Utilization and costs of health care after geriatric traumatic brain injury

Enhancing neurocognitive health, abilities, networks, & community engagement for older adults with cognitive impairments through technology: a scoping review introducing the ENHANCE Center

PURPOSE

Age associated cognitive impairments (CIs) result in difficulties with a wide range of daily activities. As the older adult population increases, so does the importance of understanding and supporting the needs and disabilities of those with CIs. The Enhancing Neurocognitive Health, Abilities, Networks, and Community Engagement (ENHANCE) Centre was established with a focus on developing assistive technology to support the socialisation, transportation, and prospective memory needs of older adults with CIs. The extent to which relevant literature in these domains existed was unknown.

MATERIALS AND METHODS

A scoping review identified existing research meeting the following criteria: participants aged 50+ years classified as having a CI due to mild cognitive impairment (MCI), traumatic brain injury (TBI), or stroke; and a focus on technology-based support for socialisation, transportation, and/or prospective memory activities.

RESULTS

Qualitative and quantitative data are reported from relevant studies. In addition to few studies available, it was common for studies to include 20 or fewer participants. Most assessed technology interactions at one time and few studies examined longitudinal use and benefit. While each paper examined one aspect of user-centred design, no technologies were reported that underwent all stages of the user-centred design process, from needs assessment to iterative design and usability testing, to efficacy trial.

CONCLUSIONS

Gaps highlight notable directions for future research and the important role ENHANCE can play in addressing the needs and disabilities of older adults with CIs. IMPLICATIONS FOR REHABILITATIONAlthough older adults with common cognitive impairments often experience challenges in the domains of socialisation, transportation, and/or prospective memory, few studies exist that examine assistive technology solutions in these domains.Additional research with more robust designs and larger sample sizes is needed to discover and assess assistive technology solutions for the needs and disabilities of older adults with mild cognitive impairment (MCI), traumatic brain injury (TBI), and post-stroke cognitive impairment (PSCI).The ENHANCE Centre will employ a systematic process of needs assessments, user testing, and efficacy tests to develop novel technology solutions to support the needs of older adults with common cognitive impairment.

Emergency Department and Inpatient Utilization Reductions and Cost Savings Associated With Trauma Center Mental Health Intervention: Results From a 5-year Longitudinal Randomized Clinical Trial Analysis

OBJECTIVE

To identify and refer patients at high risk for the psychological sequelae of traumatic injury, the American College of Surgeons Committee on Trauma now requires that trauma centers have in-place protocols. No investigations have documented reductions in utilization and associated potential cost savings associated with trauma center mental health interventions.

BACKGROUND

The investigation was a randomized clinical trial analysis that incorporated novel 5-year emergency department (ED)/inpatient health service utilization follow-up data.

METHODS

Patients were randomized to a mental health intervention, targeting the psychological sequelae of traumatic injury (n = 85) versus enhanced usual care control (n = 86) conditions. The intervention included case management that coordinated trauma center-to-community care linkages, psychotropic medication consultation, and psychotherapy elements. Mixed model regression was used to assess intervention and control group utilization differences over time. An economic analysis was also conducted.

RESULTS

Over the course of the 5-year intervention, patients demonstrated significant reductions in ED/inpatient utilization when compared with control patients [ F (19,3210) = 2.23, P = 0.009]. Intervention utilization reductions were greatest at 3 to 6 months (intervention 15.5% vs control 26.7%, relative risk = 0.58, 95% CI: 0.34, 1.00) and 12 to 15 months (intervention 16.5% vs control 30.6%, relative risk = 0.54, 95% CI: 0.32, 0.91) postinjury time points. The economic analysis suggested potential intervention cost savings.

CONCLUSIONS

Mental health intervention is associated with significant reductions in ED and inpatient utilization, as well as potential cost savings. These findings could be productively integrated into future American College of Surgeons Committee on Trauma policy discussions.

Clinical complications after a traumatic brain injury and its relation with brain biomarkers

We aimed to find out which are the most frequent complications for patients who suffer a traumatic brain injury (TBI) and its relation with brain biomarker levels. We conducted a hospital cohort study with patients who attended the Hospital Emergency Department between 1 June 2018 and 31 December 2020. Different variables were collected such as biomarkers levels after 6 h and 12 h of TBI (S100, NSE, UCHL1 and GFAP), clinical and sociodemographic variables, complementary tests, and complications 48 h and 7 days after TBI. Qualitative variables were analysed with Pearson's chi-square test, and quantitative variables with the Mann-Whitney U test. A multivariate logistic regression model for the existence of complications one week after discharge was performed to assess the discriminatory capacity of the clinical variables. A total of 51 controls and 540 patients were included in this study. In the TBI group, the mean age was 83 years, and 53.9% of the patients were male. Complications at seven days were associated with the severity of TBI (p < 0.05) and the number of platelets (p = 0.016). All biomarkers except GFAP showed significant differences in their distribution of values according to gender, with significantly higher values of the three biomarkers for women with respect to men. Patients with complications presented significantly higher S100 values (p < 0.05). The patient's baseline status, the severity of the TBI and the S100 levels can be very important elements in determining whether a patient may develop complications in the few hours after TBI.

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.

Pharmacological management of neuropsychiatric symptoms in geriatric traumatic brain injury: a scoping review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base on the pharmacological management of neuropsychiatric symptoms in geriatric TBI and identify gaps in the literature to guide future research.

METHODS

Seven electronic databases and nine gray literature databases were systematically searched for articles that examined pharmacological management of neuropsychiatric symptoms in adults aged 65 years and over with TBI. The search was guided by four main concepts and selected based on inclusion criteria. Unpublished studies and abstract-only articles were excluded.

RESULTS

Eight studies met full inclusion criteria. Patterns of psychotropic medication prescription and prescribing principles for geriatric TBI were elucidated. There were no clear or consistent prescribing guidance. Therefore, prescribing recommendations could not be addressed. Current management is inferred from research primarily done in younger adults, or extrapolated from the literature and practice of treating other psychiatric and neurological disorders.

CONCLUSION

There are significant gaps in knowledge and no evidence-based guidelines for the treatment of neuropsychiatric symptoms in geriatric TBI. TBI among older adults is distinct from those of younger adults and thereby demands a unique approach to treatment and research. The authors' proposed guideline is an important first step in facilitating guideline development and future research.

Profound prospective assessment of radiological and functional outcome 6 months after TBI in elderly

BACKGROUND

Recovery after traumatic brain injury (TBI) in older adults is usually affected by the presence of comorbidities, leading to more severe sequelae in this age group than in younger patients. However, there are only few reports that prospectively perform in-depth assessment of outcome following TBI in elderly.

OBJECTIVE

This study aims at documenting structural brain characteristics and functional outcome and quality of life in elderly patients 6 months after TBI and comparing these data with healthy volunteers undergoing the same assessments.

METHODS

Thirteen TBI patients ≥ 65 years old, admitted to the University Hospitals Leuven (Belgium), between 2019 and 2022 due to TBI, including all injury severities, and a group of 13 healthy volunteers with similar demographic characteristics were prospectively included in the study. At admission, demographic, injury, and CT scan data were collected in our database. Six months after the accident, a brain MRI scan and standardized assessments of frailty, sleep quality, cognitive function, motor function, and quality of life were conducted.

RESULTS

A total of 13 patients and 13 volunteers were included in the study, with a median age of 74 and 73 years, respectively. Nine out of the 13 patients presented with a mild TBI. The patient group had a significantly higher level of frailty than the control group, presenting a mean Reported Edmonton Frailty Scale score of 5.8 (SD 2.7) vs 0.7 (SD 1.1) (p < 0.01). No statistically significant differences were found between patient and control brain volumes, fluid attenuated inversion recovery white matter hyperintensity volumes, number of lesions and blackholes, and fractional anisotropy values. Patients demonstrated a significantly higher median reaction time in the One Touch Stockings of Cambridge (22.3 s vs 17.6, p = 0.03) and Reaction Time (0.5 s vs 0.4 s, p < 0.01) subtests in the Cambridge Neuropsychological Test Automated Battery. Furthermore, patients had a lower mean score on the first Box and Blocks test with the right hand (46.6 vs 61.7, p < 0.01) and a significantly higher mean score in the Timed-Up & Go test (13.1 s vs 6.2 s, p = 0.02) and Timed Up & Go with cognitive dual task (16.0 s vs 10.2 s, p < 0.01). Substantially lower QOLIBRI total score (60.4 vs 85.4, p < 0.01) and QOLIBRI-OS total score (53.8 vs 88.5, p < 0.01) were also observed in the patients' group.

CONCLUSION

In this prospective study, TBI patients ≥ 65 years old when compared with elder controls showed slightly worse cognitive performance and poorer motor function, higher fall risk, but a substantially reduced QoL at 6 months FU, as well as significantly higher frailty, even when the TBI is classified as mild. No statistically significant differences were found in structural brain characteristics on MRI. Future studies with larger sample sizes are needed to refine the impact of TBI versus frailty on function and QoL in elderly.

Predictors of cognitive gains during inpatient rehabilitation for older adults with traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays.

OBJECTIVE

To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care.

DESIGN

Secondary data analysis.

SETTING

Uniform Data System for Medical Rehabilitation-participating IRFs in the United States.

PATIENTS

Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N = 137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years.

MAIN OUTCOME MEASURE

Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains <3 points) cognitive outcomes.

INTERVENTIONS

Not applicable.

RESULTS

Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery.

CONCLUSIONS

Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.

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

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

Prediction of Mortality in Geriatric Traumatic Brain Injury Patients Using Machine Learning Algorithms

Background: The number of geriatric traumatic brain injury (TBI) patients is increasing every year due to the population’s aging in most of the developed countries. Unfortunately, there is no widely recognized tool for specifically evaluating the prognosis of geriatric TBI patients. We designed this study to compare the prognostic value of different machine learning algorithm-based predictive models for geriatric TBI. Methods: TBI patients aged ≥65 from the Medical Information Mart for Intensive Care-III (MIMIC-III) database were eligible for this study. To develop and validate machine learning algorithm-based prognostic models, included patients were divided into a training set and a testing set, with a ratio of 7:3. The predictive value of different machine learning based models was evaluated by calculating the area under the receiver operating characteristic curve, sensitivity, specificity, accuracy and F score. Results: A total of 1123 geriatric TBI patients were included, with a mortality of 24.8%. Non-survivors had higher age (82.2 vs. 80.7, p = 0.010) and lower Glasgow Coma Scale (14 vs. 7, p < 0.001) than survivors. The rate of mechanical ventilation was significantly higher (67.6% vs. 25.9%, p < 0.001) in non-survivors while the rate of neurosurgical operation did not differ between survivors and non-survivors (24.3% vs. 23.0%, p = 0.735). Among different machine learning algorithms, Adaboost (AUC: 0.799) and Random Forest (AUC: 0.795) performed slightly better than the logistic regression (AUC: 0.792) on predicting mortality in geriatric TBI patients in the testing set. Conclusion: Adaboost, Random Forest and logistic regression all performed well in predicting mortality of geriatric TBI patients. Prognostication tools utilizing these algorithms are helpful for physicians to evaluate the risk of poor outcomes in geriatric TBI patients and adopt personalized therapeutic options for them.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A review of caregiver costs included in cost-of-illness studies

INTRODUCTION

Economic evaluations typically focus solely on patient-specific costs with economic spillovers to informal caregivers less frequently evaluated. This may systematically underestimate the burden resulting from disease.

AREAS COVERED

Cost-of-illness (COI) analyses that identified costs borne to caregiver(s) were identified using PubMed and Embase. We extracted study characteristics, clinical condition, costs, and cost methods. To compare caregiver costs reported across studies, estimated a single 'annual caregiver cost' amount in 2021 USD.

EXPERT OPINION

A total of 51 studies met our search criteria for inclusion with estimates ranging from $30 - $86,543. The majority (63%, 32/51) of studies estimated caregiver time costs with fewer studies reporting productivity or other types of costs. Caregiver costs were frequently reported descriptively (69%, 35/51), with fewer studies reporting more rigorous methods of estimating costs. Only 27% (14/51) of studies included used an incremental analysis approach for caregiver costs. In a subgroup analysis of dementia-focused studies (n = 16), we found the average annual cost of caregiving time for patients with dementia was $30,562, ranging from $4,914 to $86,543. We identified a wide range in annual caregiver cost estimates, even when limiting by condition and cost type.

Impact of the COVID-19 Pandemic on Long-Term Recovery from Traumatic Injury

OBJECTIVE

Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort.

BACKGROUND

The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients.

METHODS

Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6-14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes.

RESULTS

Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status (SES), extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the SF-12 and to screen positive for PTSD and depression.

CONCLUSIONS

The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Characterizing health care utilization following hospitalization for a traumatic brain injury: a retrospective cohort study

Objective: The purpose of this study was to characterize health services utilization among individuals hospitalized with a traumatic brain injury (TBI) 1-year post-injury.Methods: Using a retrospective cohort design, adult patients (n = 32, 042) hospitalized with a traumatic brain injury between 2005 and 2014 were selected from a statewide traumatic brain injury registry. Data on health services utilization for 1-year post-injury were extracted from electronic medical and administrative records. Descriptive statistics and logistic regression were used to characterize the cohort and a subgroup of superutilizers of health services.Results: One year after traumatic brain injury, 56% of participants used emergency department services, 80% received inpatient services, and 93% utilized outpatient health services. Superutilizers had ≥3 emergency department visits, ≥3 inpatient admissions, or ≥26 outpatient visits 1-year post-injury. Twenty-six percent of participants were superutilizers of emergency department services, 30% of inpatient services, and 26% of outpatient services. Superutilizers contributed to 81% of emergency department visits, 70% of inpatient visits, and 60% of outpatient visits. Factors associated with being a superutilizer included sex, race, residence, and insurance type.Conclusions: Several patient characteristics and demographic factors influenced patients' healthcare utilization post-TBI. Findings provide opportunities for developing targeted interventions to improve patients' health and traumatic brain injury-related healthcare delivery.

Traumatic Brain Injury as Frequent Cause of Hypopituitarism and Growth Hormone Deficiency: Epidemiology, Diagnosis, and Treatment

Traumatic brain injury (TBI)-related hypopituitarism has been recognized as a clinical entity for more than a century, with the first case being reported in 1918. However, during the 20^th century hypopituitarism was considered only a rare sequela of TBI. Since 2000 several studies strongly suggest that TBI-mediated pituitary hormones deficiency may be more frequent than previously thought. Growth hormone deficiency (GHD) is the most common abnormality, followed by hypogonadism, hypothyroidism, hypocortisolism, and diabetes insipidus. The pathophysiological mechanisms underlying pituitary damage in TBI patients include a primary injury that may lead to the direct trauma of the hypothalamus or pituitary gland; on the other hand, secondary injuries are mainly related to an interplay of a complex and ongoing cascade of specific molecular/biochemical events. The available data describe the importance of GHD after TBI and its influence in promoting neurocognitive and behavioral deficits. The poor outcomes that are seen with long standing GHD in post TBI patients could be improved by GH treatment, but to date literature data on the possible beneficial effects of GH replacement therapy in post-TBI GHD patients are currently scarce and fragmented. More studies are needed to further characterize this clinical syndrome with the purpose of establishing appropriate standards of care. The purpose of this review is to summarize the current state of knowledge about post-traumatic GH deficiency.

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

Introduction

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

Research question

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

Materials and methods

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

Results

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

Discussion and conclusion

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

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

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

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

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

Healthcare Utilization Following Traumatic Brain Injury in a Large National Sample

OBJECTIVE

To evaluate the impact of traumatic brain injury (TBI) on healthcare utilization (HCU) over a 1-year period in a large national sample of individuals diagnosed with TBI across multiple care settings.

SETTING

Commercial insurance enrollees.

PARTICIPANTS

Individuals with and without TBI, 2008-2014.

DESIGN

Retrospective cohort.

MAIN MEASURES

We compared the change in the 12-month sum of inpatient, outpatient, emergency department (ED), and prescription HCU from pre-TBI to post-TBI to the same change among a non-TBI control group. Most rehabilitation visits were not included. We stratified models by age ≥65 and included the month of TBI in subanalysis.

RESULTS

There were 207 354 individuals in the TBI cohort and 414 708 individuals in the non-TBI cohort. Excluding the month of TBI diagnosis, TBI resulted in a slight increase in outpatient visits (rate ratio [RtR] = 1.05; 95% confidence interval [CI], 1.04-1.06) but decrease in inpatient HCU (RtR = 0.86; 95% CI, 0.84-0.88). Including the month of TBI in the models resulted in increased inpatient (RtR = 1.55; 95% CI, 1.52-1.58) and ED HCU (RtR = 1.37; 95% CI, 1.34-1.40).

CONCLUSION

In this population of individuals who maintained insurance coverage following TBI, results suggest that TBI may have a limited impact on nonrehabilitation HCU at the population level.

Health care costs of injury in the older population: a prospective multicentre cohort study in the Netherlands

Background

With the ageing population, the number of older trauma patients has increased. The aim of this study was to assess non-surgical health care costs of older trauma patients and to identify which characteristics of older trauma patients were associated with high health care costs.

Methods

Trauma patients aged ≥65 years who were admitted to a hospital in Noord-Brabant, the Netherlands, were included in the Brabant Injury Outcome Surveillance (BIOS) study. Non-surgical in-hospital and up to 24- months post-hospital health care use were obtained from hospital registration data and collected with the iMTA Medical Consumption Questionnaire which patients completed 1 week and 1, 3, 6, 12 and 24 months after injury. Log-linked gamma generalized linear models were used to identify cost-driving factors.

Results

A total of 1910 patients were included in the study. Mean total health care costs per patient were €12,190 ranging from €8390 for 65–69 year-olds to €15,550 for those older than 90 years. Main cost drivers were the post-hospital costs due to home care and stay at an institution. Falls (72%) and traffic injury (15%) contributed most to the total health care costs, although costs of cause of trauma varied with age and sex. In-hospital costs were especially high in patients with high injury severity, frailty and comorbidities. Age, female sex, injury severity, frailty, having comorbidities and having a hip fracture were independently associated with higher post-hospital health care costs.

Conclusions

In-hospital health care costs were chiefly associated with high injury severity. Several patient and injury characteristics including age, high injury severity, frailty and comorbidity were associated with post-hospital health care costs. Both fall-related injuries and traffic-related injuries are important areas for prevention of injury in the older population.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12877-020-01825-z.

Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury: Examining Associations With Demographics, Healthcare Utilization, Institutionalization, and 1-Year Outcomes

OBJECTIVES

To assess the relationship of acute complications, preexisting chronic diseases, and substance abuse with clinical and functional outcomes among adults 50 years and older with moderate-to-severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

PARTICIPANTS

Adults 50 years and older with moderate-to-severe TBI (n = 2134).

MEASURES

Clusters of comorbid health conditions empirically derived from non-injury International Classification of Diseases, Ninth Revision codes, demographic/injury variables, and outcome (acute and rehabilitation length of stay [LOS], Functional Independence Measure efficiency, posttraumatic amnesia [PTA] duration, institutionalization, rehospitalization, and Glasgow Outcome Scale-Extended (GOS-E) at 1 year).

RESULTS

Individuals with greater acute hospital complication burden were more often middle-aged men, injured in motor vehicle accidents, and had longer LOS and PTA. These same individuals experienced higher rates of 1-year rehospitalization and greater odds of unfavorable GOS-E scores at 1 year. Those with greater chronic disease burden were more likely to be rehospitalized at 1 year. Individuals with more substance abuse burden were most often younger (eg, middle adulthood), black race, less educated, injured via motor vehicle accidents, and had an increased risk for institutionalization.

CONCLUSION

Preexisting health conditions and acute complications contribute to TBI outcomes. This work provides a foundation to explore effects of comorbidity prevention and management on TBI recovery in older adults.

Lifetime history of traumatic brain injury is associated with increased loneliness in adults: A US nationally representative study

BACKGROUND/OBJECTIVES

An estimated 55 million individuals worldwide live with chronic disability associated with traumatic brain injury (TBI), which may include cognitive, behavioral, and social impairments. Reduced participation in social activities is common after TBI; however, few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness and to identify mediators of this association.

METHODS/DESIGN

Retrospective cohort study. Nationally representative sample of N = 724 adults over age 50 years (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised University of California Los Angeles (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, and education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index.

RESULTS

History of TBI was associated with a 1.28-point (95% CI, 0.46-2.11; P < .05; Cohen's D = 0.284) increase in R-UCLA Loneliness Scale scores after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms partially mediated the relationship between TBI and loneliness. All models were adjusted for US population sampling weights.

CONCLUSIONS

History of TBI was associated with greater loneliness compared with individuals without TBI in a representative sample of US adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population.

High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation

Background

The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma.

Methods

We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis.

Results

There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16–3.51) versus 1.24 (95% CI 1.04–1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03–1.30) versus 1.05 (95% CI 1.01–1.10).

Conclusion

Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.

Quality of life measures in older adults after traumatic brain injury: a systematic review

BACKGROUND

On average older adults experiencing TBI are hospitalized four times as often, have longer hospital stays, and experience slower recovery trajectories and worse functional outcomes compared to younger populations with the same injury severity. A standard measure of Qol for older adults with TBI would facilitate accurate and reliable data across the individual patient care continuum and across clinical care settings, as well as support more rigorous research studies of metadata.

PURPOSE

The aim of this systematic review was to investigate patient reported Qol measures in studies with older adults post TBI.

METHOD

A systematic review was carried out focusing on the various tools to measure Qol in older adults, ≥ 65 years of age with a diagnosis of TBI. Data bases searched included Medline, Embase, PubMed, CINAHL, and PsychInfo from date of inception to September 25, 2017.

RESULTS

A total of 20 articles met the inclusion criteria. Nine different tools were identified.

CONCLUSIONS

Findings based on the comparison of reliability and construct validity of the Qol measures reported in this review suggest that no single instrument is superior to all others for our study population. Future research in this field should include the enrollment of larger study samples of older adults. Without these future efforts, the ability to detect an optimal Qol measure will be hindered.

Experiences and Perceptions of Hospitalization and Recovery of Older Adults and Their Caregivers Following Traumatic Brain Injury: "Not Knowing"

The purpose of the current study is to describe the experience and perceptions of older adults and their caregivers following hospitalization for mild or moderate traumatic brain injury (TBI). Qualitative analysis of data obtained in individual semi-structured interviews with older adults and their caregivers (N = 11, five dyads and one individual) was performed to capture the perceptions and experiences of the survivor and their caregivers about the acute injury, hospitalization, and recovery. Data were collected over a 2-month period following discharge from the hospital. Open coding and constant comparative analysis generated codes that were revised throughout the analysis and reformulated into thematic descriptions. As a result, seven interrelated themes were identified. These findings can be used to implement interventions focused on recovery, communication, teaching, patient outcomes, and satisfaction. [Res Gerontol Nurs. 2019; 12(5):227-238].

Epidemiology of Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury

OBJECTIVES

Aging individuals with traumatic brain injury (TBI) experience multiple comorbidities that can affect recovery from injury. The objective of this study was to describe the most commonly co-occurring comorbid conditions among adults 50 years and older with TBI.

SETTING

Level I Trauma centers.

PARTICIPANTS

Adults 50 years and older with moderate/severe TBI enrolled in the TBI-Model Systems (TBI-MS) from 2007 to 2014 (n = 2134).

DESIGN

A TBI-MS prospective cohort study.

MAIN MEASURES

International Classification of Disease-9th Revision codes collapsed into 45 comorbidity categories. Comorbidity prevalence estimates and trend analyses were conducted by age strata (50-54, 55-64, 65-74, 75-84, ≥85 years). A dimension reduction method, Treelet Transform, classified clusters of comorbidities that tended to co-occur.

RESULTS

The 3 most commonly occurring comorbid categories were hypertensive disease (52.6/100 persons), other diseases of the respiratory system (51.8/100 persons), and fluid component imbalances (43.7/100 persons). Treelet Transform classified 3 clusters of comorbid codes, broadly classified as (1) acute medical diseases/infections, (2) chronic conditions, and (3) substance abuse disorders.

CONCLUSION

This study provides valuable insight into comorbid conditions that co-occur among adults 50 years and older with TBI and provides a foundation for future studies to explore how specific comorbidities affect TBI recovery.

Severe head injury in elderly: 6-year comparison of treatment and outcome between southern Finland and Navarra (Spain)

PURPOSE

To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain).

METHODS

Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals.

RESULTS

A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1-1.6) and for HTR 0.8 (0.6-1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher.

CONCLUSION

The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.

TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions

Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age

Physical activity and exercise are important adjuncts to medical treatment for overall health in individuals with traumatic brain injury (TBI); however, many individuals do not partake in the recommended weekly exercise. The objective of this study was to investigate the barriers to exercise after TBI and determine whether these barriers varied by age. The sample was 172 adults with moderate to severe TBI who completed Barriers to Physical Exercise and Disability (B-PED) survey. Lack of interest, motivation, and energy as well as cost, lack of counseling on exercise by a physician, not having home equipment, and being too lazy were reported as barriers to exercise by all age groups. Those aged 35 to 54-years-old were more likely to report that cost, lack of transportation, having health concerns, not knowing where to exercise, and fear of leaving the home as barriers to exercise than those aged 18 to 34-years-old or 55-years-old and older. Overall, adults with TBI report multiple barriers to exercise, and these barriers vary by age.

Treatment Charges for Traumatic Brain Injury Among Older Adults at a Trauma Center

OBJECTIVE

To provide charge estimates of treatment for traumatic brain injury (TBI), including both hospital and physician charges, among adults 65 years and older treated at a trauma center.

METHODS

We identified older adults treated for TBI during 2008-2012 (n = 1843) at Maryland's Primary Adult Resource Center and obtained hospital and physician charges separately. Analyses were stratified by sex and all charges were inflated to 2012 dollars. Total TBI charges were modeled as a function of covariates using a generalized linear model.

RESULTS

Women comprised 48% of the sample. The mean unadjusted total TBI hospitalization charge for adults 65 years and older was $36 075 (standard deviation, $63 073). Physician charges comprised 15% of total charges. Adjusted mean charges were lower in women than in men (adjusted difference, -$894; 95% confidence interval, -$277 to -$1512). Length of hospital and intensive care unit stay were associated with the highest charges.

CONCLUSIONS

This study provides the first estimates of hospital and physician charges associated with hospitalization for TBI among older adults at a trauma center that will aid in resource allocation, triage decisions, and healthcare policy.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

The Application of the CRASH-CT Prognostic Model for Older Adults With Traumatic Brain Injury: A Population-Based Observational Cohort Study

OBJECTIVE

To examine the performance of the Corticosteroid Randomization After Significant Head injury (CRASH) trial prognostic model in older patients with traumatic brain injury.

SETTING

The National Study on Costs and Outcomes of Trauma cohort, established at 69 hospitals in the United States in 2001 and 2002.

PARTICIPANTS

Adults with traumatic brain injury and an initial Glasgow Coma Scale score of 14 or less.

DESIGN

The CRASH-CT model predicting death within 14 days was deployed in all patients. Model performance in older patients (aged 65-84 years) was compared with that in younger patients (aged 18-64 years).

MAIN MEASURES

Model discrimination (as defined by the c-statistic) and calibration (as defined by the Hosmer-Lemeshow P value).

RESULTS

CRASH-CT model discrimination was not significantly different between the older (n = 356; weighted n = 524) and younger patients (n = 981; weighted n = 2602) and was generally adequate (c-statistic 0.83 vs 0.87, respectively; P = .11). CRASH-CT model calibration was adequate for the older patients and inadequate for younger patients (Hosmer-Lemeshow P values .12 and .001, respectively), possibly reflecting differences in sample size. Calibration-in-the-large showed no systematic under- or overprediction in either stratum.

CONCLUSION

The CRASH-CT model may be valid for use in a geriatric population.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

Predictors for Depressive Mood in Geriatric Patients After Traumatic Brain Injury: A Retrospective Cross-Sectional Study

Objective

To identify predictors for depressive mood in geriatric patients after traumatic brain injury (TBI).

Methods

A retrospective review of patients' medical charts was performed in TBI patients who were older than 60 years and referred to the Department of Rehabilitation Medicine at Severance Hospital in 2002–2016. The patients were classified into two groups based on the Geriatric Depression Scale (GDS): non-depressive group (0≤GDS≤16) and depressive group (17≤GDS≤30). Data was collected on demographic, socioeconomic, comorbidities, and trauma-related factors, as well as the pathophysiology of TBI, localization of lesion, post-traumatic complications, functional level, and cognitive and linguistic function. Significant variables from univariate analysis were analyzed using logistic regression.

Results

Forty-two patients were included, of whom 64.3% displayed a depressive mood. Patients in the depressive group had higher comorbidity scores (p=0.03), lower Functional Independence Measure (FIM) totals (p=0.03) and FIM motor (p=0.03) scores, higher modified Rankin Scale scores (p=0.04), and frequently had a bilateral or left side brain lesion (p=0.002). Higher comorbidity scores (odds ratio [OR], 1.764; 95% confidence interval [CI], 1.047–2.971), bilateral lesions (OR, 13.078; 95% CI, 1.786–95.780), and left side lesions (OR, 46.074; 95% CI, 3.175–668.502) were independently associated with a depressive mood in the multiple logistic regression analysis.

Conclusion

The risk of depressive mood in geriatric patients after TBI is associated with comorbidity, functional limitation, and the horizontal distribution of brain lesions. The most significant determining factors were comorbidity and the horizontal distribution of brain lesions. Early detection of risk factors is important to prevent and manage depressive mood in geriatric patients after TBI.

Psychotropic Medication Use among Medicare Beneficiaries Following Traumatic Brain Injury

OBJECTIVES

To characterize psychotropic medication use before and after traumatic brain injury (TBI) hospitalization among older adults. A secondary objective is to determine how receipt of indicated pharmacologic treatment for anxiety and post-traumatic stress disorder (PTSD) differs following TBI.

DESIGN

Retrospective cohort.

SETTING

United States.

PARTICIPANTS

Medicare beneficiaries aged ≥65 years hospitalized with TBI between 2006 and 2010 with continuous drug coverage for 12 months before and after TBI (N = 60,276).

MEASUREMENTS

We obtained monthly psychotropic medication use by drug class and specific drugs from Medicare Part D drug event files.ICD-9 codes were used to define anxiety (300.0x) and PTSD (309.81).

RESULTS

Average monthly prevalence of psychotropic medication use among all patients hospitalized for TBI was 44.8%; antidepressants constituted 73%. Prevalence of psychotropic medication use increased from 2006 to 2010. Following TBI, psychotropic medication use increased slightly (OR: 1.05; 95% CI: 1.03, 1.06.) Tricyclic antidepressant use decreased post-TBI (OR: 0.76; 95% CI: 0.73, 0.79) whereas use of the sedating antidepressants mirtazapine (OR: 1.31; 95% CI: 1.25, 1.37) and trazadone (OR: 1.11; 95% CI: 1.06, 1.17) increased. Antipsychotic (OR: 1.15; 95% CI: 1.12, 1.19) use also increased post-TBI. Beneficiaries newly diagnosed with anxiety (OR: 0.42; 95% CI: 0.36, 0.48) and/or PTSD (OR: 0.39; 95% CI: 0.18, 0.84) post-TBI were less likely to receive indicated pharmacologic treatment.

CONCLUSIONS

Older adults hospitalized with TBI have a high prevalence of psychotropic medication use yet are less likely to receive indicated pharmacological treatment for newly diagnosed anxiety and PTSD following TBI.

Burden of USA hospital charges for traumatic brain injury

OBJECTIVES

This study sought to estimate charges associated with USA hospital visits for traumatic brain injury (TBI), compare charges from 2006-2010 and evaluate factors associated with higher charges.

METHODS

The Nationwide Emergency Department Sample database, 2006-2010, was used to estimate charges for emergency department visits and inpatient hospital stays associated with TBI and trends in charges over time were compared. Multivariable linear regression was used to evaluate factors associated with visit charges.

RESULTS

In 2010, there were $21.4 billion (95% confidence interval (CI) = $17.7-$25.2 billion) in charges for TBI-related admissions, an increase of 22% from 2006. Charges for ED visits resulting in discharge or transfer were $8.2 billion (95% CI = $7.4-$8.9 billion), an increase of 94% from 2006. The proportion of charges for TBI-related visits was disproportionately higher than the proportion of visits for TBI across all years of the study (p < 0.001). Patient age and gender, West region, trauma centre status, non-paediatric hospital designation, metropolitan location and hospital ownership were independently associated with higher charges.

CONCLUSIONS

There was a substantial charge burden from TBI-related hospital visits and charges increased disproportionately to visit volume. There are patient and hospital factors independently associated with higher charges. These findings, as well as methods to reduce the charge burden and charge disparities, deserve further study.

Outcome and Refractory Factor of Intensive Treatment for Geriatric Traumatic Brain Injury: Analysis of 1165 Cases Registered in the Japan Neurotrauma Data Bank

OBJECTIVE

With the increase in the aged population, geriatric traumatic brain injury (gTBI) is also rapidly increasing in Japan. There is thus a need to review the effect of intensive treatments for gTBIs. The aim of this study was 1) to assess how intensive treatments influenced patient outcome and 2) to identify the refractory factor against these intensive treatments in gTBI, from the Japan Neurotrauma Data Bank (JNTDB).

METHODS

Of all 3194 patients in the JNTDB, 1165 (≥ 65 years old) with severe gTBIs were enrolled in this study. The clinical features and their outcomes based on the Glasgow Outcome Scale on discharge and 6 months after injury were compared.

RESULTS

Intensive treatments were administered to 71.4% of all patients with severe gTBI showing a significant increase over 15 years. Accordingly, mortality decreased significantly (from 62.7% to 51.1%, P = 0.001). On the other hand, severely disabled dependent survivors, who need daily help from others for living, increased accordingly (from 63.2% to 68.4%). The existence of intraventricular hemorrhage (IVH) rather than the patient's age was identified as the strongest refractory factor (odds ratio, 5.762; 95% confidence interval, 1.317-25.216) against intensive treatment.

CONCLUSIONS

This study clarified that 1) intensive treatments are associated with higher survival rates (however, they also increase the incidence of severely disabled survivors) and 2) the strongest refractory factor for intensive treatment in cases of severe gTBI was not age but the existence of IVH. These results warrant further establishment of a seamless strategy for both the acute and the chronic phase of gTBI.

What's new in the management of traumatic brain injury on neuro ICU?

PURPOSE OF REVIEW

In recent years, we have begun to better understand how to monitor the injured brain, look for less common complications and importantly, reduce unnecessary and potentially harmful intervention. However, the lack of consensus regarding triggers for intervention, best neuromonitoring techniques and standardization of therapeutic approach is in need of more careful study. This review covers the most recent evidence within this exciting and dynamic field.

RECENT FINDINGS

The role of intracranial pressure monitoring has been challenged; however, it still remains a cornerstone in the management of the severely brain-injured patient and should be used to compliment other techniques, such as clinical examination and serial imaging.The use of multimodal monitoring continues to be refined and it may be possible to use them to guide novel brain resuscitation techniques, such as the use of exogenous lactate supplementation in the future.

SUMMARY

Neurocritical care management of traumatic brain injury continues to evolve. However, it is important not to use a 'one-treatment-fits-all' approach, and perhaps look to use targeted therapies to individualize treatment.

Utilization and Cost of Health Services in Individuals With Traumatic Brain Injury

Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden. We seek to answer two questions. What is the evidence regarding the association of TBI with health services utilization and costs in the US and worldwide? What is the evidence regarding racial/ethnic, gender, geographic, socio-economic and other disparities in health services utilization and cost in the US and worldwide? To attain this goal we searched several databases using key words to perform a systematic review of the literature since 2000. We found 36 articles to be eligible for inclusion in the review. The evidence demonstrates a wide variation in health services utilization and costs depending on population of study and severity of TBI. The evidence also supports the existence of racial/ethnic, gender, insurance, geographic disparities in the US as well as other unique disparities worldwide.

Patterns of Depression Treatment in Medicare Beneficiaries with Depression after Traumatic Brain Injury

There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006-2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p<0.001). Beneficiaries with a diagnosis of depression post-TBI were less likely to receive antidepressants compared with a depression diagnosis pre-TBI (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.82, 0.92). There was no difference in receipt of psychotherapy between the two groups (OR 1.08; 95% CI 0.93, 1.26). Depression after TBI is undertreated among older adults. Knowledge about reasons for this disparity and its long-term effects on post-TBI outcomes is limited and should be examined in future work.

Stroke incidence following traumatic brain injury in older adults

OBJECTIVE

Following traumatic brain injury (TBI), older adults are at an increased risk of hemorrhagic and thromboembolic events, but it is unclear whether the increased risk continues after hospital discharge. We estimated incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among adults 65 years or older and compared them with pre-TBI rates.

PARTICIPANTS

A total of 16 936 Medicare beneficiaries 65 years or older with a diagnosis of TBI in any position on an inpatient claim between June 1, 2006, and December 31, 2009, who survived to hospital discharge.

DESIGN

Retrospective analysis of a random 5% sample of Medicare claims data.

MAIN MEASURES

Hemorrhagic stroke was defined as ICD-9 (International Classification of Diseases, Ninth Revision) codes 430.xx-432.xx. Ischemic stroke was defined as ICD-9 codes 433.xx-435.xx, 437.0x, and 437.1x.

RESULTS

There was a 6-fold increase in the rate of hemorrhagic stroke following TBI compared with the pre-TBI period (adjusted rate ratio, 6.5; 95% confidence interval, 5.3-7.8), controlling for age and sex. A smaller increase in the rate of ischemic stroke was observed (adjusted rate ratio, 1.3; 95% CI, 1.2-1.4).

CONCLUSION

Future studies should investigate causes of increased stroke risk post-TBI as well as effective treatment options to reduce stroke risk and improve outcomes post-TBI among older adults.

Ethical and regulatory considerations in the design of traumatic brain injury clinical studies

Research is essential for improving outcomes after traumatic brain injury (TBI). However, the ubiquity, variability, and nature of TBI create many ethical issues and accompanying regulations for research. To capture the complexity and importance of designing and conducting TBI research within the framework of key ethical principles, a few highly relevant topics are highlighted. The selected topics are: (1) research conducted in emergency settings; (2) maintaining equipoise in TBI clinical trials; (3) TBI research on vulnerable populations; and (4) ethical considerations for sharing data. The topics aim to demonstrate the dynamic and multifaceted challenges of TBI research, and also to stress the value of addressing these challenges with the key ethical principles of respect, beneficence, and justice. Much has been accomplished to ensure that TBI research meets the highest ethical standards and has fair and enforceable regulations, but important challenges remain and continued efforts are needed by all members of the TBI research community.

Risk for late-life re-injury, dementia and death among individuals with traumatic brain injury: a population-based study

OBJECTIVES

To determine the association of self-reported traumatic brain injury (TBI) with loss of consciousness (LOC) with late-life re-injury, dementia diagnosis and mortality.

DESIGN

Ongoing longitudinal population-based prospective cohort study.

SETTING

Seattle-area integrated health system.

PARTICIPANTS

4225 dementia-free individuals age 65 and older were randomly selected and enrolled between 1994 and 2010. Participants were seen every 2 years, with mean (range) follow-up of 7.4 (0-16) years. 606 (14%) participants reported a lifetime history of TBI with LOC at enrolment. 3466 participants provided information regarding lifetime history of TBI and completed at least one follow-up visit.

MAIN OUTCOME MEASURES

Self-reported TBI with LOC after study entry, incident all-cause dementia and Alzheimer's disease (AD), and all-cause mortality.

RESULTS

There were 25 567 person-years of follow-up. History of TBI with LOC reported at study enrolment was associated with increased risk for TBI with LOC during follow-up, with adjusted HRs ranging from 2.54 (95% CI 1.42 to 4.52) for those reporting first injury before age 25 to 3.79 (95% CI 1.89 to 7.61) for those with first injury after age 55. History of TBI with LOC was not associated with elevated risk for developing dementia or AD. There was no association between baseline history of TBI with LOC and mortality, though TBI with LOC since the previous study visit ('recent TBI') was associated with increased mortality (HR 2.12, 95% CI 1.62 to 2.78).

CONCLUSIONS

Individuals aged 65 or older who reported a history of TBI with LOC at any time in their lives were at elevated risk of subsequent re-injury. Recent TBI with LOC sustained in older adulthood was associated with increased risk for mortality. Findings support the need for close clinical monitoring of older adults who sustain a TBI with LOC.