Khushi Jain, Bhumi Sharma

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. It is one of the significant problems in older adults. In individuals aged 65 and above, TBI is the cause of more than 80,000 emergency hospital visits every year out of which more than half lead to hospitalisation. Adults aged 75 and older have the highest rates of TBI-related hospitalization and death. Falls are the leading cause of TBI for older adults (51%), and motor vehicle traffic crashes are second (9%) (Thompson et al., 2006). Age is also associated with comorbidities, such as diabetes, hypertension, and chronic renal failure, which may worsen outcomes. Also, a high percentage of older people use medications (e.g., anticoagulants and/or antiplatelets) which may worsen cerebral damage after trauma. The aged brain may be more vulnerable to TBI, with less plasticity and repair after injury (Kovacs, 2005). In addition, older people often present with alterations in cognition, memory, mood, and motor function (Glorioso and Sibille, 2011), which can hamper rehabilitation after TBI (Stocchetti et al., 2012).

It has also been observed that an average of 634,000 incidents of traumatic brain injury (TBI) occurs among children each year in the United States, with the highest TBI-related emergency room visits occurring in children under the age of 4 years and adolescents 15 years or older (Li & Liu, 2013) Traumatic brain injury in children commonly involves the frontal lobes, and is associated with distinct structural and behavioural changes. Although injuries to this region are clinically significant during brain development, the mechanisms behind secondary damage and long-term recovery remain poorly understood (Chen et al., 2013). Understanding the unique vulnerabilities of both older adults and children to TBI highlights the need for targeted prevention, early intervention, and improved rehabilitation strategies to enhance long-term outcomes.

Aging and Youth at Risk: The Impact of Traumatic Brain Injury on Older Adults and Children

Research has demonstrated that age is the strongest clinical predictor of recovery from TBI, second only to measures of injury severity (Dikmen and Machamer, 1995; Vollmer, 1993). Advanced age is considered a negative prognostic indicator. Elderly individuals appear to be at an increased risk for poor outcomes following TBI (Goleburn & Golden, 2001). After a period of relatively low risk in middle adulthood, older adults are at an increased risk for head trauma beginning at age 65 and peaking at age 70 (Fields and Coffey, 1994). In the United States, the estimated annual rate of TBI in persons in the sixth and seventh decades of life is 150–200 per 100,000 people (Cooper, as cited in Goldstein and Levin, 1995). There are age differences in the physiological structures in the structures of brains of older people as compared to younger individuals that make them susceptible to subdural hematomas after a brain injury. For instance, cerebral decline that follows aging leads to stretching of parasagittal bridging veins, leaving them more vulnerable to severe effects even after a minor trauma. In events like a fall, the impact often causes these veins to burst, causing subdural hematoma. Biologically, with aging, white matter and vasculature become more susceptible to injury, injury response mechanisms such as autophagy is dampened, and prevalence of pre-existing neurological or systemic comorbidities increases. Unsurprisingly, older adults with TBI experience higher morbidity and mortality, and slower recovery trajectories and have, on average, worse functional, cognitive, and psychosocial outcomes months or years post-injury than do younger patients (Gardner et al., 2018).

Traumatic brain injury (TBI) is a serious public health concern and is the most frequent cause of disruption to normal childhood development. TBI occurs when a sudden trauma triggers the brain to move rapidly within the skull, leading to neuronal damage. TBI can result from the head suddenly hitting an object, from a non-impact force, such as blast waves or rapid acceleration and deceleration, or from an object puncturing the skull and penetrating the brain tissue. Although TBI can occur across the lifespan, this type of brain injury can be particularly devastating for the developing brain. This interruption of normal brain development and the cascading effects of TBI may alter the course of brain development and its functioning (Laura S. Blackwell PhD et al., 2023) Traumatic brain injury (TBI) is one of the most common causes of death and long-term disability in the pediatric age range (Gotschall, 1993; Kraus, 1995). According to a report on Emergency Department (ED) visit, hospitalizations, and deaths in the United States for the years 1995–2001 (Langlois et al., 2006), nearly half a million children 0–14 years of age had TBI each year during this period. Of this number, 91.6% were treated and released from an ED, 7.8 % were hospitalized, and .6% died (Laura S. Blackwell PhD et al., 2023). 

Given the high prevalence and significant impact of TBI in children, it is crucial to monitor their development closely and assess potential long-term effects, to ensure appropriate interventions and support.

The Long-Term Impact of Traumatic Brain Injury in Older Adults: Challenges, Outcomes, and Rehabilitation

Traumatic brain injury (TBI) is a devastating injury, often resulting in death or chronic disability that disrupts family, community, and vocational ties. According to new research, the effects of TBI are greater and long-term in older populations. Elderly patients tend to have higher mortality and worse outcomes than younger patients, even if the injuries they suffer are less severe. Even if the injury sustained is similar in type and severity in both, older populations go through longer rehabilitation stays, suffer higher rehabilitation costs and have greater levels of disabilities. The risk of death after the age of 65 is the maximum. Older individuals suffering from TBI are known to suffer increased deterioration mood, psychosocial functioning, and cognition, and are less likely to have complete recovery in psychosocial areas of functioning after TBI as compared to younger patients. According to Rothweiler et al. increased age at the time of sustaining a brain injury was related to greater dependence, changes in living conditions and increased mortality rate during 1 to 2 years after the injury. In fact, 1 to 2 years after injury, 80% of their study population over the age of 60 years were moderately disabled, required assistance in basic daily activities, and were unable to resume preinjury activities. Also, 31% no longer lived independently and 75% of those previously gainfully employed were no longer working. There is also a strong relation between increased age and poorer cognitive outcome, especially in those with more severe brain injuries (Testa et al., 2005). 

According to a study done by Testa et al. older TBI patients are more prone to changing their employment status after sustaining an injury as compared to younger TBI patients. Although a large number of older patients were unemployed or retired prior to the injury, a greater proportion of these adults were unable to return to their work after their injury in comparison to younger people. Older patients are at a greater risk for post-trauma epilepsy than younger individuals and are more likely to present with delayed seizures rather than early post TBI. Although TBI is now a well-established risk factor for dementia and Parkinson’s disease, few past studies have assessed risk of dementia or PD specifically after geriatric TBI (e.g., TBI sustained in the fifth decade or beyond) (Gardner et al., 2018). Repeated TBI in older adults may be associated with greater risk for neurodegenerative outcomes than single TBI. Repeated concussive and subconcussive injuries have been associated with chronic traumatic encephalopathy (CTE), a unique degenerative tauopathy, primarily described among contact-sport athletes, blast exposed military personnel, and victims of domestic violence (Gardner et al., 2018). 

Maximising rehabilitation potential in the elderly patient with TBI can be challenging from both a medical and psychosocial perspective. As such, a multidisciplinary team approach that includes physiatrists, primary care physicians, nurses, therapists, psychologists, social workers, and home care providers offered through inpatient rehabilitation programs can be extremely helpful in managing the medical and discharge planning complexities that are required for optimal outcomes (Crownover et al., 2012).

Fragile Minds: Understanding and Overcoming Childhood Traumatic Brain Injury

Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain networks that are responsible for a range of complex neurocognitive outcomes (Laura S. Blackwell PhD et al., 2023). It is important to acknowledge that Children’s brains differ structurally and functionally from adult brains. There are important differences between a developing (immature) brain and a fully developed (mature) brain particularly with regards to responses and recovery patterns following an injury. They tend to experience worse outcomes following a traumatic brain injury (TBI) because their brains are still rapidly developing, making them more vulnerable to diffuse damage across crucial areas, particularly during critical developmental periods when specific skills are being established. This heightened vulnerability is due to the unique characteristics of the developing brain, including a larger head-to-body ratio, weaker neck muscles, and ongoing neural connections that are not yet fully solidified. Research indicates that children aged 2 to 7 years at the time of injury are particularly vulnerable to deficits in expressive language, attention, and academic achievement (Taylor et al., 2008). Following a TBI, children may experience changes in behavior, cognition, psychological well-being, and personality. Emotional challenges such as depression, post-traumatic stress disorder (PTSD), anxiety, and temporary loss of consciousness are commonly reported. Cognitive impairments are also prevalent, including reduced processing speed for visual and verbal information, difficulties with attention and concentration, memory and learning deficits, visuo-perceptual and spatial problems, and challenges with executive functioning. In terms of physical impairments, children may develop epilepsy, subtle visual problems, visual field defects, hearing loss, tremors, weakness, sensory deficits, loss of bladder control, and increased fatigue. While these impairments are not inevitable, young children with TBI are at a higher risk due to the ongoing development of their brains. Damage to the frontal lobe, in particular, can lead to distinct structural and behavioral changes that may have long-term consequences. Furthermore, the impact of TBI extends beyond the affected child, it also affects their families. Caregivers may experience feelings of guilt, believing they failed to protect their child, or they may direct blame toward individuals involved in the incident. Additionally, emotions such as anger and hopelessness can arise as they struggle to come to terms with the situation. It is essential to recognize that TBI is not the result of parental fault and that proactive steps should be taken to mitigate cognitive and behavioral deficits. A comprehensive assessment of all aspects of the brain injury is crucial, along with appropriate referrals to specialists such as child clinical neuropsychologists, physiotherapists, occupational therapists, and speech and language therapists. This multidisciplinary approach ensures a thorough understanding of the child’s needs and facilitates targeted interventions to support their development and well-being. Traumatic brain injury in early childhood can present significant challenges, early intervention, comprehensive rehabilitation, and strong family support can greatly enhance a child’s recovery and overall well-being.

Unseen Burdens: How Pre-Existing Conditions Shape TBI Outcomes and Recovery

Health factors impacting both the occurrence of, and recovery from traumatic brain injury (TBI) vary in complexity, and present genuine challenges to researchers and healthcare professionals seeking to characterize injury consequences and determine prognosis. However, attempts to clarify causal links between injury characteristics and clinical outcomes (including mortality), often compel researchers to exclude pre-existing health conditions (PECs) in their samples, including psychiatric history, medication usage, and other comorbid conditions. findings indicate that PECs significantly influenced mortality within the TBI cohort; patients having four or more PECs were associated with approximately a two times greater likelihood of dying in acute care. Additionally, cluster analyses revealed four distinct PEC clusters that are age and TBI severity dependent. 

Within the patients with TBI who were examined, the sheer number and types of PECs had consequences for outcomes. First, as the number of PECs increases, mortality rate climbs incrementally Second, distinct PEC cluster types confer differential risk for recovery following injury, and perhaps unsurprisingly, age plays a critical role in the emergence of PECs .In the early recovery period, these PEC clusters also confer risk of differential recovery following TBI, days spent in the hospital, and days in the ICU. The impact of PECs on recovery from TBI appears linked to the interactive characteristics of the chronic conditions carried by the patients with mTBI examined here, rather than the overall total number of PECs as evidenced by the small effect sizes associated with our results (Dell et al., 2021).

Challenges and Future Directions in TBI Recovery for Older Adults and Children

  Older people have a greater likelihood of becoming functionally dependent after a traumatic injury and, more specifically, of not returning to work after TBI. The implications of these findings are important for rehabilitation efforts, as well as for long-term planning (Testa et al., 2005). Functional gains in level of independence translate to increased quality of life for older TBI patients. As reported by Cifu et al, older TBI patients have slower rates of functional recovery, longer stays in rehabilitation at greater financial cost, and greater levels of disability than do younger TBI patients with comparable injuries. Thus, rehabilitation efforts with older TBI patients should focus on maximising levels of independence to limit financial and emotional costs to patients and their families (Testa et al., 2005). The incidence, risk factors, pathophysiology, complications, and rehabilitation course for elderly patients with TBI is unique. However, understanding how each of these elements plays into recovery and potential for community reintegration is essential for optimising outcome (Crownover et al., 2012). 

This article illustrates that children sustaining brain injuries in childhood are at risk for newly emerging behavioural problems, although problems are heterogeneous in both etiology and presentation and may not manifest until several years later. Even mild injury may damage a child’s neurocognitive abilities, causing deficits that may persist for several years. Developing skills such as executive function and social problem-solving are also often damaged in TBI, and such neurocognitive vulnerabilities can in turn mediate the persistence of continued or even secondary behavioral problems in children. As children age, they may become increasingly aware of their impairments, which probably become more salient as children are faced with increasing demands and expectations (e.g. higher cognitive functions, academic demands, behavioral and emotional regulation). Worsening behavioral outcomes may thus reflect actual neurocognitive sequelae as well as children’s frustrations of poor school performance and peer relations that may subsequently occur. Given the potential for lifetime behavioural impairments for survivors of paediatric TBI, it is critical that families and patients receive adequate follow-up care and appropriate information about potential behavioural consequences (Laura S. Blackwell PhD et al., 2023).

Therefore, no matter if the TBI patient is an older person or young child  it is essential for all individuals to provide care and support for TBI patients, as they remain at significant risk of long-term complications.

References 

Crownover, J., Galang, G. N., & Wagner, A. (2012). Rehabilitation considerations for traumatic brain injury in the geriatric population: Epidemiology, Neurobiology, Prognosis, and management. Current Translational Geriatrics and Experimental Gerontology Reports, 1(3), 149–158. https://doi.org/10.1007/s13670-012-0021-6 

Gardner, R. C., Dams-O’Connor, K., Morrissey, M. R., & Manley, G. T. (2018). Geriatric traumatic brain injury: Epidemiology, outcomes, knowledge gaps, and future directions. Journal of Neurotrauma, 35(7), 889–906. https://doi.org/10.1089/neu.2017.5371 

Goleburn, C. R., & Golden, C. J. (2001). Traumatic Brain Injury Outcome in Older Adults: A Critical Review of the Literature. Journal of Clinical Geropsychology, 7(3). 

Stocchetti, N., Paternò, R., Citerio, G., Beretta, L., & Colombo, A. (2012). Traumatic brain injury in an aging population. Journal of Neurotrauma, 29(6), 1119–1125. https://doi.org/10.1089/neu.2011.1995 

Testa, J. A., Malec, J. F., Moessner, A. M., & Brown, A. W. (2005). Outcome after traumatic brain injury: Effects of aging on recovery. Archives of Physical Medicine and Rehabilitation, 86(9), 1815–1823. https://doi.org/10.1016/j.apmr.2005.03.010 

Thompson, H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590–1595. https://doi.org/10.1111/j.1532-5415.2006.00894.x 

Taylor, H. G., Swartwout, M. D., Yeates, K. O., Walz, N. C., Stancin, T., & Wade, S. L. (2008b, September). Traumatic brain injury in young children: Postacute effects on cognitive and School Readiness Skills. Journal of the International Neuropsychological Society :JINS. https://pmc.ncbi.nlm.nih.gov/articles/PMC2733858/#:~:text=Specifically%2C%20children%20aged%202%20to,Ewing%2DCobbs%20et%20al.%2C 

Laura S. Blackwell PhD, Abstract Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain network, Maas, A. I. R., Teasdale, G., Wilde, E. A., DiBrito, S. R., DiGiorgio, A. M., Jassam, Y. N., Margulies, S. S., Andrzejewski, M. E., Robba, C., Pareja, J. C. M., Kobeissy, F. H., Berger, R. P., Maas, A. I., Gil, A. M., Sayal, K., Anderson, V., Blennow, K., … Figaji, A. A. (2023, July 1). Pediatric traumatic brain injury: Impact on the developing brain. PediatricNeurology. https://www.sciencedirect.com/science/article/abs/pii/S0887899423001911 

Li, L., & Liu, J. (2013, January). The effect of pediatric traumatic brain injury on Behavioral Outcomes: A systematic review. Developmental medicine and child neurology. https://pmc.ncbi.nlm.nih.gov/articles/PMC3593091/ 

Chen, C.-Y., Noble-Haeusslein, L. J., Ferriero, D., & Semple, B. D. (2013). Traumatic injury to the immature frontal lobe: A new murine model of long-term motor impairment in the absence of psychosocial or cognitive deficits. Developmental neuroscience. https://pmc.ncbi.nlm.nih.gov/articles/PMC3923401/ 

Dell, K. C., Grossner, E. C., Staph, J., Schatz, P., & Hillary, F. G. (2021, June 9). A Population-Based Study of Pre-Existing Health Conditions in Traumatic Brain Injury. 

​​Chen, C.-Y., Noble-Haeusslein, L. J., Ferriero, D., & Semple, B. D. (2013a). Traumatic injury to the immature frontal lobe: A new murine model of long-term motor impairment in the absence of psychosocial or cognitive deficits. Developmental neuroscience. https://pmc.ncbi.nlm.nih.gov/articles/PMC3923401/