Traumatic brain injury in older adults: epidemiology, outcomes, and future implications

Risk factors and consequences of traumatic brain injury in a Swiss male population cohort

OBJECTIVE

To investigate the risk factors for and the consequences (ie, substance use disorders (SUD), depression, personality traits) of traumatic brain injury (TBI) in young Swiss men.

DESIGN

This is a three-wave cohort study. Risk factors were measured at baseline (2010-2012) and at follow-up 1 (FU1; 2012-2014), while the consequences and TBI were measured at follow-up 2 (FU2; 2016-2018).

SETTING

Switzerland.

PARTICIPANTS

All participants at FU2 (Mage=25.43, SD=1.25) of the Cohort Study on Substance Use Risk Factors (N=4881 young Swiss men after listwise deletion).

MEASURES

The outcomes measured were TBI, SUD (ie, alcohol, nicotine, cannabis, other illicit drugs), depression and personality traits (ie, sensation seeking, anxiety-neuroticism, sociability, aggression-hostility) at FU2. The predictors were previous TBI (lifetime TBI but not in the past 12 months at FU2), SUD, personality traits and sociodemographics (highest level of achieved education, age, linguistic region) measured at FU1.

RESULTS

At FU2, 3919 (80.3%) participants reported to never have had TBI, 102 (2.1%) have had TBI in the last 12 months (TBI new cases), and 860 (17.6%) have had TBI during their lifetime but not in the 12 months preceding FU2 (previous TBI). Low educational attainment (OR=3.93, 95% CI 2.10 to 7.36), depression (OR=2.87, 95% CI 1.35 to 6.11), nicotine dependence (OR=1.72, 95% CI 1.09 to 2.71), high sociability (OR=1.18, 95% CI 1.07 to 1.30), high aggression-hostility (OR=1.15, 95% CI 1.06 to 1.26) and high sensation seeking (OR=1.33, 95% CI 1.04 to 1.68) at FU1 were significantly associated with TBI new cases at FU2. Previous TBI was significantly associated with nicotine dependence (OR=1.46, 95% CI 1.16 to 1.83), depression (OR=2.16, 95% CI 1.56 to 2.99) and aggression-hostility (B=0.14, 95% CI >0.00 to 0.28) at FU2.

CONCLUSION

Low educational attainment and depression are the most significant risk factors associated with increased odds of future TBI, while depression, nicotine dependence and high aggression-hostility are the main consequences of previous TBI. TBI should be considered an underlying factor in the treatment of depression, SUD or unfavourable personality profiles.

Sentinel fall presenting to the emergency department (SeFallED) - protocol of a complex study including long-term observation of functional trajectories after a fall, exploration of specific fall risk factors, and patients' views on falls prevention

BACKGROUND

Falls are a leading cause for emergency department (ED) visits in older adults. As a fall is associated with a high risk of functional decline and further falls and many falls do not receive medical attention, the ED is ideal to initiate secondary prevention, an opportunity generally not taken. Data on trajectories to identify patients, who would profit the most form early intervention and to examine the impact of a fall event, are lacking. To tailor interventions to the individual's needs and preferences, and to address the whole scope of fall risks, we developed this longitudinal study using an extensive assessment battery including dynamic balance and aerobic fitness, but also sensor-based data. Additionally, participative research will contribute valuable qualitative data, and machine learning will be used to identify trips, slips, and falls in sensor data during daily life.

METHODS

This is a mixed-methods study consisting of four parts: (1) an observational prospective study, (2) a randomized controlled trial (RCT) to explore whether a diagnostic to measure reactive dynamic balance influences fall risk, (3) machine learning approaches and (4) a qualitative study to explore patients' and their caregivers' views. We will target a sample size of 450 adults of 60 years and older, who presented to the ED of the Klinikum Oldenburg after a fall and are not hospitalized. The participants will be followed up over 24 months (within four weeks after the ED, after 6, 12 and 24 months). We will assess functional abilities, fall risk factors, participation, quality of life, falls incidence, and physical activity using validated instruments, including sensor-data. Additionally, two thirds of the patients will undergo intensive testing in the gait laboratory and 72 participants will partake in focus group interviews.

DISCUSSION

The results of the SeFallED study will be used to identify risk factors with high predictive value for functional outcome after a sentinel fall. This will help to (1) establish a protocol adapted to the situation in the ED to identify patients at risk and (2) to initiate an appropriate care pathway, which will be developed based on the results of this study.

TRIAL REGISTRATION

DRKS (Deutsches Register für klinische Studien, DRKS00025949 ). Prospectively registered on 4^th November, 2021.

Prevalence of chronic traumatic encephalopathy in the Sydney Brain Bank

Chronic traumatic encephalopathy neuropathologic change can only be definitively diagnosed post-mortem. It has been associated with repetitive mild neurotrauma sustained in amateur and professional contact, collision and combat sports, although it has also been documented in people with a single severe traumatic brain injury and in some people with no known history of brain injury. The characteristic neuropathology is an accumulation of perivascular neuronal and astrocytic phosphorylated tau in the depths of the cortical sulci. The tau-immunopositive neurons and astrocytes that are considered pathognomonic for chronic traumatic encephalopathy are morphologically indistinguishable from Alzheimer-related neurofibrillary tangles and ageing-related tau astrogliopathy, respectively, although they are found in different spatial distributions throughout the cortex. The Sydney Brain Bank collection consists of neurodegenerative diseases and neurologically normal controls. We screened 636 of these cases for chronic traumatic encephalopathy neuropathologic change. A subset of 109 cases had a known history of traumatic brain injury. Three cortical regions were screened for the presence of neuronal and astrocytic phosphorylated tau according to the current 2021 National Institute on Neurological Disorders and Stroke/National Institute of Biomedical Imaging and Bioengineering consensus criteria for chronic traumatic encephalopathy. Five cases (0.79%) showed pathological evidence of chronic traumatic encephalopathy and three of these had a history of traumatic brain injury. Three cases had coexisting Alzheimer’s and/or Lewy body disease pathology meeting criteria for neurodegenerative disease. Another eight cases almost met criteria for chronic traumatic encephalopathy neuropathological change except for an absence of neuronal tau or a strict perivascular arrangement. Ageing-related tau astrogliopathy was found in all eight cases as a coexisting neuropathology. Traumatic brain injury was associated with increased odds ratio [1.79, confidence interval 1.18–2.72] of having a higher neurofibrillary tangle stage and phosphorylated TAR DNA binding protein 43 (OR 2.48, confidence interval 1.35–4.54). Our study shows a very low rate of chronic traumatic encephalopathy neuropathological change in brains with or without neurodegenerative disease from the Sydney Brain Bank. Our evidence suggests that isolated traumatic brain injury in the general population is unlikely to cause chronic traumatic encephalopathy neuropathologic change but may be associated with increased brain ageing.

Repetitive Traumatic Brain Injury Among Older Adults

OBJECTIVE

To determine the incidence of and assess risk factors for repetitive traumatic brain injury (TBI) among older adults in the United States.

DESIGN

Retrospective cohort study.

SETTING

Administrative claims data obtained from the Centers for Medicare & Medicaid Services' Chronic Conditions Data Warehouse.

PARTICIPANTS

Individuals 65 years or older and diagnosed with TBI between July 2008 and September 2012 drawn from a 5% random sample of US Medicare beneficiaries.

MAIN MEASURES

Repetitive TBI was identified as a second TBI occurring at least 90 days after the first occurrence of TBI following an 18-month TBI-free period. We identified factors associated with repetitive TBI using a log-binomial model.

RESULTS

A total of 38 064 older Medicare beneficiaries experienced a TBI. Of these, 4562 (12%) beneficiaries sustained at least one subsequent TBI over up to 5 years of follow-up. The unadjusted incidence rate of repetitive TBI was 3022 (95% CI, 2935-3111) per 100 000 person-years. Epilepsy was the strongest predictor of repetitive TBI (relative risk [RR] = 1.44; 95% CI, 1.25-1.56), followed by Alzheimer disease and related dementias (RR = 1.32; 95% CI 1.20-1.45), and depression (RR = 1.30; 95% CI, 1.21-1.38).

CONCLUSIONS

Injury prevention and fall-reduction interventions could be targeted to identify groups of older adults at an increased risk of repetitive head injury. Future work should focus on injury-reduction initiatives to reduce the risk of repetitive TBI as well as assessment of outcomes related to repetitive TBI.

Gender Differences in Personal and Situational Risk Factors for Traumatic Brain Injury Among Older Adults

OBJECTIVE

To investigate differences between older men and women in Taiwan in personal and situational risk factors for sustaining a traumatic brain injury (TBI) versus soft-tissue injury (STI) due to a fall.

DESIGN

Matched case-control study.

PARTICIPANTS AND SETTINGS

Cases were defined as patients with a primary diagnosis of TBI due to a fall and were identified from those 60 years or older who visited the emergency department (ED) of 3 university-affiliated hospitals in 2015. Matched by the same hospital ED, gender, and time of falling, 3 controls who had no TBI and who had sustained only soft-tissue injury (STI) due to falling were selected for comparison with each case. Personal factors and situational exposures were compared between the control and case groups. In total, 96 cases and 288 controls in men and 72 cases and 216 controls in women participated in this study.

MAIN MEASURES

Personal factors (sociodemographic and lifestyle factors, medical characteristics, and functional abilities) and situational exposures (location, activities before the fall, center-of-mass change, type of fall, falling direction, protective response, and impact during the fall).

RESULTS

In men, after adjusting for other variables, older age (odds ratio [OR] = 1.04), regular alcohol use (OR = 2.03), an indoor fall (OR = 1.92), activity of getting in/out of bed (OR = 2.56), a fall due to dizziness (OR = 4.09), and falling backward (OR = 2.95) were independently associated with a higher odds of TBI. In women, an older age (OR = 1.03), the presence of Parkinson disease (OR = 10.4), activities of toileting (OR = 2.50), getting in/out of bed (OR = 4.90), and negotiating stairs (OR = 7.13), a fall due to dizziness (OR = 5.05), and falling backward (OR = 2.61) were independently associated with a higher odds of TBI.

CONCLUSIONS

Our results demonstrated similarities and differences in personal and situational risk factors for fall-related TBIs versus STIs between older men and women, and gender differences should be considered when developing intervention strategies.

Head injury among older adults and their clinical management: one year of emergency department attendances at a UK trauma center

OBJECTIVES

Primary: describe characteristics of adults aged ≥65 attending the Emergency Department (ED) at one major trauma center. Secondary: examine co-morbidities and complications; identify use of anticoagulant/antiplatelet medication among older adults presenting with Head Injury (HI); assess clinical management against UK guidelines.

METHODS

All ED admissions were screened prospectively to identify HI using case notes, hospital records and Trauma Audit Research Network data. Data were collected on demographics, cause and severity of injury, co-morbidities, anticoagulation/antiplatelet use, diagnostic imaging and discharge outcomes.

RESULTS

Over 12 months, 697 patients aged ≥65 years attended the ED for HI, representing over a quarter of adult ED attendances for HI. Mean age was 78.5 years (range 65-106), 395 (56.7%) were female. Most HIs were mild (93.5%) and 86% caused by falls. Three-quarters were discharged without hospital admission. Most had a preexisting medical condition andtaking medications prior to HI. Of these 116 were taking anticoagulants/antiplatelets but only 37 (31.9%) received a head CT scan. Half the patients were given a written HI information sheet at ED discharge.

CONCLUSIONS

Care of HI in older adults is challenging due to comorbidities. Practising evidence-based clinical management and following guidelines is important, but strict adherence is not common practice.

Application of a TEG-Platelet Mapping Algorithm to Guide Reversal of Antiplatelet Agents in Adults with Mild-to-Moderate Traumatic Brain Injury: An Observational Pilot Study

BACKGROUND

Traumatic intracranial hemorrhages expand in one third of cases, and antiplatelet medications may exacerbate hematoma expansion. However, the reversal of an antiplatelet effect with platelet transfusion has been associated with harm. We sought to determine whether a thromboelastography platelet mapping (TEG-PM)-guided algorithm could limit platelet transfusion in patients with hemorrhagic traumatic brain injury (TBI) prescribed antiplatelet medications without a resultant clinically significant increase in hemorrhage volume, late hemostatic treatments, or delayed operative intervention.

METHODS

A total of 175 consecutive patients with TBI were admitted to our university-affiliated, level I trauma center between March 2016 and December 2019: 54 preintervention patients (control) and 121 patients with TEG-PM (study). After exclusion for anticoagulant administration, availability of neuroimaging and emergent neurosurgery, 62 study patients and 37 control patients remained. Intervention consisted of administration of desmopressin (DDAVP) for nonsurgical patients with significant inhibition at the arachidonic acid or adenosine diphosphate receptor sites. For surgical patients with significant inhibition, dual therapy with DDAVP and platelet transfusion was employed. Study patients were compared with a group of historical controls, which were identified from a prospectively maintained registry and typically treated with empiric platelet transfusion.

RESULTS

Median age was 75 years (interquartile range 85-67) and 77 years (interquartile range 81-65) in the TEG-PM and control patient groups, respectively. Admission hemorrhage volumes were similar (10.7 cm³ [20.1] in patients with TEG-PM vs. 14.1 cm³ [19.7] in controls; p = 0.41). There were no significant differences in admission Glasgow Coma Scale, mechanism of trauma, or baseline comorbidities. A total of 57% of controls versus 10% of patients with TEG-PM (p < 0.001) were transfused platelets; 52% of intervention patients and 0% controls were treated with DDAVP. Expansion hemorrhage volumes were not significantly different (14.0 cm³ [20.2] patients with TEG-PM versus 13.6 cm³ [23.7] controls; p = 0.93). There was no significant difference in rates of clinical deterioration, delayed neurosurgical intervention, or late platelet transfusion between groups.

CONCLUSIONS

Among patients with hemorrhagic TBI prescribed preinjury antiplatelet therapy, our study suggests that the use of a TEG-PM algorithm may reduce platelet transfusions without a concurrent increase in clinically significant hematoma expansion. Further study is required to prove a causative relationship.

Mobile Technology for Falls Prevention in Older Adults

Falls are the leading cause of accidental death in older adults that result from a complex interplay of risk factors. Recently, the need for person-centered approach utilizing personalization, prediction, prevention and participation, known as the P4 model, in fall prevention has been highlighted. Features of mobile technology make it a suitable technological infrastructure to employ such an approach. This narrative review aims to review the evidence for using mobile technology for personalized fall risk assessment and prevention since 2017 in older adults. We aim to identify lessons learned and future directions for using mobile technology as a fall risk assessment and prevention tool. Articles were searched in PubMed and Web of Science with search terms related to older adults, mobile technology, and falls prevention. A total of 23 articles were included. Articles were identified as those examining aspects of the P4 model including prediction (measurement of fall risk), personalization (usability), prevention, and participation. Mobile technology appears to be comparable to gold-standard technology in measuring well-known fall risk factors including static and dynamic balance. Seven applications were developed to measure different fall risk factors and tested for personalization, and/or participation aspects, and four were integrated into a falls prevention program. Mobile health technology offers an innovative solution to provide tailored fall risk screening, prediction, and participation. Future studies should incorporate multiple, objective fall risk measures and implement them in community settings to determine if mobile technology can offer tailored and scalable interventions.

Long-Term Risk of Stroke after Traumatic Brain Injury: A Population-Based Medical Record Review Study

OBJECTIVE

To reliably inform secondary prevention strategies and reduce morbidity and mortality after traumatic brain injury (TBI), we sought to understand the long-term risk of stroke after TBI in patients aged 40 years and older in comparison to age- and sex-matched referents from a population-based cohort.

MATERIALS AND METHODS

TBI cases in Olmsted County, Minnesota from January 1, 1985, to December 31, 1999, were confirmed by manual review, classified by injury severity and mechanism, and nonhead trauma was quantified. Each TBI case was matched to 2 sex- and age-matched population-based referents without TBI and with similar severity nonhead trauma. Records of cases and referents were manually abstracted to confirm stroke diagnosis. Stroke events during initial hospitalization for TBI were excluded.

RESULTS

In total, 1,410 TBI cases were confirmed, 61% classified as possible TBI (least severe, consistent with concussive), with the most common mechanism being falls. There were 162 stroke events among those with TBI (11.5%) and 269 among referents (9.5%). Median time to stroke from the index date for those with TBI was 10.2 years (Q1-Q3 5.2-17.8), and for referents 12.1 years (Q1-Q3 6.2-17.3), p = 0.215. All-severity TBI was associated with increased risk of stroke (HR: 1.32, 95% CI: 1.06-1.63, p = 0.011), but only definite TBI (consistent with moderate-severe) was associated with significant risk (HR: 2.20, 95% CI: 1.04-4.64, p = 0.038) when stratified by severity.

DISCUSSION/CONCLUSION

By confirming TBI cases, stroke diagnoses, and injury severity classification using manual review with levels of accuracy not previously reported, these results indicate moderate-severe TBI increases long-term risk for stroke. These findings confirm the need to regularly assess long-term vascular risk after TBI to implement disease prevention strategies.

Long-Term Effects of Low-Level Blast Exposure and High-Caliber Weapons Use in Military Special Operators

Chronic low-level blast exposure has been linked with neurological alterations and traumatic brain injury (TBI) biomarkers. Impaired smooth-pursuit eye movements (SPEM) are often associated with TBI. The purpose of this study was to determine whether long-term operators of low-level blast exposure or high-caliber weapons use displayed oculomotor behaviors that differed from controls. Twenty-six members of an elite military unit performed a computerized oculomotor testing task using an eye tracker and completed a concussion assessment questionnaire. The participants were split into a blast exposure group and control group. The blast exposure group had a history of exposure to low-level blasts or high-caliber weapon use. The results revealed significant differences in SPEM, saccades, and fixations between the blast exposure group and control group. The blast exposure group's eye movements were slower, stopped at more frequent points when following a target, traveled further from the target in terms of both speed and direction, and showed higher rates of variation and inefficiency. Poor oculomotor behavior correlated with a higher symptom severity on the concussion assessment questionnaire. Military special operators exposed to long-term low-level blasts or high-caliber weapons usage displayed an impaired oculomotor behavior in comparison to controls. These findings further our understanding of the impact of long-term low-level blast exposure on the oculomotor behavior of military special operators and may inform practical implications for military training.

A cost-effectiveness and value of information analysis to inform future research of tranexamic acid for older adults experiencing mild traumatic brain injury

BACKGROUND

Tranexamic acid reduces head injury deaths in patients with CT scan evidence of intracranial bleeding after mild traumatic brain injury (TBI). However, the cost-effectiveness of tranexamic acid for people with mild TBI in the pre-hospital setting, prior to CT scanning, is uncertain. A large randomised controlled trial (CRASH-4) is planned to address this issue, but the economic justification for it has not been established. The aim of the analysis was to estimate the likelihood of tranexamic acid being cost-effective given current evidence, the treatment effects required for cost-effectiveness, and the expected value of performing further research.

METHODS

An early economic decision model compared usual care for mild TBI with and without tranexamic acid, for adults aged 70 and above. The evaluation was performed from a UK healthcare perspective over a lifetime time horizon, with costs reported in 2020 pounds (GBP) and outcomes reported as quality-adjusted life years (QALYs). All analyses used a £20,000 per QALY cost-effectiveness threshold.

RESULTS

In the base case analysis, tranexamic acid was associated with an incremental cost-effectiveness ratio of £4885 per QALY gained, but the likelihood of it being cost-effective was highly dependent on the all-cause mortality treatment effect. The value of perfect information was £22.4 million, and the value of perfect information for parameters that could be collected in a trial was £21.9 million. The all-cause mortality risk ratio for tranexamic acid and the functional outcomes following TBI had the most impact on cost-effectiveness.

CONCLUSIONS

There is a high degree of uncertainty in the cost-effectiveness of tranexamic acid for older adults experiencing mild TBI, meaning there is a high value of performing future research in the UK. The value in a global context is likely to be far higher.

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.

The Developments and Iterations of a Mobile Technology-Based Fall Risk Health Application

Falls are a prevalent and serious health concern across clinical populations. A critical step in falls prevention is identifying modifiable risk factors, but due to time constraints and equipment costs, fall risk screening is rarely performed. Mobile technology offers an innovative approach to provide personalized fall risk screening for clinical populations. To inform future development, this manuscript discusses the development and testing of mobile health fall risk applications for three unique clinical populations [older adults, individuals with Multiple Sclerosis (MS), and wheeled-device users]. We focus on key lessons learned and future directions to improve the field of fall risk mHealth. During the development phase, we first identified fall risk factors specific to each population that are measurable with mobile technology. Second, we determined whether inertial measurement units within smartphones can measure postural control within the target population. Last, we developed the interface of each app with a user-centered design approach with usability testing through iterative semi-structured interviews. We then tested our apps in real-world settings. Our cumulative work demonstrates that mobile technology can be leveraged to provide personalized fall risk screening for different clinical populations. Fall risk apps should be designed and tailored for the targeted group to enhance usefulness and feasibility. In addition, fall risk factors measured with mobile technology should include those that are specific to the population, are measurable with mobile technology, and can accurately measure fall risk. Future work should improve fall risk algorithms and implement mobile technology into fall prevention programs.

The Role of Intraventricular Hemorrhage in Traumatic Brain Injury: A Novel Scoring System

Traumatic intraventricular hemorrhage (tIVH) is associated with increased mortality and disability in traumatic brain injury (TBI). However, the significance of tIVH itself remains unclear. Our goal is to assess whether tIVH affects in-hospital mortality and short-term functional outcomes. We retrospectively reviewed the records of 5048 patients with TBI during a 5-year period, and 149 tIVH patients were analyzed. Confounding was reduced using the inverse probability of treatment weighting (IPTW) based on propensity score. The association between IVH and outcomes was investigated using logistic regression in the IPTW-adjusted cohort. In our study, after adjustment for analysis, the in-hospital mortality rate (11.4% vs. 9.2%) and the poor functional outcome rate (37.9% vs.10.6%) were significantly higher in the tIVH group than in the non-tIVH group. Factors independently associated with outcomes were age ≥ 65 years, Glasgow Coma Scale (GCS) severity score, and the Graeb score. The Traumatic Graeb Score, a novel scoring system for predicting functional outcomes associated with tIVH, comprised the sum of the following components: GCS scores of 3 to 4 (=2 points), 5 to 12 (=1 point), 13 to 15 (=0 points); age ≥ 65 years, yes (=1 point), no (=0 points); Graeb score (0-12 points). A Traumatic Graeb Score ≥ 4 is an optimal cutoff value for poor short-term functional outcomes.

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective

Concussion is a common yet heterogenous injury. Approximately 15-30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Hypertension and advanced age increase the risk of cognitive impairment after mild traumatic brain injury: A registry-based study

OBJECTIVE

As the global population ages, the incidence of traumatic brain injury (TBI) increases. While mild TBI can impair the cognitive function of older adults, the cause and background of mild TBI-induced cognitive impairment remains unclear, and the evaluation of risk factors for cognitive impairment after mild TBI remain open for consideration especially in the current aging society. This study aimed to evaluate the risks associated with cognitive impairment following mild TBI.

METHODS

Between January 2006 and December 2018, 2,209 patients with TBI required hospitalization in Shimane Prefectural Central Hospital. Mild TBI was defined as a Japan coma scale ≤ 10 at admission. The cognitive function of the patients was measured with the Hasegawa Dementia Rating Scale-revised or Mini-mental state examination at least twice during the patients' hospital stays. The odds ratio (OR) and 95% confidence interval (CI) of each considered risk factor was calculated with multivariable logistic regression analysis after univariate analysis.

RESULTS

Among 1,674 patients with mild TBI, 172 patients underwent cognitive function examinations, and 145 patients (84.3%) were found to have cognitive impairment at discharge. Significant risk factors for cognitive impairment included age (P = 0.008) and hypertension (P = 0.013) in univariate analysis; and age (OR 1.04: 95% CI 1.01-1.07) and hypertension (OR 5.81: 95% CI 1.22-27.68) by multivariable analysis.

CONCLUSIONS

Older patients with hypertension displayed significantly higher cognitive impairment risk after even mild TBI. For these patients, we should take carefully management even after mild TBI.

Longitudinal associations between falls and future risk of cognitive decline, the Motoric Cognitive Risk syndrome and dementia: the Einstein Ageing Study

BACKGROUND

falls share risk factors with cognitive decline but whether falls predict cognitive decline, pre-dementia syndromes and dementia is poorly understood.

OBJECTIVES

this study aimed to examine if falls are associated with cognitive decline in specific domains and the risk of Motoric Cognitive Risk (MCR) syndrome and dementia.

DESIGN

cross-sectional study.

METHODS

in older people (age 80.6 ± 5.3 years) free of dementia at baseline, the number of falls (none, one or multiple) during the year before enrolment and the first year of follow-up (exposure) were recorded. Decline in specific cognitive functions (global cognition, episodic verbal memory, verbal fluency, working memory, response inhibition and processing speed-attention), incident MCR and incident dementia were outcome measures. Linear mixed effects models were used to examine the associations between falls and cognitive decline, adjusting for confounders. Cox proportional hazards models were used to determine if falls predicted risk of incident MCR or dementia.

RESULTS

of 522 eligible participants, 140 had a single fall and 70 had multiple falls. Multiple falls were associated with a greater decline in global cognition, episodic memory, verbal fluency and processing speed-attention compared to those with no falls (P < 0.05). Over a median follow-up of 1.0 years 36 participants developed MCR and 43 participants developed dementia. Those with multiple falls had a two-fold increased risk of MCR compared to those with no falls, but no increased risk of developing dementia.

CONCLUSIONS

multiple falls may be an important marker to identify older people at greater risk of future cognitive decline and incident MCR.

Patients with Prior Craniectomy or Craniotomy Have No Increased Risk of Acute Hemorrhage after Mild Traumatic Brain Injury

The aim of this study was to retrospectively evaluate the risk of acute hemorrhagic complications in patients after either a decompressive craniectomy or a craniotomy sustaining a recurrent mild traumatic brain injury. Furthermore, we analyze whether there is a higher risk for acute hemorrhagic complications considering patients with anticoagulation compared with patients without anticoagulation in both groups. All patients with mild traumatic brain injuries after either decompressive craniectomy or craniotomy, treated between January 2005 and December 2020 at a single level 1 trauma center, were included in this retrospective analysis. Patients were screened for intracranial bleeding after mild traumatic brain injury with computed tomography. Additionally, the type of anticoagulation and its relationship concerning the clinical outcome were assessed. A total of 188 patients who had sustained a mild traumatic brain injury were included in the study. Overall, 22 patients (11.7%) presented intracranial lesions. A bony defect (decompressive craniectomy) was present in 31 patients (16.5%). In 157 patients (83.5%) who underwent decompressive craniectomy, the bony defect was closed during a second operation. There was no significant correlation between both groups on the occurrence of intracranial bleeding (p = 0.216). Furthermore, no difference was present between patients with and without anticoagulation (p = 0.794) concerning acute hemorrhagic complications after recurrent traumatic brain injury. Pre-existing bony defects after decompressive craniectomy showed no higher risk for acute hemorrhagic complications after recurrent mild traumatic brain injury compared with patients who primarily underwent craniotomy. Anticoagulation did not influence the occurrence of intracranial bleeding after mild traumatic brain injury in patients with decompressive craniectomy.

Epidemiological Characteristics of Older Patients with Traumatic Brain Injury in China

Increasing traumatic brain injury (TBI) among older adults constitutes a substantial socioeconomic burden, in step with the growing aging global population. Here, we aimed to investigate the profile of geriatric TBI in the CENTER-TBI China registry, a prospective observational study conducted in 56 centers of 22 provinces across China. Patients admitted to the hospital with a clinical diagnosis of TBI were enrolled in the study. Data on demographic characteristics, injury, clinical features, treatments, and survival at discharge were collected and assessed. The primary endpoint was survival state at discharge. We analyzed a total of 2415 patients aged ≥65 years, accounting for 18.34% of the overall population. The median age was 72 years (interquartile range [IQR]: 68-78), and 1588 (65.76%) were men. Incidental falls (n=1044, 43.23%) were the leading cause of TBI, followed by road traffic injuries (n=1034, 42.82%). Roads and homes were the main sites of injury. The median Glasgow Coma Scale (GCS) score was 13 (IQR: 9-15); 1397 (57.85%) patients had mild TBI (GCS 13-15), while 530 (21.95%) and 488 (20.21%) presented with moderate (GCS 9-12) and severe TBI (sTBI; GCS 3-8), respectively. A total of 546 (22.61%) patients underwent intracranial surgery. The overall in-hospital mortality rate was 8.24% (n=199), and most survivors were transferred home. This study revealed that the demographic patterns and injury mechanisms are changing among elderly patients with TBI in China. More attention should be given to the high incidence of geriatric TBI to improve prevention and management strategies.

Traumatic brain injury, cardiovascular disease, and risk of dementia among older US Veterans

OBJECTIVE

Traumatic brain injury (TBI) is associated with elevated rates of cardiovascular disease (CVD), and both CVD and TBI are risk factors for dementia. We investigated whether CVD and its risk factors underlie the association between TBI and dementia.

MATERIALS AND METHODS

Cox proportional hazards models among 195,416 Veterans Health Administration patients age 55+ with TBI and a non-TBI, age/sex/race-matched comparison sample.

RESULTS

Veterans +TBI were more likely to have any CVD diagnosis (24% vs 36% p = <0.001) or risk factor (83 vs. 90% p < .001) compared to -TBI. During follow-up (mean ~7 years), 12.0% of Veterans with TBI only (HR: 2.17 95% CI 2.09-2.25), and 10.3% with CVD only developed dementia (HR 1.21 95% CI 1.15-1.28), compared to 6.5% with neither. There was an additive association between TBI and CVD on dementia risk (HR 2.51, 95% CI 2.41-2.61). Among those +TBI (±CVD), risk was minimally attenuated by adjustment for CVD/CVD risk factors (unadjusted HR: 2.38, 95% CI: 2.31-2.45; adjusted HR: 2.17, 95% CI 2.10-2.23).

CONCLUSIONS

Older veterans TBI have increased prevalence of CVD/CVD risk factors. TBI and CVD had an additive statistical association, with dementia risk increased by ~2.5-fold. However, CVD accounted for little of the association between TBI and dementia. More research is needed to understand mechanisms of TBI-dementia and inform clinical guidelines post-TBI.

Oculomotor Behavior Predict Professional Cricket Batting and Bowling Performance

Importance: A new, shorter version of cricket was introduced recently (Twenty20; T20). Since its inception, T20 cricket has rapidly become a popular and exciting format of cricket. However, there is little understanding of factors such as visual-motor control that influence expert performance.

Objective: The purpose of this project is to determine if a series of oculomotor measures can predict batting and bowling performance in professional cricket players.

Design: This study used a cross-sectional design. Each participant took part in a suite of eye-tracking tests to measure oculomotor behavior compared to their performance data.

Participants: This study used a sample of 59 male T20 league professional cricket players (30 Bowlers and 29 Batsman).

Results: One-way univariate analyses of variance examined the differences in oculomotor behavior between batsman and bowlers. A series of multiple regression analyses was conducted to evaluate how well the visual variables predict bowling and batting performance variables. Results demonstrate that several oculomotor eye tracking measures were good predictors of run performance and strike rate, including sports total score, sports on-field score, and sports functional score. Likewise, several of the same metrics predicted Runs and Wicket performance for bowlers. Overall, results provided further validation to a growing body of literature supporting the use of eye-tracking technology in performance evaluation.

Traumatic brain injury in women across lifespan

Traumatic brain injury (TBI) is a leading cause of death and disability and a global public health challenge. Every year more than 50 million people suffer a TBI, and it is estimated that 50% of the global population will experience at least one TBI in their lifetime. TBI affects both men and women of all ages, however there is a male bias in TBI research as women have frequently been left out of the literature despite irrefutable evidence of male and female dimorphism in several posttraumatic measures. Women uniquely experience distinct life stages marked by levels of endogenous circulating sex hormones, as well as by physiological changes that are nonexistent in men. In addition to generalized sex-specific differences, a woman's susceptibility, neurological outcomes, and treatment success may vary considerably depending upon when in her lifespan she incurred a traumatic insult. How women impacted by TBI might differ from other women as a factor of age and physiology is not well understood. Furthermore, there is a gap in the knowledge of what happens when TBI occurs in the presence of certain sex-specific and sex-nonspecific variables, such as during pregnancy, with oral contraceptive use, in athletics, in cases of addiction and nicotine consumption, during perimenopause, postmenopause, in frailty, among others. Parsing out how hormone-dependent and hormone-independent lifespan variables may influence physiological, neurodegenerative, and functional outcomes will greatly contribute to future investigative studies and direct therapeutic strategies. The goal of this review is to aggregate the knowledge of prevalence, prognosis, comorbid risk, and response of women incurring TBI at differing phases of lifespan. We strive to illuminate commonalities and disparities among female populations, and to pose important questions to highlight gaps in the field in order to further the endeavor of targeted treatment interventions in a patient-specific manner.

Neurointensive care of traumatic brain injury in the elderly-age-specific secondary insult levels and optimal physiological levels to target need to be defined

BACKGROUND

Elderly patients with traumatic brain injury increase. Current targets and secondary insult definitions during neurointensive care (NIC) are mostly based on younger patients. The aim was therefore to study the occurrence of predefined secondary insults and the impact on outcome in different ages with particular focus on elderly.

METHODS

Patients admitted to Uppsala 2008-2014 were included. Patient characteristics, NIC management, monitoring data, and outcome were analyzed. The percentage of monitoring time for ICP, CPP, MAP, and SBP above-/below-predefined thresholds was calculated.

RESULTS

Five hundred seventy patients were included, 151 elderly ≥ 65 years and 419 younger 16-64 years. Age ≥ 65 had significantly higher percentage of CPP > 100, MAP > 120, and SBP > 180 and age 16-64 had higher percentage of ICP ≥ 20, CPP ≤ 60, and MAP ≤ 80. Age ≥ 65 contributed independently to the different secondary insult patterens. When patients in all ages were analyzed, low percentage of CPP > 100 and SBP > 180, respectively, was significant predictors of favorable outcome and high percentage of ICP ≥ 20, CPP > 100, SBP ≤ 100, and SBP > 180, respectively, was predictors of death. Analysis of age interaction showed that patients ≥ 65 differed and had a higher odds for favorable outcome with large proportion of good monitoring time with SBP > 180.

CONCLUSIONS

Elderly ≥ 65 have different patterns of secondary insults/physiological variables, which is independently associated to age. The finding that SBP > 180 increased the odds of favorable outcome in the elderly but decreased the odds in younger patients may indicate that blood pressure should be treated differently depending on age.

Development and Validation of a Functionally Relevant Comorbid Health Index in Adults Admitted to Inpatient Rehabilitation for Traumatic Brain Injury

Several studies have characterized comorbidities among individuals with traumatic brain injury (TBI); however, there are few validated TBI comorbidity indices. Widely used indices (e.g., Elixhauser Comorbidity Index [ECI]) were developed in other patient populations and anchor to mortality or healthcare utilization, not functioning, and notably exclude conditions known to co-occur with TBI. The objectives of this study were to develop and validate a functionally relevant TBI comorbidity index (Fx-TBI-CI) and to compare prognostication of the Fx-TBI-CI with the ECI. We used data from the eRehabData database to divide the sample randomly into a training sample (N = 21,292) and an internal validation sample (N = 9166). We used data from the TBI Model Systems National Database as an external validation sample (N = 1925). We used least absolute shrinkage and selection operator (LASSO) regression to narrow the list of functionally relevant conditions from 39 to 12. In internal validation, the Fx-TBI-CI explained 14.1% incremental variance over an age and sex model predicting the Functional Independence Measure (FIM) Motor subscale at inpatient rehabilitation discharge, compared with 2.4% explained by the ECI. In external validation, the Fx-TBI-CI explained 4.9% incremental variance over age and sex and 3.8% over age, sex, and Glasgow Coma Scale score,compared with 2.1% and 1.6% incremental variance, respectively, explained by the ECI. An unweighted Sum Condition Score including the same conditions as the Fx-TBI-CI conferred similar prognostication. Although the Fx-TBI-CI had only modest incremental variance over demographics and injury severity in predicting functioning in external validation, the Fx-TBI-CI outperformed the ECI in predicting post-TBI function.

Self-Reported Complaints as Prognostic Markers for Outcome After Mild Traumatic Brain Injury in Elderly: A Machine Learning Approach

Self-reported complaints are common after mild traumatic brain injury (mTBI). Particularly in the elderly with mTBI, the pre-injury status might play a relevant role in the recovery process. In most mTBI studies, however, pre-injury complaints are neither analyzed nor are the elderly included. Here, we aimed to identify which individual pre- and post-injury complaints are potential prognostic markers for incomplete recovery (IR) in elderly patients who sustained an mTBI. Since patients report many complaints across several domains that are strongly related, we used an interpretable machine learning (ML) approach to robustly deal with correlated predictors and boost classification performance. Pre- and post-injury levels of 20 individual complaints, as self-reported in the acute phase, were analyzed. We used data from two independent studies separately: UPFRONT study was used for training and validation and ReCONNECT study for independent testing. Functional outcome was assessed with the Glasgow Outcome Scale Extended (GOSE). We dichotomized functional outcome into complete recovery (CR; GOSE = 8) and IR (GOSE ≤ 7). In total 148 elderly with mTBI (median age: 67 years, interquartile range [IQR]: 9 years; UPFRONT: N = 115; ReCONNECT: N = 33) were included in this study. IR was observed in 74 (50%) patients. The classification model (IR vs. CR) achieved a good performance (the area under the receiver operating characteristic curve [ROC-AUC] = 0.80; 95% CI: 0.74-0.86) based on a subset of only 8 out of 40 pre- and post-injury complaints. We identified increased neck pain (p = 0.001) from pre- to post-injury as the strongest predictor of IR, followed by increased irritability (p = 0.011) and increased forgetfulness (p = 0.035) from pre- to post-injury. Our findings indicate that a subset of pre- and post-injury physical, emotional, and cognitive complaints has predictive value for determining long-term functional outcomes in elderly patients with mTBI. Particularly, post-injury neck pain, irritability, and forgetfulness scores were associated with IR and should be assessed early. The application of an ML approach holds promise for application in self-reported questionnaires to predict outcomes after mTBI.

Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma

OBJECTIVE

Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates.

RESULTS

Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses.

CONCLUSIONS

Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit

BACKGROUND AND OBJECTIVE

Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207).

METHODS

Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge.

RESULTS

Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes.

CONCLUSIONS

Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.

Surgical intervention and patient factors associated with poor outcomes in patients with traumatic brain injury at a tertiary care hospital in Uganda

OBJECTIVE

The purpose of this study was to investigate whether neurosurgical intervention for traumatic brain injury (TBI) is associated with reduced risks of death and clinical deterioration in a low-income country with a relatively high neurosurgical capacity. The authors further aimed to assess whether the association between surgical intervention and acute poor outcomes differs according to TBI severity and various patient factors.

METHODS

Using TBI registry data collected from a national referral hospital in Uganda between July 2016 and April 2020, the authors performed Cox regression analyses of poor outcomes in admitted patients who did and did not undergo surgery for TBI, with surgery as a time-varying treatment variable. Patients were further stratified by TBI severity using the admission Glasgow Coma Scale (GCS) score: mild TBI (mTBI; GCS scores 13-15), moderate TBI (moTBI; GCS scores 9-12), and severe TBI (sTBI; GCS scores 3-8). Poor outcomes constituted Glasgow Outcome Scale scores 2-3, deterioration in TBI severity between admission and discharge (e.g., mTBI to sTBI), and death. Several clinical and demographic variables were included as covariates. Patients were observed for outcomes from admission through hospital day 10.

RESULTS

Of 1544 patients included in the cohort, 369 (24%) had undergone surgery. Rates of poor outcomes were 4% (n = 13) for surgical patients and 12% (n = 144) among nonsurgical patients (n = 1175). Surgery was associated with a 59% reduction in the hazard for a poor outcome (HR 0.41, 95% CI 0.23-0.72). Age, pupillary nonreactivity, fall injury, and TBI severity at admission were significant covariates. In models stratifying by TBI severity at admission, patients with mTBI had an 80% reduction in the hazard for a poor outcome with surgery (HR 0.20, 95% CI 0.04-0.90), whereas those with sTBI had a 65% reduction (HR 0.35, 95% CI 0.14-0.89). Patients with moTBI had a statistically nonsignificant 56% reduction in hazard (HR 0.44, 95% CI 0.17-1.17).

CONCLUSIONS

In this setting, the association between surgery and rates of poor outcomes varied with TBI severity and was influenced by several factors. Patients presenting with mTBI had the greatest reduction in the hazard for a poor outcome, followed by those presenting with sTBI. However, patients with moTBI had a nonsignificant reduction in the hazard, indicating greater variability in outcomes and underscoring the need for closer monitoring of this population. These results highlight the importance of accurate, timely clinical evaluation throughout a patient's admission and can inform decisions about whether and when to perform surgery for TBI when resources are limited.

Objective evaluation of the risk of falls in individuals with traumatic brain injury: feasibility and preliminary validation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021;2021:4658-4661. [PMID: 34892252 DOI: 10.1109/embc46164.2021.9630020]

Falls are a significant health concern for individuals with traumatic brain injury (TBI). For developing effective preemptive strategies to reduce falls, it is essential to get an accurate and objective assessment of fall-risk. The current investigation evaluates the feasibility of a robotic, posturography-based fall-risk assessment to objectively quantify the risk of falls in individuals with TBI. Five individuals with chronic TBI (age: 56.2 ± 4.7 years, time since injury: 13.09±11.95 years) performed the fall-risk assessment on hunova- a commercial robotic platform for assessing and training balance. The unique assessment considers multifaceted fall-driving components, including static and dynamic balance, sit-to-stand, limits of stability, responses to perturbations, gait speed, and history of previous falls and provides a composite score for risk of falls, called silver index (SI), a number between 0 (no risk) and 100 (high risk) based on a machine learning-based predictive model. The SI score for individuals with TBI was 66±32.1 (min: 32, max: 100) - categorized as medium-to-high risk of falls. The construct validity of SI outcome was performed by evaluating its relationship with clinical outcomes of functional balance and mobility (Berg Balance Scale (BBS), Timed-Up and Go (TUG), and gait speed) as well as posturography outcomes (Center of Pressure (CoP) area and velocity). The bivariate Pearson correlation coefficient, although not statistically significant, suggested the presence of linear relationships (0.52 > r > 0.84) between SI and functional and posturography outcomes, supporting the construct validity of SI. A large sample is needed to further prove the validity of the SI outcome before it is used for meaningful interpretations of the risk of falls in individuals with TBI.Clinical Relevance- Clinical assessments of risk of falls are traditionally based on questionnaires that may lack objectivity, consistency, and accuracy. The current work tests the feasibility of using a robotic platform-based assessment to objectively quantify the risk of falls in individuals with TBI.

Cerebral Microbleeds May Be Less Detectable by Susceptibility Weighted Imaging MRI From 24 to 72 Hours After Traumatic Brain Injury

Purpose: A former rodent study showed that cerebral traumatic microbleeds (TMBs) may temporarily become invisible shortly after injury when detected by susceptibility weighted imaging (SWI). The present study aims to validate this phenomenon in human SWI.

Methods: In this retrospective study, 46 traumatic brain injury (TBI) patients in various forms of severity were included and willingly complied with our strict selection criteria. Clinical parameters potentially affecting TMB count, Rotterdam and Marshall CT score, Mayo Clinic Classification, contusion number, and total volume were registered. The precise time between trauma and MRI [5 h 19 min to 141 h 54 min, including SWI and fluid-attenuated inversion recovery (FLAIR)] was individually recorded; TMB and FLAIR lesion counts were assessed. Four groups were created based on elapsed time between the trauma and MRI: 0–24, 24–48, 48–72, and >72 h. Kruskal–Wallis, ANOVA, Chi-square, and Fisher’s exact tests were used to reveal differences among the groups within clinical and imaging parameters; statistical power was calculated retrospectively for each comparison.

Results: The Kruskal–Wallis ANOVA with Conover post hoc analysis showed significant (p = 0.01; 1−β > 0.9) median TMB number differences in the subacute period: 0–24 h = 4.00 (n = 11); 24–48 h = 1 (n = 14); 48–72 h = 1 (n = 11); and 72 h ≤ 7.5 (n = 10). Neither clinical parameters nor FLAIR lesions depicted significant differences among the groups.

Conclusion: Our results demonstrate that TMBs on SWI MRI may temporarily become less detectable at 24–72 h following TBI.

Cellular Senescence in Traumatic Brain Injury: Evidence and Perspectives

Mild traumatic brain injury (mTBI) can lead to long-term neurological dysfunction and increase one's risk of neurodegenerative disease. Several repercussions of mTBI have been identified and well-studied, including neuroinflammation, gliosis, microgliosis, excitotoxicity, and proteinopathy – however the pathophysiological mechanisms activating these pathways after mTBI remains controversial and unclear. Emerging research suggests DNA damage-induced cellular senescence as a possible driver of mTBI-related sequalae. Cellular senescence is a state of chronic cell-cycle arrest and inflammation associated with physiological aging, mood disorders, dementia, and various neurodegenerative pathologies. This narrative review evaluates the existing studies which identify DNA damage or cellular senescence after TBI (including mild, moderate, and severe TBI) in both experimental animal models and human studies, and outlines how cellular senescence may functionally explain both the molecular and clinical manifestations of TBI. Studies on this subject clearly show accumulation of various forms of DNA damage (including oxidative damage, single-strand breaks, and double-strand breaks) and senescent cells after TBI, and indicate that cellular senescence may be an early event after TBI. Further studies are required to understand the role of sex, cell-type specific mechanisms, and temporal patterns, as senescence may be a pathway of interest to target for therapeutic purposes including prognosis and treatment.

Aging with Traumatic Brain Injury: Deleterious Effects of Injury Chronicity Are Most Pronounced in Later Life

Understanding the effects of age on longitudinal traumatic brain injury (TBI) outcomes requires attention to both chronic and evolving TBI effects and age-related changes in health and function. The present study examines the independent and interactive effects of aging and chronicity on functional outcomes after TBI. We leveraged a well-defined cohort of individuals who sustained a moderate/severe TBI and received acute inpatient rehabilitation at specialized centers with high follow up rate as part of their involvement in the TBI Model Systems longitudinal study. We selected individuals at one of two levels of TBI chronicity (either 2 or 10 years post-injury) and used an exact matching procedure to obtain balanced chronicity groups based on age and other characteristics (N = 1993). We found that both older age and greater injury chronicity were related to greater disability, reduced functional independence, and less community participation. There was a significant age by chronicity interaction, indicating that the adverse effects of greater time post-injury were most pronounced among survivors who were age 75 or older. The inflection point at roughly 75 years of age was corroborated by post hoc analyses, dividing the sample by age at 75 years and examining the interaction between age group and chronicity. These findings point to a need for provision of rehabilitation services in the chronic injury period, particularly for those who are over 75 years old. Future work should investigate the underlying mechanisms of this interaction towards the goal of developing interventions and models of care to promote healthy aging with TBI.

Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis

BACKGROUND

It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system.

METHODS

We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis.

RESULTS

We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%).

INTERPRETATION

Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.

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).

The Longitudinal Effects of Comorbid Health Burden on Functional Outcomes for Adults With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate the impact of physical, mental, and total health condition burden on functional outcome and life satisfaction up to 10 years after moderate to severe traumatic brain injury (TBI).

SETTING

Six TBI Model Systems centers.

PARTICIPANTS

Three hundred ninety-three participants in the TBI Model Systems National Database.

DESIGN

Retrospective cohort study.

MAIN MEASURES

Self-reported physical and mental health conditions at 10 years postinjury. Functional Independence Measure Motor and Cognitive subscales and the Satisfaction With Life Scale measured at 1, 2, 5, and 10 years.

RESULTS

In 10-year longitudinal individual growth curve models adjusted for covariates and inverse probability weighted to account for selection bias, greater physical and mental health comorbidity burden was negatively associated with functional cognition and life satisfaction trajectories. Physical, but not mental, comorbidity burden was negatively associated with functional motor trajectories. Higher total health burden was associated with poorer functional motor and cognitive trajectories and lower life satisfaction.

CONCLUSIONS

This study offers evidence that comorbidity burden negatively impacts longitudinal functional and life satisfaction outcomes after TBI. The findings suggest that better identification and treatment of comorbidities may benefit life satisfaction, functional outcome, reduce healthcare costs, and decrease reinjury. Specific guidelines are needed for the management of comorbidities in TBI populations.

Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury

OBJECTIVES

To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations.

PARTICIPANTS

A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411).

DESIGN

Cross-sectional survey study.

MAIN MEASURES

Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form.

ANALYSES

Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups.

RESULTS

Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms.

CONCLUSION

History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury

BACKGROUND

"Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients.

METHODS

We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress.

RESULTS

BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds.

CONCLUSION

BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members.

LEVEL OF EVIDENCE

Therapeutic, level III.

Mild Traumatic Brain Injury in Older Adults: Are Routine Second cCT Scans Necessary?

Fall-related hospitalizations among older adults have been increasing in recent decades. One of the most common reasons for this is minimal or mild traumatic brain injury (mTBI) in older individuals taking anticoagulant medication. In this study, we analyzed all inpatient stays from January 2017 to December 2019 of patients aged > 75 years with a mTBI on anticoagulant therapy who received at least two cranial computer tomography (cCT) scans. Of 1477 inpatient stays, 39 had primary cranial bleeding, and in 1438 the results of initial scans were negative for cranial bleeding. Of these 1438 cases, 6 suffered secondary bleeding from the control cCT scan. There was no significance for bleeding related to the type of anticoagulation. We conclude that geriatric patients under anticoagulant medication don’t need a second cCT scan if the primary cCT was negative for intracranial bleeding and the patient shows no clinical signs of bleeding. These patients can be dismissed but require an evaluation for need of home care or protective measures to prevent recurrent falls. The type of anticoagulant medication does not affect the risk of bleeding.

The Impact of Age and Severity on Dementia After Traumatic Brain Injury: A Comparison Study

BACKGROUND

Growing evidence associates traumatic brain injury (TBI) with increased risk of dementia, but few studies have evaluated associations in patients younger than 55 yr using non-TBI orthopedic trauma (NTOT) patients as controls to investigate the influence of age and TBI severity, and to identify predictors of dementia after trauma.

OBJECTIVE

To investigate the relationship between TBI and dementia in an institutional group.

METHODS

Retrospective cohort study (2000-2018) of TBI patients aged 45 to 100 yr vs NTOT controls. Primary outcome was dementia after TBI (followed ≤10 yr). Cox proportional hazards models were used to assess risk of dementia; logistic regression models assessed predictors of dementia.

RESULTS

Among 24 846 patients, TBI patients developed dementia (7.5% vs 4.6%) at a younger age (78.6 vs 82.7 yr) and demonstrated higher 10-yr mortality than controls (27% vs 14%; P < .001). Mild TBI patients had higher incidence of dementia (9%) than moderate/severe TBI (5.4%), with lower 10-yr mortality (20% vs 31%; P < .001). Risk of dementia was significant in all mild TBI age groups, even 45 to 54 yr (hazard ratio 4.1, 95% CI 2.7-7.8). A total of 10-yr cumulative incidence was higher in mild TBI (14.4%) than moderate/severe TBI (11.3%) and controls (6.8%) (P < .001). Predictors of dementia include TBI, sex, age, hypertension, hyperlipidemia, stroke, depression, anxiety, and Injury Severity Score.

CONCLUSION

Mild and moderate/severe TBI patients experienced higher incidence of dementia, even in the youngest group (45-54 yr old), than NTOT controls. All TBI patients, especially middle-aged adults with minor injury who are more likely to be overlooked, should be monitored for dementia.

A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

Aim

In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Findings

Trauma mechanism, as well as injury pattern, changed over time. We found length of stay and mortality decreased despite an increase in patient age.

Message

We ascribe this observation mainly to increased use of diagnostic tools and improved treatment algorithms and underline the importance of the implementation of specialized geriatric trauma centers allowing interdisciplinary care.

Purpose

The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Methods

A descriptive analysis of the data from the TraumaRegister DGU^® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared.

Results

In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4).

Conclusion

Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Synergistic effects of brain injury and aging: common mechanisms of proteostatic dysfunction

The aftermath of TBI is associated with an acute stress response and the accumulation of insoluble protein aggregates. Even after the symptoms of TBI are resolved, insidious molecular processes continue to develop, which often ultimately result in the development of age-associated neurodegenerative disorders. The precise molecular cascades that drive unhealthy brain aging are still largely unknown. In this review, we discuss proteostatic dysfunction as a converging mechanism contributing to accelerated brain aging after TBI. We examine evidence from human tissue and in vivo animal models, spanning both the aging and injury contexts. We conclude that TBI has a sustained debilitating effect on the proteostatic machinery, which may contribute to the accelerated pathological and cognitive hallmarks of aging that are observed following injury.

Geriatric traumatology (e. g. "Alterstraumatologie") is more than orthogeriatrics-Experiences of a physician in advanced training

This article reporting the view of an early career physician focuses on the diverse components of orthogeriatric co-management in a clinical setting. Geriatric trauma patients require a multimodal and interdisciplinary management, which includes individual and age-specific aspects, such as intensified physiotherapy, trauma surgery and geriatric expertise as well as social support. In Germany this surgical and geriatric co-treatment is provided by the program geriatric traumatology (Alterstraumatologie), which is implemented and certified at special institutions called geriatric trauma centers (Alters-Trauma-Zentrum). This special care is accomplished by an orthogeriatric co-management, which combines the efforts of both modern state of the art trauma surgery and geriatric medicine, preferable by using the procedure of the so-called geriatric early rehabilitative complex treatment (geriatrische frührehabilitative Komplexbehandlung) according to the diagnosis-related group (DRG) procedure OPS 8550. This is administered in 3 periods: the preoperative period, perioperative period and postoperative period and if indicated followed and completed by a geriatric rehabilitation. According to recent studies this approach has proved to be beneficial especially with respect to a reduction of posttraumatic morbidity rates and avoiding loss of function.

Acute TBK1/IKK-ε Inhibition Enhances the Generation of Disease-Associated Microglia-Like Phenotype Upon Cortical Stab-Wound Injury

Traumatic brain injury has a poorer prognosis in elderly patients, possibly because of the enhanced inflammatory response characteristic of advanced age, known as “inflammaging.” Recently, reduced activation of the TANK-Binding-Kinase 1 (Tbk1) pathway has been linked to age-associated neurodegeneration and neuroinflammation. Here we investigated how the blockade of Tbk1 and of the closely related IKK-ε by the small molecule Amlexanox could modify the microglial and immune response to cortical stab-wound injury in mice. We demonstrated that Tbk1/IKK-ε inhibition resulted in a massive expansion of microglial cells characterized by the TMEM119⁺/CD11c⁺ phenotype, expressing high levels of CD68 and CD317, and with the upregulation of Cst7a, Prgn and Ccl4 and the decrease in the expression levels of Tmem119 itself and P2yr12, thus a profile close to Disease-Associated Microglia (DAM, a subset of reactive microglia abundant in Alzheimer’s Disease and other neurodegenerative conditions). Furthermore, Tbk1/IKK-ε inhibition increased the infiltration of CD3⁺ lymphocytes, CD169⁺ macrophages and CD11c⁺/CD169⁺ cells. The enhanced immune response was associated with increased expression of Il-33, Ifn-g, Il-17, and Il-19. This upsurge in the response to the stab wound was associated with the expanded astroglial scars and increased deposition of chondroitin-sulfate proteoglycans at 7 days post injury. Thus, Tbk1/IKK-ε blockade results in a massive expansion of microglial cells with a phenotype resembling DAM and with the substantial enhancement of neuroinflammatory responses. In this context, the induction of DAM is associated with a detrimental outcome such as larger injury-related glial scars. Thus, the Tbk1/IKK-ε pathway is critical to repress neuroinflammation upon stab-wound injury and Tbk1/IKK-ε inhibitors may provide an innovative approach to investigate the consequences of DAM induction.