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Brain injury

Major TBI ‘increases dementia risk’

Brain injuries needing hospital treatment for more than three nights are more likely to lead to dementia, research reveals

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People who are admitted to hospital following a significant traumatic brain injury (TBI) are more likely to be diagnosed with dementia in later life, a new study has revealed. 

The research revealed that those who were in hospital for three or more days following major TBI had a higher risk of developing dementia.

Researchers at the University of Helsinki looked at the hospital records of 31,909 Finnish people spanning a 20-year period. 

The participants were aged between 25 and 64, had regular health check-ups every five years between 1992 and 2012, and were monitored for dementia diagnoses for up to five years after the study.

Nearly 700 of the participants had been hospitalised with TBI between 1970 and 2017. Out of all the participants in the study, 976 were diagnosed with a form of dementia.

This study classified people as having either major or minor TBI based on the length of their stay in hospital and whether doctors found evidence of physical damage to the brain. 

The results showed that participants who were in hospital for three or more days following major TBI had a higher risk of developing dementia in later life. 

Dementia Carers Count

This was true even when age, sex and other dementia risk factors such as excessive alcohol consumption and physical inactivity were considered.

The researchers found that people who were hospitalised for up to one day following minor TBI did not have a significantly increased risk of developing dementia.

TBI is one of 12 potentially modifiable or preventable risk factors for dementia. Others include smoking, excessive alcohol consumption and physical inactivity.

Dr Rosa Sancho, head of research at Alzheimer’s Research UK, said: “There are many different risk factors for dementia including genetics, which we cannot change, but also environmental and lifestyle factors which we may be able to influence. 

Research has highlighted traumatic brain injury as an important risk factor for dementia, but there is huge variation in the severity of these injuries and we don’t yet know the point at which they will significantly affect the long-term health of the brain or how they interact with other dementia risk factors.

“This study provides further evidence that major TBI increases dementia risk, but the findings suggest that this effect was weakened in people who were physically active and didn’t drink too much alcohol. 

“The results highlight the complex nature of dementia risk and the importance of the combined effects of several factors.”

Dr Sancho also highlighted that the study does not consider the cumulative effect of repeated head impacts, which is a concern in areas including sport and domestic violence. 

“The researchers only considered TBI cases requiring hospital admission in the study and did not look at the effects of smaller, more frequent head impacts,” she said. 

“Alzheimer’s Research UK is currently working to identify the most important questions in how sport and head injuries can affect our brain health. 

“Studies like this are crucial for informing clinicians and policymakers and to implement strategies to reduce dementia risk as much as possible.” 

Brain injury

New therapy reduces veteran headaches after brain injury

Cognitive Behavioural Therapy for Headache also shown to have positive impact on PTSD symptoms

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The first therapy to be developed specifically for post-traumatic headaches significantly reduced related disability in veterans following a traumatic brain injury (TBI), a study has revealed. 

Cognitive Behavioural Therapy for Headache (CBTH) was also shown to reduce co-occurring symptoms of post-traumatic stress disorder (PTSD) comparably to a gold-standard PTSD treatment.

Furthermore, the therapy was shown to be appealing to patients with low drop-out rates, and is easy for therapists to learn and deliver, increasing its potential to be widely used and to improve the lives of servicemen and women and veterans globally. 

CBTH, which uses cognitive behavioural therapy concepts to reduce headache disability and improve mood, includes key components such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

“We are excited by this development in the treatment of post-traumatic headache, which along with TBI is poorly understood and for which treatment options are so limited,” said Dr Don McGeary, associate professor at The University of Texas Health Science Center at San Antonio (UT Health San Antonio). 

“To find the first major treatment success for post-traumatic headache, which is arguably the most debilitating symptom of TBI, and that the treatment also significantly reduces co-morbid PTSD symptoms, is a major breakthrough.”

Both TBI and PTSD are prevalent in post-9/11 military conflicts, and the two conditions commonly occur together. 

Post-traumatic headaches, or headaches that develop or worsen following a head or neck injury, become chronic and debilitating in a large percentage of those who experience a TBI such as a concussion, inhibiting their ability to engage in the activities of daily life. 

When PTSD is co-occurring, it can worsen the headaches and make them more difficult to treat.

Effective treatments exist for PTSD but not for post-traumatic headache, which along with TBI, scientists are still working to understand. 

Migraine medications commonly used to alleviate the headache pain do not relieve related disability. They also often have unwanted side effects, and their overuse can worsen headaches.

In the study, Dr McGeary and his team developed CBTH by modifying a psychotherapy for migraine headaches. They evaluated its efficacy with co-occurring post-traumatic headache and PTSD symptoms.

The study was conducted at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System. 

Participants had clinically significant PTSD symptoms and headaches persisting more than three months following a TBI. They were randomly assigned to receive either CBTH, a leading PTSD treatment called Cognitive Processing Therapy (CPT), or the usual care provided at the VA Polytrauma Center.

At the end of treatment, researchers found that, compared to usual care, those receiving CBTH reported significant reductions in disability and in negative impact on function and quality of daily life. 

They also showed improvement in PTSD symptoms comparable to the group that received CPT. All of these treatment gains were maintained six months after treatment completion.

CPT, on the other hand, led to significant and lasting improvements in PTSD symptoms, but on its own did not improve headache disability. 

“This was a surprise,” said Dr McGeary. 

“If theories about PTSD driving post-traumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Interestingly, CBTH did not reduce headache intensity or frequency compared to usual care. 

Dr McGeary said its dramatic reductions on negative life impact are likely due to its building patients’ confidence that they could control or manage their headaches, a concept known as “self-efficacy.” 

That sense of control was key to helping patients “get their lives back,” he said.

“If you can improve a person’s belief that they can control their headache, they function better,” Dr McGeary said. 

“That’s because, when dealing with a long-term, disabling pain condition, people make decisions about whether they’re going to actively engage in any kind of activity, especially if the activity exacerbates the pain condition. 

“They make those decisions based on their perceptions of their ability to handle their pain.”

In comparison to CPT, CBTH requires fewer and shorter therapy sessions—typically eight sessions of 30-45 minutes each. CPT typically involves 12 sessions lasting 60-90 minutes each.

CBTH requires only two hours to train clinicians to deliver the therapy, compared to CPT, a complex treatment that requires significant training and acquired skill. 

The research team now hope to broaden their study to be as representative as possible. 

Dr McGeary said: “We need more women, more racial and ethnic diversity, veterans as well as active military of different branches, with varying comorbidities, in different geographic regions attached to different hospitals and medical systems because we’re comparing to usual care.”

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News

Pioneering project could revolutionise capacity assessment

Sector-leading research is set to generate a framework of wellbeing indicators for patients

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Specialist neurological care provider PJ Care has partnered with the University of Leicester for a sector-leading research project that could revolutionise the assessment and care of residents who lack capacity.

The two have come together in a knowledge transfer partnership (KTP) to support the creation of a centralised system at PJ Care to create algorithms that will generate a framework of wellbeing indicators for those who are non-verbal as a result of their neurological condition.

So far, a review has been completed of existing research into this area, which will be published jointly by PJ Care and the University of Leicester later this year.

Leading the project is Dr Allan Perry, consultant clinical neuropsychologist and director of clinical services at fast-growing PJ Care.

“The current models for assessing the health and wellbeing of those without capacity and who cannot readily communicate their feelings and experiences are limited and don’t take advantage of the recent advances in technology and data analysis that can give us much more detailed information,” he explains.

“There is a wealth of monitoring technology that we use which allows us to collect real-time data on a number of wellbeing indicators such as a person’s oxygen levels, heart rate, fluid intake and the number of steps they take to reach a certain distance.

“We believe this data can be analysed by an algorithm to provide insights into personal wellbeing, sense of agency, independence and self-determination, that are more accurate than those offered by traditional methods. We can then apply this information to tailor our care to that individual.

“While there is plenty of information on bringing more technology into the care sector and using the data being created by it, this isn’t being married with the questions posed by a person’s capacity as yet. We don’t believe any other care provider is delivering anything like what we are proposing to.”

PJ Care is a specialist neurological care provider with three specialist care centres – the first of which has just celebrated its 21st anniversary – for more than 200 adults with progressive conditions such as young onset dementia and Huntington’s disease, and care and rehabilitation for people with acquired brain injuries.

Dr Zehra Turel holds a PhD in cognitive neuroscience from the University of Leicester and serves as KTP research associate for the project, working with Professor John Maltby and Professor Elizabeta Mukaetova-Ladinska of Leicester’s Department of Neuroscience, Psychology and Behaviour.  

She says there is an urgent need for an accurate assessment tool for those who have difficulty communicating.

“We have so far uncovered that the available wellbeing measurements neglect or fail in understanding of the clinical populations such as cognitively impaired individuals, with or without capacity,” says Dr Turel.  

“This project will provide micro and macro insights about residents’ health and wellbeing, and support decision-making at both resident and business level.

“With the increasing use of new data-driven technologies and streamlined data collection at PJ Care, this project will improve personalised care and provide more accurate and faster predictive and preventive measures, and more informed decision-making along with lowering costs and simplifying internal operations.”

“This KTP has the potential to develop resources that could not just be transformative for PJ Care and how our staff support people without capacity, but, eventually, for the whole care sector,” says Dr Perry.  

“We will be looking to market this if it proves to be as effective as we believe it will be.”

 

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Brain injury

Research sheds light on nerve cell changes after brain injury

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An injury to one part of the brain changes the connections between nerve cells across the whole brain, new research has revealed. 

Traumatic brain injury (TBI) affects one in three people and can lead to physical, cognitive and emotional disabilities. 

One of the biggest challenges for neuroscientists has been to fully understand how a TBI alters the cross-talk between different cells and brain regions.

In a new study from University of California, Irvine, researchers improved upon a process called iDISCO, which uses solvents to make biological samples transparent. 

The process leaves behind a fully intact brain that can be illuminated with lasers and imaged in 3D with specialised microscopes.

With the enhanced brain clearing processes, the UCI team mapped neural connections throughout the entire brain. 

The researchers focused on connections to inhibitory neurons, which are extremely vulnerable to dying after a brain injury. 

“Our study is a very important addition to our understanding of how inhibitory progenitors can one day be used therapeutically for the treatment of TBI, epilepsy or other brain disorders,” said Dr Robert Hunt, associate professor of anatomy and neurobiology and director of the Epilepsy Research Center at UCI School of Medicine whose lab conducted the study.

The team first looked at the hippocampus, a brain region responsible for learning and memory. Then, they investigated the prefrontal cortex, a brain region that works together with hippocampus. 

In both cases, the imaging showed that inhibitory neurons gain many more connections from neighbouring nerve cells after TBI, but they become disconnected from the rest of the brain.

“We’ve known for a long time that the communication between different brain cells can change very dramatically after an injury,” said Dr Hunt.

“But, we haven’t been able to see what happens in the whole brain until now.”

To get a closer look at the damaged brain connections, Dr Hunt and his team devised a technique for reversing the clearing procedure and probing the brain with traditional anatomical approaches.

The findings surprisingly showed that the long projections of distant nerve cells were still present in the damaged brain, but they no longer formed connections with inhibitory neurons.

“It looks like the entire brain is being carefully rewired to accommodate for the damage, regardless of whether there was direct injury to the region or not,” explained Alexa Tierno, a graduate student and co-first author of the study. 

“But different parts of the brain probably aren’t working together quite as well as they did before the injury.”

The researchers then wanted to determine if it was possible for inhibitory neurons to be reconnected with distant brain regions. To find out, Hunt and his team transplanted new interneurons into the damaged hippocampus and mapped their connections, based on the team’s earlier research demonstrating interneuron transplantation can improve memory and stop seizures in mice with TBI.

The new neurons received appropriate connections from all over the brain. While this may mean it could be possible to entice the injured brain to repair these lost connections on its own, Hunt said learning how transplanted interneurons integrate into damaged brain circuits is essential for any future attempt to use these cells for brain repair.

“Some people have proposed interneuron transplantation might rejuvenate the brain by releasing unknown substances to boost innate regenerative capacity, but we’re finding the new neurons are really being hard wired into the brain,” said Dr Hunt.

Dr Hunt hopes to eventually develop cell therapy for people with TBI and epilepsy. The UCI team is now repeating the experiments using inhibitory neurons produced from human stem cells.

“This work takes us one step closer to a future cell-based therapy for people,” he said.

”Understanding the kinds of plasticity that exists after an injury will help us rebuild the injured brain with a very high degree of precision. However, it is very important that we proceed step wise toward this goal, and that takes time.”

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