The Effect of Age on Functional Outcome in Mild Traumatic Brain Injury: 6-Month Report of a Prospective Multicenter Trial

Adverse impact of female reproductive signaling on age-dependent neurodegeneration after mild head trauma in Drosophila

Environmental insults, including mild head trauma, significantly increase the risk of neurodegeneration. However, it remains challenging to establish a causative connection between early-life exposure to mild head trauma and late-life emergence of neurodegenerative deficits, nor do we know how sex and age compound the outcome. Using a Drosophila model, we demonstrate that exposure to mild head trauma causes neurodegenerative conditions that emerge late in life and disproportionately affect females. Increasing age-at-injury further exacerbates this effect in a sexually dimorphic manner. We further identify sex peptide signaling as a key factor in female susceptibility to post-injury brain deficits. RNA sequencing highlights a reduction in innate immune defense transcripts specifically in mated females during late life. Our findings establish a causal relationship between early head trauma and late-life neurodegeneration, emphasizing sex differences in injury response and the impact of age-at-injury. Finally, our findings reveal that reproductive signaling adversely impacts female response to mild head insults and elevates vulnerability to late-life neurodegeneration.

Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury

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.

The Cognitive Profile of Elderly Patients With Mild Traumatic Brain Injury: A Role for Cognitive Reserve?

OBJECTIVE

To assess cognitive status in elderly patients with mild traumatic brain injury (mTBI) in the subacute phase, examine the role of cognitive reserve, and investigate associations with cognitive complaints, mental distress, and functional outcomes.

SETTING

A level 1 trauma center in the Netherlands.

PARTICIPANTS

A total of 52 individuals with mTBI and 42 healthy controls.

DESIGN

A prospective observational cohort study.

MAIN MEASURES

Neuropsychological assessment in the subacute phase (2 weeks to 6 months post-injury) to objectively measure the cognitive functioning, the Head Injury Symptom Checklist for subjective cognitive complaints, the Hospital Anxiety and Depression Scale for anxiety and depression, the Cognitive Reserve Index questionnaire for cognitive reserve, the Community Integration Questionnaire for community integration, and the Glasgow Outcome Scale Extended for functional outcome.

RESULTS

Cognitive impairments were observed in memory ( P < .001) and attention, processing speed and executive control ( P < .001). Cognitive reserve was not associated with neuropsychological test performance, except for one test measuring working memory. The relationship between injury severity and cognitive outcome was not moderated by cognitive reserve. Elderly patients reported significantly more complains than healthy controls regarding forgetfulness, concentration problems, and slowness. Complaints of concentration were associated with cognitive impairment. All cognitive complaints were significantly correlated with mental distress.

CONCLUSIONS

Cognitive impairments may be present in elderly patients in the subacute phase after mTBI, and these impairments were not significantly associated with cognitive reserve. This suggests that cognitive reserve might not serve as a protective factor against the effects of mTBI in the elderly. Concentration complaints may serve as a specific indicator for cognitive impairment, while complaints of memory and mental slowness may represent more generic indicators of mental distress. These findings highlight the importance of careful screening in older adults with mTBI, guiding clinicians toward specific treatment targets encompassing cognitive impairment, diminished mental well-being, or both.

Sexual Dimorphism in Age-Dependent Neurodegeneration After Mild Head Trauma in Drosophila : Unveiling the Adverse Impact of Female Reproductive Signaling

Environmental insults, including mild head trauma, significantly increase the risk of neurodegeneration. However, it remains challenging to establish a causative connection between early-life exposure to mild head trauma and late-life emergence of neurodegenerative deficits, nor do we know how sex and age compound the outcome. Using a Drosophila model, we demonstrate that exposure to mild head trauma causes neurodegenerative conditions that emerge late in life and disproportionately affect females. Increasing age-at-injury further exacerbates this effect in a sexually dimorphic manner. We further identify Sex Peptide (SP) signaling as a key factor in female susceptibility to post-injury brain deficits. RNA sequencing highlights a reduction in innate immune defense transcripts specifically in mated females during late life. Our findings establish a causal relationship between early head trauma and late-life neurodegeneration, emphasizing sex differences in injury response and the impact of age-at-injury. Finally, our findings reveal that reproductive signaling adversely impacts female response to mild head insults and elevates vulnerability to late-life neurodegeneration.

DOACs for Older adults with Atrial Fibrillation and Falls: Results from the prospective single-centre DOAFF study

INTRODUCTION

Falls are one of the most fearsome events in anticoagulated older adults. The evidence concerning safety of direct oral anticoagulants (DOACs) in falling elderly patients with atrial fibrillation (AF) is still limited.

METHODS

We prospectively enrolled consecutive anticoagulant-naïve patients aged 65 years and older, starting anticoagulation with DOACs for AF. The study cohort was stratified in fallers vs. non-fallers, according to the occurrence of at least one fall during the 2-year follow-up and bleeding outcomes were evaluated.

RESULTS

We enrolled 524 consecutive patients. Mean age was 80.8 years and they were mostly women (54.0%). Among the study cohort, 148 patients (28.2%) presented at least one fall episode during the study period. After the adjustment for potential confounders, no difference was found between fallers and non-fallers for all the study outcomes: major bleeding [HR: 1.04 (95%CI: 0.58-1.85)], intracranial haemorrhage [HR: 1.63 (95%CI: 0.69-3.80)], clinically relevant non-major bleeding [HR: 1.21 (95%CI: 0.83-1.76)], and all-cause death [HR: 1.51 (95%CI: 0.85-2.69)]. The presence of a prior cerebrovascular event [HR: 2.27 (95%CI: 1.12-4.62); p-value: 0.02] and polypharmacy [HR: 1.60 (95%CI: 1.08-2.39); p-value: 0.02] were the main drivers for major and clinically relevant non-major bleedings, respectively.

CONCLUSIONS

Falls in an anticoagulant-naïve population aged 65 years and over starting a DOAC for AF do not increase the bleeding risk. Thus, the presence of falls should not discourage clinicians from prescribing DOACs also in this subset of patients.

Mortality Predictors for Adult Patients with Mild-to-Moderate Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) represent a significant public health concern, with mild-to-moderate cases comprising a substantial portion of incidents. Understanding the predictors of mortality among adult patients with mild-to-moderate TBIs is crucial for optimizing clinical management and improving outcomes. This literature review examines the existing research to identify and analyze the mortality predictors in this patient population. Through a comprehensive review of peer-reviewed articles and clinical studies, key prognostic factors, such as age, Glasgow Coma Scale (GCS) score, the presence of intracranial hemorrhage, pupillary reactivity, and coexisting medical conditions, are explored. Additionally, this review investigates the role of advanced imaging modalities, biomarkers, and scoring systems in predicting mortality following a mild-to-moderate TBI. By synthesizing the findings from diverse studies, this review aims to provide clinicians and researchers with valuable insights into the factors influencing mortality outcomes in adult patients with a mild-to-moderate TBI, thus facilitating more informed decision making and targeted interventions in clinical practice.

Impaired oligodendrogenesis in the white matter of aged mice following diffuse traumatic brain injury

Senescence is a negative prognostic factor for outcome and recovery following traumatic brain injury (TBI). TBI-induced white matter injury may be partially due to oligodendrocyte demise. We hypothesized that the regenerative capacity of oligodendrocyte precursor cells (OPCs) declines with age. To test this hypothesis, the regenerative capability of OPCs in young [(10 weeks ±2 (SD)] and aged [(62 weeks ±10 (SD)] mice was studied in mice subjected to central fluid percussion injury (cFPI), a TBI model causing widespread white matter injury. Proliferating OPCs were assessed by immunohistochemistry for the proliferating cell nuclear antigen (PCNA) marker and labeled by 5-ethynyl-2'-deoxyuridine (EdU) administered daily through intraperitoneal injections (50 mg/kg) from day 2 to day 6 after cFPI. Proliferating OPCs were quantified in the corpus callosum and external capsule on day 2 and 7 post-injury (dpi). The number of PCNA/Olig2-positive and EdU/Olig2-positive cells were increased at 2dpi (p < .01) and 7dpi (p < .01), respectively, in young mice subjected to cFPI, changes not observed in aged mice. Proliferating Olig2+/Nestin+ cells were less common (p < .05) in the white matter of brain-injured aged mice, without difference in proliferating Olig2+/PDGFRα+ cells, indicating a diminished proliferation of progenitors with different spatial origin. Following TBI, co-staining for EdU/CC1/Olig2 revealed a reduced number of newly generated mature oligodendrocytes in the white matter of aged mice when compared to the young, brain-injured mice (p < .05). We observed an age-related decline of oligodendrogenesis following experimental TBI that may contribute to the worse outcome of elderly patients following TBI.

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.

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.

Mild Traumatic Brain Injury and Functional Outcome in Older Adults: Pain Interference But Not Cognition Mediates the Relationship Between Traumatic Injury and Functional Difficulties

OBJECTIVE

To examine functional status of older people 3 months after mild traumatic brain injury (mTBI) and identify whether pain interference or cognition mediates any relationship found between injury status and functional outcomes.

SETTING

Patients admitted to a Melbourne-based emergency department.

PARTICIPANTS

Older adults 65 years and older: 40 with mTBI, 66 with orthopedic injury without mTBI (TC), and 47 healthy controls (CC) without injury.

DESIGN

Observational cohort study.

MAIN MEASURES

Functional outcome was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and single- and dual-task conditions of the Timed-Up-and-Go task. Pain interference and cognitive performance at 3 months post-injury were examined as mediators of the relationship between injury status (injured vs noninjured) and functional outcome.

RESULTS

Patients with mTBI and/or orthopedic injury reported greater difficulties in overall functioning, including community participation, compared with noninjured older people (CC group). Both trauma groups walked slower than the CC group on the mobility task, but all groups were similar on the dual-task condition. Pain interference mediated the relationship between injury status and overall functioning [ b = 0.284; 95% CI = 0.057, 0.536), community participation ( b = 0.259; 95% CI = 0.051, 0.485), and mobility ( b = 0.116; 95% CI = 0.019, 0.247). However, cognition did not mediate the relationship between injury status and functional outcomes.

CONCLUSIONS

Three months after mild traumatic injury (with and without mTBI), patients 65 years and older had greater functional difficulties compared with noninjured peers. Pain interference, but not cognition, partially explained the impact of traumatic injury on functional outcomes. This highlights the importance of reducing pain interference for older patients after injury (including mTBI) to support better functional recovery.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Drosophila melanogaster as a model to study age and sex differences in brain injury and neurodegeneration after mild head trauma

Repetitive physical insults to the head, including those that elicit mild traumatic brain injury (mTBI), are a known risk factor for a variety of neurodegenerative conditions including Alzheimer's disease (AD), Parkinson's disease (PD), and chronic traumatic encephalopathy (CTE). Although most individuals who sustain mTBI typically achieve a seemingly full recovery within a few weeks, a subset experience delayed-onset symptoms later in life. As most mTBI research has focused on the acute phase of injury, there is an incomplete understanding of mechanisms related to the late-life emergence of neurodegeneration after early exposure to mild head trauma. The recent adoption of Drosophila-based brain injury models provides several unique advantages over existing preclinical animal models, including a tractable framework amenable to high-throughput assays and short relative lifespan conducive to lifelong mechanistic investigation. The use of flies also provides an opportunity to investigate important risk factors associated with neurodegenerative conditions, specifically age and sex. In this review, we survey current literature that examines age and sex as contributing factors to head trauma-mediated neurodegeneration in humans and preclinical models, including mammalian and Drosophila models. We discuss similarities and disparities between human and fly in aging, sex differences, and pathophysiology. Finally, we highlight Drosophila as an effective tool for investigating mechanisms underlying head trauma-induced neurodegeneration and for identifying therapeutic targets for treatment and recovery.

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.

Long-term health-related quality of life after trauma with and without traumatic brain injury: a prospective cohort study

To purpose was to assess and compare the health-related quality of life (HRQoL) and risk of depression two years after trauma, between patients with and without traumatic brain injury (TBI) in a mixed Swedish trauma cohort. In this prospective cohort study, TBI and non-TBI trauma patients included in the Swedish Trauma registry 2019 at a level II trauma center in Stockholm, Sweden, were contacted two years after admission. HRQoL was assessed with RAND-36 and EQ-5D-3L, and depression with Montgomery Åsberg depression Rating Scale self-report (MADRS-S). Abbreviated Injury Score (AIS) head was used to grade TBI severity, and American Society of Anesthesiologists (ASA) score was used to assess comorbidities. Data were compared using Chi-squared test, Mann Whitney U test and ordered logistic regression, and Bonferroni correction was applied. A total of 170 of 737 eligible patients were included. TBI was associated with higher scores in 5/8 domains of RAND-36 and 3/5 domains of EQ-5D (p < 0.05). No significant difference in MADRS-S. An AIS (head) of three or higher was associated with lower scores in five domains of RAND-36 and two domains of EQ-5D but not for MADRS-S. An ASA-score of three was associated with lower scores in all domains of both RAND-36 (p < 0.05, except mental health) and EQ-5D (p < 0.001, except anxiety/depression), but not for MADRS-S. In conclusion, patients without TBI reported a lower HRQoL than TBI patients two years after trauma. TBI severity assessed according to AIS (head) was associated with HRQoL, and ASA-score was found to be a predictor of HRQoL, emphasizing the importance of considering pre-injury health status when assessing outcomes in TBI patients.

Aging-Associated Thyroid Dysfunction Contributes to Oxidative Stress and Worsened Functional Outcomes Following Traumatic Brain Injury

The incidence of traumatic brain injury (TBI) increases dramatically with advanced age and accumulating evidence indicates that age is one of the important predictors of an unfavorable prognosis after brain trauma. Unfortunately, thus far, evidence-based effective therapeutics for geriatric TBI is limited. By using middle-aged animals, we first confirm that there is an age-related change in TBI susceptibility manifested by increased inflammatory events, neuronal death and impaired functional outcomes in motor and cognitive behaviors. Since thyroid hormones function as endogenous regulators of oxidative stress, we postulate that age-related thyroid dysfunction could be a crucial pathology in the increased TBI severity. By surgically removing the thyroid glands, which recapitulates the age-related increase in TBI-susceptible phenotypes, we provide direct evidence showing that endogenous thyroid hormone-dependent compensatory regulation of antioxidant events modulates individual TBI susceptibility, which is abolished in aged or thyroidectomized individuals. The antioxidant capacity of melatonin is well-known, and we found acute melatonin treatment but not liothyronine (T3) supplementation improved the TBI-susceptible phenotypes of oxidative stress, excitotoxic neuronal loss and promotes functional recovery in the aged individuals with thyroid dysfunction. Our study suggests that monitoring thyroid function and acute administration of melatonin could be feasible therapeutics in the management of geriatric-TBI in clinic.

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.

White matter degradation near cerebral microbleeds is associated with cognitive change after mild traumatic brain injury

To explore how cerebral microbleeds (CMBs) accompanying mild traumatic brain injury (mTBI) reflect white matter (WM) degradation and cognitive decline, magnetic resonance images were acquired from 62 mTBI adults (imaged ∼7 days and ∼6 months post-injury) and 203 matched healthy controls. On average, mTBI participants had a count of 2.7 ± 2.6 traumatic CMBs in WM, located 6.1 ± 4.4 mm from cortex. At ∼6-month follow-up, 97% of CMBs were associated with significant reductions (34% ± 11%, q < 0.05) in the fractional anisotropy of WM streamlines within ∼1 cm of CMB locations. Male sex and older age were significant risk factors for larger reductions (q < 0.05). For CMBs in the corpus callosum, cingulum bundle, inferior and middle longitudinal fasciculi, fractional anisotropy changes were significantly and positively associated with changes in cognitive functions mediated by these structures (q < 0.05). Our findings distinguish traumatic from non-traumatic CMBs by virtue of surrounding WM alterations and challenge the assumption that traumatic CMBs are neurocognitively silent. Thus, mTBI with CMB findings can be described as a clinical endophenotype warranting longitudinal cognitive assessment.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury Admitted to Inpatient Rehabilitation Facilities

Objective

To identify admission characteristics that predict a successful community discharge from an inpatient rehabilitation facility (IRF) among older adults with traumatic brain injury (TBI).

Design

In a retrospective cohort study, we leveraged probabilistically linked Medicare Administrative, IRF-Patient Assessment Instrument, and National Trauma Data Bank data to build a parsimonious logistic model to identify characteristics associated with successful discharge. Multiple imputation methods were used to estimate effects across linked datasets to account for potential data linkage errors.

Setting

Inpatient Rehabilitation Facilities in the U.S.

Participants

The sample included a mean of 1060 community-dwelling adults aged 66 years and older across 30 linked datasets (N=1060). All were hospitalized after TBI between 2011 and 2015 and then admitted to an IRF. The mean age of the sample was 79.7 years, and 44.3% of the sample was women.

Interventions

Not applicable.

Main Outcome Measures

Successful discharge home.

Results

Overall, 64.6% of the sample was successfully discharged home. A logistic model including 4 predictor variables: Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) scores, pre-injury chronic conditions, and pre-injury living arrangement, that were significantly associated with successful discharge, resulted in acceptable discrimination (area under the curve: 0.76, 95% confidence interval [CI]: 0.72-0.81). Higher scores on the FIM-M (odds ratio [OR]:1.07, 95% CI: 1.05-1.09) and FIM-C (OR: 1.05, 95% CI: 1.02-1.08) were associated with greater odds of successful discharge, whereas living alone vs with others (OR: 0.46, 95% CI: 0.30-0.71) and a greater number of chronic conditions (OR: 0.94, 95% CI: 0.90-0.99) were associated with lower odds of successful discharge.

Conclusions

The results provide a parsimonious model for predicting successful discharge among older adults admitted to an IRF after a TBI-related hospitalization and provide clinically useful information to inform discharge planning.

Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study

BACKGROUND

Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls.

OBJECTIVE

This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults.

METHODS

Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point.

RESULTS

Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes.

CONCLUSION

These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

Frailty independently predicts unfavorable discharge in non-operative traumatic brain injury: A retrospective single-institution cohort study

BACKGROUND

Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI).

OBJECTIVE

To assess relationships between frailty and outcomes after TBI.

METHODS

The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay.

RESULTS

100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14-15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0-1, n = 35, 35%) or high frailty (FRAIL score 2-5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI [1.02, 7.14], p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses.

CONCLUSION

Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.

Brain age estimation reveals older adults' accelerated senescence after traumatic brain injury

Adults aged 60 and over are most vulnerable to mild traumatic brain injury (mTBI). Nevertheless, the extent to which chronological age (CA) at injury affects TBI-related brain aging is unknown. This study applies Gaussian process regression to T1-weighted magnetic resonance images (MRIs) acquired within [Formula: see text]7 days and again [Formula: see text]6 months after a single mTBI sustained by 133 participants aged 20-83 (CA [Formula: see text] = 42.6 ± 17 years; 51 females). Brain BAs are estimated, modeled, and compared as a function of sex and CA at injury using a statistical model selection procedure. On average, the brains of older adults age by 15.3 ± 6.9 years after mTBI, whereas those of younger adults age only by 1.8 ± 5.6 years, a significant difference (Welch's t32 =  - 9.17, p ≃ 9.47 × 10-11). For an adult aged [Formula: see text]30 to [Formula: see text]60, the expected amount of TBI-related brain aging is [Formula: see text]3 years greater than in an individual younger by a decade. For an individual over [Formula: see text]60, the respective amount is [Formula: see text]7 years. Despite no significant sex differences in brain aging (Welch's t108 = 0.78, p > 0.78), the statistical test is underpowered. BAs estimated at acute baseline versus chronic follow-up do not differ significantly (t264 = 0.41, p > 0.66, power = 80%), suggesting negligible TBI-related brain aging during the chronic stage of TBI despite accelerated aging during the acute stage. Our results indicate that a single mTBI sustained after age [Formula: see text]60 involves approximately [Formula: see text]10 years of premature and lasting brain aging, which is MRI detectable as early as [Formula: see text]7 days post-injury.

Effect of Race and Nativity on Functional Outcomes Following Traumatic Brain Injury Among Asian, Hispanic, and Non-Hispanic White Survivors in the United States: A NIDILRR TBI Model Systems Study

OBJECTIVE

To compare the racial/ethnic differences in traumatic brain injury (TBI) recovery among Asians, Hispanics, and Whites, and explore the effect of nativity in the recovery process.

SETTING

Six Traumatic Brain Injury Model Systems (TBIMS) centers.

PARTICIPANTS

In total, 7953 patients who had at least 1 severe TBI between 2000 and 2016 were admitted to one of the TBIMS centers.

DESIGN

Secondary data analysis.

MAIN MEASURES

Functional Independent Measure (FIM instrument) ratings.

RESULTS

Asians had the lowest injury severity at admission, but they failed to make the improvements made by the Hispanics and the Whites between the rehabilitation discharge and the 1-year follow-up. The magnitude of improvement made by the foreign-born Asians was less than that made by their native-born counterparts. Both Asian and the Hispanic groups had lower functional outcomes at the 1-year follow-up, and the differences in functional outcomes between the Asian and Hispanic groups were not statistically significant. The above racial/ethnic disparities in functional outcomes were not fully explained by differences in sociodemographic status, injury characteristics, and immigration-related factors. The effect of nativity was mediated by covariates.

CONCLUSIONS

This study reveals racial/ethnic disparities post-TBI functional recovery. Despite lower injury severity and apparent financial resource advantages, Asians did not experience better functional outcomes. Although the effect of nativity was not established in this study, contextual factors related to ethnicity and immigration experiences should be further investigated.

Systematic Review and Meta-analysis of Outcome after Mild Traumatic Brain Injury in Older People

OBJECTIVE

Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation.

METHODS

Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation.

RESULTS

By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery.

CONCLUSIONS

Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.

Health care utilization and outcomes in older adults after Traumatic Brain Injury: A CENTER-TBI study

INTRODUCTION

The incidence of Traumatic Brain Injury (TBI) is increasingly common in older adults aged ≥65 years, forming a growing public health problem. However, older adults are underrepresented in TBI research. Therefore, we aimed to provide an overview of health-care utilization, and of six-month outcomes after TBI and their determinants in older adults who sustained a TBI.

METHODS

We used data from the prospective multi-center Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. In-hospital and post-hospital health care utilization and outcomes were described for patients aged ≥65 years. Ordinal and linear regression analyses were performed to identify determinants of the Glasgow Outcome Scale Extended (GOSE), health-related quality of life (HRQoL), and mental health symptoms six-months post-injury.

RESULTS

Of 1254 older patients, 45% were admitted to an ICU with a mean length of stay of 9 days. Nearly 30% of the patients received inpatient rehabilitation. In total, 554/1254 older patients completed the six-month follow-up questionnaires. The mortality rate was 9% after mild and 60% after moderate/severe TBI, and full recovery based on GOSE was reported for 44% of patients after mild and 6% after moderate/severe TBI. Higher age and increased injury severity were primarily associated with functional impairment, while pre-injury systemic disease, psychiatric conditions and lower educational level were associated with functional impairment, lower generic and disease-specific HRQoL and mental health symptoms.

CONCLUSION

The rate of impairment and disability following TBI in older adults is substantial, and poorer outcomes across domains are associated with worse preinjury health. Nonetheless, a considerable number of patients fully or partially returns to their preinjury functioning. There should not be pessimism about outcomes in older adults who survive.

Traumatic brain injury in the elderly population: a 20-year experience in a tertiary neurosurgery center in Belgium

PURPOSE

Traumatic brain injury (TBI) rates in the elderly population are rapidly increasing worldwide. However, there are no clinical guidelines for the treatment of elderly TBI to date. This study aims at describing injury patterns and severity, clinical management, and outcomes in elderly TBI patients, which may contribute to specific prognostic tools and clinical guidelines in the future.

METHODS

Clinical records of 2999 TBI patients ≥ 65 years old admitted in the University Hospital Leuven (Belgium) between 1999 and 2019 were manually screened and 1480 cases could be included. Records were scrutinized for relevant clinical data.

RESULTS

The median age in the cohort was 78.0 years (IQR = 12). Falls represented the main accident mechanism (79.7%). The median Glasgow Coma Score on admission was 15 (range 3-15). Subdural hematomas were the most common lesion (28.4%). 90.1% of all patients were hospitalized and 27.0% were admitted to intensive care. 16.4% underwent a neurosurgical intervention. 11.0% of all patients died within 30 days post-TBI. Among the 521 patients with mild TBI, 28.6% were admitted to ICU and 13.1% had a neurosurgical intervention and 30-day mortality was 6.9%.

CONCLUSION

Over the 20-year study period, an increase of age and comorbidities and a reduction in neurosurgical interventions and ICU admissions were observed, along with a trend to less severe injuries but a higher proportion of treatment withdrawals, while at the same time mortality rates decreased. TBI is a life-changing event, leading to severe consequences in the elderly population, especially at higher ages. Even mild TBI is associated with substantial rates of hospitalization, surgery, and mortality in elderly. The characteristics of the elderly population with TBI are subject to changes over time.

Age Moderates the Effect of Injury Severity on Functional Trajectories in Traumatic Brain Injury: A Study Using the NIDILRR Traumatic Brain Injury Model Systems National Dataset

Age is a risk factor for a host of poor outcomes following traumatic brain injury (TBI), with some evidence suggesting that age is also a source of excess disability. We tested the extent to which age moderates the effect of injury severity on functional trajectories over 15 years post injury. Data from 11,442 participants from the 2020 National Institute of Disability and Independent Living Rehabiitation Research (NIDILRR) Traumatic Brain Injury Model Systems (TBIMS) National Dataset were analyzed using linear mixed effects models. Injury severity was operationally defined using a composite of Glasgow Coma Scale scores, structural imaging findings, and the number of days with post-trauma amnesia. Functioning was measured using the Glasgow Outcomes Scale-Extended. Age at injury was the hypothesized moderator. Race, ethnicity, sex, education, and marital status served as covariates. The results showed a significant confounder-adjusted effect of injury severity and age of injury on the linear slope in functioning. The age effect was strongest for those with mild TBI. Thus, the effects of injury severity on functional trajectory were found to be moderated by age. To optimize outcomes, TBI rehabilitation should be developed specifically for older patients. Age should also be a major focus in TBI research.

A Prognostic Model for Predicting One-Month Outcomes among Emergency Department Patients with Mild Traumatic Brain Injury and a Presenting Glasgow Coma Scale of Fifteen

The lack of well-performing prognostic models for early prognostication of outcomes remains a major barrier to improving the clinical care of patients with mild traumatic brain injury (mTBI). We aimed to derive a prognostic model for predicting incomplete recovery at 1-month in emergency department (ED) patients with mTBI and a presenting Glasgow Coma Scale (GCS) score of 15 who were enrolled in the HeadSMART (Head Injury Serum Markers for Assessing Response to Trauma) study. The derivation cohort included 355 participants with complete baseline (day-of-injury) and follow-up data. The primary outcome measure was the Glasgow Outcome Scale Extended (GOSE) at 1-month and incomplete recovery was defined as a GOSE <8. At 1-month post-injury, incomplete recovery was present in 58% (n = 205) of participants. The final multi-variable logistic regression model included six variables: age in years (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.97-1.00), positive head CT (OR = 4.42; 95% CI: 2.21-9.33), history of depression (OR = 2.59; 95% CI: 1.47-4.69), and self-report of moderate or severe headache (OR = 2.49; 95% CI: 1.49-4.18), difficulty concentrating (OR = 3.17; 95% CI: 1.53-7.04), and photophobia (OR = 4.17; 95% CI: 2.08-8.92) on the day-of-injury. The model was validated internally using bootstrap resampling (1000 resamples), which revealed a mean over-optimism value of 0.01 and an optimism-corrected area under the curve (AUC) of 0.79 (95% CI: 0.75-0.85). A prognostic model for predicting incomplete recovery among ED patients with mTBI and a presenting GCS of 15 using easily obtainable clinical and demographic variables has acceptable discriminative accuracy. External validation of this model is warranted.

Impact of Age on Plasma Inflammatory Biomarkers in the 6 Months Following Mild Traumatic Brain Injury

OBJECTIVE

To compare plasma inflammatory biomarker concentrations to 6 months in young and older adults with and without mild traumatic brain injury (TBI).

SETTING

Level 1 trauma center.

PARTICIPANTS

Younger (21-54 years) and older (55+) adults diagnosed with mild TBI along with age-/sex-matched noninjured controls (n = 313).

DESIGN

Prospective cohort study.

MAIN MEASURES

Multiplex assays were used to quantify concentrations of selected plasma inflammatory markers at day 0, months 1 and 6.

RESULTS

Persistent aging-related differences were found between control groups in concentrations of 4 cytokines up to 6 months. At day 0, interleukin-6 (IL-6), IL-8, and fractalkine were higher in the older TBI compared with older control as well as the younger TBI groups, while IL-10 was higher in older TBI compared with controls. At month 1, significantly higher concentrations of IL-8, fractalkine, and tumor necrosis factor-α (TNF-α) were seen. At 6 months postinjury, significantly higher concentrations of IL-6 and IL-8 were seen, while a lower concentration of IL-7 was found in older versus younger TBI groups.

CONCLUSION

The neuroinflammatory signature that accompanies mild TBI in older adults differs from that of younger adults. The differences seen are notable for their roles in neutrophil attraction (IL-8), neuronal-microglial-immune cell interactions (fractalkine), and chronic inflammation (IL-6).

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.

Barriers and facilitators linked to discharge destination following inpatient rehabilitation after traumatic brain injury in older adults: a qualitative study

PURPOSE

To identify facilitators and barriers associated with returning home for older adults having received inpatient rehabilitation after traumatic brain injury (TBI).

METHODS

A qualitative design was used. Five older patients with TBI and four family caregivers were interviewed and six healthcare professionals participated in a focus group.

RESULTS

Main facilitators to returning home highlighted by all participants were: (1) Patient's adequate health condition and functional status, (2) Access to health and other services at home, (3) Availability of help from a family caregiver. Conversely, if one of these factors was not met, it represented a barrier. Other facilitators identified were (4) Attachment to one's home, (5) Feeling of commitment toward a loved one, (6) Having the possibility of going through a transitional phase, (7) United front between the patient and the family caregiver towards a return home. Additional barriers to returning home included: (8) Incongruent perspectives, and (9) Unclear knowledge about available health and other services at home.

CONCLUSION

The results of this study could be translated into a practical tool to guide patients, families and professionals in the decision about returning home or exploring an alternative option after inpatient rehabilitation for TBI in older adults.IMPLICATIONS FOR REHABILITATIONWhen orienting an older patient home or to an alternative living environment after a traumatic brain injury (TBI), the perspective of rehabilitation professionals can differ from that of patients and caregivers.Professionals tend to emphasize security, whereas patients and caregivers' focus on the well-being associated with home and on the importance of being with their loved one.Integrating the views, values and wishes of older patients with TBI and their caregivers will support a shared decision-making approach for orientation after rehabilitation.

Predictive Performance of Traumatic Brain Injury Biomarkers in High-Risk Elderly Patients

BACKGROUND

Serum glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal esterase L1 (UCH-L1) have recently received US Food and Drug Administration approval for prediction of abnormal computed tomography (CT) in mild traumatic brain injury patients (mTBI). However, their performance in elderly patients has not been characterized.

METHODS

We performed a posthoc analysis using the A Prospective Clinical Evaluation of Biomarkers of Traumatic Brain Injury (ALERT-TBI) study data. Previously recorded patient variables and serum values of GFAP and UCH-L1 from mTBI patients were partitioned at 65 years of age (herein referred to as ≥65, high-risk; <65, low-risk). We sought to assess the influence of age on predictive performance, sensitivity, and negative predictive value (NPV) of serum UCH-L1 and GFAP to predict intracranial injury by CT.

RESULTS

Elderly mTBI patients constituted 25.7% of the patient cohort (n = 504/1959). Sensitivity and NPV of GFAP/UCH-L1 were 100%, with no significant difference from younger patients (P = 0.5525 and P > 0.9999, respectively). Specificity was significantly lower in elderly patients (0.131 vs 0.442; P < 0.0001) and decreased stepwise with older age. Compared to younger patients, elderly mTBI patients without abnormal (i.e., normal) CT findings also had a significantly higher GFAP (38.6 vs 16.2 pg/mL; P < 0.0001) and UCH-L1 (347.4 vs 232.1 pg/mL; P < 0.0001).

CONCLUSIONS

Sensitivity and NPV to predict intracranial injury by CT was nearly identical between younger and elderly mTBI patients. Decrements in specificity and increased serum values suggest that special deference may be warranted for elderly patients.

Acute cognitive impairment after traumatic brain injury predicts the occurrence of brain atrophy patterns similar to those observed in Alzheimer's disease

Traumatic brain injuries (TBIs) are often followed by persistent structural brain alterations and by cognitive sequalae, including memory deficits, reduced neural processing speed, impaired social function, and decision-making difficulties. Although mild TBI (mTBI) is a risk factor for Alzheimer's disease (AD), the extent to which these conditions share patterns of macroscale neurodegeneration has not been quantified. Comparing such patterns can not only reveal how the neurodegenerative trajectories of TBI and AD are similar, but may also identify brain atrophy features which can be leveraged to prognosticate AD risk after TBI. The primary aim of this study is to systematically map how TBI affects white matter (WM) and gray matter (GM) properties in AD-analogous patterns. Our findings identify substantial similarities in the regional macroscale neurodegeneration patterns associated with mTBI and AD. In cerebral GM, such similarities are most extensive in brain areas involved in memory and executive function, such as the temporal poles and orbitofrontal cortices, respectively. Our results indicate that the spatial pattern of cerebral WM degradation observed in AD is broadly similar to the pattern of diffuse axonal injury observed in TBI, which frequently affects WM structures like the fornix, corpus callosum, and corona radiata. Using machine learning, we find that the severity of AD-like brain changes observed during the chronic stage of mTBI can be accurately prognosticated based on acute assessments of post-traumatic mild cognitive impairment. These findings suggest that acute post-traumatic cognitive impairment predicts the magnitude of AD-like brain atrophy, which is itself associated with AD risk.

Factors affecting functional outcomes of traumatic brain injury rehabilitation at a rehabilitation facility in Saudi Arabia

Objectives:

To identify the factors that affect disability after inpatient rehabilitation (IPR) in persons with traumatic brain injury (TBI).

Methods:

This retrospective study identified 140 patients aged ≥16 years who were admitted to the TBI rehabilitation unit at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia between 2015 and 2017. The collected data included demographic variables, TBI cause, coma duration, time from injury to IPR, LOS, and Functional Independence Measure (FIM) scores at IPR admission and discharge.

Results:

Majority of the patients were young males. The TBI was caused by motor vehicle accidents (MVA) in 95% of patients. The mean coma duration, time from injury to IPR admission, and LOS were 47±38, 264±357, and 75±52 days, respectively. The factors that were found to have an association with FIM change were time from injury to IPR admission (p=0.003, r=-0.250), admission FIM score (p=0.003, r=-0.253), and discharge FIM score (p<0.001, r=0.390). Employed patients had high FIM scores at admission (p=0.029, r=0.184) and discharge (p=0.003, r=0.252).

Conclusion:

Reduction in disability at discharge was positively associated with the severity of disability at admission and negatively with the time duration from injury to IPR admission, indicating a need to reduce time before admittance to an IPR setup. The high incidence of MVA causing TBI in a young male population strongly points to a need for appropriate measures of prevention.

Management of Mild Brain Trauma in the Elderly: Literature Review

Purpose

The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly.

Methods

Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients.

Results

A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies.

Conclusion

Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION

Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION

A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS

Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS

Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).

The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma

BACKGROUND

Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations.

MATERIALS AND METHODS

We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared.

RESULTS

In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm.

CONCLUSIONS

Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.

Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome

Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management.

Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment.

Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome.

Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.

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

Introduction

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

Research question

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

Materials and methods

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

Results

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

Discussion and conclusion

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

•

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

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury

OBJECTIVE

To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation.

DESIGN

Retrospective cohort.

SETTING

Six TBI Model Systems (TBIMS) centers.

PARTICIPANTS

In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity.

RESULTS

At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders.

CONCLUSIONS

People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

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.

Factors with the strongest prognostic value associated with in-hospital mortality rate among patients operated for acute subdural and epidural hematoma

INTRODUCTION

Traumatic brain injury (TBI) still remains a serious health problem and is called a "silent epidemic". Each year in Europe 262 per 100,000 individuals suffer from TBI. The most common consequence of severe head injuries include acute subdural (SDH) and epidural hematomas (EDH), which usually require immediate surgically treatment. The aim of our study is to identify factors which have the strongest prognostic value in relation to in-hospital mortality rate among of patients undergoing surgery for EDH and SDH.

PATIENTS AND METHODS

Cohort included 128 patients with isolated craniocerebral injuries who underwent surgery for EDH (28 patients) and SDH (100 patients) in a single, tertiary care Department of Neurosurgery. The data were collected on admission of patients to the Emergency Department and retrospectively analyzed. The following factors were analyzed: demographic data, physiological parameters, laboratory variables, computed tomography scan characteristics and the time between trauma and surgery. Likewise, we have investigated the in-hospital mortality of patients at the time of discharge.

RESULTS

We found that the factors with the strongest prognostic values were: the initial GCS score, respiratory rate, glycaemia, blood saturation, systolic blood pressure, midline shift and type of hematoma. Additionally, we proved that a drop by one point in the GCS score almost doubles the risk of in-hospital death while the presence of coagulopathy increases the risk of in-hospital death almost six times.

CONCLUSION

Most of the factors with the strongest prognostic value are factors that the emergency team can treat prior to the hospital admission. Coagulopathy, however that has the strongest influence on in-hospital death rate can only be efficiently treated in a hospital setting.

Exploring the relationship between visuospatial function and age-related deficits in motor skill transfer

BACKGROUND

Generalizing learned information from one motor task to another is critical for effective motor rehabilitation. A recent study demonstrated age-related declines in motor skill transfer, yet findings from other motor learning studies suggest that visuospatial impairments may explain such aging effects.

AIMS

The purpose of this secondary analysis was to test whether age-related deficits in motor skill transfer were related to low visuospatial ability.

METHODS

Forty-two participants (mean ± SD age: 72.1 ± 9.9 years) were tested on an upper extremity dexterity task before and after 3 days of training on an upper extremity reaching task. Training and control data have been published previously. Prior to training, global cognitive status and specific cognitive domains (visuospatial/executive, attention, and delayed memory) were evaluated using the Montreal Cognitive Assessment.

RESULTS

Backward-stepwise linear regression indicated that the Visuospatial/Executive subtest was related to motor skill transfer (i.e., the amount of change in performance on the untrained motor task), such that participants with higher visuospatial scores improved more on the untrained dexterity task than those with lower scores. Global cognitive status was unrelated to motor skill transfer.

DISCUSSION

Consistent with previous studies showing a positive relationship between visuospatial function and other aspects of motor learning, this secondary analysis indicates that less motor skill transfer among older adults may indeed be due to declines in visuospatial function.

CONCLUSIONS

The present study highlights the potential utility of assessing older patients' visuospatial ability within motor rehabilitation to provide valuable insight into the extent to which they may learn and generalize motor skills through training.

One-year mortality in geriatric trauma patients: Improving upon the geriatric trauma outcomes score utilizing the social security death index

BACKGROUND

Geriatric Trauma Outcomes Score (GTOS) predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients.

METHODS

The Parkland Memorial Hospital Trauma registry was queried for patients 65 years or older from 2001 to 2013. Patients were then matched to the Social Security Death Index. The primary outcome was 1-year mortality. The original GTOS formula (variables of age, Injury Severity Score [ISS], 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III).

RESULTS

There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8%, 1 year; 17.8%, 2 years; and 22.6%, 5 years. The original GTOS equation had an area under the curve of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 years vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS score (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p < 0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict 1-year mortality: (GTOSIII = age + [0.806 × ISS] + 5.55 [if transfusion in first 24 hours] + 21.69 [if low GCS] + 34.36 [if adverse discharge]); area under the curve of 0.878.

CONCLUSION

Traumatic injury in geriatric patients is associated with high mortality rates at 1 year to 5 years. GTOS III has robust test characteristics to predict death at 1 year and can be used to guide patient centered goals discussions with objective data.

LEVEL OF EVIDENCE

Prognostic, level III.

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.

Age, symptoms, and functional outcome after mild traumatic brain injury

OBJECTIVES

Previous older adult studies have examined outcome from moderate-to-severe traumatic brain injury (TBI), but fewer have focused on the effects of milder brain injuries. This study examined age-related differences in symptom reporting and whether symptoms are differentially related to functional outcome based on age.

MATERIALS & METHODS

Patients presenting with a head injury at the Tampere University Hospital emergency department (N = 325, aged 18-100) were evaluated at 1 week post injury on the Modified Rankin Scale and Rivermead Post Concussion Symptoms Questionnaire (RPQ).

RESULTS

A quarter of participants had missing RPQ data, with missingness associated with greater age and strongly associated with pre-existing functional impairment, dementia, and/or neurological conditions. Among participants with complete data, participants <65 years old endorsed headaches, noise/light sensitivity, irritability, and frustration/impatience at a greater frequency than participants ≥65 years old. However, no differences were found in the number of symptoms endorsed or the total symptom severity score. The correlations between the severity of symptoms and change in function were similar between the two age groups.

CONCLUSIONS

Older adults tended to report fewer symptoms, but symptoms had a roughly equivalent relationship with declines in functioning across age groups. A large percentage of older adults in this study had pre-injury dementia or neurological disease that contributed to missing data on the 1-week outcome measures. The results provide insight into the impact of mild spectrum TBI on older adults compared to younger patients.

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.

Ethanol consumption following mild traumatic brain injury is related to blood-brain barrier permeability

Several preclinical and clinical studies that deal with the neuropathological consequences of mild traumatic brain injury (mTBI) have focused on unraveling its effect on ethanol drinking behavior. Previous reports describe changes in ethanol consumption, both in animal models of mTBI as well as in patients, after concussive brain injury. However, the neurobiological mechanisms underlying this phenomenon are still poorly understood. In the present study, we used a unique model of mouse lines divergently selected for high (HA) or low (LA) swim stress-induced analgesia to examine the effect of mTBI on ethanol drinking behavior. In comparison with LA mice, their HA counterparts exhibited increased blood-brain barrier (BBB) permeability, lower basal alcohol preference, and lower level of stress-induced ethanol intake. Here, we showed that mTBI attenuates voluntary ethanol intake in LA, but not in HA mice. Interestingly, BBB disruption after mannitol infusion also decreases the level of ethanol drinking behavior in this line. We conclude that in alcohol-preferring LA mice, BBB disruption as a consequence of mTBI attenuates ethanol consumption. Our results suggest that the innate level of BBB integrity plays a pivotal role in regulation of ethanol consumption in mice showing differential endogenous opioid system activity.