidence relevant to Questions 1 and 2 indicates that age makes a difference within the elderly group: the oldest old (80+ or 85+) have much higher risks of dying after TBI or of making a poor recovery than is the case for the “youngest old” (65-74 or 60-69). However, the exact interaction of age andx severity BRAIN INJURY PROFESSIONAL
15
of injury cannot be determined with the currently available evidence. As to the roles of associated injuries and pre-injury health status: there currently is insufficient information. It should be noted that prior to injury many of the elderly are on anticoagulant medication, which constitutes a major risk factor for bleeding in the brain once it is injured.7 The role of the chronic disorders (arthritis, diabetes, etc.) that many elderly people suffer is unknown; there also is insufficient information on the impact of pre-injury cognitive and functional status on outcomes. Question 5: Does (mild) TBI add to the burden of the already diminished functional/health status of elderly people? This question is based on qualitative research that suggests that elderly people, because of the many chronic disorders they may suffer before (or incur after) TBI, cannot necessarily point to specific cognitive or physical functioning deficits and attribute them causally to the brain injury. The elderly tend to take it for granted that “aging” brings about a number of frailties, and they have trouble pinpointing TBI as a specific cause.8 Once again, there is insufficient information on how functioning in elderly people differs before and after TBI, physically, cognitively, emotionally or socially. Question 6: What are the rehabilitation needs of elderly people with TBI? Do they require or benefit from special “geriatric TBI” rehabilitation programs? No research has been conducted on the specific rehabilitation needs of the elderly or the potential to improve outcomes by designing special rehabilitation programs that take into account the strengths and weaknesses of the elderly individual. Question 7: Are elderly people referred to rehabilitation services based on need and likelihood of success (or does ageism play a role)? This question was suggested by information in the literature indicating that in some instances age itself, rather than physical function and reserves that may or may not wane with age, is used to make decisions on surgery or referral of the elderly (with or without TBI) to special programs. No evidence was found to demonstrate that the same occurs when it comes to referral to rehabilitation services. 16 BRAIN INJURY PROFESSIONAL
In sum, the information available is quite limited on how TBI affects people who are aged at time of injury and how they respond to treatment programs. Most information that we have is derived from general TBI population studies that analyze outcomes by age category, including an “elderly” group. The research that has specifically focused on the elderly with TBI is limited, and often counts as “old” people as young as 50 or 55 years, for instance in the series of publications by Goldstein et al.9-11 Given the high incidence of TBI in the elderly and the apparently poorer outcomes in this group compared with younger individuals, the research effort focused on this segment of the TBI population is clearly inadequate. Additional research is needed that focuses only on elderly samples, for instance, comparing outcomes of standard rehabilitation versus rehabilitation programs specifically designed for the elderly. Other valuable research would include all age groups (particularly adults), but have sufficient numbers of elderly people to make comparisons with other age groups meaningful. The authors would like to acknowledge the able assistance of James Graham, Ph.D., and Ann Charness, Ph.D., in locating literature.
Check out the NABIS Career Center!
References
1. U.S. Census Bureau. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin: 2000-2050. Retrieved July 20, 2008http:// www.census.gov/ipc/www/usinterimproj/ 2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 2004. 3. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Ger Pharmacother. 2007;5:345-351. 4. Fernandez E. Observational Studies in Epidemiology (STROBE). Medicina Clinica. 2005;125(Suppl.1):43-48. 5. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiat. 1981;44:285-293. 6. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet, 1974;2(7872):81-84. 7. Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the anticoagulated elderly patient: a lethal combination. Am Surg. 2001;67:1098-1100. 8. Layman DE, Dijkers MP, Ashman TA. Exploring the impact of traumatic brain injury on the older couple: ‘Yes, but how much of it is age, I can’t tell you ...’. Brain Inj. 2005;19:909923. 9. Goldstein FC, Levin HS Cognitive outcome after mild and moderate traumatic brain injury in older adults. f Clin Exp Neuropsychol. 2001;23:739-753. 10. Goldstein FC, Levin HS, Goldman WP, et al. Cognitive and neurobehavioral functioning after mild versus moderate traumatic brain injury in older adults. J Int Neuropsychol Soc. 2001;7:373-383. 11. Goldstein FC, Levin HS, Goldman WP, et al. Cognitive and behavioral sequelae of closed head injury in older adults according to their significant others. J Neuropsychiat Clin Neurosci. 1999;11:38-44.
View nationwide jobs in the brain injury field or post your own resume!
BRAIN INJURY PROFESSIONAL
17
18 BRAIN INJURY PROFESSIONAL
Support that brings real life into focus Learning Services programs are designed to provide specialized support for adults with brain injuries in a real life setting. All of our programs are equipped to maximize each resident’s quality of life as they take on the challenges of a brain injury. Our approach supports outcomes by offering individuals the tools necessary to live life on their terms. We offer two signature neurobehavioral programs designed to support adults with complex behavioral challenges as a result of a brain injury: one in suburban Denver, CO and another in suburban Raleigh-Durham, NC. These programs offer progressive supports that incorporate Board Certified Behavior Analysts, Neuropsychiatry, and integrated rehabilitation therapies, all in safe and homelike environments.
To learn more about how we can make a difference, call 888-419-9955 or visit learningservices.com. Learning Services Neurobehavioral Institute – West 7201 W. Hampden Avenue Lakewood, CO 80227 Learning Services Neurobehavioral Institute – East 800 Recovery Drive Creedmoor, NC 27522
WHAT MAKES
a personal injury law firm different?
RICH VANDERWAL
WE
Rehab Consultant
WERE
DIANNE HENDERSON R.N., B.A. Psych., M.Ed.,
THE
Medical Consultant
FIRST
CHARLES GLUCKSTEIN
OUR
in combining more than
J.D., LL.B
a century of legal expertise BERNARD GLUCKSTEIN,
with medical & rehab
QC
TURN WE ENSURE THAT
you and your loved ones receive the absolute best in health care delivery.
Gluckstein
“OUR MULTIDISCIPLINARY teams’ goal is to protect your rights while advocating for maximum compensation and recovery of lifestyle.”
P E R S O N A L
ARE
IN
consultants.
& A SS OCI AT E S
WE
EXTENSIVE
knowledge and skill sets in the areas of spinal cord and brain injury allow GLUCKSTEIN & ASSOCIATES LLP to consult directly with all of the healthcare providers.
I N J U R Y
LLP
L A W Y E R S
GLUCKSTEIN & ASSOCIATES LLP, and there is no such thing as business-as-usual here.
TELEPHONE
416.408.4252
toll-free
1.866.308.7722
info@gluckstein.com
WEBSITE
www.gluckstein.com
A HISTORY OF SHARED SUCCESS For a free professional assessment and excellent treatment you can count on, call us. • Fully accredited for Brain Injury, Spinal Cord Injury, Chronic Pain, and Stroke • Full spectrum of in- and outpatient services • Return of patient to highest level of function Call 504-897-8565 for a confidential professional consultation free of charge. 1401 Foucher Street • New Orleans, LA 70115 www.touro.com
Putting Lives In Motion Since 1984
Post-TBI Life Expectancy and Health: A Systematic Review
by Steven Flanagan, MD1
It is well known that traumatic brain injury is associated with a high mortality rate at the time of injury or shortly thereafter, resulting in more than 50,000 deaths yearly in the United States1. However, little is known regarding overall life expectancy and long-term health problems in individuals who survive beyond the initial period post injury, although this clearly is critically important data. The question raised in this review is: How does TBI affect long-term survival and health? Abstracts representing over 2,700 scientific manuscripts that addressed issues of mortality and health problems following TBI were reviewed. In order to focus the review on long-term issues of premature mortality and health care problems, only those studies reporting on individuals more than five years post-injury were included. Only 25 manuscripts met this criterion. Of these, 15 reported on life expectancy, causes of death and risk factors associated with premature death; 6 addressed long-term self-reported health problems; 3 reported on self-perceived quality of health. Only one examined a specific health problem diagnosed by medical examination. These categories are discussed in turn below. Reviewing the literature on life expectancy after TBI poses a challenge, primarily because of inconsistency across studies. For example, mortality may be reported in several ways. Some studies2,3 focus on life expectancy per se, which refers to the average number of years a group of individuals with similar characteristics (e.g., age, gender) are expected to live. Other studies4,5 use standardized mortality ratios, which compare mortality in a cohort of individuals with TBI to mortality in a sample of the general population with similar characteristics. Mortality may also be expressed as a proportion of a specific cohort that expired by the end of a study’s timeframe. Also, information on individuals with TBI may be obtained from a variety of databases (e.g., inpatient hospital records,3,6-10 outpatient disability services,2,4,5 New York University School of Medicine, New York, NY
1
22 BRAIN INJURY PROFESSIONAL
veterans’ records11-13), each potentially resulting in different conclusions because of dissimilarities in the samples being studied. Furthermore, the studies reviewed differed significantly in the length of time individuals were followed. Despite these inconsistencies, the main findings across studies suggest that an overall decrease occurs in the life expectancy of individuals who survive beyond the acute post-injury period.6,7,9,13 However, several factors were identified that appear to significantly modify this risk. For example, older age at the time of injury generally increased mortality risk,2,3,7,8 as did being unemployed and/or having a history of substance abuse.7,9,10 It is important to note, however, that even younger individuals appeared to be at increased risk, compared to their uninjured age-related peers, for at least seven years post injury.9 A recurring theme across several studies was that individuals with residual physical disability were at increased risk of early death, probably related to immobility, difficulty swallowing and infection.4,5,7 Some studies that assessed mortality rates over very long periods, one spanning several decades, suggested that life expectancy tended to approach that of the general population as time passed.12 However, it is worthwhile noting that these latter studies predominantly included individuals surviving war-related injuries, who may not be representative of the general population of individuals with TBI. Although it was often difficult to discern the specific cause of death in these reports, several trends emerged suggesting that individuals with TBI appeared more likely to die from seizures, suicide and accidental death than the general population.5,8 Other frequently mentioned causes of death included disorders of the circulatory, digestive and respiratory systems, which, depending on the study, occurred at either the same or increased frequency compared to the general population. Another important goal of this review was to identify long-
term health problems that afflict individuals after sustaining a TBI and how they differ in frequency from the general population. Most of the studies identified for review assessed self-reported health problems, typically using either a standardized health survey or medical interview. Findings from these studies suggest that individuals with TBI are more likely than their non-injured peers to have complaints pertaining to neurological conditions (e.g., weakness and dizziness) and endocrine problems, as well as more general complaints of headaches, visual and hearing problems, fatigue, sexual dysfunction and allergies.14-19 Three other studies examined self-perceived health, suggesting that individuals who have more TBI-related health problems were more likely to have poorer perceptions of overall health.20-22 Only one study, on pituitary gland function, examined a health problem diagnosed via medical examination.23 Pituitary gland dysfunction was found to afflict 54% of a sample of individuals with TBI within five years of injury. Abnormalities were found in levels of sex hormones, thyroid hormone, prolactin and, most prominently, growth hormone. This is potentially an important finding, as some TBI-related problems, such as fatigue, weakness and cognitive impairment, may be at least partially attributable to pituitary dysfunction In addition to confirming these reports and better specifying both the precise etiology of death as well as the medical problems faced by individuals with TBI as they age, future research should assess methods to screen, identify and treat individuals with characteristics that place them at increased risk for health problems and shortened life expectancy. For example, the increased mortality of individuals with residual physical disabilities may relate in part to poorer cardiovascular fitness, in addition to the other ill effects associated with immobility. Poor fitness may also be related to other TBI-related problems, such as impaired cognition, which potentially inhibits effective planning and meaningful participation in a regularly scheduled program of exercise. Identifying individuals at risk may result in timely implementation of specific interventions that enhance cardiovascular fitness, improve overall health and subsequently decrease the risk of premature mortality. Additional factors, such as pre-morbid health status, medication effects, nutritional status and socioeconomic status, are likely to
contribute to overall health and morbidity and need to be a focus of future studies. I would like to acknowledge the valuable input and assistance of Cynthia Harrison-Felix, Ph.D., Theo Tsaousides, Ph.D., and Dana Wiebe, Ph.D. References
1. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil. 2006;21:375-378. 2. Strauss DJ, Shavelle RM, Anderson TW. Long-term survival of children and adolescents after traumatic brain injury. Arch Phys Med Rehabil. 1998;79:1095-1100. 3. Whitnall L, McMillan TM, Murray GD, Teasdale GM. Disability in young people and adults after head injury: 5-7 year follow up of a prospective cohort study. J Neurol Neurosurg Psychiatry. 2006;77:640-645. 4. Shavelle R, Strauss D. Comparative mortality of adults with traumatic brain injury in california, 1988--97. J Insur Med. 2000;32:163-166. 5. Shavelle RM, Strauss D, Whyte J, et al. Long-term causes of death after traumatic brain injury. Am J Phys Med Rehabil. 2001;80:510-6; quiz 517-9. 6. Baguley I, Slewa-Younan S, Lazarus R, Green A. Long-term mortality trends in patients with traumatic brain injury. Brain Inj. 2000;14:505-512. 7. Harrison-Felix C, Whiteneck G, DeVivo M, et al. Mortality following rehabilitation in the traumatic brain injury model systems of care. NeuroRehabilitation. 2004;19:45-54. 8. Lewin W, Marshall TF, Roberts AH. Long-term outcome after severe head injury. Br Med J. 1979;2:1533-1538. 9. McMillan TM, Teasdale GM. Death rate is increased for at least 7 years after head injury: A prospective study. Brain. 2007;130:2520-2527. 10. Ratcliff G, Colantonio A, Escobar M, et al. Long-term survival following traumatic brain injury. Disabil Rehabil.
2005;27:305-314. 11. Corkin S, Sullivan EV, Carr FA. Prognostic factors for life expectancy after penetrating head injury. Arch Neurol. 1984;41:975-977. 12. Rish BL, Dillon JD, Weiss GH. Mortality following penetrating craniocerebral injuries. an analysis of the deaths in the vietnam head injury registry population. J Neurosurg. 1983;59:775-780. 13. Walker AE, Blumer D. The fate of world war II veterans with posttraumatic seizures. Arch Neurol. 1989;46:23-26. 14. Colantonio A, Ratcliff G, Chase S, Vernich L. Aging with traumatic brain injury: Long-term health conditions. Int J Rehabil Res. 2004;27:209-214. 15. Hibbard MR, Uysal S, Sliwinski M, Gordon WA. Undiagnosed health issues in individuals with traumatic brain injury living in the community. J Head Trauma Rehabil. 1998;13:4757. 16. Hibbard MR, Gordon WA, Flanagan S, et al. Sexual dysfunction after traumatic brain injury. NeuroRehabilitation. 2000;15:107-120. 17. Hillier SL, Sharpe MH, Metzer J. Outcomes 5 years posttraumatic brain injury (with further reference to neurophysical impairment and disability). Brain Inj. 1997;11:661-675. 18. O’Connor C, Colantonio A, Polatajko H. Long term symptoms and limitations of activity of people with traumatic brain injury: A ten-year follow-up. Psychol Rep. 2005;97:169-179. 19. Vanderploeg RD, Curtiss G, Luis CA, Salazar AM. Longterm morbidities following self-reported mild traumatic brain injury. J Clin Exp Neuropsychol. 2007;29:585-598. 20. Colantonio A, Ratcliff G, Chase S, et al. Long-term outcomes after moderate to severe traumatic brain injury. Disabil Rehabil. 2004;26:253-261. 21. Jakola AS, Muller K, Larsen M, et al. Five-year outcome after mild head injury: A prospective controlled study. Acta Neurol Scand. 2007;115:398-402. 22. Steadman-Pare D, Colantonio A, Ratcliff G, et al. Factors associated with perceived quality of life many years after traumatic brain injury. J Head Trauma Rehabil. 2001;16:330-342. 23. Bondanelli M, De Marinis L, Ambrosio MR, et al. Occurrence of pituitary dysfunction following traumatic brain injury. J Neurotrauma. 2004;21:685-696.
BRAIN INJURY PROFESSIONAL
23
Post-TBI Aging and Cognitive Functioning: A Systematic Review by Amanda Sacks, PhD,1 Angela Yi, PhD,1 Wayne A. Gordon, PhD1
Many people with TBI raise questions with regard to cognitive functioning and aging, for example: Are some domains of cognitive functioning more prone to decline than others? Will cognitive challenges prevent me from being able to care for myself as I age? Although these questions are critically important to those who raise them, most studies provide only a few hints as to changes in cognitive functioning as the person ages post TBI. Because the evidence in this area is scant, the systematic review we conducted was focused solely on the question of whether changes in cognitive functioning are found as people age after injury. To address this question, longitudinal studies were first reviewed; these examine the same indiviudals at two or more time points after injury on cogntiive measures, such as neuropsychological tests. This set of studies yielded mixed findings. For example, two studies1,2 showed visuospatial functioning to improve over time, while Himanen et al.3 found a decline. Similarly, memory studies provide inconsistent results, either showing a decline3,4 or stable functioning over time.5,6 Consensus across studies was found in the domains of processing and motor speed, where improvement over time was demonstrated.1,2 The promising news suggested by this research is that some domains of cognitive functioning appear to improve over time (whether this is due to aging or to other factors is not clear). However, definitive conclusions about the possible effects of aging on other areas of cognitive functioning are difficult to make, given the mixed findings across the longitudinal studies reviewed. Cohort (or cross-sectional) studies that examined cognitive functioning in different age groups (both with and without TBI), were also reviewed. One study7 found that, on an executive functioning task, middle-aged people with TBI performed similarly to older individuals who did not have TBI. This finding was interpreted by that study’s authors as suggesting that TBI may accelerate the emergence of the reduced cognitive functioning associated with “normal” aging. Another study8 found that younger people with TBI did worse than their non-disabled peers in comparison to older groups of people with TBI and without. Thus, age at which TBI is sustained might make a difference in cognitive functioning. Alternatively, the younger people with TBI may not have recovered to the same extent as those who were older. As with the longitudinal studies, definitive conclusions are not possible, given that the studies are few, and the findings have not been replicated. A variety of study design issues may have contributed to the Mount Sinai School of Medicine, New York, NY
1
24 BRAIN INJURY PROFESSIONAL
variability of findings across studies. When examining the effects of TBI over time, researchers need to consider at least four factors: age at injury, age at first assessment (or age of the youngest group in cohort studies), time since injury and the length of the interval between assessments (or between age groups in cohort studies). Age at injury not only varied across studies but also was not systematically examined in the respective data analyses. Injuries sustained during childhood and adolescense typically have a different impact upon cognitive functioning compared to injuries in adulthood, when the brain has fully developed. The second factor, age at the time of the initial evaluation or of the youngest group, also varied across studies. Differences in cognitive functioning can be found across age groups and should be taken into account when attempting to make conclusions regarding changes in cognitive functioning over time. With respect to the third factor, length of time since the injury, people with recent injuries may perform differently than people with older injuries on tests of cognitive functioning. The fourth factor is the time interval between assessment points or between groups in cohort studies. The length of this interval varied across studies, potentially leading to their capturing different pictures of cognitive change, as they allowed shorter or longer periods for change to become manifest. In addition to these study design issues, factors such as demographic variables, health status and re-injury after initial injury may affect cognition, and these potential effects need to be considered when a study is designed or at the point of data analysis. This review group would like to acknowledge the capable input and assistance of Dennis Zgaljardic, Ph.D. References
1. Millis SR, Rosenthal M, Novack TA, Sherer, et al. Long-term neuropsychological outcome after traumatic brain injury. Journal Head Trauma Rehabi. 2001;16:343-355. 2. Wood RL, Rutterford NA. Long-term effect of head trauma on intellectual abilities: A 16-year outcome study. J Neurol Neurosurg Psychiat. 2006;77:1180-1184. 3. Himanen L, Portin R, Isoniemi H, et al. Longitudinal cognitive changes in traumatic brain injury: A 30-year follow-up study. Neurol. 2006;66:187-192. 4. Jonsson CA, Horneman G, Emanuelson I. Neuropsychological progress during 14 years after severe traumatic brain injury in childhood and adolescence. Brain Inj. 2004;18:921-934. 5. Ashman TA, Cantor J, Gordon WA, et al. A comparison of cognitive functioning in older adults with and without traumatic brain injury. J Head Trauma Rehabil. 2008;23:139-148. 6. Thomsen IV. Late outcome of very severe blunt head trauma: A 10-15 year second follow-up. J Neurol Neurosurg Psychiat. 1984;47:260-268. 7. Klein M, Houx PJ, Jolles, J. Long-term persisting cognitive sequelae of traumatic brain injury and the effect of age. Journal Nerv Ment Dis. 1996;184:459-467. 8. Ogden JA, Wolfe M. (1998). Recovery from the post-concussional syndromw: A preliminary study comparing young and middle-aged adults. Neuropsychol Rehabil. 1998;9:413-431.
the moody prize
Post-TBI Emotional Functioning and Age: A Systematic Review by Teresa Ashman, PhD,1 Guido Mascialino, PhD1 Among the variables that comprise poor psychosocial outcome following TBI are emotional and adjustment problems1. These most often include depression, anxiety, difficulties with anger management and substance abuse. It has been estimated that as many as 50% of individuals with TBI experience clinically significant levels of anxiety and depression within a year following injury.2 Regarding emotional functioning as a person ages with TBI, this review group addressed the following questions: How does post-TBI emotional functioning change across the life span? Are any changes in emotional functioning that are found associated with aging, not just with TBI? Are differences in emotional functioning found amongst different age cohorts after TBI? Only four studies met the inclusion criteria (outlined by Dijkers et al, pp. 8-11 herein)3-6. Two studies reported that emotional functioning improved over time following the onset of TBI.3,4 Unfortunately, no studies provided evidence to address the question of whether changes in emotional functioning were a result of the aging process versus the onset of TBI. Some indication was found of differences in emotional functioning for different age cohorts. For example, one study showed that rates of negative affect were lower in middle-aged and older cohorts with TBI, compared to the younger TBI cohort3. References
1. Corrigan JD, Whiteneck G. Perceived needs following traumatic brain injury. J Head Trauma Rehabil. 2004;19:205-216. 2. Deb S, Lyons I, Koutzoukis C et al. Rate of psychiatric illness 1 year after traumatic brain injury. Am J Psychiat. 1999; 156:374-378. 3. Anstey JJ, Butterworth P, Jorm FF et al. A population survey found an association between self-reports of traumatic brain injury and increased psychiatric symptoms. J Clin Epidem. 2004;57:1202-1209. 4. Baguley IJ, Cooper J, Felmingham K. Aggressive behavior following traumatic brain injury: How common is common? J Head Trauma Rehabil. 2006;21:45-56. 5. Koponen S, Taimenen T, Portin R et al. Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study. Am J Psychiat. 2002;159:1315-1321. 6. Koponen S, Taimenen T, Kurki T et al. MRI findings and Axis I and II psychiatric disorders after traumatic brain injury: a 30-year retrospective follow-up study.
Mount Sinai School of Medicine, New York, NY
1
In 1999, the University of Texas Medical Branch at Galveston established the Robert L. Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation The award is named after Mr. Robert L. Moody, whose sustained personal dedication has created a legacy of clinical accomplishment in rehabilitation education, service and research at UTMB and throughout the world. The purpose of the award is to recognize and honor individuals or groups whose efforts have made significant contributions (1) toward advances in acquired brain injury clinical research, (2) toward developing improved treatment and rehabilitation procedures for persons who must contend with the disabilities associated with acquired brain disorders, and (3) toward increasing awareness of the need for the rehabilitation of individuals following acquired brain injury. The prize is a juried award with an honorarium of $10,000. It is hoped that this prize will continue to build awareness of the significant public health implications of acquired brain injury, and aims to increase national and international awareness of the need to expand research and improve treatment for Dr. Brent Masel, TLC persons who have President and Medical Director experienced brain injury. Previous Moody Prize winners are: Mitchell Rosenthal, Ph.D., Jeffrey Kreutzer, Ph.D., Roberta DePompei, Ph.D., Marilyn Spivack, Barbara Wilson, Ph.D., John Corrigan, Ph.D, and John Whyte M.D., Ph.D. The Prize is awarded at a gala dinner during the Galveston Brain Injury Conference. Hosted by the Transitional Learning Center, UTMB and the UTMB Center for Rehabilitation Sciences, this invitation only conference brings to Galveston the very top individuals in their field for two days of discussion and interaction in a structured, yet casual environment. The conference themes are chosen a year prior to the meeting and occur in two year blocks, to allow adequate preparation time and to allow participants to continue to work on their projects between the two meetings. Galveston Brain Injury Conference topics have included: The Establishment of Minimal Data Sets (lead by Elizabeth Sherwin, and published in Brain Injury, 2006); Defining Treatment in TBI ( lead by John Whyte and Tessa Hart, and published in JHTR, 2006); and Pediatric Issues (lead by Roberta DePompei, and published in BIP, 2006). The 2008-2009 topic is Aging with Brain Injury and Brain Injury in the Aged. BRAIN INJURY PROFESSIONAL
25
Post-TBI Vocational Status and Age: A Systematic Review by Margaret Brown, PhD 1
A systematic review of the impact of aging on post-TBI vocational status is more problematic than for most other aspects of life, because change over time is part of normal development. For example, we graduate high school or college and then enter employment; and, most people retire in their later years. Thus, the question first raised was, How do the changes associated with normal aging differ for people who have experienced a TBI? Unfortunately, studies that might address this question have not been done. The research that has been done relevant to this review allows only a much simpler question: After TBI, is age associated with vocational success (e.g., return to work, entering college)? Existing reviews1-5 of relevant studies conclude either that people who are younger at time of injury fare better vocationally than older people OR that age at injury has no effect. These differing conclusions have typically been explained in terms of inconsistent/inadequate methods being adopted across studies. So, this systematic review adopted as its goal solving the apparent “mystery” of studies reporting findings that are at odds with each other. Mount Sinai School of Medicine, New York, NY
1
26 BRAIN INJURY PROFESSIONAL
The approach adopted was to focus on the literature least flawed in the ways that would be most likely to distort the conclusions reached. The initial hypothesis was that the primary flaw that could account for the conflicting conclusions was if study methods (primarily inclusion criteria, time of follow-up and methods of defining “success”) left room for labeling normal age-related changes as TBI-related changes. For example, if a 60-year-old is working at time of injury and at a 10-year follow-up shows that he/she is not working, this is unlikely to be a vocational “failure” due to TBI, but instead a normal change in status for a 70-year-old. “Good” studies would correctly classify this transition or would exclude people nearing the normal retirement age from the study sample. Either would allow the study to avoid what I refer to as “vocational transition misattribution.” More than 100 studies were reviewed and evaluated on 11 factors that were felt to be the essence of methodological soundness, including avoidance of “work transition misattribution”. Those studies that passed muster numbered 136-18. Surprisingly, the conclusions reached in these studies about the relationship
of age and post-TBI vocational status were the same as cited above: either “younger do better” or “age doesn’t matter”. Thus, even if only the highest quality studies were included in a review, a clear explanation was not immediately obvious for studies arriving at different conclusions. What then led to an (apparent) solution to the mystery was a suggestion made by Ron Ruff19 that, within his sample, returning to school seemed to be easier than returning to work. The fact that more younger people are in school than older might account for the “younger is better” conclusion reached in many studies. A new hypothesis was formulated: If a study is otherwise “good” in terms of overall methodology, but includes “being a student” as a “successful” outcome, it will reach the conclusion that “younger is better”; if vocational “success” is limited to return to work, “age doesn’t matter” will be concluded. In fact this was found to be the case in 10 of the 13 studies. The other three9,10,13 were characterized by more complex designs and outcome measures, leading to more complex conclusions (but ones that were not counter to this hypothesis). In sum, one can paraphrase these results loosely: Schools (by and large) have to take you back after injury, but employers don’t. Since employers have more leeway in the matter, a whole range of factors will affect post-TBI return to work (or finding a new job), but age per se is likely to be a minor element in an employer’s decision. References
1. Catalano D, Pereira AP, Wu M-Y, et al. Service patterns related to successful employment outcomes of persons with traumatic brain injury in vocational rehabilitation. NeuroRehabil. 2006;21:279-293. 2. Crepeau F, Scherzer P. Predictors and indicators of work status after traumatic brain injury: a meta-analysis. Neuropsychol Rehabil.1993;3(1):5-35. 3. Ownsworth T, McKenna K. Investication of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model. Disabil Rehabil. 2004;26:765784. 4. Willemse-van Son AH, Ribbers GM, Verhagen AP, Stam H.J. Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies. Clin Rehabil. 2007;21:1024-1037. 5. Yasuda S, Wehman P, Tartgett P, et al. (2001). Return to work for persons with traumatic brain injury. Am J Phys Med Rehabil. 2001;80:852-864. 6. Asikainen I, Kaste M, Sarna S. Patients with with traumatic brain injury referred to a rehabilitation and re-employment programme: Social and professional outcome for 508 Finnish patients 5 or more years after injury. Brain Inj. 1996;10:883-899. 7. Asikainen I, Kaste M, Sarna S. Predicting late outcome for patients with traumatic brain injury referred to a rehabilitation programme: a study of 508 Finnish patients 5 years or more after injury. Brain Inj. 1998;12:95-107. 8. Bogner JA, Corrigan JD, Mysiw J, et al. A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury. Arch Phys Med Rehabil. 2001;82:571-577. 9. Corrigan JD, Lineberry LA, Komaroff E, et al. Employment after traumatic brain injury: differences between men and women. Arch Phys Med Rehabil. 2007;88:1400-1409. 10. Dawson D, Schwartz ML, Winocur G, Stuss DT. Return to productivity following traumatic brain injury: cognitive, psychological, physical, spiritual and environmental correlates. Disabil Rehabil. 2007;29:301-313. 11. Greenspan AI, Wrigley JM, Kresnow M, et al. Factors influencing failure to return to work due to traumatic brain injury. Brain Inj. 1996;10:207-218. 12. Keyser-Marcus LA, Bricout JC, Wehman, P, et al. Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up. Arch Phys Med Rehabil. 2002;83:635-641. 13. Kreutzer JS, Marwitz JH, Walker W, et al. Moderating factors in return to work and job stability after traumatic brain injury. J Head Trauma Rehabil. 2003;18:128-138. 14. Sherer M, Yablon SA, Nakase-Richardson R, Nick TG. Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury. Arch Phys Med Rehabil. 2008;89:42-47. 15. Skeel RL, Bounds T, Johnstone B, et al. Age differences in a sample of state vocational rehabilitation clients with traumatic brain injury. Rehabil Psychol. 2003;48:145-150. 16. Teasdale TW, Engberg AW. Subjective well-being and quality of life following traumatic brain injury in adults: A long-term population-based study. Brain Inj. 2005;19:1041-1048 17. Tennant A, Macdermott N, Neary D. The long-term outcome of head injury: Implications for service planning. Brain Inj. 1995;9:595-605. 18. Wood RLL, Rutterford NA. Demographic and cognitive predictors of long-term psychosocial outcome following traumatic brain injury. J Int Neuropsychol Soc. 2006;12:350-358. 19. Ruff RM, Marshall LF, Crouch J, et al. Predictors of outcome following severe head trauma: follow-up data from the Traumatic Coma Data Bank. Brain Inj. 1993;7:101-111. BRAIN INJURY PROFESSIONAL
27
Community Integration and Post-TBI Aging: A Systematic Review by Timothy A. Reistetter, PhD 1
While community integration is a primary indicator of rehabilitation success, a lack of agreement with regard to how community integration (CI) is defined and how it is measured characterize this area, as well as how these unresolved issues affect the measurement of CI in studies focusing on different age groups.1,2 For example, in this review some studies with younger adults used primarily objective measures of CI, while other studies with older adults used more subjective measures, to capture the participant’s (or “insider’s”) perspective. Two questions were raised in this systematic review: What is the effect of age on CI? How does time since injury impact CI (as time since injury can be used as a way of approximating aging with TBI)? Only 11 research reports, mostly cross-sectional, met inclusion criteria adopted in this review, based on the procedures summarized herein by Dijkers et al. (pp. 8-11). Regarding the relationship between age and CI, results were mixed. Most studies found that younger individuals with TBI were more socially integrated than older people with brain injuries,3-8 while one study found the opposite.9 Two studies found no relation between age and CI.10,11 Similar mixed results were found when examining the relationship between time since injury and CI. The studies reviewed examined elements of community integration in older adults with TBI at two, five, and ten years post injury. One study found that time since injury was associated with better home integration12, while another showed greater social isolation over time. University of Texas Medical Branch, Galveston, TX
1
28 BRAIN INJURY PROFESSIONAL
In conclusion, methodological issues, as well as insufficient research attention to this area of life after TBI, make it difficult to reach conclusions regarding the relationship between aging with TBI and community integration. References 1. 2. 3. 4. 5.
6. 7.
8.
9. 10.
11.
12.
Gordon WA, Zafonte R, Cicerone KD, et al. Traumatic brain injury rehabilitation: State of the science. Am J Phys Med Rehabil. 2006;85:343-382. McCabe P, Lippert C, Weiser M. Community reintegration following acquired brain injury. Brain Inj. 2007;21:231-257. Burleigh SA, Farber RS, Gillard,M. Community integration and life satisfaction after traumatic brain injury: Long-term findings. Am J Occup Ther. 1998;52(1):45-52. Dawson DR, Chipman M. The disablement experienced by traumatically brain-injured adults living in the community. Brain Inj. 1995;9:339-353. Fleming J, Tooth L, Hassell M, Chan W. Prediction of community integration and vocational outcome 2-5 years after traumatic brain injury rehabilitation in Australia. Brain Inj. 1999;13:417-431 Schmidt M, Garvin L, Heinemann A, Kelly J. Gender and age related role changes following brain injury. J Head Trauma Rehabil. 1995;10(4):14-27. Whiteneck G, Sendroy-Terrill M, Coll J, Brooks C. [Abstract] Long term outcomes after traumatic brain injury. Second Federal Inter-agency Conference on Traumatic Brain Injury, Bethesda MD: March 9-11, 2006. Whiteneck GG, Gerhart KA, Cusick CP. Identifying environmental factors that influence the outcomes of people with traumatic brain injury. J Head Trauma Rehabil. 2004;19:191204. Winkler D, Unsworth C, Sloan S. Factors that lead to successful community integration following severe traumatic brain injury. J Head Trauma Rehabil. 2006;21:8-21. Hoofien D, Vakil E, Gilboa,A, et al. Comparison of the predictive power of socio-economic variables, severity of injury and age on long-term outcome of traumatic brain injury: Sample-specific variables versus factors as predictors. Brain Inj. 2002;16:9-27. Teasdale TW, Engberg AW. Subjective well-being and quality of life following traumatic brain injury in adults: A long-term population-based follow-up. Brain Inj. 2005;19:10411048. Corrigan JD, Smith-Knapp K, Granger CV. (1998). Outcomes in the first 5 years after traumatic brain injury. Arch Phys Med Rehabil. 1998;79:298-305.
Post-TBI Aging and Life Satisfaction/Quality of Life: A Systematic Review by Gary A. Seale, MS,1 Beatriz Abreu, PhD 1,2
Results were mixed with respect to the first question, regarding the association between age and life satisfaction/ QOL. Age was not a predictor of life satisfaction at time of follow-up in five studies using the Satisfaction with Life Scale (SWLS),3,4,6,9,14 nor in two other studies, one using the LiSat II checklist7 and one the Life Satisfaction Index.8 Conversely, one study adopting the Life Satisfaction Index-A1 and two using measures of life satisfaction developed specifically for each respective study5,11 found that those who were older at the time of injury reported higher life satisfaction. Studies examining changes in life satisfaction over time were also mixed. Two studies3,12 demonstrated no change in life satisfaction over a brief period, while another study2 showed a significant change over time. In the latter study, life satisfaction declined in the first year after injury, then gradually increased up to year five. Of relevance here are additional findings from studies documenting change in aspects of functioning related to QOL. In one study, optimism was found to increase over time.12 In a second study, positive psychological growth (e.g., relating to others, personal strength, appreciation of life, spirituality) was documented in persons who were 10-12 years post injury, but not in those who were 1-3 years post injury.10 Finally, when life satisfaction/QOL was assessed using a measure of healthrelated QOL,13 younger people reported better health. From these studies, we concluded, with respect to the first question, that the measurement tool used and the duration of follow-up selected apparently influence whether a relationship is found between age and life satisfaction/QOL following TBI. With respect to the second question, some evidence was found that changes in positive emotion (e.g., optimism, psychological growth) take place over time following TBI. References 1. 2. 3. 4. 5.
6. 7.
In the last decade or so, increasing emphasis has been placed on life satisfaction, or quality of life, as a primary outcome measure following brain injury rehabilitation, particularly for programs providing post-acute services.1 Two questions were addressed in this systematic review: Does age at the time of injury predict life satisfaction? And, does life satisfaction/quality of life (QOL) change over time as a person ages with TBI? Of the large number of studies reviewed, only 14 met the inclusion criteria we adopted.1-14 Unfortunately, the studies examined did not provide definitive answers to the questions posed above.
8. 9. 10. 11. 12.
13. 14.
Burleigh SA, Farber RS, Gillard M. Community integration and life satisfaction after traumatic brain injury: Long-term findings. Am J Occupa Ther. 1998;52:45-52. Corrigan JD, Bogner JA, et al. Life satisfaction after traumatic brain injury. J Head Trauma Rehabil. 2001;16:543-555. Corrigan JD, Smith-Knapp K, Granger CV. Outcomes in the first 5 years after traumatic brain injury. Arch Phys Med Rehabil. 1998;79:298-305. Evans CC, Sherer M, Nick T, et al. Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury. J Head Trauma Rehabil. 2005;20:488-500. Heinemann AW, Whiteneck GG. Relationship among impairment, disability, and handicap, and life satisfaction in persons with traumatic brain injury. J Head Trauma Rehabil. 1995;10:54-63. Hicken BL, Putzke, JD et al. Life satisfaction following spinal cord and traumatic brain injury: A comparative study. J Rehabil Res and Devel. 2002;39:359-366. Johansson U, Hogberg H, et al. Participation in everyday occupations in late phase recovery after brain injury. Scand J Occupa Ther. 2007;14:116-125. Lee W, Wrigley MJ. Factors associated with life satisfaction among a sample of persons with neurotrauma. J Rehabil Res Devel. 1996;4:404-408. Pierce PS, Hanks RA. Life satisfaction after traumatic brain injury and the World Health Organization Model of Diability. Am J Phys Med. 2006;85:889-898. Powell T, Elkin-Wood A, et al. Post-traumatic growth after head injury: A long-term followup. Brain Inj. 2007;21:31-38. Siebert PS, Reedy DP, et al. Brain injury: Quality of life’s greatest challenge. Brain Inj. 2002;16:837-848. Tomberg T, Toomela A, et al. Changes in coping strategies, social support, optimism and health-related quality of life following traumatic brain injury: A longitudinal study. Brain Inj. 2007;21:479-488. Tomberg T, Toomela A, et al. Coping strategies, social support, life orientation and healthrelated quality of life following traumatic brain injury. Brain Inj. 2005;19:1181-1190. Wood RL, Rutterford NA. Demographic and cognitive predictors of long-term psychosocial outcome following traumatic brain injury. J Int Neuropsychol Soc. 2006;12: 350-358.
Transitional Learning Center, Galveston, TX University of Texas Medical Branch, Galveston, TX
1 2
BRAIN INJURY PROFESSIONAL
29
bip expert interview Ruth Brannon Former Research Director, National Institute on Disability and Rehabilitation
Why is aging with a TBI such an under-researched area? Until recently, TBI has been under-researched in every area despite the important work done by the CDC in the last decade to document that it is a high incidence/prevalence condition. Ther e have been many challenges in establishing basic diagnostic tools, treatments, and methods of measuring outcomes following TBI. TBI and its sequalae are complex conditions. That there has not been sufficient research on life span issues is not surprising. We have focused on saving lives and understanding TBI. Moving beyond this is a timing issue and will occur when there are clinical and human demands for solutions. With the many difficult problems facing individuals with TBI, including health, housing, transportation, communication, function, employment, just to name a few, aging issues haven’t risen to the top of the demand side of the equation. What is your understanding of the relationship between TBI and dementia? I’m aware of the various studies that have been done over the last 10 years or so on the potential relationship between Alzheimer ‘s and TBI. The findings about the relationship have been mixed so we don’t have definitive information; however, the conclusion that the cognitive consequences of TBI make it more difficult for people go cope with the onset of dementia is clear. Rehabilitation for individuals with TBI focuses on teaching compensatory skills, such as memory cues. Dementia would undermine an individual’s ability to recall and use such skills, undercutting the gains provided by rehabilitation and resulting in diminished quality of life for the individuals with TBI. How can the study of individuals with TBI as they aging inform our understanding of “normal aging”? To the extent that aging involves loss of both physical and mental functional abilities, individuals with TBI might be viewed as foreshadowing what might happen in the normal course of aging. Rehabilitation researchers have explored the possibility that disability contributes to early onset of numerous conditions that are normal part of the aging process but happen sooner to people with significant disabilities. Cognitive decline, onset of depression, agitation and other behavioral concerns, can all characterize individuals who are aging with TBI. Treatments and other interventions that work with individuals with TBI may provide benefit for elderly people who experience these symptoms. Are you aware of interventions that have been found to be effective in the elderly that may be useful treatments for individuals with TBI? Elderly individuals have higher rates of depression, cognitive decline, and reduced ability to carry out physical and nonphysical activities of daily living compared to nonelderly individuals. Individuals with TBI may experience the same things. Interventions aimed at improving these
30 BRAIN INJURY PROFESSIONAL
areas for elderly populations could well benefit individuals with TBI. Like the elderly, individuals with TBI often have multiple conditions, may use a variety of medications, and are at risk for numerous secondary conditions. The development of alternative therapies, such as use of movement or exercise, to reduce agitation or combat depression for the elderly population is one example of research being conducted for the elderly population with potential benefits for individuals aging with TBI. Similarly, interventions aimed at supporting elderly people to live in their homes, including fall prevention training, now the leading cause of brain injury across the age span. Why do you think the medical profession remains under-education about the potential long-terms of effects of a concussion the elderly? This question assumes that information on falls and concussion has been known for a long time; in fact, this is an evolving area of knowledge. Just this year, the CDC released a major study that documented the relationship between falls, death, and brain injury in the elderly. Fall prevention typically focuses on mitigating potential environmental hazards and predisposing factors such as muscle weakness, dizziness, and cognitive impairment. Falls resulting in brain injury can result in diminished cognition, contributing to risky behavior and more falls. Studies about this relationship are beginning to be more prevalent in the literature; however, translating this knowledge into clinical and nonclinical interventions will take time. It may well take even more time for the knowledge to be integrated into clinical training. The epidemiology of brain injury is evolving as falls in the elderly have become the leading cause of brain injury. This change will have an impact on research and treatment in the future. As indicated above, however, much research is needed to tailor existing rehabilitation strategies, mostly developed for younger individuals injured in motor vehicle accidents to a population with the confounding aspects of aging. What similarities may exist between the elderly and individuals with TBI regarding living in the community and maintaining economic security? Both groups experience challenges related to acquiring the personal and financial support needed to remain in their homes. Many persons with severe brain injury require personal assistance, often provided by family members. Elderly individuals have the same need and face the same problem of aging caregivers and limited societal support for this care. As our life span increases, more older people are seeking to remain in the workforce to stretch retirement savings and to maintain connection with others Individuals with severe brain injury have low rates of employment, but many seek jobs. As our society learns to accommodate an aging workforce, the benefit for individuals with TBI may be more acceptance and more accessibility which in turn may lead to more economic opportunity.
Lash &Associates Publishing/Training Inc. We make it easier to understand, help, treat and live with brain injury in children, adults and veterans. Aging With a Brain Injury By Mary Hibbard ~ 2006 Tip card on aging gives myths and facts about brain injury and Alzheimer’s disease, worsening memory and decision-making, repeated injuries, reliance on others and shortened life span.
The Memory Doctor By Doug Mason & Spencer Xavier Smith ~ 2005 Dr. Doug Mason clearly explains how memory works and the different types of memory that we use everyday. How we remember things is a process. By helping you understand and pay more attention to the steps of this process, you can improve your memory by using specific techniques.
Survival Kit A planner and organizer for survivors of brain injury and their families Into the Future By Debbie Leonhardt, MA ~ 2002 Planning care today for a secure life tomorrow This organizer was designed for persons with Comprehensive Rehab Consultants ~ 2003 brain injuries or other disorders affecting memory, This workbook helps families with the planning and organizational skills. difficult questions of‌ 9 Who will look after him when I am gone? All charts, checklists and organizers have been 9 How will future caregivers know what she designed to be user friendly. There are samples with written wants and needs? information that show how to use items. Survivors can use this kit in in-patient programs, out-patient programs, resi- 9 What is a guardian and how do I know if I need one? 9 What is the best way to plan financially and safeguard quality dential settings, at work, at home and in the community. of life?
For a free catalog visit our web site at www.lapublishing.com 708 Young Forest Drive, Wake Forest, North Carolina 27587-9040 (919) 562-0015 BRAIN INJURY PROFESSIONAL
31
legislative round-up Susan L. Vaughn, Editor, Legislative Issues “Defeat is not the worst of failures. Not to have tried is the true failure.” George Edward Woodberry
On September 17th, Congress on ways to capture the incidence and prevalence of the House passed returning troops with TBI. The Senate Subcommittee recommended a $2 million the Americans with Disabilities (ADA) increase for the National Institute on Disability and RehaAmendments Act to bilitation Research (NIDRR), and targets this increase to address employment support health and function research within NIDRR. The discrimination provi- Senate Subcommittee recommendations include language to sions, which over the restore funding for rehabilitation research and training centers years has been inter- (RRTC), including traumatic brain injury. Currently, there preted narrowly by the is only one RRTC on Community Integration of Individuals Supreme Court. The with Traumatic Brain Injury. During mid-September, Senators Hillary Clinton (D-NY) Senate passed the bill the week before and and Chuck Schumer (D-NY) sent a letter to the Centers for President Bush is ex- Medicare and Medicaid (CMS) urging CMS not to implepected to sign the bill. ment a proposed Medicaid regulation which narrows the The ADA has been in scope of outpatient services covered by Medicaid. The regulaexistence since 1990, tion is one of seven Medicaid regulations previously issued, and has been the impe- but it is the only proposed Medicaid regulation that was not tus for expanding access included in the moratorium passed within the supplemental to employment, telecommunications, public transportation, war appropriations bill (H.R. 2642) to delay implementation of six Medicaid regulations until April 2009. The other rules education and health care for individuals with disabilities. As the 110th Congress winds down its second session, relate to rehabilitation optional services, school-health related there are several major bills still pending. Advocates are still services and case management. The federal Medicaid law identifies outpatient hospital hoping that Congress will pass the mental health parity legislation before it recesses. Also unresolved are the appropriation services as a mandatory benefit and is defined as “preventive, bills that fund federal government. One of the primary func- diagnostic, therapeutic, rehabilitative or palliative services furtions of Congress is to pass spending bills Brain injury advocates are fortunate nished to outpatients.” The revised defi(12) to fund federal agencies and programs to have the Congressional Brain Injury nition of outpatient services would align the Medicaid definition of services more by the beginning of the new federal fisTask Force which provides informaclosely with the Medicare definition. cal year, which is October 1. In the event tion on brain injury to members of On July 15, 2008, H.R. 6331, the that spending bills are not enacted, ConCongress. The Task Force sponsors “Medicare Improvements for Patients gress will pass a Continuing Resolution(s) to provide funding authority to keep the Brain Injury Awareness Day activi- and Providers Act of 2008”, became Pubfederal government in operation until such ties in March, providing an excellent lic Law 110-275, after the House and Senate were successful in overriding the time the appropriation bills are enacted. opportunity for organizations to President’s veto of the bill. Sponsored Both the House and Senate Approprianetwork and advocate. by Reps. Charles B. Rangel (D-NY) and tions Subcommittees on Labor, Health and Human Services and Education have made their funding rec- John D. Dingell (D-MI) the law prevented the pending 10 ommendations for departmental programs for FY 2009. The percent reduction in Medicare payments for physicians and House Subcommittee’s bill includes an additional $2 million addresses preventive and mental health benefits. The new 111th Congress will be faced with a number of for the Department of Health and Human Services, Health Resources and Services Administration (HRSA) Federal TBI programs that need to be reauthorized. These include the ReState and Protection & Advocacy (P&A) Grant Program, habilitation Act and Workforce Investment Act; Developmenwhich is more than what the Senate Subcommittee has recom- tal Disabilities Assistance Bill of Rights Act; Substance Abuse mended. The House Subcommittee also recommends an in- and Mental Health Services Administration (SAMHSA); No crease for Centers for Disease Control and Prevention (CDC), Child Left Behind and the Individuals with Disabilities Eduwhich under the new TBI Act Reauthorization is to report to cation Improvement Act (IDEA). These laws authorize fund32 BRAIN INJURY PROFESSIONAL
ing and govern a number of programs and services for individuals with disabilities. Brain injury advocates are fortunate to have the Congressional Brain Injury Task Force which provides information on brain injury to members of Congress. The Task Force sponsors Brain Injury Awareness Day activities in March, providing an excellent opportunity for organizations to network and advocate. The Task Force has been supportive of funding for the Department of Defense, Veterans Administration, HRSA, CDC and NIDRR for brain injury prevention, surveillance, programs and research, as well as supporting the TBI Reauthorization Act. Well over 100 members of Congress serve on this Task Force.
Is your congressman/woman a member of the Congressional Brain Injury Task Force? If not, you may refer them to co-chairs, Reps. Bill Pascrell, Jr. (D-NY) and Todd Platts (R-PA). January, when the new Congress and Administration take office, is not that far off to begin work now on brain injury issues for the coming year. About the Editor
Susan L. Vaughn of S.L. Vaughn & Associates, consults with states on service delivery and serves as the Director of Public Policy for the National Association of State Head Injury Administrators. Ms. Vaughn retired from the State of Missouri after nearly 30 years, where she served as the first director of the Missouri Head Injury Advisory Council. She founded NASHIA in 1990, and served as its first president.
conferences 2009
2008 SEPTEMBER 18-21 – 7th Mediterranean Congress of Physical Medicine & Rehabilitation Medicine, Potorose, Slovenia. Contact: marincek.crt@mail.ir-rs.si. 24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr.co.uk. 24-27 – 6th World Stroke Congress, Vienna, Austria, Contact: www. kenes.com/stroke2008
MARCH 9-13 – 20th Anniversary of the International Center of Neurological Restoration (CIREN), Palacio de las Convenciones, La Habana, Cuba. Contact: rn2009@neuro.ciren.cu, on the web: www.ciren.ws. 12-13 – First International Conference on Culture, Ethnicity, and Traumatic Brain Injury Rehabilitation, Washington, D.C. For information about the conference and poster submissions contact Juan Carlos Arango, Ph.D., USA; jcarangolasp@vcu.edu, tel. 804 828-8797. MAY
OCTOBER 2-4 – The North American Brain Injury Society’s Sixth Annual Brain Injury Conference, New Orleans Convention Center Marriott, New Orleans, Louisiana. Contact: conference@nabis.org, or the web: www. nabis.org. 2-4 – The 21st Annual Conference on Legal Issues in Brain Injury, New Orleans Convention Center Marriott, New Orleans, Louisiana. Contact: conference@nabis.org, or on the web www.nabis.org. 15-19 – ACRM-ASNR Joint Conference, Delta Chelsea Hotel Toronto, Ontario, Canada. Contact: www.acrm.org. 22-25 – National Association of Neuropsychology Annual Meeting, New York, NY. Contact: www.nanonline.org.
7-9 – International Vocational Outcomes in Traumatic Brain Injury, Empire Landmark Hotel & Conference Centre, Vancouver BC Canada. (deadline for papers: 12/31/08). Contact: Shelley Johnson at 604-8751755 or on the web: www.tbicvancouver.com august 12-15 – MTBI 2009 – International Conference on Mild Traumatic Brain Injury, Vancouver, BC, Canada August 12 – 15, 2009. Contact: www. mtbi2009.org 27-30 – The First International Congress on Clinical Neuroepidemiology, Munich, Germany www.neuro2009.com. 2010
NOVEMBER 10-12 – Brain Injury Business Practice College, Westin Casuarina, Las Vegas, NV. Contact: www.biausa.org
8th World Congress of the International Brain Injury Association, USA (site pending announcement), Spring 2010. Contact: www.internationalbrain.org. MAY 23-27 - 17th European Congress on Physical Medicine & Rehabilitation, Venice, Italy. Contact: www.esprm.org. BRAIN INJURY PROFESSIONAL
33
non-profit news Brain Injury Association of America BIAA is pleased to announce the formation of the Brain Injury Business & Professional Council. The Council’s primary goal is to increase access to care through intensive lobbying, nationwide data collection and agreed-upon practice standards. Charter membership is open to rehabilitation facilities; individual membership will soon be available. The next Council meeting will take place in conjunction with BIAA’s Business Practices College, November 10-12, at the Westin in Las Vegas. Please visit www.biausa.org for more details on the Business Council and the Business College.
Brain Trauma Foundation The Brain Trauma Foundation is in the midst of exciting new developments aimed at helping soldiers suffering from Traumatic Brain Injury. BTF is currently developing an eye-tracking device for use in the field that can determine if a soldier has been subjected to a TBI. The device, funded through a grant from the Department of Defense, will have patients view a moving dot using virtual reality goggles, take readings of the eye reaction every millisecond and calculate the mean reaction time. According to BTF’s President, Dr. Jamshid Ghajar, “This should be able to give us a reading on TBI in 30 seconds. The fastest test available now takes 20 minutes.” For more information on this research and all BTF’s work, check our website regularly. In addition, Dr. Ghajar and his research were featured in a recent episode of NOVA scienceNOW on PBS which focused on brain trauma and aired in July. For more information on the segment, to view it, or to read Dr. Ghajar’s Ask the Expert Q&A, you may visit the NOVA site, or go to www.braintrauma.org.
International Brain Injury Association IBIA continues to make progress in planning the Eighth World Congress on Brain Injury scheduled for Spring 2010 in the United States. This will mark the first time the World Congress has been held in the USA. Ross Zafonte, MD, Chairman of the Department of PM&R at Harvard, is serving as President for the 2010 meeting and will be working with IBIA’s Scientific Planning Committee to build upon the overwhelming success of the most recent World Congress held in April of this year in Lisbon, Portugal. Brain injury professionals are reminded that membership in IBIA includes an annual subscription to IBIA’s official journal Brain Injury published by Informa Healthcare. The annual IBIA membership rate is only $250, which is a fraction of the cost non-members would pay to
34 BRAIN INJURY PROFESSIONAL
receive the journal. To learn more about IBIA or to join, visit www. internationalbrain.org.
North American Brain Injury Society Despite the recent storms in the Gulf of Mexico, the North American Brain Injury Society anticipates highly successful and productive gatherings of brain injury professionals at the 6th Annual Conference on Brain Injury and the 21st Annual Conference on Legal Issues in Brain Injury. We are pleased to report that this year for the first time, the accepted abstracts from the conference will be published in the Journal of Head Trauma Rehabilitation. Meetings and face-to-face interaction are vital for keeping up-to-date with the rapid advances in brain injury and the developments that are shaping our growing field, but for those of you unable to attend the NABIS meeting, we hope that the abstracts published in JHTR will at least give you a feel for our annual event and we hope that you will consider submitting your research for our 2009 meeting. Better yet, we hope that you will also consider becoming a member of our multidisciplinary society. We are currently planning a number of new initiatives and partnerships and encourage all brain injury professionals to visit www.nabis.org for more information.
National Association of State Head Injury Administrators There were over 200 people at NASHIA’s 19th Annual State of the States in Head Injury Conference in Williamsburg, VA. They enjoyed a wide variety of sessions on issues related to the development of TBI systems of care that address the needs of individuals with TBI and their families. Check out www.nashia.org to see the presentations from the meeting. FY 09 appropriations for the HRSA Federal TBI Program will once again be less than the $30 million that we feel is needed to meet the intent of the legislation. Be sure to contact your Congressional representative to have them join the Congressional Brain Injury Task Force and explain to them the need for more funds. NASHIA remains concerned about the influx of servicemembers with TBI. We are striving to increase awareness of how State systems of TBI services and supports will be utilized by this population. There are many innovative efforts underway by the States to ensure that servicemembers with TBI and their families receive the services and supports that they need. Check out the NASHIA website (www.nashia.org) to obtain the latest information on state systems development to meet the needs of individuals with brain injury and their families.
A Continuum of Care for Adults and Children with Brain Injuries.
Improving
Lives.
Locations throughout Southeastern Michigan.
Brain Injury Rehabilitation Programs Rainbow’s unique “Continuum of Care” approach to brain injury rehabilitation offers a variety of programs providing residential, day treatment and outpatient services for individuals of all ages. Our professional staff, specially trained in brain injury treatment, consistently provides understanding, supportive and progressive rehabilitation at every stage of the recovery process. To receive a free copy of Rainbow’s Brain Injury Rehabilitation “Continuum of Care” brochure call...
1.800.968.6644 Or log on to:
www.rainbowrehab.com
BRAIN INJURY PROFESSIONAL
35
36 BRAIN INJURY PROFESSIONAL