Epidemiology and Outcome of Brain Disorders & Damage Across the Life Span: Some Notes. Vincent W. Hevern, SJ, Ph.D. 2016

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1 Epidemiology and Outcome of Brain Disorders & Damage Across the Life Span: Some Notes Cerebrovascular Disease or Stroke Vincent W. Hevern, SJ, Ph.D A. Epidemiology of Brain Disorders & Damage Number of adults who ever had a stroke: 6.3 million % of adults who ever had a stroke: 2.6% Deaths: 133,103 (41.7/100K; 2014) From 2001 through 2011, the rate of emergency department visits for ischemic stroke or transient ischemic attack (TIA) decreased 35% for patients aged 18 and over and 51% for patients aged Alzheimer s disease An estimated 5.4 million Americans of all ages have Alzheimer s disease in This figure includes 5.2 million people age 65 and older and 200,000 individuals under age 65 who have younger-onset Alzheimer s. Nursing home residents: 50.4% (2014) Home health agency patients: 31.4% (2013) Deaths: 93,541 (29.3/100K; 2014) The age-adjusted death rate from Alzheimer's disease increased by 39 percent from 2000 through 2010 in the United States. Alzheimer's disease is the sixth leading cause of death in the United States and is the fifth leading cause among people aged 65 years and over. People aged 85 years and over have a 5.4 times greater risk of dying from Alzheimer's disease than people aged years. Brain/CNS Tumors Note: Incidence (the probability of occurrence [new cases] of a given medical condition in a population within a specified period of time) should not be confused with prevalence, which is the proportion of cases in the population at a given time rather than rate of occurrence of new cases. Thus, incidence conveys information about the risk of contracting the disease, whereas prevalence indicates how widespread the disease is. (Wikipedia)

2 2 Types of Tumors Primary Benign Malignant Secondary (Metastatic Malignant) Glial Tumors (Primary CNS tumors) Astrocytic [Astrocytomas] (most frequent) o Grade I, II o Grade III Anaplastic astrocytoma o Grade IV Glioblastoma multiforme Ependymal: Cells that line the cerebral ventricles Oligodendroglial Mixed Medulloblastoma "Medulloblastoma is a rapidly growing tumor arising in the posterior fossa and is found almost exclusively in children and young adults" Non-glial Tumors Pineal Germ cell Craniopharyngioma Meningioma: "Meningiomas arise from the meninges surrounding the brain and spinal cord and are generally slow-growing...usually curable with surgery." (Adult Brain Tumors, 2003) Choroid plexus: "rare tumors arising from choroid plexus epithelial cells" The incidence rate of all primary malignant and non-malignant brain and CNS tumors is 22/100K for a total count of 356,858 incident tumors (7.23/100K for malignant tumors for a total count of 117,023 incident tumors and 14.75/100K for non-malignant tumors for a total count of 239,835 incident tumors). The rate is higher in females (23.95/100K for a total count of 206,565 incident tumors) than in males (19.82/100K for a total count of 150,271 incident tumors). An estimated 77,670 new cases of primary malignant and non-malignant brain and CNS tumors are expected to be diagnosed in the United States in This includes an estimated 24,790 primary malignant and 52,880 nonmalignant that are expected to be diagnosed in the US in Average annual death rate in US was 4.31/100K (with 71,831 deaths due to primary malignant brain & CNS tumors in that period). Estimated 16,616 deaths in Lifetime risk of diagnosis = 0.62% [males =0.69%; females = 0.55%] (excludes lymphomas, leukemias, tumors of pituitary & pineal glands or olfactory tumors) Lifetime risk of death = 0.46% (males = 0.51%; females = 0.41%)

3 3 Age Incidence Rate/100K Count New Cases years ,366 4, years ,113 4,620 (2015) years ,083 10,390 The five year relative survival rate in the US following diagnosis of a primary malignant brain and CNS tumor (including lymphomas and leukemias, tumors of the pituitary and pineal glands, and olfactory tumors of the nasal cavity) is 34.4% (31.7% for males and 34.4% for females) ( data). Five-year survival rate after diagnosis with primary malignant brain & CNS tumor changes with age (and type of tumor) o 0-19 years: 73.6% years: 17.9% o years: 59.0% years: 10.8% o years: 32.1% 75 years+: 6.1% Five-year relative survival after diagnosis with a non-malignant brain/cns tumor is 91.9% in the US Traumatic Brain Injury ( A TBI is defined as damage to the brain caused by an external force as evidenced by altered consciousness and impairment of brain functioning ) In million TBIs occurred either as an isolated injury or along with other injuries. By 2016, the estimated number was 1.56 million who required medical attention. In 2010, about 2.5 million emergency department (ED) visits, hospitalizations, or deaths were associated with TBI either alone or in combination with other injuries in the United States. TBI contributed to the deaths of more than 50,000 people. TBI was a diagnosis in more than 280,000 hospitalizations and 2.2 million ED visits. These consisted of TBI alone or TBI in combination with other injuries. Over the past decade ( ), while rates of TBI-related ED visits increased by 70%, hospitalization rates only increased by 11% and death rates decreased by 7%. In 2009, an estimated 248,418 children (age 19 or younger) were treated in U.S. EDs for sports and recreation-related injuries that included a diagnosis of concussion or TBI.3 From 2001 to 2009, the rate of ED visits for sports and recreation-related injuries with a diagnosis of concussion or TBI, alone or in combination with other injuries, rose 57% among children (age 19 or younger) Causes of TBI: Falls (40.5%); Stuck by/against objects (15.5%); Motor vehicle traffic (14.3%), Unknown/other (19.0%) o More than half (55%) of TBIs in children 0-14 yo were caused by falls o More than 2/3rds (81%) of TBIs in adults aged 65+ were caused by falls Rates of TBI-related deaths decreased for both men and women between the years During these ten years, rates in men decreased from 27.8 to 25.4 per 100,000 and rates in women decreased from 9.6 to 9.0 per 100,000. In each year, men had more than twice the rate of TBI-related deaths compared to women. Death Rates for TBI by age

4 4 0 4 yr 5 14 yr yr yr yr 65+ yr Sequelae to Traumatic Brain Injury (TBI) Moderate to Severe TBI Five Year Outcomes (16yo+) who received in-patient rehabilitation based on data fro the NIDRR s Traumatic Brain Injury Model Systems o 22% died o 30% became worse o 22% stayed the same o 26% improved Life expectancy is decreased an average of 9 years. Seizures 50s more likely; accidental drug poisoning 11x more likely; infections 9x more likely; & pneumonia 6x more likely. Five years after surviving moderate to severe TBI o 57T are moderately or severely disabled o 55% do not have a job (but were employed at the time of injury) o 50% return to the hospital at least once o 33% rely upon others for help with everyday activities o 29% use illicit drugs or misuse alcohol o 12% reside in nursing homes or other institutions Effects (in RTC) o children who sustain a moderate-to-severe TBI before the age of 7 years have substantially worse short- and long-term outcomes than children who suffer a similar injury at an older age (RTC) children are more likely to display post-traumatic brain swelling, hypoxicischemic insult, and diffuse, rather than focal, injuries. (Kirkwood et al, 2010, p. 299). o Behavioral changes and problems in adaptive functioning (i.e., coping skills) are the most persistent negative impacts of TBI in children (RTC) Partial cognitive recovery is often seen within the first months of injury, although longitudinal work demonstrates a plateau after 6 months to a year and persistent cognitive deficits thereafter, especially following more severe injury. Across cognitive areas, effects become more prominent as effortful processing increases. Thus, overlearned knowledge and automatized skills can be relatively unaffected by TBI, whereas tasks dependent upon integrative, novel, or speeded processing usually reveal more problems. (Kirkwood et al, 2010, p. 300) brain behavior relationships based on adult models cannot be assumed after

5 5 childhood TBI. For example, in a population of school-aged children with TBI, Slomine et al. found that frontal lesion volume failed to predict performance on any measure of executive function. Power et al. failed to find a relationship between frontal lesion severity and performance on measures of attentional control. (Kirkwood et al., 2010, p. 302) o Older adults who sustain a TBI have lower survival rates and less favorable outcomes than those who sustain a TBI during young and middle adulthood (RTC) In general, studies in older adults who sustain severe TBI (GCS scores of 3 8) have reported mortality rates of 70%, whereas good outcomes occur in < 10%. In contrast, good outcomes have been observed in up to 28% of patients with moderate TBI (GCS scores of 9 12) and in up to 80% of patients with mild TBI (GCS scores of (Goldstein & Levin, 2010, p. 345, 347) a good cognitive outcome is possible after mild-moderate TBI. Consistent with investigations in young adults, uncomplicated mild head injury in adults 50 years old does not produce clinically significant, persistent cognitive deficits. (Goldstein et al., p. 352) Depression [is found in] in up to one-third of older adults with mild and moderate TBI and this may become noticeable onlyafter several months have passed Moreover, its presence can interfere with cognitive and functional recovery. (Goldstein & Levin, 2010, p. 352) o Persons with higher levels of preinjury cognitive functioning often preserve more functional capacity after TBI (Kesler, Adams, Blasey, and Bigler, 2003). This hypothesis suggests that a person might be able to use cognitive resources postinjury that were not needed or used before the injury. (RTC) RTC = Report to Congress on Traumatic Brain Injury (2015?)