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Traumatic Brain Injury and Alcohol Use Disorders
 

Traumatic Brain Injury and Alcohol Use Disorders

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  • Developed in Glasgow by Jennett, Teasdale and others in the late 60’s and 70’s to provide a prognostic scale. Due to its simplicity, reproducibility and prognostic ability (albeit limited) has become a standard component of the initial examination in the care of the head injured patient.
  • The Glasgow Coma Scale (GCS) is the most commonly used scale to determine the severity of a brain injury. It must be noted, however, that a GCS score signifies the patient’s “best” response. A patient could have a serious deficit that is not indicated by the GCS. Also, the score does not indicate the amount of stimulation required to get the patient to score at that level. A severe brain-injured patient usually has a GCS score of 3 – 8 and presents with a significant neurological deficit. The lowest GCS score is 3 (no neurological functioning). A patient with a severe brain injury also will experience loss of consciousness for more than 1 hour. Posttraumatic amnesia (PTA) refers to the loss of memory of events immediately following the injury. A typical question to ask to assess for PTA is, “What is the first thing you remember after your injury?” If the first memory occurred more than 24 hours after the injury, then, by definition, the patient has suffered a severe TBI.

Traumatic Brain Injury and Alcohol Use Disorders Traumatic Brain Injury and Alcohol Use Disorders Presentation Transcript

  • Traumatic Brain Injury and Alcohol Use Disorders E. Lanier Summerall, MD, MPH Dartmouth Medical School © AMSP 2010
  • Alcohol Abuse and Dependence
    • 80% Lifetime use
    • 15% Lifetime abuse
    • 10% Lifetime dependence
    • Intoxication, abuse, dependence=alcohol use disorders (AUD’s)
    © AMSP 2010
  • Traumatic Brain Injury in US
    • 1.4 million total each year
      • 50,000 die
      • 235,000 hospitalized
      • 1.1 million to ER
    • Mechanisms
      • Falls
      • Motor vehicle accident (MVA)
      • Struck by/against object
      • Assaults/violence
    © AMSP 2010
  • Traumatic Brain Injury
    • Location-anywhere in brain
      • Visible-bruise, bleeding, tissue deformity
      • Invisible-axon damage
    • Frontal lobe damage= “fingerprint” of TBI
      • Acceleration/deceleration
      • Bony structure of skull
    © AMSP 2010
  • © AMSP 2010
  • TBI Effects
    •  V ision, hearing
    •  A ttention/concentration
    •  L anguage skills
    •  I nsight
    •  U nacceptable behaviors
    •  M emory
    • Physical/neurological problems
    © AMSP 2010
  • AUD+TBI=Complex Relationship ↑ Risk TBI ↑ Risk AUD ↓ Recovery AUD +TBI © AMSP 2010
  • This Lecture Reviews
    • Definitions
    • Epidemiology/outcomes for AUDs before TBI
    • Epidemiology/outcomes for AUDs post-TBI
    • Prevention AUD +TBI
    • Assessment/ treatment
    © AMSP 2010
  • Glasgow Coma Scale
    • Eye opening (E): 1-4
    • Motor response(M): 1-6
    • Verbal response(V): 1-5
    • E+M+V=Total Score
    • 3 (Deep coma)-15(wide awake)
    © AMSP 2010
  • Traumatic Brain Injury Definitions © AMSP 2010
  • Definitions
    • Legal intox.=0.08% BAL (blood alcohol level)
    • Std. drink-10-12 gm
      • 0.2 gm/dl
      • 12 oz. beer
      • 5 oz. wine
      • 1 oz spirits (gin, vodka, whisky)
    © AMSP 2010
  • Alcohol Use Disorders © AMSP 2010 Intoxication 1 +:
    • -Slurred speech
    • Incoordination
    • Unsteady gait
    • Nystagmus
    •  Attention, memory
    • Stupor, coma
    Alcohol abuse 1 + in same 12 mos.: -  Role obligations -Hazardous use -Legal problems -Interpersonal problems -  Dependence Alcohol dependence 3+ in same 12 mos: -Tolerance -Withdrawal -  Amts. or more time -Desire/inability to  -  Other activities -  Consequences
  • This Lecture Reviews
    • Definitions ✔
    • Epidemiology/outcomes for AUDs before TBI
    • Epidemiology/outcomes for AUDs post-TBI
    • Prevention AUD +TBI
    • Assessment/ treatment
    © AMSP 2010
  • Intoxication and TBI
    • 45% TBI hospitalized legally intox.
    • Intoxication<19 yo ↑ risk:
      • 2 X ↑ Driving after 5+ drinks
      • 1.8 X ↑ Riding with drunk driver
      • 2.6 X ↑ Injuries
      • 2.5 X ↑ Violent behavior
    © AMSP 2010
  • Intoxication and TBI
    • Can mask TBI due to sim. signs
    • ↑ Severity of TBI
    • ↑ Intensity of treatment
      • 3X ↑ ICU days
      • 2.5 X ↑ Benzodiazepines
      • 2 X ↑ Opioids
    • ↓ Scores cog. tests 1 mo. post-injury
    © AMSP 2010
  • Abuse/dependence before TBI
    • 37% of TBI have prior abuse/dependence
    • Abuse/dependence ↑ risk TBI 60% in any year
    • Post-injury unemployment 3X > TBI alone
    • Life satisfaction < TBI alone
    • ↑ Risk multiple TBI’s
    © AMSP 2010
  • This Lecture Reviews
    • Definitions ✔
    • Epidemiology/outcomes for AUDs before TBI ✔
    • Epidemiology/outcomes for AUDs post-TBI
    • Prevention AUD +TBI
    • Assessment/ treatment
    © AMSP 2010
  • AUD’s Post-TBI
    • 50% with AUD ↓ alcohol use after TBI
    • 2 X ↑ abstinence rates after TBI (15%-30%)
    • 30% of all in AUD treatment have unreported hx. of TBI
    © AMSP 2010
  • AUD’s Post-TBI
    • 25 % develop/maintain AUD after TBI
    • Risk factors:
      • Pre-TBI AUD
      • Better physical function
      • Male
      • Younger
      • Uninsured or on Medicaid
      • Unmarried
    © AMSP 2010
  • AUD’s Post-TBI
    • ↓ Neuron reorganization from alcohol ↓ natural healing
    • TBI +AUD may ↑ atrophy
    • TBI +AUD death by suicide 4X > TBI alone
    • TBI + AUD death by suicide 7X > gen pub
    • ↑ Involvement criminal justice system
    • Alcohol use ↑ impact of TBI symptoms
    © AMSP 2010
  • This Lecture Reviews
    • Definitions ✔
    • Epidemiology/outcomes for AUDs before TBI ✔
    • Epidemiology/outcomes for AUDs post-TBI ✔
    • Prevention AUD +TBI
    • Assessment/ treatment
    © AMSP 2010
  • Prevention TBI/AUD © AMSP 2010
  • US Public Health Successes
    • MVA’s once #1 cause TBI, now #2
    • MADD ( M others A gainst D runk D riving) called for tougher laws
    • Mandatory seat belt laws in US ↓TBI’s 38%
    • Laws↓ BAL to 0.08% ↓ fatalities +TBI’s 36%
    © AMSP 2010
  • Public Health Challenges
    • ● Highest rate drunk driving=motorcycle
    • ● 2X TBI deaths in states without helmet law
    • ● <50% of states with helmet law
    © AMSP 2010
  • This Lecture Reviews
    • Definitions ✔
    • Epidemiology/outcomes for AUDs before TBI ✔
    • Epidemiology/outcomes for AUDs post-TBI ✔
    • Prevention AUD +TBI ✔
    • Assessment/ treatment
    © AMSP 2010
  • Assessment: Alcohol Withdrawal
    • Caution! TBI may mask withdrawal
      • Symptoms
      • Signs
      • Interview
      • Physical exam
    © AMSP 2010
  • Treatment: Alcohol Withdrawal
    • Benzodiazepines=gold standard
    • “ Start low, go slow”
    • Longer acting benzos preferred
      • Chlordiazepoxide- 25 mg. PO QID
      • Diazepam -5 mg. PO QID
    • Overmedication->resp.depression,coma
    • Undermedication->delirium,seizure
    © AMSP 2010
  • Early AUD Treatment after TBI
    • Motivation to change alcohol use ↑ after TBI
      • Alcohol dep. pre-TBI=↑ motivation
      • ↑ BAL at injury ≠ ↑ motivation
    • Motivational interviewing effective
      • Non-directive interview
      • Patient-centered, empathetic
      • Elicits behavior change
      • Explores/resolves ambivalence
    © AMSP 2010
  • Challenges: AUD+ TBI
    • No evidence-based algorithm for tx.
    • Cognitive barriers:
      • ↓ Attention, judgment, insight, language
      • ↓ Short term memory, behavior control
    • Interpersonal barriers
    • System barriers
      • High cost of care
      • Inpt. AUD programs exclude TBI
      • Outpatient tx. may not be enough
    © AMSP 2010
  • Assessment: AUD +TBI
    • Routine alcohol screening for all TBI patients
    • Multiple assessment modalities
      • Interview pt. alone re use
      • Review records
      • Interview family
    © AMSP 2010
  • Treatment: AUD +TBI
    • External motivators ↑ effect of tx.
      • Financial incentives
      • Case mgmt., peer support
    • Modify tx. conditions
      • ↑ Appointment time
      • ↓ Noise, visual distractions
      • Frequent breaks
    © AMSP 2010
  • Treatment: AUD + TBI
    • Concrete
      • Decision making forms (pros/cons)
      • Break complex tasks into steps
    • Behavioral focus (not insight oriented)
      • List specific activities to replace drinking
      • Pictorial daily schedule
      • Alarm/watch to initiate activities
    © AMSP 2010
  • Pharmacology: AUD +TBI ALCOHOL Benzodiazepines Oxazepam (Serax) Propanolol SSRI’s Fluoxetine (Prozac) Antiseizure Valproic acid (Depakote)
    • Processing speed
    • Seizure control
     Processing speed  Sedation Sedation, Resp. depression Arrhythmia Heart failure © AMSP 2010
  • Medications to Stop Drinking
    • Naltrexone (Revia) 50-100 mg./day
      • Opioid receptor antagonist
      • Reduces cravings, ↑ abstinence
    • Acamprosate (Campral) ~ 2g/day
      • ↑ GABA (inhibits), ↓ glutamate (excites)
      • Reduces cravings, ↑ abstinence
    © AMSP 2010
  • This Lecture Reviews
    • Definitions ✔
    • Epidemiology/outcomes for AUDs before TBI ✔
    • Epidemiology/outcomes for AUDs post-TBI ✔
    • Prevention AUD +TBI ✔
    • Assessment/ treatment ✔
    © AMSP 2010