Apathy is a term that refers to a general state of not caring—lack of initiative or drive, limited activity or energy, and no motivation to work towards goals. In traumatic brain injury, apathy is common; it’s reported in as much as 71% of patients.

Traditionally, apathy has been detrimental to rehabilitation efforts because of the difficulties in getting the apathetic patient motivated enough to participate. And treatment of apathy itself has been extremely limited, with no guiding program for rehabilitation specialists to follow.

However, a recent experimental case study has shown that apathy can be treated effectively. The treatment used motivational interviewing techniques and external compensation in order to initiate and sustain goal-oriented behaviors. The motivational interviewing included one-on-one sessions where specific goals were created, progress was reviewed, and barriers were addressed. External compensation was provided in the form of reminder alerts in the patient’s PDA.

The treatment not only significantly reduced the patient’s apathy, it also improved his functional and cognitive scores as well. Although the treatment consumed a good deal of time and energy from the rehabilitation staff, the results showed that the investment of focused treatment could ultimately provide a more efficient rehabilitation program.

Lane-Brown A, & Tate R. Evaluation of an intervention for apathy after traumatic brain injury: A multiple-baseline, single-case experimental design. Journal of Head Trauma Rehabilitation. (April 2010).

Over the last 150 years, the mortality rate in severe traumatic brain injury has dropped by nearly 50%. The reasons for this drop are not hard to comprehend—better understanding of the brain, improved therapies, and new technologies have all contributed to more people surviving.

However, a recent review of research has shown that the trend for decreased mortality has not been a smooth decline. Instead, there have been four specific periods of time that have been punctuated by major changes in the understanding of medicine, and also by changes in culture and demographics.

The review found the following trends:

1. From the late 1800s to 1930, the average mortality rate fell 3% each decade. This drop appears to be related to an increased rejection of dangerous therapies such as extreme dehydration, trephination, or CSF drainage.
2. From 1930 to 1970, there was no change in the mortality rate. During this time period, improved therapies such as ventilations, basic brain scanning, and resuscitation had been introduced. Also, there was a sharp increase in the number of neurosurgeons available in hospital. However, these improvements were offset by a tremendous increase of brain injury deaths by motor vehicle accidents.
3. From 1970 to 1990, the average mortality rate fell 9%. This decrease is largely due to the introduction of the CT scan and ICP monitors. Additionally, research about better treatment was more efficiently circulated among clinicians.
4. From 1990 until now, there has been no change in the mortality rate. Considering the tremendous advances in understanding and technology, this trend is more difficult to understand. The increased number of older adults, controversial outcomes from certain safety measures (airbags), treatment selectivity (where certain cases might not be given aggressive treatment) may all be factors in keeping the mortality rate steady in light of improved technology.

Currently, the rate of mortality is about 35% in severe TBI. Despite our increased understanding of the mechanisms of brain injury, as well as the apparent advances in therapies, the mortality rate in severe TBI has been steady for the last 20 years.

Stein, SC, Georgoff P, Meghan S, Mizra K, & Sonnan SS. 150 Years of treating severe traumatic brain injury: A systematic review of progress in mortality. Journal of Neurotrauma. (May 2010).

The release of stress hormones (such as cortisol or norepinephrine) after a traumatic injury can induce stress hyperglycemia. Past research has shown that this state of elevated glucose has been related to increased medical complications and mortality rates.

A recent study from New York verified that serum glucose levels were useful in distinguishing major from minor traumatic injury at admission. Stress hyperglycemia was a sensitive predictor for major injury (just as sensitive as base deficit or lactate), suggesting that appropriate treatment could be administered earlier. In the early stages of traumatic brain injury, when complications such as secondary brain injury can quickly lead to further damage or death, a reliable diagnosis is critical. Glucose level is a potentially sensitive indicator of major injury that should be considered at admission.

Paladino L, Subramanian RA, Nabors S, Bhadwaj S, & Sinert R. Triage hyperglycemia as a prognostic indicator of major trauma. The Journal of Trauma: Injury, Infection, and Critical Care. (April 2010).

It is generally acknowledged that antipsychotic drugs can slow cognitive and motor recovery in patients with traumatic brain injury. Recent studies have shown that antipsychotic use is also associated with an increased risk of sudden cardiac death and stroke.

A commentary by Mel Glenn, MD was recently published in the Journal of Cognitive Rehabilitation, which stated that “Each of the 6 frequently used drugs (haloperidol, thioridazine, clozapine, quetiapine, olanzapine, and risperidone) had an increased rate” ratio of sudden cardiac death and stroke. It was noted that atypical antipsychotics, such as risperidone, carry an even greater risk than typical antipsychotics. Additionally, people aged 70-74 had a risk rate 10 times that of people aged 30-34.

It is not uncommon for a traumatic brain injury patient to be given antipsychotics as a behavioral intervention. Unfortunately, symptoms such as memory impairment, visual-spatial disorders, and changes in personality can be mistaken as symptoms of psychosis, and clinicians may often dispense an antipsychotic as a short- or long-term treatment. Although there may be a place for the use of antipsychotics in a crisis situation, alternative therapies should be considered before continuing treatment in the long-term.

Glenn, MB. Sudden cardiac death and stroke with the use of antipsychotic medications: Implications for clinicians treating individuals with traumatic brain injury. Journal of Head Trauma Rehabilitation. (January-February 2010).

Depression is a common complication following traumatic brain injury and it affects a person’s ability to function well. Depression may also lead to problems with sleep, memory, and social skills—creating a complicated tangle of post-traumatic symptoms. Past research has shown conflicting evidence about the relationship between depression and brain injury, especially when addressing a history of depression prior to injury.

Australian researchers recently interviewed 100 traumatic brain injury patients to better determine how well pre-injury depression predicted post-injury depression. They also wanted to know if there were any other factors that predisposed a survivor to depression.

They confirmed that a history of depression before the injury significantly increased the risk of depression after the injury. However, they also found that “female gender, lower education, pain, post-injury unemployment, and longer time since injury” were also associated with an increased risk of post-traumatic depression.

Considering that the rate of depression increased over the first few years after injury, continued screening of depression over the long-term should be available for brain injury survivors so that appropriate treatment could be put into place.

Furthermore, the study showed that severity of injury was not a good predictor of depression. One reason could be that survivors of mild traumatic brain injury try harder to recreate their pre-injury life, and are more prone to depression or anxiety when faced with limitations.

Whelan-Goodinson R, Ponsford JL, Schonberger M, & Johnston L. Predictors of psychiatric disorders following traumatic brain injury. Journal of Head Trauma Rehabilitation. (January 2010).

Traumatic Axonal injury associated with mild traumatic brain injury can be either hemorrhagic or non-hemorrhagic. While the axons themselves do not necessarily bleed when torn, small vessels in the vicinity may. The below article discusses the utility of CT scan as it applies to outcome and predictive outcome in mTBI. The authors confirm that other factors lead to a more accurate prognosis than CT scan. In fact, though not discussed, T-3 MRI will, in virtually all cases, demonstrate structural abnormality more accurately than CT scan in the mTBI case.

The CT scan has long been considered the “golden standard” for detecting abnormalities related to brain injury. However, clinicians and researchers have struggled to establish a good relationship between the results of a CT scan and the long-term prognosis of mild traumatic brain injury (mTBI).

A team of researchers from a leading medical center in the Netherlands recently studied the medical records of nearly 3,000 individuals with mTBI (those with a Glasgow Coma Scale score of 13-15). Their goal was to determine if the CT scan was a strong predictor of outcome six months after mTBI, and, if not—were there better predictors?

They found that the number of hemorrhagic contusions (fractures that cause bleeding in the skull) found using the CT scan was helpful in determining how well the mTBI patient recovered (the smaller the number, the better the recovery). However, age, extracranial injuries (injuries to the body), and day-of-injury alcohol intoxication were better predictors of recovery than CT scan results.

It is no surprise that older mTBI patients are less likely to have a good recovery than younger mTBI patients. It is also no surprise that mTBI patients with additional bodily injuries are less likely to have a good recovery. But that the presence of alcohol intoxication often predicts a good recovery was unexpected. The researchers suggest that alcohol intoxication in the patient could have lead to an underestimation of how severe the brain injury was at assessment.

In conclusion, their study outlined how factors other than CT scan results should be taken into consideration when determining how well a patient will recover.

Jacobs B, Beems T, Stulemeijer M, et al. Outcome prediction in mild traumatic brain injury: Age and clinical variables are stronger predictors than CT abnormalities. Journal of Neurotrauma. (December 2009).

On Wednesday, October 28, 2009, House Democrats introduced their consensus health bill, HR 3962, at a rally on the Capitol’s West Front. According to House Majority Leader, Steny Hoyer, the bill could be considered on the House floor as early as November 5,2009The consensus bill prohibits insurance rating based on health status or pre-existing conditions and prohibits annual or lifetime limits on medical spending. It also establishes important consumer protections, including internal and external appeal requirements, provider network adequacy requirements, and greater transparency by insurance companies.

BIAA will continue to monitor the situation closely and alert grassroots advocates if any action is necessary.

This week, BIAA submitted comments to the National Institute on Disability and Rehabilitation Research (NIDRR) specifically regarding the fourth priority included in the proposed plan for the Rehabilitation Research and Training Centers (RRTCs) entitled, “Developing Strategies to Foster Community Integration and Participation for Individuals with Traumatic Brain Injury.”

BIAA expressed strong support for the inclusion of a brain injury related research priority. However, BIAA also detailed some concerns related to the strategies used in the priority to foster community integration and participation for affected individuals. As proposed, this priority would develop a classification system based on symptoms experienced by individuals with TBI who are living in the community.

BIAA explained that no two brains are alike and each and every individual presents with different symptoms, and each injury results in different challenges. Therefore, trying to categorize these injuries could be counterproductive to the priority’s goal.

BIAA also suggested several suggestions in lieu of a categorization strategy. For further reading, the full text will be posted on BIAA’s web site shortly.

On Friday, May 15, 2009, BIAA submitted comments to the Senate Finance Committee in response to their proposed set of recommendations regarding health care delivery system reform.

BIAA expressed support for several recommendations with respect to the coordination of chronic conditions but also made clear within the submission that the organization is strongly opposed to the bundling of post-acute care as it applies to persons with brain injury.

To view the full document, click on the link below:

http://www.biausa.org/elements/policy/2009/biaa_finance_committee_response.pdf