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2008 Galveston Brain Injury Conference

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Title: 2008 Galveston Brain Injury Conference


1
2008 Galveston Brain Injury Conference
Group Presentations
  • Moody Gardens Convention Center
  • Galveston Texas

2
TRAUMATIC BRAIN INJURY, AGING AND COGNITIVE
FUNCTIONING
  • Presented by
  • Wayne A. Gordon, PhD ABPP-CN,
  • Amanda L. Sacks PhD, Angela S. Yi PhD
  • (Group 2)

3
Purpose of Review
  • To examine the literature on the impact of aging
    on Post-TBI cognitive function.
  • Research Implications
  • Examine current literature.
  • Provide methodological recommendations for future
    research.
  • Clinical Implications
  • Provide prognostic information to patients on how
    aging will affect cognitive functioning after a
    TBI.

4
Research Questions
  • 1. Are there changes in cognitive function in
    individuals with TBI as they get older?
  • 2. If so, what are the specific changes in
    cognitive function in individuals with TBI as
    they get older?

5
Review Process Key Words used
  • word finding fluency
  • pragmatics
  • expressive language
  • receptive language
  • visuospatial
  • visual perception
  • visual construction
  • neglect
  • visual scanning
  • orientation
  • alertness
  • arousal
  • memory
  • retrieval
  • retention
  • encoding
  • concentration
  • speed of information processing
  • concept formation
  • verbal abstraction
  • nonverbal abstraction
  • executive dysfunction
  • intelligence

6
Review Process
7
Study Designs
  • Longitudinal Designs - studies that measure
    cognitive functioning of the same individual at
    two or more time points.
  • Question What happens to my cognitive
  • functioning over time?
  • Cohort Design studies that compare the
    cognitive performance between two groups at one
    time point.
  • Age 1 vs. Age 2 (TBI)
  • TBI vs. Controls (Age-matched)
  • Question How does my cognitive functioning
  • compare to different age groups?

8
2 Cohort Studies
  • AAN ratings
  • AAN Rating 3 1
  • AAN Rating 4 1
  • Strobe ratings
  • Klein et al (1996) 78
  • Ogden et al (1998) 72

9
9 Longitudinal Studies
  • AAN ratings summary (M 3 Range 2-4)
  • AAN Rating 1 0
  • AAN Rating 2 3
  • AAN Rating 3 4
  • AAN Rating 4 2
  • Strobe ratings (M 74 Range 57-87)
  • 50 lt 1 Article
  • 60-70 2 Articles
  • 70-80 4 Articles
  • 80-90 2 Articles

10
Cohort Studies
RedSimilarities Yellow Differences
11
Cohort Studies Cognitive Domains
12
Cohort Studies
  • TBI Age Interaction
  • Klein (1996) Middle age TBI group performance
    was similar to older controls on executive
    functioning task. Interpretation of authors TBI
    accelerates aging.
  • Ogden (1998) Younger TBI group does worse than
    age-matched controls. Middle aged TBI group does
    equal to or better than age-matched controls.
    (Memory and executive functioning)

13
TBI Accelerates Aging ? Or!
Visual Verbal Learning Test, Raw Scores Klein et
al. (1996)
14
Longitudinal Studies Cognition Improved
Red Similarities Yellow Differences
15
Longitudinal Studies Cognition Declined
16
Longitudinal Studies Cognition Stable
17
Longitudinal Studies Mixed Findings
18
Longitudinal Studies Cognitive Domains
19
Longitudinal Cognitive Conclusions
20
Longitudinal Cognitive Conclusions
21
Overall Conclusions
  • What will happen to
  • my cognitive functioning
  • over time?
  • No definitive conclusions can be made regarding
    Post-TBI cognitive functioning over time.

22
Differences In Study Design Varied Findings
  • There was no pattern to variability among
    studies
  • Different tests
  • Different samples
  • Age
  • Severity
  • Time since injury
  • Age at injury
  • Different age at injury, time since injury and
    interval between assessments

23
Normal Aging 2 Vectors
TIME BETWEEN ASSESSMENTS
SHORT
LONG
AGE AT INITIAL EVAL
YOUNG
OLD

24
Aging TBI 4 Vectors
TIME BETWEEN ASSESSMENTS
SHORT
LONG
TIME SINCE INJURY AT ASSESSMENT
EARLY
LATE
YOUNG
OLD
AGE AT INITIAL EVAL
AGE AT INJURY
YOUNG
OLD

POTENTIAL CONFOUNDS -Re-injury
- Onset of co-morbidity
-Treatment - Change in
psychosocial status
25
Additional Variability Across Studies
  • Sampling issues
  • Differences in demographics (i.e. education,
    ethnicity, gender)
  • Differences in severity
  • Variability of control group (i.e. matched
    control v. convenience sample)
  • Variability of Tests used (i.e. self report vs.
    objective measures)
  • Diversity of objective measures used NO GOLD
    STANDARD for examining cognitive change over time

26
Recommendations for Future Research
  • Take into account interactions between all 4
    vectors
  • Age at injury
  • Age at initial evaluation
  • Time since injury at initial assessment
  • Time between assessment.
  • Assess a diverse range of cognitive abilities
    across as many domains as possible.
  • Give same battery to all pts. at all assessment
    points.
  • Use terminology that appropriately describes
    methodology used (i.e. follow-up should have
    two points of assessment).

27
  • Thank You!

28
Ageing with Traumatic Brain Injury Medical Issues
  • Steven Flanagan, M.D.
  • Theodore Tsaousides, Ph.D.
  • Dana W. Moore, Ph.D.
  • Kenneth Ottenbacher
  • Cindy Harrison-Felix, Ph.D.

(Group 3)
29
Overarching Issue
  • What happens to individuals with TBI from a
    medical perspective as they age?
  • Are there differences from general population re
  • Mortality/survival
  • Medical problems

30
Variation From Other Groups
  • Less concerned with age as opposed to ageing
  • No age cutoff
  • Assessments made years post-injury

31
Process
  • Initial research questions
  • What are the 10 leading causes of mortality gt 10
    years post injury?
  • What are the risk factors associated with
    mortality gt 10 years post injury?
  • What are the most common long-term health
    problems gt10 years post injury?

32
Process
  • Key words (multiple variations of)
  • Brain injuries
  • Risk, mortality, health
  • Age

33
Results to Those Specific Question
  • Little more than

34
Process Adaptation
  • Is risk of early mortality different from the
    general population and if so, how?
  • What risk factors are associated with premature
    mortality?
  • What are the causes of death beyond the acute
    (sub-acute) phase following TBI?
  • What long-term health problems afflict
    individuals post-TBI?
  • Self-reported
  • Diagnosed

35
Process Adaptation
  • Questions changed to include those 5 years post
    to increase hit rate.

36
Initial Search Results
  • 2709 abstracts screened
  • 350 selected for further review
  • 72 deemed appropriate for research questions
  • 71 located
  • 25 addressed research questions

37
AAN Grade
  • Most studies reviewed achieved a grade III-IV
  • 4 Received grade II

38
3 Broad Categories
  • Mortality/Survival
  • 15 studies
  • Self-Reported Health Symptoms
  • 9 studies
  • Endocrine/Pituitary Dysfunction
  • 1 Study

39
Mortality
40
Hospitalized
41
Hospitalized
42
Mortality in This Sample
  • Literature suggests
  • Increased likelihood of pre-mature death
  • Older age at injury more likely to die
    prematurely although younger age more likely to
    die compared to age-matched population
  • Increased risk associated with physical
    disability, premorbid social/personal problems,
    substance abuse, pre-morbid neurological illness
  • Seizures, sepsis, pneumonia, digestive, injuries
    causes of death greater than general population

43
Outpatient Services
44
Mortality
  • Literature suggests
  • Increased likelihood of premature mortality
    post-TBI, associated with residual disability
  • Causes of death choking, epilepsy, GU,
    respiratory, circulatory, digestive

45
War Veterans
46
Vegetative State
47
Mortality
  • 13 studies reported increased likelihood of
    premature death
  • Different populations
  • WWI, WWII, Vietnam vets, inpatient rehab,
    outpatient services, others
  • Cause of injury/Severity
  • Penetrating/varying severity
  • Time
  • Varying times post injury
  • Different levels and places of care

48
Risk Factors
  • 13 studies addressed risk factors
  • Age at injury
  • Employment status
  • Pre-morbid EtOH/social problems
  • Post-morbid functional skills
  • Epilepsy (in vet studies only).

49
Cause of Death
  • 7 studies assessed cause of death
  • Individuals with TBI more likely to die from
  • Meningitis, seizures, drowning,
    choking/suffocation, genitourinary, respiratory,
    circulatory, gastrointestinal related conditions,
    sepsis, injuries.

50
Mortality/Survival
  • Literature suggests that
  • TBI increases likelihood of premature death
    beyond acute/subacute phase
  • Some reports suggest mortality rate decreased
    over time
  • Pre-morbid problems, post-morbid functional
    limitations, epilepsy and older age increase risk
    of early death
  • Premorbid EtOH abuse often reported as a risk
    factor

51
Mortality questions not answered
  • Does (how does) mortality risk change among
    survivors of TBI as time passes?
  • Why do individuals post-TBI have a higher rate of
    premature mortality?
  • What are the etiologies of premature death?
  • Why are individuals with TBI more likely to die
    of certain causes?

52
Self-reported Health Problems
53
(No Transcript)
54
Self-reported Symptoms
  • Literature suggests increased complaints of
  • Miscellaneous
  • HA, vision, hearing, arthritis, fatigue,
    allergies
  • Neurological
  • Weakness, muscle tone, tremors, coordination,
    dizziness
  • Endocrine
  • No assessment re complaints correlating with
    actual endocrine dysfunction
  • Emotional
  • Nervousness/anxiety/irritability/insomnia

55
Health Status Questions Not Answered
  • What are the actual (diagnosable) health problems
    afflicting individuals with TBI as they age?
  • How do they impact general health, survival, QOL,
    etc?

56
Self-Perceived Health
57
Perceived Health
  • Literature suggests
  • More TBI related symptoms associated with lower
    perceived health
  • Perception of health positively associated with
    QOL
  • Self-perceived health comparable b/t TBI and
    non-TBI

58
Self-perceived Health
  • Not clear how individuals post-TBI perceive their
    long-term health.

59
Sexuality
60
Sexuality
  • Limited literature suggests
  • TBI associated with greater likelihood of
    self-reported sexual dysfunction than general
    population

61
Sexuality Questions Not Answered
  • What are the diagnosable sexually related
    problems afflicting individuals with TBI as they
    age?
  • How do they differ from the general population?
  • What are the risk factors or associated medical
    problems?

62
Pituitary Dysfunction
  • Several studies
  • Only one fit our criteria

63
Pituitary Dysfunction
64
Pituitary Dysfunction
  • Literature suggests
  • Common
  • Older individuals at increased risk
  • Can occur at various times post-injury
  • May contribute to post-TBI morbidity

65
Pituitary Dysfunction
  • Consensus guideline for assessment published
  • Ghigo et al. Brain Injury 2005

66
Questions?
67
Aging with TBI Psychosocial/Functional Focus
  • Group 4
  • Facilitator Gary S. Seale, MS

68
Group IV Participants
  • Teresa Ashman, Ph.D. Mount Sinai
  • Tim Reistetter, Ph.D. East Carolina Univ.
  • Margaret Brown, Ph.D. Mount Sinai
  • Betty Abreu, Ph.D. TLC/UTMB

69
Initial Question(s)
  • As a person ages with TBI, what is the impact on
    psychosocial outcome?
  • in terms of demographics and injury
    characteristics, who is reaching old age with
    TBI?
  • as people age with TBI, what is the impact on
    activities and participation?
  • as people age with TBI, how does this affect
    life satisfaction and quality of life?
  • as people age with TBI, are there changes in
    emotional function what coping strategies are
    used?
  • as people age with TBI, are there changes in
    spirituality, search for meaning, etc.?
  • as people age with TBI, what is the impact of
    injury severity (mild, moderate, severe) on
    psychosocial outcome?

70
Initial Search Strategy
  • Initial set of search terms derived from ICF
    activities/participation taxonomy (130 terms).
  • Terms placed in 8 domain areas coping and
    adaptation, mobility, self-care, domestic life,
    relationships, productive activities,
    leisure/recreation, and life satisfaction.
  • Terms in each domain area were combined with AND
    statements for the age and TBI terms agreed upon
    by all groups.

71
Initial Search Strategy (cont.)
  • Example
  • quality of life or life satisfaction or
    satisfaction or happiness or subjective
    well-being, or satisfaction with life, or
    subjective quality of life or well-being or
    positive affect or positive emotion or
    health-related quality of life
  • AND
  • Aging or aged or elderly or mature or senior or
    old or old age or late life or age
  • AND
  • TBI or traumatic brain injury or closed head
    injury or diffuse axonal injury or rapid
    acceleration/deceleration injury or concussion or
    post-concussional syndrome

72
Search Strategy - Revised
  • Question As a person with TBI ages, does
    his/her functioning in terms of basic functioning
    (excluding cognitive functioning) activities1,
    participation, emotional functioning2, and
    satisfaction with life change?
  • 1Marquez de la Plata, CD et al. 2008, Arch PMR
  • 2Menzel, JC 2008, Brain Injury

73
Search Strategy - Revised
  • Criteria for inclusion (AGE)
  • Correlational at least 10-year age range is
    found AND the top of the range is at least 45
  • Cross-sectional youngest reported group is
    under 30 (on average) AND oldest group is at
    least 40 (on average) OR youngest group is over
    30 AND oldest group is at least 45
  • Longitudinal at measurement point 1, the
    average subject is under 30 and at last
    measurement point at least 10 years have elapsed,
    OR at measurement point 1 the average subject is
    over 30 and at last measurement point at least 5
    years have elapsed

74
Final Search Strategy
  • Psychosocial domain divided into four sub domain
    areas
  • - Gary Seale Quality of Life/Life Satisfaction
  • - Teresa Ashman Emotional Functioning
  • - Tim Reistetter Community Integration
  • - Margaret Brown Productive Activities
  • Additional literature searches conducted by each
    participant, including hand searches
  • Studies selected were forwarded to Renee for
    inclusion in RefWorks

75
Objectives of Presentations
  • Brief discussion of individual search strategies
  • Quality of evidence
  • Limitations of studies
  • Despite limitations, what information can be
    gleaned from studies cited
  • Gaps/future directions (discussion points for
    break-out sessions)

76
Life Satisfaction/Quality of Life and Aging with
TBI
  • Gary S. Seale, MS
  • Transitional Learning Center at Galveston

77
Guiding Question
  • As a person ages with TBI does his/her life
    satisfaction/quality of life change?

78
Quality of Evidence Life Satisfaction/Quality
of Life
  • All studies received an AAN grade of III
  • Study Designs the majority of studies were
    cross-sectional, evaluating QOL/Life satisfaction
    at a single time point.
  • Other issues affecting quality poor description
    of demographics (including age) and injury
    characteristics, mixed injury etiologies (1
    study),
  • Few studies used a comparison group (1 study used
    a non-disabled comparison, 2 studies used persons
    with spinal cord injury as comparison

79
Limitations
  • Aim/Objective of studies
  • Aging with a TBI, changes in life
    satisfaction/QOL as one ages with TBI, and
    relationship of age to life satisfaction/QOL was
    not the primary objective.
  • One study (Wood Rutterford,2006) examined
    demographic and cognitive predictors of
    psychosocial outcome following TBI

80
Limitations (cont.)
  • Terms/Measures
  • Life satisfaction/Quality of Life was
    operationally defined in only 1 study (Seibert,
    2002).
  • Life satisfaction/QOL measured differently across
    studies
  • - Satisfaction with Life Scale (5 studies)
  • - Life Satisfaction Index-A (2)
  • - LiSat11 Checklist (1)
  • - Life Satisfaction Checklist (1)
  • - Rand-36 item health survey (2)
  • - home grown measures (2)
  • for review, see Dijkers, MP 2004 Arch PMR

81
Limitations (cont.)
  • Length of follow-up period
  • Majority of studies reported only one follow-up
    after discharge from rehabilitation.
  • Majority of studies used 1 year (from D/C or
    anniversary of injury) as follow-up time point.
  • - Corrigan, 1998 examined changes over a 5 year
    period (sample stratified by time post
    discharge).
  • - Corrigan, 2001 conducted follow up at 1 and 2
    years.
  • - Tomberg, 2007 conducted follow up at 2 and 5
    years.

82
Findings
  • Findings regarding the association of age to life
    satisfaction/QOL are mixed.
  • - Age not a predictor of life satisfaction as
    measured by the SWLS (5 studies) or LiSat II (I
    study).
  • - Those who were older at time of injury
    reported higher life satisfaction/QOL (Burleigh,
    1997 using Life Satisfaction Index-A Heinemann,
    1995 Seibert, 2002 using measures developed
    specifically for the study)

83
Findings (cont.)
  • - Studies examining change in life satisfaction
    over time were mixed. Corrigan, 2001 and
    Tomberg, 2007 reported no significant change over
    time. Corrigan, 1998 reported significant change
    (decline year 1 followed by gradual increase up
    to year 5 using SWLS).
  • - Using RAND-36 (health-related QOL), younger
    reported greater level of physical health.

84
Additional Findings
  • Optimism increased over time (Tomberg, 2007)
  • Psychological growth associated with time from
    injury (Powell, 2007). Late (i.e., those
    assessed at 10-12 years post injury) showed
    positive change in appreciation of life,
    spirituality, relating to others, etc. as
    compared to early (those assessed 1-3 years
    post injury).

85
Gaps Future Directions
  • Asking the right question Age, aging with TBI,
    and association with life satisfaction/QOL as the
    primary aim/objective of study.
  • Prospective cohort/longitudinal design.
  • Duration and frequency of follow-up.
  • Operationally define SWL/QOL and select
    appropriate measures.
  • Account for changes that occur as one ages
    (without TBI)

86
2008 Galveston Brain Injury Conference
Emotional Functioning Aging with TBI
  • Moody Gardens Convention Center
  • Galveston Texas

87
Group 4 Subgroup Emotional Functioning
  • Teresa Ashman, PhD
  • Guido Mascialino, PhD
  • Mount Sinai School of Medicine

This presentation is supported in part by NIDRR
grants H133B040033 and H133A070083, as well as
CDC grant 1R 49CE 001171 to the Department of
Rehabilitation Medicine, Mount Sinai School of
Medicine, New York City.
88
Emotional Functioning Aging with TBI
  • Questions for the review
  • How does emotional functioning change across the
    life span for people who have experienced a TBI?
  • Are these changes associated with aging, not
    just recovery from TBI?
  • Are there differences in emotional functioning
    for different age cohorts after TBI?

89
Abstract Retrieval Review
  • Reviewed abstracts generated for Group IV which
    yielded three articles on emotional functioning.
    None of these met the criteria for the review.
  • Independent search identified 412 abstracts
    derived from a PubMed search using variants of
    search terms for TBI and emotional functioning
  • Reviewed 30 articles from the 412 abstracts

90
Abstract Retrieval Review (cont.)
  • Each of the 30 papers was reviewed for relevance
    using the following criteria
  • Age had to be documented in terms of age at
    injury, or current age and time since injury
  • Emotional functioning had to be documented for
    each participant at a baseline assessment and at
    each follow-up assessment
  • Only 6 met criteria for inclusion for in-depth
  • review
  • Only 4 were retained for the evidence tables
  • after closer review and scoring

91
Evaluation
  • STROBE procedures were used to evaluate the
    quality of these observational studies.
  • Evidence Tables were created for the 4 studies
    assessed to met criteria, including information
    on
  • Methods
  • Measures
  • Statistics
  • Findings
  • Limitations
  • Class of Study
  • AAN Grade
  • STROBE Rating
  • Subjective Rating
  • Study Design
  • Objectives
  • Inclusion Criteria
  • Exclusion Criteria
  • Sample Size
  • Severity of Injury
  • Age (at assessment or injury)
  • Gender

92
Emotional Functioning Articles
  • Number of Articles 4
  • Locations of Study
  • Australia - 2
  • Finland - 2
  • AAN Classifications
  • 4 Class III
  • Study Designs
  • 4 Cross-sectional

93
Aging with TBI Retrospective Follow-up
94
Cross-sectional and Retrospective Follow-up
95
Cross-sectional
96
Results
  • How does emotional functioning change across the
    life span for people who have experienced a TBI?
  • Most studies report that emotional functioning
    improves over time
  • Are these changes associated with aging, not just
    recovery from TBI?
  • None of the current literature can answer this
    question.
  • Are there differences in emotional functioning
    for different age cohorts after TBI?
  • In the one study that compared cohorts, there was
    lower rates of negative affect in the middle age
    and older cohorts as compared to the younger
    cohort.
  • However, rates for middle and older age groups
    with TBI was significantly greater than for their
    age-matched peers

97
Limitations
  • Lack of Longitudinal Studies
  • Lack of long-term longitudinal follow-up
  • Most follow-up is limited to 6 months up to 2
    years
  • Most follow-up studies do not have
    prospectively gathered baseline data
  • Often these follow-up studies have no baseline
    data
  • Samples
  • Small sample size
  • Lack of control group
  • Sampling bias who enrolls and who stays in over
    time
  • Variations in measures
  • Few use clinical assessments
  • Pre-injury prevalence usually missing

98
Recommendations for Future
  • Prospective studies that compare distinct age
    groups
  • Longer term prospective studies using within
    individual comparisons to measure change over
    time, not just group means
  • Age-matched control samples for each cohort of
    inquiry
  • Establishing measures for standard use within TBI
    (e.g., clinical assessment vs. self-report)
  • Reporting pre-injury functioning

99
Thank you
100
2008 Galveston Brain Injury Conference
  • Moody Gardens Convention Center
  • Galveston Texas

101
Community Integration and Aging
  • Timothy A. Reistetter, PhD, OTR
  • East Carolina University
  • University of Texas Medical Branch Galveston

102
Original Guiding Questions
  • Is there a significant relationship between age
    and community integration for adults (over the
    age of 50) who have sustained a traumatic brain
    injury?
  • Is there a difference between community
    integration at 2, 5 and 10 years after injury for
    those who sustain a TBI prior to age 30 compared
    to those who sustained a TBI at age 50 or later?

103
Abstract Retrieval Review
  • 709 abstracts Initial Group IV searches
  • Yielded 9 articles
  • Independent search Identified additional 72
    abstracts
  • 4 more articles, two use same data differently
  • (Fleming et al, 1999 Doig et al, 2001)
  • Total articles 13

104
Community Integration Articles
  • Number of Studies - 13 studies
  • AAN Classifications
  • 12 AAN III
  • 1 AAN IV
  • Study Designs
  • 10 cross-sectional
  • 3 cohort study
  • Location of Study
  • 2 Australia
  • 3 Canada
  • 1 Demark
  • 1 Israel
  • 1 UK
  • 5 US

105
Limitations
  • Lack of clear groups (young vs. old) explain
    differences
  • Lack of a control group
  • cannot know if association between age or time
    since injury community integration is due to
    TBI or other changes
  • Differences in measurement strategies between
    objective and subjective measures
  • Limited information on the longitudinal effects
    of TBI
  • Analysis differences between studies made
    comparisons of findings difficult.
  • Correlations
  • differences
  • regression techniques
  • cluster analysis

106
Instruments Employed
  • Community Integration Questionnaire (CIQ)
  • Craig Handicap Assessment and Reporting Technique
    (CHART)
  • Community Integration Measure (CIM)
  • Extended Activity of Daily Living Questionnaire
    (EADLQ)
  • European Brain Injury Questionnaire (EBIQ)
  • Health Activity Limitation Survey (HALS)
  • Sydney Psychosocial Reintegration Scale (SPRS)

107
Revised Question One Findings Connection Between
Age and CI
  • Younger individuals Higher social integration
  • Burleigh et al (1998) CIQ
  • Dawson et al (1995) HALS
  • Fleming et al (1999) Doig et al (2001) CIQ
  • Schmidt et al (1995) CIQ
  • Whiteneck et al (2004) CHART
  • Whiteneck et al (2006)
  • Older individuals Higher social integration
  • Winkler et al (2006) CIM, CIQ, SPRS
  • No significant difference or relationship
  • Hoofien et al (2002) EADL
  • Teasdale et al (2005) EBIQ

108
Revised Question Two Time Since Injury and
Community Integration
  • Five studies examine long term issues and
    community integration after TBI
  • Significant improvement in home integration from
    years 3 to 5 post injury - Corrigan et al (1998)
  • Longer time since injury - NOT a predictor of
    community integration - Devitt et al (2006)
  • Significant increase in isolation at 10 years
    with traumatic cerebral lesions - Teasdale
    Engberg (2005)
  • Increasing years since injury is connected with
    lower social participation greater perceived
    barriers - Whiteneck et al (2006)
  • 10 years post injury relationship status
    predicted community integration In a
    relationship had lower community integration -
    Wood Rutherford (2006)

109
Considering Age and Community Integration
  • Younger individuals had higher communality
    integration
  • Instruments objective
  • Design consistent with ICF or disability based
    measures.
  • When older individuals did better
  • One instrument was subjective (CIM)
  • One instrument measured change (SPRS)
  • One measure was objective (CIQ)
  • When there was no relation
  • Measuring the quality of relationships
  • Select items from a population survey

110
Considering Time Since Injury and Community
Integration
  • Results mixed
  • Some studies Steady improvement in one or more
    area of community integration
  • Some studies No relation
  • Others Declines in social integration
  • Two studies linking changes to additional areas
  • Relationships
  • Perceived barriers

111
Additional Findings
  • Several Studies attempted to predict future
    community integration scores using age or time in
    the equation
  • Three studies indicate that age DID NOT
    contribute to prediction of community integration
  • Devitt et al (2006)
  • Hoofien et al (2002)
  • Wood Rutterford (2006)
  • Age alone predicted community integration
  • Fleming et al (1999)
  • Age with PTA predicted community integration
  • Winkler et al (2006)

112
Future Considerations Questions
  • Need for prospective studies with typical older
    adult controls
  • Considerations of measurement approaches with
    older adults
  • Objective measures
  • Subjective measures
  • Longitudinal studies are needed
  • Researcher looking at barriers and supports
  • Attitudinal
  • Environmental
  • Community mobility
  • Relationships

113
Post-TBI Vocational Status and Aging
  • Margaret Brown, Ph.D.
  • Mount Sinai School of Medicine

This presentation is supported in part by NIDRR
grants H133B040033 and H133A070083, as well as
CDC grant 1R 49CE 001171 to the Department of
Rehabilitation Medicine, Mount Sinai School of
Medicine, New York City.
114
Question Nos. 1a and 1b
1a.How do the vocational changes associated with
normal aging across the life span differ for
people who have experienced a TBI, particularly
within the prime productive years (18-65)? 1b.How
do we know that these changes are associated with
aging, not just recovery from TBI?
115
Question Nos. 1a and 1b
  • Only one study addressed 1a, and none addressed
    1b
  • McLeod et al., 2004 focuses on retention in the
    British military, comparing soldiers with TBI or
    orthopedic injuries and healthy soldiers, over
    six years

116
Question Nos. 1a and 1b
  • Problems
  • Narrow focus military
  • Narrow age range approximately 17-39
  • Therefore, provides limited evidence on aging
    after TBI and how that affects vocational
    functioning

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How to Proceed?
  • Does the person experience TBI differently across
    the productive years in terms of vocational
    outcome?
  • Several reviews focus on how age affects
    vocational status
  • Results of reviews (1) being older at TOI is
    problematic, OR (2) age has no effect on return
    to productivity

118
Question Nos. 2 and 3
  • Does age predict return to pre-injury vocational
    status? (ie, pre-post analyses)
  • Does age predict achieving a productive vs
    non-productive status post injury? (ie, post
    injury only)

119
Procedure Followed
  • Reviewed all abstracts generated in the Texas
    search for Groups 1-5. Then reviewed hundreds
    more, based on my search of PubMed, using as
    search terms variants on TBI and variants on
    employment.
  • Judged the possible relevance of many hundreds of
    studies using the following preliminary criteria
  • Relationship between age and vocational status is
    probably analyzed, whether it is the primary
    focus or not
  • Excluded studies that clearly constituted a
    follow-up of people injured in childhood

120
Procedure Followed
  • The full paper was obtained for the abstracts
    that passed muster, plus additional relevant
    publications cited in the review articles. Each
    of 106 papers was reviewed for relevance using
    the following criteria
  • Confirmation of preliminary relevance review
  • No mixed etiologies, unless data from the TBI
    group was separately analyzed
  • Age had to be documented in terms of age at TOI,
    current age or time since injury (as a proxy for
    age)
  • For Question 2, vocational status had to be
    documented for each participant at TOI and at
    each point of follow-up

121
Procedure Followed
  • 46 studies were judged relevant. Each was
    evaluated for quality of evidence bearing on the
    age x vocational analysis only, using the
    following criteria (numbers refer to codes in
    evidence tables
  • 1 Vocational status variable is objective
    (neutral rating) vs a subjective judgment (eg,
    rating the persons voc. potential) (-)
  • 2 Sample size gt 100 () vs lt100 (-)
  • 3 Mean age 30-39 () vs lt30 or gt39 (-)
  • 4 Range restricted eg, 15-35 (-) vs broad
    eg, 16-60 ()
  • 5 Transition problems I.e., unsuccessfully
    addressing the problem of inappropriately
    classifying a normal change in vocational
    status as a success post TBI or a failure due
    to TBI eg, retiring at age 65 being classified
    as a poor outcome, when it may have had nothing
    to do with the injury -- no problem () vs
    potential or actual problem (-)

122
Procedure Followed
  • Evaluation criteria (continued)
  • 6 Severity of injury mild, moderate OR severe
    () vs moderate-severe OR all severities (-)
  • 7 Data source TBI registries or TBI MS (),
    military or all graduates of an ER visit (-),
    all others (neutral)
  • 8 Follow-up No reference is made to FU sample
    being compared to sample from which it was drawn
    (-), analysis of FU sample was done but
    differences not clear (neutral), description of
    FU sample indicated no difference or minor
    differences compared to full sample ()
  • 9 Time of FU lt 5yrs (-) vs 5 yrs ()

123
Procedure Followed
  • Evaluation criteria (continued)
  • 10 Number of points of FU at which vocational
    status is assessed One (-) vs two or more --
    cross-sectional or longitudinal ()
  • 11 Appropriateness of analysis analysis by
    logistic regression, by age group or other
    methods to avoid weakness of correlational
    approaches (), analysis by outcome group
    (neutral), correlational (-)
  • 12 Purpose of study primary focus on age x
    vocational status (), age is one predictor of
    several (neutral), age is solely a correlate (eg,
    in a regression analysis) (-)

124
Procedure Followed
  • Rated each study based on Criteria 1-12, focusing
    solely on the age x vocational analysis only
    6-pt scale, where 5 indicates most useful
    findings in addressing Questions 2 and 3, and 0
    indicates the study was not at all useful, based
    on criteria such as restricted age range,
    specialized sample (eg, military), etc. 36
    studies rated 1-5 10 studies were dropped.
  • Selected best studies from the 36 acceptable,
    based on the following criteria
  • An overall rating of 3 or higher
  • Transition problems were avoided ( on Criterion
    5)
  • No sole focus on time since injury (as age
    proxy)

125
Procedure Followed
  • 13 studies passed muster
  • Asikainen, Kaste Sarna, 1996, 1998
  • Bogner, Corrigan, Mysiw, Clinchot Fugate, 2003
  • Corrigan, Lineberry, Kormaroff, Langlois,
    Selassie Wood, 2007
  • Dawson, Schwartz, Winocur Stuss, 2007
  • Greenspan, Wrigley, Kresnow, Branche-Dorsey
    Fine, 1996
  • Keyser-Marcus, Bricout, Wehman, et a., 2002
  • Kreutzer, Marwitz, Walker, et al. 2003
  • Sherer, Yablon, Nakase-Richardson Nick, 2008
  • Skeel, Bounds, Johnstone, Lloyd Harns, 2003
  • Teasdale Engberg, Brain Injury, 19, 1041-1048,
    2005
  • Tennant, MacDermott Neary, 1995
  • Wood Rutterford, 2006

126
Procedure Followed
  • Results of looking at all 13 Same conclusions as
    in prior reviews Some showed no effect of age on
    outcome others found that younger did better
    than older in achieving post-TBI productivity.
  • In line with a suggestion by Ruff et al. (1993)
    that it is easier to return to school than to
    work, I formulated the hypothesis that if the
    vocational variable selected in a study included
    school as a good outcome, the results would
    indicate that younger people did better but if
    the vocational outcome selected focused solely on
    achieving or returning to employment, the results
    would suggest that age had no relationship with
    vocational status at FU.

127
Conclusions
  • Results from the table included in handout
    indicate that the hypothesis held for 10 of 13
    studies.
  • Where the hypothesis missed, more complex
    vocational status measures had been used (rather
    than Yes/No) or more complex analyses had been
    implemented
  • Using more complex outcome measures, both the
    Dawson and the Kreutzer studies found similar
    results younger people achieve a productivity
    status with problems, while older people achieve
    a productivity status with no problems or fail to
    achieve a productive status
  • The Corrigan study revealed very complex
    findings productive hours decreased by age
    group, but mostly for women for the latter, as
    age groups got older, women were more likely to
    be employed than in younger age groups
  • Overall conclusions

    ? No age relationship when
    employment is the focus
  • ? Younger do better if productivity, including
    school, is the outcome measure selected

128
The Consequences of TBI Occurring to the Elderly
A Systematic Review
  • Marcel Dijkers Ph.D.
  • Joshua Cantor Ph.D.
  • Mary Hibbard Ph.D.
  • Stacy Belkonen PhD
  • Adam Warshowsky PhD
  • David Layman PhD
  • (group 5)

129
Source
  • Interim projections consistent with Census 2000,
    Table 2a. Projected Population of the United
    States, by Age and Sex 2000 to 2050 (released
    March 2004)
  • http//www.census.gov/ipc/www/usinterimproj/natpro
    jtab02a.xls

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Source
  • Langlois JA, Rutland-Brown W, Thomas KE.
    Traumatic Brain Injury in the United States
    Emergency Department Visits, Hospitalizations,
    and Deaths. Atlanta (GA) Centers for Disease
    Control and Prevention, National Center for
    Injury Prevention and Control 2006.

135
Average annual TBI-related rates for ED visits,
hospitalizations, and deaths, by age group and
external cause, US, 19952001
136
Motor vehicle traffic 9
Unknown 21
Falls 52
Other 17
Assault 1
137
Shameless Plug
  • Help Seniors Live Better, Longer Prevent Brain
    Injury CDC initiative to raise awareness among
    children and other caregivers of older adults
    about ways to prevent, recognize, and respond to
    TBI in adults 75 and older
  • CDC has developed easy-to-use English- and
    Spanish-language materials for older adults and
    their caregivers
  • Questionand-answer format to provide information
    that older adults and their caregivers can use to
    take an active role in preventing, recognizing,
    and responding to TBI

138
Average annual TBI-related rates for ED-visits,
hospitalizations, and deaths, by age group,
United States, 19952001
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The Aging Brain Anatomy and Functioning
  • Dura becomes more adherent to skull
  • Bridging veins more exposed
  • Decreasing synaptic density and neural plasticity
  • Decreased production of nerve growth factor
  • Decreased cerebral perfusion
  • decreased cognitive capacity
  • increased risk for TBI

144
Community-dwelling Elderly (65) Population (US)
  • Arthritis 48
  • Hypertension 36
  • Coronary disease 27
  • Diabetes 10
  • Post-CVA 6
  • Parkinsons
  • Polypharmacy

145
  • Chronic disorder (and their treatments)
  • ?
  • Physical/cognitive disability
  • ?
  • Falls, traffic mishaps
  • ?
  • TBI
  • TBI 65 population even higher rate of chronic
    illness, cognitive and physical disability
  • TBI 65 population significant comorbidities to
    affect survival, LOS and outcomes of acute care
    and rehabilitation

146
Systematic Review Criteria, Group 5
  • Primary quantitative data
  • Status of elder group abstractable
  • No graphs
  • No correlations
  • Index TBI incurred at age 60 or over
  • 50 or 55 often criterion for older adult
  • At least 10 cases reported on (omitting case
    studies, small case series)

147
Systematic review criteria
  • Focus on natural history, treatments, status
    after emergency/acute care
  • Not epidemiology
  • Not ED, neurosurgical etc. treatment
  • Not TBI as potential cause of Alzheimers, other
    dementia (group 1)

148
Systematic Review Questions
  • Is a good outcome possible for elderly? From
    mild-moderate-severe TBI?
  • Do elderly people have worse outcomes than
    younger age groups?
  • How does recovery of the elderly compare to that
    of other adults, in terms of
  • Specific areas
  • Recovery course

149
Systematic Review Questions
  • What factors determine outcomes for the elderly?
  • Severity of injury
  • Age
  • Associated injuries
  • Pre-injury health status
  • Pre-injury cognitive and functional status
  • Does (mild) TBI add to the burden of an already
    diminished functional/ health status of elderly
    people?

150
Systematic Review Questions
  • What are the rehabilitation needs of elderly with
    TBI? Do elderly people require/benefit from
    special rehabilitation programs?
  • Are the elderly referred to rehabilitation
    services based on need and likelihood of success
    (rather than ageism)

151
Systematic Review Methods
  • Standard methodology for this project
  • Added searches for studies
  • References in chapters on TBI in the elderly
  • Search (in MedLine, CINAHL, PsycINFO) for TBI AND
    old/aging/aged/eld
  • Scan of papers reporting on large series of cases
    for tabulations showing treatments, outcomes,
    etc. by age category

152
Group 5 Data Abstraction Form
  • Year(s) of data collection _______ Country
    _______
  • Study objective ________________________________
  • Study design _________________________________
  • Statistical analysis ____________________________
    _
  • Elderly TBI group
  • Incl. criteria 1. ___________ 2. __________
    3. _____________ 4. ______________
  • Excl. criteria 1. ___________ 2. __________
    3. _____________ 4. ______________
  • N of cases total ______ attrition _____
    mean/median time since onset range ________
  • N male _______ N female ________ age range
    ________ mean/median age ________
  • severity measure ______________ N mild _______
    N mod. _______ N sev. _______
  • premorbid status-cogn __ not assessed __
    assessed _______________________________
  • premorbid status-phys __ not assessed __
    assessed _______________________________
  • Comparison group
  • nature __________________________________________
    ____ ___ (check if none)
  • (same as for elderly TBI group)

153
Group 5 Data Abstraction Form
154
Group 5 Data Abstraction Form
155
Group 5 Data Abstraction Form
156
Group 5 Data Abstraction Form
157
Group 5 Data Abstraction Form
158
Group 5 Data Abstraction Form
159
The Quality of the Evidence
  • 32 papers selected
  • Mean SD STROBE score 0.62 /- 0.15
  • AAN grades
  • I (strong) 0
  • II 4
  • III 68
  • IV (weak) 29
  • Global quality scores
  • 5 (excellent) 0
  • 4 27
  • 3 40
  • 2 27
  • 1 (very poor) 7

160
Question 1
  • Is a good outcome possible for elderly? From
    mild-moderate-severe TBI?

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Question 1
  • Is a good outcome possible for elderly? From
    mild-moderate-severe TBI?
  • Severe Good Recovery is exceptional
  • Moderate Good Recovery for 50
  • Mild Good Recovery for 80

168
Question 2
  • Do elderly people have worse outcomes than
    younger age groups?

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Question 2
  • Do elderly people have worse outcomes than
    younger age groups?
  • Yes in all GCS severity groups, in terms of GOS
    at hospital discharge and later post injury

175
Question 3
  • How does recovery of the elderly compare to that
    of other adults, in terms of
  • Specific areas
  • Recovery curve

176
Question 3
  • How does recovery of the elderly compare to that
    of other adults, in terms of
  • Specific areas
  • Recovery curve

177
Question 4
  • What factors determine outcomes for this group
  • Severity of injury
  • Age
  • Associated injuries
  • Pre-injury health status
  • Pre-injury cognitive and functional status
  • Do elderly people require/benefit from special
    rehabilitation programs?

178
Question 4
  • What factors determine outcomes for this group
  • Severity of injury YES
  • Age YES
  • Exact interaction of age and severity unknown
  • Associated injuries insufficient information
  • Pre-injury health status insufficient
    information
  • Use of anticoagulants major risk factor
  • Pre-injury cognitive and functional status
    insufficient information

179
Question 5
  • Does (mild) TBI add to the burden of an already
    diminished functional/ health status of elderly
    people?

180
Question 5
  • Does (mild) TBI add to the burden of an already
    diminished functional/ health status of elderly
    people?
  • Insufficient information

181
Question 6
  • What are the rehabilitation needs of elderly with
    TBI? Do elderly people require/benefit from
    special rehabilitation programs?

182
Question 6
  • What are the rehabilitation needs of elderly with
    TBI?
  • No evidence
  • Do elderly people require/benefit from special
    rehabilitation programs?
  • No evidence

183
Question 7
  • Are the elderly referred to rehabilitation
    services based on need and likelihood of success
    (rather than ageism)

184
Question 7
  • Are the elderly referred to rehabilitation
    services based on need and likelihood of success
    (rather than ageism)
  • No evidence

185
Discussion Shortcomings of Existing Studies
  • Mostly clinical case series
  • Retrospective designs
  • Small number of cases (at least for 60 group)
  • No or inadequate reference/comparison groups
  • Severity of injury unknown / variable / various
    measures used
  • Variability in groups studied
  • Age composition
  • Other characteristics relevant to outcomes, e.g.
  • Premorbid IQ
  • Premorbid health status
  • Social support

186
Discussion Shortcomings of Existing Studies
  • Variability of outcome measures used
  • GOS common, but too gross, variable timing
  • Correlations of age with outcomes often reported,
    without determining linearity of correlation
  • Especially problematic because often the number
    of cases 60 is quite small

187
Functions that all will produce a positive
correlation
Age
Age
Age
188
The Big Picture
  • Limited information on post-hospitalization
    functioning other than GOS (ADLs, participation,
    cognitive functioning)
  • Limited information on the effects of mild injury
  • Limited/no information on the impact of
    pre-injury morbidities on
  • Survival
  • Hospital course
  • Post-hospitalization functioning

189
The Big Question
  • Should the Galveston group (supplemented by other
    experts) issue guidelines for studies relevant
    to
  • Control group(s) (nature)
  • Age cut-off points for/in elderly
  • Minimum (retrospective) pre-TBI status
    (cognitive, social, mood, physical) assessment
  • Key outcome measures
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