Mul6- occurring Disorders are From A - Z 3/9/15. Developing Competencies with Mul4- Occurring Condi4ons. Goals

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3/9/15 Developing Competencies with Mul4- Occurring Condi4ons Geoﬀrey Lauer, MA Execu6ve Director, BIA- Iowa Janine Rapp, BSW*, BIA- Iowa Creating a better future through brain injury prevention,

1 3/9/15 Developing Competencies with Mul4- Occurring Condi4ons Geoﬀrey Lauer, MA Execu6ve Director, BIA- Iowa Janine Rapp, BSW*, BIA- Iowa Creating a better future through brain injury prevention, education, research and advocacy. Goals Increase your understanding of complexity of brain injury Describe two of the many co- occurring disorders that ooen entangle with brain injury Be able to access and u6lize basic screening tools for depression, and substance abuse. Know where to turn for support in suppor6ng individuals with BI and other condi6ons. Mul6- occurring Disorders are From A - Z Athletes Foot Auto- Immune Condi6ons Brain Injury Diabetes Intellectual Disability Mental Health diagnoses Orthopedic Challenges Substance Abuse Zoster (Herpes) Virus Diabetes Substance Abuse Brain Injury Depression 1

2 3/9/15 Why this emphasis? Recent changes in Iowa law. It is helpful to the persons served. It is helpful to those of us serving. SF an Act rela4ng to the redesign of publicly funded mental health and disability services. May 9, 2012 Centralized Medicaid Created Regions Deﬁned designated disorders North West Iowa Care Connection Approved MHDS Regions Rolling Hills Community Services Lyon Sioux County Social Services Osceola Dickinson Emmet O Brien Clay Palo Alto Kossuth Winnebago Worth Mitchell Howard Floyd Chickasaw Butler Bremer Hancock Cerro Gordo Winneshiek Allamakee Fayette Plymouth Cherokee Buena Vista Pocahontas Humboldt Webster Ida Woodbury Sioux Rivers MHDS Monona Calhoun Sac Greene Carroll Crawford Wright Franklin Hamilton Hardin Grundy Boone Clayton MHDS of East Central Region Black Hawk Buchanan Delaware Tama Marshall Story Linn Benton Heart of Iowa Dubuque Jones Jackson Clinton Cedar Harrison Central Iowa Community Services Shelby Audubon Dallas Guthrie Polk Jasper Warren Marion Poweshiek Iowa Johnson Scott Muscatine Pottawattamie Adair Cass Madison Mahaska Keokuk Washington Eastern Iowa MHDS Louisa Southwest Iowa MHDS Mills Montgomery Adams Page Taylor Union Clarke Lucas Monroe Wapello Decatur Wayne Appanoose Jefferson Henry Des Moines Fremont Ringgold Davis Van Buren Lee Southeast Iowa Link Southern Hills Regional Mental Health Provisionally Approved Exempted Mid Iowa Polk County Rural Offices of Social Services South Central Behavioral Health January 1, 2015 SF 2315 shall include measures to address the needs of persons who have two or more co- occurring mental health, intellectual or other developmental disability, brain injury, or substance- related disorders and individuals with specialized needs 2

3 3/9/15 Depression Brain Injury Substance Abuse And more * Deﬁni6ons Brain Injury (Iowa) What is brain injury? Brain injury is ooen deﬁned as either a TraumaBc Brain Injury (TBI) OR Acquired Brain Injury (ABI) 3

3/9/15 Trauma6c Brain Injury TraumaBc Brain Injury (TBI) is an insult to the brain caused by an external force that may produce a diminished or altered state of consciousness.

Acquired Brain Injury Acquired Brain Injury (ABI) is an injury to the brain which is not hereditary, congenital or degenera6ve and has occurred aoer birth.

4 3/9/15 Trauma6c Brain Injury TraumaBc Brain Injury (TBI) is an insult to the brain caused by an external force that may produce a diminished or altered state of consciousness. Causes of TBI can include falls, motor vehicle crashes, sports injuries, assaults, blast injuries. Acquired Brain Injury Acquired Brain Injury (ABI) is an injury to the brain which is not hereditary, congenital or degenera6ve and has occurred aoer birth. Causes of ABI include anoxia, aneurysms, infec6ons to the brain, stroke, brain tumors. BRAIN INJURY - IOWA: Iowa Code: IAC (249A) - Brain injury means clinically evident damage to the brain resul6ng directly or indirectly from trauma, infec6on, anoxia, vascular lesions or tumor of the brain, not primarily related to degenera6ve or aging processes, which temporarily or permanently impairs a person s physical, cogni6ve, or behavioral func6ons. The person must have a diagnosis from the following list: Does not demand evidence from imaging Is not degenera6ve or aging related (n.d.). Retrieved March 3, 2015, from hips:// pdf 4

5 3/9/15 Malignant neoplasms of brain, cerebrum. Malignant neoplasms of brain, frontal lobe. Malignant neoplasms of brain, temporal lobe. Malignant neoplasms of brain, parietal lobe. Malignant neoplasms of brain, occipital lobe. Malignant neoplasms of brain, ventricles. Malignant neoplasms of brain, cerebellum. Malignant neoplasms of brain, brain stem. Malignant neoplasms of brain, other part of brain, includes midbrain, peduncle, and medulla oblongata. Malignant neoplasms of brain, cerebral meninges. Malignant neoplasms of brain, cranial nerves. Secondary malignant neoplasm of brain. Secondary malignant neoplasm of other parts of the nervous system, includes cerebral meninges. Benign neoplasm of brain and other parts of the nervous system, brain. Benign neoplasm of brain and othe parts of the nervous system, cranial nerves. Benign neoplasm of brain and other parts of the nervous system, cerebral meninges. Encephali6s, myeli6s and encephalomyeli6s. Intracranial and intraspinal abscess. Anoxic brain damage. Subarachnoid hemorrhage. Intracerebral hemorrhage. Other and unspeciﬁed intracranial heamorrhage. Occlusion and stenosis of precerebral arteries. Occlusion of cerebral arteries. Transient cerebral ischemia. Acute, but ill- deﬁned, cerebrovascular disease. Other and ill- deﬁned cerebrovascular diseases. Fracture of vault of skull. Fracture of base of skull. Other and unqualiﬁed skull fractures. Mul6ple fractures involving skull or face with other bones. Concussion. Cerebral lacera6on and contusion. Subarachnoid, subdural, and extradural hemorrhage following injury. Other and unspeciﬁed intracranial hemorrhage following injury. Intracranial injury of other and unspeciﬁed nature. Poisoning by drugs, medicinal and biological substances. Toxic eﬀects of substances. Eﬀects of external causes. Drowning and nonfatal submersion. Asphyxia6on and strangula6on. Child maltreatment syndrome. Adult maltreatment syndrome. Secondary Consequences of Brain Injury the CDC BIG THREE 1. Depression 2. Substance Abuse 3. Unemployment For another day A complex landscape Levin, H.S., & Robertson, C.S. (2013). Mild Trauma6c Brain Injury in Transla6on. J. Neurotrauma

3/9/15 Mental Health issues and Brain Injury It is es6mated that prevalence rates for co- morbid psychiatric disorders in ABI may be as high as 44% (Hibbard, et al, 1998).

way they think and how they act. Fortunately, it is also treatable. Medical condi6ons (e.g.

6 3/9/15 Mental Health issues and Brain Injury It is es6mated that prevalence rates for co- morbid psychiatric disorders in ABI may be as high as 44% (Hibbard, et al, 1998). Deﬁni6ons Depression Depression - APA Depression (major depressive disorder) is a common and serious medical illness that nega6vely aﬀects the way that people feel, the way they think and how they act. Fortunately, it is also treatable. Medical condi6ons (e.g., thyroid, a brain tumor or vitamin deﬁciency) can mimic symptoms of depression so it is important to rule out general medical causes. So you need a licensed provider to make this diagnosis. But YOU can screen 2015, American Psychiatric Associa6on 6

7 3/9/15 Depression Causes aoer BI Physical Changes in the brain Depression may result from injury to areas of the brain that control emo6ons. Changes in the levels of certain natural chemicals (neurotransmiiers) can cause depression. Depression Causes aoer BI Emo6onal Response to Injury Depression may arise as a person struggles to adjust to temporary or las6ng disability, losses or role change within their family or their communi6es. Depression Causes aoer BI Factors unrelated to injury Some people have a higher risk for depression due to inherited genes, personal or family history, and/or other inﬂuences that existed before the injury. 7

8 3/9/15 Why use a Screening tool? l To improve the iden6ﬁca6on of pa6ent's presen6ng with depression l Leads to addi6onal assessment of symptom severity and treatment. PHQ 2 Pre- Screening Tool for Depression Two (2) just two ques6ons to consider! 1.During the past month, have you oeen been bothered by feeling down, depressed, or hopeless? Yes No 2.During the past month, have you oeen been bothered by ligle interest or pleasure in doing things? Yes No. PHQ 2 - Screening and referral If the response is yes to either ques6on, consider referring to a LHCP for more considera6on for possible depression. If the response to both ques6ons is no, the screen is nega6ve. 8

9 3/9/15 PHQ 2 - Screening and referral The PHQ 2 Screening Tool for Depression One op6on for your toolbox A small addi6on to lead to connec6ng to other LHCP s Secondary Consequences of Brain Injury the CDC BIG THREE 1. Depression 2. Substance Abuse 3. Unemployment For another day 9

10 3/9/15 Deﬁni6ons Substance Abuse (DSM V) Criteria for Substance Abuse (DSM V) A maladap6ve paiern of substance use leading to clinically signiﬁcant impairment or distress, as manifested by one (or more) of the following, occurring within a 12- month period: 1. Recurrent substance use resul6ng in a failure to fulﬁll major role obliga,ons at work, school, or home 2. Recurrent substance use in situa,ons in which it is physically hazardous (e.g., driving an automobile or opera6ng a machine when impaired by substance use) 3. Recurrent substance- related legal problems 4. Con6nued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the eﬀects of the substance The symptoms have never met the criteria for Substance Dependence for this class of substance. Co- occurrence of Substance Abuse and TBI 10

11 3/9/15 Binge Drinking 1 Year aoer Hospitaliza6on for TBI [Horner, et al, 2005 (South Carolina Follow- up Study)] 60% 70% TBI (SCTBIFR) 40% 52% Gen'l Pop (BRFSS) 20% 22% 14% 26% 16% 0% none 1 or 2 3 or more # binging occasions last 30 days 70% 60% 50% 40% 30% 20% 10% 0% % Rehabilita6on Pa6ents with Prior Histories of Abuse 43% 54% 58% Alcohol 39% 34% 29% Other Drugs 48% 58% 61% Either TBI Model Systems Ohio State University University of Washington % Clients in Substance Abuse Treatment with Histories of TBI 70% 60% 50% 40% 30% 20% 10% 0% 63% 58% 53% 48% 38% Alterman & Tarter Hillbom & Holm Malloy, et al. Gordon, et al. (upstate NY) Gordon, et al. (NYC) 11

3/9/15 Ventricle to Brain Ra6o [from Bigler, et al., 1996 and Barker, et al., 1999] 4 3.5 3 2.5 2 1.5 1 0.

Screening for Alcohol and Drug Use CAGE AID is a commonly used, 5- ques6on tool used to screen for drug and alcohol use.

12 3/9/15 Ventricle to Brain Ra6o [from Bigler, et al., 1996 and Barker, et al., 1999] on C TB I Po ly ab us e TB I+ Po ly tr ol s l I ho TB A lc o I+ TB C on tr ol s 0 Tool for screening for Substance Abuse Brief Screening for Alcohol and Drug Use CAGE AID is a commonly used, 5- ques6on tool used to screen for drug and alcohol use. The CAGE Assessment is a quick ques6onnaire to help determine if an alcohol assessment is needed. If a person answers yes to two or more quesbons, a complete assessment is advised. 12

13 3/9/15 CAGE AID - Ques6onnaire hip:// 1. Have you ever felt that you ought to cut down on your drinking or drug use? 2. Have people annoyed you by cri6cizing your drinking or drug use? 3. Have you ever felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs ﬁrst thing in the morning to steady your nerves or get rid of a hangover? Risky use: 1 or less Substance use disorder: 2 or more Richard L. Brown, et. al., A Two- Item Conjoint Screen for Alcohol and Other Drug Problems. Journal of the American Board of Family Medicine, 25 July 2000, p Screening for Brain Injury Screening for Brain Injury For other providers to consider referral for need for addi6onal brain injury informa6on, services, supports or referral 1. HELPS screening tool hip:// screeningtool.pdf 2. OSU TBI ID method hips://osuwmcdigital.osu.edu/sitetool/ sites/ohiovalleypublic/documents/ OSU_TBIform_July2013.pdf 13

3/9/15 Screening for Brain Injury Name: Current Age: Interviewer Initials: Date: Ohio State University TBI Identification Method Interview Form Step 1 Step 2 Step 3 Ask questions 1-5 below.

14 3/9/15 Screening for Brain Injury Name: Current Age: Interviewer Initials: Date: Ohio State University TBI Identification Method Interview Form Step 1 Step 2 Step 3 Ask questions 1-5 below. Record the cause of each reported injury Interviewer instruction: If the answer is yes to any of the Interviewer instruction: Ask the following questions to help and any details provided spontaneously in the chart at the bottom questions in Step 1 ask the following additional questions identify a history that may include multiple mild TBIs and of this page. You do not need to ask further about loss of about each reported injury and add details to the chart below. complete the chart below. consciousness or other injury details during this step. I am going to ask you about injuries to your head or neck that you may have had anytime in your life. 1. In your lifetime, have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about. No Yes Record cause in chart 2. In your lifetime, have you ever injured your head or neck in a car accident or from crashing some other moving vehicle like a bicycle, motorcycle or ATV? No Yes Record cause in chart Were you knocked out or did you lose consciousness (LOC)? If yes, how long? If no, were you dazed or did you have a gap in your memory from the injury? How old were you? Have you ever had a period of time in which you experienced multiple, repeated impacts to your head (e.g. history of abuse, contact sports, military duty)? If yes, what was the typical or usual effect were you knocked out (Loss of Consciousness - LOC)? If no, were you dazed or did you have a gap in your memory from the injury? What was the most severe effect from one of the times you had an impact to the head? How old were you when these repeated injuries began? Ended? 3. In your lifetime, have you ever injured your head or neck in a fall or from being hit by something (for example, falling from a bike or horse, rollerblading, falling on ice, being hit by a rock)? Have you ever injured your head or neck playing sports or on the playground? Step 1 Cause Step 2 Loss of consciousness (LOC)/knocked out No LOC < 30 min 30 min-24 hrs > 24 hrs Dazed/Mem Gap Yes No Age No Yes Record cause in chart 4. In your lifetime, have you ever injured your head or neck in a fight, from being hit by someone, or from being shaken violently? Have you ever been shot in the head? No Yes Record cause in chart 5. In your lifetime, have you ever been nearby when an explosion or a blast occurred? If you served in the military, think about any combat- or training-related incidents. No Yes Record cause in chart Interviewer instruction: If the answers to any of the above questions are yes, go to Step 2. If the answers to all of the above questions are no, then proceed to Step 3. If more injuries with LOC: How many? Longest knocked out? How many 30 mins.? Youngest age? Step 3 Typical Effect Most Severe Effect Age Dazed/ Dazed/ LOC LOC LOC Cause of repeated injury memory gap, LOC memory gap, 30 min - Began Ended < 30 min > 24 hrs. no LOC no LOC 24 hrs. Adapted with permission from the Ohio State University TBI Identification Method (Corrigan, J.D., Bogner, J.A. (2007). Initial reliability and validity of the OSU TBI Identification Method. J Head Trauma Rehabil, 22(6): Reserved 2007, The Ohio Valley Center for Brain Injury Prevention and Rehabilitation (Continuation from reverse side, if needed) Name: Current Age: Interviewer Initials: Date: Step 1 Cause Step 2 Interpreting Findings Loss of consciousness (LOC)/knocked out Dazed/Mem Gap Age Loss of consciousness (LOC)/knocked out Dazed/Mem Gap A person Age may be more likely to have ongoing 30 min 30 min-24 hrs > 24 hrs problems if they have any of the following: No LOC < Yes No WORST One moderate or severe TBI FIRST TBI with loss of consciousness before age 15 MULTIPLE 2 or more TBIs close together, including a period of time when they experienced multiple blows to the head RECENT A mild TBI in the last weeks or a more severe TBI in the last months OTHER SOURCES Any TBI combined with another way that their brain function has been impaired If more injuries with LOC: How many? Longest knocked out? How many 30 mins.? Youngest age? Step 3 Cause of repeated injury Typical Effect Most Severe Effect Age Dazed/ Dazed/ LOC LOC LOC memory gap, LOC memory gap, 30 min - Began Ended < 30 min > 24 hrs. no LOC no LOC 24 hrs. For more information about TBI or the OSU TBI Identification Method visit: Ohio Valley Center at OSU BrainLine.org (Updated July 2013) 14

15 3/9/15 What the Brain Injury Alliance does: Programs and Services Educa6on Research Advocacy Policy and Legisla6ve Ini6a6ves Disability Leadership in Iowa Preven6on Else Brain Injury Alliance of Iowa Founded in 1981 by family members and friends of persons with brain injury, the Brain Injury Alliance of Iowa is a statewide membership organiza6on dedicated to providing educa6on, outreach, preven6on, advocacy and support services to all persons aﬀected by brain injury and to the general public. 15

Iowa Preven6on Else Resource facilita6on Resource facilitation is a

information, services and supports to make informed choices and meet their

Info & Resources Resource Facilitation Case Management From: Resource

16 3/9/15 What the Brain Injury Alliance does: Programs and Services Educa6on Research Advocacy Policy and Legisla6ve Ini6a6ves Disability Leadership in Iowa Preven6on Else Resource facilita6on Resource facilitation is a partnership that helps individuals and communities choose, get and keep information, services and supports to make informed choices and meet their goals. Info & Resources Resource Facilitation Case Management From: Resource Facilita6on: A Consensus of Principles and Best Prac6ces To Guide Program Development and Opera6on In Brain Injury, Brain Injury Associa6on of America,

17 3/9/15 Connec6ng to NRF Toll free number ( ) Local calls Links from BIA-Iowa Direct s (usually from referrals) Connections at presentations or meetings Walk-ins Registry For more informa6on BIA- Iowa

The new landscape for stroke research. Enrique Leira M.D., M.S. Associate Professor of Neurology University of Iowa PI: UIRCC StrokeNet

The new landscape for stroke research Enrique Leira M.D., M.S. Associate Professor of Neurology University of Iowa PI: UIRCC StrokeNet NIH Randomized Clinical Trials (RCT) POPULATION STUDY Provide best