Epidemiology of traumatic brain injury (TBI) in the United States ^,

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  Incidence in the general population: 1.7 million

  
  
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  Prevalence in the general population: 3.17 million

  
  
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  The elderly account for more than 80,000 TBI-related emergency department visits each year in the United States

  
  
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  The TBI-related hospitalization rate is 85.1 per 100,000 for people ages 65 to 74 and rises with age. Improvements in initial medical management have led to an increase in the number of elderly living with TBI.

Sensory abnormalities of aging

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  Changes in sensorium, which can occur in the aging population, present a unique challenge in the management of the elderly population with TBI.

  
  
  
  
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    Presbycusis: 60% of older adults experience some degree of presbycusis or sensorineural hearing loss by age 65. It is important not to mistake hearing loss for another cognitive or linguistic deficit after TBI.

    
    
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    Assessment of presbycusis should include:

    
    
    
    
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      Hearing evaluation by speech language pathologist (SLP)

      
      
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      Audiology evaluation for more in-depth analysis of any significant deficits

      
      
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      Use of hearing aids/noise amplification devices when indicated (but it is important to monitor for overstimulation in the TBI population, who may be more sensitive to noise after their injuries)

    
    

  
  

Visual changes with normal aging

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  This includes decline in extraocular muscle motion, changes in visual acuity, and increases in intraocular pressure. This should be evaluated in this population by:

  
  
  
  
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    Performing a visual screen if cognitive status appropriate

    
    
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    Use of visual aids such as corrective lenses when appropriate

    
    
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    Use of strategic visual aids when appropriate (e.g., patches, partial occlusion glasses, blackout tape depending on the visual impairment).

    
    
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    Evaluation by a neuroophthalmologist may be required for in-depth assessment of visual impairments.

  
  

Orthostasis

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  This often occurs after prolonged immobility and subsequently impairs optimization of time spent in therapies. It may also present as a unique challenge in the elderly population, who may have underlying cardiac and vascular disease. Vital signs should be monitored closely as a patient progresses through therapies. These factors should be considered in management (Haring et al., 2015; Levine & Flanagan, 2013):

  
  
  
  
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    Assess medications: Initial antihypertensives may not be needed, and/or dosing adjustments may be indicated as the patient progresses through rehabilitation. (e.g., because of resolution of posttraumatic hypertension).

    
    
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    Use of abdominal binders and lower extremity pressure stockings may be helpful in supporting blood pressure. Slower transitions from supine to sitting and to standing may also decrease the occurrence of symptomatic orthostatic hypotension.

    
    
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    Pharmacological agents may be needed to increase or support blood pressure if the aforementioned nonpharmacological supportive strategies are insufficient.

  
  

Hydrocephalus

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  It is important to monitor for signs and symptoms of hydrocephalus to allow for prompt diagnosis and management.

  
  
  
  
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    The classic triad of the clinical signs—worsening cognition, alterations in gait, and urinary incontinence—may be a rare presentation or difficult to classify in TBI patients because these symptoms may be attributed to the TBI itself.

    
    
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    Clinical indication of hydrocephalus in this population will be increased fatigue or a change or lack of improvement in functional status (e.g., a change from minimal assistance to maximum assistance for transfers in patient).

    
    
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    Many of the symptoms of hydrocephalus also overlap with complications after TBI, such as infection. Therefore hydrocephalus should be included in the differential for workup of these symptoms, especially in TBI patients who have suffered subarachnoid hemorrhages that can affect the absorption of cerebrospinal fluid.

  
  

Cognition

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  Age-related cognitive changes are an expected component of normal aging.

  
  
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  Most people experience gradual decline in cognitive performance over their life span, particularly in memory.

  
  
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  It is usually minor and doesn’t affect function, termed mild cognitive impairment (MCI).

  
  
  
  
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    MCI increases risk of TBI, because it decreases functional problem-solving skills and increases risk of mechanical fall

    
    
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    Slows recovery

    
    
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    Increases rehabilitation lengths of stay

  
  
  
  
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  It is critical to establish preinjury cognitive baseline when goal setting in rehabilitation.

Affective

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  Emotional changes are common post-TBI

  
  
  
  
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    Often depression and anxiety (Albrecht et al., 2015; van Reekum et al., 1996)

    
    
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    Depression among most prevalent mental health problems in the elderly (Fann et al., 1995; Hibbard et al., 1998)

    
    
    
    
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      Associated with considerable mortality, including risk of suicide

      
      
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      Must differentiate from normal grieving, fatigue, or sleep dysfunction

    
    
    
    
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    Hard to diagnose

    
    
    
    
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      Many patients may have cognitive or linguistic deficits, making it difficult to get an accurate verbal report of symptoms

      
      
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      Sometimes must rely on behavioral indicators

    
    
    
    
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    Elderly tend to underreport depressive symptoms.

    
    
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    Many sequelae of TBI are similar to depression.

    
    
    
    
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      Fatigue, cognitive slowing, apathy, somatic complaints, disrupted sleep

    
    
    
    
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    Treatment for post-TBI depression in the elderly

    
    
    
    
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      Combination of psychotherapeutic support and medication

      
      
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      Medications: Start low and go slow.

      
      
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      Select agent carefully.

      
      
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      Consider agents to treat more than one condition to minimize polypharmacy.

    
    

  
  

Behavior

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  Behavioral dysregulation after TBI in the elderly is common.

  
  
  
  
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    Restlessness, agitation, aggression, irritability pose safety challenges and add stress to the environment of care.

    
    
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    Treatment: Nonpharmacological approach is first line.

    
    
    
    
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      Lower the level of stimulus

      
      
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      Avoid busy, high-traffic spaces

      
      
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      Limit number of visitors

      
      
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      Lower the noise level

    
    
    
    
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    Supportive counseling

    
    
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    Eliminate or treat sources of noxious stimulation: pain, constipation, urinary retention, spasticity, infection, stressful contacts.

    
    
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    Pharmacological approach is reasonable next step.

    
    
    
    
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      Atypical antipsychotics, antiepileptics, beta blockers

      
      
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      Caution with use of centrally acting medications and ensure benefits outweigh risks

    
    

  
  

Sleep disturbance

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  The combination of age-related sleep changes and altered sleep patterns in people with TBI creates challenges.

  
  
  
  
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    Sleep hygiene is first-line therapy.

    
    
    
    
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      Eliminate technology from the bedroom.

      
      
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      Retire and awaken at the same time each day.

      
      
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      Avoid emotional content in the evenings.

      
      
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      Eliminate alcohol and caffeine.

    
    
    
    
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    Cautious use of pharmacological agents may be considered in refractory cases.

    
    
    
    
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      Melatonin or melatonin analogs are safe and avoid unwanted side effects.

      
      
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      Consider benign agents that have drowsiness as a side effect, such as trazadone.

      
      
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      Avoid sedatives and hypnotics because of unwanted side effects.

    
    

  
  

Outcomes for older individuals with TBI are worse than their younger counterparts when controlling for injury severity (LeBlanc et al., 2006; Mosenthal et al., 2002).

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  Older individuals with TBI are more likely to die of their injury, be more dependent for mobility and activities of daily living (ADLs), and be discharged to long-term care facilities than younger people with similar injuries.

  
  
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  More likely to have medical comorbidities that complicate recovery

  
  
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  More likely to have less premorbid physical and cognitive reserve

Mortality acutely after TBI is the highest among the elderly than any other age group (Haring et al., 2015; Harrison-Felix et al., 2015; Ivascu et al., 2008; LeBlanc et al., 2006).

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  Age at time of injury is an independent predictor of mortality regardless of injury severity (Mosenthal et al., 2002).

  
  
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  Thought to be caused by a combination of slowed healing because of age, presence of other comorbidities, and the treatment thereof

  
  
  
  
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    Presence of anticoagulants increases risk of hemorrhage or expansion of hemorrhage but also decreases risk of venous thromboembolism.

  
  
  
  
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  Cardiovascular disease may impair compensatory responses to hypotension and hypoxemia acutely, resulting in greater secondary injury after trauma.

  
  
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  Age-related increase in subdural space may allow further hemorrhage to occur before clinical signs of neurological impairment are noticed (“silent bleeding”).

  
  
  
  
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    May also lead to higher initial Glasgow Coma Scale (GCS) scores, which is misleading

  
  

Functional outcomes ^{, , ,}

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  Elderly people with TBI are more likely to have poorer functional outcomes than their younger counterparts.

  
  
  
  
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    More often require residential settings at time of hospital discharge

    
    
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    More often require skilled assistance if discharged to home

    
    
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    Only about one-third of elderly people with TBI are discharged home without skilled assistance

    
    
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    Reasons for poor outcomes are multifactorial:

    
    
    
    
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      Aging central nervous system less able to handle stress

      
      
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      Cerebral plasticity likely less effective

      
      
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      Poorer premorbid cognitive and physical abilities

      
      
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      May be on more cognitive-impairing medications

    
    

  
  

Prevention ^,

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  Falls are the leading cause of TBI in the elderly

  
  
  
  
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    Approximately one-third of people age 65 or older fall each year.

    
    
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    Screening for falls is a huge part of primary prevention.

    
    
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    Interventions for those at risk: home modifications, correction of visual/cardiac abnormalities, therapeutic exercises, reduction/elimination of psychoactive medications, treatment of postural hypotension, assistive devices