Background: It is estimated that 1 in 10 people aged 60 and older experience abuse, neglect, or exploitation. With the older adult population rapidly growing, elder mistreatment (EM) is an important health and safety concern within healthcare. EM includes physical, sexual, psychological abuse, neglect, abandonment and financial exploitation. Patients who experienced EM are at an increased risk for emergency room visits, hospitalizations, and death. The consequences of traumatic brain injury (TBI) may place older adults at greater risk for EM and adverse outcomes, and EM may be an unrecognized cause of TBI. We explored whether previous history of TBI, EM type, and hospital setting were associated with an increased risk of TBI, mortality, and unplanned hospital readmission following hospital discharge for EM.

Methods: Using 100% of 2015-2018 national Medicare files of hospitalized Medicare Fee-for-Service beneficiaries aged 66 and over, we used Kaplan-Meier and Cox proportional hazard models to estimate TBI occurrence, mortality and unplanned readmission rates by previous history of TBI, EM type, and facility type.

Results: 7,210 patients were hospitalized with an EM diagnosis between 10/01/2015 and 12/31/2018, were at least 66 years old, with Medicare coverage and no HMO coverage in the previous year, discharged after 9/30/2016, and complete death data. Of those, 7% had a previous TBI hospitalization. The majority were female (64.1%) and Non-Hispanic/ Latinx White (74.3%). Neglect was the most common EM type. Among those hospitalized for EM, the rate of experiencing a TBI within one year of discharge was 1.3% (95%CI: 1.0-1.7). 5.3% of patients with a previous history of TBI experienced a TBI within one year compared to only 1.0% of older patients without a previous history of TBI. Having a previous history TBI was associated a greater likelihood of having another TBI within one year (HR: 4.66 [2.73 – 7.97]), while patients who were discharged from a skilled nursing facility (SNF) were less likely compared to those discharged from an acute hospital (HR: 0.29 [0.09 – 0.92]). Having a previous history of TBI was not associated with mortality or readmission. However, being hospitalized for any specific type of EM (vs. other type) and being discharged from a SNF (vs. acute hospital) were associated with an increased likelihood of death or readmission among older adults hospitalized for EM.

Conclusions: This study demonstrates that older adults with a previous history of TBI may experience EM and sustain a future TBI. In addition, older adults who have experienced EM are at an increased risk for death and mortality. Efforts should be made to increase screening for EM among hospitalized older adults to provide the necessary supports to ensure that they are returning to safe environments following discharge, especially patients discharged from a SNF.

Background: In 2009, Gary and colleagues conducted one of the first reviews that explored racial and ethnic differences in outcomes after traumatic brain injury (TBI). Since then, many studies have continue to find racial and ethnic disparities. However, it is unclear whether racial and ethnic differences in TBI outcomes continue to exist. Therefore, a systematic review was conducted to examine whether racial and ethnic differences in TBI outcomes exist in TBI over the last 15 years.

Methods: Relevant literature in English published from January 2009 to December 2023 was identified using the CINAHL, Gale OneFile, PsycINFO (Ovid), and PubMed electronic databases. Articles had to meet the following inclusion criteria: 1) used quantitative or mixed-method methodologies, 2) included individuals with TBI, 3) compared 2 or more racial or ethnic groups on post-TBI outcomes, and 4) included older adults. This systematic review followed PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Using Covidence, at least two coders independently screened abstracts and full-text articles for inclusion, and disagreements were discussed until consensus. Data were abstracted (e.g., author, title, year, design, setting, race and/or ethnicity, age, outcomes, and results), exported to Excel, and summarized.

Results: A total of 2119 studies were initially identified. After removal of duplicates, a total of 1454 abstracts were screened for inclusion or exclusion. After removal of excluded abstracts, 364 full-text articles were screened and 225 addressed racial and ethnic difference. Of those, a total of 17 articles examined racial and ethnic differences in outcomes among older adults with TBI. Most of the studies (n=17) were based on secondary data analysis. About half were experienced differences in the community, and all compared non-Hispanic white (NHW) older adults to other racial or ethnic groups. Seven articles examined differences in discharge settings, while the remainder focused on function (cognitive, behavioral, or physical), or psychosocial outcomes. All studies but two identified racial and ethnic differences, with minoritzed racial or ethnic groups consistently reporting worse outcomes than NHW older adults.

Conclusions: This systematic review revealed that racial and ethnic differences continue to exist among older adults with TBI. Structural racism is a key driver of disparities experienced by minoritized racial and ethnic groups. Future work is needed to explore other social and structural determinants of health influencing health inequities among older adults with TBI.

Importance: Veterans with mild traumatic brain injury (mTBI) face increased risk for vestibular (e.g., dizziness), sensory (e.g., headache), cognitive (e.g., forgetfulness), and mood-related (e.g., irritability) challenges. While these neurobehavioral symptoms generally resolve within three months, a subset of Veterans experience persistent challenges. Despite substantial research, there remains limited understanding of risk factors for persistent symptoms among Veterans with mTBI. Emerging evidence suggests that neighborhood disadvantage, or the lack of social and material resources associated with one’s neighborhood (e.g., low employment), may be an under-researched risk factor for persistent symptoms. Further, the presence of social risk factors co-occurring with neighborhood disadvantage may produce a compounding effect, resulting in especially severe symptoms. In particular, underrepresented Veterans with mTBI (e.g., non-White race or Hispanic ethnicity) are at disproportionate risk for neurobehavioral symptoms. Thus, the intersection of underrepresented race/ethnicity and neighborhood deprivation may produce particularly severe neurobehavioral symptoms among Veterans with mTBI. However, whether underrepresented Veterans with mTBI living in disadvantaged neighborhoods experience exacerbated symptoms relative to White, non-Hispanic Veterans and/or those with lesser neighborhood disadvantage remains unknown.

Objective: To examine whether neighborhood disadvantage is associated with more severe neurobehavioral symptoms among Veterans with mTBI; and whether Veterans in underrepresented racial/ethnic groups with high neighborhood disadvantage experience the most severe symptoms.

Methods: This was a retrospective cohort study of Veterans with the following data available in the electronic health record (2014-2020): 1) clinician-confirmed mTBI and complete Neurobehavioral Symptom Inventory as part of their Comprehensive Traumatic Brain Injury Evaluation; and, 2) Area Deprivation Index scores assessing neighborhood disadvantage from the same quarter as their CTBIE. Latent variable regression was used to examine unique and interactive relationships between neighborhood disadvantage, race/ethnicity and vestibular, sensory, cognitive, and mood-related symptoms. Estimates were adjusted for sociodemographic (e.g., gender) and clinical characteristics (e.g., co-morbid psychiatric condition).

Results: The study included 58,698 eligible Veterans. Relative to Veterans with the least neighborhood disadvantage, Veterans with greater neighborhood disadvantage reported more severe vestibular, sensory, mood-behavioral and cognitive symptoms. The strongest associations between neighborhood disadvantage and neurobehavioral symptoms were observed within the sensory (β = 0.07-0.16) and mood-behavioral domains (β = 0.06-0.15). Statistical interactions indicated that relative to White, non-Hispanic Veterans, the association between neighborhood disadvantage and neurobehavioral symptom severity did not differ among those in underrepresented groups (ps > .05).

Conclusions: Veterans with mTBI living in more disadvantaged neighborhoods reported more severe neurobehavioral symptoms relative to those in the most advantaged neighborhoods, with the strongest relationships detected within the sensory and mood-behavioral domains. While neighborhood disadvantage and underrepresented race/ethnicity were both independently associated with symptoms, these factors did not interact to produce especially negative outcomes. Findings suggest that addressing factors driving socioeconomic disadvantage may assist in mitigating symptoms in this population.

Homelessness has profound and multifaceted impacts on health, creating a cycle of poor health outcomes and barriers to effective medical care. The interplay between homelessness and health is complex, influenced by economic, social, and environmental factors. Poor health and homelessness are cyclical and mutually reinforcing, where each condition exacerbates the other. Homelessness increases the risk of poor health, while poor health can be a direct cause or consequence of homelessness.
There appears to be a bidirectional link between traumatic brain injury (TBI) and unstable housing. This complex interaction creates a cycle of vulnerability, where TBI increases the risk of homelessness, and unstable housing can increase the risk of sustaining a TBI. TBI is disproportionately high among individuals who are houseless (HL) or marginally housed (MH), which is due to a variety of factors: increased exposure to violence, accidents due to unstable living environments, malnutrition, high rates of substance abuse, and comorbid psychiatric factors. Furthermore, once homeless, they are at higher risk of further TBIS, which worsens their cognitive and physical functioning and makes it more difficult to escape homelessness.
Medical rehabilitation is a crucial step in promoting recovery and improving the quality of life for individuals who have suffered organic injury to the brain. However, little is known if medical disparities are present in rehabilitation. Therefore, an exploratory analysis was conducted to examine the demographic data of a sample of patients who are HL or MH with TBI and receiving inpatient rehabilitation at Rancho Los Amigos National Rehabilitation Center. Psychosocial comorbidities and rehabilitation outcomes were explored.
The sample included 49 inpatients from CBIP over 5 years (2018-2023) identified through medical records as HL or MH, with demographic and inpatient rehabilitation outcomes extracted from records. The sample was racially/ethnically diverse (27% Black/African American (AA), 40% Hispanic/Latino, 25% White, 6% Asian/Pacific Islander, and 2% Other). 80% of the Hispanic/Latino sample were monolingual Spanish-speakers. 71% of the sample was middle-aged (40-69 years), and 55% had less than a high school education. A higher proportion of Black/AA patients were HL or MH compared to stable housing. Auto vs. pedestrian was the most common mechanism of injury. 51% of the HL/MH sample did not have capacity at discharge and were discharged to a skilled nursing facility or returned to HL/MH housing. Regarding disparities in rehabilitation stay, t-tests revealed significantly longer rehabilitation stay with transitional care among Black/AA patients than White patients (t = -2.19, df = 14.89, p-value = 0.04), 48.23 days compared to 23 days. This may reflect disparities in hospitalization and care, injury severity, and/or other comorbid conditions that influence recovery outcomes. No differences in length of stay differed between English and Spanish-speaking patients.

Background: Several systematic reviews and meta-analyses show that people experiencing homelessness are more likely than the general population to have a history of acquired brain injury (ABI). Other studies have shown that people experiencing both homelessness and a history of ABI(s) report poorer physical and mental health outcomes than those without a history of ABI(s), as well as more criminal justice involvement and a higher likelihood of repeated ABIs. Little is known about the specific pathways and turning points into homelessness for people with ABIs. The aims of the study were to: (1) identify pathways and turning points into homelessness; (2) explore the experiences, needs and service use of people experiencing homelessness with a history of ABI.

Methods: We conducted a qualitative descriptive study in collaboration with community-based partners in Montréal and Québec City (Québec, Canada). Participants were 18 years or older, were or had been homeless in the past five years and reported at least one possible ABI in their lifetime. Eligibility was confirmed by using the Ohio State University Traumatic Brain Injury Identification Method, as well as self-reported questions on non-traumatic ABI. Life History Mapping interviews were then conducted with participants. Interviews were transcribed verbatim, and data was analyzed thematically.

Findings: Interviews were completed with 26 participants (62% male, mean age 50.7 years, age range: 21-68). Participants reported a lifetime mean of 4.4 ABIs. Most (77%) reported a first ABI before the age of 18 and 12 (46%) reported a period of repeated head injuries. Four typical pathways into homelessness were identified and showed that, for about half of the participants, ABI acted as the primary turning point into homelessness, either through the effect behavioral or functional challenges that prompted interpersonal conflicts, criminal justice involvement, loss of income and decisional autonomy, and loss of housing. For other participants, ABI was either indistinguishable from the effect of lifelong violence and adversity or contributed minimally to homelessness trajectories. Four themes emerged from the analysis: (1) complex experiences with services from multiple sectors along pathways into and in homelessness; (2) family as a residential safety net; (3) ABI as a barrier to exiting homelessness; (4) complex housing and shelter needs.

Conclusions: The findings from the study point to several missed opportunities across various sectors to prevent and reduce homelessness for people who have sustained an ABI. This calls for cross-sectoral action to fill in the gaps in services.

Background: Children, who experience acquired brain injury (ABI) or spinal cord injury (SCI) in a parent or sibling (familial injury), have an increased risk of developing psychosocial problems indicating long-term socioeconomic consequences, which remain unknown.

Objectives: To investigate the long-term socioeconomic consequences on children who experience ABI or SCI in a parent or sibling, in relation to; 1) educational achievements, 2) labour market attachment, and 3) family establishment.

Methods: A nationwide register-based study utilizing population register data provided by Statistic Denmark conducted by linking several national registers. The study population (n=111,366) included children born in Denmark from 1977 to 2006, who were 0-17 years of age at the time of familial injury. The remaining cohort of children without familial injury constituted a reference population (n=2,180,148). The study population included four groups: A) children of a parent with ABI; B) children with a sibling with ABI; C) children of a parent with SCI; D) children with a sibling with SCI. Analyses included linear and logistic regression models performed separately for the four groups, comparing each with the reference population adjusting for parental socioeconomic status.

Results: Across groups, children affected by familial injury achieved significantly lower grade point average (GPA) in 9th grade exams and had a significantly lower probability of commencing and completing upper secondary education compared to reference population. The highest mean difference (MD) in GPA was found in group B (MD -0·44 [95% CI -0·47 to -0·41]), and the lowest odds ratio (OR) regarding commencing and completing upper secondary education was found in group D (OR 0.39 [95% CI 0.26 to 0.59]) and (OR 0.34 [95% CI 0.16 to 0.72]), respectively. A significantly higher probability of long-term sick leave was found in group A, B, and C, highest in group C (OR 1.46 [95% CI 1.30 to 1.64]). A significantly higher probability of disability pension was found in group A, B, and D, highest in group D (OR 2.84 [95% CI 1.81 to 4.44]). Across groups, the children had a significantly lower probability of marriage by age 26, lowest in group D (OR 0.73 [95% CI 0.62 to 0.86]). For those married, a significantly increased risk of divorce was found in group A, B, and D, highest in group D (OR 5.24 [95% CI 2.62 to 10.49]). Lastly, children in group A, B, and C had a significantly lower probability of parenthood by age 26, lowest in group C (OR 0.84 [95% CI 0.75 to 0.94]).

Conclusion: Children exposed to familial injury were significantly affected on educational achievements, labour market attachment, and family establishment. The findings emphasize the serious impact of familial injury and the need for early and continuous supportive interventions to the children and the entire family.

Background: Although preliminary studies have identified disparities in healthcare utilization, care adherence, and recovery among racial/ethnic minorities with sport-related concussion, the influence of broader social determinants of health (SDOH) on concussion outcomes remains underexplored. Utilizing proxy measures like the Child Opportunity Index (COI), which quantifies socioeconomic factors from United States Census Tracts, provides a method to assess the impact of SDOH on healthcare outcomes. This study aimed to investigate the association between the COI and access to care, recovery duration, and follow-up adherence in pediatric concussion.

Methods: A retrospective cohort study was conducted using data from a US-based pediatric academic medical center sports medicine program. Participants included children and adolescents (N = 1414; mean age = 14.53, SD = 2.82, 40% female) stratified by COI. We examined the time from injury to initial clinic visit, time from injury to asymptomatic clinic encounter, and clinic follow-up adherence (lost to follow up: yes/no). Univariate analysis of variance and chi square analyses were used to assess the impact of COI on these outcomes, with statistical significance set at p < .05. Analyses included data from participants whose time to initial clinic encounter and recovery duration (where available) fell within 2 standard deviations of the sample mean.

Results: Our findings indicated significant variations in the time from injury to initial clinic visit among the different COI levels (F(3, 1410) = 2.94, p = .032), with patients from the "Very High" COI level experiencing significantly shorter delays in seeking care (Mean = 4.58 days, SD = 4.15) compared with patients from the “Very Low” COI level (p = .003, Cohen’s d = 0.27). However, no significant differences in recovery duration were found across COI levels (F(3, 1294) = 0.178, p = .912), indicating that SDOH index level had minimal impact on these timelines (mean days = 18.86, SD = 13.42). Chi-square analyses revealed a significant association between COI level and clinic follow-up adherence (χ²(3, N=1414) = 12.61, p = .006, Cramer’s V = 0.09), showing that of those lost to follow up, the "Very Low" COI group had a higher percentage (35%) compared with the "Very High" COI group (8%).

Conclusions: Findings demonstrate the influence of SDOH, as measured by the COI, on healthcare access and follow-up adherence in pediatric concussion recovery. Patients from lower-opportunity areas experience delays in accessing care and are at greater risk of being lost to follow-up compared to those from higher-opportunity areas. While COI may not fully capture the nuances of individual SDOH, it serves as a useful starting point. These results underscore the need for targeted interventions and policies to address systemic barriers to ensure equitable care and improve outcomes for all children recovering from concussion.

Mental health challenges are common among individuals with traumatic brain injury (TBI). However, gaps in healthcare and supports cross the continuum of care persist for this population. There is also limited information on social determinants of health (SDoH) associated with mental health challenges. This study identified the SDoH associated with psychological distress in adults with and without a self-reported history of TBI, stratified by sex. Data from the 2014-2017 cycles of the Centre for Addiction and Mental Health Monitory Survey were analyzed. This is a telephone survey representative of adults 18 years or older in Ontario, Canada. The six-item version of the Kessler Psychological Distress Scale was used to identify individuals with a self-reported moderate to severe psychological distress. Self-reported TBI was determined by asking whether participants experienced a head injury resulting in a loss of consciousness for 5 minutes or longer, or at least one night stay in the hospital. Of 7,214 participants, 16.4% of individuals self-reported experiencing a TBI. Among individuals who reported a history of TBI, 30.2% of males and 40.1% of females reported experiencing psychological distress (p=0.0109). Among individuals who did not report experiencing a TBI, 17.9% of males and 23.5% of females reported experiencing psychological distress (p < 0.0001). Multivariable logistic regression analyses were conducted and showed that SDoH associated with psychological distress were similar between individuals with and without a history of TBI: unemployment among both males and females; income below the provincial median and older age among males; and rural residence among females. This study highlights the need to identify and address psychological distress, particularly among individuals with TBI, so post-injury care considers the potential impact of psychological distress on treatment choice, adherence, and outcomes. Findings also suggest that adaptations to existing population-level mental health services and supports may be opportunities to support individuals with TBI.