Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

Incidence and predictors of mortality among road traffic accident victims admitted to hospitals at Hawassa city, Ethiopia

BACKGROUND

Globally, road traffic accidents are the eighth-leading cause of death for all age groups. The estimated number of road traffic deaths in low income countries was more than three times as high as in high-income countries. Africa had the highest rate of fatalities attributed to road traffic accidents. Ethiopia has the highest number of road traffic fatalities among Sub-Saharan African countries. The main objective of this study was to determine the incidence and predictors of mortality among road traffic victims admitted to hospitals in Hawassa City.

METHODS

A facility-based retrospective cohort study was conducted using secondary data from hospital records. A total of 398 road traffic accident victims admitted to selected hospitals in Hawassa city from January 2019 to December 2021 participated in the study. Data were analyzed using STATA version 14.1. The Cox regression model was used to determine the predictors of mortality. A hazard ratio with a 95% confidence interval and a cut-off value of P<0.05 was used to declare the risk and statistical significance, respectively.

RESULT

The incidence rate of mortality for road traffic accident victims was 7.34 per 10,000 person-hours. The predictors of mortality were the value of GCS at admission <8 (aHR = 5.86; 95% CI: 2.00-17.19), GCS at admission 9-12 (aHR = 3.27; 95% CI: 1.28-8.40), the value of SBP at admission ≤89mmHg (aHR = 4.41; 95% CI: 2.22-8.77), admission to the ICU (aHR = 3.89; 95% CI: 1.83-8.28) and complications (aHR = 5.48; 95% CI: 2.74-10.01).

CONCLUSION

The incidence of mortality among road traffic victims admitted to hospitals in Hawassa city was high. Thus, thorough follow-up and intensive management should be given to victims with critical health conditions.

Impact of dementia and socioeconomic disadvantage on days at home after traumatic brain injury among older Medicare beneficiaries: A cohort study

INTRODUCTION

Time spent at home may aid in understanding recovery following traumatic brain injury (TBI) among older adults, including those with Alzheimer's disease and related dementias (ADRD). We examined the impact of ADRD on recovery following TBI and determined whether socioeconomic disadvantages moderated the impact of ADRD.

METHODS

We analyzed Medicare beneficiaries aged ≥65 years diagnosed with TBI in 2010-2018. Home time was calculated by subtracting days spent in a care environment or deceased from total follow-up, and dual eligibility for Medicaid was a proxy for socioeconomic disadvantage.

RESULTS

A total of 2463 of 20,350 participants (12.1%) had both a diagnosis of ADRD and were Medicaid dual-eligible. Beneficiaries with ADRD and Medicaid spent markedly fewer days at home following TBI compared to beneficiaries without either condition (rate ratio 0.66; 95% confidence interval [CI] 0.64, 0.69).

DISCUSSION

TBI resulted in a significant loss of home time over the year following injury among older adults with ADRD, particularly for those who were economically vulnerable.

HIGHLIGHTS

Remaining at home after serious injuries such as fall-related traumatic brain injury (TBI) is an important goal for older adults. No prior research has evaluated how ADRD impacts time spent at home after TBI. Older TBI survivors with ADRD may be especially vulnerable to loss of home time if socioeconomically disadvantaged. We assessed the impact of ADRD and poverty on a novel DAH measure after TBI. ADRD-related disparities in DAH were significantly magnified among those living with socioeconomic disadvantage, suggesting a need for more tailored care approaches.

[Traumatic brain injury as risk factor of Alzheimer's disease and possibilities of pathogenetic therapy]

The article examines the potential role of brain mechanical damage as a trigger for the development of neurodegenerative changes. Attention is paid to dysfunction of the neurovascular unit, and disruption of the functional and compensatory capabilities of blood flow. The importance of microhemorrhages that occur in the acute period of injury and the formation of first focal and then diffuse neuroinflammation is emphasized. The importance of mitochondrial dysfunction was separately determined as a significant factor in increasing the risk of developing Alzheimer's disease (AD) in patients after traumatic brain injury (TBI). In TBI, there is a decrease in the expression of tight junction (TC) proteins of endothelial cells, such as occludin, claudin, JP, which leads to increased permeability of the blood-brain barrier. TBI, provoking endothelial dysfunction, contributes to the development of metabolic disorders of β-amyloid and tau protein, which in turn leads to worsening vascular damage, resulting in a vicious circle that can ultimately lead to the development of AD and dementia. Age-related changes in cerebral arteries, which impair perivascular transport of interstitial fluid, are currently considered as an important part of the «amyloid cascade», especially against the background of genetically mediated disorders of glial membranes associated with defective aquaporin-4 (encoded by the APOE4). Studies in animal models of TBI have revealed an increase in tau protein immunoreactivity and its phosphorylation, which correlates with the severity of injury. A comprehensive analysis of research results shows that the cascade of reactions triggered by TBI includes all the main elements of the pathogenesis of AD: disorders of energy metabolism, microcirculation and clearance of cerebral metabolic products. This leads to a disruption in the metabolism of amyloid protein and its accumulation in brain tissue with the subsequent development of tauopathy. Cerebrolysin, by modulating the permeability of the blood-brain barrier, blocks the development of neuroinflammation, reduces the accumulation of pathological forms of proteins and may be slow down the progression of neurodegeneration.

Long-term clinical evolution of patients with prolonged disorders of consciousness due to severe anoxic brain injury: A meta-analytic study

BACKGROUND AND PURPOSE

The prognosis of prolonged (28 days to 3 months post-onset) disorders of consciousness (pDoC) due to anoxic brain injury is uncertain. The present study aimed to evaluate the long-term outcome of post-anoxic pDoC and identify the possible predictive value of demographic and clinical information.

METHOD

This is a systematic review and meta-analysis. The rates of mortality, any improvement in clinical diagnosis, and recovery of full consciousness at least 6 months after severe anoxic brain injury were evaluated. A cross-sectional approach searched for differences in baseline demographic and clinical characteristics between survivors and non-survivors, patients improved versus not improved, and patients who recovered full consciousness versus not recovered.

RESULTS

Twenty-seven studies were identified. The pooled rates of mortality, any clinical improvement and recovery of full consciousness were 26%, 26% and 17%, respectively. Younger age, baseline diagnosis of minimally conscious state versus vegetative state/unresponsive wakefulness syndrome, higher Coma Recovery Scale Revised total score, and earlier admission to intensive rehabilitation units were associated with a significantly higher likelihood of survival and clinical improvement. These same variables, except time of admission to rehabilitation, were also associated with recovery of full consciousness.

CONCLUSIONS

Patients with anoxic pDoC might improve over time up to full recovery of consciousness and some clinical characteristics can help predict clinical improvement. These new insights could support clinicians and caregivers in the decision-making on patient management.

Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study

Background

The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs).

Methods

This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year.

Results

In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025).

Conclusions

These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.

The effect of age on clinical outcomes in critically ill brain-injured patients

PURPOSE

We studied the impact of age on survival and functional recovery in brain-injured patients.

METHODS

We performed an observational cohort study of all consecutive adult patients with brain injury admitted to ICU in 8 years. To estimate the optimal cut-off point of the age associated with unfavorable outcomes (mRS 3-6), receiver operating characteristic (ROC) curve analyses were used. Multivariate logistic regression analyses were performed to identify prognostic factors for unfavorable outcomes.

RESULTS

We included 619 brain-injured patients. We identified 60 years as the cut-off point at which the probability of unfavorable outcomes increases. Patients ≥ 60 years had higher severity scores at ICU admission, longer duration of mechanical ventilation, longer ICU and hospital stays, and higher mortality. Factors identified as associated with unfavorable outcomes (mRS 3-6) were an advanced age (≥ 60 years) [Odds ratio (OR) 4.59, 95% confidence interval (CI) 2.73-7.74, p < 0.001], a low GCS score (≤ 8 points) [OR 3.72, 95% CI 1.95-7.08, p < 0.001], the development of intracranial hypertension [OR 5.52, 95% CI 2.70-11.28, p < 0.001], and intracerebral hemorrhage as the cause of neurologic disease [OR 3.87, 95% CI 2.34-6.42, p < 0.001].

CONCLUSION

Mortality and unfavorable functional outcomes in critically ill brain-injured patients were associated with older age (≥ 60 years), higher clinical severity (determined by a lower GCS score at admission and the development of intracranial hypertension), and an intracerebral hemorrhage as the cause of neurologic disease.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

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.

Selecting patients for early interdisciplinary rehabilitation during neurointensive care after moderate to severe traumatic brain injury

BACKGROUND

Early interdisciplinary rehabilitation (EIR) in neurointensive care is a limited resource reserved for patients with moderate to severe traumatic brain injury (TBI) believed to profit from treatment. We evaluated how key parameters related to injury severity and patient characteristics were predictive of receiving EIR, and whether these parameters changed over time.

METHODS

Among 1003 adult patients with moderate to severe TBI admitted over 72 h to neurointensive care unit during four time periods between 2005 and 2020, EIR was given to 578 and standard care to 425 patients. Ten selection criteria thought to best represent injury severity and patient benefit were evaluated (Glasgow Coma Scale, Head Abbreviated Injury Scale, New-Injury-Severity-Scale, intracranial pressure monitoring, neurosurgery, age, employment, Charlson Comorbidity Index, severe psychiatric disease, and chronic substance abuse).

RESULTS

In multivariate regression analysis, patients who were employed (adjOR 1.99 [95% CI 1.41, 2.80]), had no/mild comorbidity (adjOR 3.15 [95% CI 1.72, 5.79]), needed neurosurgery, had increasing injury severity and were admitted by increasing time period were more likely to receive EIR, whereas receiving EIR was less likely with increasing age (adjOR 0.97 [95% CI 0.96, 0.98]) and chronic substance abuse. Overall predictive ability of the model was 71%. Median age and comorbidity increased while employment decreased from 2005 to 2020, indicating patient selection became less restrictive with time.

CONCLUSION

Injury severity and need for neurosurgery remain important predictors for receiving EIR, but the importance of age, employment, and comorbidity have changed over time. Moderate prediction accuracy using current clinical criteria suggest unrecognized factors are important for patient selection.

Long-term Multidomain Patterns of Change After Traumatic Brain Injury: A TRACK-TBI LONG Study

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.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries

Importance

Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI.

Objective

To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI.

Design, Setting, and Participants

This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022.

Exposures

Black or White race.

Main Outcomes and Measures

Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors.

Results

Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32).

Conclusions and Relevance

This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.

Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data

Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.

Validity of the Early Functional Ability scale (EFA) among critically ill patients undergoing early neurological rehabilitation

Background

A reliable assessment of the functional abilities of patients after severe brain damage is crucial for valid prognostication and treatment decisions, but most clinical scales are of limited use among this specific group of patients.

Aim

The present study investigates the usefulness of the Early Functional Ability (EFA) scale, which determines the functional abilities of severely impaired patients.

Methods

Critically ill patients consecutively admitted to early neurological rehabilitation were screened for eligibility. We assessed the correlation between the EFA scale and (i) the Early Rehabilitation Barthel Index (ERBI), and (ii) the Coma Recovery Scale-Revised (CRS-R). The 1-year outcome on the Glasgow Outcome Scale-extended (GOSE) was used to examine the predictive validity. Demographical and medical variables were entered into univariate and multivariate binary regression models to identify independent predictors of 1-year outcome.

Results

Two hundred fifty-seven patients (168 men) with a median age of 62 years (IQR = 51–75) were enrolled. The correlation of the EFA scale with the CRS-R was high but low with the ERBI upon admission. Multivariate regression analysis yielded the vegetative subscale of the EFA scale as the only independent predictor for the 1-year outcome of patients admitted to early neurological rehabilitation.

Conclusions

This study shows a high correlation of the EFA scale with the CRS-R but a weak correlation with the ERBI in patients with low functional abilities. With improving patient abilities, these correlations were partly reversed. Thus, the EFA scale is a useful tool to assess the functional abilities and the prognosis of critically ill patients adequately and may be more feasible than other scales.

Predicting outcome of patients with prolonged disorders of consciousness using machine learning models based on medical complexity

Patients with severe acquired brain injury and prolonged disorders of consciousness (pDoC) are characterized by high clinical complexity and high risk to develop medical complications. The present multi-center longitudinal study aimed at investigating the impact of medical complications on the prediction of clinical outcome by means of machine learning models. Patients with pDoC were consecutively enrolled at admission in 23 intensive neurorehabilitation units (IRU) and followed-up at 6 months from onset via the Glasgow Outcome Scale-Extended (GOSE). Demographic and clinical data at study entry and medical complications developed within 3 months from admission were collected. Machine learning models were developed, targeting neurological outcomes at 6 months from brain injury using data collected at admission. Then, after concatenating predictions of such models to the medical complications collected within 3 months, a cascade model was developed. One hundred seventy six patients with pDoC (M: 123, median age 60.2 years) were included in the analysis. At admission, the best performing solution (k-Nearest Neighbors regression, KNN) resulted in a median validation error of 0.59 points [IQR 0.14] and a classification accuracy of dichotomized GOS-E of 88.6%. Coherently, at 3 months, the best model resulted in a median validation error of 0.49 points [IQR 0.11] and a classification accuracy of 92.6%. Interpreting the admission KNN showed how the negative effect of older age is strengthened when patients' communication levels are high and ameliorated when no communication is present. The model trained at 3 months showed appropriate adaptation of the admission prediction according to the severity of the developed medical complexity in the first 3 months. In this work, we developed and cross-validated an interpretable decision support tool capable of distinguishing patients which will reach sufficient independence levels at 6 months (GOS-E > 4). Furthermore, we provide an updated prediction at 3 months, keeping in consideration the rehabilitative path and the risen medical complexity.

The Association between Skull Bone Fractures and the Mortality Outcomes of Patients with Traumatic Brain Injury

Introduction

Skull fractures are often found in patients with traumatic brain injury (TBI). Although skull fractures may indicate greater force impact and are associated with local or diffuse brain injuries, the prognostic value of skull fractures remains unclear. This retrospective study aimed to assess the association between skull fractures and mortality in patients with TBI.

Methods

This study included 5,430 TBI patients registered in the trauma registry system from January 2009 to December 2018. Clinical and demographic data including age, sex, trauma mechanisms, comorbidities, Glasgow Coma Scale (GCS) score, abbreviated injury score (AIS)-head, injury severity score (ISS), and in-hospital mortality were acquired. Multiple logistic regression and propensity score matching were used to elucidate the effect of skull fractures on mortality outcomes of TBI patients.

Results

Compared to TBI patients without skull fracture, patients with skull fractures were predominantly male, younger, had lower GCS upon arrival at the emergency room, and had higher AIS-head, ISS, and in-hospital mortality. The patients with skull fracture had 1.7-fold adjusted odds of mortality (95% confidence interval (CI): 1.27–2.25; p < 0.001) than those without skull fracture, controlling for age, sex, comorbidities, and AIS-head. Additionally, the propensity score-matched analysis of 1,023 selected paired patients revealed that skull fracture was significantly associated with increased 1.4-fold odds of risk for mortality (95% CI: 1.02–1.88; p=0.036).

Conclusions

Using a propensity score-matched cohort to attenuate the confounding effect of age, comorbidities, and injury severity, skull fracture was identified as a significant independent risk factor for mortality in patients with TBI.

Functional Connectome Dynamics After Mild Traumatic Brain Injury According to Age and Sex

Neural and cognitive deficits after mild traumatic brain injury (mTBI) are paralleled by changes in resting state functional correlation (FC) networks that mirror post-traumatic pathophysiology effects on functional outcomes. Using functional magnetic resonance images acquired both acutely and chronically after injury (∼1 week and ∼6 months post-injury, respectively), we map post-traumatic FC changes across 136 participants aged 19-79 (52 females), both within and between the brain's seven canonical FC networks: default mode, dorsal attention, frontoparietal, limbic, somatomotor, ventral attention, and visual. Significant sex-dependent FC changes are identified between (A) visual and limbic, and between (B) default mode and somatomotor networks. These changes are significantly associated with specific functional recovery patterns across all cognitive domains (p < 0.05, corrected). Changes in FC between default mode, somatomotor, and ventral attention networks, on the one hand, and both temporal and occipital regions, on the other hand, differ significantly by age group (p < 0.05, corrected), and are paralleled by significant sex differences in cognitive recovery independently of age at injury (p < 0.05, corrected). Whereas females' networks typically feature both significant (p < 0.036, corrected) and insignificant FC changes, males more often exhibit significant FC decreases between networks (e.g., between dorsal attention and limbic, visual and limbic, default-mode and somatomotor networks, p < 0.0001, corrected), all such changes being accompanied by significantly weaker recovery of cognitive function in males, particularly older ones (p < 0.05, corrected). No significant FC changes were found across 35 healthy controls aged 66-92 (20 females). Thus, male sex and older age at injury are risk factors for significant FC alterations whose patterns underlie post-traumatic cognitive deficits. This is the first study to map, systematically, how mTBI impacts FC between major human functional networks.

Tau pathology, metal dyshomeostasis and repetitive mild traumatic brain injury: an unexplored link paving the way for neurodegeneration

Repetitive mild traumatic brain injury (r-mTBI), commonly experienced by athletes and military personnel, causes changes in multiple intracellular pathways, one of which involves the tau protein. Tau phosphorylation plays a role in several neurodegenerative conditions including chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disorder linked to repeated head trauma. There is now mounting evidence suggesting that tau phosphorylation may be regulated by metal ions (such as iron, zinc and copper), which themselves are implicated in ageing and neurodegenerative disorders such as Alzheimer's disease (AD). Recent work has also shown that a single TBI can result in age-dependent and region-specific modulation of metal ions. As such, this review explores the link between TBI, CTE, ageing and neurodegeneration with a specific focus on the involvement of (and interaction between) tau pathology and metal dyshomeostasis. The authors highlight that metal dyshomeostasis has yet to be investigated in the context of repeat head trauma or CTE. Given the evidence that metal dyshomeostasis contributes to the onset and/or progression of neurodegeneration, and that CTE itself is a neurodegenerative condition, this brings to light an uncharted link that should be explored. The development of adequate models of r-mTBI and/or CTE will be crucial in deepening our understanding of the pathological mechanisms that drive the clinical manifestations in these conditions and also in the development of effective therapeutics targeted towards slowing progressive neurodegenerative disorders.

Nationwide improvements in geriatric mortality due to traumatic brain injury in Japan

BACKGROUND

Traumatic brain injury (TBI), both isolated and in combination with extracranial lesions, is a global health problem associated with high mortality. Among various risk factors for poor clinical outcomes, age is the most important independent predictor of mortality in patients with TBI. TBI-related mortality is expected to increase as the society ages. However, in a super-aged society such as Japan, little is known about the trend of TBI-related mortality among older adults. Herein, we assessed the nationwide trend of the incidence and clinical outcomes of geriatric patients with TBI in Japan using the national Japanese Trauma Data Bank (JTDB) registry.

METHODS

In this retrospective cohort study, cases of TBI (aged ≥65 years) in hospitals registered with the JTDB database between January 2004 and December 2018 were included. In-hospital mortality was the primary outcome, and mortality in the emergency department was the secondary outcome. The odds ratios (ORs) and 95% confidence intervals (CIs) for in-hospital deaths with respect to 3-year periods were assessed using multivariable analysis after adjusting for potential confounders.

RESULTS

The main cause of TBI in older individuals was falls. The proportion of patients who died after hospitalization during the study period decreased markedly from 29.5% (194/657) during 2004-2006 to 14.2% (1309/9240) during 2016-2018 in the isolated TBI group (adjusted OR = 0.42, 95% CI: 0.33-0.53) and from 48.0% (119/248) during 2004-2006 to 21.7% (689/3172) during 2016-2018 in the multiple trauma group (adjusted OR = 0.32, 95% CI: 0.23-0.45). The adjusted ORs for the 3-year increment were 0.84 (95% CI: 0.81-0.88) and 0.78 (95% CI: 0.75-0.83) for the isolated TBI and multiple trauma groups, respectively.

CONCLUSIONS

Using the national JTDB registry, we demonstrated a nationwide reduction in TBI-related mortality. Our findings in the super-aged society of Japan may provide insight for the treatment of geriatric patients with TBI worldwide.

One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study

Background

The present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation.

Methods

Early neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge.

Results

Two hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51–75) and a median duration of their disease of 18 days (IQR = 12–28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up.

Conclusion

Age was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.

Geriatric All-Terrain Vehicle Trauma: An Unhelmeted and Severely Injured Population

BACKGROUND

All-terrain vehicle (ATV) use is widespread, however, little is known about injury patterns and outcomes in geriatric patients. We hypothesized that geriatric patients would have distinct and more severe injuries than non-geriatric adults after ATV trauma.

METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing non-geriatric (18-64) and geriatric adults (≥65) presenting after ATV trauma at Level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, and outcomes data were collected, including injury severity score (ISS), abbreviated injury scale (AIS) score, discharge disposition, and mortality. We performed univariate statistical tests between cohorts and multiple logistic regression models to assess for risk factors associated with severe injury (ISS>15) and mortality.

RESULTS

23,568 ATV trauma patients were identified, of whom 1,954 (8.3%) were geriatric. Geriatric patients had higher rates of severe injury(29.2 v 22.5%,p<0.0001), and thoracic (55.2 v 37.8%,p<0.0001) and spine (31.5 v 26.0%,p<0.0001) injuries, but lower rates of abdominal injuries (14.6 v 17.9%,p<0.001) as compared to non-geriatric adults. Geriatric patients had overall lower head injury rates (39.2 v 42.1%,p=0.01), but more severe head injuries (AIS>3) (36.2 vs 30.2%,p<0.001). Helmet use was significantly lower in geriatric patients (12.0 v 22.8%,p<0.0001). On multivariate analysis age increased the odds for both severe injury (OR 1.50, 95% CI 1.31-1.72, p<0.0001) and mortality (OR 5.07, 95% CI 3.42-7.50, p<0.0001).

CONCLUSIONS

While severe injury and mortality after ATV trauma occurred in all adults, geriatric adults suffered distinct injury patterns and were at greater risk for severe injury and mortality.

Risk factors for 2-year mortality in patients with prolonged disorders of consciousness: An international multicentre study

BACKGROUND AND PURPOSE

Patients with prolonged disorders of consciousness (pDoC) have a high mortality rate due to medical complications. Because an accurate prognosis is essential for decision-making on patients' management, we analysed data from an international multicentre prospective cohort study to evaluate 2-year mortality rate and bedside predictors of mortality.

METHODS

We enrolled adult patients in prolonged vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS) after traumatic and nontraumatic brain injury within 3 months postinjury. At enrolment, we collected demographic (age, sex), anamnestic (aetiology, time postinjury), clinical (Coma Recovery Scale-Revised [CRS-R], Disability Rating Scale, Nociception Coma Scale-Revised), and neurophysiologic (electroencephalogram [EEG], somatosensory evoked and event-related potentials) data. Patients were followed up to gather data on mortality up to 24 months postinjury.

RESULTS

Among 143 traumatic (n = 55) and nontraumatic (n = 88) patients (VS/UWS, n = 68, 19 females; MCS, n = 75, 22 females), 41 (28.7%) died within 24 months postinjury. Mortality rate was higher in VS/UWS (42.6%) than in MCS (16%; p < 0.001). Multivariate regression in VS/UWS showed that significant predictors of mortality were older age and lower CRS-R total score, whereas in MCS female sex and absence of alpha rhythm on EEG at study entry were significant predictors.

CONCLUSIONS

This study demonstrated that a feasible multimodal assessment in the postacute phase can help clinicians to identify patients with pDoC at higher risk of mortality within 24 months after brain injury. This evidence can help clinicians and patients' families to navigate the complex clinical decision-making process and promote an international standardization of prognostic procedures for patients with pDoC.

Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults

OBJECTIVE

The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries.

SETTING

Five percent sample of Medicare administrative claims obtained for years 2011-2015.

PARTICIPANTS

A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI.

DESIGN

Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI.

MAIN MEASURES

TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file.

RESULTS

The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02).

CONCLUSIONS

Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.

The impact of exercise, sleep, and diet on neurocognitive recovery from mild traumatic brain injury in older adults: A narrative review

Mild traumatic brain injury (mTBI) accounts for a large majority of traumatic brain injuries sustained globally each year. Older adults, who are already susceptible to age-related declines to neurocognitive health, appear to be at an increased risk of both sustaining an mTBI and experiencing slower or impaired recovery. There is also growing evidence that mTBI is a potential risk factor for accelerated cognitive decline and neurodegeneration. Lifestyle-based interventions are gaining prominence as a cost-effective means of maintaining cognition and brain health with age. Consequently, inter-individual variations in exercise, sleep, and dietary patterns could influence the trajectory of post-mTBI neurocognitive recovery, particularly in older adults. This review synthesises the current animal and human literature centred on the mechanisms through which lifestyle-related habits and behaviours could influence acute and longer-term neurocognitive functioning following mTBI. Numerous neuroprotective processes which are impacted by lifestyle factors have been established in animal models of TBI. However, the literature is characterised by a lack of translation to human samples and limited appraisal of the interaction between ageing and brain injury. Further research is needed to better establish the therapeutic utility of applying lifestyle-based modifications to improve post-mTBI neurocognitive outcomes in older adults.

Traumatic brain injury in patients aged ≥65 years versus patients aged ≥80 years: a multicenter prospective study of mortality and medical resource utilization

Objective

This study aimed to determine whether there is a difference in mortality and medical resource utilization between geriatric (aged ≥65 years) and super-geriatric patients (aged ≥80 years) with traumatic brain injury (TBI).

Methods

We obtained comprehensive data (demographics, injury characteristics, injury severities, and outcomes) of geriatric and super-geriatric TBI patients from an emergency department-based injury surveillance system database from 2011 to 2016. Multivariate logistic regression analysis was performed to compare the mortality and nonroutine discharge (NRDC) status between both groups.

Results

Among 442,533 TBI patients, 48,624 were older than 65 years. A total of 48,446 patients (37,140 geriatric and 11,306 super-geriatric) without exclusion criteria were included in the final analysis. Both overall in-hospital mortality (adjusted odds ratio, 1.88; 95% confidence interval [CI], 1.28 to 2.74; P=0.001) and NRDC (adjusted odds ratio, 1.35; 95% CI, 1.07 to 1.71; P=0.011) were significantly higher in the super-geriatric group. In the stratified analysis, there were no significant differences in NRDC rate for all stratifications of treatment timing (emergency department vs. ward admission), but mortality remained to be significant for all stratifications.

Conclusion

Super-geriatric TBI patients showed a significantly higher risk-adjusted overall mortality and more inadequate medical resource utilization than did geriatric TBI patients. However, super-geriatric patients were more likely to undergo NRDC after admission; thus, further research about age-related health inequalities is needed in the treatment of super-geriatric patients.

Outcome and its predictors in traumatic brain injury in elderly population: Institutional study from Northern India

Introduction:

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Survival and functional outcome is significantly poor in the elderly population. There is a need to develop better geriatric specific prognostic models and evidence-based geriatric traumatic brain injury management protocols for better treatment, rehabilitation, and prevention.

Aims and objectives:

To study the frequency, outcome and correlates of traumatic brain injury in elderly patients.

Material and Methods:

Frequency, outcome and correlates of traumatic brain injury in patients more than 65 years of age admitted in tertiary care hospital were studied in 160 patients admitted between 1^st January 2016 and 31^st December 2016 (retrospective analysis) and between 1^st January 2017 and 30^th June 2018 (prospective analysis). Institutional ethical committee approval was taken.

Results:

This study concluded that road side accident was the most common cause of traumatic brain injury in elderly in this study. Incidence of traumatic brain injury in elderly was found to be 11.45%. Both non-reacting pupils and low Glasgow coma scale on arrival were significantly associated with poor outcome in terms of mortality. Most of the patients who expired or were discharged against medical advice had associated skull bone fractures, cerebral infarct, diffuse brain edema, subarachnoid hemorrhage, midline shift, lower hemaglobin, higher random blood sugar and higher creatinine as compared to patients who were discharged. All these findings were statistically significant.

Conclusion:

Low Glasgow coma scale on arrival, non reacting pupils, low hemoglobin, high random blood sugar, high creatinine and intubation on arrival are associated with increased mortality. Associated skull bone fractures, cerebral infarct, diffuse brain edema are predictors of poor outcome. Anticoagulants and associated co-morbidities do not increase the risk of mortality in traumatic brain injury in elderly.

Traumatic brain injury induced temperature dysregulation: What is the role of β blockers?

BACKGROUND

Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ββ) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ββ on PTH in critically-ill TBI patients.

METHODS

We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ββ were excluded. Patients were stratified into (ββ+) and (ββ-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed.

RESULTS

We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ββ + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ββ-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ββ+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ββ in terms of reducing the time interval between febrile episodes (p = 0.582).

CONCLUSION

Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ββ may be a potential therapeutic modality in PTH.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Treatment Experiences of Traumatic Brain Injury Patients using Doctor-Helicopter Emergency Medical Service: Early Data in a Regional Trauma Center

Objective

The purpose of this study is to analyze the results of doctor helicopter emergency medical service (HEMS) in traumatic brain injury (TBI) patients and to understand the effect and improvement of doctor HEMS.

Methods

We included TBI patients transferred by doctor HEMS of our hospital between February 2016 and December 2017. Basic characteristics, HEMS data, treatment and results data were analyzed retrospectively. We divided the patients into 3 groups as regarding severity of patient, relevance of treatment and transfer. We investigated the preventable trauma death rate (PTDR) of these groups to increase the reliability of the treatment outcome.

Results

TBI patients using doctor HEMS were indicated in 98 patients (18.7%) among 522 overall HEMS patients. The overall mortality was consisted in 21.4% and 43.2% was resulted in Glasgow outcome scale 4 or 5. The group of proper transport and treatment for severe TBI was consisted in 62.2% including 13 mortality cases and no preventable death. The group of delayed transport or treatment for severe TBI was 18.3% including 8 mortality cases and 1 preventable death. The PTDR of TBI after doctor HEMS was significantly lower than that of overall TBI (4.8% vs. 11.6%, p=0.045).

Conclusion

In patients with severe TBI, doctor HEMS can improve treatment outcomes by reducing treatment delay and unnecessary examinations and this result was evidenced that the PTDR were decreased significantly after doctor HEMS transport. The appropriate treatment is mandatory for real-time communication with the emergency doctor and treatment preparation of the trauma team during the HEMS transport.

Impact of aging on the immune response to traumatic brain injury (AIm:TBI) study protocol

BACKGROUND

Traumatic brain injury (TBI) in older adults leads to considerable morbidity and mortality. Outcomes among older adults with TBI are disparately worse than in younger adults. Differences in immunological response to injury may account for at least some of this disparity. Understanding how ageing differentially affects the immune response to TBI and how older age and these immunological changes affect the natural history of recovery following TBI are the goals of this study.

DESIGN/METHODS

A prospective multiple cohort design is being used to assess the effects of ageing and TBI on immune makers and to test predictors of impairment and disability in older adults following mild TBI. Older adults (>55 years) with mild TBI are enrolled with three comparison groups: younger adults (21-54 years) with mild TBI, non-injured older adults (>55 years) and non-injured young adults (21-54 years). For the primary analysis, we will assess the association between immune markers and Glasgow Outcome Scale-Extended at 6 months, using logistic regression. Predictors of interest will be inflammatory biomarkers. Multivariate linear regression will be used to evaluate associations between biomarkers and other outcomes (symptoms, function and quality of life) at 3 and 6 months. Exploratory analyses will investigate the utility of biomarkers to predict outcome using receiver-operating characteristic curves.

DISCUSSION

A better understanding of the recovery trajectory and biological rationale for disparate outcomes following TBI in older adults could allow for development of specific interventions aimed at reducing or eliminating symptoms. Such interventions could reduce impairment and healthcare costs.

Loss of the Antimicrobial Peptide Metchnikowin Protects Against Traumatic Brain Injury Outcomes in Drosophila melanogaster

Neuroinflammation is a major pathophysiological feature of traumatic brain injury (TBI). Early and persistent activation of innate immune response signaling pathways by primary injuries is associated with secondary cellular injuries that cause TBI outcomes to change over time. We used a Drosophila melanogaster model to investigate the role of antimicrobial peptides (AMPs) in acute and chronic outcomes of closed-head TBI. AMPs are effectors of pathogen and stress defense mechanisms mediated by the evolutionarily conserved Toll and Immune-deficiency (Imd) innate immune response pathways that activate Nuclear Factor kappa B (NF-κB) transcription factors. Here, we analyzed the effect of null mutations in 10 of the 14 known Drosophila AMP genes on TBI outcomes. We found that mutation of Metchnikowin (Mtk) was unique in protecting flies from mortality within the 24 h following TBI under two diet conditions that produce different levels of mortality. In addition, Mtk mutants had reduced behavioral deficits at 24 h following TBI and increased lifespan either in the absence or presence of TBI. Using a transcriptional reporter of gene expression, we found that TBI increased Mtk expression in the brain. Quantitative analysis of mRNA in whole flies revealed that expression of other AMPs in the Toll and Imd pathways as well as NF-κB transcription factors were not altered in Mtk mutants. Overall, these results demonstrate that Mtk plays an infection-independent role in the fly nervous system, and TBI-induced expression of Mtk in the brain activates acute and chronic secondary injury pathways that are also activated during normal aging.

Toward refining Alzheimer's disease into overlapping subgroups

Alzheimer's disease (AD) is an age-related neurodegenerative disorder characterized by progressive anterograde amnesia, cerebral atrophy, and eventual death. Current treatment has limited efficacy and cannot decelerate the disease progression. Clinical trials targeting the removal of the neuropathological hallmarks of AD, including accumulation of amyloid plaques or neurofibrillary tangles, have failed to modify disease progression. Without new or innovative hypotheses, AD is poised to become a public health crisis within this decade. We present an alternative hypothesis-that AD is the result of multiple interrelated causalities. The intention of this manuscript is to initiate a discussion regarding these multiple causalities and their overlapping similarities. The idea of creating subgroups allows for better identification of biomarkers across a narrower patient population for improved pharmacotherapeutic opportunities. The interrelatedness of many of these proposed subgroups indicates the complexity of this disorder. However, it also supports that no one single factor may initiate the cascade of events.

Multicenter prospective study on predictors of short-term outcome in disorders of consciousness

OBJECTIVE

This international multicenter, prospective, observational study aimed at identifying predictors of short-term clinical outcome in patients with prolonged disorders of consciousness (DoC) due to acquired severe brain injury.

METHODS

Patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) or in minimally conscious state (MCS) were enrolled within 3 months from their brain injury in 12 specialized medical institutions. Demographic, anamnestic, clinical, and neurophysiologic data were collected at study entry. Patients were then followed up for assessing the primary outcome, that is, clinical diagnosis according to standardized criteria at 6 months postinjury.

RESULTS

We enrolled 147 patients (44 women; mean age 49.4 [95% confidence interval 46.1-52.6] years; VS/UWS 71, MCS 76; traumatic 55, vascular 56, anoxic 36; mean time postinjury 59.6 [55.4-63.6] days). The 6-month follow-up was complete for 143 patients (VS/UWS 70; MCS 73). With respect to study entry, the clinical diagnosis improved in 72 patients (VS/UWS 27; MCS 45). Younger age, shorter time postinjury, higher Coma Recovery Scale-Revised total score, and presence of EEG reactivity to eye opening at study entry predicted better outcome, whereas etiology, clinical diagnosis, Disability Rating Scale score, EEG background activity, acoustic reactivity, and P300 on event-related potentials were not associated with outcome.

CONCLUSIONS

Multimodal assessment could identify patients with higher likelihood of clinical improvement in order to help clinicians, families, and funding sources with various aspects of decision-making. This multicenter, international study aims to stimulate further research that drives international consensus regarding standardization of prognostic procedures for patients with DoC.

Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults

BACKGROUND

Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting.

METHODS

This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater.

RESULTS

There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%-42.0%) and 90.1% specific (95% CI, 89.2%-91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%-93.7%) and 17.0% specific (95% CI, 15.8%-18.1%).

CONCLUSIONS

The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level II.

Age-dependent trends in survival after adult in-hospital cardiac arrest

BACKGROUND

While survival after in-hospital cardiac arrest (IHCA) has improved in recent years, it remains unknown whether this trend primarily applies to younger IHCA victims. The aim of this study was to assess trends in survival to hospital discharge after adult IHCA across age groups from 2000 to 2016.

METHODS

This is an observational study of IHCA patients included in the Get With The Guidelines®-Resuscitation registry between 2000 and 2016. The primary outcome was survival to hospital discharge. Patients were stratified into five age groups: <50 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years. Generalized linear regression was used to obtain absolute survival rates over time.

RESULTS

A total of 234,767 IHCA patients were included. The absolute increase in survival per calendar year was 0.8% (95% CI 0.7-1.0%, p < 0.001) for patients younger than 50 years, 0.6% (95% CI 0.4-0.7%, p < 0.001) for patients between 50 and 59 years, 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients between 60 and 69 years, 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients between 70 and 79 years, and 0.5% (95% CI 0.4-0.6%, p < 0.001) for patients older than 80 years. We observed a significant interaction between calendar year and age group (p < 0.001), indicating that the rate of improvement in survival over time was significantly different between age groups.

CONCLUSIONS

For patients with IHCA, rates of survival to discharge have improved significantly from 2000 to 2016 across all age groups.

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

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

Sleep disturbances among older adults following traumatic brain injury

Sleep disturbances are common sequelae of traumatic brain injury (TBI) that are associated with poorer recovery. This is important among older adults, who fare worse following TBI relative to younger adults and have a higher prevalence of sleep disorders. The objective of this study was to assess the risk of newly-diagnosed sleep disorders following TBI among adults ≥65 years. Using a large commercial insurance database, older adults diagnosed with TBI between 2008-2014 (n = 78,044) and non-TBI controls (n = 76,107) were identified. The first dates of diagnosis of four common sleep disorders (hypersomnia, insomnia, obstructive sleep apnea, and restless legs syndrome) and a composite of any sleep disorder were identified. To compare groups, this study used a difference-in-differences (DID) approach, accounting for pre-index differences between cohorts and the trends in sleep diagnoses over time. Individuals with TBI were more likely to have any newly-diagnosed sleep disorder before (14.1% vs 9.4%, p < 0.001) and after (22.7% vs 14.1%, p < 0.001) the index date. In fully adjusted DID models, TBI was associated with an increased risk of insomnia (rate ratio (RR) = 1.17; 95% confidence interval (CI) = 1.08-1.26) and any sleep disorder (RR = 1.13; 95% CI = 1.08-1.19). Following TBI among older adults, screening and education on sleep disorders should be considered.

The role of mood, post-traumatic stress, post-concussive symptoms and coping on outcome after MTBI in elderly patients

Elderly patients are at increased risk for persistent complaints after mild traumatic brain injury (MTBI). This study aimed to investigate the role of post-concussive symptoms, mood, post-traumatic stress, and coping on functional outcome in elderly with MTBI. Information on mood, post-concussive symptoms, post-traumatic stress, and coping was collected 2 weeks post-injury. Six months post-injury functional outcome was assessed with the Glasgow Outcome Scale Extended. One hundred and sixty-two patients aged ≥ 60 years were included, 55% male, mean age = 71 (±6.2) years. The most frequent cause of injury was falls from standing height (75%). Two weeks post-injury anxiety, depression, and post-traumatic stress were present in 15%, 12%, and 38% of patients, respectively, with 73% reporting post-concussive symptoms. Avoidant coping was the most frequently used coping style. Six months post-injury, 44% showed incomplete recovery. Higher depression scores (OR = 0.87, p = 0.005) and number of post-concussive symptoms (OR = 0.91, p = 0.03) were associated with incomplete recovery. Half of the elderly showed incomplete recovery 6 months after MTBI, with early depression or post-concussive symptoms as important factors. Coping style was not related to outcome. These results underline the need for a different approach in elderly patients, focusing on other predicting factors and fall prevention strategies.

Sarcopenia is Predictive of Functional Outcomes in Older Trauma Patients

Introduction: Older patients are more vulnerable to poor outcomes after trauma than younger patients. Sarcopenia, loss of skeletal mass, is prevalent in trauma patients admitted to the intensive care unit (ICU), and it has been shown to correlate with adverse outcomes, such as mortality and ICU days. Yet, little is known whether it predicts other outcomes. We hypothesized that sarcopenia independently predicts poor functional outcomes in older trauma patients admitted to the ICU.

Methods: We performed a retrospective review of patients aged >55 admitted to a surgical ICU in a Level I trauma center for two years. Sarcopenic status was determined by measuring total skeletal muscle cross-sectional area at the L3 level on admission computed tomography (CT), normalized for height with sex-specific cutoffs. Primary outcome measures were in-hospital mortality, functional outcomes measured by the Glasgow Outcome Scale (GOS) at discharge, and discharge disposition. Multivariable logistic regression was used to determine predictors of primary outcomes.

Results: Out of 230 patients, 32% were sarcopenic. The overall mortality was 20%, and 30% were discharged with poor functional outcomes. A higher proportion of sarcopenic patients among survivors had poor functional outcomes at discharge (55% vs. 30%, p=0.002). Sarcopenia was not predictive of in-hospital mortality but was an independent predictor of poor functional outcomes at discharge (OR 2.6; 95% confidence interval [CI] 1.3-5.5), adjusting for age, Glasgow Coma Scale (GCS) on admission, diagnosis of traumatic brain injury (TBI), Injury Severity Score (ISS), and the number of life-limiting illnesses.

Conclusions: Sarcopenia is prevalent in geriatric trauma ICU patients and is an independent predictor of poor functional outcomes. Assessing for sarcopenia has an important potential as a prognostic tool in older trauma patients.

Comorbidity in adults with traumatic brain injury and all-cause mortality: a systematic review

OBJECTIVES

Comorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of different comorbid conditions on early and late mortality post-TBI in order to (1) examine the relationship between comorbid condition(s) and all-cause mortality in TBI and (2) determine the influence of sociodemographic and clinical characteristics of patients with a TBI at baseline on all-cause mortality.

DESIGN

Systematic review.

DATA SOURCES

Medline, Central, Embase, PsycINFO and bibliographies of identified articles were searched from May 1997 to January 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies met the following criteria: (1) focused on comorbidity as it related to our outcome of interest in adults (ie, ≥18 years of age) diagnosed with a TBI; (2) comorbidity was detected by any means excluding self-report; (3) reported the proportion of participants without comorbidity and (4) followed participants for any period of time.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and assessed risk of bias using the Quality in Prognosis Studies tool. Data were synthesised through tabulation and qualitative description.

RESULTS

A total of 27 cohort studies were included. Among the wide range of individual comorbid conditions studied, only low blood pressure was a consistent predictors of post-TBI mortality. Other consistent predictors were traditional sociodemographic risk factors. Higher comorbidity scale, scores and the number of comorbid conditions were not consistently associated with post-TBI mortality.

CONCLUSIONS

Given the high number of comorbid conditions that were examined by the single studies, research is required to further substantiate the evidence and address conflicting findings. Finally, an enhanced set of comorbidity measures that are suited for the TBI population will allow for better risk stratification to guide TBI management and treatment.

PROSPERO REGISTRATION NUMBER

CRD42017070033.

Characteristics of Elderly Long-Term Care Residents Who Were Injured and Transferred to Hospital Emergency Departments in Korea: A Retrospective Multicenter Study

The objective of this retrospective multicenter study was to investigate the mechanism and characteristics of trauma experienced by patients aged ≥65 years who were transferred from a long-term care hospital to one of five university hospital emergency departments. Of 255,543 patients seen in one of the five emergency departments, 79 were transferred from a long-term care hospital because of trauma. The most common trauma mechanism was slipping down, with 33 (58.9%) patients, followed by falling from a bed (17.9%), striking an object such as a wall or corner (10.7%), overextending a joint (8.9%), and unknown mechanisms (3.6%). Many cases of slip (39.4%) occurred in relation to the bathroom. Comparing slip and fall from a bed, we found more hip fractures (95.2%) because of slipping down than falling from a bed (57.1%); traumatic brain injury only occurred in slip cases. These traumas cause significant morbidity in elderly patients; therefore, we sought to identify strategies that prevent slip in long-term care hospitals.

Association of Angiotensin-Converting Enzyme Inhibitors with Increased Mortality Among Patients with Isolated Severe Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. β-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI.

OBJECTIVE

Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI.

METHODS

A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome.

RESULTS

Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P < .001), which was even greater than the twofold increased risk of mortality associated with an Injury Severity Score ≥ 16. A second analysis that included patients who received preinjury BBs (n = 98) demonstrated slightly reduced mortality in the ACEI cohort with only a twofold increased risk in multivariate analysis (P = .05).

CONCLUSIONS

Preinjury exposure to ACEIs is associated with an increase in mortality among patients with isolated TBI. This effect is ameliorated in patients who receive BBs, which provides evidence that this class of medications may provide a protective benefit.

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

Background

The probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors.

Methods

Patients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable.

Results

Two hundred twenty patients with mean age 70 years (median 69; range 60–87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5–8), unfavorable outcome 27% (GOSE 2–4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age (p < 0.05), multiple injuries (p < 0.05), GCS M ≤ 3 on admission (p < 0.05), and mechanical ventilation (p < 0.001).

Conclusions

Overall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

Dispositional optimism and cognitive functioning following traumatic brain injury

Objective: The association of dispositional optimism with health-related factors has been well established in several clinical populations, but little is known about the role of optimism in recovery after traumatic brain injury (TBI). Given the high prevalence of cognitive complaints after TBI, the present study examined the association between optimism and cognitive functioning after TBI. Methods: 171 individuals with complicated mild, moderate or severe TBI completed a series of questionnaires via structured interview and self-report, including a self-report assessment of dispositional optimism, the revised Life Orientation Test (LOT-R), and an objective assessment of cognition, the Brief Test of Adult Cognition by Telephone (BTACT). Multiple hierarchical regression analysis was conducted to examine the relationships between optimism and cognitive functioning. Results: Dispositional optimism was significantly and positively associated with post-TBI cognitive functioning after controlling for the effects of age, race, injury severity, health status, and positive and negative affect. Conclusion: Dispositional optimism may promote higher levels of cognitive functioning in people who sustained a TBI. Research is warranted to examine whether interventions that promote optimism in clinical and social encounters can enhance cognitive recovery in individuals with TBI.

The Young Male Syndrome-An Analysis of Sex, Age, Risk Taking and Mortality in Patients With Severe Traumatic Brain Injuries

Higher risk taking is particularly characteristic for males between 15 and 35 years, the age when intrasexual competition is the strongest. This fitness-maximizing strategy, however, also has negative consequences; previous data revealed that males have a significantly higher tendency to die in accidents. This retrospective study aimed to assess whether age-related risk taking, often associated with the reproductive competition between males, and referred to as the Young Male Syndrome (YMS), may play a role in the high incidence of severe traumatic brain injury (sTBI) in young males. Derived from the available evidence and the main assumptions of the YMS, we expected that men, especially when they are in the age when their reproductive potential peaks, are more likely to suffer sTBI from highly risky behaviors that also lead to higher mortality. It was also expected that alcohol intoxication makes the demographic pattern of sTBI even more similar to what previous research on the YMS implies. We analyzed demographic data of patients with sTBI (N = 365) registered in a clinical database. To this end, we built Generalized Linear Mixed Models (GLMM) to reveal which of the demographic characteristics are the best predictors for risky behaviors leading to sTBI and death as a consequence of the injury. The data suggest that younger people acquired sTBI from riskier behaviors compared to members of older age groups, irrespective of their sex. Moreover, being male and being alcohol intoxicated also contributed significantly to risk-taking behavior. Mortality rate after the injury, however, increased with the age of the patient and did not depend on the riskiness of the behavior. The results indicate that the demographic distribution of the specific patient population in our focus cannot be simply explained by the YMS. However, higher incidence rates of males among the patients are in line with the core assumptions of the YMS. These data indicate that epidemiological studies should also take into consideration evolutionary theories and highlight the importance of age and sex specific prevention strategies.

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults

OBJECTIVE

To determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center.

DESIGN

Retrospective cohort study.

SETTING

R Adams Cowley Shock Trauma Center.

PARTICIPANTS

Black and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902).

MAIN OUTCOME MEASURES

We assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities.

RESULTS

There were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70).

CONCLUSIONS

In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome

BACKGROUND

Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients.

METHODS

Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012-2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2-3) and favourable outcome (GOS 4-5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis.

RESULTS

The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome.

CONCLUSION

Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.

Long-Term Return to Work After Acquired Brain Injury in Young Danish Adults: A Nation-Wide Registry-Based Cohort Study

Objective: (1) To determine patterns of return to work (RTW) after traumatic brain injury and other causes of acquired brain injury (ABI) among young adults aged 19–30 years and (2) to compare the stability of long-term labor-market attachment (LMA) to the background population.

Method: Nationwide registry-based inception cohort study of 10 years weekly data of employment status. Patients (n = 8,496) aged 19–30 years with first-ever diagnosis of TBI, stroke, subarachnoid hemorrhage, encephalopathy, brain tumor, or CNS infections during 1999–2015. For comparison, a general population cohort (n = 206,025) individually matched on age, sex, and municipality was identified. The main outcome was RTW, which was defined as time to LMA, i.e., a week without public assistance benefits except education grants/leave. Stable labor-market attachment (sLMA) was defined as LMA for at least 75% over 52 weeks. The cumulative incidence proportions of RTW and stable RTW in the ABI cohort were estimated with the Aalen-Johansen estimator with death as a competing event.

Results: Twelve weeks after diagnosis 46.9% of ABI cohort had returned to stable RTW, which increased to 57.4% 1 year after, and 69.7% 10 years after. However, compared to controls fewer had sLMA 1 year (OR: 0.25 [95% CI 0.24–0.27]) and 10 years after diagnosis (OR: 0.35 [95% CI: 0.33–0.38]). Despite significant variations, sLMA was lower compared to the control cohort for all subtypes of ABI and no significant improvements were seen after 2–5 years.

Conclusion: Despite relatively fast RTW only a minor proportion of young patients with ABI achieves sLMA.

Risk of Mortality in Individuals with Hip Fracture and Traumatic Brain Injury

OBJECTIVES

To estimate the prevalence of diagnosed traumatic brain injury (TBI) in individuals hospitalized with hip fracture and examine its association with all-cause mortality.

DESIGN

Nested cohort study.

SETTING

National sample of Medicare beneficiaries from 2006 to 2010.

PARTICIPANTS

Beneficiaries aged 65 and older hospitalized with hip fracture.

MEASUREMENTS

TBI at the time of hip fracture was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The main outcome was all-cause mortality during follow-up.

RESULTS

Prevalence of TBI in individuals with hip fracture was 2.7%. Absolute risk of mortality attributable to TBI in individuals with hip fracture was 15/100 person-years. TBI was significantly associated with risk of death in multivariable analysis (hazard ratio=1.24, 95% confidence interval=1.14-1.35).

CONCLUSION

TBI was associated with greater risk of mortality in individuals with hip fracture. Practitioners should consider evaluating for presence of TBI in this vulnerable population. J Am Geriatr Soc 67:124-127, 2019.