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Flores-Sandoval C, MacKenzie HM, McIntyre A, Sait M, Teasell R, Bateman EA. Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury. Arch Gerontol Geriatr 2024; 125:105488. [PMID: 38776698 DOI: 10.1016/j.archger.2024.105488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition. METHOD Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines. RESULTS 64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %). CONCLUSION Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.
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Affiliation(s)
| | - Heather M MacKenzie
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
| | - Amanda McIntyre
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Muskan Sait
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; University College Cork, Ireland
| | - Robert Teasell
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada.
| | - Emma A Bateman
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
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Ma Z, He Z, Li Z, Gong R, Hui J, Weng W, Wu X, Yang C, Jiang J, Xie L, Feng J. Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res Rev 2024; 99:102376. [PMID: 38972601 DOI: 10.1016/j.arr.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population. METHODS We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses. FINDINGS We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality. CONCLUSIONS In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population. REVIEW REGISTRATION PROSPERO CRD42022323231.
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Affiliation(s)
- Zixuan Ma
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhenghui He
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhifan Li
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Ru Gong
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Jiyuan Hui
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Weiji Weng
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Xiang Wu
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Chun Yang
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Jiyao Jiang
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Junfeng Feng
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China.
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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Woischneck D, Gräve S, Barth E, Mayer B, Oehmichen M, Pala A. Outcome after decompressive craniectomy in older adults after traumatic brain injury. Front Med (Lausanne) 2024; 11:1422040. [PMID: 39040896 PMCID: PMC11260794 DOI: 10.3389/fmed.2024.1422040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Objective Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients. Methods A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05. Results A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429). Conclusion Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.
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Affiliation(s)
- Thomas Kapapa
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
| | | | | | | | | | - Stefanie Gräve
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Eberhard Barth
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | - Andrej Pala
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
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Chen SJ, Li SJ, Hong HM, Hwang HF, Lin MR. Effects of Age, Sex, and Postconcussive Symptoms on Domain-Specific Quality of Life a Year After Mild Traumatic Brain Injury. J Head Trauma Rehabil 2024; 39:E225-E236. [PMID: 38032833 DOI: 10.1097/htr.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To identify the factors influencing longitudinal changes in patients' scores across 6 domains of the Quality of Life after Brain Injury (QOLIBRI) instrument 1 year after mild traumatic brain injury (mTBI). DESIGN This was a longitudinal cohort study. PARTICIPANTS AND SETTING Eligible patients with a new diagnosis of mTBI were recruited from the outpatient clinics of the neurosurgery departments of 3 teaching hospitals in Taipei City, Taiwan. In total, 672 patients participated in the baseline assessment. Postinjury follow-up was conducted at 6 and 12 months. MAIN OUTCOME MEASURE Six domains of the 37-item QOLIBRI: Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems. RESULTS Linear mixed-effects analyses revealed that, among patients younger than 60 years, the scores of the Cognition, Self, Daily Life and Autonomy, and Social Relationships domains significantly increased 6 months after injury; furthermore, their scores of the Cognition, Self, and Daily Life and Autonomy significantly increased 12 months after injury. By contrast, among patients 60 years and older, the scores of these domains reduced from baseline to 6 and 12 months. No significant sex-based difference was observed in the changes in scores of any QOLIBRI domain. At 6 and 12 months post-injury, the scores of the Cognition, Emotions, and Physical Problems domains were significantly higher for patients with postconcussive symptoms than for those without these symptoms. CONCLUSIONS Although multiple characteristics of patients significantly affected their baseline scores on the 6 domains of the QOLIBRI, only age and postconcussive symptoms were significantly associated with longitudinal changes in their scores 6 and 12 months after mTBI.
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Affiliation(s)
- Sy-Jou Chen
- Author Affiliations: Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (Dr Chen); Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan (Drs Chen and Lin); Departments of Emergency Medicine (Dr Li) and Nursing (Ms Hong), Taipei Medical University Hospital, Taipei, Taiwan; Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan (Dr Hwang); and Programs in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan (Dr Lin)
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Karamian A, Seifi A, Karamian A, Lucke-Wold B. Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis. J Neurol 2024; 271:3849-3868. [PMID: 38755424 DOI: 10.1007/s00415-024-12424-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants. METHODS Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis. RESULTS The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2-12.1%, I2 = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6-10.9%], with a high heterogeneity between studies (I2 = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1-2.8%, I2 = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2-10.3%], with significant heterogeneity between studies (I2 = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6-14.7%, I2 = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48-0.86, p < 0.01, I2 = 28%). CONCLUSION Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Amin Karamian
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
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Elias J, Sutherland E, Kennedy E. Concussion Management in Older People: A Scoping Review. J Head Trauma Rehabil 2024; 39:293-303. [PMID: 38453625 DOI: 10.1097/htr.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding. CONTEXT Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people. DESIGN Scoping review. METHOD A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed. RESULTS The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed. CONCLUSION Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.
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Affiliation(s)
- Josh Elias
- Author Affiliations: Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand (Mr Elias and Dr Kennedy); and Department of Physiology, University of Otago, Dunedin, New Zealand (Ms Sutherland)
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Ayton A, Spitz G, Hicks AJ, Ponsford J. Mental and Physical Health Comorbidities in Traumatic Brain Injury: A Non-TBI Controls Comparison. Arch Phys Med Rehabil 2024; 105:1355-1363. [PMID: 38521496 DOI: 10.1016/j.apmr.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
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.
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Affiliation(s)
- Amber Ayton
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; School of Psychological Sciences, Monash University, Melbourne, Australia.
| | - Gershon Spitz
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; School of Psychological Sciences, Monash University, Melbourne, Australia
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Fonseca RA, Canas M, Diaz L, Aldana JA, Afzal H, De Filippis A, Del Toro D, Day A, McCarthy J, Stansfield K, Bochicchio GV, Niziolek G, Kranker LM, Rosengart MR, Hoofnagle M, Leonard J. Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury. J Trauma Acute Care Surg 2024; 97:105-111. [PMID: 38509046 PMCID: PMC11199100 DOI: 10.1097/ta.0000000000004296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Serial neurological examinations (NEs) are routinely recommended in the intensive care unit (ICU) within the first 24 hours following a traumatic brain injury (TBI). There are currently no widely accepted guidelines for the frequency of NEs. Disruptions to the sleep-wake cycles increase the delirium rate. We aimed to evaluate whether there is a correlation between prolonged hourly (Q1)-NE and development of delirium and to determine if this practice reduces the likelihood of missing the detection of a process requiring emergent intervention. METHODS A retrospective analysis of patients with mild/moderate TBI, admitted to the ICU with serial NEs, was performed. Cohorts were stratified by the duration of exposure to Q1-NE, into prolonged (≥24 hours) and nonprolonged (<24 hours). Our primary outcomes of interest were delirium, evaluated using the Confusion Assessment Method; radiological progression from baseline images; neurological deterioration (focal neurological deficit, abnormal pupillary examination, or Glasgow Coma Scale score decrease >2); and neurosurgical procedures. RESULTS A total of 522 patients were included. No significant differences were found in demographics. Patients in the prolonged Q1-NE group (26.1%) had higher Injury Severity Score with similar head Abbreviated Injury Score, significantly higher delirium rate (59% vs. 35%, p < 0.001), and a longer hospital/ICU length of stay when compared with the nonprolonged Q1-NE group. No neurosurgical interventions were found to be performed emergently as a result of findings on NEs. Multivariate analysis demonstrated that prolonged Q1-NE was the only independent risk factor associated with a 2.5-fold increase in delirium rate. The number needed to harm for prolonged Q1-NE was 4. CONCLUSION Geriatric patients with mild/moderate TBI exposed to Q1-NE for periods longer than 24 hours had nearly a threefold increase in ICU delirium rate. One of five patients exposed to prolonged Q1-NE is harmed by the development of delirium. No patients were found to directly benefit as a result of more frequent NEs. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Ricardo A Fonseca
- From the Department of Acute and Critical Care Surgery (R.A.F., M.C., L.D., J.A.A., H.A., D.D.T., A.D., J.M., K.S., G.V.B., G.N., L.M.K., M.R.R., M.H., J.L.), Washington University in St. Louis, St. Louis, Missouri; and Department of Surgery (A.D.F.), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Graham RS, Ghadiyaram A, Feld N, Dincer A, Leonard DM, Johnson E, Opalak CF, Broaddus WC. Delayed Burr Hole Evacuation Compared With Acute Craniotomy for Acute Subdural Hematoma in Older Patients With Low-Energy Trauma. Cureus 2024; 16:e63057. [PMID: 39050324 PMCID: PMC11268878 DOI: 10.7759/cureus.63057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Acute subdural hematomas commonly require emergent surgical decompression by craniotomy. There is currently limited research on alternative surgical strategies in the elderly population. This study investigates delayed surgical intervention for stable patients with low-energy trauma presenting with acute subdural hematomas. Methodology In this retrospective chart review, 45 patients over the age of 55 presenting with acute subdural hematomas with a Glasgow Coma Scale score greater than or equal to 13 in the setting of low-energy trauma were selected. Additionally, included patients had a maximal hematoma thickness of >10 mm and/or a midline shift size of >5 mm per the current Brain Trauma Foundations guidelines for surgical intervention of subdural hematomas. The study was performed at a large tertiary care center, with records being examined from 1995 to 2020. Comparison groups were immediate craniotomy (within 24 hours) or delayed burr hole (minimum of 48 hours passing since the initial presentation). Primary outcomes included minor complications, major complications, any complications, and any complications with mortality excluded. There was no significant difference in mortality between the two cohorts. Results The immediate craniotomy group consisted of 16 patients, while the delayed burr hole group consisted of 29 patients. The results demonstrated a statistically significant increase in the incidence of any complication including mortality (relative risk (RR) = 3.17, 95% confidence interval (CI) = 1.71-5.88, p < 0.0001), major complications (RR = 2.33, 95% CI = 1.07-5.07, p = 0.031), and minor complications (RR = 2.42, 95% CI = 1.02-5.74, p = 0.041) in the immediate craniotomy group compared to the delayed burr hole group. Conclusions Our study demonstrates the decreased risk of major and minor complications for delayed burr hole evacuation in stable patients >55 years old presenting with low-energy trauma and subdural hematoma. The results suggest that for this population of patients, it appears to be beneficial to delay surgery if the patient's clinical situation allows.
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Affiliation(s)
- Robert S Graham
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Ashwin Ghadiyaram
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Noah Feld
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, USA
| | - Alper Dincer
- Department of Neurosurgery, Tufts Medical Center, Boston, USA
| | - Dean M Leonard
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Erica Johnson
- Department of Neurosurgery, West Virginia University, Morgantown, USA
| | - Charles F Opalak
- Neurosurgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, USA
| | - William C Broaddus
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
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Mokbel AY, Burns MP, Main BS. The contribution of the meningeal immune interface to neuroinflammation in traumatic brain injury. J Neuroinflammation 2024; 21:135. [PMID: 38802931 PMCID: PMC11131220 DOI: 10.1186/s12974-024-03122-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Traumatic brain injury (TBI) is a major cause of disability and mortality worldwide, particularly among the elderly, yet our mechanistic understanding of what renders the post-traumatic brain vulnerable to poor outcomes, and susceptible to neurological disease, is incomplete. It is well established that dysregulated and sustained immune responses elicit negative consequences after TBI; however, our understanding of the neuroimmune interface that facilitates crosstalk between central and peripheral immune reservoirs is in its infancy. The meninges serve as the interface between the brain and the immune system, facilitating important bi-directional roles in both healthy and disease settings. It has been previously shown that disruption of this system exacerbates neuroinflammation in age-related neurodegenerative disorders such as Alzheimer's disease; however, we have an incomplete understanding of how the meningeal compartment influences immune responses after TBI. In this manuscript, we will offer a detailed overview of the holistic nature of neuroinflammatory responses in TBI, including hallmark features observed across clinical and animal models. We will highlight the structure and function of the meningeal lymphatic system, including its role in immuno-surveillance and immune responses within the meninges and the brain. We will provide a comprehensive update on our current knowledge of meningeal-derived responses across the spectrum of TBI, and identify new avenues for neuroimmune modulation within the neurotrauma field.
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Affiliation(s)
- Alaa Y Mokbel
- Department of Neuroscience, Georgetown University Medical Center, New Research Building-EG11, 3970 Reservoir Rd, NW, Washington, DC, 20057, USA
| | - Mark P Burns
- Department of Neuroscience, Georgetown University Medical Center, New Research Building-EG11, 3970 Reservoir Rd, NW, Washington, DC, 20057, USA
| | - Bevan S Main
- Department of Neuroscience, Georgetown University Medical Center, New Research Building-EG11, 3970 Reservoir Rd, NW, Washington, DC, 20057, USA.
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Albrecht JS, Gardner RC, Bahorik AL, Xia F, Yaffe K. Psychiatric Disorders Are Common Among Older US Veterans Prior to Traumatic Brain Injury. J Head Trauma Rehabil 2024:00001199-990000000-00159. [PMID: 38833711 DOI: 10.1097/htr.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE To estimate the impact of traumatic brain injury (TBI) on prevalence of posttraumatic stress disorder (PTSD), depression, and alcohol and substance use disorders. SETTING A random sample of Veteran's Health Administration data. PARTICIPANTS A total of 14 116 veterans aged ≥55 with incident late-life TBI between October 1, 1999, and September 31, 2021, were matched 1:3 on age and TBI date to 42 678 veterans without TBI. DESIGN Retrospective cohort study. MAIN MEASURES PTSD, depression, and alcohol and substance use disorders were identified using diagnostic codes. Participants were censored after the first diagnosis during the year before and the year after the TBI or matched date. Prevalence rates of PTSD, depression, alcohol, and substance use disorders were compared before and after incident TBI or matched date using Poisson regression. RESULTS Pre-TBI prevalence rates of disorders were higher among those with TBI relative to those without TBI. Pre-TBI PTSD prevalence rates (per 1000 person-years) were 126.3 (95% CI, 120.2-132.4) compared to 21.5 (95% CI, 20.1-22.9) in the non-TBI cohort. In adjusted models, TBI was not associated with an increase in the prevalence of any of the studied disorders. CONCLUSIONS Prevalence rates of depression, PTSD, and alcohol and substance use disorders were 5 to 10 times higher among older veterans before incident TBI. We did not observe an increase in the prevalence of these disorders after incident TBI. Older veterans with these disorders may be at increased risk for TBI.
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Affiliation(s)
- Jennifer S Albrecht
- Author Affiliations: Department of Epidemiology and Public Health (Dr Albrecht), University of Maryland School of Medicine, Baltimore, Maryland; Joseph Sagol Neuroscience Center (Dr Gardner), Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; San Francisco Veterans Affairs Medical Center (Ms Xia and Dr Yaffe), San Francisco, California; Department of Psychiatry (Drs Bahorik and Yaffe), Department of Epidemiology & Biostatistics (Dr Yaffe), Department of Neurology (Dr Yaffe) , University of California San Francisco, San Francisco, California; and Northern California Institute for Research and Education (Ms Xia), San Francisco, California
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Mower WR, Akie TE, Morizadeh N, Gupta M, Hendey GW, Wilson JL, Leonid Duvergne LP, Ma P, Krishna P, Rodriguez RM. Blunt Head Injury in the Elderly: Analysis of the NEXUS II Injury Cohort. Ann Emerg Med 2024; 83:457-466. [PMID: 38340132 DOI: 10.1016/j.annemergmed.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Changes with aging make older patients vulnerable to blunt head trauma and alter the potential for injury and the injury patterns seen among this expanding cohort. High-quality care requires a clear understanding of the factors associated with blunt head injuries in the elderly. Our objective was to develop a detailed assessment of the injury mechanisms, presentations, injury patterns, and outcomes among older blunt head trauma patients. METHODS We conducted a planned secondary analysis of patients aged 65 or greater who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study. We performed a detailed assessment of the demographics, mechanisms, presentations, injuries, interventions, and outcomes among older patients. RESULTS We identified 3,659 patients aged 65 years or greater, among the 11,770 patients enrolled in the NEXUS validation study. Of these older patients, 325 (8.9%) sustained significant injuries, as compared with significant injuries in 442 (5.4%) of the 8,111 younger patients. Older females (1,900; 51.9%) outnumbered older males (1,753; 47.9%), and occult presentations (exhibiting no high-risk clinical criteria beyond age) occurred in 48 (14.8%; 95% confidence interval (CI) 11.1 to 19.1) patients with significant injuries. Subdural hematomas (377 discreet lesions in 299 patients) and subarachnoid hemorrhages (333 discreet instances in 256 patients) were the most frequent types of injuries occurring in our elderly population. A ground-level fall was the most frequent mechanism of injury among all patients (2,211; 69.6%), those sustaining significant injuries (180; 55.7%), and those who died of their injuries (37; 46.3%), but mortality rates were highest among patients experiencing a fall from a ladder (11.8%; 4 deaths among 34 cases [95% CI 3.3% to 27.5%]) and automobile versus pedestrian events (10.7%; 16 deaths among 149 cases [95% CI 6.3% to 16.9%]). Among older patients who required neurosurgical intervention for their injuries, only 16.4% (95% CI 11.1% to 22.9%) were able to return home, 32.1% (95% CI 25.1% to 39.8%) required extended facility care, and 41.8% (95% CI 34.2% to 49.7%) died from their injuries. CONCLUSIONS Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.
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Affiliation(s)
- William R Mower
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Thomas E Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA
| | | | - Malkeet Gupta
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jake L Wilson
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Phillip Ma
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Pravin Krishna
- Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
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Pease M, Mittal A, Merkaj S, Okonkwo DO, Gonzalez-Martinez JA, Elmer J, Liou WS, Pingue V, Hammond FM, Abramovici S, Castellano J, Barot N. Early Seizure Prophylaxis in Mild and Moderate Traumatic Brain Injury: A Systematic Review and Meta-Analysis. JAMA Neurol 2024; 81:507-514. [PMID: 38587858 PMCID: PMC11002778 DOI: 10.1001/jamaneurol.2024.0689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/06/2024] [Indexed: 04/09/2024]
Abstract
Importance Guidelines recommend seizure prophylaxis for early posttraumatic seizures (PTS) after severe traumatic brain injury (TBI). Use of antiseizure medications for early seizure prophylaxis after mild or moderate TBI remains controversial. Objective To determine the association between seizure prophylaxis and risk reduction for early PTS in mild and moderate TBI. Data Sources PubMed, Google Scholar, and Web of Science (January 1, 1991, to April 18, 2023) were systematically searched. Study Selection Observational studies of adult patients presenting to trauma centers in high-income countries with mild (Glasgow Coma Scale [GCS], 13-15) and moderate (GCS, 9-12) TBI comparing rates of early PTS among patients with seizure prophylaxis with those without seizure prophylaxis. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) reporting guidelines were used. Two authors independently reviewed all titles and abstracts, and 3 authors reviewed final studies for inclusion. A meta-analysis was performed using a random-effects model with absolute risk reduction. Main Outcome Measures The main outcome was absolute risk reduction of early PTS, defined as seizures within 7 days of initial injury, in patients with mild or moderate TBI receiving seizure prophylaxis in the first week after injury. A secondary analysis was performed in patients with only mild TBI. Results A total of 64 full articles were reviewed after screening; 8 studies (including 5637 patients) were included for the mild and moderate TBI analysis, and 5 studies (including 3803 patients) were included for the mild TBI analysis. The absolute risk reduction of seizure prophylaxis for early PTS in mild to moderate TBI (GCS, 9-15) was 0.6% (95% CI, 0.1%-1.2%; P = .02). The absolute risk reduction for mild TBI alone was similar 0.6% (95% CI, 0.01%-1.2%; P = .04). The number needed to treat to prevent 1 seizure was 167 patients. Conclusion and Relevance Seizure prophylaxis after mild and moderate TBI was associated with a small but statistically significant reduced risk of early posttraumatic seizures after mild and moderate TBI. The small absolute risk reduction and low prevalence of early seizures should be weighed against potential acute risks of antiseizure medications as well as the risk of inappropriate continuation beyond 7 days.
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Affiliation(s)
- Matthew Pease
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis
| | - Adi Mittal
- University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
| | - Sara Merkaj
- Yale University Medical School, New Haven, Connecticut
| | - David O. Okonkwo
- Department of Neurological Surgery, UPMC Healthcare System, Pittsburgh, Pennsylvania
| | | | - Jonathan Elmer
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Wen-Shyong Liou
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Valeria Pingue
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabiltation and Spinal Unit of the Institute of Pavia, Pavia, Italy
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis
| | - Sergiu Abramovici
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - James Castellano
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Niravkumar Barot
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Kornblith E, Diaz-Ramirez LG, Yaffe K, Boscardin WJ, Gardner RC. Incidence of Traumatic Brain Injury in a Longitudinal Cohort of Older Adults. JAMA Netw Open 2024; 7:e2414223. [PMID: 38819822 PMCID: PMC11143459 DOI: 10.1001/jamanetworkopen.2024.14223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/29/2024] [Indexed: 06/01/2024] Open
Abstract
Importance Traumatic brain injury (TBI) occurs at the highest rate in older adulthood and increases risk for cognitive impairment and dementia. Objectives To update existing TBI surveillance data to capture nonhospital settings and to explore how social determinants of health (SDOH) are associated with TBI incidence among older adults. Design, Setting, and Participants This nationally representative longitudinal cohort study assessed participants for 18 years, from August 2000 through December 2018, using data from the Health and Retirement Study (HRS) and linked Medicare claims dates. Analyses were completed August 9 through December 12, 2022. Participants were 65 years of age or older in the HRS with survey data linked to Medicare without a TBI prior to HRS enrollment. They were community dwelling at enrollment but were retained in HRS if they were later institutionalized. Exposures Baseline demographic, cognitive, medical, and SDOH information from HRS. Main Outcomes and Measures Incident TBI was defined using inpatient and outpatient International Classification of Diseases, Ninth or Tenth Revision, diagnosis codes received the same day or within 1 day as the emergency department (ED) visit code and the computed tomography (CT) or magnetic resonance imaging (MRI) code, after baseline HRS interview. A cohort with TBI codes but no ED visit or CT or MRI scan was derived to capture diagnoses in nonhospital settings. Descriptive statistics and bivariate associations of TBI with demographic and SDOH characteristics used sample weights. Fine-Gray regression models estimated associations between covariates and TBI, with death as a competing risk. Imputation considering outcome and complex survey design was performed by race and ethnicity, sex, education level, and Area Deprivation Index percentiles 1, 50, and 100. Other exposure variables were fixed at their weighted means. Results Among 9239 eligible respondents, 5258 (57.7%) were female and 1210 (9.1%) were Black, 574 (4.7%) were Hispanic, and 7297 (84.4%) were White. Mean (SD) baseline age was 75.2 (8.0) years. During follow-up (18 years), 797 (8.9%) of respondents received an incident TBI diagnosis with an ED visit and a CT code within 1 day, 964 (10.2%) received an incident TBI diagnosis and an ED code, and 1148 (12.9%) received a TBI code with or without an ED visit and CT scan code. Compared with respondents without incident TBI, respondents with TBI were more likely to be female (absolute difference, 7.0 [95% CI, 3.3-10.8]; P < .001) and White (absolute difference, 5.1 [95% CI, 2.8-7.4]; P < .001), have normal cognition (vs cognitive impairment or dementia; absolute difference, 6.1 [95% CI, 2.8-9.3]; P = .001), higher education (absolute difference, 3.8 [95% CI, 0.9-6.7]; P < .001), and wealth (absolute difference, 6.5 [95% CI, 2.3-10.7]; P = .01), and be without baseline lung disease (absolute difference, 5.1 [95% CI, 3.0-7.2]; P < .001) or functional impairment (absolute difference, 3.3 [95% CI, 0.4-6.1]; P = .03). In adjusted multivariate models, lower education (subdistribution hazard ratio [SHR], 0.73 [95% CI, 0.57-0.94]; P = .01), Black race (SHR, 0.61 [95% CI, 0.46-0.80]; P < .001), area deprivation index national rank (SHR 1.00 [95% CI 0.99-1.00]; P = .009), and male sex (SHR, 0.73 [95% CI, 0.56-0.94]; P = .02) were associated with membership in the group without TBI. Sensitivity analyses using a broader definition of TBI yielded similar results. Conclusions and Relevance In this longitudinal cohort study of older adults, almost 13% experienced incident TBI during the 18-year study period. For older adults who seek care for TBI, race and ethnicity, sex, and SDOH factors may be associated with incidence of TBI, seeking medical attention for TBI in older adulthood, or both.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry, University of California San Francisco, San Francisco
| | - L. Grisell Diaz-Ramirez
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Kristine Yaffe
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry, University of California San Francisco, San Francisco
- Northern California Institute for Research and Education, San Francisco, California
- Department of Neurology, University of California, San Francisco, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - W. John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Raquel C. Gardner
- Joseph Sagol Neuroscience Center, Sheba Medical Center, Ramat Gan, Israel
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Dubucs X, Mercier É, Boucher V, Lauzon S, Balen F, Charpentier S, Emond M. Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults. J Emerg Med 2024; 66:e606-e613. [PMID: 38714480 DOI: 10.1016/j.jemermed.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 05/10/2024]
Abstract
BACKGROUND Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury. OBJECTIVE This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages. METHODS We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1-3), vulnerable-frail (CFS score 4-6), and severely frail (CFS score 7-9). RESULTS A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4-16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44-3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41-13.6; p = 0.34) in those considered severely frail. CONCLUSIONS This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.
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Affiliation(s)
- Xavier Dubucs
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; Université Laval, Québec, Québec, Canada; Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Éric Mercier
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; VITAM, Centre de Recherche en Santé Durable de l'Université Laval, Québec, Québec, Canada
| | - Valérie Boucher
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada
| | | | - Frederic Balen
- Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Sandrine Charpentier
- Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Marcel Emond
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; Université Laval, Québec, Québec, Canada
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Coffeng SM, Abdulle AE, van der Horn HJ, de Koning ME, ter Maaten JC, Spikman JM, van der Naalt J. Good Health-Related Quality of Life in Older Patients One Year after mTBI despite Incomplete Recovery: An Indication of the Disability Paradox? J Clin Med 2024; 13:2655. [PMID: 38731184 PMCID: PMC11084863 DOI: 10.3390/jcm13092655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Older adults (OAs) with mild traumatic brain injury (OA-mTBI) are a growing population, but studies on long-term outcomes and quality of life are scarce. Our aim was to determine the health-related quality of life (HRQoL) in OA-mTBI one year after injury and to assess the early predictors of HRQoL. Methods: Data from a prospective follow-up study of 164 older (≥60 years) and 289 younger mTBI patients (<60 years) admitted to the emergency department were analyzed. Post-traumatic complaints, emotional distress and coping were evaluated 2 weeks post-injury using standardized questionnaires. At 12 months post-injury, HRQoL and functional recovery were determined with the abbreviated version of the World Health Organization Quality of Life scale and Glasgow Outcome Scale Extended (GOSE), respectively. Results: One year post-injury, 80% (n = 131) of the OA-mTBI rated their HRQoL as "good" or "very good", which was comparable to younger patients (79% (n = 226), p = 0.72). Incomplete recovery (GOSE <8) was present in 43% (n = 69) of OA-mTBI, with 67% (n = 46) reporting good HRQoL. Two weeks post-injury, fewer OA-mTBI had (≥2) post-traumatic complaints compared to younger patients (68% vs. 80%, p = 0.01). In the multivariable analyses, only depression-related symptoms (OR = 1.20 for each symptom, 95% CI = 1.01-1.34, p < 0.01) were predictors of poor HRQoL in OA-mTBI. Conclusions: Similar to younger patients, most OA-mTBI rated their HRQoL as good at one year after injury, although a considerable proportion showed incomplete recovery according to the GOSE, suggesting a disability paradox. Depression-related symptoms emerged as a significant predictor for poor HRQoL and can be identified as an early target for treatment after mTBI.
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Affiliation(s)
- Sophie M. Coffeng
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Amaal Eman Abdulle
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.E.A.); (J.C.t.M.)
| | - Harm J. van der Horn
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (H.J.v.d.H.); (J.v.d.N.)
| | - Myrthe E. de Koning
- Department of Neurology, Hospital Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands;
| | - Jan C. ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.E.A.); (J.C.t.M.)
| | - Jacoba M. Spikman
- Department of Clinical Neuropsychology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (H.J.v.d.H.); (J.v.d.N.)
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Rafieezadeh A, Zangbar B, Zeeshan M, Gandhi C, Al-Mufti F, Jehan F, Kirsch J, Rodriguez G, Samson D, Prabhakaran K. Predictors of mortality after craniotomy for geriatric traumatic brain injury. Injury 2024:111585. [PMID: 38704345 DOI: 10.1016/j.injury.2024.111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States.
| | - Muhammad Zeeshan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Chirag Gandhi
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Faisal Jehan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Gabriel Rodriguez
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - David Samson
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
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Winter L, Moriarty H, Robinson KM, Leiby BE, Schmidt K, Whitehouse CR, Swanson RL. Age Suppresses the Association Between Traumatic Brain Injury Severity and Functional Outcomes: A Study Using the NIDILRR TBIMS Dataset. J Head Trauma Rehabil 2024:00001199-990000000-00145. [PMID: 38652669 DOI: 10.1097/htr.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Recovery from traumatic brain injury (TBI) is extremely difficult to predict, with TBI severity usually demonstrating weak predictive validity for functional or other outcomes. A possible explanation may lie in the statistical phenomenon called suppression, according to which a third variable masks the true association between predictor and outcome, making it appear weaker than it actually is. Age at injury is a strong candidate as a suppressor because of its well-established main and moderating effects on TBI outcomes. We tested age at injury as a possible suppressor in the predictive chain of effects between TBI severity and functional disability, up to 10 years post-TBI. SETTING Follow-up interviews were conducted during telephone interviews. PARTICIPANTS We used data from the 2020 NDILRR Model Systems National Dataset for 4 successive follow-up interviews: year 1 (n = 10,734), year 2 (n = 9174), year 5 (n = 6,201), and year 10 (n = 3027). DESIGN Successive cross-sectional multiple regression analyses. MAIN MEASURES Injury severity was operationalized using a categorical variable representing duration of posttrauma amnesia. The Glasgow Outcomes Scale-Extended (GOS-E) operationally defined functioning. Sociodemographic characteristics having significant bivariate correlations with GOS-E were included. RESULTS Entry of age at injury into the regression models significantly increases the association between TBI severity and functioning up to 10 years post-TBI. CONCLUSIONS Age at injury is a suppressor variable, masking the true effect of injury severity on functional outcomes. Identifying the mediators of this suppression effect is an important direction for TBI rehabilitation research.
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Affiliation(s)
- Laraine Winter
- Author Affiliations: M. Louise Fitzpatrick College of Nursing (Drs Winter and Whitehouse), Villanova University, Villanova, Pennsylvania; Research Service (Dr Winter, Dr Moriarty, and Ms Schmidt), Nursing Service (Dr Moriarty), Physical Medicine and Rehabilitation/Rehabilitation Medicine Service (Dr Robinson and Dr Swanson), Center for Neurotrauma, Neurodegeneration and Restoration (Dr Swanson), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Department of Physical Medicine and Rehabilitation (Dr Robinson and Dr Swanson), Perelman School of Medicine, University of Pennsylvania, and Division of Biostatistics, Department of Pharmacology, Physiology, and Cancer Biology (Dr Leiby), Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Ahmed Z, Chaudhary F, Fraix MP, Agrawal DK. Epidemiology, Pathophysiology, and Treatment Strategies of Concussions: A Comprehensive Review. FORTUNE JOURNAL OF HEALTH SCIENCES 2024; 7:197-215. [PMID: 38708028 PMCID: PMC11067689 DOI: 10.26502/fjhs.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
A concussion is a particular manifestation of a traumatic brain injury, which is the leading cause of mortality and disabilities across the globe. The global prevalence of traumatic brain injury is estimated to be 939 instances per 100,000 individuals, with approximately 5.48 million people per year experiencing severe traumatic brain injury. Epidemiology varies amongst different countries by socioeconomic status with diverse clinical manifestations. Additionally, classifying concussions is an ambiguous process as clinical diagnoses are the only current classification method, and morbidity rates differ by demographic location as well as populations examined. In this article, we critically reviewed the pathophysiology of concussions, classification methods, treatment options available including both pharmacologic and nonpharmacologic intervention methods, etiologies as well as global etiologic differences associated with them, and clinical manifestations along with their associated morbidities. Furthermore, analysis of the current research regarding the incidence of concussion based traumatic brain injuries and future directions are discussed. Investigation on the efficacy of new therapeutic-related interventions such as exosome therapy and electromagnetic field stimulation are warranted to properly manage and treat concussion-induced traumatic brain injury.
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Affiliation(s)
- Zubair Ahmed
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
| | - Fihr Chaudhary
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
| | - Marcel P Fraix
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
| | - Devendra K Agrawal
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona CA 91766
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Kumar RG, Evans E, Albrecht JS, Gardner RC, Dams-O'Connor K, Thomas KS. Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation. J Head Trauma Rehabil 2024:00001199-990000000-00141. [PMID: 38598697 DOI: 10.1097/htr.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
OBJECTIVE The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. PARTICIPANTS Average of n= 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge. DESIGN Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. MAIN MEASURES The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. RESULTS We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β = - 0.37; 95% CI, -0.66 to -0.07). CONCLUSION In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.
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Affiliation(s)
- Raj G Kumar
- Author Affiliations: Department of Rehabilitation and Human Performance (Drs Kumar and Dams-O'Connor), Department of Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Physical Therapy (Dr Evans), College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts; Department of Epidemiology and Public Health (Dr Albrecht), University of Maryland School of Medicine, Baltimore, Maryland; Joseph Sagol Neuroscience Center (Dr Gardner), Sheba Medical Center, Ramat Gan, Israel; and Department of Health Services, Policy, and Practice (Dr Thomas), Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
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21
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Lafiatoglou P, Ellis-Hill C, Gouva M, Ploumis A, Mantzoukas S. Older adults' lived experiences of physical rehabilitation for acquired brain injury and their perceptions of well-being: A qualitative phenomenological study. J Clin Nurs 2024; 33:1134-1149. [PMID: 38014630 DOI: 10.1111/jocn.16939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
AIM To explore the experiences of older adults (65+) living with acquired brain injury regarding their sense of well-being during physical rehabilitation within the Greek Healthcare System. BACKGROUND With the increasing ageing population and the life-changing effects of acquired brain injury, there is a need to focus on care for older people and their potential to live well. Rehabilitation systems deserve greater attention, especially in improving the well-being of those who are using them. DESIGN A qualitative study design with a hermeneutic phenomenological approach was used. METHODS Fourteen older adults living with acquired brain injury and undergoing physical rehabilitation in Greece were purposively sampled. Semi-structured interviews were conducted to collect data and were thematically analysed using van Manen's and Clarke and Braun's methods. The COREQ checklist was followed. RESULTS Four themes emerged from the analysis: (1) Challenges of new life situation, (2) Seeking emotional and practical support through social interaction, (3) Identifying contextual processes of rehabilitation, (4) Realising the new self. CONCLUSIONS The subjective experiences, intersubjective relations and contextual conditions influence the sense of well-being among older adults living with acquired brain injury, thus impacting the realisation of their new self. The study makes the notion of well-being a more tangible concept by relating it to the degree of adaptation to the new situation and the potential for older adults to create a future whilst living with acquired brain injury. RELEVANCE FOR CLINICAL PRACTICE Identifying the factors that impact older adults' sense of well-being during rehabilitation can guide healthcare professionals in enhancing the quality of care offered and providing more dignified and humanising care. PATIENT OR PUBLIC CONTRIBUTION Older adults living with acquired brain injury were involved in the study as participants providing the research data.
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Affiliation(s)
- Panagiota Lafiatoglou
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Mary Gouva
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Avraam Ploumis
- Department of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Stefanos Mantzoukas
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
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Criado-Marrero M, Ravi S, Bhaskar E, Barroso D, Pizzi MA, Williams L, Wellington CL, Febo M, Abisambra JF. Age dictates brain functional connectivity and axonal integrity following repetitive mild traumatic brain injuries. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.25.577316. [PMID: 38328104 PMCID: PMC10849649 DOI: 10.1101/2024.01.25.577316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Traumatic brain injuries (TBI) present a major public health challenge, demanding an in-depth understanding of age-specific signs and vulnerabilities. Aging not only significantly influences brain function and plasticity but also elevates the risk of hospitalizations and death following repetitive mild traumatic brain injuries (rmTBIs). In this study, we investigate the impact of age on brain network changes and white matter properties following rmTBI employing a multi-modal approach that integrates resting-state functional magnetic resonance imaging (rsfMRI), graph theory analysis, diffusion tensor imaging (DTI), and Neurite Orientation Dispersion and Density Imaging (NODDI). Utilizing the CHIMERA model, we conducted rmTBIs or sham (control) procedures on young (2.5-3 months old) and aged (22-month-old) male and female mice to model high risk groups. Functional and structural imaging unveiled age-related reductions in communication efficiency between brain regions, while injuries induced opposing effects on the small-world index across age groups, influencing network segregation. Functional connectivity analysis also identified alterations in 79 out of 148 brain regions by age, treatment (sham vs. rmTBI), or their interaction. Injuries exerted pronounced effects on sensory integration areas, including insular and motor cortices. Age-related disruptions in white matter integrity were observed, indicating alterations in various diffusion directions (mean, radial, axial diffusivity, fractional anisotropy) and density neurite properties (dispersion index, intracellular and isotropic volume fraction). Inflammation, assessed through Iba-1 and GFAP markers, correlated with higher dispersion in the optic tract, suggesting a neuroinflammatory response in aged animals. These findings provide a comprehensive understanding of the intricate interplay between age, injuries, and brain connectivity, shedding light on the long-term consequences of rmTBIs.
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Manrique-Gutiérrez G, Rodríguez-Cayetano Q, Samudio-Cruz MA, Carrillo-Mora P. The role of cognitive reserve in traumatic brain injury: a systematic review of observational studies. Brain Inj 2024; 38:45-60. [PMID: 38219070 DOI: 10.1080/02699052.2024.2304876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Evaluate the role of cognitive reserve (CR) on cognitive and physical sequelae in traumatic brain injury (TBI). METHODS A comprehensive search strategy was conducted in four databases in English and Spanish in the last 12 years (2011-2023). Inclusion criteria: original cross-sectional and longitudinal studies whose main or secondary objective was to evaluate the effect of CR in adult patients with TBI. PRISMA guidelines were used to report the search and selection method and STROBE checklist was used to evaluate the quality of studies. RESULTS Eighteen observational studies were included in this review. Multiple sources of variability were observed: number of patients, time of evolution, severity of the TBI, type of CR proxy, cognitive assessment instrument, etc. However, the most commonly used indicators of CR were premorbid IQ and educational attainment. A positive and consistent association between CR and performance on cognitive tests after injury was found. CONCLUSIONS CR has a consistent positive effect on cognition and on some other aspects of recovery in traumatic brain injury. In future studies, it will be necessary to promote the use of CR indices based on various indicators and explore the effects of CR on other aspects related to the recovery of brain trauma.
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Affiliation(s)
- Gabriel Manrique-Gutiérrez
- PECEM (Plan de Estudios Combinados en Medicina), Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | | | - María Alejandra Samudio-Cruz
- Division de Neurociencias Clinicas, Instituto Nacional de Rehabilitación "Luis Guillerimo Ibarra Ibarra", México City, México
| | - Paul Carrillo-Mora
- Division de Neurociencias Clinicas, Instituto Nacional de Rehabilitación "Luis Guillerimo Ibarra Ibarra", México City, México
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24
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Riviati N, Legiran, Indrajaya T, Saleh I, Ali Z, Irfannuddin, Probosuseno, Indra B. Serum Albumin as Prognostic Marker for Older Adults in Hospital and Community Settings. Gerontol Geriatr Med 2024; 10:23337214241249914. [PMID: 38720941 PMCID: PMC11078084 DOI: 10.1177/23337214241249914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 05/12/2024] Open
Abstract
Serum albumin, known for its multifaceted role in health, is hypothesized to serve as a prognostic marker for older adults, both in hospital and community settings. Nine studies were included in the review, revealing consistent associations between low serum albumin levels and increased mortality risk in hospitalized older individuals. In community settings, low serum albumin levels were linked to higher mortality rates compared to those with normal levels. The synthesis of evidence underscores the potential of serum albumin as a prognostic marker for older adults, offering valuable insights for risk stratification and targeted interventions. While robust evidence supports its utility in hospital settings, further research is warranted in community settings to address current limitations and enhance the applicability of serum albumin as a prognostic tool. This review merges existing knowledge of the prognostic significance of serum albumin in older adults across hospital and community settings. The findings emphasize the importance of serum albumin as a potential prognostic marker, urging continued research efforts to refine its application in diverse healthcare contexts and improve outcomes for the aging population.
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Affiliation(s)
- Nur Riviati
- University of Sriwijaya, Palembang, Indonesia
| | - Legiran
- University of Sriwijaya, Palembang, Indonesia
| | | | - Irsan Saleh
- University of Sriwijaya, Palembang, Indonesia
| | | | - Irfannuddin
- University of Sriwijaya, Palembang, Indonesia
| | - Probosuseno
- University of Sriwijaya, Palembang, Indonesia
| | - Bima Indra
- University of Sriwijaya, Palembang, Indonesia
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25
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Jung W, Vogel M, Figuracion KCF, Byun E, Thompson H. The Perceived Meaning of Traumatic Brain Injury for Older Adults: A Longitudinal-Multiple Case Study. Rehabil Nurs 2024; 49:14-23. [PMID: 38156950 DOI: 10.1097/rnj.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE The aim of this study was to explore the perceived meaning of traumatic brain injury (TBI) over the first-year postinjury among older adults and to explore if and how meaning changes. DESIGN A longitudinal multiple-case study design was used. METHODS Semistructured face-to-face interviews were completed at 1 week and 1, 3, 6, and 12 months postinjury. Transcripts were analyzed using inductive thematic analysis. RESULTS Fifty-five interviews were conducted with 12 participants. Four themes were identified: gratitude, vulnerability and dependence, slowing down and being more careful, and a chance for reflecting on life. Most participants' perceptions of their TBI remained either consistently positive or negative over the first-year postinjury. CLINICAL RELEVANCE Nurses should elicit and support patients' positive illness perceptions regarding their brain injury, which can contribute to a higher quality of life. For those patients with negative illness perceptions, nurses should provide resources in order to support coping and resilience following brain injury. CONCLUSIONS This study is the first study to explore individual perceptions over time of the meaning made from experiencing TBI among older adults. Findings can serve as a foundation for tailored supportive interventions among older adults following TBI to maximize quality of life.
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Affiliation(s)
- Wonkyung Jung
- RESILIENCE Center, School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Mia Vogel
- Center for Public Health Systems Science, Institute for Clinical and Translational Science, Brown School, Washington University in St. Louis, St Louis, MO, USA
| | - Karl Cristie F Figuracion
- School of Nursing, Alvord Brain Tumor Center, Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Eeeseung Byun
- Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
| | - Hilaire Thompson
- Department of Biobehavioral Nursing & Health Informatics, School of Nursing, Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
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Al-Rahbi A, Al Mahrouqi O, Al Ibrahim H, Al Saidi M, Abid Shah Y, Al-Saadi T. Cost Associated with Geriatric Traumatic Brain Injury in Developing Countries: An Observational Study. World Neurosurg 2024; 181:e990-e1000. [PMID: 37952885 DOI: 10.1016/j.wneu.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) in the geriatric population is a serious public health problem and has a huge impact on mortality and morbidity. METHODS A retrospective cohort study including patients aged above 65 admitted to a tertiary specialized trauma center, in the period from January 2016 to 31 December 2019. The data collected include patients' demographics, diagnosis, Glasgow Coma Scale (GCS) on arrival, length of stay, investigations, and type of surgery done. RESULTS Total number of TBI cases in our study is 145. The most frequent single diagnosis was subdural hematoma (85). Subsequently, it was the costliest diagnosis with an average cost of 3569 USD per patient. Length of stay on average was 17.11 ± 41 hours, with the majority (109 patients) having nonprolonged hospital stay (<14 days). Most of those managed by observation have below-average costs compared to other patients (P < 0.001). Complete blood count was the highly requested test with a total cost 5070 $ in the study period. And head computed tomography had the highest total cost 58,864 $. 21 craniotomies and 30 burr holes were made with a total cost of 30,000 and 25,325 respectively. Patients with lower GCS (64.6%) have below-average hospitalization costs compared to those who got high GCS scores (P < 0.001). CONCLUSIONS This study provides the first estimates of the financial burden of Geriatric TBI in the region, which signifies the importance of developing strategies to prevent TBIs and help in resource allocation and healthcare policy formation.
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Affiliation(s)
- Adham Al-Rahbi
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Omar Al Mahrouqi
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Hashim Al Ibrahim
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Maryam Al Saidi
- College of Medicine & Health Sciences, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Yusra Abid Shah
- College of Medicine & Health Sciences, National University of Science and Technology, Sohar, Oman
| | - Tariq Al-Saadi
- Department of neurosurgery, Khoula Hospital, Muscat, Sultanate of Oman; College of Medicine & Health Sciences, McGill University, Montreal, Quebec, Canada.
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Chen Z, Ford K, Islam M, Iamsawat S, Davis B, Weiss C, Schwulst S. ANTI-CD49D ANTIBODY TREATMENT IMPROVES SURVIVAL AND ATTENUATES NEUROCOGNITIVE DEFICITS AFTER TRAUMATIC BRAIN INJURY IN AGED MICE. Shock 2024; 61:112-119. [PMID: 38010092 PMCID: PMC10841910 DOI: 10.1097/shk.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Patients 65 years and older account for an increasing proportion of traumatic brain injury (TBI) patients. Aged TBI patients experience increased morbidity and mortality compared with young TBI patients. We previously demonstrated a marked accumulation of CD8 + T-cells within the brains of aged TBI mice compared with young TBI mice. Therefore, we hypothesized that blocking peripheral T-cell infiltration into the injured brain would improve neurocognitive outcomes in aged mice after TBI. Young and aged male C57BL/6 mice underwent TBI via controlled cortical impact versus sham injury. Two hours after injuries, mice received an anti-CD49d antibody (aCD49d Ab) to block peripheral lymphocyte infiltration or its isotype control. Dosing was repeated every 2 weeks. Mortality was tracked. Neurocognitive testing for anxiety, associative learning, and memory was assessed. Motor function was evaluated. Plasma was collected for cytokine analysis. Flow cytometry was used to phenotype different immune cells within the brains. Consequently, aCD49d Ab treatment significantly improved post-TBI survival, anxiety level, associative learning, memory, and motor function in aged mice 2 months after TBI compared with isotype control treated mice. aCD49d Ab treatment augmented T H 2 response in the plasma of aged mice 2 months after TBI compared with isotype control-treated mice. Notably, aCD49d Ab treatment significantly reduced activated CD8 + cytotoxic T-cells within aged mouse brains after TBI. Contrastingly, no difference was detected in young mice after aCD49d Ab treatment. Collectively, aCD49 Ab treatment reduced T-cells in the injured brain, improved survival, and attenuated neurocognitive and gait deficits. Hence, aCD49d Ab may be a promising therapeutic intervention in aged TBI subjects-a population often excluded in TBI clinical trials.
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Affiliation(s)
- Zhangying Chen
- Department of Surgery, Division of Trauma and Critical
Care, Northwestern University Feinberg School of Medicine, Chicago IL, USA
- Driskill Graduate Program in Life Sciences, Northwestern
University Feinberg School of Medicine, Chicago IL, USA
| | - Kacie Ford
- Department of Surgery, Division of Trauma and Critical
Care, Northwestern University Feinberg School of Medicine, Chicago IL, USA
| | - Mecca Islam
- Department of Surgery, Division of Trauma and Critical
Care, Northwestern University Feinberg School of Medicine, Chicago IL, USA
| | - Supinya Iamsawat
- Department of Microbiology and Immunology, Northwestern
University Feinberg School of Medicine, Chicago, IL
| | - Booker Davis
- Department of Surgery, Division of Trauma and Critical
Care, Northwestern University Feinberg School of Medicine, Chicago IL, USA
| | - Craig Weiss
- Department of Neuroscience, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois, USA
| | - Steven Schwulst
- Department of Surgery, Division of Trauma and Critical
Care, Northwestern University Feinberg School of Medicine, Chicago IL, USA
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Forssten SP, Ahl Hulme R, Forssten MP, Ribeiro MAF, Sarani B, Mohseni S. Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls. Front Med (Lausanne) 2023; 10:1290201. [PMID: 38152301 PMCID: PMC10751787 DOI: 10.3389/fmed.2023.1290201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Methods Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. Results A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. Conclusion When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.
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Affiliation(s)
- Sebastian Peter Forssten
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Ahl Hulme
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Marcelo A. F. Ribeiro
- Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
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Herrero Babiloni A, Bouferguene Y, Exposto FG, Beauregard R, Lavigne GJ, Moana-Filho EJ, Arbour C. The prevalence of persistent post-traumatic headache in adult civilian traumatic brain injury: a systematic review and meta-analysis on the past 14 years. Pain 2023; 164:2627-2641. [PMID: 37390366 DOI: 10.1097/j.pain.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/23/2023] [Indexed: 07/02/2023]
Abstract
ABSTRACT The most recent prevalence estimate of post-traumatic headache (PTH) after traumatic brain injury (TBI) in veterans and civilians dates back to 2008. The prevalence was found to be 57.8%, with surprising higher rates (75.3%) in mild TBI when compared with those with moderate/severe TBI (32.1%). However, the revision of mild TBI diagnostic criteria and an historic peak of TBI in the elderly individuals attributed to the ageing population may lead to different results. Thus, we conducted a systematic review and meta-analysis to assess the updated prevalence of PTH during the past 14 years only in civilians. A literature search was conducted following PRISMA guidelines guided by a librarian. Screening, full-text assessment, data extraction, and risk of bias assessment were performed blindly by 2 raters. Meta-analysis of proportions using the Freeman and Tukey double arcsine method of transformation was conducted. Heterogeneity, sensitivity analysis, and meta-regressions were performed with the predictors: year of publication, mean age, sex, TBI severity, and study design. Sixteen studies were selected for the qualitative analysis and 10 for the meta-analysis. The overall prevalence estimate of PTH was 47.1%, (confidence interval = 34.6, 59.8, prediction intervals = 10.8, 85.4), being similar at different time points (3, 6, 12, and 36+ months). Heterogeneity was high, and none of the meta-regressions were significant. The overall prevalence of PTH after TBI over the past 14 years remains high even if assessed only in civilians. However, the prevalence rates attributed to mild and moderate/severe TBI were similar, differing significantly from previous reports. Efforts are needed to improve TBI outcomes.
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Affiliation(s)
- Alberto Herrero Babiloni
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Yasmine Bouferguene
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Fernando G Exposto
- Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
- Scandinavian Center for Orofacial Neurosciences (SCON), Aarhus, Denmark
| | - Roxanne Beauregard
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Gilles J Lavigne
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
- Faculty of Dental Medicine, Université de Montréal, QC, Canada
| | - Estephan J Moana-Filho
- Division of TMD and Orofacial Pain, School of Dentistry, University of Minnesota, Minneapolis, MN, United States
| | - Caroline Arbour
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
- Faculty of Nursing, Université de Montréal, QC, Canada
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Yuguero O, Bernal M, Farré J, Martinez-Alonso M, Vena A, Purroy F. Clinical complications after a traumatic brain injury and its relation with brain biomarkers. Sci Rep 2023; 13:20057. [PMID: 37973882 PMCID: PMC10654919 DOI: 10.1038/s41598-023-47267-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023] Open
Abstract
We aimed to find out which are the most frequent complications for patients who suffer a traumatic brain injury (TBI) and its relation with brain biomarker levels. We conducted a hospital cohort study with patients who attended the Hospital Emergency Department between 1 June 2018 and 31 December 2020. Different variables were collected such as biomarkers levels after 6 h and 12 h of TBI (S100, NSE, UCHL1 and GFAP), clinical and sociodemographic variables, complementary tests, and complications 48 h and 7 days after TBI. Qualitative variables were analysed with Pearson's chi-square test, and quantitative variables with the Mann-Whitney U test. A multivariate logistic regression model for the existence of complications one week after discharge was performed to assess the discriminatory capacity of the clinical variables. A total of 51 controls and 540 patients were included in this study. In the TBI group, the mean age was 83 years, and 53.9% of the patients were male. Complications at seven days were associated with the severity of TBI (p < 0.05) and the number of platelets (p = 0.016). All biomarkers except GFAP showed significant differences in their distribution of values according to gender, with significantly higher values of the three biomarkers for women with respect to men. Patients with complications presented significantly higher S100 values (p < 0.05). The patient's baseline status, the severity of the TBI and the S100 levels can be very important elements in determining whether a patient may develop complications in the few hours after TBI.
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Affiliation(s)
- Oriol Yuguero
- ERLab, Emergency Medicine Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain.
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain.
| | - Maria Bernal
- Clinical Laboratory, University Hospital Arnau de Vilanova, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Joan Farré
- Clinical Laboratory, University Hospital Arnau de Vilanova, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Montserrat Martinez-Alonso
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Systems Biology and Statistical Methods for Biomedical Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Ana Vena
- ERLab, Emergency Medicine Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Francisco Purroy
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Clinical neurosciences group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
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Shen H, Liu H, He J, Wei L, Wang S. Risk factors of prognosis in older patients with severe brain injury after surgical intervention. Eur J Med Res 2023; 28:479. [PMID: 37925438 PMCID: PMC10625240 DOI: 10.1186/s40001-023-01473-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Older patients (aged ≥ 60 years) with severe brain injury have a high mortality and disability rate. The objective of this retrospective study was to assess the clinical risk factors of prognosis in older patients with severe brain injury after surgical intervention and to analyze the prognosis of the surviving group of patients 1 year after discharge. METHODS Clinical data of older patients with severe brain injury who were admitted to two neurosurgical centers between January 2010 and December 2020 were collected. Patient age, sex, Glasgow Coma Scale (GCS) score at admission, underlying disease, mechanisms of injury, abnormal pupillary reflex, head computed tomography imaging findings (such as hematoma type),intraoperative brain swelling and other factors were reviewed. All the patients were categorized into a good prognosis (survival) group and a poor prognosis (death) group by the Glasgow Outcome Score (GOS); also, the related factors affecting the prognosis were screened and the independent risk factors were identified by the Binary logistic regression analysis. GOS was used to evaluate the prognosis of the surviving group of patients 1 year after discharge. RESULTS Out of 269 patients, 171 (63.6%) survived, and 98 (36.4%) died during hospitalization. Univariate analysis showed that age, GCS score at admission, underlying diseases, abnormal pupillary reflex, the disappearance of ambient cistern, the midline structure shift, intraoperative brain swelling, oxygen saturation < 90%, and cerebral hernia were risk factors for the prognosis of older patients with severe brain injury after surgical intervention. Multivariate analysis showed that age, underlying diseases, disappearance of ambient cistern, Oxygen saturation < 90% and intraoperative brain swelling were independent risk factors of the prognosis in the population. The effect of surgical intervention differed among various age groups at 1-year follow-up after surgery. CONCLUSIONS The results of this retrospective study confirmed that age, underlying diseases, disappearance of ambient cistern, intraoperative brain swelling, and oxygen saturation < 90% are associated with poor prognosis in older postoperative patients with severe brain injury. Surgical intervention may improve prognosis and reduce mortality in older patients (age < 75 years). But for those patients (age ≥ 75 years), the prognosis was poor after surgical intervention.
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Affiliation(s)
- Hanchao Shen
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
- Department of Neurosurgery, Cangshan Hospital District of the 900th Hospital, Fuzhou, China
| | - Haibing Liu
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
| | - Jiongzhou He
- Department of Neurosurgery, Cangshan Hospital District of the 900th Hospital, Fuzhou, China
| | - Lianqfeng Wei
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China
| | - Shousen Wang
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, 350025, China.
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Kreitzer N, Adeoye O, Wade SL, Kurowki BG, Thomas S, Gillespie L, Bakas T. Iterative Development of the Caregiver Wellness After Traumatic Brain Injury Program (CG-Well). J Head Trauma Rehabil 2023; 38:E424-E436. [PMID: 36951450 PMCID: PMC10517076 DOI: 10.1097/htr.0000000000000869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES (1) To iteratively design a web/phone-based intervention to support caregivers of adults acutely following traumatic brain injury (TBI), Caregiver Wellness (CG-Well), and (2) to obtain qualitative and quantitative feedback on CG-Well from experts and caregivers to refine the intervention. SETTING A level I trauma and tertiary medical center. PARTICIPANTS Convenience sample of a total of 19 caregivers and 25 experts. DESIGN Multistep prospective study with iterative changes to CG-Well: (1) developed intervention content based on qualitative feedback from a prior study and literature review; (2) obtained qualitative feedback from 10 experts; (3) refined content using a modified Delphi approach involving 4 caregivers and 6 experts followed by qualitative interviews with 9 caregivers; (4) designed CG-Well website and videos; and (5) obtained feedback on program acceptability, appropriateness, and feasibility from 6 caregivers and 9 experts. INTERVENTIONS CG-Well included content on TBI, self-care and support, and skill-building strategies delivered through a website and telephone calls. MAIN OUTCOME MEASURES Qualitative data were analyzed using content analysis. Caregivers and experts completed Likert-type scales to rate module relevance, clarity, accuracy, utility and website acceptability, appropriateness, and feasibility (1 = strongly disagree to 5 = strongly agree). Means and standard deviations (SD) characterized ratings. RESULTS Qualitative findings were instrumental in designing and refining CG-Well. Ratings were positive for modules (means and SD for relevant [4.9, 0.33], clear [4.6, 0.53], accurate [4.9, 0.33], and useful [5, 0]) and the website (means and SD for acceptable [4.8, 0.36], appropriate [4.8, 0.35], and feasible [4.8, 0.36]). CONCLUSIONS The iterative design process for CG-Well resulted in a highly acceptable program. An early-stage randomized controlled trial is underway to estimate treatment effects for a future well-powered clinical trial.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine (Drs Kreitzer and Gillespie and Ms Thomas) and College of Nursing (Dr Bakas), University of Cincinnati, Cincinnati, Ohio; Department of Emergency Medicine, Washington University, St Louis, Missouri (Dr Adeoye); Departments of Pediatrics (Dr Wade) and Pediatrics and Neurology and Rehabilitation Medicine (Dr Kurowki), Division of Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and University of Cincinnati College of Medicine, Cincinnati, Ohio (Dr Kurowki)
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Burton KR, Magidson PD. Trauma (Excluding Falls) in the Older Adult. Clin Geriatr Med 2023; 39:519-533. [PMID: 37798063 DOI: 10.1016/j.cger.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.
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Affiliation(s)
- Kyle R Burton
- Department of Emergency Medicine, Johns Hopkins Hospital, 1830 Eas, Monument Street, Suite 6-110, Baltimore, MD 21287, USA
| | - Phillip D Magidson
- Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A150, Baltimore, MD 21224, USA.
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Yashkin AP, Gorbunova GA, Tupler L, Yashin AI, Doraiswamy M, Akushevich I. Differences in Risk of Alzheimer's Disease Following Later-Life Traumatic Brain Injury in Veteran and Civilian Populations. J Head Trauma Rehabil 2023; 38:E384-E393. [PMID: 36854141 PMCID: PMC10460823 DOI: 10.1097/htr.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To directly compare the effect of incident age 68+ traumatic brain injury (TBI) on the risk of diagnosis of clinical Alzheimer's disease (AD) in the general population of older adults, and between male veterans and nonveterans; to assess how this effect changes with time since TBI. SETTING AND PARTICIPANTS Community-dwelling traditional Medicare beneficiaries 68 years or older from the Health and Retirement Study (HRS). DESIGN Fine-Gray models combined with inverse-probability weighting were used to identify associations between incident TBI, post-TBI duration, and TBI treatment intensity, with a diagnosis of clinical AD dementia. The study included 16 829 older adults followed over the 1991-2015 period. For analyses of veteran-specific risks, 4281 veteran males and 3093 nonveteran males were identified. Analysis of veteran females was unfeasible due to the age structure of the population. Information on occurrence(s) of TBI, and onset of AD and risk-related comorbidities was constructed from individual-level HRS-linked Medicare claim records while demographic and socioeconomic risk factors were based on the survey data. RESULTS Later-life TBI was strongly associated with increased clinical AD risk in the full sample (pseudo-hazard ratio [HR]: 3.22; 95% confidence interval [CI]: 2.57-4.05) and in veteran/nonveteran males (HR: 5.31; CI: 3.42-7.94), especially those requiring high-intensity/duration care (HR: 1.58; CI: 1.29-1.91). Effect magnitude decreased with time following TBI (HR: 0.72: CI: 0.68-0.80). CONCLUSION Later-life TBI was strongly associated with increased AD risk, especially in those requiring high-intensity/duration care. Effect magnitude decreased with time following TBI. Univariate analysis showed no differences in AD risk between veterans and nonveterans, while the protective effect associated with veteran status in Fine-Gray models was largely due to differences in demographics, socioeconomics, and morbidity. Future longitudinal studies incorporating diagnostic procedures and documentation quantifying lifetime TBI events are necessary to uncover pathophysiological mediating and/or moderating mechanisms between TBI and AD.
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Affiliation(s)
- Arseniy P. Yashkin
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, NC, USA
| | - Galina A. Gorbunova
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, NC, USA
| | - Larry Tupler
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anatoliy I. Yashin
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, NC, USA
| | - Murali Doraiswamy
- Departments of Psychiatry and Medicine, Duke University School of Medicine and Duke Institute for Brain Sciences, Durham, NC, USA
| | - Igor Akushevich
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, NC, USA
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Ratha Krishnan R, Ting SWX, Teo WS, Lim CJ, Chua KSG. Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups. Life (Basel) 2023; 13:2047. [PMID: 37895429 PMCID: PMC10608274 DOI: 10.3390/life13102047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/18/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.
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Affiliation(s)
- Rathi Ratha Krishnan
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
| | - Samuel Wen Xuan Ting
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Wee Shen Teo
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health, Singapore 737628, Singapore
| | - Karen Sui Geok Chua
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Maxson R, Leland CR, McFarland EG, Lu J, Meshram P, Jones VC. Epidemiology of Dog Walking-Related Injuries among Adults Presenting to US Emergency Departments, 2001-2020. Med Sci Sports Exerc 2023; 55:1577-1583. [PMID: 37057718 DOI: 10.1249/mss.0000000000003184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
PURPOSE Dog walking is a popular daily activity, yet information regarding its injury burden is limited. This study describes the epidemiology of injuries related to leash-dependent dog walking among adults presenting to US emergency departments from 2001 to 2020. METHODS A retrospective analysis was performed using the National Electronic Injury Surveillance System database to identify adults (≥18 yr) presenting to US emergency departments with leash-dependent dog walking-related injuries between 2001 and 2020. Outcomes included annual estimates of injury incidence, injury characteristics, and risk factors for sustaining a fracture or traumatic brain injury (TBI). Weighted estimates and 95% confidence intervals (CI) were generated using National Electronic Injury Surveillance System sample weights. RESULTS Between 2001 and 2020, an estimated 422,659 adults presented to US emergency departments with injuries related to leash-dependent dog walking. The annual incidence increased more than fourfold during this period ( n = 7282 vs n = 32,306, P < 0.001). Most patients were women (75%) and adults age 40 to 64 yr (47%), with a mean age of 53 ± 0.5 yr. Patients commonly injured their upper extremity (51%) and were injured while falling when pulled or tripped by the leash (55%). The three most common injuries were finger fracture (6.9%), TBI (5.6%), and shoulder sprain/strain (5.1%). On multivariate analysis, fracture risk among dog walkers was higher in adults age ≥65 yr (odds ratio [OR], 2.1; 95% CI, 1.8-2.5) and women (OR, 1.5; 95% CI, 1.3-1.7). Risk of TBI was also elevated among older dog walkers (OR, 1.6; 95% CI, 1.3-2.0). CONCLUSIONS Dog walking is associated with a considerable and rising injury burden. Dog owners should be informed of this injury potential and advised on risk-reduction strategies.
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Affiliation(s)
- Ridge Maxson
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Edward G McFarland
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Jim Lu
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Prashant Meshram
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Vanya C Jones
- Department of Behavior, Health, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Alter SM, Knopp BW, Solano JJ, Hughes PG, Clayton LM, Shih RD. Repeat Fall Risk in Geriatric Patients After Fall-Induced Head Trauma. Cureus 2023; 15:e45056. [PMID: 37829982 PMCID: PMC10567099 DOI: 10.7759/cureus.45056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.
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Affiliation(s)
- Scott M Alter
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
- Department of Emergency Medicine, Delray Medical Center, Delray Beach, USA
| | - Brandon W Knopp
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Joshua J Solano
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
- Department of Emergency Medicine, Delray Medical Center, Delray Beach, USA
| | - Patrick G Hughes
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
- Department of Emergency Medicine, Delray Medical Center, Delray Beach, USA
| | - Lisa M Clayton
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
- Department of Emergency Medicine, Delray Medical Center, Delray Beach, USA
| | - Richard D Shih
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
- Department of Emergency Medicine, Delray Medical Center, Delray Beach, USA
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Brett BL, Temkin N, Barber JK, Okonkwo DO, Stein M, Bodien YG, Corrigan J, Diaz-Arrastia R, Giacino JT, McCrea MA, Manley GT, Nelson LD. Long-term Multidomain Patterns of Change After Traumatic Brain Injury: A TRACK-TBI LONG Study. Neurology 2023; 101:e740-e753. [PMID: 37344231 PMCID: PMC10437015 DOI: 10.1212/wnl.0000000000207501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic brain injury (TBI) may be a chronic condition carrying risk of future sequelae; few prospective studies examine long-term postinjury outcomes. We examined the prevalence of functional, cognitive, and psychiatric change outcomes from 1 to 7 years postinjury. METHODS Transforming Research and Clinical Knowledge in TBI LONG (TRACK-TBI LONG) participants were prospectively enrolled within 24 hours of injury and followed up to 1 year postinjury; a subset participated in long-term follow-up from 2 to 7 years postinjury. Reliable change thresholds for the Brief Test of Adult Cognition by Telephone General Composite (cognition) and Brief Symptom Inventory (BSI)-18 (psychiatric) were derived from orthopedic trauma controls (OTCs). Multiple assessments were completed (postinjury baseline assessment and 2 or 3 visits 2-7 years postinjury) within a sample subset. Change was assessed for functional outcome (Glasgow Outcome Scale-Extended [GOSE]) and self-report/informant report of decline. Prevalence ratios for outcomes classified as stable, improved, and declined were reported individually and collectively. The Fisher exact test and log-binomial regression models examined factors associated with decline and improvement. RESULTS Of the sample (N = 1,264; mild TBI [mTBI], Glasgow Coma Scale [GCS] 13-15, n = 917; moderate-to-severe TBI [msTBI], GCS 3-12, n = 193; or OTC n = 154), "stable" was the most prevalent outcome. Functional outcome showed the highest rates of decline, regardless of TBI severity (mild = 29%; moderate/severe = 23%). When measures were collectively considered, rates of decline included mTBI (21%), msTBI (26%), and OTC (15%). Age and preinjury employment status were associated with functional decline (per 10 years; relative risk [RR] 1.16, 95% CI 1.07-1.25, p < 0.001; higher in retired/disabled/not working vs full-time/part-time; RR 1.81, 95% CI 1.33-2.45, respectively) in the mTBI group. Improvement in functional recovery 2-7 years postinjury was associated with higher BSI scores (per 5 points; RR 1.11, 95% CI 1.04-1.18, p = 0.002) and GOSE score of 5-7 (GOSE = 8 as reference; RR 2.64, 95% CI 1.75-3.97, p < 0.001). Higher BSI scores and identifying as Black (RR 2.28, 95% CI 1.59-3.25, p < 0.001) were associated with a greater likelihood of improved psychiatric symptoms in mTBI (RR 1.21, 95% CI 1.14-1.29, p < 0.001). A greater likelihood of cognitive improvement was observed among those with higher educational attainment in msTBI (per 4 years; RR 2.61, 95% CI 1.43-4.79, p = 0.002). DISCUSSION Function across domains at 1-year postinjury, a common recovery benchmark, undergoes change across the subsequent 6 years. Results support consideration of TBI as a chronic evolving condition and suggest continued monitoring, rehabilitation, and support is required to optimize long-term independence and quality of life.
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Affiliation(s)
- Benjamin L Brett
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.).
| | - Nancy Temkin
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Jason K Barber
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - David O Okonkwo
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Murray Stein
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Yelena G Bodien
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - John Corrigan
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Ramon Diaz-Arrastia
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Joseph T Giacino
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Michael A McCrea
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Geoffrey T Manley
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Lindsay D Nelson
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
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Kunapaisal T, Phuong J, Liu Z, Stansbury LG, Vavilala MS, Lele AV, Tsang HC, Hess JR. Age, admission platelet count, and mortality in severe isolated traumatic brain injury: A retrospective cohort study. Transfusion 2023; 63:1472-1480. [PMID: 37515367 DOI: 10.1111/trf.17476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND We asked whether patients >50 years of age with acute traumatic brain injury (TBI) present with lower platelet counts and whether lower platelet counts are independently associated with mortality. METHODS We combined trauma registry and laboratory data on a retrospective cohort of all patients ≥18 years of age admitted to our Level 1 US regional trauma center 2015-2021 with severe (Head Abbreviated Injury Score [AIS] ≥3), isolated (all other AIS <3) TBI who had a first platelet count within 1 h of arrival. Age and platelet count were assessed continuously and as groups (age 18-50 vs. >50, platelet normals, and at conventional transfusion thresholds). Outcomes such as mean admission platelet counts and in-hospital mortality were assessed categorically and with logistic regression. RESULTS Of 44,056 patients, 1298 (3%, median age: 52 [IQR 33,68], 76.1% male) met all inclusion criteria with no differences between younger and older age groups for (ISS; 18 [14,26] vs. 17 [14,26], p = .22), New ISS (NISS; 29 [19,50] vs. 28 [17,50], p = .36), or AIS-Head (4 [3,5] vs. 4 [3,5]; p = .87). Patients aged >50 had lower admission platelet counts (219,000 ± 93,000 vs. 242,000 ± 76,000/μL; p < .001) and greater in-hospital mortality (24.5% vs. 15.6%, p < .001) than those 18-50. In multivariable regression, firearms injuries (OR9.08), increasing age (OR1.004), NISS (OR1.007), and AIS-Head (OR1.05), and decreasing admission platelet counts (OR0.998) were independently associated with mortality (p < .001-.041). Platelet transfusion in the first 4 h of care was more frequent among older patients (p < .001). CONCLUSIONS Older patients with TBI had lower admission platelet counts, which were independently associated with greater mortality.
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Affiliation(s)
- Thitikan Kunapaisal
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Jim Phuong
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Zhinan Liu
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
| | - Lynn G Stansbury
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Pediatrics, UW SOM, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Hamilton C Tsang
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW SOM, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW SOM, Seattle, Washington, USA
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Hosseinpour H, El-Qawaqzeh K, Magnotti LJ, Bhogadi SK, Ghneim M, Nelson A, Spencer AL, Colosimo C, Anand T, Ditillo M, Joseph B. The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities. Am J Surg 2023; 226:271-277. [PMID: 37230872 DOI: 10.1016/j.amjsurg.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/27/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients. METHODS Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition. RESULTS We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001). CONCLUSIONS This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.
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Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Mira Ghneim
- R. Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, Baltimore, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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Buenaventura RG, Harvey AC, Burns MP, Main BS. Traumatic brain injury induces an adaptive immune response in the meningeal transcriptome that is amplified by aging. Front Neurosci 2023; 17:1210175. [PMID: 37588516 PMCID: PMC10425597 DOI: 10.3389/fnins.2023.1210175] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/07/2023] [Indexed: 08/18/2023] Open
Abstract
Traumatic Brain Injury (TBI) is a major cause of disability and mortality, particularly among the elderly, yet our mechanistic understanding of how age renders the post-traumatic brain vulnerable to poor clinical outcomes and susceptible to neurological disease remains poorly understood. It is well established that dysregulated and sustained immune responses contribute to negative outcomes after TBI, however our understanding of the interactions between central and peripheral immune reservoirs is still unclear. The meninges serve as the interface between the brain and the immune system, facilitating important bi-directional roles in healthy and disease settings. It has been previously shown that disruption of this system exacerbates inflammation in age related neurodegenerative disorders such as Alzheimer's disease, however we have an incomplete understanding of how the meningeal compartment influences immune responses after TBI. Here, we examine the meningeal tissue and its response to brain injury in young (3-months) and aged (18-months) mice. Utilizing a bioinformatic approach, high-throughput RNA sequencing demonstrates alterations in the meningeal transcriptome at sub-acute (7-days) and chronic (1 month) timepoints after injury. We find that age alone chronically exacerbates immunoglobulin production and B cell responses. After TBI, adaptive immune response genes are up-regulated in a temporal manner, with genes involved in T cell responses elevated sub-acutely, followed by increases in B cell related genes at chronic time points after injury. Pro-inflammatory cytokines are also implicated as contributing to the immune response in the meninges, with ingenuity pathway analysis identifying interferons as master regulators in aged mice compared to young mice following TBI. Collectively these data demonstrate the temporal series of meningeal specific signatures, providing insights into how age leads to worse neuroinflammatory outcomes in TBI.
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Affiliation(s)
| | | | | | - Bevan S. Main
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University, Washington, DC, United States
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Shan M, Thomas KS, Gutman R. A Bayesian MultiLayer Record Linkage Procedure to Analyze Post-Acute Care Recovery of Patients with Traumatic Brain Injury. Biostatistics 2023; 24:743-759. [PMID: 35579386 PMCID: PMC10345988 DOI: 10.1093/biostatistics/kxac016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 07/20/2023] Open
Abstract
Understanding associations between injury severity and postacute care recovery for patients with traumatic brain injury (TBI) is crucial to improving care. Estimating these associations requires information on patients' injury, demographics, and healthcare utilization, which are dispersed across multiple data sets. Because of privacy regulations, unique identifiers are not available to link records across these data sets. Record linkage methods identify records that represent the same patient across data sets in the absence of unique identifiers. With a large number of records, these methods may result in many false links. Health providers are a natural grouping scheme for patients, because only records that receive care from the same provider can represent the same patient. In some cases, providers are defined within each data set, but they are not uniquely identified across data sets. We propose a Bayesian record linkage procedure that simultaneously links providers and patients. The procedure improves the accuracy of the estimated links compared to current methods. We use this procedure to merge a trauma registry with Medicare claims to estimate the association between TBI patients' injury severity and postacute care recovery.
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Affiliation(s)
- Mingyang Shan
- Department of Biostatistics, Brown University, 121 South Main Street, Box G-S121-7, Providence, RI 02912, USA
| | - Kali S Thomas
- Department of Health Services, Policy and Practice, Brown University Box G-S121(6), Providence, RI 02912, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University, 121 South Main Street, Box G-S121-7, Providence, RI 02912, USA
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Kailash KA, Guertler CA, Johnson CL, Okamoto RJ, Bayly PV. Measurement of relative motion of the brain and skull in the mini-pig in-vivo. J Biomech 2023; 156:111676. [PMID: 37329640 PMCID: PMC11086683 DOI: 10.1016/j.jbiomech.2023.111676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/19/2023]
Abstract
The mechanical role of the skull-brain interface is critical to the pathology of concussion and traumatic brain injury (TBI) and may evolve with age. Here we characterize the skull-brain interface in juvenile, female Yucatan mini-pigs from 3 to 6 months old using techniques from magnetic resonance elastography (MRE). The displacements of the skull and brain were measured by a motion-sensitive MR imaging sequence during low-amplitude harmonic motion of the head. Each animal was scanned four times at 1-month intervals. Harmonic motion at 100 Hz was excited by three different configurations of a jaw actuator in order to vary the direction of loading. Rigid-body linear motions of the brain and skull were similar, although brain rotations were consistently smaller than corresponding skull rotations. Relative displacements between the brain and skull were estimated for voxels on the surface of the brain. Amplitudes of relative displacements between skull and brain were 1-3 μm, approximately 25-50% of corresponding skull displacements. Maps of relative displacement showed variations by anatomical region, and the normal component of relative displacement was consistently 25-50% of the tangential component. These results illuminate the mechanics of the skull-brain interface in a gyrencephalic animal model relevant to human brain injury and development.
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Affiliation(s)
- Keshav A Kailash
- Washington University in St. Louis, Biomedical Engineering, United States
| | - Charlotte A Guertler
- Washington University in St. Louis, Mechanical Engineering and Material Science, United States
| | | | - Ruth J Okamoto
- Washington University in St. Louis, Mechanical Engineering and Material Science, United States
| | - Philip V Bayly
- Washington University in St. Louis, Biomedical Engineering, United States; Washington University in St. Louis, Mechanical Engineering and Material Science, United States.
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Hassett L. Physiotherapy management of moderate-to-severe traumatic brain injury. J Physiother 2023; 69:141-147. [PMID: 37286387 DOI: 10.1016/j.jphys.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Leanne Hassett
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Implementation Science Academy, Sydney Health Partners, Sydney, Australia.
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Chua KSG, Kwan HX, Teo WS, Cao RX, Heng CP, Ratha Krishnan R. Changing Epidemiology and Functional Outcomes of Inpatient Rehabilitation in Asian Traumatic Brain Injury Cases before and during the COVID-19 Pandemic: A Retrospective Cohort Study. Life (Basel) 2023; 13:1475. [PMID: 37511850 PMCID: PMC10381117 DOI: 10.3390/life13071475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study aimed to compare acute injury and rehabilitation characteristics for traumatic brain injury (TBI) inpatients during the pre and post COVID-19 pandemic periods. METHODS A retrospective study of TBI inpatients between 1 April 2018 and 31 December 2019 (pre COVID-19 period), and 1 July 2020 and 31 March 2022 (post COVID-19 period) was performed to compare demographics, premorbid comorbidity, TBI characteristics, rehabilitation complications, admission and discharge functional independence measure (FIM®), length of stay and discharge status. RESULTS A total of 187 data sets were analyzed (82 pre COVID-19 and 105 post COVID-19). Post COVID-19 TBI inpatients were older by 11 years (pre COVID-19 mean 55 years vs. post COVID-19 mean 66 years, and p < 0.001), with 23% higher female inpatients (pre COVID-19 13.4% vs. post COVID-19 36.2%, and p < 0.001) and 25% higher presence of comorbidities (pre COVID-19 52.4% vs. post COVID-19 77.1%, and p < 0.001). In the post COVID-19 group, total discharge FIM (Td-FIM) was significantly lower by ~12 points (pre COVID-19 94.5 vs. post COVID-19 82, and p = 0.011), Td-FIM ≥ 91 was lower by ~18% (pre COVID-19 53.7% vs. post COVID-19 36.2%, and p = 0.017), and the need for caregivers increased by ~17% (pre COVID-19 68% vs. post COVID-19 85.4%, and p = 0.006) Conclusions: Our findings signal a demographic shift towards older, frailer TBI with lower functional independence levels post COVID-19.
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Affiliation(s)
- Karen Sui Geok Chua
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Hui Xuan Kwan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
| | - Wee Shen Teo
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
| | - Ruo Xi Cao
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
| | - Choon Pooh Heng
- Clinical Research and Innovation Office, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Rathi Ratha Krishnan
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Aghajanian S, Shafiee A, Ahmadi A, Elsamadicy AA. Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis. J Clin Neurosci 2023; 114:120-128. [PMID: 37390775 DOI: 10.1016/j.jocn.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/09/2023] [Accepted: 06/17/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Modified frailty index (MFI) is an emerging quantitative measure of frailty; however, the quantified risk of adverse outcomes in surgeries for intracranial tumors associated with increasing MFI scores has not been thoroughly reviewed in a comprehensive manner. METHODS MEDLINE (PubMed), Scopus, Web of Science, and Embase were searched to identify observational studies on the association between 5 and 11 item-modified frailty index (MFI) and perioperative outcomes for neurosurgical procedures including complications, mortality, readmission, and reoperation rate. Primary analysis pooled all comparisons with MFI scores greater than or equal to 1 versus non-frail participants using mixed-effects multilevel model for each outcome. RESULTS In total, 24 studies were included in the review and 19 studies with 114,707 surgical operations were included in the meta-analysis. While increasing MFI scores were associated with worse prognosis for all included outcomes, reoperation rate was only significantly higher in patients with MFI ≥ 3. Among surgical pathologies, glioblastoma was influenced by a greater extent to the impact of frailty on complications and mortality that most other etiologies. In agreement with qualitative evaluation of the included studies, meta-regression did not reveal association between mean age of the comparisons and complications rate. CONCLUSION The results of this meta-analysis provides quantitative risk assessment of adverse outcomes in neuro-oncological surgeries with increased frailty. The majority of literature suggests that MFI is a superior and independent predictor of adverse outcomes compared to age.
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Affiliation(s)
- Sepehr Aghajanian
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Arman Shafiee
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Ahmadi
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA.
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Lindstad MØ, Obstfelder AU, Sveen U, Stigen L. Feasibility of the Perceive, Recall, Plan and Perform system of intervention for persons with brain injury in community-based rehabilitation: a pilot for a multiple-baseline design study. BMJ Open 2023; 13:e067593. [PMID: 37380207 PMCID: PMC10410811 DOI: 10.1136/bmjopen-2022-067593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 06/14/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVES This paper describes a pilot study investigating the feasibility of the Perceive, Recall, Plan and Perform (PRPP) system for persons with cognitive impairments after acquired brain injury in the context of community-based rehabilitation for older individuals. DESIGN The feasibility, acceptability and practicability of the research procedures were evaluated by exploring the effectiveness of the PRPP intervention with non-concurrent multiple baseline designs. SETTING AND PARTICIPANTS Three participants (63+years of age) from two health centres were included. INTERVENTION In the PRPP intervention, the occupational therapist (OT) supports the participant in applying cognitive strategies in everyday activities to enhance task mastery, with nine sessions of 45-60 min over 3 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES The participants completed measurements of five everyday tasks in each phase as dependent variables. PRPP assessment stages 1 and 2 served as the primary and secondary outcome measures, respectively. The percentage of mastery of the tasks and the participants' application of cognitive strategies at baseline acted as a control and was therefore compared with the other phases within the participant. The Goal Attainment Scale and Barthel Index served as generalisation measures. The uncertainties and acceptability of the procedures were also investigated with a procedural checklist and qualitative statements reported in the procedures or noted in dialogue meetings with the conducting OTs. RESULTS The procedures were acceptable for the OT and the participants and were feasible if the steps in the research procedure were clearly understood. The target behaviour should be changed to the use of one task with five measurement points instead of measuring five tasks. This can enable the application of recommended analysis methods. CONCLUSIONS The outcomes of this study led to a change in the target behaviour and clarification of the research procedure for the planned PRPP intervention study. TRIAL REGISTRATION NUMBER NCT05148247.
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Affiliation(s)
- Marte Ørud Lindstad
- Department of Health Science Gjøvik, Norwegian University of Science and Technology, Trondheim, Norway
| | - Aud Uhlen Obstfelder
- Department of Health Science Gjøvik, Norwegian University of Science and Technology, Trondheim, Norway
| | - Unni Sveen
- Department of Occupational Therapy, Prosthetics and Orthotics, Oslo Metropolitan University, Oslo, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Linda Stigen
- Department of Health Science Gjøvik, Norwegian University of Science and Technology, Trondheim, Norway
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Pappadis MR, Malagaris I, Kuo YF, Leland N, Freburger J, Goodwin JS. Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury. J Am Geriatr Soc 2023; 71:1806-1818. [PMID: 36840390 PMCID: PMC10330166 DOI: 10.1111/jgs.18308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/27/2022] [Accepted: 12/31/2022] [Indexed: 02/26/2023]
Abstract
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.
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Affiliation(s)
- Monique R. Pappadis
- Department of Population Health and Health Disparities, School of Public and Population Health, University of Texas Medical Branch (UTMB) at Galveston, Galveston, TX, USA
- Sealy Center on Aging, UTMB, Galveston, TX, USA
| | - Ioannis Malagaris
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Natalie Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Janet Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - James S. Goodwin
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Internal Medicine, Division of Geriatrics, School of Medicine, UTMB, Galveston, TX
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50
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Diomede L, Zanier ER, Moro F, Vegliante G, Colombo L, Russo L, Cagnotto A, Natale C, Xodo FM, De Luigi A, Mosconi M, Beeg M, Catania M, Rossi G, Tagliavini F, Di Fede G, Salmona M. Aβ1-6 A2V(D) peptide, effective on Aβ aggregation, inhibits tau misfolding and protects the brain after traumatic brain injury. Mol Psychiatry 2023; 28:2433-2444. [PMID: 37198260 PMCID: PMC10611578 DOI: 10.1038/s41380-023-02101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/21/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
Alzheimer's disease (AD), the leading cause of dementia in older adults, is a double proteinopathy characterized by amyloid-β (Aβ) and tau pathology. Despite enormous efforts that have been spent in the last decades to find effective therapies, late pharmacological interventions along the course of the disease, inaccurate clinical methodologies in the enrollment of patients, and inadequate biomarkers for evaluating drug efficacy have not allowed the development of an effective therapeutic strategy. The approaches followed so far for developing drugs or antibodies focused solely on targeting Aβ or tau protein. This paper explores the potential therapeutic capacity of an all-D-isomer synthetic peptide limited to the first six amino acids of the N-terminal sequence of the A2V-mutated Aβ, Aβ1-6A2V(D), that was developed following the observation of a clinical case that provided the background for its development. We first performed an in-depth biochemical characterization documenting the capacity of Aβ1-6A2V(D) to interfere with the aggregation and stability of tau protein. To tackle Aβ1-6A2V(D) in vivo effects against a neurological decline in genetically predisposed or acquired high AD risk mice, we tested its effects in triple transgenic animals harboring human PS1(M146 V), APP(SW), and MAPT(P301L) transgenes and aged wild-type mice exposed to experimental traumatic brain injury (TBI), a recognized risk factor for AD. We found that Aβ1-6A2V(D) treatment in TBI mice improved neurological outcomes and reduced blood markers of axonal damage. Exploiting the C. elegans model as a biosensor of amyloidogenic proteins' toxicity, we observed a rescue of locomotor defects in nematodes exposed to the brain homogenates from TBI mice treated with Aβ1-6A2V(D) compared to TBI controls. By this integrated approach, we demonstrate that Aβ1-6A2V(D) not only impedes tau aggregation but also favors its degradation by tissue proteases, confirming that this peptide interferes with both Aβ and tau aggregation propensity and proteotoxicity.
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Affiliation(s)
- Luisa Diomede
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy.
| | - Elisa R Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Federico Moro
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Gloria Vegliante
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Laura Colombo
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Luca Russo
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Alfredo Cagnotto
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Carmina Natale
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Federica Marta Xodo
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Ada De Luigi
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Michele Mosconi
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Marten Beeg
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy
| | - Marcella Catania
- Neurology V - Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Giacomina Rossi
- Neurology V - Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Fabrizio Tagliavini
- Neurology V - Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Giuseppe Di Fede
- Neurology V - Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Mario Salmona
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, Milan, Italy.
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