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Landscape of Traumatic Brain Injury in Older Adults¹

The National Academies of Sciences, Engineering, and Medicine hosted a 1-day public workshop on October 21, 2024, to identify unmet research needs in traumatic brain injury (TBI) among adults 65 years and older. Although TBI is a major cause of disability for older adults, knowledge gaps and clinically relevant differences in TBI injury, recovery, and outcomes in this age group limit evidence-based care guidance. The workshop examined the underrepresentation of older adults in TBI research and explored approaches to address gaps and support the translation of knowledge to practice. This Proceedings of a Workshop highlights key points made by workshop participants during the presentations and panel discussions. See Appendixes A and B for the workshop statement of task and agenda and Appendix C for biographies of planning committee members and speakers.

The first session of the workshop explored the landscape of TBI in older adults, focusing on unique considerations and unmet research needs related to this population.

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¹ The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

UNIQUE CONSIDERATIONS FOR TRAUMATIC BRAIN INJURY IN OLDER ADULTS

Kristen Dams-O’Connor, Icahn School of Medicine at Mount Sinai, noted that TBI is rapidly increasing in the oldest segments of the U.S. population (Dams-O’Connor et al., 2013a; Kureshi et al., 2021). Older adults are at a higher risk of experiencing a TBI if they have a history of TBI, impairment in activities of daily living, depression, cerebrovascular disease, and frailty. TBI can manifest fundamentally differently in older adults than in the general population. These differences are due to neurological, musculoskeletal, cognitive, and mood factors, as well as higher rates of multimorbidity and polypharmacy. Moreover, frontline strategies for characterizing TBI, such as the Glasgow Coma Scale clinical assessment and some blood-based biomarker measurements, may underperform or present misleading results in older adults.² Advancements in biomarker development and psychometric tools with modified thresholds for older adults can enhance the effectiveness and sensitivity of these methods, she said.

“We have this common perception that older adults [with TBI] will not do as well,” Dams-O’Connor continued. However, it is not that straightforward. Medical comorbidities likely play a greater role in TBI outcome than does age. Longitudinal data-modeling methods would allow more careful consideration of individual risk trajectories for patients with TBI, she noted. Studies have found that about 20 percent of the population attributable risk for later-life TBI is associated with a prior injury and that post-TBI rehospitalization is most common in patients with comorbidities aged 50 years and older (Dams-O’Connor et al., 2013b; Kumar et al., 2020).³ Other important risk factors highlighted by Dams-O’Connor include

• Active daily living impairment
• Depression
• Frailty
• Prior TBI history
• Socioeconomic disadvantage
• Homebound-ness (leaving home fewer than 1 to 2 days a week upon discharge)
• Preexisting Alzheimer’s disease and related dementias.

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² Dams-O’Connor highlighted that, in 2024, the National Institutes of Health convened working groups that proposed a framework for improved TBI characterization and classification. This framework includes clinical symptoms, biomarkers, imaging, and modifiers, with recognition that each of these elements will require threshold adjustments in older adults.

³ While age 65 years and older was the age cutoff defining older adults in this workshop, the definition of “older adult” may change by context. Dams-O’Connor acknowledged that large datasets allow greater exploration of the link between age strata, comorbidities, and post-TBI outcomes.

“We cannot have a talk about older adults and brain injury without talking about [Alzheimer’s disease and related dementias],” Dams-O’Connor stated. The clinical and neuropathological features of dementia in patients with a history of TBI differ from those with dementia without a history of TBI, and include increased neurobehavioral and mood symptoms, motor impairment, and comorbidities. She emphasized that rigorous methods to disentangle the effects of TBI from the effects of preexisting cognitive decline are an urgent need. “A better understanding of these factors will allow us to stratify people according to risk and deploy treatment and prevention strategies accordingly,” she concluded.

Dams-O’Connor ended by identifying several questions and considerations to address current gaps in TBI prevention and treatment for older adults:

• How can conceptions of age and injury be more thoughtful?
• What would it look like if federal agencies encouraged inclusion of adults aged 65 and older in research studies unless there was a compelling scientific rationale otherwise?
• In 2024, the Centers for Medicare & Medicaid Services (CMS) added TBI to the list of qualifying “severe or disabling chronic condition[s]” for Medicare Advantage chronic special needs plans (CMS, 2024). How might this open the door for existing case management models to be adapted and deployed for disability accommodations in TBI?
• Falls are the leading cause of TBI in older adults. What can be done to modify existing evidence-based fall prevention protocols?
• TBIs from assaults or elder abuse may be an underestimated contributor to TBI in older adults and receive relatively less attention. How can these causes of injury be effectively screened for and addressed?
• While waiting for evidence-based clinical guidelines to emerge, can patient-centered guidance based on expert consensus be used in the meantime?

TBI, RECOVERY, AND ADVOCACY: PERSPECTIVES ON UNMET RESEARCH NEEDS FROM LIVED EXPERIENCES

Cindy Daniel, National Concussion Management Center, offered the perspective of a person living with TBI as a chronic condition. After sustaining a cheerleading injury in the 1980s, she felt dismissed by doctors who were pessimistic about her long-term outlook, commenting on a fear that, “she will not ever be anything to anybody.” Nonetheless, Daniel did recover. She regained mobility as a walking paraplegic, notwithstanding

permanent vertigo and other ongoing symptoms. Her career achievements, among others, include service as the executive director of a nonprofit that advocates for a common understanding of best practices in concussion management and care throughout the life cycle, an appointment to the President’s Committee on Employment of People with Disability, and engagement in the development of a congressional bill (HR 3083, 2023) that would create a clearinghouse of TBI informational resources to clinicians, patients, and other stakeholders.⁴ Daniel outlined the following opportunities for improved research and care:

• Echoing Dams-O’Connor, Daniel emphasized that it was important not to “brush [older adults] aside because of their age.”
• She highlighted an unmet need in diagnostic and prognostic tools benchmarked for use in older adults.
• Regarding the clinical encounter, she emphasized that respectful communication between providers and patients should involve eye contact, attentive listening, and checking in to confirm mutual understanding.

ADDRESSING KNOWLEDGE GAPS IN THE NEUROEPIDEMIOLOGY OF GERIATRIC TBI

Jeremiah Kinsman, Office of Emergency Medical Services (EMS) at the National Highway Traffic Safety Administration, and Dana Waltzman, Centers for Disease Control and Prevention (CDC), discussed the neuroepidemiology of geriatric TBI.

Kinsman shared information from the National EMS Information System (NEMSIS),⁵ which captures data from all 50 states, the District of Columbia, three territories, many tribal nations, and over 14,000 EMS agencies that operate within those jurisdictions. Currently, NEMSIS collects over 55 million data records annually, each containing numerous data elements pertaining to the patient and EMS response. Given that emergency medical technicians make clinical impressions rather than diagnoses, EMS uses the term head injury for potential TBI. In 2023, EMS responded to 261,931 older adults with head injury as the primary impression, he said. Falls caused 77 percent of these head injuries, 27 percent of which occurred in nursing homes. Patients’ median age was 80 years, and 59 percent were

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⁴ National Concussion and Traumatic Brain Injury Clearinghouse Act of 2023, HR 3083, 118th Cong., 1st sess. The bill was introduced in the House but did not receive a vote and would need to be reintroduced in 119th Congress.

⁵ NEMSIS; https://nemsis.org/ (accessed January 30, 2025).

female. About 90 percent of cases were transported by EMS to a hospital or trauma center.

Outlining prehospital knowledge gaps and research needs, Kinsman noted that TBI phenotypes could be developed by linking and analyzing EMS and hospital data. This characterization could help inform EMS triaging of older patients with head injury. Tools to improve prehospital assessment of TBI—such as point-of-care blood biomarker testing, portable infrared brain scanners, and telemedicine physician consult—may potentially decrease the numbers of patients triaged to hospitals. During discussion, Kinsman noted that NEMSIS data have been linked with census and social vulnerability index data in aggregate to analyze geographical trends by zip code. Efforts are also under way to link NEMSIS records with trauma registries. Linking EMS and emergency department data would help capture individuals who experience TBI but do not utilize emergency medical services.

According to Waltzman, an estimated 768,000 older adults visited the ED for head injuries and 97,000 were hospitalized for TBI in 2022.⁶ Older adults have the highest rates of TBI-related deaths, at over 30,000 in 2022.⁷ She noted that these estimates are based on surveillance of vital records and health care data and therefore do not capture individuals who did not seek hospital care and/or had undiagnosed TBI. National surveys that use self-report can complement administrative data by collecting information on context of injury, health care use, and individual and family characteristics. In 2018, CDC launched the National Concussion Surveillance System (NCSS),⁸ and NCSS data indicate that older adults are at an increased risk of TBI-related morbidity and mortality compared to younger people, with falls being the primary mechanism of injury.

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⁶ U.S. Consumer Product Safety Commission. 2023. NEISS coding manual: All trauma. https://www.cpsc.gov/Research--Statistics/NEISS-Injury-Data (accessed January 27, 2025); AHRQ (Agency for Healthcare Research and Quality). 2024. Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). https://www.hcup-us.ahrq.gov/ (accessed January 27, 2025); and CDC (Centers for Disease Control and Prevention). 2025. WONDER (Wide-ranging ONline Data for Epidemiologic Research). https://wonder.cdc.gov/mcd.html (accessed January 27, 2025).

⁷ CDC WONDER; https://wonder.cdc.gov/mcd.html (accessed January 27, 2025).

⁸ https://www.cdc.gov/traumatic-brain-injury/programs/index.html (accessed January 27, 2025).

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