Acquired Brain Injury

“Any type of injury that acutely affects brain structures in people born without any kind of brain damage, causing a permanent neurological deterioration and leading to a reduction in functional capacity and quality of life”

According to this definition, four criteria must be met for a patient’s condition to be classed as acquired brain injury (ABI):

The injury affects part or all of the brain (brain, brainstem, and cerebellum).

The clinical debut is acute (it occurs over a period lasting from a few seconds to a few days).

As a result of the injury, the patient develops a disorder that can be diagnosed through clinical examination or diagnostic tests.

This disorder causes a deterioration in the patient’s functional state and quality of life.

Terapia ocupacional. Servicio de Neurorehabilitación de hospitales Nisa

In essence, acquired brain injury is a broad concept for three key reasons:

There are numerous causes of ABI. It does not have just one aetiology.

It is not a clinically defined syndrome. ABI may affect the functional systems of the brain in just one way or in several ways, and some effects may be more severe than others.

The clinical course of ABI also varies.

CAUSES

The two most common causes of ABI are traumatic brain injury (TBI) and strokes. The third most common cause is cerebral hypoxia. Another group of even less common causes of ABI consists of infections of the central nervous system (CNS). The effects of toxins, physical agents, brain tumours, and autoimmune inflammatory diseases of the CNS are the least common causes of ABI. Table 1 shows the aetiology of ABI.

The overall importance of each of these causes depends on its public health repercussions. To estimate the importance of each cause, we must focus on three key epidemiological factors:

The overall rate of occurrence, in terms of both incidence (rate of new cases per year) and prevalence (rate of total cases up to a given moment).

The profile of the affected population (age, work status, etc.).

The severity of the secondary disorders of the illness.

The public health repercussions of each cause of ABI are greater for the causes that occur most frequently, affect younger people, and lead to the most severe secondary disorders. We must also bear in mind that the consequences of ABI affect the patient’s environment, especially the patient’s family. Hence, the patient’s family should be an important part of the therapeutic approach.

BRAIN INJURY IN FIGURES

Because of the broad range of types of ABI, determining the epidemiological scope of the problem is difficult. Data from the Spanish Survey of Disabilities, Personal Autonomy, and Situations of Dependence (Encuesta de Discapacidad, Autonomía Personal y Situaciones de Dependencia – EDAD) conducted by the Spanish national statistics institute (INE, 2008) give us an approximate idea of the problem we are facing. According to the survey:

There are 420,064 people with acquired brain injury living in Spain.
In 78% of these cases, the condition is due to an accident, and the remaining 22% of cases are due to other causes of acquired brain injury (TBI, anoxia, tumours, and brain infections).
The most common problems facing patients with ABI are difficulties associated with mobility, self-care, domestic life, learning, knowledge, and communication.

Table 2.  Distribution of patients with acquired brain injury by type of disability and cause of brain injury. Source: Spanish Survey of Disabilities, Personal Autonomy, and Situations of Dependence

ABI due to cerebrovascular accidents

Visual impairment

31%

Hearing impairment

26%

Communication disorder

39%

Difficulties in learning and applying knowledge

34%

Mobility impairment

86%

Self-care disability

74%

Disability in domestic life

75%

Disability in personal interactions

30%

ABI due to other causes

Visual impairment

19%

Hearing impairment

15%

Communication disorder

62%

Difficulties in learning and applying knowledge

63%

Mobility impairment

72%

Self-care disability

73%

Disability in domestic life

73%

Disability in personal interactions

55%

According to data from the survey, 52.5% of people with ABI are women and 47.5% are men. The proportion of men and women, however, varies with age. For example, in the age range of 6 to 64 years old, 57.9% of patients are men and 42.1% are women. Of all patients with ABI, 65.03% are aged 65 or older, whereas just 34.97% of patients with ABI are younger than 65 years old.

Table 3. Number of patients with acquired brain injury by cause. Source: Spanish Survey of Disabilities, Personal Autonomy, and Situations of Dependence

Edad DCA

Table 4. People with ABI by sex and age range (Spain, 2008). Source: Spanish Survey of Disabilities, Personal Autonomy, and Situations of Dependence

Men Age 6 to 64

43%

Men 65 or older

57.4%

Women Age 6 to 64

28.1%

Men 65 or older

72%

The overall rate of prevalence of patients with ABI in Spain is 9.3/1000 population (8.9 in men and 9.7 in women). The maximum rate of prevalence is 13.1 in Galicia, and the minimum is 5.8 in La Rioja.

By aetiology, the rate of prevalence of ABI following a stroke is 7.3/1000 population (6.7 in men and 7.8 in women) and 2/1000 for other causes (2.2 in men and 1.8 in women). As the data show, the main cause of brain injury in Spain is a stroke, although among younger patients, the main cause is TBI.

Because not all acquired brain injuries cause the same degree of disability, an interesting way of analysing the data from the Spanish Survey of Disabilities, Personal Autonomy, and Situations of Dependence is to examine the repercussions of the brain injury on some basic functions or activities such as the basic activities of daily living (BADL), which include eating, personal grooming, hygiene, showering and bathing, and self-feeding. According to detailed results of the survey, 375,912 people with ABI have some trouble performing the BADL (89%). Of these people, 71% of patients cannot perform one of these activities if they do not receive some kind of assistance.

IV. THE COST OF BRAIN INJURY

According to the World Health Organization, mental illness is the most common cause of loss of health-related quality of life (HRQoL) in Europe. Mental illnesses cause around 25% of overall loss of HRQoL due to illness. Organic brain disease accounts for 35% of the total burden due to all illnesses. Strokes are in second place in terms of the burden of disease in Europe (strokes are responsible for 6.8% of the loss in disability-adjusted life years, or DALY) (6.8%), whereas road traffic accidents are in seventh place (2.5%). In light of these figures, it is unsurprising that the cost of treating this pathology is so high.

To calculate the cost of medical attention associated with caring for patients with ABI, it is important to consider direct costs – which include medical or professional costs as well as non-professional costs (carers or family members) – and indirect costs – associated with the loss of production of goods and services due to illness. According to a 2011 survey conducted in Navarra and the Basque Country (Spain), the total annual economic burden of medical attention for patients with conditions caused by ABI is 382.12 million Euros, consisting of 215.27 and 166.87 million Euros in formal and informal care, respectively. Extrapolating this data to the national level implies that the total annual cost is more than 3 billion Euros, with an average annual per capita cost of 21,040 Euros.

V. BENEFITS OF REHABILITATION

Regardless of the cause of ABI, including patients with ABI in early, intensive, specific, and ongoing rehabilitation programmes yields proven economic benefits in both the early and late stages of the disorder.

During the acute phases of the disorder, it has been estimated that patients’ early inclusion in rehabilitation reduces time spent in hospital and consequently lowers costs by an estimated $40,000 per patient.

During chronic care, rehabilitation programmes have been found to increase the rate of labour and family reinsertion in less serious cases and reduce the need for care, especially in more serious cases. Regarding the need for specialized care, studies have assessed whether the benefits outweigh the costs of rehabilitating these patients in specific programmes. These studies have shown that although these programmes are expensive, the costs are usually recovered over the expected lifetime of these patients. Therefore, in terms of cost-efficiency, specific treatment programmes perform far better than non-specific treatments. Benefits in terms of the cost of the different treatments cover both motor and cognitive behavioural areas.