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October 19, 2011

Invisible injury

Recent survey shows link between homelessness and brain trauma

A canary yellow knit blanket and plastic bag sit near the door of Phoenix Health Center, a free medical, dental and mental health clinic for the homeless in downtown Louisville. It’s not uncommon for someone to crash here with the hope of being first in line.

On this Monday morning, the clinic’s been open two hours and already 12 men fill the waiting room. One reads. A few doze. All ignore the CNN health story airing on a wall-mounted television. A man slumped over in his chair talks of irrepressible violent thoughts as casually as one would a toothache.

It’s likely the counselor who tries to untangle this man’s rage will screen him for a traumatic brain injury (TBI). Has he ever been in a car accident? Was he abused or viciously shaken as a child?

To be clear, a TBI is not brain damage one is born with, but it results from a severe blow to the head. Symptoms can include disorientation, anger, and difficulty with walking or impulse control.

In the last few years, brain trauma among the homeless has received greater attention, in part due to more cities performing “vulnerability indexes.” These surveys gauge the severity of health problems suffered by longtime homeless individuals.

Last month, as part of an initiative to find the most vulnerable on Louisville’s streets, 244 homeless men and women were interviewed. Louisville’s Coalition for the Homeless tallied 55 individuals who said they have a brain injury. That’s about 23 percent.

Other cities have reported even higher percentages. A study published in the Canadian Medical Association Journal showed 53 percent of 900 homeless men and women in Toronto reported having a brain injury. A survey of Milwaukee’s homeless showed 48 percent. The Centers for Disease Control and Prevention estimates 2 percent of the general population lives with traumatic brain injuries.

Tim Welsh, the mental health coordinator at Phoenix Health Center, believes the percentage of homeless with TBI in Louisville is likely higher than 23 percent, but many don’t realize they might be at risk.

Welsh recalls a new patient who recently arrived very confused. When asked if he had a traumatic brain injury, he said no. But upon further questioning, it was revealed that the changes in behavior that ultimately led to homelessness occurred around the time he was hit by a car.

“People don’t think in terms of brain injury,” Welsh says. “They just know they had a concussion once.”

While Welsh and his team might suspect TBI, diagnosis can be difficult. University Hospital is the only provider of MRIs and CT scans for the poor and uninsured, and it often takes several months to secure an appointment.

Brain injury can range from mild and functional to severe and homebound. Sometimes TBI triggers the unraveling of familial relationships, resulting in homelessness. In other cases, the injury happens once a person is already out on the street. Last month’s survey showed 102 of the 244 surveyed had been involved in a physical attack.

A 2008 report by the National Health Care for the Homeless Council discusses TBI’s link to “social failure.” Essentially, a traumatic brain injury can produce the onset of depression or anxiety, stymieing everyday human interaction.

What makes this messier in the homeless population is the prevalence of substance abuse and lack of education, two factors that can easily explain nonsensical, slow or loud behavior. The 2008 National Health Care for the Homeless report states that it’s common for TBI to go undetected and untreated: “If a homeless patient presents to ER staggering, incoherent, smelling of alcohol and unable to give any history, he/she may be diagnosed as intoxicated, and observed until discharge, rather than evaluated for a brain injury.”

The story of Mike Webster may be among the most dramatic when it comes to TBI. The Pittsburgh Steelers player helped his team win four Super Bowls in the 1970s. He retired in 1990, and slowly the effects of brain damage — dementia, depression — took hold. According to an ESPN story, he ended up living in his truck and ultimately died homeless at age 50.

Webster’s death has heightened the attention given to football’s acute potential for brain injury. This year, another high-profile case jolted pro-football players and fans. In February, a former Chicago Bears star shot himself in the chest. Boston University researchers studying brain damage reported that his brain had developed the same trauma found in 20 other NFL players.

The Department of Veterans Affairs is also keenly aware of this issue. According to the Brain Trauma Foundation, TBI has become the signature injury of the wars in Iraq and Afghanistan, largely due to IED attacks, with anywhere from 10-20 percent suffering some level of traumatic brain injury.

Todd Dedas is the health care coordinator for homeless veterans at the VA Hospital in Louisville. He anticipates that once the wars end, some veterans who fought in the Middle East will eventually end up at his door. An estimated one-fifth of homeless individuals are veterans.

“Typically, veterans that are coming back from active duty don’t go straight into homelessness,” Dedas says, adding that the fall stems from several factors, including post-traumatic stress disorder, substance abuse and/or traumatic brain injury. “So it might take two to five years before the veteran becomes homeless. He would typically burn several bridges before he ended up on the street.”

Dedas says the VA offers rehab for TBI through its neurological clinic as well as occupational and physical therapy. But for homeless non-veterans, treatment is harder to procure. Kentucky has an Acquired Brain Injury waiver that pays for case management, therapy and personal care. But an individual must have Medicaid to qualify. Many homeless do not.

Additionally, the waiting list for those waivers is 200 deep.

At Phoenix Health Center, Welsh says clinicians try to at least treat the symptoms of traumatic brain injury. Medication can help impulse control and mood swings.

It frustrates Welsh that society is quick to label the homeless as drunks or bums. He believes brain injury could be the forgotten factor: “I think it’s one of the hidden, underlying causes of being homeless.”