10 minute read
Rehabilitation and Outcome Disparities in Older Adults with Traumatic Brain Injury
Carmen M. Tyler, MA, MEd • Paul B. Perrin, PhD
Older adults represent a progressively increasing number and proportion of the world’s population1 as lifespans rise worldwide.2 For example, in the U.S., the percentage of older adults age 65 and above rose from 12.76% to 16.21% of the population over the ten years from 2009-2019, while other age groups remained about the same percentage or decreased.3 By 2060, projections are that the over-65 age group will be approximately double what it was in 2018, comprising nearly one-quarter of the U.S. population. The number of oldest old (ages 85 and over) is expected to double in the next 15 years and triple by 2060 to approximately 19 million people.4 TBI rates are increasing for older adults, with the greatest number of TBIs incurred by those aged 80 years and older.5 TBI-related morbidity and mortality rates are highest for older adults compared to other groups,6,7 with the primary cause for TBI in older adults being falls.8 As age increases, the likelihood of returning to live alone or at a private residence after TBI decreases, perhaps because although older adults experience less severe TBIs, rehabilitation takes longer with less improvement in functionality and greater disability.9
The increased risk associated with TBI in older adults is not a recent observation,10 but explanations about causality and severity differ. Some theorize that commonly used TBI assessment instruments like the Glasgow Coma Scale (GCS), in addition to having problems with inter-rater reliability and confounds,11 are not as sensitive for older adults as they are for younger adults, leading to underestimations of TBI severity.12 Several studies have demonstrated that older adults with GCS scores in the normal range are at higher risk for undetected intracranial lesions.7 Neuroinflammatory pattern differences in older versus younger adults have been noted up to 6 months after TBI, but it is still unclear as to whether these differences are age- or injury-related.13 Physical health conditions commonly experienced in older age are linked with increased fall risk14 and may contribute to worse outcomes for older adults with TBI.15 Others propose that physiological changes related to aging16 may increase vulnerability accompanying TBI in older adults. As adults age, structural and metabolic changes occur in the brain16 and throughout the body,17 resulting in reductions in functional efficiency of bodily systems. TBI may also increase vulnerability to developing illnesses like Parkinson’s disease18 and Alzheimer’s disease19 and mental health conditions such as schizophrenia20 and depression,21 which could limit function. Although observation of the link between sustaining moderate-to-severe TBI and subsequent development of Alzheimer’s disease is not new,22 ongoing research is elucidating the physiological processes that contribute to neurodegenerative diseases such as dementia and Parkinson’s disease after TBI.23
Older adults tend to sustain less severe TBI than younger people, but they have more disability post-TBI and are more likely to have a change in where they live after hospital discharge.9 TBI severity and GCS score can predict function in older adults at discharge from the hospital,24 and level of functioning at that time also predicts long-term functioning.25 However, greater age is associated with lower functional independence for older adults with TBI.26 Not only have older adults shown lower functional independence ratings than younger adults at discharge from the hospital and at 6 months post-discharge and more declines in ability 5 years post-injury, but these lower levels of functional independence have occurred despite lower injury ratings.27,28
Older age has also been noted as a consideration in postacute TBI treatment decisions. Early, intensive, and continuous implementation of rehabilitation is more effective at improving long-term functional outcomes for those with severe TBI than rehabilitation started in the subacute phase.29 Discharge from the hospital to a specialized rehabilitation facility has been associated with greater functional independence, and younger people are admitted directly to TBI rehabilitation more frequently than older adults with TBI, despite equivocal injury severity levels. 30
In addition to traditional demographics and psychosocial variables, research has established the detrimental effects of ageism on health outcomes.31 Negative aging stereotypes portraying older adults as being unattractive, incompetent, frail, and financial and social liabilities are ubiquitous, including in healthcare settings.32 Health care professionals who hold ageist beliefs may engage in discriminatory practices such as underordering diagnostic tests and treatments33 or dismissive, infantilizing, and patronizing communication or behaviors34 with older adults in their care. Perceptions of age discrimination by others and internalized ageist beliefs have been associated with greater functional impairment and higher mortality in older adults.35-37
Conclusion
Although functional outcomes after TBI have been examined in various studies,30 research on older adults with TBI has been relatively sparse.
Lifespan is increasing worldwide,2 and as a result, the proportion and number of older adults is increasing steadily.1 Morbidity and mortality rates are higher for older adults after TBI than they are for younger adults,6,7 and older adults have worse recovery outcomes even when injury severity is milder.9,28 As the risk for incurring a TBI increases with age5 and given the ubiquity of ageism,32 the greater number of older adults alone makes examination of factors contributing to poorer functional independence outcomes an important area of study and clinical intervention. Older adults with TBI have less chance of returning to independent living or employment after TBI,9,25 and their increased need for post-TBI assistance could have serious repercussions for additional demands imposed on healthcare systems, health insurance systems, local and national economies, and family and social systems.
References
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Author Bios
Carmen M. Tyler, MA, MEd, is a licensed clinical mental health counselor and a doctoral candidate in the Counseling Psychology program at Virginia Commonwealth University. Carmen graduated summa cum laude with a BS in Psychology from Saint Leo University in 2014 and master’s degrees in Psychology (Adult Development and Aging-2017) and Education (Clinical Mental Health Counseling-2018) from Cleveland State University. Carmen’s research and clinical work has focused on older adults with chronic illnesses or neurological impairments associated with neurocognitive disorders, brain injuries, and severe mental illness and their caregivers.
Paul Perrin, PhD, is a Professor of Psychology and Physical Medicine & Rehabilitation at Virginia Commonwealth University, where he is the Director of the Health Psychology PhD Program. He has a joint appointment as a research psychologist at the Central Virginia Veterans Affairs Health Care System, where he co-directs the Polytrauma Rehabilitation Center Traumatic Brain Injury Model Systems Program. Paul's area of research is called "Social Justice in Disability and Health," and he is passionate about using and teaching students to use science in order to fight oppression in all of its forms, particularly as it manifests itself in within health care systems and rehabilitation services in the U.S. and globally. He teaches undergraduate and doctoral courses on health disparities, social determinants of health, multiculturalism, community intervention, research methods, and applied multivariate statistics.
