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Keywords:

  • Brain injury;
  • rehabilitation;
  • practice implications

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References

Purpose

In the United States, traumatic brain injury (TBI) remains a serious health problem contributing to lifelong disability. Little has been written about nutrition problems experienced postrehabilitation discharge. Our objective was to describe the nutrition and weight management characteristics of TBI survivors after discharge from rehabilitation and to identify characteristics of individuals at risk for weight control issues.

Method/Design

Twenty-six TBI survivors admitted to a freestanding rehabilitation hospital were followed for 1 year postdischarge. Data on height, weight, disability rating, diet and activity were collected at admission, 3, 6, 9 and 12 months after discharge.

Findings

Approximately 30% of the participants showed an increasing body mass index from discharge to 1-year follow up. Two patients had more complete long-term data and are highlighted.

Conclusion/Clinical Relevance

The case studies provide insight into the need for rehabilitation nurses to provide nutrition education to TBI survivors that will accommodate changes in lifestyle and activity after discharge.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References

In the United States, traumatic brain injury (TBI) remains a serious health problem contributing to 50,000 deaths each year and leaving 80,000 survivors with lifelong disability. The outcome of a TBI is dependent upon not only the severity of the initial injury but also on the development of secondary complications. One such serious complication is the development of the intense metabolic response that often follows a severe TBI. The etiology of this hypermetabolic state is not well understood, but is thought to be due to the release of various cytokines and counter-regulatory hormones during the acute phase of the injury (Foley, Marshall, Pikul, Salter, & Teasell, 2008). This hypermetabolism may persist for 4–6 weeks during hospitalization, resulting in an increased loss of lean body mass; increased cortisol, glucagon, and catecholamines; decreased albumin; and altered fluid and electrolyte balances. All of these nutritional imbalances can worsen cognitive and physical impairments and lead to worsened functional outcomes for brain injury survivors. The question of whether vigorous early nutritional support favorably influences the outcome of a severe brain injury has been addressed by numerous studies (Young et al., 1987; Krakau, Omne-Ponten, Karlsson, & Borg, 2006; Perel, Yanagawa, Bunn, Roberts, & Wentz, 2006; Bistrian, Askew, Erdman, & Oria, 2011; Chiang et al., 2012; Wang et al., 2013). Although a great deal of randomized control trials and nonrandomized prospective studies have compared the effects of timing and formulas of enteral versus parenteral feedings during the acute care hospitalization and on morbidity and mortality, very little information exists about nutrition problems experienced by TBI survivors during rehabilitation and postrehabilitation phases of recovery. It is not known why no one has looked at nutritional issues after the acute care phase of brain injury recovery. It may be due to lack of follow-through on the part of survivors, lack of interest in participating in a study by survivors and family members, or the burden of participating in a study on those who are already overwhelmed by care issues. To better understand the nutritional issues experienced by TBI survivors living in the community, we conducted a small descriptive study to identify what nutritional issues, if any, exist and how they might impact recovery in post-acute rehabilitation. Our objective was to describe the nutrition and weight management characteristics of TBI survivors after discharge from rehabilitation and to identify characteristics of individuals at risk for weight control issues as defined by their body mass index (BMI).

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References

Subjects

A convenience sample of 26 patients with the primary diagnosis of TBI who were admitted between April 2006 and May 2008 to a freestanding urban academic specialty rehabilitation hospital for comprehensive acute inpatient brain injury rehabilitation were enrolled into the study. Participants were 16 years of age or older and were followed up to 1-year postrehabilitation discharge. The study was approved by the Northwestern University Institutional Review Board. All participants gave consent either directly or through a surrogate when appropriate.

Procedures

On admission to the rehabilitation facility, age, gender, marital status, and location of the brain injury were documented for each patient. Within the first week of the rehabilitation stay, each patient underwent a comprehensive nutritional assessment performed by a nurse practitioner. The type of diet (general, pureed, soft, chopped, or enteral) was documented. The patient's height and weight were recorded. The patient's weight before injury, if known, was also recorded. The height and weight were used to calculate BMI preinjury and postinjury. A BMI rating of 18.5 or lower was classified as underweight, a rating from 18.5 to 24.9 was classified as normal weight, a rating from 25.0 to 29.9 was classified as overweight, and a rating 30.0 or above was classified as obese. In addition, serum albumin and serum prealbumin levels were measured.

Participants were contacted either by phone or in person at 3, 6, 9, and 12 months after discharge. At each follow-up contact, the subject's weight, dietary intake, disability rating, and physical activity were recorded. Patients were assessed using the Disability Rating Scale (DRS). The DRS was developed and tested with older juvenile and adult individuals with moderate and severe TBI in an inpatient rehabilitation setting. The DRS has been proven to be reliable and valid (Wright, 2000). The first three items of the DRS (eye opening, communication ability, motor response) are a slight modification of the Glasgow Coma Scale (GCS) and reflect impairment ratings. Cognitive ability for “feeding,” “toileting,” and “grooming” reflects level of disability. The “level of functioning” item and the “employability” item reflect societal limitations. The maximum score a subject can obtain on the DRS is 29 (extreme vegetative state). A person without disability would score zero. One advantage of using the DRS is its ability to track an individual from onset of injury to community reentry. Measurements across a wide span of recovery are possible because various items in this scale address all three World Health Organization categories: impairment, disability, and societal limitations. The DRS was used to measure level of disability at each follow-up contact. To assess physical activity, participants completed a 24-hour activity log that recorded their daily activities for the 3 days before the follow-up assessment. The log was created by the study nurse practitioner as a way for the patients to document what type of activity they were participating in each hour of the day. Patients were asked to summarize what activity they participated in the majority of that hour and write it in the activity log. A compendium of physical activities was used to estimate the energy cost of the activities listed in each log (Ainsworth et al., 2000). Participants also completed a diet log, created by the study nurse practitioner, for these same 3 days. The diet log recorded the amount and type of food consumed throughout the day. Calorie counts were calculated from the diet logs and averaged for the 3-day time period. The primary caregiver assisted patients with severe cognitive or motor impairments who could not complete the logs on their own.

Results

Twenty-six participants were enrolled into the study. Of the 26, 23 were discharged to the community at the completion of their rehabilitation program. Two patients were discharged to a nursing home and one patient was discharged to an acute care facility. The results of the study are based on the 23 participants who were discharged to the community.

A description of demographic and brain injury characteristics for the sample of 23 participants is provided in Table 1. The majority of the participants were male (65%), with an average of 38 years of age at onset of their brain injury. A subarachnoid hemorrhage was the cause of injury in 44% of the patients. The average length of rehabilitation stay of the patients participating in the study was 55.6 days. Most participants had either their parents (39%) or a spouse (26%) identified as their primary caregiver at the time of discharge.

Table 1. Demographics and traumatic brain injury characteristics
Mean age at onset ± SD (years)38.0 ± 18.6
Age range16–74 years
Gender, n (%)
Male15 (65%)
Female8 (35%)
Type of brain injury
Subarachnoid hemorrhage10 (44%)
Subdural hematoma7 (30%)
Intracranial hemorrhage2 (9%)
Other4 (17%)
Mean rehabilitation length of stay ± SD (days)55.6±30.6
Primary caregiver at discharge
Parents9 (39%)
Spouse6 (26%)
Other relative5 (22%)
Other3 (13%)

The Disability Rating Scale was obtained on 19 of the patients at discharge from rehabilitation. Approximately two-thirds of the patients had disability ratings ranging from mild to moderate disability at discharge (Table 2).

Table 2. Disability rating scale scores at rehabilitation discharge
DRS CategoryLevel of Disabilityn, %
0None0
1Mild1 (5%)
2–3Partial0
4–6Moderate8 (42%)
7–11Moderately severe4 (21%)
12–16Severe1 (5%)
17–21Extremely severe2 (11%)
22–24Vegetative state3 (16%)
25–29Extreme vegetative state0

During preliminary data analysis, we noticed a trend in approximately 30% of the patients with an increasing BMI from discharge to 1-year follow-up (Figure 1). For two of the participants, this was considered a desirable outcome. Both patients were underweight at rehabilitation discharge, but had achieved a normal weight by 9 months postdischarge. These two participants were able to maintain a normal weight at 12-month follow-up. Five participants had been at a normal weight at discharge, but had gained weight by the 12-month follow-up. Of that group, three patients had become overweight, one had become obese, and one was still within the normal weight range, but with a gradual and constant increase in weight. Three patients were overweight at discharge, two of whom had become obese by 12 months postdischarge follow-up.

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Figure 1. Body mass index at discharge and follow-up.

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Unfortunately, we did not have enough complete data on physical activity and dietary intake on the entire sample to draw any conclusions about the relationship between changes in weight and other factors, such as caloric intake, food choices, exercise, and activity. We did have two cases with more complete long-term data on their nutritional status and activity levels. They are presented below.

Case Studies

Subject 111 is a 70-year-old female of Mediterranean descent who suffered a subdural hematoma secondary to a motor vehicle collision. She spent 75 days in an acute care hospital and 132 days in an acute rehabilitation program. During her rehabilitation stay, she was on a soft diet and her average caloric intake was approximately 3,000 calories per day. Her protein level was 6.0 g/dL (normal is 6–8.4) and her serum albumin level was 3.3 g/dL (normal 3.5–5.0). She was discharged to home with her husband and daughter as her primary caregivers. At discharge from rehabilitation, her DRS score was 11, indicating a moderately severe disability. At that time, she required maximal to moderate assistance with eating, personal care, and transfers. Her BMI at discharge was 24.0, which was in the normal range. Her preinjury BMI also was 24.0. At 9 months postdischarge, her DRS score had improved to 8.5, but still indicated a moderately severe disability. She had improved in her ability to perform self-care activities, requiring only supervision for eating, grooming, and bathing and moderate assistance with dressing. She still needed maximal assistance with mobility activities and transfers. Her activity logs indicated that she was quite sedentary, spending the majority of the day sitting in a chair or wheelchair. She was now on a general diet with an average caloric intake of approximately 2,000 calories per day and her BMI had increased to 32.0. According a dietary guideline reference, women over the age of 50 years who are sedentary generally require 1,600 calories per day (U.S. Department of Agriculture & U.S. Department of Health & Human Services, 2010). This individual was consuming well over that amount and her weight had drastically increased in the year after her discharge from rehabilitation. Within just 1 year postdischarge, she had gained 44 pounds.

Subject 116 is a 20-year-old male college student who was diagnosed with a right subdural hematoma, facial and shoulder fractures from a motorcycle collision. His hospitalization was complicated by pneumonia. He spent 48 days in a comprehensive rehabilitation program for his brain injury. His average caloric intake during rehabilitation was approximately 2,500 calories per day. His protein level was 5.9 g/dL and his serum albumin level was 3.2 g/dL, both of which are slightly below normal levels. He was discharged to home with his parents as primary caregivers. At the end of his rehabilitation, he needed minimal to moderate assistance with eating, personal hygiene, and mobility. His DRS score was 6, indicating moderate disability. At discharge, his weight was 140 pounds and his BMI was in the normal range at 22.8. His preinjury BMI was in the normal range at 20.7. By 9 months postdischarge, he had improved to complete independence in his self-care and mobility. His DRS score was 1, indicating a mild level of disability. His parents owned a farm and he was able to assist them with daily farm activities. In addition, he had resumed some of his leisure activities. His caloric intake averaged approximately 3,000 calories per day and was as high as 4,500 calories on some days. His BMI had increased to 26.0, which placed him in the overweight range. At 12 months after discharge, his activity levels and food intake had remained the same. He gained 34 pounds in 1 year.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References

Addressing proper nutrition and its impact on health and wellness is an important topic for TBI survivors and their caregivers. Proper nutrition should not just be addressed while the TBI survivor is in the hospital, but is an important aspect of recovery that should continue to be monitored well after the person has been discharged to home. To date, few studies have focused on the nutritional intake of chronic brain injury survivors. Most of the literature on nutrition in brain injury has focused on the acute management phase. Henson and colleagues (1993) followed 20 mild to moderately traumatic brain-injured patients who were at least 6 months postinjury. They reported that when compared with nonbrain-injured match controls, the brain-injured group had a higher overall intake due strictly to an increase in the amount of calories ingested during meals rather than the number of meals. The brain injury group ate meals that were about 14% larger than their matched controls (Henson, DeCastro, Stringer & Johnson, 1993).

The case studies from our study are consistent with some of the findings in the Henson et al. study. Both Subjects 111 and 116 did not consume many between-meal snacks, but obtained most of their daily calories at regular meal times. Subject 116 had been an active college student. Although we do not know his preinjury eating habits, it has been well documented that college students often have unhealthful eating behaviors, including skipping meals, frequent snacking on energy-dense food, and engaging in unhealthful weight loss habits (Gerend, 2009). Dietary intake of college students appears to be high in fat, saturated fat, cholesterol, and sodium (Ha & Cain-Bish, 2009). Subject 116's food choices during the follow-up period included chocolate milk, sausage pizza, and chocolate chip cookies. These poor food choices could explain the increase in body mass index after the injury, putting him in the overweight category despite his becoming more physically active during the follow-up period. In addition, both patients come from very close-knit families. Family members may have tried to compensate for the subject's injury by providing favorite foods. This may have contributed to the larger calorie intake.

Problems with maintaining proper weight are not only experienced by the more physically impaired survivor. In our study, the individual who had no physical impairments and was younger also experienced problems with weight management. TBI survivors may have difficulty estimating the appropriate calories needed to maintain a healthy weight in comparison to the activity performed. It is not clear if this is due to the survivor's cognitive deficits. In both of these cases, survivors relied on caregivers to provide nutrition. Henson and colleagues (1993) also identified that lack of response to social cues existed in brain-injured subjects. Brain-injured patients showed an exaggerated response to the estimated premeal stomach content (Henson et al., 1993).

There are several limitations to this study. The values in the compendium do not estimate the energy cost of physical activity in individuals in ways that account for difference in body mass, adiposity, age, sex, efficiency of movement, geographic and environmental conditions in which the activities are performed. Thus, individual differences in energy expenditure for the same activity may be large and the true energy cost for an individual may or may not be close to the stated metabolic level as presented in the compendium (Ainsworth et al., 2000). The diet log calorie counts were also an estimation of calories for the day based on the reported amount of intake by the patient or caregiver. Although no one participant formally dropped out of the study, many participants did not complete or return all of the material sent to them after discharge from the inpatient rehabilitation setting. Many survivors and their caregivers mentioned being overwhelmed at the amount of work involved being out of the hospital in addition to their activities of daily living, such as doctor visits, therapy, phone calls, insurance paperwork. Completing the paperwork for this study was not looked at as equally important and therefore not completed. A less time-consuming method of documenting dietary intake and daily activities/exercise needs to be developed. It may be more helpful to survivors and their caregivers to complete this documentation 12 months after discharge. This may allow more time for survivors and families to return to their daily routine and feel less overwhelmed when completing the documentation requested.

Lastly, we did not measure pituitary function in the individuals participating in the study. Studies have shown that hypopituitarism can occur at some point postinjury in 30%–68% of people with a TBI (Agha, Phillips, O'Kelly, Tormey, & Thompson, 2005; Park, Kim, Lee, Nam, & Park, 2010). Although many patients recover normal pituitary function by 6 months postinjury, hypopituitarism can persist in some patients (Agha et al., 2005). One study of TBI patients with long-lasting cognitive disorders, followed up for a mean of 6.5 years after injury, found that activity performance, functional outcomes, and cognitive function were worse in those with hypopituitarism (Kozlowski Moreau, Yollin, Merlen, Daveluy, & Rousseaux, 2012). Symptoms of hypopituitarism can include weight gain and fatigue.

Based on the data from our study, the trend in weight gain occurred in 30% of those patients we followed from discharge to 1 year postrehabilitation discharge. Unfortunately, given the lack of complete data with regard to physical activity and caloric intake, we were unable to conclude whether these factors impacted weight gain. A better method needs to be developed to monitor caloric intake and physical activity in the brain injury population without putting additional burden on the primary caregiver.

Based on data from the two case studies, weight gain was related to caloric intake in relation to the amount of physical activity. It is important that rehabilitation nurses teach patients and their caregivers how to adjust their nutritional intake after discharge from rehabilitation. Rehabilitation nurses often instruct patients on proper nutrition with regard to disability, chronic illness, developmental disabilities, prevention of malnutrition, impaired swallow, and risk of aspiration; therefore, this task is not outside the scope of nursing practice. The Specialty Practice of Rehabilitation Nursing: A Core Curriculum identifies nursing interventions to promote nutritional adequacies, such as teaching daily recommended intake of essential nutrients, and encouraging and supporting weight loss. Rehabilitation nurses are in an excellent position and should educate brain injury survivors and their families about the need to change nutritional intake throughout their recovery based on disability and activity. Not only is prevention important but rehabilitation nurses should intervene in those who may be identified as developing a potential problem. Brain injury survivors may need target numbers to maintain an ideal body weight secondary to cognitive deficits. Family members or caregivers may need to be taught when to decrease portion size based on the survivor's weight. For those patients or families having difficulty matching caloric intake to level of physical activity, the rehabilitation nurse may need to work closely with a dietician to ensure that patients are getting sufficient nutrition and not just eating foods with no nutritional value or empty calories. Providing individuals with sample diets, which include daily food choices and, more important, appropriate portion sizes, may be needed. For those TBI survivors with more functional impairments who may rely on prepackaged meals for ease of preparation, the rehabilitation nurse may need to identify which meals have better nutritional choices and make specific recommendations on what meals to select. Working with the physical or occupational therapist on amount of exercise to be done daily can help the rehabilitation nurse devise a daily schedule to avoid long periods of sedentary activity for patients. Excessive weight gain in this population can only negatively affect mobility, worsen fatigue, and complicate general health conditions, such as hypertension and diabetes. Follow-up visits with rehabilitation nurses should also address issues of overweight or obesity, especially if developed after discharge. Overweight and obesity in individuals with brain injury can produce the same health complications and. in some cases, even more when compared with individuals without physical, cognitive, or behavior deficits. More research needs to be carried out to look at how best to identify which TBI survivor will be at risk for weight control issues and how the rehabilitation nurse working closely with other team members can best address these problems.

Key Practice Points
  • The outcome of a TBI is dependent upon not only the severity of the initial injury but also on the development of secondary complications.
  • All of these nutritional imbalances can worsen cognitive and physical impairments and lead to worsened functional outcomes for brain injury survivors.
  • Proper nutrition should not just be addressed while the survivor is in the hospital but is an important aspect of recovery that should continue to be addressed well after the person has been discharged home.
  • Rehabilitation nurses are in an excellent position to educate brain injury survivors and their families about the need to change nutritional intake throughout their recovery based on disability and activity.

Acknowledgment

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References

Funding for this study was provided by the Spastic Paralysis Research Foundation, Illinois–Eastern Iowa District of Kiwanis International.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Discussion
  6. Acknowledgment
  7. References
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