Slide 1
The Changing VA Population:
Young, Active Duty and Brain Injured
or
It’s A Co-Morbid World
Harriet Katz Zeiner, PhD
Slide 2
There’s a New Population in Town And They Require Systemic Change To Deal With Them Effectively
Why?
How Big Is The Problem?
Why Won’t The Old Ways Work?
What Do I Have To Change To Deal Effectively With Them?
Slide 3
While serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), military service members are sustaining multiple severe injuries as a result of explosions and blasts.
Slide 4
Improvised explosive devices, blasts, landmines and fragments account for 65% of combat injuries
(Peake JB, N Engl J Med 2005 jan 20, 352 (3):219-222)
Slide 5
Of these injured military personnel, 60% have some degree of traumatic brain injury
http://www.dvbic.org
Slide 6
If the War Ended Today:
30,000 WIA
65% of these are IED = 19,500
60% of IED injuries involve head injuries = 11,070
1500 combat-wounded polytrauma patients have been treated at the 4 PRCs
Currently, 10,200 people with head injury have been discharged home—and don’t know why they think, feel and behave differently
* These numbers are from April 2008-Underestimate since only includes the wounded, not the exposed
Slide 7
10,000 people with undiagnosed mild TBI have been sent home.
Mild TBI refers to the time period of unconsciousness, not to the effects on the person’s life.
Mild TBI can have MAJOR impact on marriages, jobs, relationships, children and roles
This is not a political issue—it is a major health care problem in America, which the VA is charged to deal with.
Slide 8
Occult (Hidden) Brain Injury
How many people with TBI you find depends on whether or not you are looking
Degree to which you look is the degree to which you find
If your facility uses PTSD/BI screen, you will find them in the outpatient clinics—at a large VA the rate is 10 new cases per month
Slide 9
Clinical Reminder
Did the Vet serve in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) after Sept 11, 2001?
Afghanistan
Iraq
Kuwait
Saudi Arabia
Turkey
Other OIF services
Slide 10
PTSD Screen
Have you had an experience in the past month that was so frightening or upsetting that you:
Had nightmares or unwanted thoughts
Went out of your way to avoid reminders
Constantly on guard, watchful, or easily startled
Felt numb or detached from others
Slide 11
Brain Injury Screen
Did you have any injuries during your deployment from:
Fragments
Bullets
Vehicular crash including airplane
Fall
Blast (IED, RPG, grenade, land mine)
Other injury
Slide 12
Brain Injury Screen
Did any injury result in:
Being dazed, confused, seeing stars
Not remembering the injury
Losing consciousness for any amount of time
Concussion
Head injury
Slide 13
Brain Injury Screen
Are you experiencing any of the following from a head injury/concussion:
Headaches
Dizziness
Memory problems
Balance problems
Ringing in the ears
Irritability
Sleep problems
Other
Slide 14
Occult (Hidden) Brain Injury
Half the patients with head injury will be blast exposed
Half will be the result of motor vehicle accidents
Slide 15
There are also a large number of post-combat head injuries
Look for an unusually large number of motor vehicle accidents with head injuries in recently-returned Iraq/Afghanistan returnees—within 1 month of discharge and return home.
The army reports a 70% increase in motor vehicle accidents
Slide 16
Issues for Brain-Injured Active Duty/Vets:
Problems in memory
Problems in attention
Problems in problem solving
Problems in social appropriateness
Problems in organization
Problems in fatigue
Slowed speed of information processing
Anger outbursts
Slide 17
What Does BI Do to People?
Unable to utilize the medical system as it was constituted
Difficulty in maintaining social roles, marriages
Difficulty holding jobs
Difficulty in school/training (vocational/college/WBRC)
Slide 18
The four Traumatic Brain Injury Centers within the VA had already treated a majority of the severely combat injured requiring inpatient rehabilitation
Since Desert Storm (Iraq 1) 1992
Slide 19
The VA reorganized the TBI lead centers Polytrauma Rehabilitation Centers, dividing the USA into 4 geographical zones
Palo Alto VAHCS, CA
Maguire VAMC, Richmond VA
James Haley VAMC, Tampa FL
Minneapolis VAMC, Minneapolis MN
Slide 20
VISN
VA integrated system network
(Slide graphic)
Map of the United States showing the network: 1 (ME, VT, NH, MA, CT), 2 (NY), 3
4 (PA, DE, WV,
Slide 21
Polytrauma Network Sites (PNS)
Each PNS Team consists of:
Physiarist
Neuropsychologist
Occupational Therapist
Case Manager
Social Worker
Physical Therapist
Speech Pathologist
Prosthetist
Slide 22
The Mission of the Polytrauma Center
Provide comprehensive inpatient rehabilitation services for individuals with complex physical and mental health sequelae of severe and disabling trauma and provide support to their families.
Slide 23
Intensive case management is essential to coordinate complex components of care for polytrauma patients and their families
Coordination of care from combat theater to acute hospitalization to acute rehabilitation to his/her home community ultimately MUST OCCUR SEAMLESSLY
The treatment of brain injury sequelae needs to occur before or in conjunction with rehabilitation of other disabling conditions
Slide 24
IED Mechanisms of Injury
1. Dynamic pressure wave
2. Shrapnel
3. Acceleration / De-acceleration injury from hitting objects
4. Crush injuries from collapsing buildings
Slide 25
Polytrauma Sequelae
Auditory: TM rupture, ossicular disruption, cochlear damage, foreign body
Eye, Orbit, Face: Perforated globe, foreign body, air embolism, fractures
Respiratory: Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of embolism), airway epithelial damage, aspiration pneumonitis, sepsis
Slide 26
Digestive: Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism
Circulatory: Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypertension, peripheral vascular injury, air embolism induced injury
Slide 27
CNS injury: Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism induced injury, anoxia, hypoxia
Slide 28
Renal injury: Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia
Extremity injury: Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism induced injury
Slide 29
Who Are The Head Injured?
18-25 age group
Active duty Army
Marines
35-45 age group
National Guard
National Reserve
20% are women
Family constellations are different
Slide 30
Culture Clash (Old VA vs New VA)
Communication among patients who band together like birds in a flock
They Google you and everything you say.
Get used to being challenged—it’s a sign of their involvement in the process.
Slide 31
They are in the early stages of adult development
Issues of late adolescence—separation, anger, appearance, jewelry, body piercing, make-up, clothes—in VA setting
First job, beginning job skills
Worried about appearance, “date-ability”—developmental task is to find a partner
Slide 32
Problems for women in the military:
Pregnancy
Family with children
Vocation (MOS)
Friendly fire issues
Sexual harassment
Rape
Slide 33
Problems for women who sustain brain injury in the military
Seen as insubordinate
Seen as lazy
Seen as disorganized
Seen as passive
Frequently demoted or threatened with court martial—offered separation as an alternative
Slide 34
Problems for women who sustain brain injury in the military
Several were offered separation for pregnancy—no mention of brain injury
C&P affected
No service connection for brain injury
Slide 35
Issues for Women Warriors on Polytrauma
Too open and vulnerable for civilian world
Don’t read social or sexual cues
Give out wrong sexual cues—wrong means “unintended cues”
Gum-balling—saying what you think
Slide 36
Issues for Women Warriors on Polytrauma
Failure to use birth control
Failure to self-protect during sex: STD, HIV
No memory of pregnancy
No memory of infant daughter’s first milestones
Slide 37
Issues for Women Warriors on Polytrauma
Women Warriors are different in the abilities they bring to war—they are not simply “little men”
Women Warriors are different in how they are treated in the military after they sustain an unrecognized head injury
Women Warriors have different social issues and place in society, and their head injuries affect them in their roles and in their place in the family and society
Slide 38
Training of Staff
Not just clinical staff—all staff needs training in:
Polytrauma/Co-morbidity
Traumatic Brain Injury (TBI)
Post Traumatic Stress Disorder (PTSD)
Issues of late adolescence
Military vs civilian culture
Slide 39
Issues for Brain-Injured Active Duty/Vets:
Problems in Visuo spatial functioning
Problems in memory
Problems in attention
Problems in problem solving
Problems in social appropriateness
Problems in organization
Problems in fatigue
Slowed speed of information processing
Anger outbursts
Slide 40
One of the major difficulties in
assessing BI is that
symptoms of BI are not
pathognomonic,
and are often
confused with psychiatric
symptoms.
Slide 41
This can have several negative effects:
People may be placed on inappropriate medications that do not treat the symptomatology
They can be inappropriately labeled with a psychiatric diagnosis
They have no understanding about the nature and course of the cognitive and emotional changes that have occurred
Slide 42
For Community College/Educational Centers:
This means the presence of students who have no idea what their learning and memory characteristics are.
Slide 43
The purpose of this next section is:
To present the most common “complaints” regarding changes in behavior, function, and personality that result from TBI.
Slide 44
Teachers, family members, employers of people with Mild TBI, often complain of “personality” changes.
When questioned specifically, they mention:
fatigue
anger
emotional outbursts
problems with concentration/attention
slowed information processing
memory problems
Spatial perception problems
Slide 45
1. Why are people with TBI so tired all the time?
Slide 46
Fatigue:
Many of the cognitive functions, which are automatic and reflexive for people without cognitive impairment,
take 2-3 times the mental effort for people with TBI.
This is due to the fact that people with TBI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.
Slide 47
All thinking requires some expenditure of mental energy:
Paying attention,
Switching attention to a new person,
Keeping up with the topic of conversation,
Organizing an answer to a question,
Making a decision,
Trying to decide what to do next,
Organizing your day’s activities
Slide 48
Concept of Energy Budget
Slide 49
How to Compensate for the TBI Symptom of Fatigue.
Make important decisions when the person has the greatest amount of mental energy, usually in the morning.
Make as many activities as possible into a routine to minimize choice. This saves mental energy.
Do not fill up the student’s day with scheduled activities.
Do one important thing/day
The use of an organizer, either written, taped or electronic is essential.
Slide 50
2. Why are people with TBI angry so much of the time?
Slide 51
Cognitive deficits —
slowed rate of information processing, reduced span of attention, loss of the ability to multitask (“Now I’m a one-trick pony”), memory problems for new information, visual-spatial difficulty in perceiving the environment —
all serve to make the world seem a more difficult place to comprehend.
The anger expressed by people with TBI is often a symptom of stimulus overload.
Slide 52
“Catastrophic reactions”
are emotional responses of neurologically impaired people when the environment is too complex for them cognitively.
There are four variants:
silly laughing
flight
tears
anger
Slide 53
Intervention:
1. First, staff can point out the irritability, frustration, or anger when it occurs,
2. suggest to the student with BI that too much is coming at them too fast.
3. Delay, Simplify, or Avoid. Discuss later with resource person
4. Strike While the Iron Is Cold.
Slide 54
Staff can be taught to speak with pauses
(Speak as if you threw a handful of commas into your speech.)
When you pause in parts of the sentence, the person with BI can “catch up” in information processing.
Slide 55
The student can be asked to talk to people one-on-one
rather than in groups
speaking to two or more people places a strain on attentional mechanisms).
Slide 56
For recording:
1. Consider recommending Sony Digital Pro Duo recorders with Pro Duo card.
2. Puts lecture (audio) into MP3 file
3. Used in combination with Dragon Naturally speaking- puts audio into text form
4. Can transfer lectures onto IPod
5. Parrot Electronic Calendars
Slide 57
Other Sources of Anger
Disability is So Unfair!
Slide 58
TBI often challenges people’s assumptions about how the world works. We all hold some false beliefs about the world, such as:
Slide 59
Life’s fair. This is untrue. In dealing with unfairness, it helps to change the frame of reference.
Slide 60
For example: Everyone who is alive today has beaten the odds. The odds are 100,000,000 to 1 that a particular sperm would fertilize the egg, which resulted in a particular individual. Those are the odds we all win at conception. After we are born, everything else is gratis, icing on the cake.
This is offered as an alternative viewpoint for those who feel cheated of a fair share of good health and long life with any untoward events.
Slide 61
Cognitive Disability
Reduced efficiency, pace and persistence of functioning
Decreased effectiveness in the performance of routine activities of daily living (ADLs)
Failure to adapt to novel or problematic situations
Slide 62
The Hallmark of Brain Injury is Inconsistency, not Incapacity-
Rather, the person is not reliable.
Slide 63
Swiss Cheese Model
Loan function only in the “holes”.
He/she who does the behavior is the one who gets “brain trained”.
It’s not about efficiency, it’s about building new circuits.
Slide 64
Changes in Learning and memory
Slide 65
Learning Changes
Slide 66
Learning/Memory: teaching new characteristics
Registration
working span (no. of bits or chunks)
effect of overage
no. of verbal stage commands (1,2,3)
Sawtooth learning curve of acquisition
New limits of asymptote (not 100%)
Massed vs. distributed practice
What was premorbid learning style
Passive vs. active learner (groups material)
Fatigability (effect on accuracy)
Over learning (repetitions to 100%, reps to over learning)
Slide 67
Learning/Memory: teaching new characteristics
Storage
Percent retention
Ability to abstract themes (relevant from irrelevant points
Slide 68
Learning/Memory: teaching new characteristics
Retrieval
Spontaneous recall
The role of association or context vs. rote memorization
Cueing effects- best modality, degree of completeness
Ability to recognize the correct answer
Slide 69
Learning/Memory: teaching new characteristics
Presence of procedural learning
Presence of emotional learning
Separation of verbal and motor learning
(Squire)
Effect of proactive interference
Slide 70
Learning/Memory: teaching new characteristics
Best Modality Route:
Visual, auditory,
Effect of writing
Modality of disturbance or distortion
Verification of accuracy
Slide 71
Qualitative Changes in Learning
Underwhelm don’t overwhelm
Too much means no learning
Rest breaks, small sessions of distributed , not massed, practice.
No cramming is possible!
Slide 72
Learning/Memory: Teaching New Characteristics
The primary memory compensation:
1. Student knows the characteristics of new memory functioning and
2. That he/she needs to compensate for the changes.
3. Primarily by requesting the world repeat, slow down, present itself in smaller bites.
Slide 73
Learning/Memory: teaching new characteristics
Use of a Memory book:
1. Used to record compensations and info to remember- not a diary.
2. (2) Loose leafs with dividers
3. Size you will carry
4. Calendar: day at a glance or week at a glance
Slide 74
Learning/Memory: teaching new characteristics
Use of a Memory book:
5. Record appointments
6. Break down projects
7. Review Today and Tomorrow after every meal
Slide 75
About Interventions
Whenever possible
Tie a compensation to a physiological response
Or
a negative feeling that is a symptom of overload.
This is what leads to generalization.
Slide 76
Learning/Memory: teaching new characteristics
Memory book: Use to record compensations.
Examples:
OT: Because your information processing is slow, you practiced writing your name as rapidly as possible, and we kept track of the times.
Slide 77
Learning/Memory: teaching new characteristics
Memory book: Use to record compensations.
Examples:
PT: Because you learn best when information is given in three steps, we worked on theses three steps in doing transfers today:
Step 1. Lock brakes