Jeanne M. Hoffman

Falls in the Medicare Population: Incidence, Associated Factors, and Impact on Health Care

Background and Purpose: Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries. Participants: The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS). Methods: Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data. Results: Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, “fallers” consistently had larger utilization costs than “nonfallers” for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information. Discussion and Conclusions: Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.

Natural History of Headache after Traumatic Brain Injury

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

Mobility Limitations in the Medicare Population: Prevalence and Sociodemographic and Clinical Correlates

Objectives: To examine the prevalence of and clinical markers associated with mobility limitations in Medicare Current Beneficiary Community Survey (MCBS) respondents.

The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial

Background: Mild traumatic brain injury (MTBI) is a significant public health problem affecting approximately 1 million people annually in the USA. A total of 10–15% of individuals are estimated to have persistent post-traumatic symptoms. This study aimed to determine whether focused, scheduled telephone counselling during the first 3 months after MTBI decreases symptoms and improves functioning at 6 months. Methods: This was a two-group, parallel, randomised clinical trial with the outcome assessed by blinded examiner at 6 months after injury. 366 of 389 eligible subjects aged 16 years or older with MTBI were enrolled in the emergency department, with an 85% follow-up completion rate. Five telephone calls were completed, individualised for patient concerns and scripted to address education, reassurance and reactivation. Two composites were analysed, one relating to post-traumatic symptoms that developed or worsened after injury and their impact on functioning, the other related to general health status. Results: The telephone counselling group had a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score, 95% confidence interval (CI) 1.2 to 12.0), but no difference in general health outcome (1.5 difference in adjusted mean functional score, 95% CI 2.2 to 5.2). A smaller proportion of the treatment group had each individual symptom (except anxiety) at assessment. Similarly, fewer of the treatment group had daily functioning negatively impacted by symptoms with the largest differences in work, leisure activities, memory and concentration and financial independence. Conclusions: Telephone counselling, focusing on symptom management, was successful in reducing chronic symptoms after MTBI. Trial registration number: ClinicalTrials.gov, #NCT00483444

A Longitudinal Study of Depression From 1 to 5 Years After Spinal Cord Injury

OBJECTIVE To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury. DESIGN Longitudinal cohort study. SETTING SCI Model System. PARTICIPANTS Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher. RESULTS Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found. CONCLUSION In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

A prospective study of prevalence and characterization of headache following mild traumatic brain injury

Background Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI). Methods We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache. Results Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods. Conclusions Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.

Characterization of headache after traumatic brain injury

Background: Headache is a common and persistent symptom following traumatic brain injury (TBI). Headaches following TBI are defined primarily by their temporal association to injury, but have no defining clinical features. To provide a framework for treatment, primary headache symptoms were used to characterize headache. Methods: Three hundred and seventy-eight participants were prospectively enrolled during acute in-patient rehabilitation for TBI. Headaches were classified into migraine/probable migraine, tension-type, or cervicogenic headache at baseline and 3, 6, and 12 months following TBI. Results: Migraine was the most frequent headache type occurring in up to 38% of participants who reported headaches. Probable migraine occurred in up to 25%, tension-type headache in up to 21%, then cervicogenic headache in up to 10%. Females were more likely to have endorsed pre-injury migraine than males, and had migraine or probable migraine at all time points after injury. Those classified with migraine were more likely to have frequent headaches. Conclusions: Our data show that most headache after TBI may be classified using primary headache criteria. Migraine/probable migraine described the majority of headache after TBI across one year post-injury. Using symptom-based criteria for headache following TBI can serve as a framework from which to provide evidence-based treatment for these frequent, severe, and persistent headaches.

The efficacy of a scheduled telephone intervention for ameliorating depressive symptoms during the first year after traumatic brain injury

ObjectiveTo determine whether an intervention designed to improve functioning after traumatic brain injury (TBI) also ameliorates depressive symptoms. DesignSingle-blinded, randomized controlled trial comparing a scheduled telephone intervention to usual care. ParticipantsOne hundred seventy-one persons with TBI discharged from an inpatient rehabilitation unit. MethodsThe treatment group received up to 7 scheduled telephone sessions over 9 months designed to elicit current concerns, provide information, and facilitate problem solving in domains relevant to TBI recovery. Outcome MeasuresBrief Symptom Inventory-Depression (BSI-D) subscale, Neurobehavioral Functioning Inventory-Depression subscale, and Mental Health Index-5 from the Short-Form-36 Health Survey. ResultsBaseline BSI-D subscale and outcome data were available on 126 (74%) participants. Randomization was effective except for greater severity of depressive symptoms in the usual care (control) group at baseline. Outcome analyses were adjusted for these differences. Overall, control participants developed greater depressive symptom severity from baseline to 1 year than did the treatment group. The treated group reported significantly lower depression symptom severity on all outcome measures. For those more depressed at baseline, the treated group demonstrated greater improvement in symptoms than did the controls. ConclusionsTelephone-based interventions using problem-solving and behavioral activation approaches may be effective in ameliorating depressive symptoms following TBI. Proactive telephone calls, motivational interviewing, and including significant others in the intervention may have contributed to its effectiveness.

A Randomized Controlled Trial of Exercise to Improve Mood After Traumatic Brain Injury

To test the hypothesis that a structured aerobic exercise regimen would decrease the severity of depressive symptoms in people with traumatic brain injury (TBI) who reported at least mild depression severity at baseline.

Benefits of Exercise Maintenance After Traumatic Brain Injury

OBJECTIVE To examine the effect of exercise intervention on exercise maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression. DESIGN Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention. SETTING Community. PARTICIPANTS Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9. INTERVENTIONS Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group. MAIN OUTCOME MEASURE Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week. RESULTS Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health. CONCLUSIONS Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.