Successful Aging of Individuals with Brain Injury

by Paul F. Aravich, Ph.D., Eastern Virginia Medical School, and Anne H. McDonnell, MPA, OTR/L, Brain Injury Association of Virginia

Successful aging is a goal for all creatures great and small. This is true for the lowly mayfly living one day and for the inspiring, if not scrawny, bristlecone pine tree living 4000 years. However, successful aging in people requires more than longevity: it requires the maintenance of physical, cognitive, and social function (Lowry, Vallejo and Studenski, 2012).

Aging is not a disease; it starts at birth and continues across various developmental life stages. But environmental and lifestyle factors play a more important role in successful aging than genetic factors. More research is needed to identify the modifiable environmental and lifestyle factors that are unique to long-term survivors of brain injury. This requires a leap beyond the simple biology to a greater understanding of the biopsychosocial model of successful aging.

The following 10 rules, built upon concepts identified by the Alzheimer’s Association, are designed to promote successful aging in persons with brain injury:

Rule 1: Take Care of the Heart

Since brain injury survivors have an already increased risk for Alzheimer’s disease, survivors with diabetes, hypertension, or an adverse lipid profile compound that increase their risk for heart disease and stroke. The promotion of successful aging in brain injury survivors requires a focus that goes beyond the brain and includes the early diagnosis and treatment of cardiovascular risk factors.

Rule 2: Exercise the Body

There is little doubt that physical fitness protects against the three leading causes of death in North America: heart disease, cancer, and stroke. It is also clear that moderate exercise promotes respiratory fitness and improves balance, reducing the risks of falls (which are a leading cause of traumatic brain injury). Regular movement also reduces the risk of deep venous thrombus (DVT) formation and premature death from pulmonary thromboembolism. Exercise is not just for rehabilitation – it promotes of successful aging. Consider innovative ways to overcome the limitations of brain injury, such as combining exercise with the virtual reality (Lee et al., 2003) and dance therapy (Pratt, 2004).

Rule 3: Exercise the Brain

There is good evidence that cognitively stimulating activities protect against Alzheimer’s disease and other potential complications of aging with a brain injury. Stimulating your brain through intellectual activities like taking a class, learning a new language, and volunteering provides benefits for brain health and can affect how well the brain functions. Strategies building on the principles of music therapy (Kleinstäuber, et al, 2001), art therapy (Rentz, 2002), and theater arts (Noice et al., 2004) are beneficial in exercising the brain.

Rule 4: Feed the Brain

Nutrition is critical to successful aging; it is vital for immunity and essential for cognitive function. Evidence suggests that a Mediterranean diet, rich in whole grain, vegetable, fruit, and olive oil, is beneficial for overall health. A heart healthy diet, which is also a brain healthy diet, should also include regular fish consumption. Fatty fish are rich in various nutrients, including omega-3 fatty acids, which are associated with a reduced risk for Alzheimer’s disease (Morris et al., 2003), potential benefits in mood disorders (Freeman, 2000), and the promotion of neuroplasticity.

Rule 5: Promote Mental Health

Mental illnesses, such as depression, bipolar disorder, and schizophrenia, are major risk factors for suicide and increase the risk of a traumatic brain injury (TBI) by 70% (Fann et al., 2002). Even without a pre-injury history, once a TBI occurs, the lifetime risk of depression is increased by 54% (Holsinger et al., 2002). Psychiatric disorders negatively affect successful aging by affecting cognition, emotion, cardiovascular fitness, and general quality of life. Issues of loss and social isolation, combined with the psychological burden of finding adequate housing, education, and transportation, are significant stressors affecting mental health. The importance of early and aggressive mental health interventions, the battle to reduce the stigma against mental illness, and the battle for health insurance parity for mental health coverage are imperatives for the promotion of successful aging.

Rule 6: Avoid Drugs of Abuse

Substance use increases the risk of brain injury and is linked to worse outcomes (Substance Abuse and Mental Health Services Administration, 2010); users are at greater risk of falls, seizures, and certainly damage from use of the substances themselves.Persons with brain injury are more susceptible to developing substance use disorders and they are often prescribed opioids after their injury to manage pain. Nearly 25% of people entering brain injury rehabilitation are there as a result of drugs or alcohol, and approximately half of people receiving substance abuse treatment have at least one brain injury (Brain Injury Association of America, 2018). It is important to recognize that drugs of abuse affect the reward circuitry of the brain, and once this circuit is injured, it is difficult for the chemically dependent person to just say no.

Rule 7: Avoid Social Isolation

It has been said that the human brain is a social brain. Fundamental human emotions like love and happiness depend upon social and physical contact with others. Animal research shows that social isolation causes physical injury to the brain and is associated with cognitive and emotional deficits (Whitaker-Azmitia et al., 2000). Social engagement and enrichment are essential requirements for brain fitness and successful aging in both survivors and caregivers

Rule 8: Protect the Brain

While the human brain is one of the most miraculous things in the universe, it is also among the most fragile. A brain injury is terrible, but a preventable brain injury is much worse. Protection of the brain goes beyond personal protective equipment and includes regular fall assessments in older people and in people with disabilities (Chang et al., 2004). Protection of the brain also involves letting it sleep; driving skills of sleep-deprived people are similar to those who are intoxicated with alcohol (Arnedt et al., 2001). Sleep deprivation related to lifestyle issues and to various pathologies also impairs impulse control, cognition, mood, attention, abstinence from drugs of abuse, and immune function (Roehrs and Roth, 2004). Data indicate that more sleep disturbances occur in survivors with mild TBI than those with severe TBI (Mahmood et al., 2004). Protect your brain: get some sleep.

Rule 9: Form More Partnerships for Individuals with Brain Injury

Mental health, brain injury, and Alzheimer advocacy groups have overlapping issues regarding lack of services, social isolation, guardianship, end of life issues, stigma, and the need for respite care. It is obvious there should be close partnerships between brain injury, Alzheimer’s disease, and mental health professionals. Brain injury can cause behavioral and psychiatric symptoms that are distinct from those associated with mental illnesses, and injury to the prefrontal lobes often impairs the empathy and bonding necessary for psychotherapy; these problems are not unlike the behavioral and psychiatric problems associated with the irreversible dementias.

Rule 10: Look for Greatness in Each Person

The human brain is the last frontier of science. We will know more about parallel universes, colliding galaxies, and black holes long before we understand the universe between our ears. The human brain has nearly as many neurons as there are stars in the Milky Way Galaxy (more than 100 billion). Each neuron makes connections with thousands of other neurons, and these synaptic connections change each time we do something, experience something, or learn something. This continuing, unrelenting reorganization of the brain is called neural plasticity. Another name for neuroplasticity is hope. Every person, with or without a brain injury, has a magnificent and unique brain. There are an infinite number of possible synaptic connections in every brain, injured or not. The organization of the human brain has limitless possibilities. If you look for greatness in people with brain injury, you will see it. If you look for greatness in caregivers, you will see it. If you look for greatness in other professionals, you will see it. Valuing the bonds you have with other people will help you as you age.

References

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2. Brain Injury Association of America, 2018. The Solution to Opioids is Treatment.
3. Chang, J. T., Morton, S. C., Rubenstein L. Z. et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 328(7441):680, 2004.
4. Fann J. R., Leonetti A., Jaffe K. et al. Psychiatric illness and subsequent traumatic brain injury: a case control study. J Neurol Neurosurg Psychiatry 72(5):615-620, 2002.
5. Freeman M.P. Omega-3 fatty acids in psychiatry: a review. Ann Clin Psychiatry 12(3):159-165, 2000.
6. Holsinger T., Steffens D. C., Phillips C. et al. Head injury in early adulthood and the lifetime risk of depression. Arch Gen Psychiatry 59(1):17-22, 2002.
7. Lee J. H., Ku J., Cho W. et al. A virtual reality system for the assessment and rehabilitation of the activities of daily living. Cyberpsychol Behav 6(4):383-388, 2003.
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9. Kleinstäuber, Maria & Gurr, Birgit. (2006). Music therapy in brain injury rehabilitation. Journal of Cognitive Rehabilitation.
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13. Pratt R. R. Art, dance, and music therapy. Phys Med Rehabil Clin N Am 15(4):827-41, 2004.
14. Rentz C. A. Memories in the making: outcome-based evaluation of an art program for individuals with dementing illnesses. Am J Alzheimers Dis Other Demen 17(3):175-181, 2002.
15. Roehrs T. and Roth T. Sleep disorders: an overview. Clin Cornerstone 6(Suppl 1C):S6-S16, 2004.
16. Substance Abuse and Mental Health Services Administration. 2010. Treating Clients with Traumatic Brain Injury, Substance Abuse Treatment Advisory.
17. Whitaker-Azmitia P., Zhou F., Hobin J. et al. Isolation-rearing of rats produces deficits as adults in the serotonergic innervation of hippocampus. Peptides 21(11):1755-1759, 2000.

Paul F. Aravich, Ph.D., is a neuroscientist and associate professor in the Department of Pathology and Anatomy and the Glennan Center for Geriatrics and Gerontology at Eastern Virginia Medical School in Norfolk, Va. He has served as Chair of the Virginia Brain Injury Council and as a member of the Governor’s Public Guardian and Conservator Advisory Board, the National Alliance for the Mentally Ill of Virginia, the Southeastern Virginia Chapter of the Alzheimer’s Association, and the Society for Neuroscience. His research interests include nutrition, exercise, and the brain.

Anne McDonnell, MPA, OTR/L, CBIST, is executive director of the Brain Injury Association of Virginia. She has 30 years of experience in brain injury rehabilitation across a continuum of hospital and community-based settings and holds a clinical faculty position in the School of Occupational Therapy at Virginia Commonwealth University. She is interested in increasing public awareness of brain injury, expanding community-based service options for survivors, and educating of survivors, caregivers, and professionals.

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This article originally appeared in Volume 12, Issue 3 of THE Challenge! published in 2018.