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Traumatic brain injury (TBI) in late life is associated with a significant increase in the risk for new-onset dementia. The risk is especially elevated (by as much as 69%) within the first 5 years following the injury, according to newly published study findings. 

Though TBI, which results from direct impact or indirect force to the head, has long been recognized as a midlife risk factor for dementia, the risk that TBI poses in adults aged 65 years or older has been unclear. 

“Older adults’ TBI presentation is very different compared with [that of patients with] motor vehicle-related or sports-related injuries, which tend to occur in younger people,” lead study author Yu Qing Huang, MD, geriatrician at Saint Michael’s Unity Health Toronto, Toronto, told Medscape Medical News. 

The symptoms of TBI are clinically complex and may be confounded with symptoms of cognitive impairment, “which means that TBI in older adults is often unrecognized,” she said. 

The data were published on October 6 in CMAJ. 

Increased Care Use

Using several Ontario-based health administrative databases, Huang and her team analyzed information about community-dwelling adults older than 65 years who sustained a new TBI and visited an emergency department or were hospitalized between April 1, 2004, and March 1, 2020. Adults with late-life TBI were matched to older adults without TBI on age, sex, and a propensity score of baseline covariates, resulting in 132,113 matched pairs. Follow-up ended on March 1, 2021. 

The researchers aimed to assess the relationship between late-life TBI, rates of incident dementia at ≤ 5 years and > 5 years, and care needs (including use and intensity of publicly funded home care and admission to a long-term care facility). 

Participants with TBI had a shorter median time to incident dementia diagnosis (7.2 years) than participants without TBI (9.2 years). After the researchers accounted for the competing risk for death, late-life TBI was associated with an elevated rate of incident dementia within the first 5 years after the injury (hazard ratio [HR], 1.69), which declined slightly beyond 5 years (HR, 1.56). 

Late-life TBI also was associated with increased use of publicly funded home care (HR, 1.30) and long-term care home admission (HR, 1.45). Notably, complex TBI (which the researchers defined according to length of hospital stay using an expert consensus cutoff reflecting clinical complexity) appeared to be associated with higher rates of all outcomes than noncomplex TBI. 

Huang is especially interested in how social determinants of health might promote these outcomes in older adults with TBI. 

“In terms of risk, we found that older women from lower income areas were most affected and more likely [than their male counterparts] to move into a nursing home,” she said. At the same time, patients who lived in larger communities were likely to be admitted to long-term care housing, which Huang said might result from a lack of certain services and resources. 

Early Supports Needed

In older adults, TBI symptoms often fit into many domains, making diagnosis challenging. “Older people will often have delirium due to illness or a urinary tract infection, and those symptoms can be similar to simple depression and also a brain injury,” Araba Chintoh, MD, PhD, Canada Research Chair, assistant professor of psychiatry, and full member of the Hotchkiss Brain Institute at the University of Calgary, Calgary, told Medscape Medical News. Chintoh was not involved in the study.

Early intervention is important, she explained. “The problem is that there is no magic pill that treats brain injury,” she said. “But what we can do is put supports in place so if somebody has had a brain injury and they already have some cognitive decline, then we can increase supports and mitigate other risk factors that could worsen the decline.” 

Strategies detailed in The Lancet might include being more fastidious about medication regimens to avoid drug-drug interactions, or addressing hearing or vision loss, improving simple physical activity, and ensuring social interaction. 

“After clinicians recognize TBI and review fall prevention [strategies] and risk factors, the next step would be to assess rehabilitation programs and specialized clinics that are available to older patients,” said Huang. Discussions with family members around planning for future decline is also important, she said. 

Policy planning that addresses gaps in specialized care and improves access to services, especially in smaller communities, is also sorely needed, she said. 

“At the end of the day, our patients sit in front of us for a half hour, 45 minutes maximum, once a week, maximum,” said Chintoh. “The supports around them are key to ensuring their health and wellness.” 

The study was funded by the Knowledge Translation Program of St. Michael’s Hospital and Physicians Services Incorporated Foundation Research Grant. Huang reported having no relevant financial relationships. Chintoh declared receiving fees for being a member of the Scientific Committee for World Rugby.

Liz Scherer is an independent health journalist who frequently reports on Canadian and European health news.