Half of all homeless people may have had a traumatic brain injury (TBI) at some point in their lives, research shows.
Studies in the UK and North America over the last decade have found levels of past TBI experiences among homeless people to generally range between around 45 and 55%
Research also suggests the vast majority of TBIs happened before homelessness occurred (90% in one study in Leeds in 2012).
Such stark figures prompt serious questions about the way brain injuries cases are diagnosed and handled.
With homelessness rising sharply in recent years – by 55% in England alone between 2010 and 2015 – there is also a pressing need to better address the many TBI cases out of reach of the vital interventions they may need.
Closing the road from brain injury to homelessness requires work from every angle, including healthcare, social services and politics.
Getting the many homeless people with a past brain injury o the streets and receiving adequate care requires a similarly all-encompassing approach.
A solution to this escalating, labyrinthine challenge may well be taking shape in the West Midlands, thanks to a small band of pioneers.
“We’re not suggesting what we’re doing needs to be rolled out as it’s too premature for that,” says Dr Andrew Worthington, a neuropsychologist who runs Birmingham- based rehabilitation group Headwise.
“We are giving an example of one model and we’re going to evaluate its impact.”
Headwise has joined forces with the charity Headway Birmingham and Solihull to employ a ‘homelessness caseworker’ to assess the needs of homeless brain injured people and help them move their lives forward.
The post, funded by Headwise and based at Headway, is part of a wider research project by the partnership to explore links between brain injury and homelessness.
At the time of writing, the scheme is nearing the first six-monthly follow up with homeless people and Worthington is hopeful of some meaningful data.
“We’re primarily doing an intervention study. The idea is to provide a support and signposting service for people with a brain injury. When the needs of an individual are related to a brain injury we will provide that support.
“Where they just happen to have a brain injury, but their primary needs may be drug or alcohol abuse, domestic violence or simply that they have nowhere to sleep at all, we’ll signpost them to other services.
“We don’t necessarily think everyone’s problems are all down to the brain injury, but it’s important to have a point of reference where they can be properly assessed and provided with support.
“Previously they might have been given a leaflet and left to get on with it, with nobody following them up. We’re providing a dedicated case worker who’ll work with them.”
The main research element of the scheme is to compare the results between people accessing this new model and those receiving the usual standard of care.
“It’s very early days but hopefully we’ll have some evidence as to what works and will be able to develop a model that can be tweaked and may be rolled out elsewhere.
“It’s only the last 10 years or so that we’ve become aware of the problem of homelessness and brain injury so we’re still trying to work out the scale of the problem.”
Solutions which emerge in the future to stop TBI acting as a catalyst for homelessness will need to address several major challenges; including the disjointed nature of services which come into contact with vulnerable people.
“There’s a broader need to educate the agencies which work with the homeless, such as social services and the voluntary sector, to recognise amongst all the other problems, signs of head injury.
Although an individual may be drunk, for example, have they got behavioural difficulties because of a previous head injury? We’ve also got to give them some options for services to refer on to.
“What’s at the heart of this, and the reason why the government and local authorities have struggled to deal with it, is the fact that it cuts across boundaries.
“Homeless individuals can have multiple problems, one of which may seem more urgent than others at different times.
“Any service that comes into contact with homeless people, whether that be a shelter, dentist or GP, needs to be aware of what specialist services are available.
“Currently there is a problem in trying to provide joined-up services. If everyone is focusing only on their area, no-one is looking at the bigger picture.”
A homeless person living out of reach of regular contact with local services might reappear on the radar with a trip to A and E. In this pressured environment, with the immediate health of the individual taking priority over anything else, previous brain injuries often go undetected.
“They may have been assaulted or be drunk. Understandably the pressing problem is dealt with and they are discharged. Rather than getting to the root of the problem, they may go back to the streets. So we have this revolving door syndrome.
“Often it’s difficult to know how to help, because the problems can be very complex and usually hospital staff aren’t aware of the specialist services available for homeless people.
“On the other side of the coin, homeless services are often unable to identify the relevant medical problems.”
Furthermore, if the police or social services come into contact with a homeless person, they may also deal with the individual’s most urgent need rather than tracing the reasons for their homelessness. Finding that person a place to live is effectively treating their symptoms with a “sticking plaster”, says Worthington.
Even if past head injuries are identified, getting someone at risk of homelessness to partake in rehabilitation and engage in brain injury services can be hugely challenging.
“They might move out of the area and, if they don’t turn up for an appointment, a lot of services won’t bother to enquire why.
“Also, they often have certain problems with mental health and substance abuse disorders which then makes it difficult for them to meet the criteria to be helped by brain injury services.
“Some brain injury services have exclusion criteria which means that many people who are homeless and need the service can’t access them.”
Preventing homelessness among people with brain injuries, rather than getting them o the streets and on the road to recovery, presents an entirely different challenge.
“It’s quite likely that individuals who have had head injuries as children or adolescents may be at a greater risk of being homeless in later life, although there is no evidence of this yet.
“They might not develop normally, their education may be interrupted and they may not acquire the skills that adults to a certain degree might have. If it can’t be addressed early on or isn’t addressed quickly enough then this changes their trajectory for the rest of their life.”
There is an argument that some people who are considered risk-takers might be susceptible to both homelessness and head injuries – rather than one being a result of the other.
“Certain antisocial behavioural activities could have caused them to be on the streets, such as drug-taking, which could have also contributed to a brain injury.
“What we do know quite clearly is that having a brain injury massively increases any existing problems you might already have.”
While the Headwise/Headway project remains at an early stage, there are examples of successful models that are already improving the way homeless people with head injuries are treated.
Worthington cites the PIE (psychologically informed environment) system as one approach to learn from.
“The idea is to provide an environment, perhaps in an accommodation setting, that meets the person’s needs for shelter but also their psychological and emotional needs too.
“These have been known to reduce offending behavior among homeless people with mental health issues and could have possible implications to help people with brain injuries.”
Worthington’s long-term vision is for a system that helps, not hinders, homeless people with brain injuries.
“In North America they have collaborative models of care that cut across boundaries. We’ve struggled with that here because everyone has their own ring-fenced budgets,” he says.
“We need a coordinated system that will pick people up after discharge from hospital, which is staffed by people with knowledge of head injury who are able to undertake assessments of their social and health needs and then help them access the relevant support. We need a network of services for people that are homeless.
“Currently in hospitals, if they haven’t got a discharge destination, they are either kicked onto the streets or kept in for longer than they need to be, ultimately blocking beds.
“There needs to be a service to which these individuals must be referred. We can find them temporary accommodation and get the assessments done and refer them on to other services to give them the support they need.”
Before that ideal is realised, support in tackling the issue is needed from many sources, including charities – especially against the backdrop of austerity measures.
“The third sector is going to play a critical role in this. NHS budgets are so stretched and are skewed towards acute services. Social services budgets are also stretched.
“It would help if we could make social services more informed. But ultimately they are not going to have the resources to address these complex needs, so I think a lot of responsibility is going to fall on charities.”
If charities are to take on this burden, they will need considerable support.
“Often a charity might lack medical expertise. What’s innovative in our model is that we’ve got a partnership between my professional, medical organisation and Headway, the charity.
“The future needs to be collaborative and it’s going to be incumbent on the charities to develop or access professional support.”
For now, Worthington takes optimism from the way in which brain injuries among criminals have been handled over the last decade.
What was once a suspected link between brain injury and criminal activity, now has a vast weight of evidence behind it.
With as many as 60% of prisoners reporting a head injury, according to one study on male inmates, the issue has infiltrated politics and is beginning to influence decisions and discussions about the future of the justice system.
In October, for example, the House of Commons justice select committee mentioned the increased risk among young offenders of head injury in its report on why the under-25s should be kept out of adult prisons.
In contrast, a parliamentary report published in the same month related to the Homelessness Reduction Bill 2016/17 made no mention of TBI among its list of the causes of homelessness.
In fact, there was no mention of head or brain injury anywhere in the document.
“A few years ago we were in the same position with brain injury and criminal activity and now we have a much better understanding of it.
“So I think in 10 year’s time that’s where we’ll be with homelessness and brain injury. It’s taking a while and we remain at a very early stage, but we’ve made a good start.”
TBI and homelessness: The evidence
A 2012 study by the Disabilities Trust found that 48 of the 100 homeless people it questioned in Leeds had experienced a head injury.
Of those, 90% suffered the injury before they became homeless.
The 48% figure was more than double the proportion of head injuries reported by those in a comparator control group of non-homeless people.
Another Disabilities Trust study, in Glasgow, used hospital records of admission to assess the city’s homeless population.
It found that the frequency of admission to hospital with head injury among the homeless was five times higher than that of the city’s general population.
In Toronto in 2004/05, 601 men and 303 women at homeless shelters and meal programmes were surveyed.
Overall, 53% had experienced a TBI, with 12% reporting a moderate or severe TBI. In this study 70% of respondents sustained their injury before they were homeless.
In 2014, researchers at St Michael’s Hospital in Toronto surveyed 111 homeless men and found that 45% of them had suffered at least one TBI in their life, and 87% of those injuries occurred before they were homeless.
Among the general population, TBI rates are estimated to be 12%, according to a 2013 meta-analysis of studies from developed countries.
Astrocytes identified as master ‘conductors’ of the brain
In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.
Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.
When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.
Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.
“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.
Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.
However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.
“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”
Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.
Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.
Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.
“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”
Carers at risk of being forgotten
A study has found that 68% of people believe they should ‘reach out’ to carers more often – with 60% of respondents only asking carers how they are ‘now and again’, ‘rarely’ or ‘almost never’; leaving carers at risk of feeling forgotten.
Furthermore, 72% of respondents worried that carers struggled with ‘loneliness’ thanks to the full-on nature of care leaving them little time for socialising.
Throughout the pandemic, caregivers have been at the forefront of the fight, looking after the most vulnerable in society and putting their own lives on the line to do so. In light of this, a campaign called #ReachOutAndHelpOut has been launched to encourage support for carers as they continue to deliver essential care to those in need – amidst fears that carers’ wellbeing is often overlooked.
Spearheaded by Sentai, a British technology start-up focused on helping the elderly live more independently in their own homes, the campaign looks to highlight the vital role that carers play.
Respondents, mindful of the associated health impact of winter, believe the biggest fears to be faced by carers in coming months is another ‘national lockdown’ (60%), while 53% of respondents saw ‘excessive workload’ as a primary worry. 50% also believed ‘difficulty visiting family and friends due to their care commitments’ was a central concern, while ‘juggling different responsibilities’ was a key issue according to 46%.
Other concerns included ‘lack of time’ (32.9%) and carers ‘feeling they’re not doing enough’ (25%).
Professor Ray Jones, professor of health informatics at Plymouth University and director of eHealth Productivity and Innovation in Cornwall and the Isles of Scilly (EPIC), which focuses on the provision of internet based healthcare services (eHealth) voiced his support for the campaign, highlighting the difficulties carers face.
He said: “The impact of the coronavirus crisis has been profound on almost all aspects of society. For carers though, this impact has been magnified to a far higher degree. The physical and psychological toll of caring during a pandemic is huge. We must be mindful of the burden placed on carers and do what we can to help. The service they provide is essential, and we’re all indebted to their hard work. The very least we can do then is simply ask them how they’re doing and offer whatever assistance we’re able to give.”
These sentiments were echoed by Philip Marshman, founder of Sentai and orchestrator of #ReachOutAndHelpOut, who said: “The role of a carer is often overlooked. It’s all too easy to ask how the recipient of care is without extending that concern beyond to take into account the person looking after them. Carers are people, not robots, and now, more than ever we must do what we can to consider and support their wellbeing and mental health.”
Sentai has launched a Kickstarter campaign to raise funds for the next stage of its smart device development, the success of which will see its pioneering technology brought to mass market – allowing those in need to benefit from its advanced offering.
Philip said: “The experience of looking after my own father led me to create Sentai, and it’s been developed to help both the care recipient and the caregiver. Through revolutionary voice technology it initiates intelligent conversations, helping to alleviate boredom and loneliness, while also providing helpful reminders. It’s safety properties also allow the caregiver to monitor the care recipient remotely and unobtrusively, providing reassurance that the care recipient is OK and acting as normal, thereby helping to ease stress and worry for the caregiver.”
He added: “We have everything in place to deliver a successful solution – we want to get Sentai into people’s homes as quickly as possible – whether that’s someone’s own home, or a care home. Raising funds in this way means we can stay true to our mission which is helping people live more independently, for longer.”
Further details of the Kickstarter campaign can be found via https://www.kickstarter.com/projects/sentai/sentai.
To find out more about the #ReachOutAndHelpOut campaign and the different ways to get involved, including the chance to win a well-deserved break away, please visit sentai.ai/ReachOut.
Others in the care industry who have expressed support for the #ReachOutAndHelpOut campaign, include Dr Stephen Ladyman, founder of Oak Retirement and former Minister of Health responsible for Social Care, and Shaleeza Hasham, founder of the Adopt a Grandparent scheme and head of hospitality at care home and home care provider, CHD Living.
PhysioFunction setting the trend for telerehab
Having been an early adopter of telerehab, PhysioFunction was perhaps less daunted than most at the prospect of responding to the COVID-19 lockdown and ensuring their clients’ needs were met.
The specialist neuro physiotherapy practice has, for the past year, used video calls to enable its clients to receive one-to-one sessions in addition to those provided in person, with its staff supporting them to install and use the technology remotely.
It is also an early adopter of the MindMotion GO, a first-of-its-kind mobile neurorehabilitation therapy system which uses gaming to support the recovery of brain injury and neuro patients.
PhysioFunction has reported strong levels of engagement and progress among clients as a result of its telerehab programme, which has increased in its use during the past few months amidst the pandemic.
From its specialist outpatient rehabilitation unit in Northampton, PhysioFunction supports patients from a 100-mile radius, which was a key driver in the adoption of virtual means of delivering therapy.
Claire Everett, clinical operations manager at PhysioFunction and a senior neurological physiotherapist, said: “For some time now, we have tried to embrace the use of online means for therapy, and it has really helped many of our clients. By doing sessions in their own homes, we see them taking ownership of their rehabilitation and it delivers benefits to them in their own settings.
“For example, we might be doing a session by video with a client on how to cope in the kitchen – but because it’s their own kitchen they’re in, that makes it even more relatable.
“It is a very useful way for some clients who perhaps struggle to get to us once a week, but cope much better with two half-hour weekly sessions by telerehab. We do carry out home visits, and will combine the remote sessions with hands-on therapy wherever we can, but some clients live quite a distance away or maybe it isn’t easy for them to get out of the house.
“By holding sessions by video, it doesn’t matter where they live, whether it’s round the corner or two hours away, and we’ve had a great response to our telerehab work. It’s changed our practice in some really positive ways.”
When lockdown came, while for many organisations a swift and seismic move to the adoption of remote communication was needed, PhysioFunction were in the enviable position of being able to build on what they had already created.
“With us already being established with many clients, we didn’t have to start from scratch, and we could look at how to build on what we had already done. By extending our telerehab programme, we could continue to support our clients effectively,” says Claire.
“The team were able to take our classes online from a very early stage, with Taher Dhuliawala and Keiran Cox very much holding the fort during lockdown. The classes followed the same format as in person, with small numbers of participants so we can easily spot if someone needs help, but we were able to increase the frequency of them. Being able to do these kinds of sessions in your own living room was really welcomed.
“With clients who were already able to use video, we also were able to introduce the MindMotion GO, which is fantastic as we can interact with the technology and, for example, increase the intensity as required. But at the start of the pandemic, we still had some clients who didn’t use video, and the fact we have supported them to use it meant they had an extra channel of communication with their family during lockdown, and that was a lovely extra benefit.
“Even aside from COVID, with the flu and winter weather coming, we are expecting further demand for our telerehab sessions. We’re currently running a blended approach of online and in-person sessions, although a few people are still choosing not to come in at all, but they have found our telerehab so effective that they’re still progressing with their therapy.”
While remote working was a ‘needs must’ for many practices during lockdown, and to help mitigate ongoing restrictions, PhysioFunction intend to continue to build telerehab as a core function.
“We are very into innovation and technology here and our team have worked really hard to do what we’ve done, I’m really proud of what we’ve achieved,” adds Claire.
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