The Elderly and Traumatic Brain Injury

Granddaughter hugging her grandmother, both smiling at camera

Quick Facts

  • Older persons (>65 years) have the second highest incidence of TBI, following adolescents/young adults (14-24 years).
  • Growing numbers of older persons are living with TBI, due to the increasing aging population and to medical advances that improve survival after TBI.
  • Research suggests that many older persons are capable of returning to their communities following a TBI if they receive intensive inpatient rehabilitation.

Falls and TBI

  • Falls are the most frequent cause of TBI in older persons, followed by motor vehicle accidents.
  • Two-thirds of those who have experienced one fall will have another fall within 6 months.
  • Approximately 60% of falls in older persons happen in the home.
  • At least 1/3 of these falls are due to environmental hazards in the home.

More Information about the Elderly and Traumatic Brain Injury

Risk Factors for TBI due to Falls

Risk Factors for Falls

  • Increasing age
    • Fall risk increases with age due to numerous physical and cognitive factors.
  • Gender
    • Among older persons, women are at greater risk for falls than men.
  • Cognitive impairment or dementia
    • Problems with judgment and reduced awareness one’s own functioning may contribute to fall risk.
  • Physical limitations
    • Older persons may have problems with balance, reduced strength, and slower reaction times that can increase the risk of falls.
  • Medications
    • Older persons are more likely to have chronic medical issues for which they take medications that can have side effects including dizziness, balance difficulties, fatigue.
  • Vision impairments
    • Poor vision increases the chance of missteps or tripping.
  • Inappropriate footwear
    • Shoe type may affect risk of falls: high heels impair balance and shoes with no fixation (e.g., flip-flop sandals, slides) may increase risk of tripping.

Strategies for Reducing Fall Risk

  • Regular exercise
  • This includes purposeful exercise activities (e.g., classes, walking) as well as daily tasks that involve physical activity (e.g., gardening).
  • This ideally would include a range of activities that together improve:
  • Balance
  • Strength
  • Flexibility
  • Endurance
  • Home safety checks
  • Assessment of home environment to identify hazards that increase fall risk.
  • Occupational therapists often can conduct these in-home evaluations.
  • Potential risks include:
  • Loose rugs on the floor
  • Cluttered walking space
  • Poorly lit areas
  • Lack of handrails where needed (e.g., stairs, bathroom)
  • Proper footwear
    • Wearing of shoes that provide good fit, adjustable fixation (e.g., laces), no-slip soles, and appropriate heel height (e,g,, no high heels).

Special Issues with TBI in Elderly

Each age group has unique considerations. The following are some issues that are especially important to consider in the elderly TBI population:

  • Social Support — availability and limitations
    • Does the patient have a significant other who can be a caregiver?
    • Does the potential caregiver have cognitive or physical limitations of his/her own?
    • Does the patient have children or grandchildren who could be helpful in caretaking?
    • Do family or friends live nearby?)
  • Pre- and Post-Injury Physical Limitations
    • How might the person’s pre-TBI physical limitations complicate their functioning post-TBI?
    • Did the person sustain other injuries in addition to the TBI (e.g., hip fracture, injury to a hand) that is also compromising his/her functioning?
  • Pre- and Post-Injury Activity Levels
  • How active was this person prior to the TBI?
  • Has the person been sedentary?
  • Is he/she retired?
  • Does he/she have home responsibilities?
  • Will the person have opportunities to engage in cognitive, social, and physical activities when he/she is discharged home?
  • Transportation
    • Was the person driving before the injury? If so, how well?
    • Are there concerns about his/her ability to drive following the TBI?
    • Does the patient have access to transportation options if he/she cannot drive?
  • Power of Attorney/Guardianship
    • Is assumption of POA or Guardianship indicated for the patient?
    • Is there a family member of friend who is intact and appropriate for this role?)
    • See Guardianship section for additional detail.
  • Pre-TBI Cognitive Impairment/Dementia

Elderly and TBI Outcomes

  • It has long been thought that advanced age was associated with relatively poorer outcomes following TBI.
  • Elderly persons may have less cognitive “reserve” to compensate for the negative effects of a TBI.
  • Research suggests that elderly persons are at increased risk for neurological effects (e.g., increased risk for subdural hemorrhage) with trauma to the head.
  • However, recent research has suggested that other factors may interact with age (e.g., cognitive difficulties pre-dating the TBI) to affect post-injury functioning.
  • Importantly, as in other age groups, elderly individuals can benefit from participation in rehabilitation therapies (e.g., occupational therapy, physical therapy, speech therapy) to promote their optimal functioning and level of independence.

TBI and Dementia

Factors associated with dementia warrant special consideration in the elderly, as the majority of dementias (e.g., Alzheimer’s disease) typically present and/or persist into this age range.

Key Points

  • Incurring a TBI at any point in life may increase the risk for later developing dementia in some people.
    • Dementia may increase the risk for falling and/or having a motor vehicle accident.
  • Cognitive impairment may result in poor decision making, impaired driving abilities, etc.
    • Dementia can impede the recovery process following a TBI.
  • Participation in rehabilitation involves learning new skills/strategies and thus may be limited by memory problems and other cognitive difficulties.
  • Cognitive impairment may limit a person’s ability to consistently follow medical recommendations (e.g., regarding medications).
    • The presence of dementia may cloud the picture when considering cognitive functioning. Questions that need to be asked include:
  • Are the observed deficits due to the dementia or the head injury?
  • Is the decline simply the dementia progressing?
  • Has the patient recovered or are the persisting deficits due to the TBI?
    • Persons with cognitive impairment and/or dementia may not acknowledge or be able to articulate when they have sustained a head injury.
  • This may delay treatment and therefore negatively affect long-term outcomes.
  • Persons with cognitive impairment and/or dementia may not be consistently able to report when they are experiencing issues in recovery (e.g., persisting headache, fatigue).

When a person with dementia has sustained trauma to the head, careful monitoring is needed, as symptoms indicating a TBI has occurred (e.g., confusion) overlap with those caused by dementia.

1 Cifu, D.X., Kreutzer, J.S., Marwitz, J.H., et al., (1996). Functional outcomes of older persons with traumatic brain injury: a prospective, multicenter analysis. Archives of Physical Medicine & Rehabilitation, 77, 883-888.