.... It explored unaddressed challenges for caregivers of geriatric traumatic brain injury (TBI) patients, approaches to integrating patient priorities and outcome goals into clinical decision making, research gaps regarding bio-psycho-socio-ecological factors that affect recovery outcomes, postacute ... access, quality, and continuity, and increased risk of subsequent neurologic and vascular disorders....

... Michele Nelson, University of California, San Francisco, described the experiences and needs common among caregivers of older adults with TBI and discussed approaches to addressing unmet needs. Limited available evidence suggests that caregivers experience emotional effects and challenges in ... to the physical, cognitive, and behavioral changes in their loved ones and to their new role as caregivers. Through her research with the Transforming Clinical Research and Clinical Knowledge in Geriatric Traumatic Brain ... (TRACK-GERI) study, Nelson is working to expand research on TBI caregiver experiences (Nelson et al., 2024). In her interviews with caregivers, many highlighted the need for resources and support ... decision making and navigating follow-up care, including assistance with follow-up care coordination (e.g., online tasks, phone calls), help in navigating systems across ...

... TBI-specific resources, and opportunities to take part in caregiver support groups. Acknowledging that most study participants were white and higher resourced, she emphasized the importance of understanding the needs and experiences of a varied caregiver population....

... Nelson called for additional research on older adults with TBI and their caregivers, including participatory action research that actively involves TBI patients and caregivers, studies on quality of life, and ... studies focused on enhancing health outcomes after TBI, integrating technology-based supports, and understanding health care utilization. Strategies to prevent patient decline and reduce caregiver burden are needed to improve policy and practice for this ... , said Nelson. Insights from research on caregivers of patients with Alzheimer’s disease could be used, she suggested, and partnerships among health care providers, policy makers, technology companies, and health support organizations can contribute to addressing ...

... CARE MODELS FOR INTEGRATING PATIENT-CENTERED AND PERSONALIZED GOALS IN RECOVERY...

... Mary Tinetti, Yale University, described models for integrating patient-centered and personalized goals in recovery after TBI, emphasizing the importance of considering the patient’s individualized goals, functioning, and life ... percent of older adults with TBI have multiple preinjury conditions. A focus on disease-specific outcomes may not align with patient priorities, and interventions for multiple conditions may create a treatment burden, in which adherence to numerous recommendations may cause harm and negatively ... a patient’s quality of life. Patients, their caregivers, and involved health professionals should identify outcomes that are applicable across all conditions, rather than TBI specific, and use interventions ... target those outcomes, said Tinetti. For instance, a patient may have the goal of being able to babysit a grandchild. Specific, measurable, actionable, realistic, and time-bound (SMART) goals aligned with patient priorities guide intervention selection and ... of associated progress, Tinetti explained. Thus, patient-focused care after TBI considers the medical, functional, socioeconomic, and environmental factors that impede patient goals and prioritizes medical, rehabilitative, palliative, and/or community interventions that address ...

... Research indicates that older adults with and without cognitive impairment and their caregivers can identify SMART goals, said Tinetti (Vu et al., 2023). Her research demonstrates that care guided by the patient’s goals (1) ... perceived treatment burden, (2) reduces unwanted interventions and increases desired care, (3) discontinues unwanted prescription...

... medications with no negative outcomes, and (4) creates a modest increase in healthy days at home (Tinetti et al., 2019, 2024). Health professionals can incorporate these SMART goals in ... making, workflow, and electronic health records. She noted that the Department of Veterans Affairs (VA) has disseminated this approach in primary care clinics for older ... . Looking to the future, she encouraged pragmatic trials of care guided by patient goals for TBI interventions to provide evidence on feasibility and effectiveness. She suggested that this evidence, along with quality and payment measures, could help catalyze a shift from disease-focused practice ...

... TBI AMONG OLDER ADULTS AND THE SOCIAL DETERMINANTS OF HEALTH...

...élemy of the State University of New York Downstate Health Sciences University, described how the interplay of biological, psychological, social, and other (bio-psycho-socio-ecological) factors can affect a person’s care journey after TBI and change their recovery trajectory—including missed or ... diagnosis and difficulty in accessing specialized and/or continuous care. He emphasized the ongoing effort to develop a more precise framework for TBI classification, highlighting the recent National ... of Health (NIH)-proposed clinical, biomarker, imaging, and modifier (CBI-M) framework that encourages consideration of the social determinants of health that can modify a person’s care and recovery pathway....

... dementia, including research into biomarkers of dementia risk in populations that have so far been underrepresented in translational TBI and dementia studies. An age-adjusted mortality analysis indicated that Black individuals had higher mortality rates from neurological disease than other ... and racial groups irrespective of neurological diagnosis, he said (Woolf et al., 2023). Using the NIH All of Us Database, which was designed to capture a ... nationally representative dataset of health in the U.S. population, Barthélemy and colleagues studied neuropsychiatric diagnoses after TBI and found that new diagnosis of dementia happened more commonly in white patients compared to Black individuals, with no discernable influence from ... differences as reflected by Social Deprivation Index scores. Dementia literature indicates that Black and Hispanic patients are more likely than white patients to experience a missed or delayed clinical dementia diagnosis (Lin et al., 2021), he said, ...

... Barthélemy also highlighted the role of implementation science in changing systems and behaviors, identifying as priorities the need to miti-...

... gate barriers to participating in translational research and clinical trials and to investigate the efficacy of strategies for improving access to post-TBI outpatient care. He emphasized the importance of data and evidence in ... reimbursement practices to facilitate the ability of patients and families to access post-TBI services, including potentially reforming or expanding relevant Medicaid and Medicare policies....

... OPTIMIZING CARE TRANSITIONS AND IMPROVING REHABILITATIVE OUTCOMES...

... Care pathways after TBI are influenced by factors including the person’s functional status, availability of beds in facilities, insurance coverage, and financial status. There are differences among individuals and communities in access to TBI care—in emergency, acute, rehabilitation, outpatient, ... home, hospice, and community settings—as well as in recovery outcomes (Asemota et al., 2013; Budnick et al., 2017; Chang et al., 2008; Gorman et al., 2020; McQuistion ... al., 2016; Meagher et al., 2015; Zarshenas et al., 2019). Differences in recovery outcomes and transition back to the community for older adults with TBI have also been associated with age, number of chronic conditions, sex, education, ... means, geographical location, and availability of a caregiver, Pappadis said (Anderson et al., 2021; Daras et al., 2018; Evans et al., 2021, 2022; Faul et al., 2016; Pretz et al., 2017). For example, she reported that older adults ... are socioeconomically disadvantaged, live in rural areas, or have functional impairment are less likely to ultimately recover and return to the community....

..., she reported. Meanwhile, individuals who returned home without services but have primary care providers are more likely to return to the community and have a lower risk of emergency department visits and readmission, she said. Greater motor and cognitive functioning are also associated with a higher ... of successfully returning home, whereas patients who live alone, have multiple chronic conditions, and/or are in rural locations are less likely to return home rather than to an inpatient rehabilitation facility. Pappadis outlined facilitators that ... successful transition home after TBI, including increasing access to home health and community-based services and focusing on patient health status and improved functioning. She encouraged care providers to identify interventions and programs to support an individual’s ability to return to their ... and to connect TBI patients with primary care providers....

... PROMOTING BRAIN HEALTH AFTER TBI IN OLDER ADULTS: LESSONS LEARNED FROM THE EPIDEMIOLOGY OF NEUROLOGIC AND VASCULAR OUTCOMES...

... Andrea Schneider, University of Pennsylvania, discussed brain health after TBI in older adults. She differentiated between older adults who had a TBI in ... life and those who had a TBI event in older age, noting that some individuals belong in both categories. Although TBI-related mortality was stable in the ... TBI increases the risk of ischemic stroke by 1.3 times over a median of 27 years postinjury (Elser et al., 2024), with greater head injury frequency and severity associated with higher risk, and a stronger association between TBI and stroke for more severe ischemic strokes....

... year (Schneider et al., 2023). Another analysis of ARIC data found that TBI carried a risk for cognitive decline equivalent to being 7.4 years older, and having two or more TBIs posed a risk equivalent to being 10 years older (Schneider et al., 2024a). Moreover, TBI was associated with 1.4 times the ...

... Given these intersections of TBI history with later-life vascular and neurologic outcomes, Schneider suggested that research needs to shift from treating TBI as an independent risk factor to better contextualizing TBI ... context of brain health. She encouraged the use of existing longitudinal datasets as a cost-efficient method of gaining new insights into TBI risk and resilience factors across the life course....

... Discussion expanded on the needs and opportunities for patient-guided care after TBI. Care that is guided by the patient’s goals is not as time con-...

... might expect, Tinetti stated; once a care provider becomes comfortable with the process, it does not require more time than traditional approaches, and Medicare codes created in recent years cover aspects of patient-goal-guided care, enabling billing and reimbursement for the process. Biese added ...

... Tinetti emphasized that variability in TBI presentation and recovery makes the use of individualized outcome measures more meaningful than generic ones. Establishing individualized outcome metrics involves ... patient priorities, translating those into specific and measurable goals, and conducting goal attainment scaling to quantify progress. Tinetti added that the National Committee for Quality Assurance is researching the use of ... -attainment scaling as a clinical practice quality measure and as a potential payment measure. Nelson noted research indicating that access to a telephone-based care navigator upon hospital discharge reduces ... and cost of care, while improving care quality and quality of life in patients with dementia and their caregivers. Noting the value of identifying protective factors for dementia risk after TBI, Schneider highlighted current research analyzing ... data to understand the effects of midlife social networks on dementia rates....