Arizona Department of Health Services Division of Behavioral Health Services (ADHS/DBHS) Traumatic Brain Injuries

Transcription

1 Arizona Department of Health Services Division of Behavioral Health Services (ADHS/DBHS) Traumatic Brain Injuries May 2011

2 Anatomy of the Brain

3 Introduction The Department of Health decided to increase its focus on the coordination of care for individuals and families dealing with mild to moderate Traumatic Brain Injuries. Reasons for the Project: 1. Mild-Moderate TBI members were being missed diagnosed 2. Poor Coordination of Care 3. Lack of knowledge regarding this special population

4 E-Learning for BH Providers Accessible e-learning to increase the TBI knowledge of behavioral health providers within Arizona s public mental health system. The disciplines of focus will include case management, clinical staff, and medical staff. Goals: To promote diagnostic expertise among providers who evaluate and assess individuals with BH disorders and co-morbid TBI To Increase the understanding of the cognitive, physical, and behavioral aspects of TBI To diagnose TBI accurately and in a timely manner To review neuro-anatomy related to TBI

5 Goals (continued) To improve health related outcomes for patients with TBI To reduce morbidity from TBI To increase RBHA providers ability to work with consumers and families who live with TBI To increase the RBHA providers understanding of the pharmacological management of TBI and its sequelae. To improve RBHA management of patients with TBI and thereby improve patient outcomes To identify the critical decision points in management of patients with TBI

6 Goals (continued) To appropriately assess and identify those patients who present with symptoms following a TBI or other consequences of head injury To identify those patients who may benefit from early intervention and treatment to prevent future complications from TBI To identify those patients who may benefit from further assessment, brief intervention and /or ongoing treatment

7 E-Learning Modules 1. Epidemiology of Injury and Pathophysiology 2. Neuroanatomy ~ Neurodevelopmental Implications 3. Post-Acute / Chronic Sequelae & Screening 4. Concussion Management: Sequelae & Mild TBI 5. Life After TBI & Impact on the Family 6. Substance Abuse & TBI 7. Depression & TBI 8. Other Issues (Referrals, resources, etc )

8 Statistics The Centers for Disease Control and Prevention (CDC) has estimated that each year: Approximately 1.5 million Americans survive a traumatic brain injury (TBI), among whom approximately 230,000 are hospitalized. Approximately 50,000 Americans die each year following traumatic brain injury, representing one third of all injury-related deaths.

9 Statistics (cont.) The leading causes of TBI are: Falls (28%), Motor vehicle-traffic accidents (20%), Struck by/against events (19%) and assaults (11%). It is estimated that of the total reported TBIs, the vast majority (75%- 90%) of these fit the categorization of mild-tbi and that approximately ninety percent ( 90%) of these follow a predictable course and experience few, if any, ongoing symptoms and do not require any special medical treatment. More than 1.1 million patients with TBI are treated and released from an emergency department each year. Only a small sub-set of these patients (10%) experience post-injury symptoms of a long lasting nature.

10 Traumatic brain injury is classified as a public health epidemic in America. Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: A Report to Congress. (January 16, 2001).

11 The number reported with TBI underestimates the magnitude of the problem because the following are not included in those estimates: Those treated by private physicians. Those treated in private clinics, and urgent care centers. Individuals who did not seek medical care.

12 TBI and Military Population TBI is more frequent in Iraq and Afghanistan than in prior wars Nature of the warfare IED, rocket propelled grenade, suicide bombers, etc. Improved protective gear Kevlar helmets and body armor Improved military medicine

13 The recent RAND Center for Military Health Policy Research Invisible Wounds of War - Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery report on OIF/OIE veterans, discussed that of the1.64 million service members who have been deployed for OIF/OIE as of October 2007, they estimate that 300,000 individuals currently suffer from PTSD or major depression and that 320,000 individuals experienced a probable TBI during deployment.

14 The report further discussed that Of those reporting a probable TBI, 57 per cent had not been evaluated by a physician for brain injury Some specific groups that were understudied (e.g. Reserve Components, those who left military service) may be at higher risk for suffering from these conditions.

15 Glasgow Coma Scale Motor Responses Verbal Responses Eye Opening Total Score possible =3-15

16 Glasgow Coma Scale Coma is defined as: (1) not opening eyes, (2) not obeying commands, and (3) not uttering understandable words. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories.

17 Severity Grades of TBI Mild ( Grade 1) Moderate (Grade 2) Severe ( Grade 3 and 4) Altered or LOC, <30 min. with normal CT and/or MRI LOC< 6 hours with abnormal CT and/or MRI GCS GCS 9-12 GCS<9 LOC> 6 hours with abnormal CT and/or MRI PTA < 24 hours PTA <7days PTA>7 days

18 Diagnostic Criteria TBI(mild) 1. Traumatically induce physiologic disruption of the brain as indicated by at least one of the following: A. Any period of loss of consciousness B. Any loss of memory of events immediately before or after the accident C. Any alteration in mental state at the time of accidents D. Focal neurologic deficits that may or may not be transient

19 Diagnostic Criteria cont d. 2. Severity of the injury does not exceed: A. Loss of consciousness of 30 min. B.GCS score of after 30min. C. Post-traumatic amnesia of 24 hours

20 Mild TBI Approximately 80% of patients who sustain TBIs had a mild TBI(Alexander,1995). MTBI is believed to result when injury triggers the pathologic neuro-chemical cascade, but is insufficient to produce widespread neuronal dysfunction or the axonal disruption that characterizes more severe brain injuries. The majority make excellent recovery but many have persistent and disabling symptoms.

21 Primary Injuries Diffuse Axonal Injury (DAI): Results from rotational acceleration deceleration forces. DAI can actually be observed in histological specimens, it is also inferred from neurological symptoms in the absence of abnormal findings or in the presence of WM changes. Focal Lesions: subdural/epidural/subarachnoid/ ICH and cortical contusions.

22 Secondary Injury Following the initial injury to the brain, mechanisms of cellular response and metabolic cascades are set in motion. There are increases in amino acids (glutamate, neurotoxic free radicals, increased Ca++, and lipases). Hypoventilation or elevated ICP can lead to secondary hypoxic injury.

23 Functional Correlates of Injury Pathophysiology Injury Usual Cause Deficits Focal Cortical Contusions Diffuse Axonal Injury Hypoxic/ Ischemic Grand Level Fall( GLF), Assault, Gunshot wound MVA, Non-ground level fall Hemiparesis,Aphasia, seizures, Visuoperceptual Confused language,amnesia, Apraxia, Hypoarousal Quardraparesis, Spasticity, Confusion, Amnesia, Hypoarousal.

24 AAN: Level of Concussion Grade 1: Transient confusion, No loss of consciousness Grade 2: Transient confusion, no loss of consciousness, concussion symptoms or mental status abnormalities on examination last more than 15 minutes Grade 3: Any loss of consciousness, either brief (seconds) or prolonged ( minutes).

25 Frequency of PCS in TBI(mild) Symptoms Percent of patients Percent of People in the General Population Poor concentration 71% 14% Irritability 66% 16% Tired of lot more 64% 13% Depression 63% 20% Memory problems 59% 20% Headaches 59% 13% Anxiety 58% 24%

26 TBI Screening The assessment of TBI is complicated by co-morbid behavioral health diagnosis. Example, Depressive symptoms and Traumatic psychological issues can cloud the identification and assessment of traumatic brain injury symptoms. Early identification and intervention is imperative in the recovery and stabilization of TBI symptoms. Historically, Behavioral Health training programs do not put a great deal of focus on Traumatic Brain Injury Symptoms. Clinical Care systems have a tendency to provide assessment and interventions for severe TBI disorders and not the less severe. Nevertheless, these mild to moderate disorders have significant behavioral, physical and cognitive complications.

27 Misdiagnosis or Missed Diagnosis Evidence of minor cerebral injury is typically absent from the standard neurological examination, CTScans, and EEGs BUT ABSENCE OF EVIDENCE IS NOT PROOF OF ABSENCE. Differential Diagnoses: Post-concussion syndrome vs. PTSD PCS vs. MDD PCS Vs Malingering

28 There is a potential for symptoms to be dismissed, rejected, misdiagnosed, or misunderstood due to a delay in the manifestations of some of the symptoms and the similarities to mental illness. Individuals may be presenting with possible psychiatric illnesses where brain injury is really the underlying cause or driving the illness. Cognitive changes following brain injury may impair the individual s ability to access and use cognitive behavioral strategies.

29 Cognitive, emotional, and/or behavioral challenges after brain injury can result in referrals to systems and services that do not have adequate knowledge, understanding, training, and/or experience working with individuals with brain injury and their families. This may result in: inappropriate evaluations, assessments and treatment; inaccurate assessment of response to treatment; exacerbation of symptoms; Inappropriate medications or overmedication; Substance abuse.

30 Medical Treatments for Mild TBI T Non-medications treatments: Focus on cognitive behavioral model of symptom maintenance with relaxation, reduction in symptoms and resumption of pre-morbid activities.

31 Behavioral Health: Pharmacotherapy Brain injured patients are more sensitive to side effects: watch closely for toxicity and drug-drug interactions. Limit quantities of medications with high risk for suicide as the suicide rate is higher in this population. Educate patients and family/care givers to avoid the use of alcohol with the medications. Minimize caffeine and avoid herbal, diet supplements such as energy products as some contain agents that cross-react with the psychiatric medications and lead to a hypertensive crisis. Avoid medications that contribute to cognitive slowing, fatigue or daytime drowsiness

32 Behavioral Health: Pharmacotherapy Considerations for use of medications in TBI: avoid medications that lower the seizure threshold (e.g., bupropion or traditional antipsychotic medications) or those that can cause confusion (e.g., lithium, benzodiazepines, anticholinergic agents). before prescribing medications, rule out social factors (abuse, neglect, caregiver conflict, environmental issues). unless side effects prevail, give full therapeutic trials at maximal tolerated doses before discontinuing a medication trial. Under-treatment is common. Start low and go slow with titration.

33 Screening Instruments DBHS has identified two screening instruments to use in AZ behavioral health system -- HELPS and OHIO State University s TBI Identification Method. HELPS is for those with little or not knowledge of TBI and is administered by reading the following questions to the client: (H) Did you ever hit your head? Were you ever hit on the head? (E) Were you ever seen in an emergency room? (by a doctor or hospitalized?)

34 (L) Did you lose consciousness? For how long? (P) Did you have any problems after you hit your head? ( posttraumatic amnesia; headaches, pain, dizziness, or loss of balance; changes in behavior; irritability or impulsivity; memory problems; motor or sensory problems; other stressors that may interfere with optimum functioning; difficulties in school or work performance; and changes in relationships with family or friends) (S) Any other significant sickness? (e.g., hospitalizations for brain cancer, meningitis, stroke, heart attack; domestic violence or repeated shaking as a child) One point is scored for every question answered "yes." If the client scores two or more points, and particularly if the client's functioning has been affected (P), then there exists a sign of possible injury and the need for a more extensive interview and medical work-up (Picard et al., 1991).

35 HELPS HELPS was designed to be used by professionals whose primary field of practice is other than TBI (chemical dependency counselors, law enforcement officials, state vocational rehabilitation counselors, physicians, and teachers).

36 Screening The Ohio State University TBI Identification Method (OSU TBI-ID) is a standardized procedure for eliciting lifetime history of TBI via a structured interview based on CDC recommendations for surveillance of TBI.

37 The OSU TBI-ID provides data for calculating summary indices reflecting the likelihood that consequences have resulted from lifetime exposure to TBI. Summary indices from the OSU TBI-ID can be used in both research and clinical care. Versions have been developed that vary in length; and it can be customized for clinical screening, treatment planning, system administration or research applications.

38 Goals: Referral Pathways To develop local referral pathways to Medical Providers and Allied provider within the system effective coordination of care is the goal. Coordination of care includes PCPs, neurologists, speech and hearing specialists, physical rehabilitation specialists, pain specialists, driving skills evaluators, etc. To improve the quality and continuum of care for patients with TBI.

39 Possible Referrals for TBI Audiologist Kinesiotherapist Neuro-opthalmologist Occupational therapist Physical therapist Recreation therapist Speech and Language Pathologist Case manager Neurologist Neuropsychologist Physiatrist Psychiatrist Social worker Vocational Rehab. Counselor

40 E-Learning Module Sample 8 Modules Online Self paced Interactive Pre and Post Tests CMEs

41 Help! Currently looking for medical and psychological professionals to help TEST Module 2 online. Please Claudia Sloan at sloanc@azdhs.gov or provide your name and address today if you would be interested in reviewing this module.

42 Questions?