Treating Traumatic Brain Injury
Falls can result in traumatic brain injury that can impair cognitive function and affect older adults' functional independence. Appropriate treatment can improve cognitive deficits and limit dysfunction.
The continuing pervasive concussion-related articles have focused increasing attention on the alarming consequences of concussion. However, concussions resulting from older adults' falls often go unnoticed or overlooked. Concussion frequently results in devastating cognitive changes that can negatively alter older adults' functional independence. Prevention of such injuries is, of course, the ultimate goal.
When a concussion-related accident occurs, however, it is critical to make the appropriate assessment and implement proper treatment. Keeping abreast of the professional services available in your area can help to provide the appropriate referrals that can result in optimal outcomes.
Margaret was looking up a long stairway. All she knew was that everything hurt, and she was surrounded by darkness. She recalled the event months later as she began to relate the story of her unfortunate accident that resulted in a concussion.
Margaret and her family had gone out for dinner to celebrate a special occasion, and she'd had some wine as part of the celebration. Later that night, she awakened and needed to use the bathroom. All she remembers is finding herself at the bottom of a staircase. She had stepped through the wrong doorway, mistaking it for the door to the bathroom, and toppled all the way down a flight of stairs. Fortunately, one of her daughters was in town and spending the night in Margaret's home. Her daughter called 911 and had her mother transported to the nearest emergency department (ED).
Some might say that Margaret was lucky, that it could have been worse. It probably could have, but recovering from injuries she sustained as a result of the fall took several months, at minimum. Surgery and other interventions for bone fractures and soft tissue injuries resulted in a good recovery.
The effects of the concussion Margaret sustained were another story. The effects of concussion can be life changing, even if an individual does not lose consciousness following impact.
People aged 75 and older suffer the highest rates of traumatic brain injury (TBI)-related hospitalizations and death. Rates of TBI-related ED visits in people aged 65 and older increased from 373 in 2001–2002 to 603 in 2009–2010. The proportion of TBI-related ED visits attributed to falls in this age group was 81%. During that same time period, the rates of TBI-related deaths in the over-65 age group increased from 41.2 per 100,000 to 45.2 per 100,000. Between 2006 and 2010, falls accounted for 54.4% of deaths in those aged 65 and older. When injury type was considered, falls were also responsible for the greatest proportion of hospitalization in the over-65 age group.1
Particularly for older adults like Margaret, it's fortunate that concussion has been highlighted in the news more frequently in the past few years. Perhaps a new awareness of potentially life-changing effects will influence delivery of care.
Many people recognize that contact sports are major culprits in the occurrence of concussion. However, any of us, including those whose days on the playing fields have passed, could sustain a brain injury in the course of completing our daily routines. It can be useful to consider information regarding prevention and treatment of brain injury in the retirement-aged population.
Fall Prevention Is Key
We tend to become attached to our home décor, which creates a comfortable environment. Unfortunately, some creature comforts pose risks. Throw rugs sometimes slide underfoot, or their edges cause people to trip over them. Furniture and other fixtures can interrupt clear pathways in the home and interfere with navigation. Vision changes with aging, and more lighting becomes necessary. Personal items such as books, shoes, and clothing, if placed carelessly, become potential obstacles.
Occupational therapists are professionals who are trained to evaluate home safety, especially in the context of an individual's unique health needs. It is often possible to have a person's home environment assessed by an occupational therapist so that appropriate modifications can be made to improve safety. In order to qualify for this intervention, a patient must have a condition that necessitates evaluation. Potential diagnoses include visual impairment and physical impairment that interferes with mobility and independence.
Various health conditions can potentially compromise an individual's ability to ambulate safely in the home and in public places. Such conditions include visual impairments; changes in judgment and attention; balance impairments; sensory impairments, such as neuropathy; musculoskeletal injury; decreased endurance; and drug effects, including alcohol use.
Studies that have been conducted with older adults in nursing facilities and in their own homes have determined that exercise regimens, especially those that address balance and strength, have yielded the best results. Other practices that have been found to reduce fall rates in some cases include reduction of psychotropic medications, vitamin D supplementation, and patient education.2
Some of the symptoms of mild TBI include persistent low-grade headache; difficulty remembering, concentrating, or taking in new information; fatigue; sleeping more or less than usual; increased sensitivity to light and/or sound; sensory changes; and mood changes.
More severe brain injury may result in additional symptoms, including onset of seizures, nausea/vomiting, dilatation of one or both pupils, speech changes, extremity weakness or incoordination, headache that worsens/persists, and confusion/restlessness/irritability.
When patients are treated and released from the ED, follow-up with the patient's primary care physician and/or neurologist is typically recommended. This protocol should be observed. Concussion sufferers may not associate their mental fogginess, patchy memory, or changing sleep patterns with the recent bump on the head. Reevaluation is appropriate to determine whether a patient has resumed activity that is normal for him or her. A patient who lives alone is at greater risk, as he or she may sometimes ignore functional changes, whereas a spouse or others in the same living space may notice such changes.
Concussion and TBI are diagnoses that are accepted by most third-party providers. In addition to the primary care provider, professionals who might become part of a treatment team include neurologists, orthopedic specialists, psychiatrists, ophthalmologists, speech-language pathologists, occupational therapists, and physical therapists. Assessment by a neuropsychologist is often warranted to obtain comprehensive information regarding a patient's cognitive status.
In optimal settings, options available on the care continuum would include acute care hospitalization, inpatient rehabilitation, long term care and home care. Not all patients require acute hospitalization, so some of these steps can be omitted. Access to care varies, depending on geographic location, insurance coverage, and socioeconomic status.
When in doubt regarding specialized services, contact the Brain Injury Association of America (BIAA). This organization provides training through the Academy of Certified Brain Injury Specialists and confers certification upon qualified individuals. A network of chartered state affiliates provides resources for brain-injured individuals and their care providers. By contacting the BIAA, state affiliates can be located. More information is available at www.biausa.org.
Following a fall involving brain injury, usually among the first problems to be detected are orthopedic injuries and other injuries that compromise patients' mobility and activities of daily living functions. These are typically addressed in a rehabilitation program provided by occupational and/or physical therapy. While balance impairments are typically addressed by a physical therapist, vestibular disorders require specialized evaluation and treatment. The Vestibular Disorders Association website (www.vestibular.org) provides information regarding these impairments and the professionals who are trained to evaluate and treat them.
Treating Brain Injury
Ideally, a spouse or family member will accompany a patient to outpatient treatment sessions in order to facilitate the carryover of recommendations. Generally, a treating clinician will discuss treatment plans with a patient to establish appropriate functional goals.
Margaret was a successful business owner. She was in her mid-80s at the time of her accident. Her attention/concentration skills were compromised. Most brain injury survivors complain of the inability to multitask. She was no exception. She reported that she was sometimes missing turns when driving, or having to think carefully about driving routes that she would have previously navigated automatically.
During one treatment session, she mentioned that she had taken a business call on her way to the appointment and lost track of where she was on her route. This was an easy fix: Phone use while driving is unacceptable under any circumstances. Margaret was advised to avoid phone use while driving. If she needed to answer her phone or make a call, she should pull off the road when possible, turn off her engine, and use her phone.
Drivers who utilize a mobile phone are approximately four times more likely to be involved in a crash than drivers who do not use a phone while driving, according to data provided by the World Health Organization. The organization cannot provide conclusive evidence to show that hands-free phoning is any safer than hand-held phoning, as cognitive distraction is a factor in both instances.3 Remind patients always to use cell phones only when a car is stopped and parked.
Another change Margaret reported was the difficulty recalling what she had read. She had belonged to a book group for several years. Recently she was noticing that she could no longer recall all of the characters in a novel or the details of the plot, as had been typical previously. She received assistance with developing a plan for reading shorter segments, taking notes if necessary, and reviewing details when she stopped reading. She was a visual learner, so she developed her own visual imagery that assisted with the recall of content.
Margaret also became prone to forgetting some of the necessary items when she went out to run several errands. She benefitted from coaching to pause and think carefully about each stop on her route, and to review the items required for each location. For example, she focused on the grocery list and her canvas tote bags, a written prescription to drop off at the pharmacy, and letters to be mailed. She also learned ways to keep track of various tasks she needed to complete. Listing these in categories and then plotting them into her busy schedule resulted in more reliable and timely completion.
She was particularly motivated to improve her functional competence. That trait, combined with her premorbid level of intelligence, contributed to her success. Margaret was confident that she could resume familiar activities. She was able to implement the recommended strategies independently. In fact, most became second nature because she practiced them regularly. Hers was as close to an ideal scenario as possible. It was likely that her good health at baseline contributed to both the relatively limited cognitive impairments as well as her ability to manage her deficits.
Unfortunately, the cognitive changes he experienced went mostly unnoticed, so he did not receive treatment. At times, he made some mildly inappropriate comments. His memory became a bit less reliable, and he failed to initiate the way he had previously. Prior to this accident he had frequently participated in the organized activities within his facility. After the fall, he rarely went from one place to another without encouragement. He had been an avid reader but lost interest in newspapers and books. Another likely result of the blow to his head was his lack of insight regarding his injury; that is, he demonstrated no awareness of his own cognitive changes.
Perhaps staff attributed Gordon's behavioral changes to aging. He was, after all, in his 90s and somewhat frail. His quality of life could likely have been improved with a treatment program that enlisted staff to help him to use strategies to enhance orientation, memory, and attention. Volunteers could have been enlisted to cue him to attend and/or to accompany him to preferred activities. Volunteers might also have read to him or provided audio books if attention to written information was too taxing. Written reminders may have helped with tracking the day of the week, and the time and location of activities.
Joan also had some premorbid health conditions, including diabetes, elevated blood pressure, anxiety, and depression. She had a particularly troubled relationship with her spouse, so support for implementation of strategies was not available. Her husband was invited to attend treatment sessions but chose not to.
Due to her emotional status, Joan had difficulty identifying and describing cognitive changes that had resulted from her concussion. Following assessment and extensive interview, memory and organization deficits became apparent. Unfortunately, little could be done to help Joan compensate for cognitive changes. She missed appointments because of her difficulty with organization. She slept poorly, and this sometimes resulted in oversleeping, contributing to missed appointments. The stress she experienced related to her primary relationship negatively influenced her recovery as well.
— Deborah Crabbs MacDonald, MS, CCC-SLP, CBIS, is a speech-language pathologist who treats outpatients in Massachusetts. She is a certified brain injury specialist.
2. Kiel. DP. Falls: prevention in community-dwelling older persons. UpToDate website. http://www.uptodate.com/contents/falls-prevention-in-community-dwelling-older-persons
3. Mobile phone use: a growing problem of driver distraction. World Health Organization website. http://www.who.int/violence_injury_prevention/publications/road_traffic/distracted_driving_summary.pdf
Brain Injury Prevention Recommendations for Older Adults
• Stay active. A physician-approved exercise program including strength and balance work is ideal.
• Ensure the home environment has clear paths for walking.
• Repair/replace handrails as needed.
• Install light switches at the top and bottom of stairways.
• Use ample lighting; replace light bulbs as needed.
• Keep frequently used household items within easy reach.
• Have vision checked at least once a year.
• Review medications regularly.