OBJECTIVES

• Describe long term issues after TBI

• Identify resources required as an individual ages

• Identify directions for prevention and treatment planning

Successful Aging Requires Maintenance

of:

• Physical function

• Cognitive function

• Social function

Age at Injury Affects Plasticity & Recovery

Issues• Adult brain has decreasing ability to

repair itself as it ages because of a decreasing number of neurons

• Greater likelihood of repeated insults to the brain based on age at onset.

• 40-50% increase in the odds of a poor outcome for every 10 years of age at onset.(Hukkelhoven, C. et al, 2003)

Long Term Outcome Profile in Community

Based TBI Clients• 5-7 years post injury, it was found

significant deficits in cognition, ADL’s and psychosocial areas; Noted reasonably good motor recovery within first decade post TBI. (Oddy, Brooks, Tate, Hibbard 1998)

• Lifespan of a person with a TBI injured before age 30 is 78.6 years. (NIH 2000)

• Overestimate their function and competencies with aging (Prigatano 2005)

TBI As Risk Factor for AD

• Moderate to severe TBI- 2 times the risk for Alzheimer’s and other dementias (Zaszler, 2007, Mazel, 2009)

• APOEe4 allele and TBI may have synergistic effect as risk factors for AD

• Neuropsychological testing to assess ongoing cognitive function

TBI and Age: Newer Review of the Literature

• Cognitive decline (Himanen, 2006)

• Poorer functional outcomes with age at injury (Testa, 2005)

• Deficits more pronounced. (Goldstein, 2001)

• Arthritis and sleep (Colantoni, 2004)

• Increased seizures, pain and medication use. (ACRM, 2001)

• Persistent affective and behavioral symptoms (Colantoni, 2004)

Aging: Over More than Three Decades (Sendroy-Terrill,

M et.al 2010)

• Decline of physical and cognitive function

• Decline in societal participation and social isolation

• Increase in contractures• Increase in fatigue• Decline in perceived environmental

barriers.

Aging: Over More than Three Decades (Sendroy-Terrill, M

et.al 2010)Conclusion: • Cognitive, physical and social functioning

all were significantly influenced by severity of injury over time.

• With overuse and/or natural aging process, produces an increase in secondary conditions characteristic of aging with TBI

One Post Acute Brain Injury Profile- Medically

Compromised- (n=58)

Average age of participants 46 years Time Since Injury Average 145 months Range 25-290 months Coma Length Average (n=46) 102 days Range 60-180 days

Reported Health Issues(n=58)

Abnormal Blood Pressure 67%Balance 60%Muscle/Joint stiffness 55%Urinary control difficulty 53%Weight gain greater than 10 lbs. 48%Sleep disorder 41%Spasticity 41%Chronic headache 34%

Hospitalizations/ER visits in the last year 28%Thyroid condition 21%Skin-vascular changes 17%Symptomatic Epilepsy 17%Diabetes Mellitus 1%

Acute and Worsening Neurologic and Physical

Changes• Neglect and sensory changes• Increased frequency of seizures• Hemiparesis and decreased trunk control;

Changes in balance and righting reactions• Dystonia, increased tone and spasticity• Diabetes insipidus/changes in sodium• Dysphagia with aspiration pneumonia and

difficulties with maintaining hydration and nutrition

• Urinary incontinence

Cognitive & Functional Changes

• Diminished attention and concentration• Slowed processing, disorientation and confusion• Increased supervision and safety measures to prevent

falls• Observations and care for seizures• Toileting every two hours to prevent incontinence• Increased physical assistance for AM and PM routines

and transfers• Supervision for meals• All household activities requiring minimal assistance

eventually changed from moderate to maximum assistance.

Impact on Daily LifeAltered daily

routines

Recreational & Vocational changes

• Additional staff for safety and support

• Environmental changes with grab bars, equipment etc.

• Less participation in community : work, volunteering, church, gym & out to dinner.

• Development of quiet, in-home pursuits.

Recommendations

Maintain physical function: Assess motor status; keep mobile and provide exercises

• Build Strength: Balance Group, Yoga, Aquatics, gym

• Obtain equipment for safety: low profile bed, alarms, ambulation equipment

• Assess ADL skills: modify environment

Maintain Cognitive function: assess cognition, provide strategies, consider technology

Maintain Social function: stay involved

• Reclassify TBI as a chronic disease model & develop models of chronic disease management. (Masel, 2010)

• Life care/resource planning considering: care giver support, nursing, therapy, technology & equipment, new medical interventions, stable activity, long term decision making.

• Need for ongoing evaluations and episodic therapy

• Medication evaluation : choose wisely and assess- long term impact potential

Conclusions