Life Care Planning for Acquired Brain Injury – Anatomy of the Brain (I)

Life Care Planning for Acquired Brain Injury – Classification and Complications (II)

Life Care Planning for Acquired Brain Injury – Case study and Conclusion (III)

Traumatic brain injury (TBI) is one of the leading causes of neurological impairment in the United States and in 2004 accounted for over 1.4 million visits to the emergency room each year with 50,000 deaths, 235,000 admissions to the hospital, and 1.1 million being treated and released (Centers for Disease Control, 2008a). Further, the Centers for Disease Control (CDC) in 2008 estimated that approximately 5.3 million Americans have a lifelong need for care. Acquired brain injury (ABI) is the leading cause of neurological impairment for individuals between the ages of 16 and 30 years of age. ABI technically includes brain injury as a result of cerebrovascular disease (or stroke), but for the purposes of this post, the focus will predominately be on brain injury of traumatic etiology (Kraus et al., 1984).

Creating an appropriate life care plan for an individual with ABI can be a formidable challenge. The brain, as the neurological control center for the body, affects almost every aspect of physi­ological functioning. Injury to the brain therefore can affect almost every function (Rosenthal, 1990; Kraus, 1991; Kaufman et al., 1993; Macciocchi et al., 1993; Piek, 1995). Practitioners in the field of brain injury rehabilitation must be prepared to deal with problems in essentially every organ system in the body, as well as a variety of cognitive and behavioral problems (Wood, 1987; Uomoto & Brockway, 1992).

Because the majority of people who sustain a brain injury are young at the time of their injury, in the time of their lives when career goals are being set and established, it is difficult in many cir­cumstances to estimate lifetime earning capacity and needs (Wehman et al., 1988; Stapleton et al., 1989; Corthell, 1993; Dikmen et al., 1994; Goodall et al., 1994; Ip et al., 1995; Horn & Zasler, 1996; Zasler, 1997). Additionally, as acute trauma management and medical and rehabilitation care improve, the survival of patients with these injuries continues to increase (High et al., 1996; Kreutzer et al., 2001). The result is that many more people survive with increasingly complex medical and rehabilitation problems (Centers for Disease Control, 2008). Due to the variability in recovery following TBI, life care planners are often forced to develop, in a sense, multiple care plans to accommodate the different potential outcomes that may occur in a single individual.

Due to a variety of descriptions used by medical professionals throughout the years, and the problems this caused with communication, the American Congress of Rehabilitation Medicine (ACRM) in 1993 proposed a uniform nomenclature for brain injury. The following definitions are part of the ACRM’s recommendations (American Congress of Rehabilitation Medicine Head Injury Interdisciplinary Special Interest Group, 1993):

¦    Acquired brain injury: Injury to the brain that occurs after the brain has developed; may be due to trauma, surgery, intracranial bleeding, ischemia, or tumor.

¦    Traumatic brain injury: Injury to the brain caused by trauma. One form of acquired brain injury.

¦    Coma: Specific diagnostic term indicating lack of arousability, including loss of sleep—wake cycles on EEG, and lack of meaningful interaction/response to the environment.

¦    Vegetative state: Patients who have no meaningful response to the environment after their eyes are open.

¦    Persistent vegetative state: A vegetative state that persists longer than 3 months, or 1 year if due to trauma.

¦    Locked-in syndrome: A condition in which patients are awake, capable of communication, aware of their environment, but unable to move or speak.

¦    Minimally responsive: Patients who are no longer comatose or vegetative but remain severely disabled (used for patients who are demonstrating inconsistent responses to stimuli yet have some meaningful interaction with the environment).

As noted previously, it is estimated that approximately 1.4 million TBIs occur in the United States each year. Also, as noted in 2005, there were an estimated 235,000 hospitalizations for a primary diagnosis of TBI. The U.S. Centers for Disease Control and Prevention (2008a) have determined that the annual combined total incidence for TBI is estimated to be 102 cases per 100,000 people. It is useful to break down the incidence of TBI based on injury severity. However, the incidence when breaking down by injury severity is 14 per 100,000 for severe TBI, 15 per 100,000 for moderate TBI, and 131 per 100,000 for mild TBI.

There are several factors associated with a higher risk for TBI. Males are more than twice as likely as females to sustain a TBI (CDC, 2008b). Additionally, patients with brain injury tend to be from lower socioeconomic groups, have a history of substance use or abuse, and have a history of engaging in risky behaviors. Additionally, brain-injured patients are more likely to live in an urban area. Alcohol is frequently involved in accidents resulting in brain injury and is considered to be the most common preventable cause of TBI. Education about safety, such as wearing seatbelts and bicycle helmets, and not driving while intoxicated, seems to have contributed to a slight decline in the incidence of hospitalization following TBI in recent years.

Brain injury generally follows a bimodal distribution with respect to age. The largest peak is in late adolescence and early adulthood, when individuals are more likely to engage in high-risk activities. The later peak begins for individuals older than age 65, when falls become more com­mon. Because the largest peak occurrence is in the period of time from late adolescence to early adulthood, life care planning for this group is particularly challenging, as lifelong concerns must be taken into consideration, including aging and aging issues, education, vocational rehabilitation, and community reintegration. Age may also be correlated with outcomes, as older individuals (over age 65) tend to have a slower recovery following brain injury.

The costs associated with treating TBI are estimated to be $48.3 billion annually. Costs associated with hospitalization were estimated to be $60 billion in 2000, the most current data available (Finkelstein, Corso, Miller, & Associates, 2006, as cited by the CDC, 2008a; Brown, Elovic, Kothari, Flanagan, & Kwasnica, 2008).

Review of model systems data for 2007 reveals that the average cost for inpatient treatment of a case of TBI was approximately $154,000 (Traumatic Brain Injury Model Systems, 2008). This estimate was based on the cost for acute hospital care and acute inpatient rehabilitation and does not include rehabilitation efforts (which were reported to be an additional $56,901 after the patient has left the hospital); it also does not include physicians’ fees.

ABI of nontraumatic etiology may include cerebrovascular accidents (stroke), bleeding within the brain, infections, tumors, or surgery. A cerebrovascular accident (CVA), commonly called a stroke or a brain attack, usually occurs as a result of thromboembolic phenomenon, usually as a result of vascular disease. A thrombus is a clot of fibrin, platelets, and blood cells that can form on the inner lining of blood vessels. This thrombus may embolize, or travel from the location where it was formed to another area, where it can become lodged, blocking blood flow. Nontraumatic ABIs may also occur as a result of lack of oxygen getting to the brain due to problems with the lungs, heart, or bleeding. Some ABIs are due to hemorrhage within the brain due to vascular disease or aneurysms that have ruptured. Another significant cause of ABI is due to tumors, both benign and malignant. Additionally, injury to the brain may occur as sequelae from intracranial surgery.

Traumatic brain injuries can occur as a result of trauma from a number of causes. The most frequent cause is from motor vehicle accidents, accounting for almost two-thirds of all injuries. The second most frequent cause is falls. Falls are the most common cause of TBI in the elderly and very young. Assaults are the third most common cause overall, and in urban areas, assaults may actu­ally be a greater cause than falls. Other less common causes of TBI include sports and recreational injuries, work-related injuries, and miscellaneous injuries, such as being struck by falling objects. At least half of all traumatic brain injuries involve alcohol consumption in one way or another, and alcohol represents the single most preventable cause of TBI in the United States (CDC 2008b; Traumatic Brain Injury Model Systems, 2008).

The brain is protected by a number of layers of differing tissue. A layer of skin is the outermost cov­ering, followed by a layer of connective tissue and muscle. The bony calvarium, or skull, provides the greatest protection of the brain. Fractures of the skull are present in a number of brain injuries and are generally associated with a more severe injury. Under the skull are three distinct layers that provide the direct cover of the brain. The outermost, thickest layer is called the dura mater and is attached to the inner layer of the skull in many places. Underneath this layer is the arachnoid mater, which derives its name from its similarity in appearance to a spider web. The arachnoid mater fol­lows the surface of the brain closely, but does not follow the surface down deep into the crevices, or sulci, on the surface of the brain. The innermost layer of covering is called the pia mater, and this layer does follow the brain into the sulci.

The outer surface of the brain is called the cerebral cortex. There are many convolutions of the surface of the brain, which serve to increase the surface area of the outside of the brain. The bulges
are referred to as gyri, and the involutions are referred to as sulci. The origination of neural messages to the rest of the body, for the most part, occurs on the surface of the brain. In most cases, seizure activity also originates at the level of the cortex.

The cortex of the brain is divided into lobes that represent areas of specific functioning. The frontal lobe is responsible for higher cognitive processes, such as planning, orga­nization, and problem solving. It is also the part of the brain responsible for control of impulsive and instinctual behavior (Grafman et al., 1996). Lastly, the origination of motor activity occurs in the most posterior portion of the frontal lobe.

The parietal lobe is predominately concerned with the registration of sensory information, particularly the ability to sense when something has touched the skin. Other types of sensory information are processed in this area, and the parietal lobe gives us the ability to orient objects in space, follow a map, and appreciate music. Individuals with injury to the parietal lobe will often exhibit neglect, or lack of awareness of part of their own body.

The temporal lobes are located on the sides of the brain. These lobes are critical in the registra­tion of auditory information and are critical in the understanding and formulation of language. The inner portion of the temporal lobes also contains structures that are responsible for memory formation, as well as the origination of emotions. Individuals with seizures most frequently have injury to their temporal lobe.

The occipital lobe is located on the most posterior aspect of the brain. Visual information is registered and processed here. Individuals with injury to this area may have cortical blindness, which is an inability to see because of failure of the brain to recognize the neural signals sent from the eyes.

The midbrain (Figure 13.2) contains a number of structures whose predominant activities are to receive signals transmitted from other parts of the brain or from elsewhere in the body, and to modify the signal before transmitting it on to where it ultimately will register. Structures within the midbrain help to control movement, interpret sensory information, and also help with such activi­ties as controlling our level of consciousness. Patients who are comatose or who are in a persistent vegetative state have impaired functioning in the midbrain.

The brain stem (Figure 13.2) is the most inferior portion of the brain and is not always considered a part of the brain at all. However, this part of the brain is critical for basic life-sustaining functions, as it is responsible for regulating breathing and heart rates. Most of the cranial nerves exit here, so the brain stem is intimately involved in the transmission and reception of sensory and motor information of the head, such as tongue movement, facial movement, and sensation. Because all sensory and motor information to and from the body and brain must travel through the brain stem, even a very small area of injury to the brain stem can have devastating effects on the person with the injury.

The cerebellum is an area of the brain that facilitates coordinated motor movements. There are extensive neural pathways between the cerebellum and other areas of the brain concerned with motor movement. Individuals with injury to the cerebellum exhibit ataxia, or lack of control of smooth, coordinated movements. Interestingly, patients with ataxia often have no problems with strength and often have the muscle strength to carry out any activity you ask. However, they lack an ability to control their limbs’ movements, such that it is often difficult or impossible for them to perform basic activities like picking up a glass or walking.