Towards a better understanding of the impact of the sequelae of TBI on the social participation of seniors

Background: The multiple sequelae caused by traumatic brain injuries (TBIs) can considerably reduce the ability of seniors to resume their activities of daily living and their leisure activities, and to return to meaningful relationships so they can participate in the life of their community. Purpose of the study: This article aims to put forward the perceptions of older participants about the sequelae they themselves identify as consecutive, short or medium long term, with their TBI and consequently, the limitations they experienced in terms of their social participation. Results: The fi ndings reveal a correspondence between the multiple sequelae of the TBI identifi ed by the participants and those documented in the scientifi c writings. These sequelae could be grouped according to the limitations found in the operational framework’s three spheres of activities related to social participation: those that promotes self-realization through an autonomous and independent everyday life; through pastimes and leisure activities; and through relationships with others. Main fi ndings: The fi ndings are innovative compared with what is generally described in the scientifi c literature, since existing studies offer few concrete examples of the limitations encountered in terms of social participation due to sequelae following a TBI. Four sequelae namely memory loss, loss of balance, lack of motivation or apathy and fatigue, appear to have many impacts on a variety of activities which could explain their signifi cance for participants. Conclusion: The fi ndings pave the way for new research avenues that focus on analyzing social participation opportunities of older adults by reinforcing their capacities. Potential implications: Results provide benchmark for health care and social services professionals for the mobilization of most effective resources and services to help seniors to engage in rewarding, meaningful social participation activities. Research Article Towards a better understanding of the impact of the sequelae of TBI on the social participation of seniors Marie-Josée Levert1*, Hélène Lefebvre2, Mélanie Levasseur3, Isabelle Gélinas4, Michelle McKerall5, Odette Roy6 and Michelle Proulx7 1Associate Professor, Faculty of Nursing, Université de Montréal, Researcher, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Researcher, Interdisciplinary Research Group on Resilience and Community Rehabilitation (GIRR-CRIR), Canada 2Professor, Researcher, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Researcher, Interdisciplinary Research Group on Resilience and Community Rehabilitation (GIRR-CRIR), Canada 3Assistant professor, School of rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Canada 4Associate Professor, School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada, Researcher, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR),Researcher, Interdisciplinary Research Group on Resilience and Community Rehabilitation (GIRR-CRIR), Canada 5Associate professor, Department of psychology, Université de Montréal (Québec, Canada), Researcher, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Canada 6Executive assistant, Nursing administration, Research and education, Researcher, Maisonneuve-Rosemont Hospital Centre, Associate professor Faculty of Nursing, Université de Montréal, Québec, Canada 7Research professional, Interdisciplinary Research Group on Resilience and Community Rehabilitation (GIRR-CRIR), Montréal, Québec, Canada Dates: Received: 23 June, 2017; Accepted: 22 July, 2017; Published: 24 July, 2017 *Corresponding author: Marie-Josée Levert, Associate Professor, Faculty of Nursing, Université de Montréal, Researcher, Centre for, Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Researcher, Interdisciplinary Research Group on Resilience and Community Rehabilitation (GIRR-CRIR), C.P. 6128, Succ. Centre-Ville, Montréal, QC, H3C 3J7, Tel: 5143432178; Fax: 5143432306; E-mail:


Introduction
Seniors often express a desire to remain in their living environment for as long as possible, even if their autonomy and functional mobility are limited [1]. This calls for the implementation of public policies promoting cohesive, adapted environments, and programs or interventions focused on optimizing active aging and social participation [2][3][4][5]. Highly valued by seniors [6], social participation is considered a protection factor for mental health and cognitive functioning, and contributes to maintaining social skills and quality of life [4,5,7,8]. It is defi ned as the optimal involvement of individuals in meaningful activities that provide opportunities for them to thrive in their daily lives, leisure activities and social interactions [4,9,10]. It is a complex process based on participation of seniors. Arch Nurs Pract Care 3(1): 068-076. DOI: http://dx.doi.org/10.17352/anpc.000029 mutual, equal, meaningful and quality interactions between individuals and their social environment and within their community, where individuals are the principal actors in their lives and fully exercise their rights [11].
In this context, seniors who have a traumatic brain injury (TBI) represent an at-risk group. Indeed, over the last ten years, the prevalence of TBIs has signifi cantly increased in the elderly population [12,13], with individuals over 75 years of age representing the majority of emergency room cases, hospitalizations, and fatalities resulting from a TBI [12].
According to the Center for Disease Control, 62% of TBIs in seniors are caused by falls as opposed to traffi c accidents, which account for 17% of cases [14]. Compared with younger adults, seniors suffering from a TBI must overcome additional challenges since they are at greater risk of experiencing functional decline after the injury due to disabilities associated with normal aging [15][16][17][18][19][20][21]. These factors increase the risk of additional falls [21] and may considerably limit seniors' ability to resume their activities of daily living, to return to their meaningful interpersonal relationships, and to participate socially [9,20].
The social participation context specifi c to these seniors is given little consideration in the scientifi c literature. Studies focus primarily on very young or middle-aged adults, and very few touch on the particular situation of seniors with a TBI, who are almost systematically excluded from research protocols.
Conversely, the few studies that focus on this population tend to describe the very broad impacts of the injury [17] and share few concrete examples concerning the effects of each type of sequela on social participation. They do highlight some diffi culties in completing activities of daily living and attribute these to cognitive sequelae, but do not draw an explicit link between these diffi culties and the obstacles faced when performing varied activities that are meaningful to the individual [18,22]. This article aims to provide a general overview of the obstacles to social participation from the perspective of seniors who have sustained a TBI, according to the different sequelae they associate with their injury. Although we recognize that it may be diffi cult for seniors to differentiate sequelae resulting from the TBI from those associated with the normal aging process [17,20], this article wishes to present the perceptions of older adults about the sequelae resulting from their TBI and the impact on their social participation.

Conceptual framework
The article relies on the operationalization of the concept of social participation in light of a review of writings by Hardaker [9]. The concept centers on three main spheres of activities related to the social participation of seniors who have a TBI.
Autonomous and independent daily living: To be able to participate socially, seniors must be able to function in an enabling environment that will allow them to meet their own challenges. They must be able to perform their activities of daily living as autonomously and independently as possible [4].
Hobbies and leisure activities: Seniors must be able to participate in the recreational, social, cultural, and spiritual activities that are meaningful to them. These activities may vary according to their abilities (e.g. spending time at a senior citizen day center, volunteering, going to the movies or a coffee shop) [5].
Relationships with others: Maintaining or fostering social and family relationships can motivate seniors to get involved in the life of their community. The presence and support of others is in fact considered one of the fundamental pillars of social participation [4,5]. In light of this operational framework, we can assume that seniors having a TBI can have an optimal social participation when they autonomously and independently accomplish activities of their choice, in a context of equal, positive and motivating relationships with others and in a vitalizing and welcoming personal and social environment.

Methods
The data were collected during the fi rst phase of a longitudinal qualitative study that aimed to adapt, implement and assess the Personalized citizen assistance for social participation program (APIC) with seniors who have a TBI. In conjunction with the existing community resources, the APIC offers support to seniors to promote their social participation through mentoring to help them carry out the daily living and leisure activities that are meaningful to them [23,24]. The APIC study relies on the constructivist paradigm [25] and offers opportunities for learning and refl ection. It takes into account the perspective of seniors on the support they received during the course of the program in order to identify the best ways to promote their social participation. It has been approved by the Research Ethics Board of the APIC's partner institutions.

Population
Participants were intentionally selected based on specifi c criteria and for the purposes of diversity [26]. The criteria were as follows: have participated in the APIC program for a twelve months period, have sustained a mild or moderate TBI; be 65 or older; live at home or in an intermediate resource.
Recruitment took place in partnering rehabilitation centers in the Greater Montreal area based on a review of medical records and referrals from clinicians in TBI programs. The sample consisted of 11 participants (Table 1), including 7 women and 4 men, ranging in age from 65 to 96 years (average age is 78). Most participants lived alone because they were separated/ divorced or widowed, and several had children. Generally, they had a complicated mild TBI 2 to 4 years ago, for an average of 3.5 years (the highest number of years: 9). According to the available data (3 missing data), the TBI was most often caused by a fall (N=8), and in one case by a traffi c accident (N=1). The majority of participants had co-existing health problems, sometimes pre-existing (e.g. arthritis, CVA, diabetes, heart problems) ( with the aim of documenting the impact of the TBI on their social participation prior to the start of the APIC intervention. Interviews were audio-recorded and subsequently transcribed verbatim, and were conducted using a validated grid adapted to the elderly clientele [27]. The grid was developed using two recognized measurement tools: the Activities of Daily Living Scale (ADL scale v.5,) [28] and the Profi le of Leisure Activities v.3.0 [29].
The ADL Scale is used to assess participants' perceived changes to social participation and the performance of activities of daily living. The Profi le of Leisure Activities assesses the level of involvement in leisure activities. A questionnaire which included general socio-demographic (e.g. age, sex, marital status) and health (e.g. comorbidities, treatment, medication) questions was administered at the end of each interview.

Analysis
A thematic content analysis [30] was conducted to obtain a detailed understanding of the elderly participants' perceptions and experiences regarding the obstacles to social participation they encountered due to the sequelae resulting from their TBI. The data collected during the semi-structured interviews were analyzed using pre-determined and emerging categories.

Results
Prior to the APIC-intervention, participants identifi ed multiples sequelae resulting from their TBI. These sequelae could be grouped according to the operational framework's three spheres of activities related to social participation: those that promotes self-realization through an autonomous and independent everyday life; through pastimes and leisure activities; and through relationships with others. It is important to note that participants mentioned at least three sequelae affecting their social participation, and that some types of sequelae were highlighted by a larger number of participants, including fatigue (N=9 participants sur 11), loss of balance (7 participants sur 11), memory problems (6 participants sur 11), and apathy (6 participants sur 11) ( Table 2).

Limitations experienced in terms of autonomy in everyday life
All the participants faced limitations to their daily autonomy and level of independence, and all expressed, to varying degrees, diffi culties in performing personal tasks and domestic duties ( Table 3).
The vast majority mention fatigue (lack of energy, vitality, muscle weakness or drowsiness), lack of interest and motivation (apathy), memory loss, loss of balance, and in isolated cases, increased sensitivity to noise, visual impairments (double vision, loss of visual fi eld) and a state of confusion or inattention as factors limiting their ability to complete household tasks. Among the household chores that are the most diffi cult to accomplish for those suffering from fatigue, visual impairments or related physical injuries sustained at the time of the TBI (back pain) are tasks that involve carrying heavy objects, bending down or being higher up, those that require a lot of physical strength (washing windows, mopping fl oors) or that take a long time. A lack of motivation or interest in action as well as fatigability (somnolence) are expressed in others by a tendency to stay in bed until late in the day, to take less care of their appearance, or to abandon tasks.
Participants also describe being slower in their movements since the TBI and consequently have diffi culty getting up or out of bed. Because of inattention problems (or confusion), some experience diffi culty maintaining their efforts when it comes to completing tasks, whereas others, due to memory losses, encounter diffi culties with planning, especially when it comes to cooking more complicated recipes or managing Loss of sense of smell 1 8%

Limitations experienced in hobbies and leisure activities
All the participants report that the TBI is accompanied by mourning and disconnects regarding their aspirations and lifestyles. They all regret not being able to take part in satisfying recreational or productive activities (   activities that they used to take part in. An increased sensitivity to auditory stimuli as well as visual impairments impact their ability to go to the movies, watch television, complete puzzles, and perform activities that require fi ne motor skills (e.g. knitting, sewing).
Several participants report a lack of motivation (apathy) to resume activities. Two of the four male participants, who were employed or socially involved (e.g. volunteer work), now state that they are deprived of opportunities to socialize, feel useless and unproductive within society, and have lower self-esteem.
These participants say they lack the enthusiasm to once again take up activities. Some female participants, who were very active and independent before their TBI, fi nd it diffi cult that they are now unable to drive and have to rely on their loved ones to get around.
A large majority of participants fi nd it diffi cult to get around outside their home, in particular because of loss of balance, and more rarely due to fatigue (diffi culty staying up), visual impairments, physical symptoms (e.g. knee or leg pain), and/or problems with orientation. Several fear falling when they are getting around, a fear that is particularly strong in participants whose TBI was caused by a fall. One of them is in fact excessively apprehensive due to the circumstances surrounding her TBI: a physical assault followed by a fall when she was out. To face their fear of falling, some participants use avoidance strategies, i.e., they no longer use public transit or avoid going out alone. This insecurity is a recurring theme for several participants and increases depending on the climate, icy sidewalks, and the cold, which discourage the majority of participants from leaving their houses.

Limitations experienced in interpersonal relationships
Participants report signifi cant diffi culties in maintaining satisfying interpersonal and social relationships.The relationship limitations experienced by participants (Table 5) include trouble following conversations if people are speaking too quickly, or if more than one person is speaking at the same time, due to memory loss, trouble concentrating, or an increased sensitivity to noise. Those who have a tendency to search for their words during conversations highlight trouble communicating. They consequently feel excluded from conversations. Others are apprehensive of getting involved in volunteer activities for fear of exasperating others, being judged, or forgetting the instructions given because of their memory loss. Some participants feel embarrassed when they fi nd themselves in social situations and are unable to remember individuals who know them, or because they have diffi culty following the conversations due to language diffi culties. Others hesitate to get involved because of behaviors deemed unacceptable or inappropriate, including aggressiveness, anger, and irritability that are sometimes manifested in front of others and that they have trouble controlling.
All of these diffi culties hinder participation in activities that could provide opportunities for participants to socialize and develop a new social network. Leaving the house less often, taking part in less leisure activities as well as boredom can all lead to demoralization, weariness, and feelings of worthlessness in seniors. These feelings are expressed, to varying degrees, by all participants, who all fi nd social isolation and the lack of interaction alarming with negative effects on their wellbeing. Even though they live in residences, some participants also lament the lack of meaningful social relationships, with the situation more apparent for those who have little contact with their immediate family. These participants suffer from loneliness and feel the need to interact and communicate. Others complain about the lack of communication with the spouse, son or daughter they live with (e.g. only a few minutes of interaction a day) or the fact that they feel excluded from their social circle.
At the outset, several participants expressed the need for company and relationships with others. The vast majority need to speak, converse, communicate what they feel, which is sometimes diffi cult to do with a loved one. They need support

Discussion
The aim of this article was to establish an overview of the obstacles to social participation experienced by seniors who had sustained a TBI, according to the various sequelae they associate with their injury. The study reveals a correspondence between the multiple sequelae of the trauma identifi ed by the participants and those documented in the scientifi c literature, in particular fatigue, loss of balance, memory and visual impairments, speech and hearing problems, confusion, apathy, personality or behavioral changes, as well as physical symptoms [13,19,32,33]. conducted by Rappoport et al. [18] and Powell et al. [22] establish associations between cognitive impairments (e.g. language problems, executive function defi cits, memory loss) and lower performance levels when completing basic activities of daily living in seniors with a TBI. The nature of the present study allows the researchers to qualitatively record the impact of the specifi c sequelae of TBI on the abilities of the elderly participants to take part in various social participation activities, an avenue that has yet to be properly explored.
In this regard, the study identifi es the types of sequelae of TBI that are mentioned most frequently by participants when referring to limitations in the different spheres of activities of social participation used in our operational framework, namely memory loss, loss of balance, lack of motivation (or apathy) and fatigue. These four sequelae appear to be a signifi cant part of participants' experience, to a much greater extent than confusion, slowness, speech impairments, hearing problems, loss of smell, irritability. The importance of each of these four sequelae is refl ected in the scientifi c literature focused on adults with a TBI, regardless of age [2,17,19,20,[33][34][35][36][37][38]. In a mixed research design study conducted by Dumont [2] with 53 adults below the age of 50 who sustained a TBI, fatigue was identifi ed as the most persistent and frequently mentioned sequela associated with obstacles to work, leisure and social activities. Memory problems [35] were also recognized as having a signifi cant impact on the performance of complex tasks, on the ability to read, and on the retention of information.
With fatigue [2,33,35], these diffi culties were mentioned, in higher proportions, in the great majority of studies reviewed by Dumont [2] as factors that hindered social participation.
Other studies that have specifi cally focused on apathy or loss of balance also showed some effects on social participation in adults with TBI [34]. The adverse effects of apathy were highlighted as a barrier to interest in activities of daily living [36]. Mobility diffi culties related to loss of balance were recognized as affecting the capacity to function in everyday complex environments. These diffi culties were associated with a slower pace and cautious behaviors when getting around on foot [38]. To our knowledge, to this day no study illustrates the impacts between fatigue, memory loss, loss of balance or apathy and the limitations on social participation experienced by seniors with a TBI, which is clearly emphasized in the many accounts of participants. These four sequelae appear to have many impacts, and on a variety of activities in at least two of the three spheres of activities of social participation of the study's operational framework, which could explain their signifi cance for participants, compared with other types of sequelae such as confusion, slowness, speech impairments, hearing problems, loss of smell or irritability. Rather, these others sequelae seem to limit participants with regard to specifi c targeted activities, and over which they appear to have a greater feeling of control.
Confronted with visual or hearing impairments (increased sensitivity to noise), some recounted, for example, their use of active compensation strategies, (e.g. taking steps to access the services of an optometrist, wearing earplugs when vacuuming).
Furthermore, the analyses reveal that, for all participants, populations [13,20,22,39,40]. Obstacles to self-realization through hobbies and leisure activities also emerged, including problems reading or using a computer, and diffi culty watching television or knitting. These activities carried out at home were identifi ed as meaningful and rewarding for seniors which is documented in the writings [41]. Also important to note is the fact that many participants regretted the diffi culties they experienced walking, getting around outside, and using public transit. Several of them also expressed their fear of falling when getting around, specifi cally because of a loss of balance, which occurs frequently in individuals with a TBI, regardless of age [19,37,38]. Insecurity and fear of suffering a fall are cause for concern for seniors with or without a TBI and are described as determining factors when choosing a neighborhood or a place to visit [5,7,[42][43][44][45][46][47]. Being able to move, getting out, and planning outings are essential to seniors since they promote improved cognitive and functional abilities, better quality of life, and physical health [7,8,48]. where there would be social interaction. These diffi culties are documented in scientifi c literature [49,50]. Some participants indicated that they now avoid participating in organized social activities (e.g. volunteering) or informal ones, either because they had diffi culty following conversations in groups due to memory loss or increased sensitivity to noise, or because they were embarrassed when they exhibited uncontrollable aggressive or inappropriate behaviors in social situations.
This is of concern given that being engaged in satisfactory interpersonal relationships is viewed as a powerful indicator of social participation [6,19,51,52], whether these relationships take place in the privacy of the home, in the neighborhood, during sport or leisure activities, or through an involvement in the community [6]. The living environment, including family, is in this regard recognized as providing positive support to people with a TBI [19,[53][54][55]. However, some participants seemed to experience a contentious family situation, and were dependent fi nancially, emotionally and for support [50], which could hinder their rehabilitation and social participation [19,51]. Faced with this fi nding, interventions or programs need to be put in place in order to help loved ones fi nd the best ways to meet the demands and needs of seniors with a TBI, to inform them on the appropriate supervision to provide, and to ensure they live and evolve alongside them in a positive environment [53].

Strengths and Limitations
The scientifi c rigor of the study, supported by the high level of data saturation and the triangulation of the analyses, led to a thorough understanding of participants' perceptions of the concrete impacts of the sequelae of TBI on the social participation of elderly participants, which makes this an original and innovative study for the rehabilitation sector as well as the fi elds of geriatrics and public health.
Yet, the sampling method used calls for some caution when it comes to the generalization of the fi ndings. In fact, it is possible that the study's participants exhibit disabilities or personal characteristics that distinguish them from other seniors with a TBI who refused to participate in the APIC program (because they didn't have the time, they already had access to adequate support, or did not feel the need to receive help with their social participation). The data collected do not shed light on this matter. On the other hand, the present data were collected before the APIC intervention. Thus, it is possible that the overall picture of the sequelae associated by participants to the TBI will change over time to refl ect the evolution of the assistance, and consequently participants may identify other types of sequelae that hinder their social participation. Those that seemed less important at the outset may progressively take on greater importance. Finally, this article focused on the sequelae that participants themselves associated with their TBI. These fi ndings are important to mention, while keeping in mind that it is diffi cult, impossible even, to determine whether the sequelae mentioned are a result of the injury, or of a degenerative process due to normal aging, which began before the injury [17,20].

Conclusion
Several interventions have been implemented to promote the social participation of seniors, with or without a TBI, by offering support to engage in meaningful activities. These formal support resources take various forms (mentorship, respite care, friendly visits, home support, help engaging in activities, advocacy, transportation, etc.) and take place in various contexts: education, work, community life, activities of daily living, and leisure activities (assistance schedule). These resources generally do not focus on promoting the person's strengths, developing their abilities, or self-determination.
Also, they are not systematically concerned with the values, interests and personal life project of the accompanied seniors.
In order to improve the assistance provided, the innovative