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Perspectives on Addressing Unmet Research Needs in Acute TBI Care for Older Adults

The second session of the workshop discussed knowledge gaps in care and recovery of older adults after a traumatic brain injury (TBI), considered opportunities to leverage injury prognostication to guide decisions on neurocritical care, and explored research gaps in geriatric TBI populations with preexisting cognitive impairment and dementia.

EMERGENCY MEDICINE IN GERIATRIC TBI: GAPS IN PROGNOSTICATION AND POTENTIAL FOR IMPROVED IMPLEMENTATION OF VALUE-BASED AND PATIENT-CENTERED CARE

Kevin Biese, University of North Carolina at Chapel Hill, emphasized emergency medicine’s role in TBI prevention and care for older adults. Falls are a common source of TBI for this population, and fall prevention strategies include medication reconciliation, mobility assessment, and physical therapy referral. Care practices also affect recovery. Offering a case study, he described a patient with a small traumatic subarachnoid hemorrhage who remained in the emergency department (ED) while waiting for an available hospital bed. In this situation, interventions were not undertaken for the hemorrhage and the patient left the hospital with far less mobility than when he arrived.

Biese explained that a capacity crisis has developed because of frequent delays in hospital admittance and discharge coupled with increasing lengths of stay, contributing to potential harm and making improved TBI diagnosis and prognostication even more important in informing appropriate care.

However, many studies exclude patients over the age of 65, which affects the establishment of clinical decision rules, such as when to use computed tomography (CT) scans for older adults. As a result, older adults who may not require CT scans for TBI are exposed to the potential harms and increased risk of delirium posed by transfers, Biese contended. In some cases, more strategic telehealth could enable the transfer of information without necessitating patient movement, as “there is real harm taking someone 3 hours from their home to see a specialist to be told that there is no intervention needed.”

He also noted the lack of effective and personalized prognostic tools for older adults with TBI and inadequate dissemination of existing tools. He cautioned that elevating the ceiling of the TBI knowledge base without also improving the standard of care is unlikely to address the challenges of ensuring delivery of effective recovery interventions to patients and families. The Geriatric Emergency Department Collaborative¹ and the American College of Emergency Physicians Geriatric Emergency Department Accreditation program work together to improve ED care of older adults and have accredited over 500 U.S. EDs. Biese added that Geriatric Emergency Department programs offer a network for collaborative learning, and accreditation serves as an effective incentive for hospitals to integrate best practices.

NEUROCRITICAL CARE SYSTEMS IN GERIATRIC TBI: MULTIDISCIPLINARY TEAMING IN COORDINATED SYSTEMS OF PATIENT-CENTERED CARE FROM TRIAGE TO RECOVERY

Neha Dangayach, Icahn School of Medicine at Mount Sinai, remarked that each phase of care for people with TBI—including emergency medical services, ED, interhospital transfer, and hospital settings—offers opportunities for research. Emphasizing the importance of integrating clinical research into improved care delivery, she identified the need for (1) novel imaging modalities for TBI diagnosis and prognosis, (2) improved and cost-effective biomarkers, (3) multimodality monitoring, (4) enhanced neurosurgical decision making, (5) education that considers patients and families, and (6) the establishment of learning health systems.

Dangayach identified a number of research gaps on TBI among older adults. These include methods for monitoring and treating abnormal cerebral autoregulation, for differentiating TBI-related impairment from postintensive care syndrome, and for measuring effective multidisciplinary care. Neuroprognostication tools are needed to better predict survival, level of disability, and recovery time for older adults after TBI, she said. Better

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¹ See https://gedcollaborative.com/ (accessed January 27, 2025).

understanding the multimodal parameters that drive health and the ability to recover after TBI could yield cutoff points that are less arbitrary than age, but she reiterated the challenges brought about by older adults not being included in clinical trials. A lack of data integration also poses a barrier to the implementation of cerebral multimodality monitoring (Tas et al., 2022). Platform trials of bundles of various interventions throughout the stages of care could improve outcomes for older adults, she said, while improvements in prognosticating would provide tools for patients and families and better equip clinicians to implement research findings. Regional and coordinated networks providing neurocritical care and support are also valuable, she said, although risks from fragmentation of care need to be addressed.

TRAJECTORIES OF FUNCTION IN THE FIRST YEAR POSTINJURY

Raquel Gardner, Chaim Sheba Medical Center at Tel HaShomer, highlighted that one in eight community-dwelling older adults receives a TBI diagnosis, according to Medicare claims data over an 18-year study period (Kornblith et al., 2024). Most TBI studies exclude individuals with preinjury cognitive impairment or multimorbidity. Such exclusionary criteria contribute to the underrepresentation of older adults and the minimal evidence available to guide TBI care for this population (Gardner et al., 2018). Building on close collaboration between TBI and dementia/geriatrics clinical research experts, a two-site study through the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) network, called Transforming Clinical Research and Clinical Knowledge in Geriatric Traumatic Brain Injury (TRACK-GERI), is designed to help fill this gap by studying individuals aged 65 and older without excluding those with preinjury health conditions. Rather than excluding heterogeneity, TRACK-GERI measures it. Emerging data indicate that although most study patients had a Glasgow Coma Scale (GCS) score of 15 (i.e., the highest score, indicating normal responsiveness), most had findings on head CT scans indicating injury, and one-third were admitted to the intensive care unit, she said, signifying that GCS does not necessarily represent severity of injury for older adults. Widely used CT-based mortality prediction models demonstrated less than 60 percent sensitivity for older adults, she indicated.

TRACK-GERI is exploring the influence of cognitive status on TBI outcomes, Gardner explained. Nearly half of the enrollees have preinjury mild cognitive impairment (MCI) or dementia per Clinical Dementia Rating (CDR) scores. In the 6 months following injury, CDR worsened in 16 percent of MCI participants and in 37 percent of patients with normal preinjury CDR scores. Glasgow Outcome Scale Extended (GOSE) scores varied widely, indicating that at 6 months postinjury, 19 percent of individuals had complete recovery while 17 percent died. Preinjury cognitive status may

be a greater predictor of complete recovery than age, she said, as 28 percent of participants with normal preinjury cognition recovered compared to only 7 percent of those with MCI or dementia; age was associated with less variation, with 19 percent of patients under age 80 and 15 percent of those aged 80 years or older recovering. Groningen Frailty Index (GFI) scores indicated frailty at baseline for over half of the TRACK-GERI cohort, and GFI scores were found to be an independent predictor of GOSE scores.

Gardner highlighted research method priorities for older adults with TBI, and remarked that common data elements are needed for this population. She said that preinjury health status often serves as proxy exclusion criteria for older adults and needs to be treated similarly to inclusion of both men and women in studies to avoid underrepresentation of the real-world TBI population. Multidisciplinary research teams also need to include both TBI and dementia/geriatrics experts to better address the older adult community. She suggested that the top research priority for older adults is a large-scale, multicenter prospective cohort study of TBI severity that does not exclude for preinjury health and is designed to immediately inform clinical guidelines and clinical trials.

DISCUSSION

Discussion focused on areas where advances in knowledge, tools, and practices could improve understanding of TBI among older adults. There are several opportunities for TBI blood biomarkers to improve care, Gardner highlighted, including (1) ruling out hemorrhage requiring neurosurgical management and preventing unnecessary transfers, (2) ruling out hemorrhage expansion to eliminate follow-up imaging and shorten time in the hospital, and (3) identifying TBI in those with negative head CT imaging.

Continued efforts to improve prognostic tools for an older adult’s anticipated recovery after TBI is important, said Dangayach. Coupling improved prognostication with the use of probabilistic language with families could help decrease nihilism about recovery outcomes and the potential for premature withdrawal of life-sustaining therapies. Biese expanded on ED-relevant opportunities to identify and prevent older-adult TBI from causes beyond falls, such as caregiver abuse. Staff training, designating specific employees to conduct risk screenings, and establishing protocols for responding to screenings that indicate risk for abuse can all contribute, he said.