TBI: A step on the path to homelessness?

1. TBI: A step on the path to homelessness? Dr. Ruth Staus, DNP, RN, ANP-BC Adult Nurse Practitioner Love Grows Here Wellness

2. The chicken and the egg quandary • Trauma survivors may have suffered brain injury as children through abuse or accident, or during military service. • Without adequate assessment, continued follow up, cognitive rehabilitation, and supportive living conditions, many spiral into poverty and homelessness. (HCH Provider Network, 2008)

3. The chicken and the egg quandary • People living on the streets or in shelters are often victims of accidents and violence that may cause new brain injuries or exacerbate old ones. (HCH Provider Network, 2008)

4. TBI: The numbers • The population of individuals with TBI is extremely heterogeneous: children, older adults, homeless individuals, soldiers, and young adults (Gordon et al., 2006). • 1.4 million US civilians sustain a TBI each year • Over a million are treated and released from an emergency department • 235,000 are hospitalized • 50,000 die • Children under 14 years of age account for 435,000 of these emergency department visits (HCH Provider Network, 2008)

5. TBI in the elderly: An unrecognized epidemic • Falls are the most common cause of TBI (28%) in all age groups • Bimodal distribution of TBI; peak ages 15-24 and 70 and older • Elders: 80,000 ER visits per year, 75% of these elders need to be hospitalized (Menzel, 2008)

6. TBI: The numbers • These numbers don't include individuals who suffer TBI but receive no care. • Unless there are obvious signs of trauma, TBI symptoms are often subtle and may not appear at the time of the injury (HCH Provider Network, 2008)

7. TBI Basics • Every brain injury is different. • The level of severity of the initial injury can be related to many different variables, including how much force was involved and how fast the head or object was moving at the time of injury. • When an injury is referred to as uncomplicated mild, complicated mild, moderate, or severe, it is in reference to the initial injury itself – not the eventual outcome that an individual with TBI may experience. • It is possible that a person with an initial rating of mild TBI may experience a poor outcome. • Likewise, someone who presents initially with a severe injury may experience a very good outcome. (Struchen, Davis, & McCauley, 2010)

8. Common comorbid mental health issues • Common comorbid emotional and behavioral disorders associated with TBI include: • postconcussion syndrome • depression • post-traumatic stress disorder and generalized anxiety disorders • anger, agitation, and aggression • problems with behavioral regulation • lack of deficit awareness • sexual dysfunction • alcohol and substance abuse issues (Struchen, Davis, & McCauley, 2010)

9. How does TBI lead to homelessness? • The frontal lobe is most commonly injured in TBI, regardless of the point of impact to the head. • As a result, deficits in executive functioning and self-regulation are frequently observed after TBI

11. Test your frontal lobe

12. Test your frontal lobe

13. Secondary effects of impaired executive functioning • Decreased automatic responses • Slow processing • More effort required to learn and respond

14. Deficits in self-regulation • frequently misunderstood • Persons can appear to be deliberately uncooperative with treatment or unmotivated. • In fact, these individuals may have goals consistent with treatment, but are not able to act in a manner consistent with those goals.

15. Deficits in self-regulation Impulsivity/disinhibition: • Persons in treatment for substance use disorders may diligently attend treatment sessions, but if there is a bar on the way home they may stop for a drink, despite intentions to remain sober. • An individual with TBI might be attracted to another person and, rather than initiating an appropriate interaction, they might try to kiss/touch the person or make a sexually inappropriate comment.

16. Deficits in self-regulation Lack of initiation: • One goal of treatment might be to get a job. In the treatment session, the client discusses this goal with the therapist. It is decided that before the next session the individual would look up employment ads and apply for at least one job. • The client returns to the next session having failed to initiate either of these tasks. The client repeats that he or she wants to get a job, and appears sincere. However, the client cannot provide any satisfactory explanation for the lack of follow-through.

18. Depression and TBI • Depression is the most common affective disturbance after TBI and incidence rates exceed those of community base rates. • Depression after TBI is known to exacerbate TBI-related cognitive impairments including problems with memory, mental processing speed, sustained attention, and executive functions such as inhibition and concept formation. • Depression also adds significantly to functional impairment and decreased quality of life for those with TBI.

19. Depression and TBI • The diagnosis of depression following TBI can be complicated. • Changes in sleep, libido, fatigue, and difficulties with concentration and/or memory could be a direct result of the brain injury itself, rather than a psychological reaction, and can lead a clinician to mistakenly diagnose the patient with clinical depression. • Alternatively, although some patients may actually be depressed, impaired self-awareness as a result of the TBI may lead such patients to be unaware or actively deny the presence of depressed mood, resulting in under-diagnosis of the problem. (Struchen, Davis, & McCauley, 2010)

20. Suicide and TBI • Persons with TBI and major depression are at increased risk for suicide relative to depressed persons without TBI. • The strongest predictors of suicide attempts in patients with TBI are young age, male gender, increased feelings of hostility and aggression, and substance use. • Patients with post-TBI comorbid diagnoses of mood disorder and substance abuse were at 21 times higher odds of suicide attempt than persons without TBI. (Struchen, Davis, & McCauley, 2010)

21. ETOH/substance abuse and TBI • Pre-injury alcohol abuse is found in half to two-thirds of patients • Pre-injury illicit drug use is found in about 30-40% of patients. • A pre-injury history of alcohol abuse is related to higher mortality, greater frequency of mass lesions (e.g., hematomas), poorer neuropsychological functioning both acutely and at one year post-injury, and poorer global outcome. • Approximately 15-25% of persons with TBI who were abstinent or light drinkers before their injury subsequently become heavy drinkers afterwards. (Struchen, Davis, & McCauley, 2010)

22. The path to homelessness: A case study (Helgeson, 2011) • A 26 year old man is admitted to an inpatient mental health unit. • He tells the psychiatric nurse that “There is something wrong with my head and I can’t keep a job”. • PMH: Father left when he was 6, father physically abused the client who had to be hospitalized for broken bones

23. The path to homelessness • He was hit by a car at age 10 which resulted in hospitalization for multiple injuries • Placed in special education due to trouble learning and controlling his behavior • At age 14 began drinking alcohol and using street drugs • Involved in another MVA at age 16 that resulted in hospitalization

24. The path to homelessness • His ability to concentrate, remember, and control his temper became even worse. • After high school he enlisted in the National Guard and spent several months in Iraq. • He was injured in an attack. • Upon his return to the US he could not keep a job. • The drug use escalated and he ended up in jail. • He ended up living in his car.

25. The path to homelessness • The nurse recognized the likelihood of TBI. • Neuropsychological testing revealed that he had unidentified TBI. • Client was linked to appropriate services and supports and was able to obtain supported employment and move along with his life. (Helgeson, 2011)

26. TBI Screening Program at Love Grows Here Wellness Center • Goal: To identify homeless individuals who have experienced TBI • TBI diagnosis qualifies them for SSI benefits including Medicaid • Multidisciplinary assessment/screening approach: Public Health Nursing, Advanced Practice Nursing, Psychologist, Social Worker • Clients who screen for TBI will be referred on for appropriate services- medical, rehab, housing, financial

27. Initial screening • Metro State RN-BSN students taking PHN course • Screening to be done at BP/triage table at LGHWC • Students will utilize OSU TBI-ID for screening

28. Purpose of using TBI screening tools • The client is often seeking help for a problem unrelated to the injury. • When obtaining a health history, the client frequently will not spontaneously tell you that they have sustained a TBI either due to the lack of knowledge about what defines a TBI or the presence of cognitive problems that can interfere with the patient’s ability to provide accurate medical history information. • Therefore, as part of the gathering of general information about the client’s medical history in a population at high-risk for TBI, it is recommended that a research-validated set of questions be used to help determine whether the patient has sustained a TBI. (Struchen, Davis, & McCauley, 2010)

29. Ohio State University TBI Identification Method (OSU TBI-ID) • See D2L site for the form • PHN students will ask all clients questions 1-5 on the form and record causes. • If client answers “yes” to any questions, need to then be referred to NP ( if client is willing). • NP will complete the history using the OSU TBI-ID.

30. Cognitive Assessment • NP will utilize the Montreal Cognitive Assessment (MOCA) Version 7.1 • NP will also perform neurological exam

31. Comorbid mental health disorders assessment • Clients will then be referred to a psychologist from Walk-in Counseling for evaluation of mood disorders and other comorbid mental health problems.

32. Connecting clients to resources • Client will be referred to LGHWC Social Worker to begin SSI application for clients found to have TBI and obtain referrals for other social services. • NP will make referrals for any needed medical care. • PHN faculty will make referrals for public health nursing services. • Psychology will make referrals for on-going mental health care services.