Research Objectives To develop a systematic protocol to retrospectively determine presence of traumatic brain injury (TBI) using electronic medical records (EMR). Design Our systematic manual chart review protocol to determine TBI status was based on an adaptation of the ACRM’s mild TBI definition. Using EMR notes corresponding to acute care encounters, we identified past medically attended TBIs based on EMR notes (e.g., Emergency Department Triage, History & Physical, Discharge Summary) that document evidence of TBI based on the observations of clinicians, self-reports, witness reports, and/or radiologist findings. We developed a decision tree workflow to document retrospective EMR evidence of TBI. We conducted a test-retest inter-rater study to determine the reliability of our protocol across two independent raters. We excluded cases corresponding to cases of suspected chronic or sub-acute cases, and those we could not make definitive TBI determination as a result of missing information or confounding secondary to other plausible causes of symptoms (e.g., aneurysm). Setting Multiple hospitals in a single healthcare system, Mount Sinai Hospital, in New York City Participants Two raters evaluated n=55 total patients who presented to the Mount Sinai Hospital system in 2019 with a head CT scan. Interventions None Main Outcome Measures Evaluation of inter-rater reliability was determined based on concordance agreement between two-raters on retrospective ascertainment of TBI. Results We examined the reliability of our protocol with two trained data collectors in this preliminary study. There was a 51/55 (92.7%) agreement between raters as to whether to include a case in our study. There were two cases where both raters agreed should be excluded. Among the 49 included cases, there was a 93.9% agreement (46/49) on TBI diagnosis. Among the three cases of disagreement, one was a categorical disagreement (yes vs. no evidence of TBI diagnosis), and two cases in which one rater decided there was evidence of TBI, and the other determined “unknown/inconclusive” evidence of TBI. Conclusions We have developed a systematic protocol to retrospectively determine TBI diagnoses from EMR records. Our preliminary test-retest study shows strong reliability (>90% concordance) between two trained data collectors on their determination of TBI status. Future work will increase the size of the test-retest study and also validate the performance of EMR records versus administrative claims data.

Research Objectives To identify distinct clinical phenotypes from a sample of U.S. military Veterans living with chronic traumatic brain injury (TBI). Design We collected standardized multidimensional clinical data using performance-based neurocognitive tests, self-report surveys of mood and behavioral symptoms, and a standardized motor assessment from a sample of military Veterans the Late Effects of TBI (LETBI) study. Principal components analysis (PCA) reduced the dimensionality of the clinical data into 2 components that represented 46.7% cumulative variance in the data. We then used the 2 components as inputs in a hierarchical cluster analysis on principal components (HCPC) to group participants into meaningful clusters based on similar clinical profiles. We descriptively evaluated demographic variables (age, sex, race, education) associated with cluster membership. Setting Community-based setting Participants N=115 U.S. military Veterans with a history of chronic TBI (>1 year post-injury) enrolled in the LETBI study. Interventions None Main Outcome Measures A comprehensive battery of 40 TBI Common Data Elements (CDEs), subjective assessments, and performance-based tests spanning cognitive, behavioral, mood, motor, and health domains. Results We observed four distinct clinical phenotypes that we qualitatively described as: Cluster 1: social/emotional deficits and self-rated general health and pain concerns (12.2%); Cluster 2: severe cognitive deficits (13.9%); Cluster 3: few clinical deficits or concerns (40%); and Cluster 4: predominant physical deficits (33.9%). The average age was highest (∼56 years old) in Clusters 3 (few deficits) and 4 (physical deficits), and lowest (∼42 years old) in Cluster 1 (Social/emotional deficits and health concerns). The overall sample was predominantly male (86%); the highest proportion of females was found in Cluster 1 (∼36% female; social/emotional deficits and health concerns). Cluster 3 (few deficits) has the highest proportion of White participants (65%). Conclusions This study evaluated comprehensive and multidimensional clinical data spanning cognitive, behavioral, mood, motor, and health variables from 115 U.S. Veterans living with chronic TBI. We observed four distinct clinical phenotypes that diverged from prior phenotypic classification studies in civilian and mixed populations. Demographics trends with cluster membership could inform prognostic models. Future analyses will evaluate how lifetime patterns of head trauma and military exposures are associated with cluster membership, in addition to how cluster groupings may correlate with neuroanatomical imaging and blood-based biomarkers.

Research ObjectivesTo investigate the relationship between change in cognition (i.e., Brief Test of Adult Cognition [BTACT] Executive Function [EF] and Episodic Memory [EM] scores, from rehabilitation discharge to one-year post-TBI) and one-year participation and quality of life outcomes in individuals with moderate-severe traumatic brain injury.DesignSecondary analysis of data prospectively collected for the Traumatic Brain Injury Model Systems Model Systems (TBIMS) National Database cohort study.SettingInpatient rehabilitation/community.ParticipantsIndividuals with moderate-severe TBI enrolled in TBIMS during inpatient rehabilitation and followed at one-year post-injury.InterventionsNot applicable.Main Outcome MeasuresParticipation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS) at one-year post-injury.ResultsParticipants (n = 499, 72% male) were mean (SD) 45 (19) years old at the time of injury. In a multivariable linear regression model adjusting for clinical and demographic variables and baseline (i.e., rehabilitation discharge) Functional Independence Measure [FIM] Motor, and FIM Cognitive scores, change in BTACT EF from inpatient rehabilitation discharge to one-year post-TBI was not associated with participation (PART-O: b = 0.087, 95 % CI = -0.004, 0.178, p = 0.061) or quality of life (SWLS: b = 0.091, 95% CI = -0.0001, 0.182, p = 0.050) at one-year post-injury. Using a multivariable linear regression with the same model structure, BTACT EM change from rehabilitation discharge to one-year post-injury was associated with SWLS (b = 0.103, 95% CI= 0.014, 0.191, p = 0.023) scores at one-year post-injury, but not with PART-O (b = 0.067, 95% CI = -0.10, 0.145, p = 0.089).ConclusionsThe magnitude of gains in episodic memory between inpatient rehabilitation discharge and one-year post-TBI were related to greater quality of life one-year post-injury in individuals with moderate-severe TBI. Targeting memory during outpatient therapy in the year following inpatient rehabilitation may positively impact quality of life.Author(s) DisclosuresNo disclosures relevant to the abstract.

Research ObjectivesTo examine whether women with a history of intimate partner violence (IPV) and traumatic brain injury (TBI) have greater exposure to lifetime trauma relative to women with TBI and no IPV history and to determine the effects of lifetime trauma and community violence on psychological outcomes following TBI.DesignSecondary data analysis of prospective cohort study.SettingClinical TBI programs at academic medical centers and community-based settings.Participants72 female participants (age M = 50.5 years, SD = 15.4 years) who sustained at least one complicated mild-severe TBI.InterventionsNot applicable.Main Outcome MeasuresThe Brain Injury Screening Questionnaire (BISQ) assessed lifetime history of TBI, and the BISQ-IPV module characterized head trauma secondary to IPV. Lifetime trauma exposure was examined with self-report questionnaires assessing adverse childhood experiences (ACEs) and exposure to community violence (CV). Psychological functioning was assessed with the Primary Care Post-traumatic Stress Disorder (PTSD) Screen for DSM-5 and the Quality of Life in Neurological Disorders (Neuro-QOL) Anxiety and Depression scales.ResultsWomen with IPV and TBI (n = 19) experienced more ACEs (t(23.21) = 3.99, p <.001) and greater CV (t(25.18) = 4.58, p <.001) compared to those with TBI and no IPV history (n = 53). Exposure to CV partially mediated (43.8%) the relationship between ACEs and IPV exposure (indirect effect OR = 1.26, 95% CI= 1.24-1.28). ACEs (β = 0.19, 95% CI = 0.01-0.36) and CV (β = 0.06, 95% CI= 0.00-0.12) predicted worse PTSD symptoms following TBI (F(5, 64) = 8.41, p <.001), while IPV alone did not.ConclusionsThe results highlight the need to address lifetime trauma in TBI assessment and treatment, which may aid in improving psychological outcomes. CV may be a key factor in the relationship between ACEs and IPV exposure. Addressing CV could potentially reduce the risk of IPV.Author(s) DisclosuresThe authors have no conflicts of interest to declare.

ObjectiveTo describe the characteristics and outcomes of older (65+) Medicare beneficiaries with traumatic brain injury (TBI) treated in inpatient rehabilitation facilities between 2013 and 2018.DesignDescriptive study using IRF Patient Assessment Instrument (IRF-PAI) data reporting trends of the sociodemographic and clinical characteristics and outcomes of inpatient rehabilitation facilities Medicare patients with TBI.SettingInpatient rehabilitation facilities in the United StatesParticipants99,804 older Medicare fee-for-service and Medicare Advantage patients with TBI.InterventionsNot applicableMain Outcome MeasuresLength of stay, self-care and mobility functional outcomes, discharge destination.ResultsThe number of older Medicare beneficiaries with TBI treated in inpatient rehabilitation facilities increased from 14,657 in 2013 to 18,791 in 2018, an increase of 28.2%. In addition to this overall increase in patients, we also found the percentage of males increased slightly (52.9% to 54.8%), there was a higher percentage of patients with tier 3 comorbidities, there was a decrease in the variability of length of stay, there was slightly more self-care and mobility improvement and a slightly higher percentage of patients discharged to the community (67.8% in 2013 and 71.6% in 2018). Newer standardized data showed that prior to the injury, more than one-third used a walker and more than three-quarters had a history of recent falls.ConclusionsBetween 2013 and 2018, the number of Medicare beneficiaries with TBI treated in IRFs increased by approximately 28 percent. The characteristics of IRF older patients with TBI changed between 2013 and 2018 toward a slightly higher proportion of males, more comorbidities, and a higher percentage being discharged home after inpatient rehabilitation.

Abstract Discharge home following post-acute care for traumatic brain injury (TBI) has historically been viewed as an unequivocally positive post-treatment outcome. Payors incentivize hospitals to discharge patients home and minimize readmissions. A historically overlooked topic in post-acute TBI care is homeboundness, which is the state where an individual rarely or never leaves home. Homeboundness is associated with premature mortality and poor physical and mental health. Our study investigates the prevalence and correlates of homeboundness among 6,595 non-institutionalized adults (mean age=42, range 16-99) who received inpatient rehabilitation for TBI in the TBI Model Systems National Database, a multicenter prospective cohort study. Our definition of homebound was based on self-reported number of days participants get out of the house in a typical week. We found that 14.2% of participants were completely homebound (never left the home) or partially homebound (left the home 1-2 times/week) 1-year after TBI. Using multivariable regression, we found the following variables were significantly associated with being completely/partially homebound at 1-year post-injury: older age, < college degree, Medicaid insurance, living alone and rural settings, not driving independently, and having functional needs for walking, upper body dressing, bowel and bladder, problem solving, and social interactions. These variables together had an area-under-the-curve of 0.81 distinguishing homeboundness. Our study elucidates an invisible subgroup of non-institutionalized adults living with TBI in the community who require ongoing support services or other follow-up care to improve functional status and participation. Implications for community integration will be discussed.

Objective:Women have a greater lifetime risk of developing Alzheimer’s disease (AD) dementia than men, a sex/gender disparity that cannot be explained by female longevity alone. There is substantial evidence for sex differences in the effects of APOE £4 on risk for AD. While APOE e4 increases AD risk in both sexes, women who carry APOE e4 are disproportionately vulnerable to cognitive impairment and AD compared to their counterpart men. In contrast to APOE e4, APOE £2 is associated with slower cognitive decline and a lower risk of AD. Although a less robust literature, APOE e2 may also have sex-specific effects. Because APOE e2 is the rarest major APOE allele, well-powered studies are needed to examine sex-specific effects. The objective of the present study was to examine sex-specific associations of APOE e2 carriage with longitudinal cognitive decline in a large cohort of clinically unimpaired adults.Participants and Methods:We used observational data from two sources: the National Alzheimer’s Coordinating Center (NACC) and the Rush Alzheimer’s Disease Center (ROS/MAP/MARS) studies. We included data from clinically unimpaired adults who were >50 years old at baseline who self-identified as non-Hispanic White (NHW) or non-Hispanic Black (NHB). Participants were categorized as APOE £2, £4, or £3/e3 carriers. APOE e2/e4 carriers were excluded. The same battery of neuropsychological tests was used to assess global cognition in participants from both data sources. Linear mixed models examined interactive associations of genotype (£2 or £4 vs. £3/£3), sex, and time on longitudinal cognition in NHW and NHB participants separately. Analyses were first performed in a pooled sample of NACC and ROS/MAP/MARS participants and if significant they were repeated separately in each data source.Results:Across both data sources, 9,766 NHW (mean (SD) age=73.0(9.00) years, mean (SD) education=16.3(2.83) years, n(%) women=6,344(65.0)) and 2,010 NHB participants (mean(SD) age=71.3(7.59) years, mean(SD) education=14.9(3.10) years, n(%) women=1,583(78.8)) met inclusion criteria. Sex modified the association between APOE £2 and cognitive decline in NHW (ß=0.097, 95% CI: 0.023-0.172, pint=.01) but not NHB participants (ß=-0.011, 95% CI: -0.153-0.131, pint=.9). In sex-stratified analyses of NHW participants, APOE £2 (vs. £3/£3) carriage was associated with attenuated cognitive decline in men (ß=0.096, 95% CI: 0.037-0.155, p=.001), but not women (ß=-0.001, 95% CI: -0.044-0.043, p=.97). In analyses comparing men and women APOE £2 carriers, men exhibited slower cognitive decline than women (ß=0.120, 95% CI: 0.051-0.190, p=.001). Analyses performed separately in NACC and ROS/MAP revealed the same pattern of male-specific APOE £2 protection in NHW participants in both data sources.Conclusions:In light of the longstanding view that APOE £2 protects against AD and dementia, our results provide evidence that APOE £2 is associated with attenuated cognitive decline in men but not women among NHW adults. This male-specific protection may contribute to sex differences in AD-related cognitive decline. Our findings have important implications for understanding the biological drivers of sex differences in AD risk, which is crucial for developing sex-specific strategies to prevent and treat AD dementia.

Abstract There is evidence health utilization increases after incident dementia, particularly toward the end of life. However, less is known about utilization in the years before dementia. Our study objectives were to compare outpatient emergency department (ED) and inpatient hospital utilization in the six years preceding incident dementia compared to a reference group without dementia. We obtained data on n=5,547 Beneficiaries from the Health and Retirement Study-Medicare linked sample, and defined dementia using a validated algorithm. Those with (n=1,241) and without (n=4,306) dementia were balanced on confounders using inverse probability weighting applied to longitudinal Generalized Estimating Equation models. We found persons with dementia had greater odds of ED (OR=1.46, 95% CI: 1.21, 1.77) and inpatient hospital (OR=1.35, 95% CI: 1.12, 1.63) usage in the years preceding dementia compared to those without dementia across a comparable timespan. This study provides evidence to suggest greater healthcare burden may exist before manifestation of dementia.

Objective To evaluate the impact of the “Movember” awareness campaign (men’s health campaign that takes place every November) on internet search trends for information online about prostate cancer and to compare the results with those for “Pinktober” (the breast cancer awareness campaign that takes place in October) in the Spanish language as an indirect measure of its effectiveness. Methods Google Trends was used to evaluate the monthly relative search volumes (RSV) of the terms “cáncer de próstata” (prostate cancer), “cáncer de mama” (breast cancer), and “Movember” from January 2009 to December 2019 both in Spain and worldwide (in the Spanish language). Breast cancer was used as a comparator of the campaign impact. Mean increase in RSV on-campaign and off-campaign was calculated and compared using the Mann-Whitney U test and Joinpoint regression analysis to assess loss or gain of interest. Results The term “cáncer de próstata” showed a statistically significant increase during the campaign months both in Spain (17.4%; P < 0.001) and worldwide (35.4%; P < 0.001). Both “cáncer de próstata” and Movember showed a decreasing trend worldwide and in Spain, while “cáncer de mama” showed an increasing trend. Conclusion The Movember campaign generates a statistically significant increase in the search trends on “cancer de próstata” (prostate cancer) during the month of November (both in Spain and worldwide); when compared with the breast cancer campaign “Pinktober” these increases are of a lesser magnitude but still significant, suggesting that the campaign is effective beyond the English language, although the interest has been decreasing throughout the years.

Sleep problems after traumatic brain injury (TBI) affect anywhere between 30%-70% of survivors. Moreover, sleep problems can have a tremendous effect on physical health, the ability to think, and emotional well-being. The purpose of this fact sheet is to provide people living with TBI a quick reference about common sleep problems and things you can do at home to manage these problems and help improve your sleep.

Background: Seriously ill individuals rely heavily on family caregivers at the end of life. Yet many do not have family support. Aim: To characterize the size and composition of decedents' family networks by cause of death, demographic, clinical, socioeconomic, and geographic characteristics. Design: A cross-sectional population-level study with data collected from nation-wide registers. Setting/participants: All adults in Denmark born between 1935 and 1998 who died of natural causes between 2009 and 2016 were linked at the time of death to living adult spouses/partners, children, siblings, parents, and grandchildren. Results: Among 175,755 decedents (median age: 68 years, range: 18-81 years), 61% had a partner at the time of death and 78% had at least one adult child. Ten percent of decedents had no identified living adult family members. Decedents with family had a median of five relatives. Males were more likely to have a spouse/partner (65%) than females (56%). While 93% of decedents dying of cancer had adult family, only 70% of individuals dying of dementia had adult family at the time of death. The majority of cancer decedents co-resided or lived within 30 km of family (88%), compared to only 65% of those dying from psychiatric illness. Conclusions: While the majority of adults had an extensive family network at the time of death, a substantial proportion of decedents had no family, suggesting the need for non-family based long-term service and support systems. Assessment of family networks can expand our understanding of the end-of-life caregiving process and inform palliative care delivery.