The Changing Population:Young, Old, Active Duty and

Brain Injured.

By

Harriet Katz Zeiner, PhD

Harriet.Zeiner@va.gov

A traumatic brain injury (TBI) is a blow or a jolt to the head that temporarily or permanently disrupts brain function – i.e. who we are and how we think, act, and feel.

The injury is caused by falls, motor vehicle crashes, assaults and other incidents.

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?

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.

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)

Of these injured military personnel, 60% have some degree of traumatic brain

injury

www.dvbic.org

If the War Ended Today:

37,980WIA65% of these are IED = 24,68760% of IED injuries involve head injuries =

14,8122000 combat-wounded Polytrauma patients have been

treated at the 4 PRCs

Currently, over 12,000 people with head injury have been

discharged home with TBI from those identified as WIA

FROM THOSE IDENTIFIED AS WOUNDED—and many of them don’t know why they think, feel and behave differently

* These numbers are from June, 2010 from the DoD

Currently, over 12,000 people with head injury have been discharged home with TBI

FROM THOSE IDENTIFIED AS WOUNDED IN ACTION—

and many don’t know why they think, feel and behave differently

This does not include those exposed to blast who are not identified as WIA.

Estimates of Rand Corp in:*Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.” April 17, 2008

1. 1.6 million military personnel have been deployed since the war in Afghanistan began in late 2001.

2. 19% (320,000 service members) report experiencing a possible TBI while deployed. Range is from mild concussion to severe head wounds.

About 7% report both a probable TBI and PTSD or major depression.

Only 53% of service members with PTSD or Depression sought help over the past year.

Reasons cited:1. Worried about side effects of medication.2. Believe family and friends can help.3. Feared seeking help might damage their

careers.

320,000 service members report experiencing a possible TBI while deployed. Range is from mild concussion to severe head wounds.

Only 43% reported being evaluated by a physician for their head injuries.

Assuming all are concussions (they are not)Assuming they have been exposed to only

one blast, (unlikely), and only 25% show permanent effects=

320,000 x 25% = 80,000 people with undiagnosed mild TBI have been sent home

+12,000 undiagnosed from the WIA group=

92,000 with mild TBI sent home who don’t know they have a TBI.

Severity LOC AOC PTA

Mild 0-30 min < 24 hrs < 24 hrs

Moderate 30 mins-24 hrs >24 hrs 24 hrs- <7 days

Severe > 24 hrs >24 hrs > 7 days

LOC Loss of ConsciousnessAOC Alteration of ConsciousnessPTA Post Traumatic Amnesia

92,000 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.

Families are impacted severely, whether the diagnosis is mild, moderate or severe TBI. I will address issues of all three in my presentation.

PTSD ScreenHave 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

Brain Injury ScreenDid you have any injuries during your

deployment from:FragmentsBulletsVehicular crash including airplaneFallBlast (IED, RPG, grenade, land mine)Other injury

Brain Injury ScreenDid any injury result in:Being dazed, confused, seeing starsNot remembering the injuryLosing consciousness for any amount of timeConcussionHead injury

Brain Injury ScreenAre you experiencing any of the following

from a head injury/concussion:HeadachesDizzinessMemory problemsBalance problemsRinging in the earsIrritabilitySleep problemsOther

Clinical Reminders only cover OIF/OEFAdd the following:

1. Have you ever experienced loss of consciousness or been dazed during your military service?

2. Have you ever lost consciousness or been dazed after a fight, a fall, or during work or sports?

3. Have you ever been in a motor vehicle, motorcycle accident? Did you hit your head?

4. Have you ever had a fall when you’ve been drinking?

Moderate-Severe Brain InjuryHalf the patients with head injury will be

blast exposedHalf will be the result of motor vehicle

accidents

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

Only 5 out of 10 eligible for VA services choose them.

5/10 are choosing Tri-care or insurance through work or nothing.

Why Is This Important/ What Does this Mean?

This means 50% of all discharged OIF/OEF military personnel with either mild TBI or co-morbid TBI/PTSD will never be seen by the VA.

They will appear in the civilian sector, they will use non VA, non military therapists

They will come to a Vet Center

And, they usually do not complain of either TBI and/or PTSD to their therapists/physicians.

This is more than “ an out reach issue for the VA”

It means:

1. A massive need for therapists who can handle neurologically impaired patients.

2. And their families.3. A need for civilian institutions to

accommodate to those with mild brain injury.

92,000 military personnel with undiagnosed mild TBI have been sent home.

In the civilian population alone every year, more than 1.5 million people sustain brain injuries from falls, car crashes, assaults and contact sports. Males are more likely than females to sustain brain injuries. Children, teens and seniors are at greatest risk.

60 % of that 1.5 million people per year is 900,000 people, and their families affected by TBI

900,000 people, will experience the onset of a long term disability associated with a TBI.

This number per year in the civilian sector exceeds all the veterans with TBI from all the years combined total from Iraq and Afghanistan.

90,000 people, will experience the onset of a long term disability associated with a TBI.

This number per year in the civilian sector equals all the veterans with TBI from all the years combined total from Iraq and Afghanistan.

The number of U.S. Citizens likely to sustain a TBI is 5 times the total number of people

with multiple sclerosis, spinal cord injury, HIV/AIDS and breast cancer combined

•So prevalent

•Insurance coverage often doesn’t pay for it

•Physicians aren’t trained about TBI in medical school.

Issues for People with Brain-Injury:

Problems in memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger outbursts

What Does TBI Do to People?Unable to utilize the medical system as it was

constitutedDifficulty living independentlyDifficulty in maintaining social roles,

marriagesDifficulty holding jobsDifficulty in school (vocational/college)Difficulty navigating the legal system

Who Are The Head Injured?Civilians:18-34 age group most at risk for having a TBI

5x more men than women

Children and seniors are more likely to die

475,000 children each year in the U.S. sustain a TBI

TBI is the leading cause of death and disability among youngsters

Who Are The Head Injured?Military

18-25 age groupActive duty Army Marines

35-45 age groupNational GuardNational Reserve

20% are women

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

Problems for women with TBI:

PregnancyFamily with childrenVocation (MOS)Sexual harassmentRape

Problems for women who sustain brain injury in the military

Seen as insubordinateSeen as lazySeen as disorganizedSeen as passive

Frequently demoted or threatened with court martial—offered separation as an alternative

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

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”

Gumballing—saying what you think

Issues for Women Warriors on Polytrauma

Failure to use birth control

Failure to self-protect during sex: VD, HIV

No memory of pregnancy

No memory of infant daughter’s first milestones

Issues for Women Warriors on Polytrauma

Custody battles in divorce

Visitation versus care of children

Supervision of children and household

Driving and being dependent

Financial dependence

Being competent to make decisions over medical needs, legal needs, personal needs

Issues for Women Warriors who get a TBI

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

When confronted with patients with TBI, non rehabilitation psychologists/physicians frequently misdiagnose patients with neurological impairment with psychiatric diagnoses.

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 and offered behavioral therapy not designed for TBI

• They have no understanding about the nature and course of the cognitive and emotional changes that have occurred

What Does BI Do to People?Unable to utilize the medical system as it was

constitutedDifficulty in maintaining social roles,

marriagesDifficulty holding jobsDifficulty in school (vocational/college)Difficulty navigating legal systems

Difficulty in college/vocational school

Why Is This Important/ What Does this Mean?

75% of those enlisting in the volunteer military, did so to use educational benefits.

If they have mild TBI- or co-morbid TBI/PTSD, their learning/memory/attentional characteristics will have changed, and they won’t know it until they fail.

In CA, Pilot Project between Butte Community College and VA OutreachOIF/OEF Veterans with BI may take 12 units

of classes for a year without using GI benefits or paying tuition.

They are routed through Learning Resource Centers to learn “Study Habits”.

College receives money from state for students’ attendance.

Issues for Brain-Injured:

Problems in memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger outbursts

The purpose of this next section is:

To present the most common “complaints” regarding changes in behavior, function, and personality.

Why-

Because a major portion of the treatment of families who have a severely impaired member is psychoeducation about neurological impairment

Family members of people with TBI, often complain of “personality” changes.

When questioned specifically, they mention:

1. fatigue 2. anger 3. emotional outbursts 4. problems with concentration/attention5. slowed information processing6. memory problems

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.

Concept of Energy Budget

Compensation:Regularize the day/night cycle

Live by a routine, a schedule.

• Make important decisions when the survivor of TBI has the greatest amount of mental energy, usually in the morning.

Characteristics of Brain Injurythat Therapists/Doctors Will Have To Deal With

Inefficient memory: especially for appointments, episodic events

1. 3 missed appointments, clinics drop them2. Need for memory prostheses and training

(often too slow)3. Can’t come back later—they will

disappear; solve the issue now4. Allow tape recording of information

More Characteristics of Cognitive Impairmentthat Therapists Will Have To Deal With.

Slowed information processing-1. People with TBI need written back-up, not

densely packed2. Repetition,3. Tape recording of information- 4. Someone guiding them through the process.5. More dependence on a resource person,

counselor, buddy

Characteristics of Cognitive Impairmentthat Therapists Will Have To Deal With.

Attentional problems- 1. Can track one thing at a time,2. Forms are overwhelming- they don’t scan well3. Being sent multiple places is overwhelming

Characteristics of Cognitive Impairmentthat Therapists Will Have To Deal With.

Organizing Difficulty1. Don’t understand legal rules, school rules, work rules- these often require multitasking.2. Can follow a plan, but not come up with one3. If one part of solution is blocked, they

drop out

Bridge the Gap- Loan Them Your Organizing Ability

Communication Tips In Dealing With People With Cognitive Difficulty

1. Use every day language, not medical-ese or VA language:”Anyone in your shoes would need the stress load reduced”

instead of “You have PTSD” or, “Do you receive monthly money from the VA?” instead of “What percent service connected are you?” 2. Respond best to closed ended questions, choices. “Are you feeling good or bad today?”

Is better than “How are you?”

3. Slow your speech down with commas.