BrainLine sat down with Dr. Steven Flanagan to talk about the issues of aging after a traumatic brain injury. Dr. Flanagan is professor and chairman of the Department of Rehabilitation Medicine, New York University School of Medicine, and the medical director of the Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center.
BrainLine: Are there any increased risks as people age after a traumatic brain injury?
Dr. Flanagan: We think the answer is yes. Although aging after a brain injury has not been terribly well studied to date, some research, including a study conducted in 2008 by the Institute of Medicine, has suggested that people with TBI are at an increased risk of seizures. We have also found that people with poorly controlled seizures are at a higher risk of dying at an earlier age than people without brain injury-related seizures.
Studies also suggest that the more physically disabled a person is post-injury, the more likely he is to have a shorter life span. This is common sense. For example, if a person has trouble swallowing or can’t exercise at all post-injury, he will more likely have medical complications earlier on in life than someone who can move around, stay physically healthy, and swallow without problems.
Medical evidence also suggests that after a moderate or severe TBI, a person is more likely to develop Parkinson’s disease or Parkinson-like symptoms. The same is true for the development of dementia. That being said, the medical evidence to date shows an association between TBI and these problems, not a direct cause and effect.
For people with a mild TBI, there is little evidence of any association between TBI and developing Parkinson’s or early-onset dementia.
BrainLine: Are there symptoms to watch for? If so, which ones in particular?
Dr. Flanagan: That is a tough question because everyone is different. Symptoms can differ across the board but can include anything from depression to problems with balance. But if a person has more significant physical or cognitive problems that resulted from a moderate or severe brain injury, he should get checked by his doctor on a regular basis, meaning once or twice a year; and his doctor should be someone who specializes in or has experience with traumatic brain injury.
People with what’s called “complicated mild TBI” — a mild TBI with symptoms that don’t resolve quickly or that remain chronic — should also check in with their doctor periodically.
BrainLine: What can people do to protect their health after a TBI? Are there long-term health problems that may crop up?
Dr. Flanagan: This is an important question because people who live with long-term effects from TBI often forget that they have other parts of their bodies to look after. Everyone — with or without a TBI — should do “upkeep” tests like pap smears and mammograms for women, prostate exams for men, colonoscopies at 50 years old, cholesterol checks, and so forth. They should also maintain a good diet and fitness regimen.
It’s easy for people with TBI to focus solely on their brain and the long-term issues that persist from their injury; however, it’s crucial not to forget about the rest of the body.
A person with TBI should also make sure his doctor keeps signs and symptoms of Parkinson’s disease and early-onset dementia on the radar screen. Again, TBI is not a cause of these other diseases, rather an association.
BrainLine: How does a brain injury affect cognitive issues as a person ages?
Dr. Flanagan: This has not been well studied at all and is difficult to answer. Some studies suggest that people with moderate to severe TBI have accelerated cognitive decline as they age. But, again, this has not been proven.
Ideally, we need to have a long-term study that looks at how brain injury affects cognition as a person gets older. For example, if we could study the cognitive skills of people with TBI versus those without TBI at 30 years of age and then at 60 years of age, we would probably learn a great deal. However, that kind of study is almost impossible because it is hard to follow people for so many years.
That said, people with TBI, especially those with long-term cognitive issues, should stay in touch with their doctor, preferably a physician knowledgeable about TBI.
BrainLine: How does a brain injury affect physical issues as a person ages?
Dr. Flanagan: Folks with TBI who have chronic problems with balance, for example, may need to schedule periodic sessions with a physical therapist or an occupational therapist. Sometimes these “tune ups” bring people back to a safer level of function. As we get older, our sensory system changes, more so for people who may have had their sensory system disrupted or damaged from a brain injury. Therefore, we need to pay more attention to how we move and do things. Balance can get worse and our bones and muscles weaker, making it harder to move safely through the world. So, getting a therapy here and there can be incredibly helpful not just physically but also emotionally, for one’s self-confidence.
BrainLine: How does a brain injury affect emotional or behavioral issues as a person ages?
Dr. Flanagan: Behavioral problems are part of what separates people with TBI from others in rehabilitation medicine. Many behavioral and emotional problems that are a result of a brain injury can be chronic, and the severity of these problems can fluctuate over time. Depression is a significant risk. Anxiety and other mood disorders can also persist. People who have a hard time multitasking or concentrating tend to be vulnerable to frustration, anger, and depression.
We are not sure if the risk of these types of emotional or behavioral issues ever goes away entirely after a brain injury. Data show, for example, that there is an increased risk of depression for people with TBI even years after an injury.
BrainLine: What do you tell people who are concerned about developing Alzheimer’s disease or early-onset dementia after a brain injury?
Dr. Flanagan: We definitely don’t know all the answers about Alzheimer’s disease, especially as it relates to brain injury. There is ongoing research on many fronts related to Alzheimer’s, but, to date, we don’t have any definitive answers. However, studies suggest that there is an association between genetics and developing the disease and between TBI and developing the disease. Again, there is an association with severe TBI, not a cause and effect. That is an important distinction.
It’s important to remember that most people in general do not get Alzheimer’s. The best thing to do is to stay focused on staying physically active, socializing with supportive friends and family, getting out and staying involved in the world, and keeping our minds sharp and engaged.
BrainLine: More and more studies are being conducted about contact sports and progressive brain injury. What is chronic traumatic encephalopathy, and what should we be doing to protect young athletes?
Dr. Flanagan: For years, we have known about a type of neurodegenerative disease that may affect amateur and professional boxers, known as dementia pugilistica. Symptoms and signs of dementia pugilistica can develop progressively over a long period of time. Chronic traumatic encephalopathy, or CTE, may be similar and may be seen in more and more athletes who play contact sports like football or ice hockey. How much can the brain take, after all? It makes sense that a football player who is hit time and time again and who suffers multiple concussions could develop some sort of neurological trauma. The research that is being done on CTE is important, but it needs to be followed up with more research.
I think the increased awareness about traumatic brain injury is very helpful as is the awareness that a person doesn’t have to lose consciousness to sustain a concussion. This awareness will help everyone — from young athletes and coaches to soldiers serving in Iraq and Afghanistan. Everyone, including healthcare professionals at all levels, needs to know that TBI is not necessarily a benign event and sometimes symptoms do not go away.
BrainLine: How long do you follow up with a patient after a brain injury?
Dr. Flanagan: For most of my patients, they remain my patients for life. I never discharge them. For those with moderate to severe TBI, once their active rehab or restorative therapy is over, I follow up with them approximately one to two times a year. When they are still in rehab, I am actively involved and check in with them about once a month or so.
For my patients with mild TBI — unless they make a full recovery and are symptom-free within the first three months post-injury — I also follow up with them once or twice a year.
I find it important to follow up once or twice a year with patients to make sure the therapy and/or medications are still appropriate for them. For example, a patient may no longer need the same amount of an anti-depressant or a sleep aide as his life settles back into a new normal. Or maybe a patient needs more physical therapy for balance or strength. Recovery is a life-long endeavor for many people with TBI, and we want to make sure they are getting the right care at every step along the way.
BrainLine: What type of long-term medical follow-up do you recommend for people with brain injury? Which specialists should they see, and how often?
Dr. Flanagan: When necessary, I refer my patients to specialists like endocrinologists, psychiatrists, or neurologists. I also make sure that all my patients have a primary care doctor to ensure that they are doing the “regular” health maintenance checks like cholesterol tests, pap smears, and colonoscopies.
BrainLine: Why is long-term follow up important for people with TBI?
Dr. Flanagan: In a nutshell, long-term follow up is important for people with TBI because they can be more susceptible to the effects of aging, like depression or physical and cognitive changes that naturally come with age.
BrainLine: Does having a brain injury put a person at greater risk for other health problems? Of dying at a younger age?
Dr. Flanagan: Depending on the severity of the injury and the associated long-term consequences, some people may be at risk for certain health problems. Certainly, if people are less physically active or emotionally unhealthy, they are more susceptible to age-related effects — from problems with balance to depression. The stronger people’s bodies, minds, and spirits are — whether they have a TBI or not — the more effectively they will postpone the effects of aging … and enjoy life.
Dr. Steven Flanagan is professor and chairman of the Department of Rehabilitation Medicine, New York University School of Medicine, and the medical director of the Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center. He has served on medical advisory boards of many national and international committees and has presented at scientific meetings both nationally and internationally, most notably on topics pertaining to brain injury rehabilitation.