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How Is Traumatic Brain Injury Different in Older Adults?

Older adults should take a better-safe-than-sorry approach


spinner image A male doctor examining a female patient's eyes for a concussion
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Video: Why TBIs Can Be More Dangerous in Older Adults

On a November afternoon in 2022, Scott Chatham and Tucker, a rambunctious golden retriever, set out for a walk around his North Carolina neighborhood. Just a few yards away from the house, Tucker jerked the leash to pursue something. As the 73-year-old scrambled to recover control, he flipped over the dog, coming down hard and headfirst on the asphalt.

Chatham’s teenage grandson witnessed the scene from the house and ran outside to help. Tucker was quickly recaptured and Chatham, who enjoys five- to seven-mile hikes a couple of times a week, judged himself to be fine despite a black eye and a cut on his eyebrow, both on the right side. “I didn’t even have a headache,” says the retired ob-gyn. The walk with Tucker resumed without incident.

Five days later, Chatham got on his stationary bike and began cycling. He doesn’t remember finishing the workout or dismounting the bike. “The next thing I knew I was in the kitchen, and my wife was saying, ‘Do you know what room you're in? Where are we?’ ” Chatham couldn’t answer her. He was alert but “disoriented and confused.”

After he made his way to a comfortable chair in the den, Chatham's daughter grew more concerned when he couldn’t recall his four grandchildren’s birthdays. She brought him to the ER, where an EEG measuring electrical activity in his brain showed abnormalities in the left temporal lobe causing seizures and leading to Chatham’s occasional confusion. The doctor prescribed the anticonvulsant drug Keppra.

Today, almost one year later, Chatham still takes the drug. He has had two more EEGs which show that the seizures persist, though they are becoming less frequent. Some of those periodic episodes make him feel like he’s watching the world through “a fish-eye lens where things aren’t quite in focus.” It’s as if, he says, “there's a time delay on everything that happens and nothing is connected to anything else.” But his symptoms are improving gradually, and he remains active, hiking about twice a week, kayaking twice a month, and using his indoor bicycle when the weather is disagreeable.

What is traumatic brain injury?

Chatham experienced a non-penetrating, traumatic brain injury, or TBI. A TBI may occur with a blow or jolt to the head or a hit to the body that can move the head quickly back and forth, sloshing the soft brain around inside the hard, bony “helmet” that is the skull. This movement can cause stretching or tearing of brain cells and blood vessels in the brain, leading to bruising, bleeding, inflammation and brain swelling. These changes to the brain can affect how a person thinks, learns, feels, acts or sleeps. TBIs exist along a spectrum from mild to very severe. A mild TBI is sometimes called a concussion.

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In some cases, the signs of injury on the outside can obscure the full story of what’s happening inside. When Chatham fell, the impact on the right side of his head caused his brain to rebound in the opposite direction, damaging his left temporal lobe. For some injuries, the damage is immediate. But in other cases, and especially in older adults, the effects of a TBI can come on gradually — hours or even days later.

Older adults and TBI

Traumatic brain injury used to be considered “very much an injury of the young, dumb male,” says Geoff Manley, M.D., professor of neurosurgery at University of California, San Francisco. It was something that primarily happened to boys doing the “silly, stupid things that we all did when we were young.” But today, Manley says that more than half the patients he sees at UCSF’s trauma center are over the age of 65.

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.

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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

spinner image a man holding a woman that has fallen
Getty Images

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.

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