Testosterone, sex steroids, and aging in neurodegenerative disease after acquired brain injury: a commentary.

PRIMARY OBJECTIVE: Traumatic brain injury (TBI) is associated with higher incidence of neurodegenerative disease and the effects of aging appear more pronounced after TBI. This paper examines the potential interaction of aging, TBI, and change in male testosterone production. METHODS AND PROCEDURES: An abbreviated review of literature documenting hypogonadism after TBI is provided. Potential mechanisms of endocrine dysgrasia associated with aging are reviewed as they relate and interact with endocrine change after TBI in males. These factors align to suggest the need for development of surveillance guidelines for male individuals living with TBI. OUTCOMES AND RESULTS: The neuroprotectant, neuroactivation, growth, and cell therapy characteristics of testosterone in the central nervous system are considerable. Age-related decrements in testosterone production may be accelerated after TBI. CONCLUSIONS: Testosterone deficiency in male individuals after TBI can be present after TBI or can develop during aging. Age-related decreases in testosterone production after TBI may act to amplify endocrine dysfunction after TBI. Ongoing clinical surveillance for testosterone deficiency associated with both TBI and aging may be reasonable.

Prevalence of growth hormone deficiency in middle-age adults recovering from stroke.

Objective: The prevalence of chronic growth hormone deficiency (GHD) and its association with other hormonal deficiencies was determined in middle-aged patients post-stroke with and without consideration of body mass index (BMI).Methods: Clinical records were reviewed to determine pituitary function at least 3 months post-stroke. Patients with a history of endocrine anomalies were excluded. GHD was determined by utilizing standard peak GH cutoffs following the glucagon stimulation test. A secondary analysis was conducted with stricter BMI-adjusted cutoffs. The accuracy of IGF-1 in predicting GHD was also examined.Results: GHD was diagnosed in 54% of patients (≥5.0 µg/L), with 32% falling into the severe (≤3 µg/L) category. Patients with GHD had lower levels of FSH, T3, LH, and SHBG. Analyzes of BMI-adjusted GH levels, revealed that 14% of patients were GHD. These patients had higher prolactin. IGF-1 values were not predictive of GHD. Latency to be admitted to post-acute rehabilitation was greater in patients with GHD.Conclusions: Evidence suggests patients with stroke may be at risk for developing GHD. GHD was associated with decreased levels of other hormones. Co-morbidities for stroke and neuroendocrine dysfunction overlap and may have implications for recovery following stroke.

First Do No Harm: An Opinion on Bundled Care for Stroke Patients.

The Center for Medicare and Medicaid Innovation under the Centers for Medicare and Medicaid Services has invited institutions to demonstrate ways to bundle services into a 90-day episode of acute care that will lower costs and hospital re-admission rates. While these goals are laudable, they overlook the need for and value attained in postacute treatment. This article argues for elimination of the diagnosis of stroke from the proposed demonstration project due to misaligned financial incentives that will severely compromise patient outcomes.

The influence of post-acute rehabilitation length of stay on traumatic brain injury outcome: a retrospective exploratory study.

OBJECTIVE: Data regarding length of stay (LOS) in a rehabilitation programme after traumatic brain injury (TBI) are limited. The goal of this study was to examine the effect of LOS and disability on outcome following TBI. METHODS: Records from patients in a multidisciplinary rehabilitation programme at least 3 months after TBI were analysed retrospectively to study the influence of LOS on functional outcome at different levels of disability. Functional status was determined by the Mayo-Portland Adaptability Inventory (MPAI) and the Community Integration Questionnaire (CIQ). Patients were further grouped by time since injury of 3-12 months or over 1 year. RESULTS: Those with a mild and moderate disabilities and over 1 year chronicity showed improvements after 90 days of rehabilitation. Patients with a severe disability and over 1 year chronicity required at least 180 days to show improvements. Moderately and severely disabled patients with an injury chronicity of 3-12 months showed improvements in the MPAI after 90 days. However, further improvement was observed after 180 days in the severely disabled group. CONCLUSIONS: Results suggest that both, level of disability and injury chronicity, should be considered when determining LOS. Data also show an association between LOS and changes in the MPAI and CIQ.

The Impact of Traumatic Brain Injury on Later Life: Effects on Normal Aging and Neurodegenerative Diseases.

The acute and chronic effects of traumatic brain injury (TBI) have been widely described; however, there is limited knowledge on how a TBI sustained during early adulthood or mid-adulthood will influence aging. Epidemiological studies have explored whether TBI poses a risk for dementia and other neurodegenerative diseases associated with aging. We will discuss the influence of TBI and resulting medical comorbidities such as endocrine, sleep, and inflammatory disturbances on age-related gray and white matter changes and cognitive decline. Post mortem studies examining amyloid, tau, and other proteins will be discussed within the context of neurodegenerative diseases and chronic traumatic encephalopathy. The data support the suggestion that pathological changes triggered by an earlier TBI will have an influence on normal aging processes and will interact with neurodegenerative disease processes rather than the development of a specific disease, such as Alzheimer's or Parkinson's. Chronic neurophysiologic change after TBI may have detrimental effects on neurodegenerative disease.

Detection of Growth Hormone Deficiency in Adults with Chronic Traumatic Brain Injury.

This study examined the prevalence of growth hormone deficiency (GHD) in patients with traumatic brain injury (TBI) during the post-acute phase of recovery and whether GHD was associated with increased disability, decreased independence, and depression. A secondary objective was to determine the accuracy of insulin-like growth factor-1 (IGF-1) levels in predicting GHD in patients with TBI. Anterior pituitary function was assessed in 235 adult patients with TBI through evaluation of fasting morning hormone levels. GH levels were assessed through provocative testing, specifically the glucagon stimulation test. GHD was diagnosed in a significant number of patients, with 45% falling into the severe GHD (≤3 µg/L) category. IGF-1 levels were not predictive of GHD. Patients with GHD were more disabled and less independent compared with those patients who were not GHD. Those patients with more severe GHD also showed decreased levels of cortisol and testosterone. Symptoms of depression were also more prevalent in this group. In addition, patients with severe GHD had delayed admission to post-acute rehabilitation. This study confirms the high prevalence of GHD in patients with TBI and the necessity to monitor clinical symptoms and perform provocative testing to definitively diagnose GHD.

Post-acute traumatic brain injury rehabilitation: effects on outcome measures and life care costs.

Rehabilitation is the predominant post-acute treatment for patients with traumatic brain injury (TBI). We retrospectively evaluated the effectiveness of post-acute TBI rehabilitation by comparing outcome measures and life care cost with that of patients with cerebrovascular accident (CVA) who underwent a multidisciplinary rehabilitation program within the same facility. To better assess the effects of rehabilitation, we only included patients with no benefit limitations from the insurance carrier. Functional effectiveness was determined by comparing outcome scales, which included the Disability Rating Scale, Mayo Portland Inventory, Occupational Status Scale, Living Status Scale, and the Centre for Neuro Skills Scale. Cost-effectiveness was determined by having certified life care planners create separate cost projections from the admission and discharge patient files. This allowed us to compare cost projections with and without rehabilitation for each patient. Significant decreases in the cost projections, i.e., rehabilitation savings (RS), were found after rehabilitation for TBI. These RS were equivalent to those of patients with CVA. Likewise, equivalent improvements were found on all of the outcome scales for both brain injury groups. We also evaluated if the latency from TBI to admission in the rehabilitation program had an influence on outcome. Cost and functional effectiveness was more marked when rehabilitation was initiated within the first year after TBI. The effects of age of TBI were also evaluated. Although RS were most marked in younger patients, improvements in outcome measures were observed in all age groups after post-acute rehabilitation.

Remediation of information processing following traumatic brain injury: a community-based rehabilitation approach.

Traumatic brain injury (TBI) results in disruption of information processing via damage to primary, secondary, and tertiary cortical regions, as well as, subcortical pathways supporting information flow within and between cortical structures. TBI predominantly affects the anterior frontal poles, anterior temporal poles, white matter tracts and medial temporal structures. Fundamental information processing skills such as attention, perceptual processing, categorization and cognitive distance are concentrated within these same regions and are frequently disrupted following injury. Information processing skills improve in accordance with the extent to which residual frontal and temporal neurons can be encouraged to recruit and bias neuronal networks or the degree to which the functional connectivity of neural networks can be re-established and result in re-emergence or regeneration of specific cognitive skills. Higher-order cognitive processes, i.e., memory, reasoning, problem solving and other executive functions, are dependent upon the integrity of attention, perceptual processing, categorization, and cognitive distance. A therapeutic construct for treatment of attention, perceptual processing, categorization and cognitive distance deficits is presented along with an interventional model for encouragement of re-emergence or regeneration of these fundamental information processing skills.

Repairing the injured brain: why proper rehabilitation is essential to recovering function.

Recovery from a brain injury is a slow process with no obvious end point-a practical dilemma for patients, caregivers, and medical professionals. While research continues to advance the field to determine optimal interventions (see this complementary article on the neurobiology of injury), front-line providers, like author Mark J. Ashley, founder and CEO of the Centre for Neuro Skills, have found that certain rehabilitation environments and procedures encourage a stronger recovery than others. But even as specialized facilities make strides, many people face barriers to adequate care.