Traumatic brain injury in adults

Abstract

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Falls, assaults and road traffic accidents are the most common causes, with alcohol precipitating 65% of adult cases. The incidence of TBI is highest in men. As the UK population ages, however, the incidence of TBI in the elderly is rising. Approximately 1 million people affected in the UK have long-term sequelae, and GPs should be aware of the common causes and consequences of TBI. This article will focus primarily on mild TBI in adults.

The GP curriculum and traumatic brain injury

Clinical module 3.03: Care of acutely ill people requires:

Recognition of the signs of illnesses and conditions that require urgent intervention

Making patient safety a priority

Informing patients and offering appropriate explanations for any new symptoms, signs or changes in an existing condition that patients/carers should report back to you so that no serious complications are missed (safety netting)

Clinical module 3.10: Care of people with mental health problems requires:

Understanding of the psychological effects of trauma, for example post-traumatic stress disorder

Clinical module 3.18: Care of people with neurological problems requires:

Knowledge of the key National Institute of Health and Care Excellence guidelines that influence healthcare provision for neurological problems

Understanding of the sources of help and support that are available in the local community for people with neurological disabilities

Definitions

The terms mild traumatic brain injury and mild head injury are synonymous; they are used interchangeably in the literature. For the purpose of this article, reference will be made to mild traumatic brain injury (TBI). The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (ACRM) defines mild TBI as:

A traumatically induced physiological disruption of brain function from an external mechanical force, as manifested by at least one of the following: any period of loss of consciousness, any loss of memory for events immediately before or after the accident, any alteration in mental state at the time of the accident (for example feeling dazed, disoriented, or confused) or focal neurologic deficits, which may or may not be transient.

A Glasgow Coma Scale (GCS) of between 13 and 15 is also mandatory for classification of mild TBI (ACRM, 2016).

Assessment in primary care

The most important role of the GP in the first consultation is to take a focussed history, identifying the red flag symptoms and then performing an appropriate examination of the patient. Patients may present first in primary care or following discharge from the Emergency Department (ED) with on-going symptoms following any trauma to the head. The most common symptoms in the history are headache and dizziness with equal numbers of patients reporting cognitive and behavioural features (Headway, 2016). Most patients with mild TBI have very few, if any, physical signs to find on examination. It is a challenge to complete a comprehensive assessment within a 10-minute general practice consultation. Box 1 highlights the National Institute of Health and Care Excellence (NICE) red flag criteria for referral to the ED and further investigation to rule out sinister intracranial pathology, including intracranial haemorrhage.

Box 1.

NICE guidelines warranting referral to the ED for examination of a head injury.

• A GCS less than 15 on first assessment

• Loss of consciousness

• Any focus of neurological deficit

• Suspected skull fracture or penetrative head injury

• Inability to remember events before or after the injury

• Continuing headache post-injury

• Vomiting after the injury

• Post-injury seizures

• History of prior brain surgery.

• A head injury that was of high-energy impact

• A bleeding or clotting disorder history

• Current use of anticoagulant medication such as warfarin

• Drug or alcohol intoxication

• Concerns over safeguarding

• On-going concern about the diagnosis or management by a professional

In the absence of any of the risk factors above, consider referral to an ED if any of the following factors are present, depending on judgement of severity:

• Irritability or altered behaviour, particularly in infants and children aged under 5 years

• Visible trauma to the head not covered above but still of concern to the healthcare professional

• No one is able to observe the injured person at home

• Continuing concern by the injured person or their family or carer about the diagnosis

Source: NICE (2014) .

Management

The NICE (2014) guidelines recommend that if any red flag symptoms are present following assessment in primary care, the patient should be referred immediately to the local ED accompanied by a friend or relative. Most patients with TBI, but without red flag criteria, will improve within 3 months and require no treatment.

Some groups, such as the elderly, require special consideration. The elderly are a high-risk group and can present with non-specific symptoms from a slow intracranial haemorrhage after mild TBI many weeks after the initial event. These symptoms include confusion, recurrent falls, dizziness, mood fluctuations and behavioural changes. Patients and relatives need to be informed at first presentation that the development of such symptoms should prompt urgent assessment in the ED (Adhiyaman, Asghar, Ganeshram, & Bhowmick, 2002).

General advice to give the patient

Explanation, education and reassurance form the mainstay of management. Not rushing back into activities or work, reducing stress levels, getting good quality sleep, avoiding drugs and alcohol, and treating headaches with simple analgesics (such as paracetamol) are all helpful suggestions and constitute appropriate advice (Patient, 2016). Ideally, a friend or relative should be present during the consultation, as cognitive problems may prohibit the patient from recalling advice given. Where symptoms have not improved by 3 months, referral to rehabilitation medicine teams should be implemented.

Providing safety netting advice is of paramount importance. There are many symptoms and signs of which the patient should be aware; they should prompt urgent review in the ED. These are highlighted in Box 2.

Box 2.

Safety netting: Symptoms about which the patient needs to be vigilant.

• Severe or worsening headaches

• Vomiting

• Confusion

• Seizures

• Visual disturbance

• Dizziness or lack of coordination

• Weakness in the limbs

• Clear fluid or blood coming out of ears or nose

• New deafness in one or both ears

• Amnesia

Source: Patient (2016) .

Computed tomography scan guidelines in patients with on-going symptoms

Patients who meet any of the criteria for review in the ED should be assessed for computed tomography (CT) brain imaging. It has been deemed both safe and cost-effective for those patients with a GCS of 15 and a normal CT scan to be discharged (NICE, 2014). NICE recommends ED doctors send a discharge summary to the GP within 48 hours of their patient being sent home from hospital, and it is imperative that these are reviewed in primary care and acted on as necessary. A very small number of patients will develop late complications despite having no signs or symptoms, a GCS of 15 and a normal CT scan. The frequency of an intracranial haematoma in a patient with a GCS score of 15 has been estimated as 1 in 3615 (SIGN, 2009).

In some cases, the patient is sent home from the ED after a period of observation without having a scan, and a small number of these patients may then go on to re-present either to primary care or directly to secondary care if they develop symptoms. This is often seen within 48 hours of discharge, but can be weeks or even months later. There should be a low threshold for CT scanning of these patients to assess for intracranial bleeding. This is especially important if the patient is in a high-risk group (for example, the elderly, those patients on anticoagulation or history of clotting disorder, and patients with a history of alcoholism or problem drinking). The GP may need to expedite referral if they have presented again in primary care or in rare cases where patients have been sent home from the ED for a second time without imaging. It should be noted that the NICE guidelines serve as a source of advice, but clinical assessment must be made on an individual basis. Therefore, any patients causing concern in general practice need to be re-assessed in the ED. It should be noted that a retrospective study with a cohort of 606 patients re-attending a trauma unit after mild TBI found that 53.3% of patients had a CT scan and in 14.4% of these re-attenders scans demonstrated intracranial abnormalities. A significant number (5%) of these re-attending patients required neurosurgery (Voss, Knottenbelt, & Peden, 1995).

Concussion

The force of injury to the head causes the brain to move within the skull. This causes transitory disruption of cellular electrical activity and normal brain function is temporarily halted. This explains the three main features of concussion: headache, confusion and memory loss (Patient, 2016). In most cases these symptoms are transient and self-limiting, and there are usually no long-term or sinister sequelae from concussion. Follow-up in general practice can be guided by the clinical presentation, and where appropriate, with consultations, telephone consultations or email updates from the patient or relatives.

Post-concussion syndrome

Post-concussion syndrome (PCS) describes a range of symptoms that patients may develop after concussion. Patients more likely to experience PCS include young men, the elderly, homeless people, sports players and patients with a history of mental health problems. Common symptoms include headaches, reduced hearing, dizziness or vertigo, nausea, diplopia, blurred vision, fatigue, irritability and insomnia. These symptoms can sound sinister; however, providing the clinical examination is unremarkable, then a watch-and-wait approach can be adopted with reassurance that resolution is typically seen within 1 month. In rare cases, the symptoms can last up to 3 months (Triebel et al., 2012). Should the symptoms persist beyond this period, referral to secondary care for further assessment can be considered, with options including rehabilitation medicine, neurology, ear nose and throat or ophthalmology, depending on symptoms.

Seizures

The overall future risk of a seizure following a mild TBI is 3%. An early seizure (one which occurs in the first week following the injury) does not usually need long-term treatment with an anti-epileptic drug (AED). Those with late seizures (occurring after 1 week) should be counselled about the use of AEDs, taking their lifestyle into consideration (Annegers, Hauser, Coan, & Rocca, 1998). Patients presenting in primary care with seizures following head injury require an urgent referral to a specialist for further investigation and management (NICE, 2016). General advice about not driving and informing the Driver and Vehicle Licensing Agency (DVLA) needs to be given and clearly documented. Information about reducing seizure risk should be reiterated, including eating at regular mealtimes, avoiding over stimulating environments, avoiding alcohol and ensuring another competent adult is present with certain activities (e.g. swimming).

Sleep

Sleep disorders are common following TBI. In mild injuries, variable sleep–wake symptoms are reported in one-third of patients within the first 10 days and in 50% at 6 weeks (Chaput, Giguère, Chauny, Denis, & Lavigne, 2009). The most common manifestations include: insomnia, pleiosomnia (increased need for sleep) and excessive daytime somnolence.

The management of sleep disorders in TBI is the same as in the general population. It is important to review medication, to determine any iatrogenic triggers, and to rule out alternative, reversible causes. Sleep hygiene and stimulus control methods should be tried. Referral for cognitive behavioural therapy (CBT) may occasionally be recommended. If these measures have been unsuccessful, short-term use of non-benzodiazepine agonists (zopiclone or zolpidem) can be considered. Referral for specialist sleep studies may be required in difficult cases.

Cognitive impairment

Cognition refers to a person’s thinking skills; the ability to understand, learn and remember information. Following mild TBI, studies have shown that areas of cognition commonly affected include: attention, working memory, processing speed and reaction time. These symptoms are often apparent within the first week following injury and are not usually severe. Recovery is rapid in the initial weeks, and by 1 to 3 months, patients have usually returned to their baseline level of cognitive function (Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, 2005).

GPs need awareness of cognitive issues following TBI, as they can be distressing for both the patient and their family, and have a significant impact on activities of daily living. Reassurance about prognosis is appropriate, but if there are any concerns, early referral is recommended. Specialist community neurological rehabilitation services can assess and manage on-going cognitive impairment with involvement of occupational therapists. Neuropsychologists can also be involved, depending on local services and availability.

Behavioural problems

Behavioural difficulties are common following mild TBI, and a significant number of patients and families report personality changes, including irritability and aggression (Kreutzer, Seel, & Gourley, 2001). Family members often report that their relative is ‘not the same as he/she used to be’ or ‘he/she is not the person I married’. GPs have an important role in recognising personality changes related to TBI, and in referring to psychotherapy or neuropsychology for assessment and management when appropriate.

Depression

There is an increased risk of depression (up to 45%) in patients following a TBI (Gaber, 2008). As expected, the long-term outcomes are worse for patients with depression after TBI. GPs are best placed to diagnose depression. Typical symptoms of low mood, anergia and anhedonia may be present, but it is important to recognise somatic symptoms, such as low back pain and non-specific aches and pains, as possible manifestations of depression in patients following TBI (Gaber, 2008).

Psychological support in the form of counselling should be offered to all patients, and morbidity is often reduced further with concurrent administration of a selective serotonin reuptake inhibitor (SSRI). In TBI, sertraline is the SSRI of choice, given at a dose of 50 mg once daily for 3 months followed by gradual withdrawal after 3 months (Bombardier et al., 2010). It is important to consider methods of providing psychological support, and therefore, knowledge of local counselling services is helpful. In patients with TBI and mobility difficulties, home or telephone counselling may be more appropriate if available. Web-based therapy may be an alternative, depending on patient choice and ability to engage with this modality of therapy.

Anxiety and post-traumatic stress disorder

Anxiety symptoms are common following TBI. Feeling irritable, restless and worried, reduced concentration, depersonalisation and derealisation are common symptoms. Physical symptoms can occur with anxiety including palpitations, shortness of breath and chest tightness. CBT can be very helpful for these symptoms, and in some cases SSRIs can also be effective (Ward, Barnes, Stark, & Ryan, 2009a).

The main symptoms of post-traumatic stress disorder include flashbacks, nightmares, hypervigilance and avoidance of the scene of trauma. In most cases, referral to psychological services is appropriate (Ward Barnes, Stark, & Ryan, 2009b).

Drug and alcohol management

After TBI patients should not drink alcohol for 6 months. Alcohol can slow neuronal recovery in the brain, increase the likelihood of seizures, increase the incidence of depression and worsen any cognitive deficit (Bombardier, 2013). Almost two-thirds of patients have a history of hazardous drinking (Bombardier et al., 2013) and in these complex cases referral to specialist alcohol treatment services is essential.

Driving

Driving requires both physical and cognitive skills, which can be impaired following a mild TBI. The DVLA states that patients diagnosed with a mild TBI and holding a valid UK driving licence have a legal obligation to inform the DVLA of the diagnosis. This does not mean that the patient must stop driving, but specific features may make this necessary (such as with a seizure following TBI). Each case is considered on an individual basis.

Most patients with a mild TBI have no lasting effects, and will be able to drive again when all symptoms have resolved. Patients with on-going sequelae related to the TBI, and impaired ability to drive safely, must be told to stop driving and to inform the DVLA (UK Government, 2016a).

Employment

The cognitive and behavioural disruption experienced by patients with TBI can be significant enough to hinder return to work. TBI is common in patients of working age, and providing a fit note where appropriate can help reduce associated stress for patients and keep employers informed. Further reports can help strengthen patients’ work applications. Where cognitive dysfunction is minimal, patients often seek employment or return to work independently. Vocational rehabilitation may be available in some areas with GP referral.

Substantial information, including advice on Employment Support Allowance, Disability Support Allowance, and the Personal Independence Payment (PIP) can be accessed at www.gov.uk/financial-help-disabled. PIP provides between £21.80 and £139.75 per week (UK Government, 2016a, 2016b) depending on how the patient concerned is affected by the TBI. That website also gives advice on how to decipher job adverts for patients with a disability, referenced with a disability confidence symbol. Patients can also apply for an access to work grant, which can help with equipment adaptation, public transport fare relief, a job coach or support worker and training for work colleagues, focusing on disability awareness.

Severe TBI

Severe TBIs account for 5% of all TBIs (Headway, 2016). Patients who have experienced a severe TBI are managed in secondary care and require protracted admission. When medically stable, patients undergo intensive rehabilitation and are discharged back to the community with regular follow-up from the rehabilitation team. A discharge prescription is formulated and sent to the GP, with details about the admission, treatments received and the on-going management plan. Referral to community teams will usually be in place before discharge.

In severe TBI, GPs can support and facilitate on-going care. Major trauma centres with designated rehabilitation units are few and far between in the UK, and GPs may need support from enhanced local services in the care of patients with severe TBI. GPs have an important role in the care of patients with severe TBI, and are encouraged to attend multi-disciplinary team meetings before patient discharge, but attendance may not be practicable. It is hoped that more rehabilitation units will open in the future, and this has the potential to improve the interface between primary and secondary care for the management of more complex patients.

Key points

Mild TBIs are common, and the majority of patients make a complete recovery

Cognitive and behavioural changes are the most common sequelae of TBI, and a collateral history is helpful in assessment of patients after injury

Patient education is important in the management of mild TBI; it includes specific advice on rehabilitation, work, driving, alcohol and vigilance for important sequelae

Mild TBI can have a significant impact on future relationships, driving and employment

Awareness of local services, including rehabilitation and neuropsychology services, is important in the management of TBI

Footnotes

Acknowledgement

We would like to thank Dr Paul Wainman for his help with the writing of this article under the InnovAiT ‘buddy’ scheme.

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