On November 27, 2018, we conducted a nationwide search for any reported decision of a court involving a will contest or trust contest arising out of incapacity due to traumatic brain injury (TBI). We were surprised to see the results: zero. That’s right, our search revealed no instances where a decedent’s estate planning had been challenged or a will contest or trust contest filed because of dementia or incapacity onset through TBI. With the increasing scientific evidence and ability to screen for such problems, perhaps the issue will develop. We imagine significant complexity involving the estates of many competitive athletes, for example, as an area for extreme care in the estate planning process.
In our previous post we defined what TBI is, the symptoms and causes. Today we will examine the risk factors, complications and possible prevention.
RISK FACTORS
The individuals most at risk of traumatic brain injury include:
- Children, especially newborns to 4-year-olds
- Adults age 60 and older
- Males in any group
- Athletes in contact sports
TBI COMPLICATIONS
Several complications can occur immediately or soon after a traumatic brain injury. Naturally, severe injuries increase the risk and severity of complications.
Altered consciousness
Moderate to severe TBI can result in prolonged or permanent changes in a person’s state of consciousness, awareness or responsiveness. Different states of consciousness include:
- Coma. A person in a coma is unconscious, unaware of anything and unable to respond to any stimulus. This results from widespread damage to all parts of the brain. After a few days to a few weeks, a person may emerge from a coma or enter a vegetative state.
- Vegetative state. When widespread damage to the brain has occurred in can result in a vegetative state. Although the person is unaware of surroundings, he or she may open his or her eyes, make sounds, respond to reflexes, or move.
- A vegetative state can become permanent, but often individuals progress to a minimally conscious state.
- Minimally conscious state. This is a condition of severely altered consciousness with some signs of self-awareness or awareness of one’s environment. It is sometimes a transitional state from a coma or vegetative condition to greater recovery.
- Brain death. This state occurs when there is no measurable activity in the brain and the brainstem. In a person who has been declared brain dead, removal of breathing devices will result in cessation of breathing and eventual heart failure. Brain death is considered irreversible.
Physical Complications
The following list of complications can linger for a few weeks to a few months after a traumatic brain injury. This is currently referred to as persistent post-concussive symptoms. When a combination of these symptoms last for an extended period of time, this is generally referred to as post-concussion syndrome.
- Seizures. Sometimes individuals with TBI develop seizures. They may occur only in the early stages, or years after the injury. Recurrent seizures are called post-traumatic epilepsy.
- Fluid buildup in the brain (hydrocephalus). Cerebrospinal fluid may build up in the spaces in the brain of some people who have had traumatic brain injuries, causing increased pressure and swelling in the brain.
- Infections. Skull fractures or penetrating wounds can tear the layers of protective tissues that surround the brain. This can allow bacteria to enter the brain and cause infections. This infection, called meningitis, could spread to the rest of the nervous system if not treated.
- Blood vessel damage. Several small or large blood vessels in the brain may be damaged in a traumatic brain injury. Damage of these vessels could lead to a stroke, blood clots or other complications.
- Headaches. Frequent headaches are very common after a traumatic brain injury. They may begin within a week after the injury and could persist as long as several months.
- Vertigo. Many people experience vertigo, a condition characterized by dizziness, after a traumatic brain injury.
Traumatic brain injuries at the base of the skull can cause damage to the cranial nerves that emerge directly from the brain. Cranial nerve damage may result in:
- Paralysis of facial muscles or loss of facial sensation
- Loss of or altered sense of smell
- Loss of or altered sense of taste
- Loss of vision or double vision
- Swallowing problems
- Dizziness
- Ringing in the ear
- Hearing loss
Intellectual Complications
Many individuals who have had a significant brain injury will experience changes in their thinking skills. They may have difficulty focusing and it may take longer to process thoughts. Traumatic brain injury can result in problems with many skills, including: memory, learning, reasoning, judgement and concentration.
Executive functioning problems
Executive functions are a set of processes that all have to do with managing oneself and one’s resources to achieve a goal. It is an umbrella term for the neurologically-based skills involving mental control and self-regulation. The areas that can be compromised with TBI include:
- Problem-solving
- Multitasking
- Organization
- Planning
- Decision-making
- Beginning or completing tasks
Communication Complications
Language and communications problems are common following traumatic brain injuries. These problems often cause frustration, conflict and misunderstanding for people with a traumatic brain injury, as well as family members, friends and care providers. Communication complications may include:
Cognitive problems
- Difficulty understanding speech or writing
- Difficulty speaking or writing
- Inability to organize thoughts and ideas
- Trouble following and participating in conversations
Social problems
- Trouble with turn taking or topic selection in conversations
- Problems with changes in tone, pitch or emphasis to express emotions, attitudes or subtle differences in meaning
- Difficulty understanding nonverbal signals
- Trouble reading cues from listeners
- Trouble starting or stopping conversations
- Inability to use the muscles needed to form words (dysarthria)
Behavioral Complications
People who’ve experienced brain injury often experience changes in their behavior. These may include:
- Difficulty with self-control
- Lack of awareness of abilities
- Undertaking risky behavior
- Difficulty in social situations
- Verbal or physical outbursts
Emotional changes
Emotional changes may include:
- Depression
- Anxiety
- Mood swings
- Irritability
- Lack of empathy for others
- Anger
- Insomnia
Sensory issues
Problems involving senses may include:
- Persistent ringing in the ears
- Difficulty recognizing objects
- Impaired hand-eye coordination
- Blind spots or double vision
- A bitter taste, a bad smell or difficulty smelling
- Skin tingling, pain or itching
- Trouble with balance or dizziness
Development of Degenerative Brain Diseases
Research suggests that repeated or severe traumatic brain injuries might increase the risk of degenerative brain diseases. Researchers are still investigating how traumatic brain injuries might be related to degenerative brain diseases. Degenerative brain disorder can cause gradual loss of brain functions, including:
- Alzheimer’s disease, which primarily causes the progressive loss of memory and other thinking skills.
- Parkinson’s disease, a progressive condition that causes movement problems, such as tremors, rigidity and slow movements.
- Dementia pugilistica, most often associated with repetitive blows to the head in career boxing, which causes symptoms of dementia and movement problems.
PREVENTION
The following steps can be instrumental in reducing the risk of brain injury:
- Seat belts and airbags. Always wear a seat belt in a motor vehicle. Children should always sit in the back seat of a car, secured in a child safety seat or booster seat that is appropriate for their size and weight.
- Alcohol and drug use. Don’t drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive.
- Helmets. Although not a perfect answer, always wear a helmet while riding a bicycle, skateboard, motorcycle, snowmobile or all-terrain vehicle. Also wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding or riding a horse.
Preventing falls
The following tips can help older adults avoid falls around the house:
- Install handrails in bathrooms
- Put a non-slip mat in the bathtub or shower
- Remove area rugs
- Install handrails on both sides of staircases
- Improve lighting in the home
- Keep stairs and floors clear of clutter
- Get regular vision checkups
- Get regular exercise
Preventing head injuries in children
The following tips can help children avoid head injuries:
- Install safety gates at the top of a stairway
- Keep stairs clear of clutter
- Install window guards to prevent falls
- Put a non-slip mat in the bathtub or shower
- Use playgrounds that have shock-absorbing materials on the ground
- Make sure area rugs are secure
- Don’t let children play on fire escapes or balconies
If you would like to read more about TBI, check out our blog Explaining Traumatic Brain Injury, Part I.
For further reading Sadaka Farid and Tanya Quinn detail the management of TBI patients in their book “Traumatic Brain Injury” starting with the intensive care unit through hospital discharge and recovery to assimilation back into society and family.