How Is Traumatic Brain Injury Different in Older Adults?

Older adults are more likely to be hospitalized or even die from a TBI compared to all other age groups, data from the Centers for Disease Control and Prevention show. People 75 and older accounted for about a third of approximately 214,110 TBI-related hospitalizations in 2020. These estimates do not include the many TBIs that are treated outside the in-patient hospital setting or that go untreated.

Rather than injuries from rough-and-tumble contact sports, like football and soccer, TBI in older people is usually caused by simple falls. Common mishaps, such as tripping over a carpet, slipping on the sidewalk or getting tangled up in a dog’s leash can do it. In other words, the kinds of events that people might consider too minor to warrant a trip to the emergency room.

Thankfully there are steps you can take to minimize your risk of experiencing a TBI. And if you do fall and have a head injury, there’s good news about ways you can recover.

TBI symptoms in older adults

When any of these symptoms – memory lapse, confusion, blurred or double vision, slurred speech, dizziness, seeing stars, ringing in the ears, headache, nausea or loss of consciousness even for an instant – occur immediately after a head trauma, it’s a good idea to go to an emergency room or trauma center to be assessed for a TBI.

Raquel Gardner, M.D., goes a step further: She advises that any older person who falls and hits their head should go to the ER, even if they have no immediate symptoms. Gardner is director of Clinical Research at the Joseph Sagol Neuroscience Center in the Sheba Medical Center in Ramat Gan, Israel. Her advice is especially important for older people who are taking a blood thinner such as aspirin, warfarin or apixaban, she adds. Even a minor head bump, such as hitting the door frame while getting out of a car, should be looked at because blood thinners may increase the risk for bleeding in the brain.

The challenges of diagnosing a TBI

At the hospital, a patient who reports potential head trauma will typically undergo a neurological examination and possibly a head CT to look for bleeding in the brain. The exam may include a blood test measuring two biomarkers in the blood, which, when elevated, can indicate a brain injury. Biomarker tests, including a new one that was approved by the Food and Drug Administration in 2023, could help doctors sort out a TBI in older adults from other preexisting conditions, Gardner says.

Sometimes older people may have undiagnosed cognitive impairment or dementia before the TBI. This can make it difficult for them to report symptoms. Sometimes, Manley says, an older person comes in with a TBI “and it turns out that probably they had evolving mild cognitive impairment (or MCI) prior to the head injury and the MCI actually contributed to them getting the head injury.”

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“Now anytime we see an older adult who comes in with a traumatic brain injury, we carefully do some testing to see if there’s mild cognitive impairment. Oftentimes, we talk to the family who will say, ‘come to think of it we’ve noticed in the last six to nine months that they seem to be a little bit slower and a little bit more confused.’ We think that’s why when they got up in the middle of the night to go pee, they turned left instead of right and went down the steps.” Manley recommends that people with MCI and their families make changes to reduce the risk of traumatic brain injury.

Another complication in diagnosing older people is that aging can lead to shrinkage of the brain. Ordinarily when there is bleeding in the brain, the pressure of the blood pushing on the brain will cause neurological symptoms that are hard to miss. But if the brain is taking up less space in the skull, there’s extra room for the blood to accumulate inside. The injured person may have no symptoms right after the fall or bump. This is why vigilance is important and the person shouldn’t be left alone in the days after the injury: The blood may accumulate gradually, and after several hours or days, the person may suddenly develop severe or even life-threatening symptoms.

How is TBI treated?

When people go to the hospital with a brain injury, they may expect a straightforward diagnosis and treatment plan, as they’d probably get if they had cancer or heart disease. But, says Manley, people may have to do some research to find someone in their area who actually knows about traumatic brain injury.

“Few intensive care physicians follow-up patients after discharge from the ICU, and follow-up of patients with milder forms of injury is particularly deficient,” Manley and colleagues wrote in a 2023 editorial published in Injury. Physicians should follow up with their patients, “at 6 to 12 months after injury, preferably in-person,” the researchers wrote. At the very least, “patients should be instructed to return in case of persisting symptoms.”

It’s not clear that a person leaving the hospital today, however, would be told what persistent symptoms to look for. Many clinicians do not understand that things like headache, sleep disturbance, blurry vision and dizziness are quite common in the wake of TBI, Manley says. While it’s true that doctors don’t have a quick fix, they can offer plenty of ways to manage symptoms.

Time for recovery

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Common fall risks among older adults

• Joint problems and difficulties with walking and balance
• Use of prescription and over-the-counter medicines that can affect steadiness and balance
• Vision problems, including reduced peripheral vision

Even for those with a mild TBI, about half still experience limitations six and 12 months later, Manley and colleagues reported in 2023 in the journal Injury.

Not long ago, experts believed that for better or worse, “what you looked like at six months [post-injury] is what you were going to look like forever,” Manley says. That’s no longer the case, now that researchers understand that recovery can continue over many years.

Manley and his colleagues who treat and study TBI in older adults “have been pleasantly surprised” that healthy older people “can have exactly the same kind of recovery as somebody in their 30s and 40s. It just takes longer.”

No matter one’s age, a successful outcome after TBI depends on multiple factors, including a person’s physical health, mental health, coping skills and social supports – both before and after the injury, Manley says.

A very healthy 80-year-old who has medical problems and a healthy lifestyle may be as resilient or even more resilient than a very unhealthy 50-year-old, Gardner says. Scott Chatham’s injury and ongoing recovery is a great example, but even he is glad he wasn’t alone in the days after his fall. It’s hard for the person who fell to know very accurately if something isn’t right, he acknowledges. Although he offers an amused caveat on the question his daughter asked that sparked enough concern to send him to the hospital: “I’ve never known my grandchildren’s birthdays.”

Editor’s note: This article was updated on February 13, 2024 to add details about Scott Chatham’s experience.