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Traumatic brain injury (TBI) is common among the elderly mainly through the association with falls. TBI in the elderly presents special issues for the clinician to consider in the management of these patients, including a higher risk of poor recovery and physiatric and neuropsychiatric comorbidity. This chapter will review the epidemiology of TBI, mechanisms of injury, features on brain imaging, cognitive and psychosocial outcomes, and postacute management, with particular attention to research and practice with geriatric patients.

TBI is craniocerebral trauma associated with decreased consciousness, cognitive or neurologic abnormalities, skull fracture, or intracranial injuries. More than 5.3 million Americans have disabilities related to TBI. With approximately 1.6 million incident cases per year, resulting in 1.2 million emergency department visits, 290 000 hospitalizations, and 51 000 deaths, TBI is a common cause of morbidity and mortality. Approximately 444 per 100 000 population are evaluated in the emergency department for TBI. In adults older than 85 years, the incidence of TBI-related emergency department evaluations is more than double the average (see Figures 68-1 and 68-2 for age breakdown). The annual incidence of hospitalized trauma or death is 101 per 100 000. The incidence of mild TBI across all ages (not resulting in hospitalization or death) is 392 TBI-related emergency department visits per 100 000 population.

Figure 68-1.

Incidence of emergency department (ER) visits with a TBI-related ICD-9 coding. Adults older than 85 yrs have high rates of TBI-related ER visits as do infants and toddlers. (This graph is derived from Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Acad Emerg Med. 2000;7(2):134–140.)

Figure 68-2.

When TBI occurs in the older adult, it results in greater rate of hospitalization compared with other age groups.

The economic consequences of TBI are alarming. The annual costs of TBI are approximately $60 billion. Estimates for the cost of lifetime care for a person with severe TBI range between $600 000 and $1.9 million. These estimates do not account for lost income of the patients, and time and lost earnings of family members who care for patients with TBI. Nor do these include the opportunities these victims have lost and their reduced quality of life.

The older patient may have a number of age-related existing risk factors or conditions that increase vulnerability to both TBI and unfavorable outcome. These risks include, but are not limited to, cognitive slowing/impairment, orthopedic/mobility issues, visual acuity, balance difficulty, and neurologic and cardiac diseases. These issues increase risk for falls and motor vehicle accidents, the two major etiologies for TBI. These and other etiologies of injury are categorized in Figure 68-3. It is estimated that 28% to 36% of TBI are because of falls, followed by motor vehicle accidents (19%), being struck by or against an object (18%), assault (10%), ...

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