TBI Potpourri: Update 2011
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  • Somnolence (or " drowsiness ") is a state of near- sleep , a strong desire for sleep, or sleeping for unusually long periods (cf. hypersomnia ). It has two distinct meanings, referring both to the usual state preceding falling asleep, and the chronic condition referring to being in that state independent of a circadian rhythm . Somnolence goes back to the Latin "somnus" meaning "sleep.“ Fatigue (also called exhaustion , lethargy , languidness , languor , lassitude , and listlessness ) is a state of awareness describing a range of afflictions, usually associated with physical and/or mental weakness, though varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles. Physical fatigue is the inability to continue functioning at the level of one's normal abilities. [1] [2] [3] It is widespread in everyday life, but usually becomes particularly noticeable during heavy exercise . Mental fatigue, on the other hand, rather manifests in somnolence (sleepiness). Fatigue is considered a symptom , as opposed to a medical sign , because it is reported by the patient instead of being observed by others. Fatigue and ‘feelings of fatigue’ are often confused.

TBI Potpourri: Update 2011 TBI Potpourri: Update 2011 Presentation Transcript

  • TBI Potpourri: Update 2011 Michael R. Yochelson, MD VP of Medical Affairs Medical Director, Brain Injury Programs October 27, 2011 NRH/ReMeD/BIADC Joint Conference An Overview of Brain Injury: 25 Years of Experience
  • Topics
    • Sleep
    • Fatigue
    • Psychosis
    • Neuro-endocrine dysfunction
    • Sports related TBI
    • Blast Injury (military)
    • TBI vs PTSD
    • The real potpourri
  • SLEEP
    • Insomnia
    • Circadian Rhythm Disorders
      • Delayed Sleep Phase (DSP)
      • Irregular Sleep Wake Cycle (ISWC)
    • Sleep apnea
      • Obstructive
      • Central
    • Narcolepsy
  • Circadian Rhythm Dysfunction
  • SLEEP
    • 68% of mod-severe patients admitted to inpatient rehab unit
    • Increased length of stay
    • Impact on behavior
    • Impact on cognition
    • Impact on function
    • Impact on headaches/pain
  • SLEEP
    • Evaluation
      • Patient/caregiver survey
      • Observational logs
      • Actigraph
        • Accelerometer which is worn on the wrist
  • SLEEP
    • Treatment
      • OSA/CSA
        • CPAP/BiPAP
        • Avoid TCA
        • Reduce/avoid opioids if possible (may cause opioid induced sleep apnea)
      • Circadian Rhythm Dysfunction
        • Light therapy (not studied in TBI)
        • Sleep consolidation
      • Sleep Hygeine
  • SLEEP
    • Treatment
      • Pharmacological
        • Circadian Rhythm
          • Melatonin
          • Ramelteon (Rozerem), a melatonin analog
        • Sleep initiation/maintenance
          • Zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata)
          • Benzodiazapines (e.g., Ativan, Valium) ???
  • SLEEP
    • Treatment
      • Insomnia associated with depression
        • Trazodone (Desyrel)
        • SSRIs
        • Tricyclic antidepressants (e.g. amytriptyline/Elavil; nortriptyline/Pamelor)
      • Insomnia associated with agitation/ psychosis
        • Newer generation antipsychotics: quetiapine (Seroquel), ziprasidone (Geodon), olanzapine (Zyprexa), risperidone (Risperdal)
  • FATIGUE
    • Secondary to sleep dysfunction
    • Independent of sleep dysfunction
    • Evaluate for sleep problems and treat if indicated
  • FATIGUE
    • Physical fatigue
    • Mental fatigue
    • Frequent or long naps
  • FATIGUE
    • Neuro-stimulants
      • Methylphenidate (Ritalin, Concerta)
      • Dextroamphetamine (Dexedrine)
    • Modafinil (Provigil)
      • Jha, Weintraub et al. 2008 study showed no improvement in fatigue in 53 patients with mod-severe TBI (required inpatient rehab) who are at least 1 year post-TBI
      • Kaiser, Valco, et al. 2010 study showed no improvement in fatigue 20 patients, but DID show improvement in EDS
    • Activating antidepressants
      • Sertraline (Zoloft)
    • Other antidepressants
  • PSYCHOSIS
    • Acquired Brain Injury Related Psychosis (ABIRP)
      • Incidence: 0.7-9%
      • Hallucinations
      • Delusions
      • Lacks negative symptoms (e.g. catatonia)
  • PSYCHOSIS
    • Risk Factors
      • Male
      • Premorbid neurodevelopmental hx
      • Premorbid psychiatric d/o
      • Substance abuse
      • Family h/o schizophrenia
      • Severity: severe>moderate>mild
      • Abnormal CT/MRI
      • Abnormal EEG/epilepsy
      • Cognitive impairment
      • Other psych d/o
  • PSYCHOSIS
    • Evaluation
      • Infectious
      • Metabolic
      • Hydrocephalus/shunt malfunction
      • Medication side effects
      • Seizures
  • PSYCHOSIS
    • Treatment of ABIRP
      • Atypical antipsychotics
        • Quetiapine
        • Risperidone
        • Olanzapine (avail oral disolving tablet “Zydis”)
        • Ziprasidone (avail IM)
      • Other options?
        • Haloperidol
        • Clozaril
        • Benzodiazepines
  • NEURO-ENDOCRINE
    • Dysfunction
      • 5-20% of TBI patients will have some neuro-endocrinological dysfunction
      • 25% decreased growth hormone
      • 50% (severe TBI) decreased AM cortisol
      • Other common dysfunction: hypo- or hyperthyroidism, decreased testosterone, increased prolactin
      • Increased prolactin  decreased dopamine
  • NEURO-ENDOCRINE
    • Subjective cold sensation (normal TSH)
      • Treat with DDAVP intranasal spray x 1-2 months
    • Acne
      • Treat with minocycline
  • SPORTS
    • Concussion: Features of concussion frequently observed
      • Vacant stare (befuddled facial expression)
      • Delayed verbal and motor responses (slow to answer questions or follow instructions)
      • Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities)
      • Disorientation (walking in the wrong direction, unaware of time, date. and place)
      • Slurred or incoherent speech (making disjointed or incomprehensible statements)
      • Gross observable incoordination (stumbling, inability to walk tandem/straight line)
      • Emotions out of proportion to circumstances (distraught, crying for no apparent reason)
      • Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes)
      • Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal)
  • SPORTS: Symptoms of Concussion
    • Early (minutes and hours)
      • Headache
      • Dizziness or vertigo
      • Lack of awareness of surroundings
      • Nausea or vomiting
    • Late (days to weeks):
      • Persistent low grade headache
      • Light-headedness
      • Poor attention and concentration
      • Memory dysfunction
      • Easy fatigability
      • Irritability and low frustration tolerance
      • Intolerance of bright lights or difficulty focusing vision
      • Intolerance of loud noises, sometimes ringing in the ears
      • Anxiety and/or depressed mood
      • Sleep disturbance
  • SPORTS: When to return to play
    • Graduated Return to Play Protocol (Zurich, 2008)
    Rehab Stage Functional Exercise Objective No activity Complete physical & cognitive rest. Recovery Light Aerobic Walk, stationary bike, swim. <70% max pred HR. No resistance exercise. Increase HR Sport specific exercise Skating drill (ice hockey), running drills (soccer). No head impact activities. Add movement Non-contact training drills More complex training drills (e.g., passing drills). May begin progressive resistance training. Exercise, coordination, cognitive load Full contact practice AFTER medical clearance, participate in normal training activities. Restore confidence; assessment of functional skills by coaching staff Return to play Normal game play.
  • BLAST INJURY
    • PRIMARY INJURY
      • Pressure wave transmitted through calvarium
    • SECONDARY INJURY
      • Blunt or penetrating trauma
        • Flying debris
    • QUATERNARY INJURY
      • Victim thrown
    • QUATERNARY INJURY
      • Gas, chemicals, etc. from explosion
    • QUINARY INJURY
      • Hyperinflammatory state
      • Biologics
    • Brain injury in…
    • Vietnam War: 12-14%
    • Persian Gulf War: 8%
    • OIF/OND/OEF*: 22%
    • *OIF = Operation Iraqi Freedom
    • OND = Operation New Dawn
    • OEF = Operation Enduring Freedom
    • US Statistics:
      • Iraq (OIF) March 19, 2003-August 31, 2010
        • Fatalities: 4,421 U.S. Troops
        • Wounded: 31,921 U.S. Troops
      • Afghanistan (OEF) Oct 2001-Sept 2011
        • Fatalities: 1,749 U.S. Troops
        • Wounded: 13,609
    • Approximately 8% of US Troops leave theater with a diagnosis of TBI.
    • UK Statistics:
      • Iraq (Op TELIC) January 1, 2003-July 31, 2009
        • Fatalities: 179 UK Military & Civilian
        • Wounded: 537 UK Military & Civilian
      • Afghanistan (Op HERRICK) October 1, 2001-September 15, 2011
        • Fatalities: 381 UK Military & Civilian
        • Wounded: 2,326 UK Military & Civilian
    US & UK CASUALTIES IN IRAQ & AFGHANISTAN http://www.defense.gov/news/casualty.pdf Accessed on September 6, 2011 http:// www.mod.uk/DefenceInternet/FactSheets/ Accessed on October 2, 2011
  • BLAST RELATED TBI: Incidence
    • Approximately 20% of all deployments
    • Approximately 28% of all service members medically evacuated out of Iraq/ Afghanistan
    • Approximately 88% of all service members medically evacuated to WRAMC
    • Up to 97% of injuries are blast related (data from 1 unit)
      • 53% involved head & neck
    • The number of Iraqi and Afghan civilian casualties is even greater.
    • Increasing number of civilian blast injuries worldwide.
  • TBI vs PTSD
    • TBI
      • Cognitive dysfunction
      • Physical impairment
        • Weakness, imbalance
      • Dizziness
      • Headache
      • Depression/anxiety
      • Personality/behavioral changes
      • Sleep dysfunction
      • Fatigue
      • Impulsive
    • PTSD
      • Cognitive dysfunction
      • Dizziness
      • Sleep dysfunction
      • Fatigue
      • Depression
      • Anxiety
      • Nightmares
      • Hypervigilant
      • Startles easily
  • TBI vs PTSD
    • TBI
      • Neuropsychology
        • Neuropsych Testing
        • Cognitive remediation/ psychotherapy
      • SLP
        • Speech, Language & Cognitive skills
      • PT/OT
        • Improve function, edurance
      • Medications
        • Headaches, depression, fatigue, sleep disturbance
    • PTSD
      • Psychology
        • Psychotherapy
      • Medications
        • Anxiety
        • Depression
        • Pain
        • Hallucinations
        • Fatigue
        • Sleep disturbance
  • TBI vs PTSD
    • Can you get PTSD after TBI?
      • After mild?
      • After severe?
      • After blast?
    • How can you differentiate TBI from PTSD?
    • Is there a need to differentiate TBI from PTSD?
    • Are there markers?
  • The real potpourri
    • Omega-3 Fatty Acid Docosahexaenoic Acid (DHA)
      • Animal studies
      • Taking DHA prior to TBI appears to be protective
  • The real potpourri
    • Hypothermia
      • Therapeutic vs. non-therapeutic hypothermia
      • Preliminary data suggests that therapeutic hypothermia is beneficial.
      • Retrospective study of non-therapeutic hypothermia in severe TBI.
        • 10% incidence of SICU severe TBI population
        • Significant increase in mortality (OR 2.9)
  • The real potpourri
    • Long-term Consequences of TBI
      • Causal relationship
        • Penetrating TBI  premature mortality
        • Severe or moderate TBI  unprovoked seizures
  • The real potpourri
    • Long-term Consequences of TBI
      • Association
        • Penetrating TBI  decline in neurocognitive function
        • Penetrating TBI  long-term unemployment
        • Severe TBI  neurocognitive deficits
        • Mod-Sev TBI  Alzheimer’s dementia
        • Mod-Sev TBI  Parkinsonism
        • Mod-Sev TBI  Endocrine dysfunction (esp. hypopituitarism)
        • Mod-Sev TBI  growth hormone insufficiency
  • The real potpourri
    • Long-term Consequences of TBI
      • Association
        • Mod-Sev TBI  Long-term adverse social-function outcomes (esp. unemployment, relationships)
        • TBI  Depression
        • TBI  Aggressive behaviors
        • TBI  Postconcussion symptoms
        • Professional boxing  dementia pugilistica
  • The real potpourri
    • Miscellaneous neuroprotection
      • Citicoline
        • Improve memory & behavior
        • NIH study: Citicoline for the Treatment of TBI
      • Progesterone
        • Decrease cerebral edema, increase BBB protection, limits cellular necrosis & apoptosis
        • Decrease mortality (30 vs 13% in phase II trial)
        • Phase III trial: Study of the Neuroprotective Activity of Progesteroen in Severe TBI (SyNAPSe)
  • The real potpourri
    • Miscellaneous neuroprotection
      • Cyclosporine
        • Improve CPP & cerebral metabolism
        • Phase II trials only; limited data
      • Decompressive craniectomy
        • 2 phase III trials enrolling
          • Surgery vs. medical management
  • The real potpourri
  • The real potpourri
  • CONCLUSIONS
    • Sleep dysfunction is a significant problem for patients with TBI and should be evaluated and treated appropriately.
    • Fatigue may be related to sleep dysfunction or independent.
    • Psychosis is not that common, but can be severely impairing and can lead to severe psychosocial problems.
    • Know your grading and guidelines for sports concussion/TBI.
    • Blast injury – what’s the impact?
    • Much research needed in differentiating TBI from PTSD
  • QUESTIONS?