Trajectory of disability and quality-of-life in non-geriatric and geriatric survivors after severe traumatic brain injury

Mental and Physical Health Comorbidities in Traumatic Brain Injury: A Non-TBI Controls Comparison

OBJECTIVE

To examine whether aging with a TBI was associated with a greater burden of health-related comorbidities compared with a non-TBI control cohort and examine the associations between comorbidity burden, emotional outcomes, and health-related quality of life (HRQoL) after TBI across ages.

DESIGN

Cross-sectional.

SETTING

Research center or telephone.

PARTICIPANTS

The study included 559 participants (NTBI=291, NControls=268). Participants with TBI were recruited during inpatient rehabilitation and had sustained a moderate-severe TBI 1-33 years previously. Non-TBI controls were a convenience sample recruited through advertisements in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The number of cardiovascular, general physical health, and mental health comorbidities was compared between cohorts and age strata using Poisson regression. The relationships between comorbidities, age, emotional outcomes (Generalized Anxiety Disorder Scale-7, Patient Health Questionnaire-9), and HRQoL (PROMIS Global Health Measure) were examined with linear regression. Distinct subgroups of comorbidities were identified using latent class analysis. Associations between comorbidity classes with demographic and outcome variables were evaluated using multinomial logistic and linear regressions, respectively.

RESULTS

TBI participants had a significantly higher comorbidity burden than controls, primarily driven by elevated rates of mental health disorders (RR=2.71, 95% confidence interval [1.37, 5.35]). Cardiovascular and physical health comorbidities were not elevated in the TBI group compared with controls. Both cohorts had 3 similar comorbidity subgroups, suggesting consistent patterns of co-occurring health conditions regardless of TBI exposure. Physical and mental health comorbidities were associated with elevated depression and anxiety symptoms and diminished HRQoL after TBI compared with controls.

CONCLUSION

TBI was associated with greater mental, but not physical, health comorbidities in the decades after injury. However, physical and mental health comorbidities significantly affected emotional and HRQoL status after TBI, underscoring a greater need for long-term support for individuals with TBI coping with both physical and mental health comorbidities.

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

Improvement in Functional Outcome from 6 to 12 Months After Moderate and Severe Traumatic Brain Injury Is Frequent, But May Not Be Detected With the Glasgow Outcome Scale Extended

The aims of this study were (1) to report outcome and change in outcome in patients with moderate and severe traumatic brain injury (mo/sTBI) between 6 and 12 months post-injury as measured by the Glasgow Outcome Scale Extended (GOSE), (2) to explore if demographic/injury-related variables can predict improvement in GOSE score, and (3) to investigate rate of improvement in Disability Rating Scale (DRS) score, in patients with a stable GOSE. All surviving patients ≥16 years of age who were admitted with mo/sTBI (Glasgow Coma Scale [GCS] score ≤13) to the regional trauma center in Central Norway between 2004 and 2019 were prospectively included (n = 439 out of 503 eligible). GOSE and DRS were used to assess outcome. Twelve-months post-injury, 13% with moTBI had severe disability (GOSE 2-4) versus 27% in sTBI, 26% had moderate disability (GOSE 5-6) versus 41% in sTBI and 62% had good recovery (GOSE 7-8) versus 31% in sTBI. From 6 to 12 months post-injury, 27% with moTBI and 32% with sTBI had an improvement, whereas 6% with moTBI and 6% with sTBI had a deterioration in GOSE score. Younger age and higher GCS score were associated with improved GOSE score. Improvement was least frequent for patients with a GOSE score of 3 at 6 months. In patients with a stable GOSE score of 3, an improvement in DRS score was observed in 22 (46%) patients. In conclusion, two thirds and one third of patients with mo/sTBI, respectively, had a good recovery. Importantly, change, mostly improvement, in GOSE score between 6 and 12 months was frequent and argues against the use of 6 months outcome as a time end-point in research. The GOSE does, however, not seem to be sensitive to actual change in function in the lower categories and a combination of outcome measures may be needed to describe the consequences after TBI.

Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury

BACKGROUND

An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission.

METHODS

We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission.

RESULTS

In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08-1.25]), Hispanic ethnicity (OR = 2.01 [1.80-2.25]), "other" race (OR = 2.19 [1.73-2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 [1.20-1.46]), discharge to SNF (HR = 1.56 [1.48-1.65]) or IRF (HR = 1.49 [1.40-1.59]), having prior PCP (HR = 1.23 [1.17-1.30]), dual eligibility (HR = 1.11 [1.04-1.18]), and prior TBI diagnosis (HR = 1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission.

CONCLUSIONS

Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.

Group-Based Patterns of Life Satisfaction and Functional Independence over the 10 Years after Traumatic Brain Injury in Older Adults: A Model Systems Study

BACKGROUND

Older adults who sustain a traumatic brain injury (TBI) have been shown to have reduced functional independence and life satisfaction relative to younger individuals with TBI. The purpose of this study was to examine the covarying patterns of functional independence and life satisfaction over the 10 years after TBI in adults who were 60 years of age or older upon injury.

METHOD

Participants were 1841 individuals aged 60 or older at the time of TBI, were enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure and Satisfaction with Life Scale scores during at least one time point at 1, 2, 5, and 10 years after TBI.

RESULTS

A k-means cluster analysis identified four distinct group-based longitudinal patterns of these two variables. Three cluster groups suggested that functional independence and life satisfaction generally traveled together over time, with one group showing relatively high functional independence and life satisfaction over time (Cluster 2), one group showing relatively moderate functional independence and life satisfaction (Cluster 4), and one group showing relatively low functional independence and life satisfaction (Cluster 1). Cluster 3 had relatively high functional independence over time but, nonetheless, relatively low life satisfaction; they were also the youngest group upon injury. Participants in Cluster 2 generally had the highest number of weeks of paid competitive employment but lower percentages of underrepresented racial/ethnic minority participants, particularly Black and Hispanic individuals. Women were more likely to be in the cluster with the lowest life satisfaction and functional independence (Cluster 1).

CONCLUSION

Functional independence and life satisfaction generally accompany one another over time in older adults, although this does not always occur, as life satisfaction can still be low in a subgroup of older individuals after TBI with higher functioning. These findings contribute to a better understanding of post-TBI recovery patterns in older adults over time that may inform treatment considerations to improve age-related discrepancies in rehabilitation outcomes.

Profound prospective assessment of radiological and functional outcome 6 months after TBI in elderly

BACKGROUND

Recovery after traumatic brain injury (TBI) in older adults is usually affected by the presence of comorbidities, leading to more severe sequelae in this age group than in younger patients. However, there are only few reports that prospectively perform in-depth assessment of outcome following TBI in elderly.

OBJECTIVE

This study aims at documenting structural brain characteristics and functional outcome and quality of life in elderly patients 6 months after TBI and comparing these data with healthy volunteers undergoing the same assessments.

METHODS

Thirteen TBI patients ≥ 65 years old, admitted to the University Hospitals Leuven (Belgium), between 2019 and 2022 due to TBI, including all injury severities, and a group of 13 healthy volunteers with similar demographic characteristics were prospectively included in the study. At admission, demographic, injury, and CT scan data were collected in our database. Six months after the accident, a brain MRI scan and standardized assessments of frailty, sleep quality, cognitive function, motor function, and quality of life were conducted.

RESULTS

A total of 13 patients and 13 volunteers were included in the study, with a median age of 74 and 73 years, respectively. Nine out of the 13 patients presented with a mild TBI. The patient group had a significantly higher level of frailty than the control group, presenting a mean Reported Edmonton Frailty Scale score of 5.8 (SD 2.7) vs 0.7 (SD 1.1) (p < 0.01). No statistically significant differences were found between patient and control brain volumes, fluid attenuated inversion recovery white matter hyperintensity volumes, number of lesions and blackholes, and fractional anisotropy values. Patients demonstrated a significantly higher median reaction time in the One Touch Stockings of Cambridge (22.3 s vs 17.6, p = 0.03) and Reaction Time (0.5 s vs 0.4 s, p < 0.01) subtests in the Cambridge Neuropsychological Test Automated Battery. Furthermore, patients had a lower mean score on the first Box and Blocks test with the right hand (46.6 vs 61.7, p < 0.01) and a significantly higher mean score in the Timed-Up & Go test (13.1 s vs 6.2 s, p = 0.02) and Timed Up & Go with cognitive dual task (16.0 s vs 10.2 s, p < 0.01). Substantially lower QOLIBRI total score (60.4 vs 85.4, p < 0.01) and QOLIBRI-OS total score (53.8 vs 88.5, p < 0.01) were also observed in the patients' group.

CONCLUSION

In this prospective study, TBI patients ≥ 65 years old when compared with elder controls showed slightly worse cognitive performance and poorer motor function, higher fall risk, but a substantially reduced QoL at 6 months FU, as well as significantly higher frailty, even when the TBI is classified as mild. No statistically significant differences were found in structural brain characteristics on MRI. Future studies with larger sample sizes are needed to refine the impact of TBI versus frailty on function and QoL in elderly.

Cognitive functioning following traumatic brain injury in older adults: associations with social participation and health-related quality of life

OBJECTIVES

To describe objective and subjective cognitive functioning older adults who sustained TBI at age 65 or over, and to determine whether cognitive functioning is associated with health-related quality of life (HRQoL) and social participation.

METHOD

The sample consisted of 40 individuals with TBI (mean age = 73 years; 65% mild, 35% moderate/severe TBI). On average 15 months post-injury, they completed measures of objective and subjective cognitive functioning (Telephone Interview for Cognitive Status-Modified, Alphaflex, Medical Outcomes Study Cognitive Functioning Scale), HRQoL (SF-12), and social participation (Participation Assessment with Recombined Tools - Objective).

RESULTS

Mean score for objective cognitive functioning was lower than normative values, while mean scores for executive functioning and subjective cognitive functioning were comparable to normative values. There was no relationship between objective and subjective measures. Subjective cognitive functioning and (to a lesser extent) global objective cognitive functioning were significantly associated with mental HRQoL but not with physical HRQoL or social participation.

CONCLUSION

These results underscore the importance of considering both subjective perception and objective performance when assessing and intervening on cognition to promote better mental HRQoL in older adults with TBI.

Racial and Ethnic Differences in the Prevalence of Do-Not-Resuscitate Orders among Older Adults with Severe Traumatic Brain Injury

Background

Older adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI.

Methods

We conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation).

Results

Compared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.40-0.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (−2.07 days, 95% CI −3.07 to −1.08) and duration of mechanical ventilation (−1.09 days, 95% CI −1.52 to −0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12).

Conclusions

We found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization.

Prevalence of Disability Associated With Head Injury With Loss of Consciousness in Adults in the United States: A Population-Based Study

OBJECTIVE

To provide nationally representative prevalence estimates of disability associated with prior head injury with loss of consciousness in the United States and to examine associations between prior head injury and disability.

METHODS

This was a cross-sectional analysis of 7,390 participants ≥40 years of age in the 2011-2014 National Health and Nutrition Examination Surveys (NHANES). Head injury with loss of consciousness was assessed by self-report. Domains of disability were assessed with a standardized structured questionnaire and measured grip strength. Logistic and linear regression models adjusted for demographic, socioeconomic/behavioral, and medical comorbidity variables were used. Multiple imputation was used to account for missing covariate data.

RESULTS

Mean age of participants was 58 years; 53% were female; 71% were non-Hispanic White; and 16% had a history of head injury with loss of consciousness. Overall, participants with a history of head injury had higher prevalence of disability in at least 1 domain of functioning compared to individuals without head injury (47.4% vs 38.6%, p < 0.001), with the highest prevalence of disability in the domains of mobility and work productivity. In fully adjusted models, head injury was significantly positively associated with disability in all domains assessed on the standardized questionnaire (all p < 0.05). Participants with head injury had greater grip strength (all p < 0.05).

CONCLUSIONS

We found that 47.4% of individuals ≥40 years of age in the United States with a history of head injury are living with disability in at least 1 domain of functioning, corresponding to 11.4 million affected individuals. This significant burden of disability suggests that efforts are needed to improve functioning among individuals with head injury.

Self-Rated Health Among Patients With Severe Traumatic Brain Injury and Their Close Relatives: The Role of Posttraumatic Stress Symptoms

OBJECTIVE

Severe traumatic brain injury (sTBI) is accompanied by significant declines in self-rated health (SRH). Although such deteriorations in SRH are related to various consequences of sTBI, the effect of posttraumatic reactions (i.e., posttraumatic stress [PTS] symptoms) has been tested insufficiently to date, especially among civilians. The present investigation is based on Trajectories of Recovery After Severe Traumatic brain injury-Matters In families (TRAST-MI), a unique study among civilians with sTBI and their families. Previous research revealed that civilian sTBI has effects beyond the injured patient, influencing their close relatives as well. The aim of this study was to assess the association between PTS symptoms and SRH among patients with civilian sTBI and their close relatives.

METHODS

Patients with sTBI (assessed by an Abbreviated Injury Scale of the head region score >3) and their close relatives participated in TRAST-MI. One hundred twenty-six patient-relative dyads were assessed at 3, 6, and 12 months after the injury.

RESULTS

Multilevel modeling revealed that patients' PTS symptoms were associated with consequent SRH (slope = 0.42; p < .001), and relatives' PTS symptoms were associated with their respective SRH (slope = 0.2; p = .012).

CONCLUSIONS

The findings of this study reveal that SRH of both patients with sTBI and their relatives are negatively affected by their own PTS symptoms. These findings underline the understanding that sTBI is not merely a medical trauma but rather a comprehensive psychosocial trauma, which has consequences for the whole family system.

Mental Health Outcomes Among Military Service Members After Severe Injury in Combat and TBI

INTRODUCTION

Studies examining the mental health outcomes of military personnel deployed into combat zones have focused on the risk of developing post-traumatic stress disorder conferred by mild or moderate traumatic brain injury (TBI). However, other mental health outcomes among veterans who sustained critical combat injuries have not been described.

MATERIALS AND METHOD

We examined the associations of moderate and severe TBI and combat injury with the risk for anxiety and mood disorders, adjustment reactions, schizophrenia and other psychotic disorders, cognitive disorders, and post-traumatic stress disorder. We conducted a retrospective cohort study of U.S. military service members critically injured in combat during military operations in Iraq and Afghanistan from February 1, 2002, to February 1, 2011. Health care encounters from (1) the Department of Defense (DoD) Trauma Registry (TR), (2) acute and ambulatory care in military facilities, and (3) civilian facilities are reimbursed by Tricare. Service members who sustained severe combat injury require critical care. We estimated the risk of mental health outcomes using risk-adjusted logit models for demographic and clinical factors. We explored the relationship between TBI and the total number of mental health diagnoses.

RESULTS

Of the 4,980 subjects who met inclusion criteria, most injuries occurred among members of the Army (72%) or Marines (25%), with mean (SD) age of 25.5(6.1) years. The prevalence of moderate or severe TBI was 31.6% with explosion as the most common mechanism of injury (78%). We found 71% of the cohort was diagnosed with at least one poor mental health condition, and the adjusted risk conferred by TBI ranged from a modest increase for anxiety disorder (odds ratio, 1.27; 95% confidence interval [CI], 1.11-1.45) to a large increase for cognitive disorder (odds ratio, 3.24; 95% CI, 2.78-3.77). We found TBI was associated with an increased number of mental health diagnoses (incidence rate ratio, 1.52; 95% CI, 1.42-1.63).

CONCLUSIONS

Combat-associated TBI may have a broad effect on several mental health conditions among critically injured combat casualties. Early recognition and treatment for trauma-associated mental health are crucial to improving outcomes among service personnel as they transition to post-deployment care in the DoD, Department of Veterans Affairs, or community health systems.

Longitudinal study of quality of life in acquired brain injury: A self- and proxy-report evaluation

After an acquired brain injury (ABI), the person remains with several impairments and disabilities that cause a decrease in his/her quality of life (QoL), which could change over time. The objective of the study was to analyse the evolution patterns of QoL in a sample of persons with ABI for one-year as well as the differences in proxy- and self-report versions of a QoL instrument. Method: The sample comprised 402 persons with ABI with ages ranging between 18 and 91 years, whom 36.20% had had the accident recently (i.e., three years or less). Patients, professionals and relatives responded at three evaluation points to the CAVIDACE scale, an ABI-specific QoL tool. Results: ANOVAs showed an improvement in QoL in the two follow-ups; the improvement was especially significant in the period between baseline and six months. The respondent factor did not interact with the evaluation time, but significant differences were found between respondents, with scores of patients higher than that for proxies. Finally, the QoL’s evolution interacts with the time elapsed since injury, showing significant improvements in the most recent group (i.e., three years or less). Conclusions: QoL must be considered from the earliest moments after ABI to obtain more significant improvements.

Psychological risk factors that characterize the trajectories of quality of life after a physical trauma: a longitudinal study using latent class analysis

BACKGROUND

The course and corresponding characteristics of quality of life (QOL) domains in trauma population are unclear. Our aim was to identify longitudinal QOL trajectories and determine and predict the sociodemographic, clinical, and psychological characteristics of trajectory membership in physical trauma patients using a biopsychosocial approach.

METHODS

Patients completed a questionnaire set after inclusion, and at 3, 6, 9, and 12 months follow-up. Trajectories were identified using repeated-measures latent class analysis. The trajectory characteristics were ranked using Cohen's d effect size or phi coefficient.

RESULTS

Altogether, 267 patients were included. The mean age was 54.1 (SD = 16.1), 62% were male, and the median injury severity score was 5.0 [2.0-9.0]. Four latent trajectories were found for psychological health and environment, five for physical health and social relationships, and seven trajectories were found for overall QOL and general health. The trajectories seemed to remain stable over time. For each QOL domain, the identified trajectories differed significantly in terms of anxiety, depressive symptoms, acute stress disorder, post-traumatic stress disorder, Neuroticism, trait anxiety, Extraversion, and Conscientiousness.

DISCUSSION

Psychological factors characterized the trajectories during 12 months after trauma. Health care providers can use these findings to identify patients at risk for impaired QOL and offer patient-centered care to improve QOL.

Functional outcome, dependency and well-being after traumatic brain injury in the elderly population: A systematic review and meta-analysis

Introduction

Traumatic brain injury (TBI) rates in the elderly are increasing worldwide, mainly due to fall accidents. However, TBI's impact on elderly patients' lives has not been thoroughly investigated.

Research question

This systematic review and meta-analysis aims at describing post-TBI incidence of functional decline, dependency, nursing home admission, reduced quality of life and depression in the elderly.

Materials and methods

A systematic literature search was performed in PubMed, EMBASE, Web Of Science, BIOSIS, Current Contents Connect, Data Citation Index, MEDLINE, SciELO, Cochrane library and CINAHL. Study selection was conducted by two independent reviewers. Meta-analysis was performed using a random-effects model.

Results

Twenty-seven studies were included in the qualitative synthesis and twenty-five in a random-effects meta-analysis. The prevalence of unfavorable functional outcomes after TBI was 65.2% (95% CI: 51.1–78.0). Admission to a nursing home had a pooled prevalence of 28.5% (95% CI: 17.1–41.6) and dependency rates ranged between 16.9% and 74.0%. A reduced quality of life was documented throughout follow-up with SF12/36 scores between 35.3 and 52.3/100.2.6–4.8% of the patients with mild TBI reported depressive symptoms. A large heterogeneity was found among studies for functional outcomes and discharge destination.

Discussion and conclusion

In conclusion, elderly patients have a significant risk for functional decline, dependency, nursing home admission and low quality of life following TBI. Moreover, more severe injuries lead to worse outcomes. These findings are important to provide accurate patient and family counseling, set realistic treatment targets and aim at relevant outcome variables in prognostic models for TBI in elderly patients.

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Traumatic Brain Injury in the elderly has a major impact on functional outcomes.

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Traumatic Brain Injury in elderly leads to dependency and nursing home admission.

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Elderly patients have a lower quality of life after Traumatic Brain Injury.

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Older age and injury severity are risk factors for poor functional outcome.

Effect of Age on Longitudinal Changes in Symptoms, Function, and Outcome in the First Year After Mild-Moderate Traumatic Brain Injury

OBJECTIVE

The aim of this study was to describe and compare the recovery and disability trajectory at 1 year post injury for younger and older adults with traumatic brain injury (TBI).

METHODS

This was a prospective longitudinal cohort study. Individuals 21 years and older with mild to moderate TBI were recruited from the emergency department (n = 33). We measured symptoms, function (Glasgow Outcome Scale-Extended, Functional Status Examination), and health-related quality of life (HRQOL) at 1 week and 1, 3, 6, and 12 months post injury.

RESULTS

Whereas the total number of symptoms does not differ between younger and older adults after TBI, the specific constellation of symptoms experienced does. Older adults are more likely to experience physical symptoms such as fatigue, balance, and coordination problems as well as complain of being bothered by noise. Younger adults, in contrast, endorse more psychological symptoms such as anxiety. Functioning as measured by the Glasgow Outcome Scale-Extended and Functional Status Examination was lower in older adults at 1 year post injury. Physical HRQOL was consistently poorer in the year post injury among older adults compared with younger adults after TBI. Mental HRQOL, in contrast, was higher in older adults post TBI at 1 year.

CONCLUSIONS

During the first year post TBI, older adults report different symptom clusters than do younger adults post TBI. To foster improved recovery and HRQOL in the older adult post TBI, nursing management strategies should focus on balance, coordination, and energy conservation.

TBI as a Risk Factor for Substance Use Behaviors: A Meta-analysis

OBJECTIVE

To quantify the relationship between substance use behaviors before and after traumatic brain injury (TBI), to identify populations that may benefit more from targeted interventions to reduce the effect of substance use on TBI recovery, and to establish areas for further study.

DATA SOURCES

Studies were identified via literature searches using MEDLINE, PsychInfo, PsychArticles, PubMed, and GoogleScholar (published before January 2019), as well as reference section reviews and forward searches. Searches were conducted using search terms for TBI and substance use behaviors.

STUDY SELECTION

Studies were included if they (1) contained both a measure of TBI and a measure of substance use behaviors; (2) reported an effect size representing the relationship between substance use behaviors before and after TBI, compared TBI vs non-TBI groups on substance use behaviors controlling for pre-TBI substance use, or compared groups with differing TBI severity on subsequent substance use behaviors controlling for pre-TBI substance use; (3) were written in English; and (4) were human subjects research. Studies examining effects of substance use intervention for people sustaining TBI were excluded from this study.

DATA EXTRACTION

Study variables included substance use behaviors, TBI severity, time since TBI, military status, age, race, and sex.

DATA SYNTHESIS

Substance use behaviors had a small but statistically significant decrease after moderate-severe TBI. After moderate-severe TBI, there was a statistically significant decline in both substance use (d=-0.29, P<.01) and negative substance use consequences (d=-0.67, P=.01). There was no significant change in substance use behaviors after mild TBI.

CONCLUSIONS

Substance use behaviors had a small decrease after moderate to severe TBI and no significant change after mild TBI. Study findings suggest the need for accurate assessment to identify those at greatest risk for problematic substance use behaviors after TBI.

Physical and Mental Health and Functioning Among Traumatic Brain Injury Close Relatives: The Role of Posttraumatic Stress Symptoms

Severe Traumatic brain injury (sTBI) often instigates widespread long-lasting disability and is accompanied by extensive rehabilitation. Unsurprisingly, sTBI also holds malignant consequences for patients' close relatives. The burden caused by the injury and its severity explains some of the ramifications for the relatives. Additionally, some findings demonstrate that patients with sTBI and their relatives develop posttraumatic stress (PTS) symptoms. However, although the link between PTS symptoms and physical and mental health is well-documented in literature, the effect of PTS symptoms on relatives of patients with sTBI has barely been examined. This study examines the influence of PTS symptoms of patients with sTBI and their relatives on the physical and mental health and functioning of the relatives. Patients who sustained a severe sTBI (Abbreviated Injury Scale of the head region > 3) and close relatives were included in a multi-center, prospective cohort study (TRAST-MI). One-hundred patients and their relatives were assessed at 2, 6, and 12 months post injury. Outcome variables included health-related quality of life (SF-12) as well as emotional, cognitive, interpersonal, and total functioning (PCRS). Relatives' physical health was predicted by relatives' PTS symptoms (Slope=-1.76; p = .043), and mental health was predicted by both patients' (Slope=-2.77; p = .034) and relatives' (Slope=-6.59; p < .001) PTS symptoms. Functioning level was only predicted by patients' PTS symptoms (Slope=-.25; p_< .001). The findings emphasize that TBI should be considered a comprehensive traumatic experience reaching further than mere physical damage to the brain and its direct consequences, affecting the injured individual and close relatives.

Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.

The Increasing Age of TBI Patients at a Single Level 1 Trauma Center and the Discordance Between GCS and CT Rotterdam Scores in the Elderly

Introduction: Traumatic brain injury (TBI) is frequently encountered in geriatric patients, but there is a paucity of data describing TBI in the elderly. Here, we show the age of patients with TBI is increasing at our medical center and discuss the relationship between age and injury severity with patient outcomes. Methods: This is a retrospective analysis of 3,179 adult patients with TBI treated at the University of California, Davis Level 1 Trauma Center between 2009 and 2016. Age, Glasgow Coma Scale (GCS), and CT Rotterdam Scores were recorded. Age was analyzed as both a continuous and categorical variable (18-34, 35-50, 51-65, >65 years-old). Extended Glasgow Outcome Scale was obtained at 3 and 6 months and dichotomized into favorable and unfavorable outcomes. Multivariable general linear regression models, chi-square, logistic regression analyses and ANOVA were used for statistical analyses; a p < 0.05 was considered significant. Results: The mean age of patients was 52.2 ± 21.9 years with a male predominance (69%). There was a significant trend (p = 0.002) toward an increase in mean age each year, increasing by 4.4 years (p = 0.008) over the course of the analysis. Older patients had a higher mean GCS compared to younger patients with the same CT Rotterdam Score (p = 0.027), this becoming more pronounced with worse CT Rotterdam Scores. The >65 group had a 4-fold increased risk for unfavorable outcome when compared to the 18-34 group, this effect being most pronounced after mild TBI. Conclusions: The mean age of TBI patients is increasing at our trauma center. The largest disparity in outcomes across age was seen in patients with a mild GCS and low CT Rotterdam Scores, suggesting that these markers of injury severity may underestimate the severity of injury in the elderly population. This information highlights the need for clinical trials and validation of outcome markers in geriatric TBI.

Quality of life measures in older adults after traumatic brain injury: a systematic review

BACKGROUND

On average older adults experiencing TBI are hospitalized four times as often, have longer hospital stays, and experience slower recovery trajectories and worse functional outcomes compared to younger populations with the same injury severity. A standard measure of Qol for older adults with TBI would facilitate accurate and reliable data across the individual patient care continuum and across clinical care settings, as well as support more rigorous research studies of metadata.

PURPOSE

The aim of this systematic review was to investigate patient reported Qol measures in studies with older adults post TBI.

METHOD

A systematic review was carried out focusing on the various tools to measure Qol in older adults, ≥ 65 years of age with a diagnosis of TBI. Data bases searched included Medline, Embase, PubMed, CINAHL, and PsychInfo from date of inception to September 25, 2017.

RESULTS

A total of 20 articles met the inclusion criteria. Nine different tools were identified.

CONCLUSIONS

Findings based on the comparison of reliability and construct validity of the Qol measures reported in this review suggest that no single instrument is superior to all others for our study population. Future research in this field should include the enrollment of larger study samples of older adults. Without these future efforts, the ability to detect an optimal Qol measure will be hindered.

Prediction of long-term quality of life after severe traumatic brain injury based on variables at hospital admission

Objectives: Variables collected early after severe traumatic brain injury (sTBI) could predict health-related quality of life (HRQoL). Our aim was to determine the prevalence of patients with a low HRQoL 4 years after sTBI and to develop a prediction model including early variables.Methods: Adult patients with both sTBI [abbreviated injury score of the head region (HAIS) >3] and disease-specific HRQoL assessments using the 'Quality of Life after Brain Injury' (QOLIBRI) were included. The outcome was the total score (TS) of QOLIBRI; cutoff for low HRQoL: <60 points. A multivariate logistic regression model and prediction model were performed.Results: One hundred-sixteen patients [median age 50.8 years (IQR 25.9-62.8; 21.6% >65 years)] were included; 68 (58.6%) with HAIS = 4, 48 (41.4%) with HAIS = 5. Median Glasgow Coma Scale (GCS) was 13 (IQR 3-15). Median TS was 77 (IQR 60-88). Low HRQoL was observed in 28 patients (24.1%). Two variables were associated with low HRQoL: GCS <13, working situation other than employed or retired. The prediction model had an AUROC of 0.765; calibration was moderate (Hosmer Lemeshow Chi2 6.82, p = .556).Conclusion: One in four patients had a low HRQoL after 4 years. A lower GCS and working situations were associated with low HRQoL.

Ontario Brain Injury Association Peer Support Program: a mixed methods protocol for a pilot randomised controlled trial

INTRODUCTION

The objective of this study is to conduct a pilot randomised controlled trial (RCT) of the Ontario Brain Injury Association (OBIA) Peer Support Program. The RCT is designed to evaluate the effectiveness and dose-response of the Peer Support Program in improving participation and mood for people with moderate-to-severe traumatic brain injury compared with a wait-list control group.

METHODS AND ANALYSIS

The proposed research is a three-phase, mixed methods pilot RCT. Consistent with an integrated knowledge translation approach, the study design has been informed in consultation with the knowledge user (ie, OBIA). It will include an initial qualitative examination of barriers and enablers to the trial implementation (phase 1), a pilot RCT (phase 2) and conclude with a qualitative component (phase 3). A qualitative descriptive approach will be adopted for both qualitative phases of the study (n=20-25) and thematic analysis will be used. The 6 months phase-2 trial will be conducted with 60 participants. These participants will be randomised to one of three groups: a twice a week programme (n=20), a once a week programme (n=20) or the wait-list control group (n=20). The feasibility of participant recruitment and retention, data collection, as well as participant adherence to the OBIA Peer Support Program will be evaluated. The primary outcome measure will be participation, as measured by the Participation Assessment with Recombined Tools-Objective. Other proposed outcomes of interest will include mood, health-related quality of life and self-efficacy.

ETHICS AND DISSEMINATION

Ethics approval will be obtained from the principal author's institution (University Health Network Research Ethics Board). The results of this study will inform the development of a larger scale RCT and will inform future iterations of the OBIA Peer Support Program including a revised programme curriculum.

TRIAL REGISTRATION NUMBER

NCT03450460; Pre-results.

Global Outcome Trajectories up to 10 Years After Moderate to Severe Traumatic Brain Injury

Aims: Based on important predictors, global functional outcome after traumatic brain injury (TBI) may vary significantly over time. This study sought to: (1) describe changes in the Glasgow Outcome Scale-Extended (GOSE) score in survivors of moderate to severe TBI, (2) examine longitudinal GOSE trajectories up to 10 years after injury, and (3) investigate predictors of these trajectories based on socio-demographic and injury characteristics. Methods: Socio-demographic and injury characteristics of 97 TBI survivors aged 16-55 years were recorded at baseline. GOSE was used as a measure of TBI-related global outcome and assessed at 1-, 2-, 5-, and 10-year follow-ups. Hierarchical linear models were used to examine global outcomes over time and whether those outcomes could be predicted by: time, time^*time, sex, age, partner relationship status, education, employment pre-injury, occupation, cause of injury, acute Glasgow Coma Scale score, length of post-traumatic amnesia (PTA), CT findings, and Injury Severity Score (ISS), as well as the interactions between each of the significant predictors and time^*time. Results: Between 5- and 10-year follow-ups, 37% had deteriorated, 7% had improved, and 56% showed no change in global outcome. Better GOSE trajectories were predicted by male gender (p = 0.013), younger age (p = 0.012), employment at admission (p = 0.012), white collar occupation (p = 0.014), and shorter PTA length (p = 0.001). The time^*time^*occupation type interaction effect (p = 0.001) identified different trajectory slopes between survivors in white and blue collar occupations. The time^*time^*PTA interaction effect (p = 0.023) identified a more marked increase and subsequent decrease in functional level among survivors with longer PTA duration. Conclusion: A larger proportion of survivors experienced deterioration in GOSE scores over time, supporting the concept of TBI as a chronic health condition. Younger age, pre-injury employment, and shorter PTA duration are important prognostic factors for better long-term global outcomes, supporting the existing literature, whereas male gender and white collar occupation are vaguer as prognostic factors. This information suggests that more intensive and tailored rehabilitation programs may be required to counteract a negative global outcome development in survivors with predicted worse outcome and to meet their long-term changing needs.

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

The Tragically Hip: Trauma in Elderly Patients

Old age is a risk factor for poor outcome in trauma patients, as a result of undertriage and the presence of occult life-threatening injuries. The mechanisms of injury for geriatric trauma differ from those in younger patients, with a much higher incidence of low-impact trauma, especially falls from a low height. Frailty is a risk factor for severe injury after minor trauma, and caring for these patients require a multidisciplinary team with both trauma and geriatric expertise. With early recognition and aggressive management, severe injuries can still be associated with good outcomes, even in very elderly patients.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.