2. Epidemiology and Long-term Outcomes Following Acquired Brain Injury

Transcription

1 2. Epidemiology and Long-term Outcomes Following Acquired Brain Injury Robert Teasell MD FRCPC, Jo-Anne Aubut BA, Mark Bayley MSc, MD FRCPC, Nora Cullen MSc, MD FRCPC ERABI Parkwood Hospital 801 Commissioners Rd E, London ON x Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

2 Table of Contents 2.1 Epidemiology of Acquired Brain Injury Prevalence Gender Differences in Causes of Injury Age and TBI Impact of Older Age on TBI and Subsequent Recovery Impact of Aging with an Established ABI The Impact of ABI on Survivors and Family Members Prognostic Indicators Long-Term Outcomes Reference List Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

3 Table and Figure Directory Figure 2.1 Head Injury Admission by Gender in Canada ( ) Figure 2.2: Causes of ABIs as Reported by CIHI in Canada ( ) Figure 2.3: Numbers of ABIs Admitted to Hospital as reported by CIHI in Canada ( ) Figure 2.4: Number of Hospital Deaths Related to ABI as reported by CIHI in Canada ( ) Figure 2.5: Service Use and the Perceived Need for Services among Adults with ABI, 2005 Figure 2.6: Service Use vs Perceived Need for Services among Youth (15-19) with ABI, 2005 Figure 2.7: Service Use vs Perceived Need for Services among Children with ABI, 2005 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Common Prognostic Indicators for ABI Long-Term Outcomes Up to Two Years Post Injury Long-Term Outcomes at Three to Five Years Long-Term Outcomes at Greater than Five Years Long-Term Outcomes for Productivity, Independence, and Place of Residence 3 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

4 2.1 Epidemiology of Acquired Brain Injury Prevalence Acquired Brain injury (ABI), particularly of the traumatic brain injury (TBI) type, is one of the leading causes of death and lifelong disability in North America, particularly in children and adolescents (Greenwald et al., 2003; Thurman and Guerrero 1999) In developed Western countries, incidence figures for TBI are estimated to be per 100,000 population (Campbell 2000; Liss and Willer 1990). It is estimated that the annual incidence of TBI in the United States ranges from 1.4 to 1.5 million (Thurman and Guerrero 1999; Zaloshnja et al., 2008). In Ontario, the Ontario Brain Injury Association (2004) d damage caused by the primary and secondary insults to the brain, it has been argued that no two head injuries are neuropathologically alike (Liss and Willer 1990) Gender Differences in Causes of Injury Traumatic brain injuries are three times more common in men (Greenwald et al., 2003). It has been reported that the highest rate of injury occurs in young men between the ages of 15 and 24 (Murdoch and Theodoros 2001). Numbers released by CIHI indicate that males (of all ages) are at a higher risk of sustaining an ABI when compared to females (Canadian Institute for Health Information 2008). (see Figure 2.1) Figure 2.1: Head Injury Admission by Gender in Canada ( ) 80% 70% 67% 79% 73% 68% 60% 50% 40% 30% 33% 21% 27% 32% 20% 10% 0% 0-19 yrs 20-39yrs yrs 60 years Females Males The increased incidence in men may result from greater risk-taking activities, occupational hazards and more violence related injuries when compared with women. The estimated incidence of traumatic brain injury doubles between the ages of 5 and 14 years and peaks in 4 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

5 both males and females during adolescence and early adulthood to approximately 250 per 100,000; 20% of these are moderate or severe traumatic brain injuries Age and TBI Evidence suggests that the etiology of TBI varies with age. Overall, motor vehicle or related transportation accidents and falls comprise the most common cause of TBI. Transportation accidents, particularly for young males (15 to 24 years), by some estimates account for more than 50% of all head injuries (Murdoch & Theodoros, 2001). Child abuse, sporting accidents, and falls are the most common causes of TBI in children while falls are the most common causes of TBI in the elderly (see Figure 2.2) (Murdoch and Theodoros2001; Tokutomi et al., 2008; Mosenthal et al., 2002; Rapoport and Feinstein 2000; Wagner 2001). The increased risk of falls in the elderly may be linked to decreased balance and neuronal loss that accompanies the aging process (Wagner2001). Non-traumatic brain injuries are more prevalent in those over the age of 40. Vascular insults, brain tumors, meningitis, encephalitis, anoxia have been found to be the most frequent causes of non-tbis (ABI Dataset Pilot Project Team, 2009). Figure 2.2: Causes of ABIs as Reported by CIHI in Canada ( ) % % 24.4% 20.4% % 7.1% 8% 13.9% 13.9% 14.9% 3.9% 1.1% yrs yrs yrs 60yrs Falls Motor Vehicle Related Assaults or Intentional Injury Although the incidence of TBI is greater in younger patients (<60 years of age) when compared with the elderly (see Figure 2.3), older ABI/TBI victims usually show greater severity of injury and higher mortality rates (see Figure 2.4) (Ashman and Mascialino 2008; Wagner2001; Tokutomi et al., 2008;Mosenthal et al., 2002). 5 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

6 Figure 2.3: Numbers of ABIs Admitted to Hospital as reported by CIHI in Canada ( ) n=4966 n=4902 n=3637 n= yrs yrs yrs 60yrs Figure 2.4: Number of Hospital Deaths Related to ABI as reported by CIHI in Canada ( ) 900 n= n=120 n=217 n= yrs yrs yrs 60yrs Impact of Older Age on TBI and Subsequent Recovery Those who sustain a TBI, regardless of age, may develop circulatory, digestive or respiratory problems, be diagnosed with neurological issues such as endocrine problems, seizures, swallowing difficulties, and with some an increased risk of infection (Flanagan 2008). However, those 65 and older at the time of injury are more likely to report dizziness and weakness. Pennings et al. (1993) found individuals over the age of 60 required a greater number of 6 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

7 resources to obtain favorable outcomes compared to younger patients (40 years old or younger) with similar severities of injury. In a cohort study of Senathi-Raja et al. (2010) the authors concluded that older age at the time of injury was associated with poorer performance on various cognitive domains. It has been postulated, for those who are older at time of injury, less neuronal plasticity may negatively affect the brain s ability to compensate in the same way a younger brain does post injury (Senathi-Raja et al., 2010). Findings from several studies appear to support this premise that elderly ABI patients do not do as well. Marquez de la Plata (2008) in a study examining the effects of TBI over a 5 year time period found those in the oldest age group (40 to 85) had poorer outcomes when compared to the younger groups. They also reported that those individuals who declined post injury and post rehabilitation tended to be in the two older age groups (>26 years). Cognitive impairments, such as performing poorly on tests of word fluency, visual and verbal memory, abstract reasoning and processing speed, are more common and more serious post ABI in those over the age of 65 (Ashman and Mascialino 2008). For those in the older age group, a longer length of stay in hospital is often necessary to address their slower rates of functional gain (Cifu et al., 1996). Aging is often accompanied by a number of chronic conditions such as diabetes, arthritis, cardiovascular disease or cerebrovascular disease. These comorbid conditions are rarely taken into account when assessing the impact an ABI has on an older person (Rapoport and Feinstein2000; Colantonio et al., 2004). These pre-existing health issues may also contribute to increased lengths of rehabilitation stay and a reduction in functional gains as measured by the Glasgow Outcome Scale (Dijkers et al. 2008, Mosenthal et al. 2002). Further, Mosenthal et al. (2002) found older subjects (>64 years of age) had a significantly higher mortality rate (p<0.001) than their younger peers regardless of the level of ABI sustained. Study authors suggested this increase in deaths may have been the result of medical complications occurring post injury (Mosenthal et al., 2004) Impact of Aging with an Established ABI Few studies have examined the effects of an ABI on life expectancy; however, it has been suggested that sustaining an ABI in the younger years could shorten one s life by 10 years (Corrigan et al. 2007). Ratcliff et al. (2005) found an ABI doubled mortality risk, even though many survived 20 years post injury. Older adults who sustain an ABI are also at an increased risk (compared to the general population) of a shortened life expectancy (Ratcliff et al., 2005; Flanagan 2008). Another area that has garnered a great deal of discussion is the potential link between TBI and Alzheimer s disease or dementia. Unfortunately study results are mixed (Trudel et al., 2008; Rapoport and Feinstein 2000). It has not yet been shown that individuals who sustain an ABI early in life are at greater risk of developing Alzheimer s disease or dementia post injury. To date study findings are inconclusive, confusing and often contradictory. More research is needed. 7 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

8 There is very little consistency from study to study regarding the measures that are used to assess patients. There is also the question of the ineffectiveness of using existing measures as they may not be adaptable and appropriate to use with an older population (Dijkers et al., 2008). Coupled with this is the lack of consistency in how aging is defined or how an older population is defined. Is it 50 and up, 65 and up or is it 70 and up? More research is needed along with agreed upon definitions and guidelines The Impact of ABI on Survivors and Family Members To assess the impact an ABI may have on individuals as they age is difficult. Unlike stroke, which has a typical onset later in life, survivors of ABI typically live for several decades postinjury? Thus, because the lives of most survivors of moderate to severe TBI involve chronic, lifelong disabilities with varying degrees of dependence, the cost in suffering, family burden, and financial burden to society can be very high for the injured individual. This is particularly true in children and adolescents who are more likely than adults to survive following a TBI; however, longitudinal studies to assess the impact the injury has on the individual, their family, and their community are expensive and the risk that a significant number of subjects will be lost to follow-up. Current data indicates large proportions of brain injury patients do not appear to be fully accessing the rehabilitation services that they need. The following three figures (Figures 2.5 to 2.7) present the results from an Ontario Brain Injury Association survey conducted in 2005 on the number of adults, youth (15-19yrs) and children using services versus those not using services (Ontario Brain Injury Association 2007) Figure 2.5: Service Use and the Perceived Need for Services among Adults with ABI, 2005 Case Managemt Homemaker Service Family Support Group Individual or Family Vocational Training Nursing Services Occupational Therapy 21.5% 25.0% 29.2% 25.7% 22.4% 4.2% 11.4% 28.5% 17.9% 15.2% 18.5% 26.7% 5.2% 15.9% Cognitive Therapy Physical Therapy 38.2% 46.7% 20.5% 15.2% 0% 20% 40% 60% 80% Using Services 8 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

9 Figure 2.6: Service Use vs Perceived Need for Services among Youth (15-19) with ABI, 2005 Case Managemt 25.0% 56.3% Homemaker Service 6.3% 43.8% Family Support Group 25.0% 37.5% Individual or Family Counseling 25.0% 43.8% Vocational Training Nursing Services Occupational Therapy 6.3% 6.2% 18.9% 31.3% 31.3% 62.5% Cognitive Therapy Physical Therapy 31.3% 31.3% 31.3% 68.8% 0% 10% 20% 30% 40% 50% 60% 70% Not Using but Believed to be Beneficial Using Services Figure 2.7: Service Use vs Perceived Need for Services among Children with ABI, 2005 Case Managemt Homemaker Service Family Support Group Individual or Family Counseling Vocational Training Nursing Services Occupational Therapy Cognitive Therapy Physical Therapy 7.2% 4.5% 0.1% 2.7% 18.5% 14.8% 33.3% 33.3% 51.9% 25.9% 29.6% 7.4% 44.4% 29.5% 14.6% 37.0% 22.2% 66.7% Using Services 0% 20% 40% 60% 80% 100% Not Using but Believed to be Beneficial Particularly noteworthy is the apparent lack of access to services for psychological issues. The perceived need for increased rehabilitation services is in contrast to the current contraction of rehabilitation services. 9 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

10 2.2 Prognostic Indicators For TBI rehabilitation, it is important to know which prognostic indicators are significantly related to outcomes. Prognostic indicators can include such variables as injury severity, etiology, age, length of stay, duration of post-traumatic amnesia (PTA), etc. The table below summarizes the most common TBI prognostic indicators identified in the literature. Table 2.1 Common Prognostic Indicators for ABI Age Gender Presence of prior brain injury Injury severity Length of coma Initial Glasgow Coma Scale (GCS) score Injury etiology Rehabilitation length of stay Duration of post-traumatic amnesia (PTA) Timing of rehabilitation Intensity of rehabilitation Bushnik et al. (2003) focused on a variety of etiologies, such as motor vehicle accidents (MVAs), assaults, and falls. They demonstrated that individuals involved in motor vehicle crashes initially incurred more severe injuries than individuals with TBI associated with assaults, falls, or other causes. However, at one year post-injury individuals with TBI related to motor vehicle accidents reported the best functional and psychosocial outcomes, while individuals with violence-related TBI reported the highest unemployment rates and lowest Community Integration Questionnaire scores. Individuals with TBI related to falls or other etiologies had outcomes that fell somewhere between victims of MVAs and assaults. This occurred despite the fact that there were no functional differences between the four groups at discharge from rehabilitation. Zafonte et al. (2001) assessed outcomes only for individuals with penetrating brain injuries resulting from gunshot wounds to the head. Although they reported that this cohort had a high early mortality rate, survivors who participated in an inpatient rehabilitation program experienced good functional improvement. Asikainen et al. (1998) focused on the effects of hospital admission GCS score, length of coma, and duration of PTA on outcomes. While hospital admission GCS score positively correlated with functional outcome, as measured by GOS scores, length of coma and duration of PTA correlated with both functional and occupational outcome. Outcomes also varied by age group with the best chance for good recovery found in the 8-16 and age groups and the worst chance for a good recovery found in the youngest ( 7) and oldest (> 40) age groups. Yody and Strauss (1999) found that shorter lengths of stay in rehabilitation resulted in negative effects on employment and recreational activity. In summary, the best relative outcomes appear to be associated with individuals between the ages of 8-40 who are victims of motor vehicle accidents. 10 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

11 2.3 Long-Term Outcomes There remain a number of key questions about the long-term outcomes after brain injury. These questions include: 1. What is the expectation of functional recovery months or even years post-injury? 2. What might a person who has sustained a moderate or expect with respect to issues such as cognitive improvement, return to productive activity, and level of supervision required to perform activities of daily living or possibly within a school or employment setting? In an attempt to address these questions, some of the most salient studies related to long-term outcomes were identified and reviewed. Participants follow-up periods ranged from three months to more than ten years. The ten studies included in the review were separated into two groups according to participants injury severity: 1) Moderate to (when both moderately and severely injured participants were included in the study) and; 2) Severe ABI (when only severely injured participants were included in the study). Studies were also arbitrarily separated according to three follow-up periods: 1) Three months to two years; 2) Three to five years, and; 3) Greater than five years. These divisions allow clinicians to inform patients what they might reasonably expect, vis-à-vis recovery, at different time periods postinjury, based on the severity of their injury. (Tables 2.2 to 2.4 below summarize the relevant findings.) Individual Studies Table 2.2 Long-Term Outcomes Up to Two Years Post Injury Moderate to Severe ABI Author/Year/ Country/D&B Score Dombovy & Olek (1997) No Score Cope et al., (1991) Malec et al., (1993) Study Summary At a follow-up of three and six months (n=51 and n=48 at each follow-up respectively), residual physical disability, as measured by the Functional Independence Measure, was minimal. At six months, the unemployment rate of participants studied was 60.5%. At a follow-up of six, twelve, and twenty-four months of 145 individuals, there was no deterioration in the positive trends experienced in place of residence and productivity. No increase occurred in the percentage of those not engaged in productive activity. There was no loss of gain in attendant care requirements either. At a one-year follow-up of 29 individuals, 86% were living with no supervision, 10% with partial supervision, and 5% with 24-hour supervision. Additionally, 48% were in an independent work placement, 5% in a transitional work placement, 14% in supported work, 5% in sheltered work, and 29% were unemployed. 11 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

12 Severe ABI Author/Year/ Country/D&B Score Novack et al., (2000) No Score Mills et al., (1992) Harrick et al., (1994) Canada Study Summary In a follow-up of 72 individuals, there was an increase of those involved in productive activity and employment from 13.8% and 5.5% at six months to 26.4% and 20.8% at twelve months. At a six-month follow-up of 42 patients (29 males/13 females, average age = 28.6 years), 87.5% maintained or improved their status in the home and community and 90% maintained or improved their status in leisure and vocational function. These gains continued to be maintained or improved at a follow-up of twelve and eighteen months. At a one-year follow-up of 21 persons, 62% were engaged in productive activity. Of this group, 10% were self-supported, 24% were both self-supported and aided, and 62% were aided. No one required an institutional setting. In addition, 81% received informal support, 19% received partial support, and no one required institutional support. Also, 33% reported loneliness as the most frequent problem. Table 2.3 Long-Term Outcomes at Three to Five Years Severe ABI Author/Year/ Country/D&B Score Harrick et al., (1994) Canada Kaitaro et al., (1995) Finland No Score Study Summary At a three-year follow-up of 21 persons, 67% were engaged in productive activity. Of this group, 15% were self-supported, 15% were self-supported and aided, and 73% were aided. No one required an institutional setting. In addition, 77% received informal support, 24% received partial support, and no one required institutional support. Also, 29% reported loneliness as the most frequent problem. At a five-year follow-up of 19 patients, none of the participants required institutional care, 68% were living with their families or spouses, and 89% were retired despite attempts to work. 12 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

13 Table 2.4 Long-Term Outcomes at Greater than Five Years Moderate to Severe ABI Author/Year/ Country/D&B Score Klonoff et al., (2001) Study Summary At a follow-up of eleven years of 164 patients, 83.5% were productive in some capacity. Of these, 46.3% were gainfully employed full-time, 11.6% were in fulltime school or school/work, and 9.2% were in part-time gainful work or school for a total of 67.1%. Another 12.2% worked as volunteers and 16.5% were not productive in any capacity. Additionally, younger age, being male, and higher staff working alliance ratings of patients and their families were associated with better vocational/school outcomes. Severe ABI Author/Year/ Country/D&B Score Wilson (1992) UK Johnson (1998) UK No Score Study Summary At a follow-up of five to ten years of 26 patients, 81% (n=21) were living in their own homes either alone, with relatives, or with friends. The remaining were in long-term residential care, residential college, or warden controlled accommodation and 42% (n=11) were in paid employment. However, only one of the eleven individuals in paid employment was in a position comparable to pre-injury status. At a follow-up of ten years or more of 64 patients, 42% had re-established themselves in employment, 20% had an irregular pattern of work; the remainder were not in the workforce. Overall, most of the studies reported favorable results regarding the three most common outcomes measured. These included participant involvement in productive activity, living in a residential setting, and level of independence attained. In these studies productive activity did not necessarily mean paid employment. Three of the ten studies found that the majority of participants remained unproductive over the long-term. In one study, the authors reported that 60.5% of participants were unemployed at a follow-up of six months post-injury (Dombovy and Olek 1997). In another study, 89% of participants had retired at five years post-injury, despite attempts to return to work (Kaitaro et al., 1995). In the third study, eleven of twenty-six subjects (42%) remained in paid employment situations at five to ten years post-injury, but only one of these subjects was in a position comparable to their pre-injury status (Wilson 1992). Table 2.5 summarizes whether each long-term outcome study described in the three tables above reported a positive or negative outcome regarding participants productivity, independence, and place of residence. Productivity outcomes were defined as positive if the 13 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

14 person performed any form of paid or unpaid labour, including volunteer work, in which the majority ( 50%) of participants were involved. If the majority of participants were not taking part in any of the aforementioned types of productive activity (e.g. they were retired) then it was considered a negative outcome. Independence was related to the level of supervision required. Positive outcome was noted as long as the majority of participants did not require institutional care or support. However, if the majority of participants did require this type of assistance it was deemed a negative outcome. Positive place of residence outcomes were defined as the majority of participants in the study were not living in an institutional setting. Otherwise, it was considered a negative outcome. Positive trends and increases regarding productivity, independence, and place of residence were also viewed as positive outcomes. Individual Studies Table 2.5 Long-Term Outcomes for Productivity, Independence, and Place of Residence Author/Year/ Country Injury Severity Follow-Up Period Productivity Independence Place of Residence Dombovy & Olek (1997) No Score moderate to three months to two years - (60.5%) Cope et al., (1991) Malec et al., (1993) moderate to moderate to three months to two years three months to two years (no deterioration in positive trends from 6 months to 24 months) (72%) (no deterioration in positive trends from 6 months to 24 months) (96%) (no deterioration in positive trends from 6 months to 24 months) Novack et al., (2000) No Score Mills et al., (1992) three months to two years three months to two years (12.6% increase in those involved in productive activity from 6 months to 12 months) (90%) Harrick et al., (1994) Canada three months to two years (62%) (100%) (100%) Harrick et al., (1994) Canada three to five years (67%) (100%) (100%) 14 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

15 Author/Year/ Country Kaitaro et al., (1995) Finland No Score Klonoff et al., (2001) Injury Severity moderate to Follow-Up Period three to five years greater than five years Productivity Independence Place of Residence - (89%) (100%) (83.5%) Wilson (1992) UK greater than five years - (42%) (81%) (81%) Johnson (1998) UK No Score greater than five years (62%) = positive outcome; - = negative outcome; = not applicable; ( ) = % of participants who experienced positive/negative outcome In summary, although methodological differences between the various studies do not permit direct comparison with respect to the variables employed, it is generally true that those who have moderate to appear to fare better than those with exclusively on the dimension of productivity in particular. Moreover, even those who have might expect to have generally favorable outcomes with respect to return to independent living. However, return to productive activity is less certain for those with. 15 Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

16 2.4 Reference List Estimated incidence of traumatic brain injury in Ontario. Ontario Brain Injury Association (On-line) Available: Ashman T, Mascialino G. Post-TBI emotional functioning and age: A systematic review. Brain Injury Professional 2008; 5: 25. 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: Bushnik T, Hanks RA, Kreutzer J, Rosenthal M. Etiology of traumatic brain injury: characterization of differential outcomes up to 1 year postinjury. Arch Phys Med Rehabil 2003; 84: Campbell M. Understanding traumatic brain injury. Rehabilitation for traumatic brain injury: physical therapy practice in context. Toronto: Churchill Livingstone; p Canadian Institute for Health Information. The Burden of Neurological Diseases, Disorders and Injuries in Canada Cifu DX, Kreutzer JS, Marwitz JH, Rosenthal M, Englander J, High W. Functional outcomes of older adults with traumatic brain injury: a prospective, multicenter analysis. Arch Phys Med Rehabil 1996; 77: Colantonio A, Ratcliff G, Chase S, Vernich L. Aging with traumatic brain injury: long-term health conditions. Int J Rehabil Res 2004; 27: Cope DN, Cole JR, Hall KM, Barkan H. Brain injury: analysis of outcome in a post-acute rehabilitation system. Part 2: Subanalyses. Brain Inj 1991; 5: Corrigan JD, Selassie AW, Lineberry LA et al. Comparison of the Traumatic Brain Injury (TBI) Model Systems national dataset to a population-based cohort of TBI hospitalizations. Arch Phys Med Rehabil 2007; 88: Dijkers M, Gordon WA, Abreu B, Graham J, Charness A. The intersection of aging/age and TBI: Systematic review methodology. Brain Injury Professional 2008; 5: Dombovy ML, Olek AC. Recovery and rehabilitation following traumatic brain injury. Brain Inj 1997; 11: Flanagan S. Post-TBI life expectancy and health: A systematic review. Brain Injury Professional 2008; 5: Greenwald BD, Burnett DM, Miller MA. Congenital and acquired brain injury. 1. Brain injury: epidemiology and pathophysiology. Arch Phys Med Rehabil 2003; 84: S3-S7. Harrick L, Krefting L, Johnston J, Carlson P, Minnes P. Stability of functional outcomes following transitional living programme participation: 3-year follow-up. Brain Inj 1994; 8: Johnson K, Davis PK. A supported relationships intervention to increase the social integration of persons with traumatic brain injury. Behaviour Modification 1998; 22: Kaitaro T, Koskinen S, Kaipio ML. Neuropsychological problems in everyday life: a 5-year follow-up study of young severely closed-head-injured patients. Brain Inj 1995; 9: Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

17 Klonoff PS, Lamb DG, Henderson SW. Outcomes from milieu-based neurorehabilitation at up to 11 years postdischarge. Brain Inj 2001; 15: Liss M, Willer B. Traumatic brain injury and marital relationships: a literature review. Int J Rehabil Res 1990; 13: Malec JF, Smigielski JS, DePompolo RW, Thompson JM. Outcome evaluation and prediction in a comprehensiveintegrated post-acute outpatient brain injury rehabilitation programme. Brain Inj 1993; 7: Marquez de la Plata CD, Hart T, Hammond FM et al. Impact of age on long-term recovery from traumatic brain injury. Arch Phys Med Rehabil 2008; 89: Mills VM, Nesbeda T, Katz DI, Alexander MP. Outcomes for traumatically brain-injured patients following postacute rehabilitation programmes. Brain Inj 1992; 6: Mosenthal AC, Lavery RF, Addis M et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma 2002; 52: Mosenthal AC, Livingston DH, Lavery RF et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma 2004; 56: Murdoch BE, Theodoros DG. Introduction: epidemiology, neuropathophysiology, and medical aspects of traumatic brain injury. Traumatic brain injury: associated speech, language and swallowing disorders. San Diego CA: Singular Thomson Learning; p Novack TA, Alderson AL, Bush BA, Meythaler JM, Canupp K. Cognitive and functional recovery at 6 and 12 months post-tbi. Brain Inj 2000; 14: Ontario Brain Injury Association. Caregiver Information and Support Link: 2005 A year in review. In: Dumas J, editor. Ontario Brain Injury Association; p Pennings JL, Bachulis BL, Simons CT, Slazinski T. Survival after severe brain injury in the aged. Arch Surg 1993; 128: Rapoport MJ, Feinstein A. Outcome following traumatic brain injury in the elderly: a critical review. Brain Inj 2000; 14: Ratcliff G, Colantonio A, Escobar M, Chase S, Vernich L. Long-term survival following traumatic brain injury. Disabil Rehabil 2005; 27: Senathi-Raja D, Ponsford J, Schonberger M. Impact of age on long-term cognitive function after traumatic brain injury. Neuropsychology 2010; 24: Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA 1999; 282: Tokutomi T, Miyagi T, Ogawa T et al. Age-associated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank. J Neurotrauma 2008; 25: Trudel TM, Mackay-Brandt A, Temple RO. Traumatic brain injury and dementia: A systematic review. Brain Injury Professional 2008; 5: Module 2-Epidemiology and Long-term Outcomes Following ABI-V9

18 Wagner AK. Functional prognosis in traumatic brain injury. Physical Medicine and Rehabilitation: state of the arts reviews 2001; 15: Wilson B. Recovery and compensatory strategies in head injured memory impaired people several years after insult. J Neurol Neurosurg Psychiatry 1992; 55: Yody BB, Strauss D. The effect of decreasing lengths of stay on long-term TBI patient outcomes. J Rehabil Outcomes Meas 1999; 3: Zafonte RD, Wood DL, Harrison-Felix CL, Valena NV, Black K. Penetrating head injury: a prospective study of outcomes. Neurol Res 2001; 23: Zaloshnja E, Miller T, Langlois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, J Head Trauma Rehabil 2008; 23: Module 2-Epidemiology and Long-term Outcomes Following ABI-V9