Anxiety and Posttraumatic Stress Disorder Among Medicare Beneficiaries After Traumatic Brain Injury

Co-Occurring Mental and Physical Health Conditions Among Older Adults With and Without Post-traumatic Stress Disorder: A Case Control Study

ObjectivesRates of post-traumatic stress disorder (PTSD) among older adults range from 0.4%-4.5%. Research examining PTSD in adults has demonstrated numerous associations between physical and mental health conditions; however, these are less well characterized in older adults. The current study aimed to identify base rates of such conditions among older adults with and without a history of PTSD.MethodIn a case control design using the National Alzheimer's Coordinating Center Uniform Data Set, adults 65 years or older from the United States who endorsed either the presence or absence of PTSD were matched by age to assess between-group differences (N = 472; 236 pairs). We examined differences across self-reported sociodemographics and physical health, mental health, and substance use histories.ResultsMore participants with a history of PTSD identified as Hispanic, non-white, non-married, and functionally independent. Compared to individuals without a history of PTSD, significantly more individuals with a history of PTSD had histories of depression, anxiety, substance abuse, Parkinson's disease, seizures, insomnia, and TBI. Among participants without PTSD history, only 14.7% reported a history of TBI, compared to 41.1% of individuals with PTSD history.ConclusionsFindings showed expected trends toward worse physical and mental health among older adults with self-reported PTSD. There was a striking difference in the frequency of TBI history between participants with and without PTSD. These findings underscore a need to assess for PTSD among older adults, particularly those reporting a history of TBI.

Hospital and Patient Level Predictors for 90-d Readmission Following Burn Injury

INTRODUCTION

Predictors and contributing factors for hospital readmission following burn injury are currently not well described. Previous studies evaluating readmission following burn injury have been limited to specific patient subpopulations or to a short-term period after injury, for example, 30 d. We describe predictors for all cause, 90-d hospital readmission following burn injury among the US adult population.

METHODS

An observational cohort study was conducted using the Healthcare Cost and Utilization Project 2017-2020 Nationwide Readmissions Database data. Individuals ≥18 y of age at the time of admission were included in the study, and International Classification of Diseases, Tenth Revision diagnosis codes were utilized to identify burn injury. Patient demographics, payor status, total charges, comorbidities, markers of socioeconomic status, and hospital characteristics were included in a multivariable logistic regression analysis to identify predictors for hospital readmission within 90-d postdischarge.

RESULTS

We identified 153,760 patients with a burn injury in the study period, of whom 20.8% required a readmission within 90 d postdischarge. Increased age, the presence of a comorbid condition, and lower socioeconomic status increased the likelihood of 90-d readmission. At the hospital level, admission to a private investor-owned and smaller bed size hospitals were associated with an increased likelihood of readmission.

CONCLUSIONS

Identification of factors that lead to increased likelihood of 90-d readmission following hospitalization for a burn injury may be beneficial in clinical decision making, allowing for more individualized care and minimization of unplanned readmissions.

Neighborhood Deprivation and Recovery Following Traumatic Brain Injury Among Older Adults

OBJECTIVE

Understanding the extent to which neighborhood impacts recovery following traumatic brain injury (TBI) among older adults could spur targeting of rehabilitation and other services to those living in more disadvantaged areas. The objective of the present study was to determine the extent to which neighborhood disadvantage influences recovery following TBI among older adults.

Setting and Participants: Community-dwelling Medicare beneficiaries aged ≥65 years hospitalized with TBI 2010-2018.

DESIGN AND MAIN MEASURES

In this retrospective cohort study, the Area Deprivation Index (ADI) was used to assess neighborhood deprivation by linking it to 9-digit beneficiary zip codes. We used national-level rankings to divide the cohort into the top 10% (highest neighborhood disadvantage), middle 11-90%, and bottom 10% (lowest neighborhood disadvantage). Recovery was operationalized as days at home, calculated by subtracting days spent in a care environment or deceased from monthly follow-up over the year post-TBI.

RESULTS

Among 13,747 Medicare beneficiaries with TBI, 1713 (12.7%) were in the lowest decile of ADI rankings and 1030 (7.6%) were in the highest decile of ADI rankings. Following covariate adjustment, beneficiaries in neighborhoods with greatest disadvantage [rate ratio (RtR) 0.96; 95% confidence interval (CI) 0.94, 0.98] and beneficiaries in middle ADI percentiles (RtR 0.98; 95% CI 0.97, 0.99) had fewer days at home per month compared to beneficiaries in neighborhoods with lowest disadvantage.

CONCLUSION

This study provides evidence that neighborhood is associated with recovery from TBI among older adults and highlights days at home as a recovery metric that is responsive to differences in neighborhood disadvantage.

Psychiatric Disorders Are Common Among Older US Veterans Prior to Traumatic Brain Injury

OBJECTIVE

To estimate the impact of traumatic brain injury (TBI) on prevalence of posttraumatic stress disorder (PTSD), depression, and alcohol and substance use disorders.

SETTING

A random sample of Veteran's Health Administration data.

PARTICIPANTS

A total of 14 116 veterans aged ≥55 with incident late-life TBI between October 1, 1999, and September 31, 2021, were matched 1:3 on age and TBI date to 42 678 veterans without TBI.

DESIGN

Retrospective cohort study.

MAIN MEASURES

PTSD, depression, and alcohol and substance use disorders were identified using diagnostic codes. Participants were censored after the first diagnosis during the year before and the year after the TBI or matched date. Prevalence rates of PTSD, depression, alcohol, and substance use disorders were compared before and after incident TBI or matched date using Poisson regression.

RESULTS

Pre-TBI prevalence rates of disorders were higher among those with TBI relative to those without TBI. Pre-TBI PTSD prevalence rates (per 1000 person-years) were 126.3 (95% CI, 120.2-132.4) compared to 21.5 (95% CI, 20.1-22.9) in the non-TBI cohort. In adjusted models, TBI was not associated with an increase in the prevalence of any of the studied disorders.

CONCLUSIONS

Prevalence rates of depression, PTSD, and alcohol and substance use disorders were 5 to 10 times higher among older veterans before incident TBI. We did not observe an increase in the prevalence of these disorders after incident TBI. Older veterans with these disorders may be at increased risk for TBI.

Incidence of anxiety after traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Traumatic brain injury (TBI) is defined as acquired cerebral damage caused by an external mechanical impact, which has the potential to lead to transient or enduring debilitation. TBI is associated with many forms of long-lasting psychiatric conditions, including anxiety disorders. As anxiety is highly debilitating by causing impaired social functioning and decreased quality of life for the afflicted, especially in the form of anxiety disorders such as generalized anxiety disorder, certain efforts have been made to explore the factors associated with it, and one such factor is TBI.

METHODS

We searched PubMed, Scopus, and Web of Science on January 26th, 2024 for observational case-control or cohort or cross-sectional studies assessing the incidence of anxiety symptoms or disorders in patients with TBI compared to healthy individuals or the same individuals if pre-TBI information regarding anxiety was available. We calculated the pooled incidence and relative risk (RR) and 95% confidence interval (95CI) using the inverse variance method. Publication bias was assessed using Eggers's regression test. Quality assessment was performed using the Newcastle-Ottawa scale. Sub-group analyses were conducted for the type of anxiety (anxiety disorder vs anxiety symptoms), TBI severity, and type of anxiety disorders.

RESULTS

The incidence rate of anxiety after traumatic brain injury was 17.45% (95CI: 12.59%, 22.31%) in a total of 705,024 individuals. Moreover, TBI patients were found to be 1.9 times as likely to have anxiety compared to their non-TBI counterparts [Random effects model RR = 1.90 [1.62; 2.23], p-value < 0.0001] using a population of 569,875 TBI cases and 1,640,312 non-TBI controls. Sub-group analysis revealed TBI severity was not associated with anxiety and generalized anxiety disorder was the most common type of anxiety disorder reported post-TBI.

CONCLUSION

Patients who have experienced a TBI exhibit a significantly greater incidence of anxiety symptoms and anxiety disorders in the aftermath when compared to healthy individuals.

Dysregulation of the dopaminergic system secondary to traumatic brain injury: implications for mood and anxiety disorders

Traumatic brain injury (TBI) represents a public health issue with a high mortality rate and severe neurological and psychiatric consequences. Mood and anxiety disorders are some of the most frequently reported. Primary and secondary damage can cause a loss of neurons and glial cells, leading to dysfunction of neuronal circuits, which can induce imbalances in many neurotransmitter systems. Monoaminergic systems, especially the dopaminergic system, are some of the most involved in the pathogenesis of neuropsychiatric and cognitive symptoms after TBI. In this work, we summarize the studies carried out in patients who have suffered TBI and describe alterations in the dopaminergic system, highlighting (1) dysfunction of the dopaminergic neuronal circuits caused by TBI, where modifications are shown in the dopamine transporter (DAT) and alterations in the expression of dopamine receptor 2 (D2R) in brain areas with dopaminergic innervation, thus establishing a hypodopaminergic state and (2) variations in the concentration of dopamine and its metabolites in biological fluids of post-TBI patients, such as elevated dopamine (DA) and alterations in homovanillic acid (HVA). On the other hand, we show a large number of reports of alterations in the dopaminergic system after a TBI in animal models, in which modifications in the levels of DA, DAT, and HVA have been reported, as well as alterations in the expression of tyrosine hydroxylase (TH). We also describe the biological pathways, neuronal circuits, and molecular mechanisms potentially involved in mood and anxiety disorders that occur after TBI and are associated with alterations of the dopaminergic system in clinical studies and animal models. We describe the changes that occur in the clinical picture of post-TBI patients, such as alterations in mood and anxiety associated with DAT activity in the striatum, the relationship between post-TBI major depressive disorders (MDD) with lower availability of the DA receptors D2R and D3R in the caudate and thalamus, as well as a decrease in the volume of the substantia nigra (SN) associated with anxiety symptoms. With these findings, we discuss the possible relationship between the disorders caused by alterations in the dopaminergic system in patients with TBI.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

HIGHLIGHTS

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

Stress and traumatic brain injury: An inherent bi-directional relationship with temporal and synergistic complexities

Traumatic brain injury (TBI) and stress are prevalent worldwide and can both result in life-altering health problems. While stress often occurs in the absence of TBI, TBI inherently involves some element of stress. Furthermore, because there is pathophysiological overlap between stress and TBI, it is likely that stress influences TBI outcomes. However, there are temporal complexities in this relationship (e.g., when the stress occurs) that have been understudied despite their potential importance. This paper begins by introducing TBI and stress and highlighting some of their possible synergistic mechanisms including inflammation, excitotoxicity, oxidative stress, hypothalamic-pituitary-adrenal axis dysregulation, and autonomic nervous system dysfunction. We next describe different temporal scenarios involving TBI and stress and review the available literature on this topic. In doing so we find initial evidence that in some contexts stress is a highly influential factor in TBI pathophysiology and recovery, and vice versa. We also identify important knowledge gaps and suggest future research avenues that will increase our understanding of this inherent bidirectional relationship and could one day result in improved patient care.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

Black or White race.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Voluntary Exercise to Reduce Anxiety Behaviour in Traumatic Brain Injury Shown to Alleviate Inflammatory Brain Response in Mice

Traumatic brain injury is a leading cause of neuroinflammation and anxiety disorders in young adults. Immune-targeted therapies have garnered attention for the amelioration of TBI-induced anxiety. A previous study has indicated that voluntary exercise intervention following TBI could reduce neuroinflammation. It is essential to determine the effects of voluntary exercise after TBI on anxiety via inhibiting neuroinflammatory response. Mice were randomly divided into four groups (sham, TBI, sham + voluntary wheel running (VWR), and TBI + VWR). One-week VWR was carried out on the 2nd day after trauma. The neurofunction of TBI mice was assessed. Following VWR, anxiety behavior was evaluated, and neuroinflammatory responses in the perilesional cortex were investigated. Results showed that after one week of VWR, neurofunctional recovery was enhanced, while the anxiety behavior of TBI mice was significantly alleviated. The level of pro-inflammatory factors decreased, and the level of anti-inflammatory factors elevated. Activation of nucleotide oligomerization domain-like thermal receptor protein domain associated protein 3 (NLRP3) inflammasome was inhibited significantly. All these alterations were consistent with reduced microglial activation at the perilesional site and positively correlated with the amelioration of anxiety behavior. This suggested that timely rehabilitative exercise could be a useful therapeutic strategy for anxiety resulting from TBI by targeting neuroinflammation.

In-depth assessment of quality of life and real life impact of mild traumatic brain injury in elderly by means of a focus group study

Traumatic Brain Injury (TBI) in the elderly population leads to more severe consequences than in young patients. However, the impact that TBI has on elderly patients' Quality of Life (QoL) has not been thoroughly investigated and is still unclear. Therefore, the main objective of this study is to qualitatively investigate changes in QoL after mild TBI in elderly patients. A focus group interview was conducted with 6 mild TBI patients, with a median age of 74 years old, admitted to the University Hospitals Leuven (UZ Leuven) between 2016 and 2022. The data analysis was performed following the guide provided by Dierckx de Casterlé et al. in 2012, using Nvivo software. Three themes emerged from the analysis: functional disturbances and symptoms, daily life after TBI, and life quality, feelings and satisfaction. The most reported factors that deteriorated QoL 1-5 years post-TBI in our cohort were the lack of support from partners and families, changes in self-perception and social life, tiredness, balance disturbances, headache, cognitive deterioration, changes in physical health, senses' disturbances, changes in sexual life, sleep problems, speech disturbances and dependence for daily life activities. No symptoms of depression or feelings of shame were reported. The acceptance of the situation and hope for improvement were shown to be the most important coping mechanisms for these patients. In conclusion, mild TBI in elderly patients frequently leads to changes in self-perception, daily life activities and social life 1-5 years after the injury, which could contribute to a loss of independence and QoL deterioration. The acceptance of the situation and a good support network seem to be protective factors for these patients' well-being after TBI.

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

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

Rehabilitation for Impaired Attention in the Acute and Post-Acute Phase After Traumatic Brain Injury: A Narrative Review

Impaired attention is the most common and debilitating cognitive deficit following a traumatic brain injury (TBI). Attention is a fundamental function that profoundly influences the performance of other cognitive components such as memory and execution. Intriguingly, attention can be improved through cognitive rehabilitation. This narrative review summarizes the essential elements of rehabilitation for attention problems in acute and post-acute TBI. In the acute phase of mild TBI, investigations into the medical history and daily life performance, neurological examination, screening and management of concomitant sleep-wake disorders or neuropsychiatric disorders, and support and education on the natural course of concussion are covered. Rehabilitation for patients with moderate-to-severe TBI consists of serial assessment for patients with disorders of consciousness and a post-traumatic confusion state. In the post-acute phase after TBI, components of rehabilitation include investigating medical history; neurological, imaging, and electrophysiological tests; evaluation and treatment of factors that may impact attention, including sleep-wake, emotional, and behavioral disorders; evaluation of attention function; and cognitive rehabilitation as a matter of course. We summarized metacognitive strategy, direct attention training, computer-based cognitive interventions, medication, and environmental control as interventions to enhance attention.

Neuroimaging Correlates of Syndromal Anxiety Following Traumatic Brain Injury: A Systematic Review of the Literature

BACKGROUND

Traumatic brain injury (TBI) can precipitate new-onset psychiatric symptoms or worsen existing psychiatric conditions. To elucidate specific mechanisms for this interaction, neuroimaging is often used to study both psychiatric conditions and TBI. This systematic review aims to synthesize the existing literature of neuroimaging findings among patients with anxiety after TBI.

METHODS

We conducted a Preferred Reporting Items for Systematic Review and Meta-Analyses-compliant literature search via PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases before May, 2019. We included studies that clearly defined TBI, measured syndromic anxiety as a primary outcome, and statistically analyzed the relationship between neuroimaging findings and anxiety symptoms.

RESULTS

A total of 5982 articles were retrieved from the systematic search, of which 65 studied anxiety and 13 met eligibility criteria. These studies were published between 2004 and 2017, collectively analyzing 764 participants comprised of 470 patients with TBI and 294 non-TBI controls. Imaging modalities used included magnetic resonance imaging, functional magnetic resonance imaging, diffusion tensor imaging, electroencephalogram, magnetic resonance spectrometry, and magnetoencephalography. Eight of 13 studies presented at least one significant finding and together reflect a complex set of changes that lead to anxiety in the setting of TBI. The left cingulate gyrus in particular was found to be significant in 2 studies using different imaging modalities. Two studies also revealed perturbances in functional connectivity within the default mode network.

CONCLUSIONS

This is the first systemic review of neuroimaging changes associated with anxiety after TBI, which implicated multiple brain structures and circuits, such as the default mode network. Future research with consistent, rigorous measurements of TBI and syndromic anxiety, as well as attention to control groups, previous TBIs, and time interval between TBI and neuroimaging, are warranted. By understanding neuroimaging correlates of psychiatric symptoms, this work could inform future post-TBI screening and surveillance, preventative efforts, and early interventions to improve neuropsychiatric outcomes.

Incidence of New Neuropsychiatric Disorder Diagnoses Following Traumatic Brain Injury

BACKGROUND

Neuropsychiatric disturbances (NPDs) are common following traumatic brain injury (TBI) and associated with poor recovery. Prior estimates of NPD following TBI failed to account for preexisting NPDs or potential confounding.

METHODS

We estimated the risk of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, and alcohol and substance dependence disorder diagnoses associated with TBI using administrative claims data from a large insurer in the United States, 2008-2014. We calculated rates of new NPD diagnoses during the 12 months before and 24 months after TBI and estimated the risk of NPD following TBI using a difference-in-difference approach and adjusting for confounders.

RESULTS

Before the TBI occurred, rates of NPD diagnoses were more than double in the TBI cohort (n = 207 354) relative to the no-TBI cohort (n = 414 708). TBI was associated with an increased risk of anxiety (rate ratio [RtR] = 1.08; 95% confidence interval [CI], 1.05-1.12) and PTSD (RtR = 1.41; 95% CI, 1.24-1.60) diagnoses. Rates of alcohol (RtR = 0.32; 95% CI, 0.30-0.34) and substance use disorder (RtR = 0.57; 95% CI, 0.55-0.59) diagnoses decreased following TBI.

CONCLUSIONS

In this large national study, rates of NPD were much higher among individuals with TBI than those in a non-TBI cohort, even before the TBI took place. TBI was associated with an increased risk of anxiety and PTSD diagnoses. Results from this study also suggest that individuals who sustain TBI have increased contact with the healthcare system during the months prior to injury, providing a window for intervention, especially for individuals diagnosed with alcohol dependence disorder.

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.

Traumatic Brain Injury and Incidence Risk of Sleep Disorders in Nearly 200,000 US Veterans

OBJECTIVE

To test the hypothesis that veterans with traumatic brain injury (TBI) have an increased subsequent risk of sleep disorders, we studied the longitudinal association between TBI and incident sleep disorders in nearly 200,000 veterans.

METHODS

We performed a cohort study of all patients diagnosed with a TBI in the Veterans Health Administration system from October 1, 2001, to September 30, 2015, who were age-matched 1:1 to veterans without TBI. Veterans with prevalent sleep disorders at baseline were excluded. Development of sleep disorders was defined as any inpatient or outpatient diagnosis of sleep apnea, hypersomnia, insomnia, or sleep-related movement disorders based on ICD-9 codes after the first TBI diagnosis or the random selection date for those without TBI. We restricted the analysis to those with at least 1 year of follow-up. We used Cox proportional hazards models to examine the association between TBI and subsequent risk of sleep disorders.

RESULTS

The study included 98,709 veterans with TBI and 98,709 age-matched veterans without TBI (age 49 ± 20 years). After an average follow-up of 5 (1-14) years, 23,127 (19.6%) veterans developed sleep disorders. After adjustment for demographics, education, income, and medical and psychiatric conditions, those who had TBI compared to those without TBI were 41% more likely to develop any sleep disorders (hazard ratio 1.41 [95% confidence interval 1.37-1.44]), including sleep apnea (1.28 [1.24-1.32]), insomnia (1.50 [1.45-1.55]), hypersomnia (1.50 [1.39-1.61]), and sleep-related movement disorders (1.33 [1.16-1.52]). The association was stronger for mild TBIs, did not differ appreciably by presence of posttraumatic stress disorder, and remained after a 2-year time lag.

CONCLUSION

In 197,418 veterans without sleep disorders, those with diagnosed TBI had an increased risk of incident sleep disorders over 14 years. Improved prevention and long-term management strategies for sleep are needed for veterans with TBI.

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Sleep disturbances among older adults following traumatic brain injury

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

Plasma Exosome-derived MicroRNAs as Novel Biomarkers of Traumatic Brain Injury in Rats

Traumatic brain injury (TBI) is a widespread central nervous system (CNS) condition and a leading cause of death, disability, and long-term disability including seizures and emotional and behavioral issues. To date, applicable diagnostic biomarkers have not been elucidated. MicroRNAs (miRNAs) are enriched and stable in exosomes in plasma. Therefore, we speculated that miRNAs in plasma exosomes might serve as novel biomarkers for TBI diagnosis and are also involved in the pathogenesis of TBI. In this study, we first isolated exosomes from peripheral blood plasma in rats with TBI and then investigated the alterations in miRNA expression in exosomes by high-throughput RNA sequencing. As a result, we identified 50 significantly differentially expressed miRNAs, including 31 upregulated and 19 downregulated miRNAs. Then, gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis revealed that the most highly correlated pathways that were identified were the MAPK signaling pathway, regulation of actin cytoskeleton, Rap1 signaling pathway and Ras signaling pathway. This study provides novel perspectives on miRNAs in peripheral blood plasma exosomes, which not only could be used as biomarkers of TBI diagnosis but could also be manipulated as therapeutic targets of TBI.

Gender Disparities in Trauma Care: How Sex Determines Treatment, Behavior, and Outcome

Trauma data bank and other research reveal sex disparities in trauma care. Risk-taking behaviors leading to traumatic injury have been associated with sex, menstrual cycle timing, and cortisol levels. Trauma patient treatment stratified by sex reveals differences in access to services at trauma centers as well as specific treatments, such as venous thromboembolism prophylaxis and massive transfusion component ratios. Trauma patient outcomes, such as in-hospital mortality, multiple organ failure, pneumonia, and sepsis are associated with sex disparities in the general trauma patient. Outcome after general trauma and specifically traumatic brain injury show mixed results with respect to sex disparity.