Ethical Considerations in Chronic Brain Injury.

A growing number of individuals are living with chronic traumatic brain injury. As these individuals and their families attempt to reintegrate into their communities, several ethical questions arise for clinicians and researchers. These include issues around alignment of perspectives and priorities, as well as responsibilities for ongoing treatment, education, community outreach, and research. An action plan for addressing these questions is outlined.

Longitudinal Effects of Medical Comorbidities on Functional Outcome and Life Satisfaction After Traumatic Brain Injury: An Individual Growth Curve Analysis of NIDILRR Traumatic Brain Injury Model System Data.

OBJECTIVE: To explore associations of specific physical and neuropsychiatric medical conditions to motor and cognitive functioning and life satisfaction over the first 10 years following traumatic brain injury (TBI). SETTING: Telephone follow-up through 6 TBI Model System centers. PARTICIPANTS: In total, 404 individuals or proxies with TBI enrolled in the TBI Model System longitudinal study participating in 10-year follow-up. DESIGN: Individual growth curve analysis. MAIN MEASURES: FIM Motor and Cognitive subscales, Satisfaction With Life Scales, and Medical and Mental Health Comorbidities Interview. RESULTS: Hypertension, diabetes, cancers, rheumatoid arthritis, and anxiety negatively affected the trajectory of motor functioning over time. Diabetes, cancers, chronic bronchitis, anxiety, and depression negatively impacted cognitive functioning. Numerous neuropsychiatric conditions (sleep disorder, alcoholism, drug addiction, anxiety, panic attacks, posttraumatic stress disorder, depression, and bipolar disorder), as well as hypertension, liver disease, and cancers, diminished life satisfaction. Other medical conditions had a negative effect on functioning and satisfaction at specific follow-up periods. CONCLUSION: Natural recovery after TBI may include delayed onset of functional decline or early recovery, followed by progressive deterioration, and is negatively affected by medical comorbidities. Results contribute to the growing evidence that TBI is most appropriately treated as a chronic medical condition complicated by a variety of comorbid conditions.

Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury: Examining Associations With Demographics, Healthcare Utilization, Institutionalization, and 1-Year Outcomes.

OBJECTIVES: To assess the relationship of acute complications, preexisting chronic diseases, and substance abuse with clinical and functional outcomes among adults 50 years and older with moderate-to-severe traumatic brain injury (TBI). DESIGN: Prospective cohort study. PARTICIPANTS: Adults 50 years and older with moderate-to-severe TBI (n = 2134). MEASURES: Clusters of comorbid health conditions empirically derived from non-injury International Classification of Diseases, Ninth Revision codes, demographic/injury variables, and outcome (acute and rehabilitation length of stay [LOS], Functional Independence Measure efficiency, posttraumatic amnesia [PTA] duration, institutionalization, rehospitalization, and Glasgow Outcome Scale-Extended (GOS-E) at 1 year). RESULTS: Individuals with greater acute hospital complication burden were more often middle-aged men, injured in motor vehicle accidents, and had longer LOS and PTA. These same individuals experienced higher rates of 1-year rehospitalization and greater odds of unfavorable GOS-E scores at 1 year. Those with greater chronic disease burden were more likely to be rehospitalized at 1 year. Individuals with more substance abuse burden were most often younger (eg, middle adulthood), black race, less educated, injured via motor vehicle accidents, and had an increased risk for institutionalization. CONCLUSION: Preexisting health conditions and acute complications contribute to TBI outcomes. This work provides a foundation to explore effects of comorbidity prevention and management on TBI recovery in older adults.

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury.

OBJECTIVE: To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation. DESIGN: Retrospective cohort. SETTING: Six TBI Model Systems (TBIMS) centers. PARTICIPANTS: In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity. RESULTS: At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders. CONCLUSIONS: People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

Relationship Between Hispanic Nativity, Residential Environment, and Productive Activity Among Individuals With Traumatic Brain Injury: A TBI Model Systems Study.

OBJECTIVE: To examine the influence of nativity and residential characteristics on productive activity among Hispanics at 1 year after traumatic brain injury (TBI). SETTING: Acute rehabilitation facilities and community follow-up. PARTICIPANTS: A total of 706 Hispanic individuals in the TBI Model Systems National Database. DESIGN: Secondary data analysis from a multicenter longitudinal cohort study. MAIN MEASURES: Nativity (foreign born or US native), productive activity derived from interview questions regarding employment status, and other demographic information. Census data were extracted by zip code to represent residential characteristics of aggregate household income and proportion of foreign language speakers (FLS). RESULTS: Among foreign-born individuals with TBI, those living in an area with a higher proportion of FLS were 2.8 times more likely to be productive than those living in areas with a lower proportion of FLS. Among individuals living in an area with a lower proportion of FLS, US-born Hispanics were 2.7 times more likely to be productive compared with Hispanic immigrants. CONCLUSION: The relationship between nativity and productive activity at 1 year post-TBI was moderated by the residential proportion of FLS. Findings underscore the importance of considering environmental factors when designing vocational rehabilitation interventions for Hispanics after TBI.

Epidemiology of Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury.

OBJECTIVES: Aging individuals with traumatic brain injury (TBI) experience multiple comorbidities that can affect recovery from injury. The objective of this study was to describe the most commonly co-occurring comorbid conditions among adults 50 years and older with TBI. SETTING: Level I Trauma centers. PARTICIPANTS: Adults 50 years and older with moderate/severe TBI enrolled in the TBI-Model Systems (TBI-MS) from 2007 to 2014 (n = 2134). DESIGN: A TBI-MS prospective cohort study. MAIN MEASURES: International Classification of Disease-9th Revision codes collapsed into 45 comorbidity categories. Comorbidity prevalence estimates and trend analyses were conducted by age strata (50-54, 55-64, 65-74, 75-84, ≥85 years). A dimension reduction method, Treelet Transform, classified clusters of comorbidities that tended to co-occur. RESULTS: The 3 most commonly occurring comorbid categories were hypertensive disease (52.6/100 persons), other diseases of the respiratory system (51.8/100 persons), and fluid component imbalances (43.7/100 persons). Treelet Transform classified 3 clusters of comorbid codes, broadly classified as (1) acute medical diseases/infections, (2) chronic conditions, and (3) substance abuse disorders. CONCLUSION: This study provides valuable insight into comorbid conditions that co-occur among adults 50 years and older with TBI and provides a foundation for future studies to explore how specific comorbidities affect TBI recovery.

Physical, Cognitive, and Psychosocial Characteristics Associated With Mortality in Chronic TBI Survivors: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To compare a group of individuals who died more than 1 year posttraumatic brain injury (TBI) with a matched group of survivors and to identify physical function, cognitive function, and/or psychosocial function variables associated with mortality. DESIGN: Secondary analysis of data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities and community follow-up. PARTICIPANTS: Individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM), Disability Rating Scale, Participation Assessment with Recombined Tools Objective, Extended Glasgow Outcome Scale, Satisfaction With Life Scale. RESULTS: Individuals who died were distinguishable from their surviving counterparts. They demonstrated significantly poorer global functioning on all physical, cognitive, and psychosocial functioning variables at their most recent study follow-up visit prior to death. FIM Motor demonstrated the largest difference between survival groups, suggesting that independence in mobility may be particularly indicative of likelihood of longer-term survival. CONCLUSIONS: These findings may inform continued research to elucidate functional characteristics of individuals postchronic TBI prior to their death and to identify opportunities for prevention of accelerated death and interventions to improve health, longevity, and quality of life.

Feasibility of a Skills-Based Group Reintegration Workshop for OEF/OIF Veterans: STEP-Home.

OBJECTIVE: To evaluate the feasibility of a newly developed reintegration workshop for Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) Veterans that is based on an evidence-based rehabilitation program shown to be effective in treating mild traumatic brain injury-related symptoms in civilians. Underutilization and resistance to mental health treatment remain a significant problem for OEF/OIF Veterans. Innovative, integrative, transdiagnostic, and acceptable interventions are needed, particularly for this heterogeneous group. PARTICIPANTS: Eighty-four OEF/OIF/Operation New Dawn Veterans (74 male and 10 female)-mean age = 35; standard deviation = 7.4. SETTING: VA Healthcare System. INTERVENTION: A 12-week, 2-hour/wk, group skills-based workshop with individual skill building to assist all OEF/OIF Veterans (with and without psychiatric and/or traumatic brain injury) in reintegration after military service. MAIN MEASURES: Primary outcomes were feasibility measures including treatment fidelity, acceptability, tolerability/adherence, and treatment-related skill acquisition. Secondary outcomes were interest and engagement in future treatment and reintegration status. RESULTS: Veterans' enrollment, adherence, and attrition data indicated that Short-Term Executive Plus adapted for Veteran civilian reintegration (STEP-Home) was acceptable and tolerable. Pre-/postintervention differences in attention, problem-solving, and emotional regulation skills demonstrated treatment-related skills acquisition. Secondary outcome data demonstrated Veterans who were hesitant to participate in mental health treatments before enrollment were more open to treatment engagement after STEP-Home, and reintegration status improved. CONCLUSIONS: This study demonstrated that the STEP-Home workshop is feasible in OEF/OIF Veterans and changes in treatment-related skill acquisition and reintegration status were observed. STEP-Home has potential to facilitate readjustment and serves as a gateway to additional, critically needed Veterans Administration services.

Improving Emotion Regulation Following Web-Based Group Intervention for Individuals With Traumatic Brain Injury.

OBJECTIVE: Preliminary evaluation of the efficacy of a Web-based group intervention (Online EmReg) to improve emotion regulation (ER) in individuals with traumatic brain injury (TBI). DESIGN: Pre-/post-within-subject design with baseline, end-of-treatment, and 12-week follow-up assessments. PARTICIPANTS: Ninety-one individuals with TBI and deficits in ER. INTERVENTION: Twenty-four sessions of training in ER skills delivered by group videoconference. MEASURES: Difficulties in Emotion Regulation Scale (DERS), Positive Affect Negative Affect Schedule (PANAS), Satisfaction With Life Scale (SWLS), Problem Solving Inventory (PSI), Social Problem Solving Inventory-Revised: Short Form (SPSI-R:S), and Dysexecutive Questionnaire (DEX). RESULTS: Significant changes with large effect sizes were found for the DERS at the 12-week follow-up assessment. Significant and moderate changes were found on the SWLS, DEX, PSI, and subscales of the PANAS and SPSI-R:S. CONCLUSIONS: Online EmReg appears to be a promising method of delivering a group intervention to improve ER following TBI.

Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To describe the rates and causes for rehospitalization over 10 years after moderate-severe traumatic brain injury (TBI), and to characterize longitudinal trajectories of the probability of rehospitalization using generalized linear mixed models and individual growth curve models conditioned on factors that help explain individual variability in rehospitalization risk over time. DESIGN: Secondary analysis of data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities and community follow-up. PARTICIPANTS: Individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Rehospitalization (and reason for rehospitalization) as reported by participants or proxy during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. RESULTS: The greatest number of rehospitalizations occurred in the first year postinjury (27.8% of the sample), and the rates of rehospitalization remained largely stable (22.1%-23.4%) at 2, 5, and 10 years. Reasons for rehospitalization varied over time: Orthopedic and reconstructive surgery rehospitalizations were most common in year 1, whereas general health maintenance was most common by year 2 with rates increasing at each follow-up. Longitudinal models indicate that multiple demographic and injury-related factors are associated with the probability of rehospitalization over time. CONCLUSIONS: These findings can inform the content and timing of interventions to improve health and longevity after TBI.

Rehospitalization in the First Year Following Veteran and Service Member TBI: A VA TBI Model Systems Study.

OBJECTIVE: To determine the incidence and causes of rehospitalization following military or Veteran traumatic brain injury (TBI). SETTING: Department of Veterans Affairs (VA) Veterans Health Administration Polytrauma Rehabilitation Centers (VHA PRCs). PARTICIPANTS: Consecutive sample of VHA TBI Model System participants (N = 401). DESIGN: Prospective observational cohort study. MAIN MEASURES: Number and type of rehospitalizations in first year post-TBI. RESULTS: Forty-one percent of 401 participants were rehospitalized. Rehospitalization status was associated with greater injury severity and receipt of TBI while active duty. Of those rehospitalized, 30% had 2 or more readmissions. Participants experiencing multiple rehospitalizations (2+) were more likely to have sustained their TBI during deployment than those with none or single rehospitalization. This group also sustained more severe injuries and spent more time in VA PRC inpatient rehabilitation. Common reasons for rehospitalization included inpatient rehabilitation (33%), unspecified (26%), orthopedic (10%), seizures (8%), infection (8%), and psychiatric (7%). CONCLUSION: This is the first study examining military and Veteran rehospitalization following TBI requiring inpatient rehabilitation at a VA PRC. Findings indicate frequent rehospitalizations in the first year postinjury, suggesting the need for preventive models of health maintenance following inpatient rehabilitation discharge. Greater surveillance of those with deployment-related TBI or active duty at the time of injury and greater TBI severity may be warranted.

Global Outcome Trajectories After TBI Among Survivors and Nonsurvivors: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To compare long-term functional outcome trajectories of individuals with traumatic brain injury (TBI) who survive with those who expire more than 5 years postinjury, using individual growth curve analysis. DESIGN: Secondary analysis of data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities that are current or former TBI Model Systems. PARTICIPANTS: Individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Glasgow Outcome Scale-Extended; Disability Rating Scale. RESULTS: Individuals in the TBI Model Systems who expire several years after injury demonstrate worse functional status at baseline and a steeper rate of decline over time as measured by both the Glasgow Outcome Scale-Extended and the Disability Rating Scale. There was significant variability in each growth parameter (P < .05) for both instruments. A reduced model was built for each outcome, including all covariates that related significantly to the growth parameters. An interactive tool was created for each outcome to generate individual-level trajectories based on various combinations of covariate values. CONCLUSION: Individuals with TBI who die several years after injury demonstrate functional trajectories that differ markedly from those of survivors. Opportunities should be sought for health management interventions to improve health and longevity after TBI.

Screening for traumatic brain injury: findings and public health implications.

OBJECTIVE: To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI). SETTING: Diverse community settings. PARTICIPANTS: Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396). DESIGN: Cross-sectional. MAIN MEASURE: Brain Injury Screening Questionnaire. RESULTS: Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms. CONCLUSION: Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Mortality after surviving traumatic brain injury: risks based on age groups.

OBJECTIVE: To assess mortality, life expectancy, risk factors, and causes of death by age groups among persons who received inpatient traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective cohort study. SETTING: The TBI Model Systems. PARTICIPANTS: 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized mortality ratio, life expectancy, and cause of death. RESULTS: Moderate-severe TBI increases risk of mortality compared with the general population in all age groups, with the exception of those 85 years or older at the time of injury. Teenagers to middle-aged adults are at particular risk. Risk factors for death varied by age group and included gender, marital and employment status, year and cause of injury, and level of disability. External causes of death predominate in younger groups. For the youngest male participants in the sample, longevity was reduced up to 16 years. CONCLUSION: Risk factors and causes of death varied considerably by age group for individuals with moderate-severe TBI who were receiving acute care rehabilitation. Moderate-severe TBI is a chronic health condition.