... 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 ... 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, ... assessment, and physical therapy referral. Care practices also affect recovery. Offering a case study, he described a patient with a small traumatic subarachnoid ... 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 ...

... 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 ...

... 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 ... 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 ... 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 ...

... 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, ...

... 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 ... care. Neuroprognostication tools are needed to better predict survival, level of disability, and recovery time for older adults after TBI, she said. Better...

... 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 ... 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 ...

... 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/ ... 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 ( ... -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 ... 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. ...

... (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 ...

... 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- ... 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 ... 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 ... 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 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 ... 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....

... 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 ...