A focused approach to clinical care
In the era of individualized medicine, many fields are utilizing patient characteristics and clinically relevant bio-markers to guide care. The application of individualized medicine to the treatment of TBI is in its infancy; however, some groups are working diligently on its development. Recent advances include:
• Trauma-field triage criteria to optimally identify older adults with TBI who require emergent transfer to a trauma center
• Neurorehabilitation practices specific to older adults with a focus on removing “excess disability”
• Neurocritical care teams involving geriatricians
• Incorporating accreditation standards for geriatric trauma care in future editions of Resources for Optimal Care of the Injured Patient,11 and the Textbook of Traumatic Brain Injury16
This progress should be viewed as a success, although many challenges remain. One such limitation is that the measures used to diagnose TBI and evaluate its outcome were developed in younger cohorts; this makes it difficult to know how applicable these clinical practices are to older adults. As an example, the commonly used Glasgow Coma Scale (GCS) is a reliable predictor of morbidity and mortality in younger, but not older adults who have an abnormal GCS at baseline or an intact GCS despite accumulating intracranial hemorrhage.
Prognostic models for outcome prediction after TBI (eg, CRASH CT, IMPACT) show poor performance in older adults. This could be attributed to the models excluding key geriatric outcome predictors such as comorbidities, polypharmacy, baseline function, and frailty. There remains much work to be done to implement current evidence into widespread practice.
A geriatric approach to TBI clinical research
Many clinical studies on TBI implement upper age limits or exclude patients with preexisting conditions. Although this is done in an effort to study true cases of TBI, it excludes older adults and limits the generalizability of a given study. By combining methods commonly used in geriatric research with those already used in TBI studies, the challenges of including older adults in TBI research can be overcome. As an example, in the study of neurodegenerative diseases, a battery of neuroimaging- and blood-based biomarkers are used to supplement clinician evaluations and inform on diagnosis in challenging or ambiguous cases. More research, however, is needed to identify the optimal diagnostic biomarkers in TBI. To address preexisting conditions, geriatric studies often systematically measure and study, rather than exclude for, preexisting conditions and disability. In this way, real-world generalizability can be improved.
Dr Narapareddy is a Neuropsychiatry Fellow, Ms Richey is Research Coordinator, and Dr Peters is Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Centers for Disease Control and Prevention. Traumatic Brain Injury and Concussion. 2016. https://www.cdc.gov/traumaticbraininjury/data/index.html. Accessed March 3, 2019.
2. Albrecht JS, Hirshon JM, McCunn M, et al. Increased rates of mild traumatic brain injury among older adults in US emergency departments, 2009-2010. J Head Trauma Rehab. 2016;31:E1-E7.
3. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths: United States, 2007 and 2013. MMWR Surveill Summ. 2017;66:1-16.
4. Flanagan SR, Hibbard MR, Gordon WA. The impact of age on traumatic brain injury. Phys Med Rehabil Clin N Am. 2005;16:163-177.
5. Barnes DE, Byers AL, Gardner RC, et al. Association of mild traumatic brain injury with and without loss of consciousness with dementia in US military veterans. JAMA Neurol. 2018;75:1055-1061.
6. Mendez MF, Paholpak P, Lin A, et al. Prevalence of traumatic brain injury in early versus late-onset Alzheimer disease. J Alzh Dis. 2015;47:985-993.
7. Crane PK, Gibbons LE, Dams-O’Connor K, et al. Association of traumatic brain injury with late-life neurodegenerative conditions and neuropathologic findings. JAMA Neurol. 2016;74:1062-1069.
8. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. J Am Geriatr Soc. 2006;54:1590-1595.
9. Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343:100-105.
10. Gardner RC, Dams-O’Connor K, Morrissey MR, Manley G. Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions. J Neurotrauma. February 15, 2017; Epub ahead of print.
11. Peters ME, Gardner RC. Traumatic brain injury in older adults: do we need a different approach? Concussion. October 3, 2018; Epub ahead of print.
12. Gardner RC, Burke JF, Nettiksimmons J, et al. Dementia risk after traumatic brain injury vs nonbrain trauma: the role of age and severity. JAMA Neurol. 2014;71:1490-1497.
13. Deb S, Burns J. Neuropsychiatric consequences of traumatic brain injury: A comparison between two age groups. Brain Inj. 2007;21:301-307.
14. Albrecht JS, Peters ME, Smith GS, Rao V. Anxiety and posttraumatic stress disorder among medicare beneficiaries after traumatic brain injury. J Head Trauma Rehab. 2017;32:178-184.
15. Mak CHK, Wong SKH, Wong GK, et al. Traumatic brain injury in the elderly: is it as bad as we think? Curr Transl Geriatr Exp Gerontol Rep. 2012;1:171-178.
16. Silver JM, McAllister TW, Arciniegas DB, Eds. Textbook of Traumatic Brain Injury, 3rd ed. Washington, DC: American Psychiatric Association Publishing; 2019.