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Neuropsychology of Mild TBI: Neuropsychology of Mild TBI: What Do We Know? What Do We Know? Heather G. Belanger, Ph.D., ABPP- -CN CN Heather G. Belanger, Ph.D., ABPP James A. Haley Veterans Hospital, Tampa, FL James A. Haley Veterans Hospital, Tampa, FL and Assistant Professor of Psychology, and Assistant Professor of Psychology, University of South Florida University of South Florida Disclaimer Disclaimer The views expressed in this presentation are The views expressed in this presentation are those of the author and do not do not reflect the reflect the those of the author and official policy of the official policy of the Department of Veterans Affairs Department of Veterans Affairs or or the United States Government the United States Government 1

Objectives Objectives  Briefly define mild TBI  Briefly define mild TBI  Present neuropsychological outcome data  Present neuropsychological outcome data related to mild TBI related to mild TBI  What we do know What we do know   What we think we know What we think we know   What we don What we don’ ’t know t know  Diagnosis Diagnosis 2

American Congress of American Congress of Rehabilitation Medicine Criteria Rehabilitation Medicine Criteria Definition of Mild TBI Definition of Mild TBI Traumatically induced physiologic disruption of   Traumatically induced physiologic disruption of brain function as indicated by at least one of the brain function as indicated by at least one of the following: following: Any period of loss of consciousness Any period of loss of consciousness   Any loss of memory for events immediately before or after the Any loss of memory for events immediately before or after the   accident accident Any alteration in mental state at the time of the accident Any alteration in mental state at the time of the accident   Focal neurologic deficits that may or may not be transient Focal neurologic deficits that may or may not be transient   Severity of the injury does not exceed:   Severity of the injury does not exceed: Loss of consciousness of 30 min Loss of consciousness of 30 min   GCS score of 13- GCS score of 13 -15 after 30 min 15 after 30 min   Posttraumatic amnesia of 24 hr Posttraumatic amnesia of 24 hr   Mild Traumatic Brain Injury Mild Traumatic Brain Injury  Mild TBI accounts for about 80 Mild TBI accounts for about 80- -90% of 90% of  reported new cases of head injuries each reported new cases of head injuries each year year  Controversy exists regarding the long  Controversy exists regarding the long- -term term cognitive functioning effects of mild TBI on effects of mild TBI on cognitive functioning 3

Criteria for Severity of TBI Criteria for Severity of TBI Mild Moderate Severe Mild Moderate Severe LOC < LOC < 30 min 30 min LOC < LOC < 6 6 LOC > 6 hours LOC > 6 hours with with hours with hours with with with normal CT &/or normal CT &/or normal or normal or normal or normal or MRI abnormal CT abnormal CT MRI abnormal CT abnormal CT &/or MRI &/or MRI &/or MRI &/or MRI GCS 13- GCS 13 -15 15 GCS 9- GCS 9 -12 12 GCS < 9 GCS < 9 PTA < PTA < 24hr 24hr PTA < PTA < 7days 7days PTA > 7days PTA > 7days Complicated Mild TBI Complicated Mild TBI  When clinical  When clinical neuroimaging neuroimaging findings are findings are present following a MTBI, the classification present following a MTBI, the classification changes to “ “complicated MTBI, complicated MTBI,” ” which has which has changes to a 6- -month outcome more similar to month outcome more similar to a 6 moderate TBI 1,2 1,2 moderate TBI 1 1 Williams DH, Levin HS, Eisenberg HM. Mild head injury classifica Williams DH, Levin HS, Eisenberg HM. Mild head injury classification. tion. Neurosurgery 1990;27(3):422 1990;27(3):422- -8. 8. Neurosurgery 2 2 Kashluba S, Hanks RA, Casey JE, Millis SR. Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic Neuropsychologic and and functional outcome after complicated mild traumatic brain injury. . functional outcome after complicated mild traumatic brain injury Arch Phys Med Arch Phys Med Rehabil Rehabil 2008; 89(5): 904 2008; 89(5): 904- -11. 11. 4

TBI Screening Reminder TBI Screening Reminder April 2007 April 2007 “TBI Screening Reminder “ TBI Screening Reminder” ” Functions Functions  Identify possible OIF/OEF Participants Identify possible OIF/OEF Participants   Confirm deployment to OIF/OEF Theatres Confirm deployment to OIF/OEF Theatres  of Deployment of Deployment  Screen for TBI if deployed in OIF/OEF Screen for TBI if deployed in OIF/OEF  Theatres Theatres  Identify those with an OIF/OEF  Identify those with an OIF/OEF- -related related history of TBI history of TBI 5

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Screening Questions: Screening Questions: 4 Sections 4 Sections  Section 1:  Section 1: Events Events  Section 2:  Section 2: Immediate Immediate Disturbance of Disturbance of Consciousness Consciousness Symptoms after Events Symptoms after Events  Section 3: Section 3: New or Worsening New or Worsening Symptoms Symptoms  after the event after the event  Section 4: Section 4: Current Current Symptoms Symptoms  Screen Interpretations Screen Interpretations  A A “ “no no” ” response to any of the sections response to any of the sections  terminates screening and is a “ “negative negative terminates screening and is a screen screen” ”  A A “ “yes yes” ” response to ALL FOUR sections response to ALL FOUR sections  is a “ is a “positive screen positive screen” ” 7

Screen Interpretations Screen Interpretations  The screen will not yield a positive result  The screen will not yield a positive result if there is an historical TBI and there are if there is an historical TBI and there are currently no symptom complaints currently no symptom complaints  This is therefore *not* a screen for mild  This is therefore *not* a screen for mild TBI but rather a screen for ongoing TBI but rather a screen for ongoing symptom complaints + history of symptom complaints + history of “possible possible” ” TBI TBI “ Private Sector Diagnosis Private Sector Diagnosis  Accuracy of Mild Traumatic Brain Injury Accuracy of Mild Traumatic Brain Injury  Diagnosis Diagnosis (Powell, Ferraro, Dikmen Dikmen, , Temkin Temkin & Bell, 2008) & Bell, 2008) (Powell, Ferraro, • Compared identification of mild TBI via Compared identification of mild TBI via • • (1) retrospective chart reviews of Emergency • (1) retrospective chart reviews of Emergency Department Department • (2) prospective identification of cases using (2) prospective identification of cases using • structured interview and medical record data. structured interview and medical record data. 8

Private Sector Diagnosis Private Sector Diagnosis  Accuracy of Mild Traumatic Brain Injury  Accuracy of Mild Traumatic Brain Injury Diagnosis Diagnosis (Powell, Ferraro, Dikmen (Powell, Ferraro, Dikmen, , Temkin Temkin & Bell, 2008) & Bell, 2008)  Of those cases identified in the ED by study Of those cases identified in the ED by study  personnel as having mild TBI, 56% did not 56% did not personnel as having mild TBI, have a documented diagnosis from the ED have a documented diagnosis from the ED physician indicative of mild TBI. physician indicative of mild TBI. 9

Neuropsychologist Role Neuropsychologist Role  Assist in clarifying diagnosis Assist in clarifying diagnosis   Symptoms can support a diagnosis of mild TBI Symptoms can support a diagnosis of mild TBI  but cannot be used to make the diagnosis but cannot be used to make the diagnosis  In most cases (due to lack of injury severity In most cases (due to lack of injury severity  medical records) diagnosis based on: Careful medical records) diagnosis based on: Careful interview of events: interview of events:  Ask them to describe in detail what happened Ask them to describe in detail what happened   Assess for mechanism of injury (i.e., blunt trauma or Assess for mechanism of injury (i.e., blunt trauma or  acceleration/deceleration forces) acceleration/deceleration forces)  Assess for any period of confusion, disorientation, or Assess for any period of confusion, disorientation, or  impaired consciousness associated with mechanism impaired consciousness associated with mechanism Postconcussion Symptoms Postconcussion Symptoms  Physical Physical   Headache, dizziness, fatigue, noise/light Headache, dizziness, fatigue, noise/light  intolerance, insomnia intolerance, insomnia  Cognitive Cognitive   Memory complaints, poor concentration Memory complaints, poor concentration   Emotional Emotional   Depression, anxiety, irritability, lability Depression, anxiety, irritability, lability  10