Aging With Traumatic Brain Injury: Cross-Sectional Follow-Up of People Receiving Inpatient Rehabilitation Over More Than 3 Decades

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ORIGINAL ARTICLE

Aging With Traumatic Brain Injury: Cross-Sectional Follow-Up of People Receiving Inpatient Rehabilitation Over More Than 3 Decades Melissa Sendroy-Terrill, MA, Gale G. Whiteneck, PhD, Cynthia A. Brooks, MSHA ABSTRACT. Sendroy-Terrill M, Whiteneck GG, Brooks CA. Aging with traumatic brain injury: cross-sectional follow-up of people receiving inpatient rehabilitation over more than 3 decades. Arch Phys Med Rehabil 2010;91:489-97. Objective: To investigate aging with traumatic brain injury (TBI) by determining if long-term outcomes after TBI are predicted by years postinjury and age at injury after controlling for the severity of the injury and sex. Design: Cross-sectional follow-up telephone survey. Setting: Community residents who had received initial treatment in a comprehensive inpatient rehabilitation hospital. Participants: Survivors of TBI (N⫽243) stratified by years postinjury (in seven 5-year cohorts ranging from 1 to over 30 years postinjury) and by age at injury (in 2 cohorts of people injured before or after age 30). Interventions: None. Main Outcome Measures: Measures of postconcussive symptoms, major secondary conditions including fatigue (Modified Fatigue Impact Scale), physical and cognitive activity limitations (FIM, Alertness Behavior Subscale of the Sickness Impact Profile, Medical Outcomes Study 12-Item Health Status Survey Short Form), societal participation restrictions (Craig Handicap Assessment and Reporting Technique), environmental barriers (Craig Hospital Inventory of Environmental Factors), and perceived quality of life (Satisfaction with Life Scale). Results: Most problems identified by the outcome measures were reported by one fourth to one half of the study participants. Increasing decades postinjury predicted declines in physical and cognitive functioning, declines in societal participation, and increases in contractures. Increasing age at injury predicted declines in functional independence, increases in fatigue, declines in societal participation, and declines in perceived environmental barriers. Conclusions: This investigation has increased our understanding of the aging process after TBI by demonstrating that both components of aging (years postinjury and age at injury) are predictive of several outcomes after TBI.

From the Research Department, Craig Hospital, Englewood, CO (Sendroy-Terrill, Whiteneck, Brooks). Preliminary results were presented to the Brian Injury Association of Colorado, September 28 –30, 2006, Vail, CO; the 2nd Federal TBI Interagency Conference, March 9 –11, 2006, Bethesda, MD; and 22nd Annual Western Michigan Brain Injury Network Symposium, April 15, 2008, Grand Rapids, MI. The study was previously published as an abstract (Whiteneck G, Sendroy-Terrill M, Coll J. Long-term outcomes after traumatic brain injury. J Head Trauma Rehabil 2006:21:435). Supported by an award to Rocky Mountain Regional Brain Injury Model Systems from the National Institute of Disability Rehabilitation and Research (grant no. H133A020510). The opinions expressed are those of the authors and do not necessarily reflect the views of the National Institute of Disability Rehabilitation and Research. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Melissa Sendroy-Terrill, MA, Craig Hospital, 3425 S Clarkson, Englewood, CO 80113, e-mail: [email protected]. 0003-9993/10/9103-00702$36.00/0 doi:10.1016/j.apmr.2009.11.011

Key Words: Brain injuries; Brain injury; chronic; Follow-up studies; Outcomes assessment (health care); Rehabilitation. © 2010 by the American Congress of Rehabilitation Medicine HROUGH THE NORMAL aging process, people experT ience changes in physical and cognitive function, and as they get older, most report an increase in health-related problems. Several of these ailments can be exacerbated in people with disabilities. Careful investigations of the long-term consequences of disabilities acquired early in life have frequently revealed unique patterns of aging among people with different disabilities. Researchers looking at postpolio syndrome describe a deterioration of function occurring after decades of relatively stable impairment.1 People with paraplegia frequently experience shoulder problems from use of their upper extremities for wheeling, transfers, and ambulation.2-6 In these cases, the original impairments occurring early in life interact with decades of overuse or the natural aging process to produce an increased likelihood of secondary conditions characteristic of aging with a particular disability. While aging with TBI has yet to be thoroughly investigated, it has consistently been identified as a major concern of people with TBI, their families, and the clinicians providing services to them. It is only natural that people with TBI would worry about their future quality of life. TBI survivors and their families recognize the importance of family and community-based supports and have concerns about the effects that time will have on those supports. In terms of incidence of TBI, epidemiologists report that the age distribution in the late adolescent and adult population (18 and older) is bimodal. The first peak occurs in young adults (people in their late teens and twenties), with motor vehicle crashes being the major cause of TBI. The second peak occurs within the elderly population, with falls being the predominant cause of TBI.7 The kinds of health problems and outcomes associated with TBI have been found to differ between those who are injured as young adults versus those injured later in life.8-14 This finding stresses the List of Abbreviations CHART CHIEF LOC MFIS OR SF-12 SF-36 SIP SWLS TBI

Craig Handicap Assessment and Reporting Technique Craig Hospital Inventory of Environmental Factors loss of consciousness Modified Fatigue Impact Scale odds ratio Medical Outcomes Study 12-Item Short Form Survey Medical Outcomes Study 36-Item Short Form Survey Sickness Impact Profile Satisfaction With Life Scale traumatic brain injury

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need to better understand both how young adults age with TBI and how TBI affects the elderly. The Long-Term Consequences of TBI When it comes to outcomes following injury, the phrase long-term has been used to describe a wide range of time periods from 1 year to decades postinjury. This broad definition requires closer scrutiny of all reported outcomes within the context of the time frame. The reported long-term consequences of TBI include both cognitive and physical impairments as well as symptoms and complications. These consequences range from postconcussive symptoms that may include headaches, sleep disturbance, fatigue, problems concentrating, being bothered by light and noise, and irritability to cognitive deficits including difficulties with memory, processing speed, attention, problem solving, executive functioning, and/or learning. Research has demonstrated that although many of these symptoms and deficits typically improve over the first few months postinjury, many persist for much longer periods of time.10,15-17 Whiteneck et al15 followed a population-based sample of people hospitalized for TBI up to 4 years postinjury who reported postconcussive symptoms and behavioral sequelae. Rates of symptoms and complications remained constant over the 4 years. Other researchers have reported that for those with moderate to severe TBI, some degree of cognitive deficits may persist over the lifetime.10,16-18 The relationship between brain injury and aging remains unknown. While cognitive impairments are assumed to worsen over the decades, some evidence suggests that the greater neuropsychologic impairment seen in older persons with TBI is mainly due to normal aging.19 Yet findings from a study of persons averaging 14.2 years post-TBI who received inpatient rehabilitation suggest that the aging process is accelerated with worsening cognition and physical and sensory function.20 Physical disabilities acquired secondary to a TBI are known to continue over time; however, these usually do not present the greatest challenge for persons living with TBI.21 Several investigators have identified psychosocial problems (including personality changes) as a major long-term challenge facing TBI survivors.22-33 Families also report psychosocial disabilities as a major problem.34-37 Persons with TBI report social isolation as the major problem.26,31,32,38,39 Studies of TBI survivors often identify high incidence of anxiety and depression.25,28,29,40-47 The risk of depression has been found to increase with time postinjury.48 Decreased quality of life and difficulty occupying one’s time are associated with long-term TBI,49,50 with 1 study indicating the prevalence of work and social interaction handicaps at 90% or greater.51 But the truly long-term picture of TBI outcomes is far from clear.21 Studies examining the consequences of TBI even 10 to 20 years postinjury are limited in number, scope, and sample size.21,31,44,52,53 Most of these studies have contributed to a more comprehensive understanding of long-term outcomes after TBI, but none of these efforts has focused attention on the outcomes of aging after 3 or more decades with TBI. Multidecade longitudinal research will ultimately be required to fully address the complexity of aging with TBI, but the potential for such research is literally decades away from completion. Until then, cross-sectional studies systematically addressing outcomes (and predictors of outcomes) over multiple decades after TBI are needed. Comprehensive cross-sectional investigations of very– long-term outcomes can quickly identify differences among age and injury cohorts and shed light on important issues for longitudinal investigations to follow.54 Arch Phys Med Rehabil Vol 91, March 2010

The Older Adult Population Sustaining New TBI According to projections by the U.S. Census Bureau, the older adult population, ages 65 and older, will represent nearly 20% of the total U.S. population in 2030; that is twice as large as in 2000.55 With a growing older adult population and advances in medical technology, it can be expected that as the older adult population grows, the number of older people sustaining a new TBI and surviving will increase.9 It has been shown that older adults sustaining TBI have longer length of stays in both the acute and rehabilitation hospitals, with significantly slower progress in rehabilitation,56,57 and are more likely to be discharged to nursing homes than younger adults.57 Currently, mortality rates are higher for older adults sustaining a new TBI than for the younger adult TBI population and for age-matched noninjured older adults.58,59 Testa et al60 compared outcomes in TBI versus orthopedic injuries as a function of age. They found that age becomes a risk factor for poorer prognosis when the central nervous system is injured. Yet improvements of function and cognition of older adults with TBI have been shown after patients received intensive rehabilitation with hospital stays more than twice as long as the young adults.61 Many studies report that older persons sustaining a new TBI have increased rates of long-term disability,8,61-63 with more impairments in cognition and behavior.61,64,65 The older adults with a new TBI also demonstrate poorer functional outcomes than their younger counterparts.66-70 The goal of the current study was to focus on the very–longterm consequences of TBI including postconcussive symptoms, major secondary conditions such as fatigue, and depression, physical and cognitive activity limitations, societal participation restrictions, changing environmental barriers, and perceived quality of life across the decades. This study evaluated long-term differences in TBI outcomes in an effort to better understand the process of aging with TBI. One overarching research question guided this investigation: “Are longterm outcomes after TBI predicted by years postinjury and age at injury after controlling for sex and the severity of the injury?” (Sex and severity of injury have been shown to significantly affect outcomes postinjury.)15 METHODS Participants A total of 243 persons with TBI who received treatment in a comprehensive inpatient rehabilitation hospital consented to be interviewed. One research assistant collected all data using a structured interview over the telephone. Demographic variables were collected by medical record abstraction. An effort was made to enroll 20 persons in each of 14 cohorts based on years postinjury (1–5y, 6 –10y, 11–15y, 16 –20y, 21–25y, 26 – 30y, ⬎30y) and age at injury (injured before or after turning 30). However attempts to contact and obtain consent from persons who were over 30 years of age at the time of injury and who were over 20 years postinjury were less successful because of the fewer number of people injured in these categories and greater mortality of persons in these categories. Therefore, the study included interviews with 243 people instead of the projected sample of 280. Based on epidemiology statistics of TBI,7 the decision was made to divide participants who were under the age of 30 and those who were over 30, which would allocate more equal representation of groups. This design allowed for comparisons both among the 7-year postinjury cohorts and also the 2 age-at-injury cohorts. Of the 243 people interviewed in this study, 73% were men; 91% were white, with 3% Hispanic, 2% Asian, 2% African

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American, 1% East Indian, and 1% unknown. Less than 5% of the participants had a duration of unconsciousness (LOC) of less than 1 day, 41% showed LOCs ranging from 1 day to 1 week, 31% had LOCs from 1 week to 1 month, and 24% had LOCs from 1 month to 1 year. For the protection of participants, this study was reviewed and approved by the HealthOne Inc Institutional Review Board. Measures Basic demographics of the participants and characteristics of the injury for each participant were abstracted from their initial rehabilitation medical record. Telephone interviews were conducted by a trained interviewer with the individual participant or, if necessary, a proxy. However, proxies were not asked questions seeking information from the perspective of the TBI survivor, including the emotional subscale questions on SF-12, the cognitive subscale questions on the MFIS, the CHIEF, and the Deiner SWLS. The approximately half-hour interview included the following sections and measures designed to assess major aspects of life status, health and function, community integration, environmental barriers, and quality of life. Current life status section. The interview began with basic questions regarding current living situation and marital, education, and employment status. Health and function section. Designed to capture a wide range of physical, cognitive, and functional conditions, this section of the interview included a checklist of health conditions often associated with TBI and 4 brief standardized instruments. The checklist of health conditions included the postconcussive symptoms used in the Colorado TBI Registry and Follow-up System15 and selected secondary conditions after TBI identified by Ravesloot et al.71 The symptoms checklist included difficulty with headaches, vision, tasting and smelling, getting tired easily, sleeping, irritability, loss of temper, dizziness, balance, seizures, use of seizure medication, and being bothered by light and noise. Participants were asked if they had the symptom and responses were either “yes” or “no,” with the number of symptoms endorsed counted for use in the analyses. The secondary conditions checklist included problems with pain, physical condition, written and spoken communication, contractures, spasticity, and substance use. Respondents were asked to what degree the symptom was problematic. Responses were given on a 4-point Likert scale with answer categories ranging from no problem experienced to a significant problem. Higher scores indicated the presence of a more problematic symptom. The 4 standardized instruments included the following. Health and function section: FIM. The FIM72 is the most widely used measure of physical and cognitive function in rehabilitation, and its reliability and validity have been wellestablished.73 Eighteen items were assessed on a 7-point scale indicating the degree of independence with which they are performed. A higher FIM score indicated more functional independence. A structured interview based on the decision tree in the FIM manual was used. A previous study has demonstrated the reliability of FIM administered over the phone.74 Health and function section: Alertness Behavior Subscale of the SIP. Designed to assess perceived cognitive function in greater detail, the Alertness Behavior Subscale of the SIP75 10-item tool asked respondents if they have trouble with confusion, accidents, reacting slowly, finishing things, reasoning, disorientation, forgetfulness, attentiveness, mistakes, and concentration. Responses were either a “yes” or “no,” with the endorsed responses counted in the analyses. The SIP has been found to be reliable, appropriate for TBI use, and related to

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TBI severity.76 Higher scores on the SIP indicated more dysfunction. Health and function section: SF-12. The SF-1277 was used in this study as a summary health status measure. The 12-item version of the longer SF-36 was selected for its brevity and the ability to compare results with a wide variety of health conditions. The SF-12 provided scores for both the physical and mental domains as well as all the subscales included in the SF-36. The SF-12 has been validated for use in TBI research.78 The SF-12 has a standard score of 0 to 100, with 50 being the average. Higher scores on the SF-12 indicated better health status. Health and function section: Modified Fatigue Impact Scale. The MFIS79 is a measure designed to focus on significant sequelae strongly related to TBI. Because there are no measures of fatigue developed specifically for use in TBI populations, we chose the MFIS because it has been found to be valid and reliable in other clinical populations,79 captures the multidimensional nature of fatigue (cognitive, physical, psychosocial), assesses the functional impact of fatigue, and has been used in research on persons with TBI.80 The MFIS is a 21-item self-report instrument in which subjects were asked to rate the extent to which fatigue has impacted their cognitive, physical, and psychosocial functioning on a Likert scale where higher scores indicated that fatigue has a greater impact on function. Societal participation section. The CHART–Short Form81,82 was used to assess physical and cognitive independence, community mobility and integration, productive use of time, and economic self-sufficiency. This 19-item tool was developed and validated for use with people with various disabilities and has been used extensively in TBI.82 Six subscale scores are produced for physical independence, cognitive independence, mobility, social integration, occupation, and economic selfsufficiency. A higher score on CHART shows less handicap and greater societal participation. Environmental barriers section. The instrument used to assess the impact of environmental factors on participation was the CHIEF83,84 a measure of the frequency and magnitude of environmental barriers to participation reported by respondents. This instrument included assessment of 25 types of physical, attitudinal, and policy barriers. For each of the 25 items, the respondent was asked whether the barrier was experienced “daily, weekly, monthly, less than monthly, or never.” Respondents were then asked whether they considered it a big or little problem. Five subscale scores were produced for physical/structural barriers, attitudes/support, service system barriers, policy barriers, and work/school barriers. Participants who did not either work or go to school at the time of the interview were counted as missing data for the work/school subscale, thus accounting for the high number of missing data for that variable. Greater magnitude and frequency of the barriers experienced is shown by a higher score on the CHIEF. Quality of life section. The Diener SWLS85 was used as a global rating of overall subjective well-being. This 5-item tool is a brief, summary, quality of life measure, which is part of the TBI Model Systems database.86 Greater life satisfaction is indicated with a higher score on the SWLS. Severity of injury. Severity of injury was measured by days of LOC, which was abstracted from the medical record and then divided by 7 to indicate weeks of LOC. Glasgow Coma Scale score, posttraumatic amnesia, and any other neuroimaging results were not used in this study because some of the participants received inpatient rehabilitation decades ago, thus these other severity measures were not recorded in the medical record at that time. Arch Phys Med Rehabil Vol 91, March 2010

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Analysis Linear regression was used when the dependant variables were relatively normally distributed continuous measures, with Beta coefficients reported. Measurements with continuous variables included in the linear regression were SF-12, SWLS, MFIS, Alertness Behavior Subscale of the SIP, and the number of symptoms reported on the symptoms checklist. Logistic regression was used with dichotomous variables, which included the following CHART total score and CHART subscales: CHART Physical Independence, CHART Cognitive independence, CHART Mobility, CHART Occupation, CHART Social Integration, and CHART Economic; FIM total score and FIM subscales: FIM Cognitive and FIM Physical; CHIEF total score and CHIEF subscales; CHIEF Policy: CHIEF Physical, CHIEF Work, CHIEF Attitude, CHIEF Service; and Secondary Health Conditions consisting of spasticity, contractures, physical fitness problems, chronic pain, and joint and muscle pain. ORs were used to assess the predictive value of years postinjury and age at injury. To address continuous variables with nonnormal distributions (absolute value of skew ⬎1), those variables were dichotomized to run logistic regression. Following methods previously employed,87 scores for each CHART subscale (highest possible score,100) were dichotomized with a cut point of 75 and above. The cut point for total CHART (maximum score, 600) was a score of 450 and above. A score below the cut point was an indication of a significant restriction or limitation. A score less than 6 on any FIM item indicates functional dependence—the need for assistance from another person for physical or cognitive activities of daily living. Therefore, FIM scores were dichotomized to reflect independence versus assistance required. If any item in the FIM physical or cognitive subscale or the FIM total score was scored less than 6, then the participant required some assistance on that scale, while if no item was less than 6, then the participant was independent. The CHIEF subscales and total scores were dichotomized as either none (indicating no barriers reported) or greater than zero (indicating barriers reported). Finally, each symptom in the secondary conditions checklist (spasticity, contractures, physical fitness, chronic pain, and joint/muscle pain) (highest possible score, 3) was dichotomized according to whether or not the reported symptom or secondary condition was reported as problematic, with a cut point of 1 (indicating a problem) and above. Four independent variables were included in all regression analyses: years postinjury and age at injury to assess the impact of aging with TBI, and days of LOC and sex to control for severity of injury and sex differences. To aid in the interpretation of results, both age at injury and years postinjury were converted to decades. RESULTS Tables 1 and 2 report the results of logistic and linear regression, respectively. The first 3 columns of table 1 indicate the outcome variables analyzed, the dichotomized value predicted in the logistic regression, the sample size with valid data, and the percentage of cases reporting the problem (predicted value). The most frequent problem identified, affecting about half of the study participants, was needing assistance from another person on 1 or more FIM items (51% needed assistance on at least 1 FIM item, and 47% needed assistance on at least 1 of the FIM cognitive items). A significant problem with productive use of time was reported by over 40% of the respondents (with 44% scoring below 75 on the occupation Arch Phys Med Rehabil Vol 91, March 2010

subscale of CHART). Thirty percent or more of the respondents reported significant problems with economic participation (36%), social integration (31%), and overall societal participation (33%). Other problems reported by 20% or more were joint or muscle pain (29%), contractures (27%), cognitive (28%) or physical (23%) dependence as measured by CHART, the need for physical assistance (26%) as measured by FIM, lack of physical fitness (24%), and chronic pain (23%). The only study variables reported as problems by less than 20% of the participants were spasticity (18%), community mobility (17%), and environmental barriers (16% to 20%, depending on the type). Columns 4 through 11 in table 1 indicate the ORs, significance, and confidence intervals of the 4 independent variables in the logistic regressions: years postinjury and age at injury (in decades), length of LOC (in weeks), and sex (being women, with men as the reference group). ORs in table 2 can be interpreted as the relative risk of a problem occurring (dependent variable) with each unit increase (decade, week, sex) in the independent variable (after controlling for the effect of all other independent variables). For example, there was a 62% increase (OR⫽1.62) in the likelihood of the Total CHART score being less than 450 associated with each additional decade postinjury. The last column of table 1 reports Nagelkerke pseudo R2 as a measure of total variance explained by the independent variables. The columns in table 2, which report the linear regressions, indicate the outcome variables, the valid sample size, the Beta coefficients and significance for the independent variables (years postinjury and age at injury in decades, length of LOC in weeks, sex), and the R2 for the combined independent variables. Beta coefficients in table 2 can be interpreted as the change in scores in the dependent variable associated with the change of 1 unit (decade, week, sex) in the independent variable (after controlling for the effect of all other independent variables). For example, a drop of 1.75 points (␤ coefficient⫽⫺1.75) in the SF-12 physical score was associated with an increase of 1 decade postinjury. The logistic and linear regression results, which are statistically significant at the alpha level of P⫽.05 or less, are bolded and organized by each of the 4 independent variables. Decades Postinjury In the logistic regression, the total CHART score and 3 subscales were significantly predicted by the number of decades postinjury of the respondent at the time of the interview. The likelihood of substantial overall restrictions in participation (total CHART ⬍450) increased by 62% (OR⫽1.62, P⫽.02) for each increase of 1 decade postinjury. A significant increase in the likelihood of 3 CHART subscales being below 75 was also predicted by each increase in a decade postinjury: physical independence by 91% (P⬍.01), cognitive independence by 61% (P⫽.01), and occupation by 83% (P⬍.01). Cognitive FIM was significantly predicted by decades postinjury in the logistic regression. With each increase in a decade postinjury, the likelihood of needing assistance with cognitive functions increased by 47% (P⫽.02). Logistic regression also identified that with each decade postinjury, the likelihood of needing assistance with physical functions increased 54% (P⫽ .03). Analysis of environmental barriers as measured by CHIEF identified only 1 significant relationship with decades postinjury, indicating improvement over time. The likelihood of reporting barriers at work dropped in half (P⫽.05) with each associated increase in decades postinjury. This could either reflect a lessening of barriers or greater adjustment. No other

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AGING AND TRAUMATIC BRAIN INJURY REHABILITATION, Sendroy-Terrill Table 1: Logistic Regression of Outcome Variables Predicted by Years Postinjury, Age at Injury, LOC, and Sex Predicted Value

CHART Total Physical independence Cognitive independence Mobility Occupation Social Integration Economic FIM Total Cognitive Physical CHIEF Total Policy Physical Work Attitude Service Spasticity Contractures Physical fitness problems Chronic pain Joint/muscle pain

n (% with problem)

YPI/10 OR (sig)

95% CI of OR

Injury Age/10 OR (sig) 95% CI OR

LOC/7 OR (sig)

95% CI of OR

Female OR (sig)

95% CI of OR

Nagelkerke R2

⬍450

224 (33) 1.62 (.02) 1.09–2.42

1.25 (.21)

0.89–1.77 1.27 (.00) 1.14–1.42 0.48 (.10) 0.20–1.15

.35

⬍75

242 (23) 1.91 (.00) 1.24–2.94

1.55 (.02)

1.07–2.25 1.22 (.00) 1.12–1.32 0.79 (.61) 0.33–1.92

.36

⬍75 ⬍75 ⬍75 ⬍75 ⬍75

243 (28) 241 (17) 242 (44) 242 (31) 226 (36)

1.12–2.31 0.87–2.00 1.29–2.59 0.86–1.64 0.86–1.66

1.09 (.61) 1.16 (.45) 1.47 (.01) 0.80 (.17) 0.72 (.05)

0.78–1.52 0.79–1.71 1.09–1.98 0.58–1.10 0.52–1.00

.24 .16 .28 .125 .11

243 (51) 1.19 (.30) 0.86–1.63 243 (47) 1.47 (.02) 1.08–2.00 243 (26) 1.54 (.03) 1.04–2.30

1.02 (.90) 0.94 (.64) 1.41 (.05)

0.78–1.33 1.17 (.00) 1.06–1.29 0.78 (.43) 0.25–1.81 0.71–1.23 1.07 (.02) 1.01–1.13 0.72 (.53) 0.48–1.66 1.00–2.00 1.21 (.00) 1.11–1.32 0.87 (.73) 0.42–1.45

.29 .12 .31

⬎none ⬎none

124 (16) 193 (17) 127 (20) 125 (19) 196 (17) 196 (17) 241 (18) 241 (27)

0.42–1.64 0.61–1.54 0.32–1.24 0.23–0.99 0.56–1.38 0.58–1.49 0.79–1.69 0.96–1.86

0.30 (.01) 0.98 (.94) 0.79 (.32) 0.46 (.00) 0.67 (.08) 0.76 (.23) 0.97 (.88) 0.94 (.72)

0.13–0.69 0.66–1.47 0.49–1.26 0.25–0.84 0.43–1.05 0.49–1.19 0.68–1.40 0.69–1.30

.25 .01 .14 .25 .05 .02 .08 .06

⬎none ⬎none ⬎none

241 (24) 1.00 (.98) 0.71–1.40 241 (23) 0.77 (.14) 0.54–1.09 240 (29) 0.99 (.97) 0.72–1.37

0.97 (.86) 0.98 (.90) 0.87 (.37)

0.71–1.33 1.03 (.16) 0.99–1.07 1.59 (.18) 0.82–3.08 0.72–1.09 1.01 (.74) 0.96–1.05 1.05 (.88) 0.52–2.12 0.64–1.18 1.03 (.09) 1.00–1.07 1.06 (.85) 0.56–2.04

⬍6 on any item ⬍6 on any item ⬍6 on any item ⱖ1 ⱖ1 ⱖ1 ⱖ1 ⱖ1 ⱖ1

1.61 (.01) 1.32 (.19) 1.83 (.00) 1.19 (.31) 1.19 (.29)

0.83 (.59) 0.97 (.89) 0.63 (.18) 0.48 (.05) 0.88 (.59) 0.93 (.77) 1.16 (.45) 1.33 (.09)

1.13 (.00) 1.09 (.00) 1.17 (.00) 1.07 (.01) 1.05 (.03)

0.82 (.31) 1.01 (.77) 0.71 (.14) 0.80 (.25) 1.05 (.20) 0.99 (.78) 1.06 (.01) 1.04 (.08)

1.06–1.21 1.04–1.15 1.07–1.28 1.02–1.12 1.01–1.10

0.55–1.21 0.94–1.09 0.46–1.11 0.55–1.17 0.98–1.12 0.88–1.10 1.01–1.10 1.00–1.08

0.87 (.70) 1.11 (.81) 0.54 (.09) 0.56 (.11) 0.65 (.22)

3.36 (.03) 1.46 (.37) 2.08 (.15) 2.92 (.04) 1.56 (.29) 1.09 (.84) 0.62 (.26) 1.19 (.61)

0.41–1.81 0.48–2.55 0.27–1.09 0.28–1.13 0.32–1.30

1.12–10.14 0.64–3.32 0.78–5.50 1.04–8.17 0.69–3.53 0.46–2.61 0.27–1.42 0.61–2.33

.03 .02 .03

NOTE. Bolded values indicate statistical significance at the alpha level of Pⱕ.05. Abbreviations: CI, confidence interval; sig, significant; YPI, years postinjury.

study variables were significantly associated with changes in years postinjury. Age at Injury While overall societal participation as measured by total CHART was not related to age at injury, the productivity subscale (occupation) was significantly predicted by age at injury in the logistic regression. With each increase of a decade in age at injury, the likelihood of substantial restrictions in occupational participation increased by 47% (P⫽.01). Logistic regression also identified that for each decade increase in age at

injury, the likelihood of substantial physical dependence increased by 55% (P⫽.02). Among the FIM measures, the physical FIM score was significantly related to age at injury—the need for assistance with at least 1 physical FIM item increased 41% (P⫽.05) with each additional decade of age at injury. The analyses relating environmental barriers as measured by CHIEF with age at injury indicated that the perception of barriers reduced with older age at injury. The logistic regression identified significant associations between age at injury and perceived barriers encountered overall and perceived bar-

Table 2: Linear Regression of Outcome Variables Predicted by Years Postinjury, Age at Injury, LOC, and Sex

SF-12 Physical Emotional SWLS total MFIS Total Physical Cognitive Psychological SIP Symptoms total

N

Mean ⫾ SD

Years Postinjury/10 (sig)

Age at Injury/10 (sig)

LOC/7 (sig)

Sex (sig)

R2

197 197 196

47.6⫾9.5 48.2⫾10.9 23.3⫾7.7

⫺1.38 (.09) 0.95 (.31) ⫺1.00 (.15)

ⴚ1.75 (.01) 0.84 (.31) ⫺0.29 (.62)

⫺.26 (.08) .30 (.08) .12 (.34)

⫺1.14 (.45) ⫺.2.19 (.22) ⫺1.38 (.28)

.07 .05 .02

222 229 227 239 233 227

23.7⫾21.1 10.2⫾9.6 11.4⫾10.4 2.0⫾2.3 4.2⫾3.1 4.9⫾3.1

0.63 (.71) 0.92 (.22) ⫺0.50 (.55) 0.21 (.22) 0.09 (.73) ⫺0.07 (.80)

2.67 (.07) 1.63 (.02) 0.54 (.46) 0.41 (.01) 0.23 (.30) 0.09 (.68)

⫺.04 (.89) ⫺.05 (.69) ⫺.02 (.87) ⫺.01 (.82) .03 (.28) ⫺.01 (.83)

8.36 (.01) 3.70 (.01) 3.88 (.02) 0.53 (.13) 0.19 (.70) 0.89 (.07)

.04 .05 .04 .04 .01 .02

NOTE. Bolded values indicate statistical significance at the alpha level of Pⱕ.05. Abbreviation: sig, significant.

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riers at work. With each additional decade, the likelihood of reporting barriers of any type decreased by 70% (P⫽.01). With each additional decade the likelihood of reporting barriers at work dropped in half (P⬍.01). Only 3 other outcomes were found to be significantly predicted by age at injury. With each additional decade of age at injury, perceived physical health as measured by the SF-12 dropped 2 points on a 100-point scale (P⫽.01), physical fatigue impact score (MFIS) increased 2 points on a 36-point scale (P⫽.02), and the score of psychosocial fatigue impact score increased one half point on an 8-point scale (P⫽.01). Control Variables: Length of LOC and Sex The significance and magnitude of relationships between outcomes and years postinjury and/or age at injury reported were all calculated after controlling for injury severity (as measured by weeks of LOC) and sex. The impact of these 2 control variables are also reported in tables 1 and 2. It can be seen that the total scores and all subscores on both CHART and FIM were significantly predicted by the weeks of unconsciousness in the logistic regression (with greater severity associated with poorer CHART and FIM scores), but no CHART or FIM score was predicted by sex in either analysis. The only outcome found to have a significant association with weeks of unconsciousness was spasticity with a positive relationship; in other words, the more weeks of unconsciousness, the more severe spasticity was reported. Sex was significantly associated with impact of fatigue (physical, cognitive, total) with women reporting more fatigue impact. Likewise, women perceived significantly more overall, and work-related environmental barriers. The last columns in tables 1 and 2 provide an indication of the degree to which the 4 study independent variables together predict the various outcome variables. The CHART is the best predicted outcome with the 4 independent variables accounting for about a third of the variance in the CHART total score and between a third and a fourth of the variance in physical independence, cognitive independence, and occupation subscales. Likewise, the total FIM and its physical subscale and the total CHIEF and its work subscale were fairly well predicted, but only about a tenth or less of the variance in the rest of outcomes was accounted for by the 4 independent variables. DISCUSSION This investigation has increased our understanding of the aging process after TBI by demonstrating that both components of aging (years postinjury, age at injury) predict several outcomes after TBI. Increasing years postinjury predicted declines in physical and cognitive functioning and declines in societal participation. Increasing age at injury predicted declines in functional independence, increases in fatigue impact, declines in societal participation, and declines in perceived environmental barriers. The magnitude of these aging effects was, however, generally less than the magnitude of effects resulting from severity of injury as measured by duration of unconsciousness. Cognitive, physical, and social functioning all were significantly influenced by the severity of the injury. On the other hand, sex did not appear to be a major contributor to long-term outcomes, with only fatigue and environmental factors being significantly predicted by sex. Many of the outcomes investigated were frequently problematic, with approximately half of study participants acknowledging needing assistance from another person on 1 or more FIM items, including 1 or more cognitive FIM items. Over 40% reported fatigue impact and a significant problem with productive use of time; about a third reported significant problems with economic participation, social integration, and overArch Phys Med Rehabil Vol 91, March 2010

all societal participation, as well as psychosocial fatigue impact; about a fourth reported joint or muscle pain, contractures, cognitive or physical dependence as measured by CHART, the need for physical assistance as measured by FIM, lack of physical fitness, and chronic pain; with only spasticity, community mobility, and environmental barriers being cited by less than a fifth of the study participants. On the other hand, the impact on these problems of aging with TBI may not be as dramatic as feared. First, it appears that the initial severity of the TBI is a stronger predictor of most outcomes than either the years postinjury or the age at injury. The standardized beta coefficients of severity in the linear regressions (not reported in table 2) were substantially larger than for either of the 2 aging factors. Similarly, the ORs in the logistic regressions indicate that from 1 week to 1 month of unconsciousness has a greater impact on outcomes than a decade of years postinjury or age at injury. Second, the percentage of variance explained by the combination of all 4 independent study variables is small for most outcomes, indicating that there are other variables besides aging, severity, and sex that account most of the variance in outcomes. Finally, the rates of change over time in the study variables appear smaller than the effects of aging in other disability groups, particularly spinal cord injury, where far more secondary conditions have been strongly related to spinal cord injury aging.88 In general, the findings in this study were relatively consistent with previous research. Even the finding that less environmental barriers are reported by persons injured later in life is consistent with spinal cord injury research and is likely explained by people avoiding situations with barriers rather than there actually being reduction of barriers.87 There are some major limitations to the present study. It was a cross-sectional rather than a longitudinal design, which limits the study interpretations to only describing associations among variables and not even temporal sequences, let alone causation. The outcome measures investigated were limited to those that could be collected in a brief telephone interview. This meant that no objective measures of cognitive function such as neuropsychologic tests were employed. This limitation was particularly important, since declines in cognitive functioning may be one of the most likely and most devastating impacts of aging with TBI. Similarly, the duration of unconsciousness was the only measure of injury severity that could be included in the study, since potentially more sensitive measures of severity and recovery patterns were not documented in medical records 3 and 4 decades ago. Another limitation is that no correction was made for the number of analyses performed. However, the numbers of significant results were greater than would be expected by chance alone. While it is rare for a majority of the barriers to be endorsed in the CHIEF instrument, this was particularly low in this population, which may be a limitation to this study and the use of this instrument in the TBI population. Finally, the study participants come from only 1 TBI rehabilitation center, and therefore may not be representative of the larger population of inpatient rehabilitation clients and certainly not of TBI survivors generally. CONCLUSION While further research is clearly needed to better understand the nature of TBI aging and develop effective interventions to address the associated problems, this investigation provides crude but important early indications that both components of aging with TBI (age at injury and years postinjury) influence a variety of physical, functional, and psychosocial outcomes. Multicenter longitudinal research including clinical assessments, neuropsychologic testing, and multiple measures of

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