Changing Demographic Profiles of Patients With Traumatic Brain Injury: An Aging Concern

Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals

BACKGROUND

Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population.

METHODS

We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses.

FINDINGS

We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality.

CONCLUSIONS

In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population.

REVIEW REGISTRATION

PROSPERO CRD42022323231.

Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups

Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.

Quality of life and psychological health after mild traumatic brain injury in older people: Three- and six-month follow up

OBJECTIVES

Examine quality of life (QoL) and psychological health after mild traumatic brain injury (mTBI) in older people (65+ years) at 3- and 6-month follow-up and explore which injury factors predicted QoL.

METHODS

mTBI patients were compared to trauma comparison (TC) and community comparison (CC) groups. QoL and psychological health were measured at both timepoints. After accounting for 3-month psychological health, injury severity, neuroimaging, and 3-month neuropsychological performance were assessed as predictors of 6-month QoL.

RESULTS

Overall 3-month QoL was lower for mTBI (Cohen's d = 0.938) and TC (Cohen's d = 0.485) groups compared to CCs, but by 6 months only mTBI patients continued to report poorer overall QoL (Cohen's d = 0.577) and physical QoL (Cohen's d = 0.656). Despite group differences, QoL for most (~92%) was within normative limits. 3-month psychological health predicted QoL 6-months postinjury (β = -.377, 95% CI -.614, -.140) but other proposed risk factors (GCS <15, neuroimaging, 3-month neuropsychological performance) did not uniquely predict QoL.

CONCLUSIONS

Older adults following mTBI reported lower QoL up to 6-months postinjury compared to non-injured peers, indicating that mTBI patients were particularly susceptible to ongoing differences in QoL 6-months postinjury.

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.

Changing Epidemiology and Functional Outcomes of Inpatient Rehabilitation in Asian Traumatic Brain Injury Cases before and during the COVID-19 Pandemic: A Retrospective Cohort Study

BACKGROUND

This study aimed to compare acute injury and rehabilitation characteristics for traumatic brain injury (TBI) inpatients during the pre and post COVID-19 pandemic periods.

METHODS

A retrospective study of TBI inpatients between 1 April 2018 and 31 December 2019 (pre COVID-19 period), and 1 July 2020 and 31 March 2022 (post COVID-19 period) was performed to compare demographics, premorbid comorbidity, TBI characteristics, rehabilitation complications, admission and discharge functional independence measure (FIM^®), length of stay and discharge status.

RESULTS

A total of 187 data sets were analyzed (82 pre COVID-19 and 105 post COVID-19). Post COVID-19 TBI inpatients were older by 11 years (pre COVID-19 mean 55 years vs. post COVID-19 mean 66 years, and p < 0.001), with 23% higher female inpatients (pre COVID-19 13.4% vs. post COVID-19 36.2%, and p < 0.001) and 25% higher presence of comorbidities (pre COVID-19 52.4% vs. post COVID-19 77.1%, and p < 0.001). In the post COVID-19 group, total discharge FIM (Td-FIM) was significantly lower by ~12 points (pre COVID-19 94.5 vs. post COVID-19 82, and p = 0.011), Td-FIM ≥ 91 was lower by ~18% (pre COVID-19 53.7% vs. post COVID-19 36.2%, and p = 0.017), and the need for caregivers increased by ~17% (pre COVID-19 68% vs. post COVID-19 85.4%, and p = 0.006) Conclusions: Our findings signal a demographic shift towards older, frailer TBI with lower functional independence levels post COVID-19.

Different brain activation patterns in the prefrontal area between self-paced and high-speed driving tasks

The purpose of this study was to investigate the effects on prefrontal cortex brain activity when participants attempted to stop a car accurately at a stop line when driving at different speeds using functional near-infrared spectroscopy (fNIRS). Twenty healthy subjects with driving experience drove their own cars for a distance of 60 m five times each at their own pace or as fast as possible. The variation in the distance between the stop line and the car was not significantly different between the self-paced and high-speed tasks. However, oxygenated hemoglobin concentration in the prefrontal cortex was significantly higher in the high-speed task than in the self-paced task. These findings suggest that driving at high speed requires more divided attention than driving at self-paced speed, even though the participants were able to stop the car at the same distance from the target. This study shows the advantages and usefulness of fNIRS .

Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients

BACKGROUND

Mortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI (_ITBI) patients and polytrauma patients with TBI (_PTBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients.

METHODS

A 3-year cohort study compared polytrauma patients with TBI (_PTBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI (_ITBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences.

RESULTS

259 patients were included; 111 _PTBI and 148 _ITBI patients. The median age was 54 [33-67] years, 177 (68%) patients were male, median ISS was 26 [20-33]. Seventy-nine (31%) patients died. Patients with _PTBI developed more ARDS (7% vs. 1%, p = 0.041) but had similar MODS rates (18% vs. 10%, p = 0.066). They also stayed longer on the ventilator (7 vs. 3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with _PTBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards _ITBI patients (24% vs. 35%, p = 0.06).

DISCUSSION

There was no difference in mortality rates between _PTBI and _ITBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.

Demographics of traumatic brain injury and outcomes of continuous chain of early rehabilitation in Singapore

Background:

Evidence shows that early initiation of a continuous chain of rehabilitation is associated with better functional outcomes in traumatic brain injured patients. The Department of Rehabilitation Medicine initiated early screening and review of patients with all traumatic brain injury (TBI) severity within 72 hours of acute admission, followed by direct transfer of suitable patients to acute inpatient rehabilitation (AIR).

Objectives:

This study aim to document the demographics and clinical characteristics of all TBI patients admitted to the local acute hospital; determine the characteristics of patients with TBI who are directly transferred to AIR following early screening and review; and determine clinical predictors affecting functional outcomes of patients of all TBI severity.

Methods:

A total of 491 patients were screened and reviewed; 116 patients were directly transferred to AIR.

Results:

The median age of the screened cohort was 67.0 years (interquartile range 50.0–77.0 years). Falls were the leading mechanism of TBI. Infection (odds ratio (OR)=2.95, 95% confidence interval (CI) 1.59–5.49) and neurosurgical intervention (OR=2.18, 95% CI 1.24–3.81) increased the odds of transfer to AIR. The Functional Independence Measure (FIM) gain after receiving AIR was significant ( p<0.001). Increased age, complications, high motor admission FIM (AFIM) and long rehabilitation length of stay (RLOS) were negatively associated with FIM gain and FIM efficiency.

Conclusions:

Our study demonstrated that falls were the leading mechanism of TBI, with the majority of patients being older. Infection and neurosurgical intervention increased the likelihood of transfer to AIR. There was functional improvement after AIR. Age, complications, motor AFIM and RLOS were negatively associated with FIM gain and FIM efficiency. Further local research is warranted to confirm these findings.

Severe traumatic brain injury (TBI) - a seven-year comparative study in a Department of Forensic Medicine

Deaths caused by traumatic brain injury (TBI) increase in incidence every year worldwidely, mainly in developing countries. Thus, World Health Organization (WHO) estimates that in 2020, TBI will become the third main cause of death. In our study, we evaluated the deaths caused by TBI recorded within the Institute of Forensic Medicine of Craiova, Romania, between 2011 and 2017. Therefore, according to age, the cases were divided into two groups: people aged 0-18 years old (including 18 years old) and people aged over 18 years old (a total of 1005 cases, of which 971 were adults and 34 included in the age group 0-18 years old). In both groups, most patients were males from the rural area. In adults, falling was the main legal entity of the cases, followed by car accidents (which were the most common in children). In both groups, in car accidents, most of them were pedestrians and car occupants. Various aggressions (human, animal, self-injury) were found in 94 (9.68%) of the adult cases and in four (11.76%) cases of children. Another parameter under study was the blood alcohol concentration, being observed that most of the subjects with positive blood alcohol content died from car accidents. By evaluating the Glasgow Coma Scale (GCS) score as a prognostic factor, most of the subjects presented third and fourth degree coma at admission; still, 5.14% of the adult patients who deceased had GCS score 15 at admission, death occurring probably by developing some intracranial hematomas in time. Regarding the morphology of the lesions, most patients presented various forms of cranial fractures, 185 (19.05%) adults in association with extradural hemorrhages∕hematomas, but also there were four cases with extradural hematomas without any cranial fractures. In children, there was highlighted a single case of extradural hemorrhage under the fracture line. Seventy-eight percent of the adults and 44.12% of children presented subdural hematomas associated with other meningo-cerebral lesions. Also, 83.63% of the adults and 97% of children presented brain contusions. In both groups, brain laceration was observed in approximately 50% of the cases.