The Changing Population: Young, Old, Active Duty and Brain Injured. By Harriet Katz Zeiner, PhD

1. The Changing Population: Young, Old, Active Duty and Brain Injured. By Harriet Katz Zeiner, PhD Harriet.Zeiner@va.gov

2. A traumatic brain injury (TBI) is a blow or a jolt to the head that temporarily or permanently disrupts brain function – i.e. who we are and how we think, act, and feel.

3. The injury is caused by falls, motor vehicle crashes, assaults and other incidents.

4. There’s a New Population in Town And They Require Systemic Change To Deal With Them Effectively Why? How Big Is The Problem? Why Won’t The Old Ways Work? What Do I Have To Change To Deal Effectively With Them?

5. While serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), military service members are sustaining multiple severe injuries as a result of explosions and blasts.

6. Improvised explosive devices, blasts, landmines and fragments account for 65% of combat injuries (Peake JB, N Engl J Med 2005 jan 20, 352 (3):219-222)

7. Of these injured military personnel, 60% have some degree of traumatic brain injury www.dvbic.org

8. If the War Ended Today: • 37,980WIA • 65% of these are IED = 24,687 • 60% of IED injuries involve head injuries = 14,812 • 2000 combat-wounded Polytrauma patients have been treated at the 4 PRCs Currently, over 12,000 people with head injury have been discharged home with TBI from those identified as WIA FROM THOSE IDENTIFIED AS WOUNDED—and many of them don’t know why they think, feel and behave differently * These numbers are from June, 2010 from the DoD

9. Currently, over 12,000 people with head injury have been discharged home with TBI FROM THOSE IDENTIFIED AS WOUNDED IN ACTION— and many don’t know why they think, feel and behave differently This does not include those exposed to blast who are not identified as WIA.

10. Estimates of Rand Corp in:*Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.” April 17, 2008 • 1.6 million military personnel have been deployed since the war in Afghanistan began in late 2001. 2. 19% (320,000 service members) report experiencing a possible TBI while deployed. Range is from mild concussion to severe head wounds.

11. About 7% report both a probable TBI and PTSD or major depression. Only 53% of service members with PTSD or Depression sought help over the past year. Reasons cited: • Worried about side effects of medication. • Believe family and friends can help. • Feared seeking help might damage their careers.

12. 320,000 service members report experiencing a possible TBI while deployed. Range is from mild concussion to severe head wounds. Only 43% reported being evaluated by a physician for their head injuries.

13. Assuming all are concussions (they are not) Assuming they have been exposed to only one blast, (unlikely), and only 25% show permanent effects= • 320,000 x 25% = 80,000 people with undiagnosed mild TBI have been sent home • +12,000 undiagnosed from the WIA group= • 92,000 with mild TBI sent home who don’t know they have a TBI.

14. SeverityLOC AOCPTA Mild 0-30 min < 24 hrs < 24 hrs Moderate 30 mins-24 hrs >24 hrs 24 hrs- <7 days Severe > 24 hrs >24 hrs > 7 days LOC Loss of Consciousness AOC Alteration of Consciousness PTA Post Traumatic Amnesia

15. 92,000 people with undiagnosed mild TBI have been sent home. • Mild TBI refers to the time period of unconsciousness, not to the effects on the person’s life. • Mild TBI can have MAJOR impact on marriages, jobs, relationships, children and roles • This is not a political issue—it is a major health care problem in America, which the VA is charged to deal with.

16. Families are impacted severely, whether the diagnosis is mild, moderate or severe TBI. I will address issues of all three in my presentation.

17. PTSD Screen • Have you had an experience in the past month that was so frightening or upsetting that you: • Had nightmares or unwanted thoughts • Went out of your way to avoid reminders • Constantly on guard, watchful, or easily startled • Felt numb or detached from others

18. Brain Injury Screen Did you have any injuries during your deployment from: • Fragments • Bullets • Vehicular crash including airplane • Fall • Blast (IED, RPG, grenade, land mine) • Other injury

19. Brain Injury Screen Did any injury result in: • Being dazed, confused, seeing stars • Not remembering the injury • Losing consciousness for any amount of time • Concussion • Head injury

20. Brain Injury Screen Are you experiencing any of the following from a head injury/concussion: • Headaches • Dizziness • Memory problems • Balance problems • Ringing in the ears • Irritability • Sleep problems • Other

21. Clinical Reminders only cover OIF/OEF • Add the following: • 1. Have you ever experienced loss of consciousness or been dazed during your military service? • 2. Have you ever lost consciousness or been dazed after a fight, a fall, or during work or sports? • 3. Have you ever been in a motor vehicle, motorcycle accident? Did you hit your head? • 4. Have you ever had a fall when you’ve been drinking?

22. Moderate-Severe Brain Injury • Half the patients with head injury will be blast exposed • Half will be the result of motor vehicle accidents

23. There are also a large number of post-combat head injuries • Look for an unusually large number of motor vehicle accidents with head injuries in recently-returned Iraq/Afghanistan returnees—within 1 month of discharge and return home. • The army reports a 70% increase in motor vehicle accidents

24. Only 5 out of 10 eligible for VA services choose them. • 5/10 are choosing Tri-care or insurance through work or nothing.

25. Why Is This Important/ What Does this Mean? • This means 50% of all discharged OIF/OEF military personnel with either mild TBI or co-morbid TBI/PTSD will never be seen by the VA. • They will appear in the civilian sector, they will use non VA, non military therapists • They will come to a Vet Center • And, they usually do not complain of either TBI and/or PTSD to their therapists/physicians.

26. This is more than “ an out reach issue for the VA” It means: • 1. A massive need for therapists who can handle neurologically impaired patients. • 2. And their families. • 3. A need for civilian institutions to accommodate to those with mild brain injury.

27. 92,000 military personnel with undiagnosed mild TBI have been sent home.

29. In the civilian population alone every year, more than 1.5 million people sustain brain injuries from falls, car crashes, assaults and contact sports. Males are more likely than females to sustain brain injuries. Children, teens and seniors are at greatest risk.

30. 60 % of that 1.5 million people per year is 900,000 people, and their families affected by TBI 900,000 people, will experience the onset of a long term disability associated with a TBI. This number per year in the civilian sector exceeds all the veterans with TBI from all the years combined total from Iraq and Afghanistan.

31. 90,000 people, will experience the onset of a long term disability associated with a TBI. This number per year in the civilian sector equals all the veterans with TBI from all the years combined total from Iraq and Afghanistan.

32. The number of U.S. Citizens likely to sustain a TBI is 5 times the total number of people with multiple sclerosis, spinal cord injury, HIV/AIDS and breast cancer combined

33. So prevalent • Insurance coverage often doesn’t pay for it • Physicians aren’t trained about TBI in medical school.

34. Issues for People with Brain-Injury: Problems in memory Problems in attention Problems in problem solving Problems in social appropriateness Problems in organization Problems in fatigue Slowed speed of information processing Anger outbursts

35. What Does TBI Do to People? • Unable to utilize the medical system as it was constituted • Difficulty living independently • Difficulty in maintaining social roles, marriages • Difficulty holding jobs • Difficulty in school (vocational/college) • Difficulty navigating the legal system

36. Who Are The Head Injured?Civilians: • 18-34 age group most at risk for having a TBI • 5x more men than women • Children and seniors are more likely to die • 475,000 children each year in the U.S. sustain a TBI • TBI is the leading cause of death and disability among youngsters

37. Who Are The Head Injured?Military • 18-25 age group • Active duty Army • Marines • 35-45 age group • National Guard • National Reserve 20% are women

38. They are in the early stages of adult development • Issues of late adolescence—separation, anger, appearance, jewelry, body piercing, make-up, clothes—in VA setting • First job, beginning job skills • Worried about appearance, “date-ability”—developmental task is to find a partner

39. Problems for women with TBI: Pregnancy Family with children Vocation (MOS) Sexual harassment Rape

40. Problems for women who sustain brain injury in the military Seen as insubordinate Seen as lazy Seen as disorganized Seen as passive Frequently demoted or threatened with court martial—offered separation as an alternative

41. Problems for women who sustain brain injury in the military Several were offered separation for pregnancy—no mention of brain injury C&P affected No service connection for brain injury

42. Issues for Women Warriors on Polytrauma Too open and vulnerable for civilian world Don’t read social or sexual cues Give out wrong sexual cues—wrong means “unintended cues” Gumballing—saying what you think

43. Issues for Women Warriors on Polytrauma Failure to use birth control Failure to self-protect during sex: VD, HIV No memory of pregnancy No memory of infant daughter’s first milestones

44. Issues for Women Warriors on Polytrauma Custody battles in divorce Visitation versus care of children Supervision of children and household Driving and being dependent Financial dependence Being competent to make decisions over medical needs, legal needs, personal needs

45. Issues for Women Warriors who get a TBI • Women Warriors are different in the abilities they bring to war—they are not simply “little men” • Women Warriors are different in how they are treated in the military after they sustain an unrecognized head injury • Women Warriors have different social issues and place in society, and their head injuries affect them in their roles and in their place in the family and society

46. When confronted with patients with TBI, non rehabilitation psychologists/physicians frequently misdiagnose patients with neurological impairment with psychiatric diagnoses.

47. This can have several negative effects: • People may be placed on inappropriate medications that do not treat the symptomatology • They can be inappropriately labeled with a psychiatric diagnosis and offered behavioral therapy not designed for TBI • They have no understanding about the nature and course of the cognitive and emotional changes that have occurred

48. What Does BI Do to People? • Unable to utilize the medical system as it was constituted • Difficulty in maintaining social roles, marriages • Difficulty holding jobs • Difficulty in school (vocational/college) • Difficulty navigating legal systems

49. Difficulty in college/vocational school Why Is This Important/ What Does this Mean? • 75% of those enlisting in the volunteer military, did so to use educational benefits. If they have mild TBI- or co-morbid TBI/PTSD, their learning/memory/attentional characteristics will have changed, and they won’t know it until they fail.

50. In CA, Pilot Project between Butte Community College and VA Outreach • OIF/OEF Veterans with BI may take 12 units of classes for a year without using GI benefits or paying tuition. • They are routed through Learning Resource Centers to learn “Study Habits”. • College receives money from state for students’ attendance.