Rehabilitation and Outcome Disparities in Older Adults with Traumatic Brain Injury

Carmen M. Tyler, MA, MEd • Paul B. Perrin, PhD

Older adults represent a progressively increasing number and proportion of the world’s population1 as lifespans rise worldwide.2 For example, in the U.S., the percentage of older adults age 65 and above rose from 12.76% to 16.21% of the population over the ten years from 2009-2019, while other age groups remained about the same percentage or decreased.3 By 2060, projections are that the over-65 age group will be approximately double what it was in 2018, comprising nearly one-quarter of the U.S. population. The number of oldest old (ages 85 and over) is expected to double in the next 15 years and triple by 2060 to approximately 19 million people.4 TBI rates are increasing for older adults, with the greatest number of TBIs incurred by those aged 80 years and older.5 TBI-related morbidity and mortality rates are highest for older adults compared to other groups,6,7 with the primary cause for TBI in older adults being falls.8 As age increases, the likelihood of returning to live alone or at a private residence after TBI decreases, perhaps because although older adults experience less severe TBIs, rehabilitation takes longer with less improvement in functionality and greater disability.9

The increased risk associated with TBI in older adults is not a recent observation,10 but explanations about causality and severity differ. Some theorize that commonly used TBI assessment instruments like the Glasgow Coma Scale (GCS), in addition to having problems with inter-rater reliability and confounds,11 are not as sensitive for older adults as they are for younger adults, leading to underestimations of TBI severity.12 Several studies have demonstrated that older adults with GCS scores in the normal range are at higher risk for undetected intracranial lesions.7 Neuroinflammatory pattern differences in older versus younger adults have been noted up to 6 months after TBI, but it is still unclear as to whether these differences are age- or injury-related.13 Physical health conditions commonly experienced in older age are linked with increased fall risk14 and may contribute to worse outcomes for older adults with TBI.15 Others propose that physiological changes related to aging16 may increase vulnerability accompanying TBI in older adults. As adults age, structural and metabolic changes occur in the brain16 and throughout the body,17 resulting in reductions in functional efficiency of bodily systems. TBI may also increase vulnerability to developing illnesses like Parkinson’s disease18 and Alzheimer’s disease19 and mental health conditions such as schizophrenia20 and depression,21 which could limit function. Although observation of the link between sustaining moderate-to-severe TBI and subsequent development of Alzheimer’s disease is not new,22 ongoing research is elucidating the physiological processes that contribute to neurodegenerative diseases such as dementia and Parkinson’s disease after TBI.23

Older adults tend to sustain less severe TBI than younger people, but they have more disability post-TBI and are more likely to have a change in where they live after hospital discharge.9 TBI severity and GCS score can predict function in older adults at discharge from the hospital,24 and level of functioning at that time also predicts long-term functioning.25 However, greater age is associated with lower functional independence for older adults with TBI.26 Not only have older adults shown lower functional independence ratings than younger adults at discharge from the hospital and at 6 months post-discharge and more declines in ability 5 years post-injury, but these lower levels of functional independence have occurred despite lower injury ratings.27,28

Older age has also been noted as a consideration in postacute TBI treatment decisions. Early, intensive, and continuous implementation of rehabilitation is more effective at improving long-term functional outcomes for those with severe TBI than rehabilitation started in the subacute phase.29 Discharge from the hospital to a specialized rehabilitation facility has been associated with greater functional independence, and younger people are admitted directly to TBI rehabilitation more frequently than older adults with TBI, despite equivocal injury severity levels. 30

In addition to traditional demographics and psychosocial variables, research has established the detrimental effects of ageism on health outcomes.31 Negative aging stereotypes portraying older adults as being unattractive, incompetent, frail, and financial and social liabilities are ubiquitous, including in healthcare settings.32 Health care professionals who hold ageist beliefs may engage in discriminatory practices such as underordering diagnostic tests and treatments33 or dismissive, infantilizing, and patronizing communication or behaviors34 with older adults in their care. Perceptions of age discrimination by others and internalized ageist beliefs have been associated with greater functional impairment and higher mortality in older adults.35-37

Conclusion

Although functional outcomes after TBI have been examined in various studies,30 research on older adults with TBI has been relatively sparse.

Lifespan is increasing worldwide,2 and as a result, the proportion and number of older adults is increasing steadily.1 Morbidity and mortality rates are higher for older adults after TBI than they are for younger adults,6,7 and older adults have worse recovery outcomes even when injury severity is milder.9,28 As the risk for incurring a TBI increases with age5 and given the ubiquity of ageism,32 the greater number of older adults alone makes examination of factors contributing to poorer functional independence outcomes an important area of study and clinical intervention. Older adults with TBI have less chance of returning to independent living or employment after TBI,9,25 and their increased need for post-TBI assistance could have serious repercussions for additional demands imposed on healthcare systems, health insurance systems, local and national economies, and family and social systems.

Older age has also been noted as a consideration in post-acute TBI treatment decisions.

References

1. Worldometer. World population (2020 and historical). Accessed August 29, 2021. https://www. worldometers.info/world-population/#growthrate 2. GHE: Life expectancy and healthy life expectancy (2019). Accessed August 29, 2021. https://www. who.int/data/maternal-newborn-child-adolescent-ageing/advisory-groups/gama/gama-advisorygroup-members 3. Statista. U.S.: Age distribution. Statista. Accessed April 10, 2021. https://www.statista.com/ statistics/270000/age-distribution-in-the-united-states/ 4. Vespa J, Medina L, Armstrong DM. Population estimates and projections. demographic turning points for the United States: Population projections for 2020 to 2060. Accessed April 11, 2021. https://www. census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf 5. CDC. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2014 (2019). https://www.cdc.gov/traumaticbraininjury/ pdf/TBI-Surveillance-Report-FINAL_508.pdf 6. Dams-O’Connor K, Gibbons LE, Bowen JD, McCurry SM, Larson EB, Crane PK. Risk for late-life reinjury, dementia and death among individuals with traumatic brain injury: a population-based study. J Neurol Neurosurg Psychiatry. 2013;84(2):177-182. doi:10.1136/jnnp-2012-303938 7. Gardner RC, Dams-O’Connor K, Morrissey MR, Manley GT. Geriatric traumatic brain injury: Epidemiology, outcomes, knowledge gaps, and future directions. Journal of Neurotrauma. 2018;35(7):889-906. doi:10.1089/neu.2017.5371 8. Haring RS, Narang K, Canner JK, et al. Traumatic brain injury in the elderly: morbidity and mortality trends and risk factors. Journal of Surgical Research. 2015;195(1):1-9. doi:10.1016/j.jss.2015.01.017 9. Cuthbert JP, Harrison-Felix C, Corrigan JD, et al. Epidemiology of adults receiving acute inpatient rehabilitation for a primary diagnosis of traumatic brain injury in the United States. The Journal of Head Trauma Rehabilitation. 2015;30(2):122-135. doi:10.1097/HTR.0000000000000012 10. Vollmer DG, Torner JC, Jane JA, et al. Age and outcome following traumatic coma: why do older patients fare worse? Journal of Neurosurgery. 1991;75(Supplement):S37-S49. doi:10.3171/ sup.1991.75.1s.0s37 11. Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury assessment: A critical review. Brain Injury. 2009;23(5):371-384. doi:10.1080/02699050902926267 12. Yap SGM, Chua KSG. Rehabilitation outcomes in elderly patients with traumatic brain injury in Singapore: Journal of Head Trauma Rehabilitation. 2008;23(3):158-163. doi:10.1097/01. HTR.0000319932.15085.fe 13. Thompson HJ, Rivara F, Becker KJ, Maier R, Temkin N. Impact of aging on the immune response to traumatic brain injury (AIm:TBI) study protocol. Injury Prevention. 2020;26:471-477. doi:10.1136/ injuryprev-2019-043325 14. Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorkston K, Chan L. Falls in the Medicare population: Incidence, associated factors, and impact on health care. Physical Therapy. 2009;89(4):324-332. doi:10.2522/ptj.20070107 15. Dams-O’Connor K, Gibbons LE, Landau A, Larson EB, Crane PK. Health problems precede traumatic brain injury in older adults. Journal of the American Geriatrics Society. 2016;64(4):844-848. doi:10.1111/jgs.14014 16. Liu H, Yang Y, Xia Y, et al. Aging of cerebral white matter. Ageing Res Rev. 2017;34:64-76. doi:10.1016/j.arr.2016.11.006 17. Winter DA, Patla AE, Frank JS, Walt SE. Biomechanical walking pattern changes in the fit and healthy elderly. Physical Therapy. 1990;70(6):340-347. doi:10.1093/ptj/70.6.340 18. Gardner RC, Burke JF, Nettiksimmons J, Goldman S, Tanner CM, Yaffe K. Traumatic brain injury in later life increases risk for Parkinson’s disease. Ann Neurol. 2015;77(6):987-995. doi:10.1002/ana.24396 19. Ikonomovic MD, Mi Z, Abrahamson EE. Disordered APP metabolism and neurovasculature in trauma and aging: Combined risks for chronic neurodegenerative disorders. Ageing Res Rev. 2017;34:51-63. doi:10.1016/j.arr.2016.11.003 20. Molloy C, Conroy RM, Cotter DR, Cannon M. Is traumatic brain injury a risk factor for schizophrenia? A meta-analysis of case-controlled population-based studies. Schizophrenia Bulletin. 2011;37(6):1104-1110. doi:10.1093/schbul/sbr091 21. Jean-Bay E. The biobehavioral correlates of post-traumatic brain injury depression. Journal of Neuroscience Nursing. 2000;32(3):169-176. 22. Plassman BL, Havlik RJ, Steffens DC, et al. Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurology. 2000;55(8):1158-1166. doi:10.1212/ wnl.55.8.1158 23. Brett BL, Gardner RC, Godbout J, Dams-O’Connor K, Keene CD. Traumatic brain injury and risk of neurodegenerative disorder. Biol Psychiatry. Published online June 2, 2021:S0006-3223(21)01359-7. doi:10.1016/j.biopsych.2021.05.025 24. Thompson HJ, Dikmen S, Temkin N. Prevalence of comorbidity and its association with traumatic brain injury and outcomes in older adults. Res Gerontol Nurs. 2012;5(1):17-24. doi:10.3928/19404921-20111206-02 25. Testa JA, Malec JF, Moessner AM, Brown AW. Outcome after traumatic brain injury: Effects of aging on recovery. Archives of Physical Medicine and Rehabilitation. 2005;86(9):1815-1823. doi:10.1016/j. apmr.2005.03.010 26. Sendroy-Terrill M, Whiteneck GG, Brooks CA. Aging with traumatic brain injury: Cross-sectional follow-up of people receiving inpatient rehabilitation over more than 3 decades. Archives of Physical Medicine and Rehabilitation. 2010;91(3):489-497. doi:10.1016/j.apmr.2009.11.011 27. Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. Journal of Trauma and Acute Care Surgery. 2004;56(5):1042-1048. doi:10.1097/01.TA.0000127767.83267.33 28. Marquez de la Plata CD, Hart T, Hammond FM, et al. Impact of age on long-term recovery from traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2008;89(5):896-903. doi:10.1016/j.apmr.2007.12.030 29. Andelic N, Bautz-Holter E, Ronning P, et al. Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury? J Neurotrauma. 2012;29(1):66-74. doi:10.1089/neu.2011.1811 30. Sveen U, Røe C, Sigurdardottir S, et al. Rehabilitation pathways and functional independence one year after severe traumatic brain injury. European Journal of Physical and Rehabilitation Medicine. 2016;52(5):12. 31. Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons’ health: A systematic review. PLOS ONE. 2020;15(1):e0220857. doi:10.1371/journal.pone.0220857 32. Wyman, M, Shiovitz-Ezra, S, & Bengel, J. Ageism in the health care system: Providers, patients, and systems. In Ayalon L, Tesch-Römer C, eds. Contemporary Perspectives on Ageism. Vol 19. Springer International Publishing; 2018. doi:10.1007/978-3-319-73820-8 33. Madan AK, Cooper L, Gratzer A, Beech DJ. Ageism in breast cancer surgical options by medical students. Tenn Med. 2006;99(5):37-38, 41. 34. Vale MT, Bisconti TL, Sublett JF. Benevolent ageism: Attitudes of overaccommodative behavior toward older women. The Journal of Social Psychology. 2020;160(5):548-558. doi:10.1080/00224545.2019 .1695567 35. ]Sutin AR, Stephan Y, Carretta H, Terracciano A. Perceived discrimination and physical, cognitive, and emotional health in older adulthood. The American Journal of Geriatric Psychiatry. 2015;23(2):171179. doi:10.1016/j.jagp.2014.03.007 36. ]Moser C, Spagnoli J, Santos-Eggimann B. Self-perception of aging and vulnerability to adverse outcomes at the age of 65–70 years. The Journals of Gerontology: Series B. 2011;66B(6):675-680. doi:10.1093/geronb/gbr052 37. ]Ng R, Allore HG, Monin JK, Levy BR. Retirement as meaningful: Positive retirement stereotypes associated with longevity. J Soc Issues. 2016;72(1):69-85. doi:10.1111/josi.12156

Author Bios

Carmen M. Tyler, MA, MEd, is a licensed clinical mental health counselor and a doctoral candidate in the Counseling Psychology program at Virginia Commonwealth University. Carmen graduated summa cum laude with a BS in Psychology from Saint Leo University in 2014 and master’s degrees in Psychology (Adult Development and Aging-2017) and Education (Clinical Mental Health Counseling-2018) from Cleveland State University. Carmen’s research and clinical work has focused on older adults with chronic illnesses or neurological impairments associated with neurocognitive disorders, brain injuries, and severe mental illness and their caregivers.

Paul Perrin, PhD, is a Professor of Psychology and Physical Medicine & Rehabilitation at Virginia Commonwealth University, where he is the Director of the Health Psychology PhD Program. He has a joint appointment as a research psychologist at the Central Virginia Veterans Affairs Health Care System, where he co-directs the Polytrauma Rehabilitation Center Traumatic Brain Injury Model Systems Program. Paul's area of research is called "Social Justice in Disability and Health," and he is passionate about using and teaching students to use science in order to fight oppression in all of its forms, particularly as it manifests itself in within health care systems and rehabilitation services in the U.S. and globally. He teaches undergraduate and doctoral courses on health disparities, social determinants of health, multiculturalism, community intervention, research methods, and applied multivariate statistics.