January/February 2024

Recovery From Geriatric Traumatic Brain Injury
By Avivit Ben-Aharon, MS Ed, MA CCC-SLP, and Joy Siegel, EdD, MBA
Today’s Geriatric Medicine
Vol. 17 No. 1 P. 10

How Virtual Therapy Can Help Older Adults Restore Speech and Communication Skills

Geriatricians are familiar with the growing incidence of traumatic brain injury (TBI) in their patient population, as the term “geriatric TBI”1 describes incident TBI that’s sustained in older adulthood. This differs from the topic of older adults with a history of earlier-life TBI and describes an injury that affects how the brain works.

While TBI is an important public health problem in the United States, older adults have the highest incidence of TBI of any age group, and adults 75 years or older have the highest rates of TBI-related hospitalization and death,2 accounting for about 32% of TBI-related hospitalizations and 28% of TBI-related deaths.3

Geriatric TBIs can result from head bumps, blows, jolts, or penetrating injuries such as a gunshot. 4 Ground-level falls2 are the primary cause of TBI in elderly patients, often related to the use of multiple medications that can precipitate falls, cause confusion, or worsen bleeding. Chronic conditions and polypharmacy reduce elderly patients’ capacity to compensate for traumatic injuries, with medications like aspirin or anticoagulants like coumadin potentially exacerbating traumatic intracranial bleeds.

Frailty5 is also identified as a related cause of falls and TBIs, a lifestyle modifier that deeply affects many older adults as they age. Unfortunately, in the absence of evident signs of frailty, it can be an indicator of health issues that may ultimately affect speech and cognition.

Motor vehicle crashes are the second leading cause of geriatric TBI. Although driving may help older adults stay mobile and independent, there are several risk factors for greater mortality and injury in motor vehicle crashes involving drivers and pedestrians who are older,6 including vision problems, slower reflexes, decreased bone density, comorbid conditions, frailty, cognitive impairment, and alcohol and medication use.

Older assault victims with TBI7 trend up with age, and those who are severely assaulted are much more commonly men and typically younger than geriatric victims of accidental trauma. Typical injury patterns include facial and head injuries, and TBI is common. Furthermore, a history of a single fall is a major risk factor for a subsequent fall, increasing the risk of repetitive TBI.8

Concussion,9 the most common10 form of TBI that’s increasing rapidly among older adults, poses particular risks to geriatric individuals who are at higher risk for severe outcomes. Some observers associate this with advances in cardiac and oncologic care, as well as the growing number of procedures like joint replacements, which enable older people to stay active for longer periods of time but can also raise their risk of falling. Sometimes, providers or caregivers confuse concussion symptoms with those of dementia, which may result in patients delaying care.

Assessing, Diagnosing, and Managing Speech & Language Difficulties
Higher morbidity and mortality rates among older vs younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation,1 suggesting that chronological age and TBI severity alone are inadequate prognostic markers.

Assessing and diagnosing geriatric TBIs can be more complicated than doing so for those that occur in younger populations. One reason for this challenge may be a limited appreciation of how common comorbidities and preexisting conditions (ie, diabetes, cardiovascular disease, pulmonary disorders, dementia) may play a role in TBIs.11,12 TBIs may be missed or misdiagnosed in older adults13 because symptoms overlap with other medical conditions that are common among them, such as Alzheimer’s, dementia, or Parkinson’s—conditions that often result in significant communication challenges.

When combined with polypharmacy and aging effects, these preexisting comorbid conditions14 compound the risks, severity, and outcomes following TBI. There are common cognitive communication symptoms following the onset of TBI across the age span, including deficits in attention, processing speed, memory, executive functioning, and language. Therefore, it’s important to differentiate between symptoms of speech and language issues resulting from TBI in older adults vs what may be preexisting due to mild cognitive impairment, dementia, confusion, or age-related cognitive changes as previously described.

The Impact of Geriatric TBI and the Role of Speech-Language Pathologists
Geriatric TBI causes communication difficulties by impairing the ability to speak. This is precisely where the value of speech-language pathologists (SLPs) is evident: SLPs focus on muscles of the face, throat, and mouth since brain injury very often can affect the basics of facial expression. For these reasons, the speech goals for geriatric TBI patients may include cognition,15 speech, and memory. An SLP may incorporate therapies to improve memory as part of the brain injury recovery plan and help to increase the patient’s social language dysfunction and cognitive communication skills. SLPs also focus on improving a patient’s ability to maintain attention, develop problem solving strategies, and enhance remaining skills that may compensate16 for deficits caused by the injury.

Therapies for Dysarthria
When brain injury affects the nerves controlling speech muscles, it can lead to slurred, slow, or muffled speech.17 SLPs use exercises to enhance speech intelligibility, focusing on lip and tongue coordination, breath support, and muscle strength in the mouth, jaw, tongue, and throat.

Therapies for Apraxia
Apraxia, another common condition in brain injury recovery, causes difficulty with sounds and syllables. SLPs suggest exercises to slow speech rate and improve word pronunciation. If the condition is severe, the SLP may introduce an alternative or augmentative and alternative communication device to assist communication.18

Virtual Speech Therapy: A Key Opportunity for Referring Geriatric Patients
Older adults who experience speech and language difficulties after TBI can learn how to develop these skills or alternative ways to effectively communicate by engaging in a speech therapy program. While geriatricians may be familiar with virtual care services—such as primary and urgent care—they may not be aware of the availability of online “virtual” speech therapy experienced from the comfort of home. SLPs providing care in a virtual, online speech therapy program play an important role in a geriatric TBI patient’s brain injury recovery.

This option eliminates transportation challenges for older adults who may not have access to a vehicle or public transportation or have mobility issues resulting from TBI that affect their ability to access care at a brick-and-mortar clinic or rehabilitation center. Following geriatric TBI, patients may benefit from select approaches to virtual speech therapy that provide licensed SLPs throughout the country who can assess and treat cognitive challenges that focus on the patient’s communication.

Achieving independence in communication is always one of the most important needs expressed by geriatric TBI patients. The introduction of virtual speech therapy has dramatically changed the landscape and significantly improved access to care for the elderly.

Criteria for Selecting a Virtual Speech Therapy Program
Since geriatricians may not yet be familiar with these virtual care options, the following are some important characteristics to consider when referring geriatric TBI patients.

Synchronous and Asynchronous Capabilities
A hybrid plan provides a patient portal to optimize opportunities for geriatric TBI patients to extend the value of their live sessions and further accelerate their speech therapy goals.

• Synchronous live sessions with a speech therapist enable the remote exchange of patient information through direct, real-time interaction between the therapist and a patient—also referred to as a client or member of a health plan.

• Asynchronous access to a unique practice portal allows the therapist to assign practice exercises or “homework” for patients to complete at their convenience. These assignments help extend the value of their live sessions and further accelerate their progress.

Matching Therapists With Specific Patients or Conditions, Such as Geriatric TBI
By aggregating all information about the therapists’ background, training, and experience, this approach ensures patients are paired with the most qualified speech therapists. Rather than simply scheduling a patient into the next open time slot, multiple data points are considered to create the best-indicated therapy/patient care partnership to provide more specialized care, more focused therapy, and faster results in a shorter timeframe.

Health Plan Coverage and Medicare Certification
Identify a virtual speech therapy company that’s certified by Medicare and has contracted with multiple insurance plans to provide patients with in-network coverage. This should include a program that serves Medicare and Medicare Advantage members nationwide.

Scheduling Flexibility
Geriatric TBI patients get the most value from a program that offers personalized sessions that can be accessed from the comfort of their homes, with therapist availability on evenings and weekends to accommodate the busy schedules of patients and their family caregivers. This also helps to resolve key social determinants of health by improving access to care that reduces loneliness and social isolation, resolves transportation issues, and eliminates long wait times and the time spent in a clinician’s waiting room at a brick-and-mortar facility.

National Network of SLPs
A virtual care solution powered by a national network of licensed therapists removes the limitations of only working with local speech therapists or reduced availability.

Need for Research
Thanks to the collective work and efforts of many clinicians, researchers, patients, and advocates, geriatric TBI is increasingly recognized as a priority. Despite these advances, a silent epidemic of older adults who sustain TBI remains.19 These individuals, as well as those aging with TBIs from earlier in life, warrant a focused approach to scientific study and treatment that is informed by, yet distinct from, that of TBI in disparate populations.

Notwithstanding the prevalence of TBI in older adult populations and post-TBI cognitive-communication difficulties having the potential to affect adults of all ages, little is known about cognitive-communication outcomes and management following TBI sustained by adults aged 55 years and older.20 There are few, if any, evidence-based TBI guidelines specifically for older adults11 to inform the diagnosis and management of TBI that optimally tailor identification, management, and rehabilitation for this population.

One reason for the lack of TBI guidelines for older adults is a lack of clinical trials for treatment of TBI that target older adults.20 The shortage of research in this area presents challenges for clinicians aiming to deliver evidence-based care to older adults following TBI, especially given the nuances of the TBI population of people who were injured in older adulthood. Gaining an understanding of the value of SLPs—where they work in the care pathway and how they deliver services to the older adult TBI population—is needed.

Relieving the Burdens on Geriatric Physicians
As the proportion of older adults increases in the United States, the number of older adults who experience TBI can be expected to also increase,21 placing further burdens on a shrinking number of primary care providers who specialize in geriatrics. The number of geriatricians22 per 10,000 adults older than 65 years of age has decreased steadily since 2000.

Because the problems that result from TBI, such as those of thinking and memory, are often not visible, and because awareness about TBI among the elderly population and the general public is limited, TBIs are frequently referred to as the “silent epidemic.”23 With the highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occurring in older adults, it’s unfortunate that there are few geriatric-specific TBI guidelines to assist with complex management decisions,1 and TBI prognostic models do not perform optimally in this population.

The implementation of evidence-based prevention and management efforts is paramount11 for helping older adults age in place.

— Avivit Ben-Aharon, MS Ed, MA CCC-SLP, is the founder, CEO, and clinical director at Great Speech, Inc, a virtual speech therapy company founded in 2014. She trailblazed nationwide virtual access to speech therapy, allowing anyone who is committed to improving their communication to receive expert services, regardless of location or scheduling limitations. Her work has been featured on Good Morning America, US News and World Report, the Miami Herald, and more. She graduated from The City University of New York with a Master of Arts in speech-language pathology and Hunter College with a Master of Science in special education and teaching. You can connect with her on LinkedIn or email her at avivit@greatspeech.com.

— Joy Siegel, EdD, MBA, has an expansive career in health care, social services, education, and community engagement. As a gerontologist and health care consultant, she designs outreach programs for insurance companies, hospital systems, and consumers to provide wellness, healthy aging, and self-care. She is a frequent developer of educational materials for clinicians, nurses, and allied health care providers throughout the world, with expertise in nonclinical aspects of wellbeing and aging. Siegel is on faculty at Nova Southeastern University’s Dr. Kiran C. Patel College of Osteopathic Medicine and is the cochair of the Alliance for Aging New Face of Aging Conference in Miami. She holds a doctoral degree in organizational leadership and gerontology, as well as an MBA in nonprofit management.

References
1. Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions. J Neurotrauma. 2018;35(7):889-906.

2. Albrecht JS, Gardner RC. Traumatic brain injury in older adults: epidemiology, management, outcomes. Practical Neurology. April 2023. https://practicalneurology.com/articles/2023-apr/traumatic-brain-injury-in-older-adults-epidemiology-management-outcomes

3. Get the facts about TBI. Centers for Disease Control and Prevention website. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Updated April 20, 2023.

4. Fast facts: firearm Violence Prevention. Centers for Disease Control and Prevention website. https://www.cdc.gov/violenceprevention/firearms/fastfact.html. Updated September 19, 2023.

5. Clark D, Kotronia E, Ramsay SE. Frailty, aging, and periodontal disease: basic biologic considerations. Periodontol 2000. 2021;87(1):143-156.

6. National Highway Traffic Safety Administration. Traffic safety facts 2000: older population. https://rosap.ntl.bts.gov/view/dot/4855. Published 2001.

7. Rosen T, Clark S, Bloemen EM, et al. Geriatric assault victims treated at U.S. trauma centers: five-year analysis of the national trauma data bank. Injury. 2016;47(12):2671-2678.

8. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-49.

9. Blum D. Concussions pose particular risks for older adults. New York Times. March 10, 2023. https://www.nytimes.com/2023/03/10/well/live/concussion-risks-symptoms-treatment.html

10. Cassidy JD, Carroll LJ, Peloso PM, et al. Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004;(43 Suppl):28-60.

11. Waltzman D, Haarbauer-Krupa J, Womack LS. Traumatic brain injury in older adults—a public health perspective. JAMA Neurol. 2022;79(5):437-438.

12. Hawley C, Sakr M, Scapinello S, Salvo J, Wrenn P. Traumatic brain injuries in older adults—6 years of data for one UK trauma centre: retrospective analysis of prospectively collected data. Emerg Med J. 2017;34(8):509-516.

13. Older adults. Centers for Disease Control and Prevention website. https://www.cdc.gov/stillgoingstrong/olderadults/index.html. Updated September 12, 2023.

14. Mattingly E, Roth CR. Traumatic brain injury in older adults: epidemiology, etiology, rehabilitation, and outcomes. Perspect ASHA Spec Interest Groups. 2022;7(4):1166-1181.

15. Hance S. Examples of speech goals for traumatic brain injuries. Healthfully website. https://www.livestrong.com/article/115678-examples-speech-goals-traumatic-brain/. Published August 14, 2017.

16. The practice portal. American Speech-Language-Hearing Association website. https://www.asha.org/practice-portal/

17. Dysarthria. American Speech-Language-Hearing Association website. https://www.asha.org/public/speech/disorders/dysarthria/

18. Augmentative and alternative communication (AAC). American Speech-Language-Hearing Association website. https://www.asha.org/public/speech/disorders/aac/

19. Narapareddy BR, Richey LN, Peters ME. TBI in older adults: a growing epidemic. Psychiatric Times. April 24, 2019. https://www.psychiatrictimes.com/view/tbi-older-adults-growing-epidemic

20. Shorland J, Douglas J, O’Halloran R. Cognitive-communication difficulties due to traumatic brain injury sustained in adults 55 years and older: a survey of speech-language pathology professional practice in Australia [published online March 15, 2023]. Int J Speech Lang Pathol. doi: 10.1080/17549507.2023.2169352.

21. Garza N, Toussi A, Wilson M, Shahlaie K, Martin R. The increasing age of TBI patients at a single level 1 trauma center and the discordance between GCS and CT Rotterdam scores in the elderly. Front Neurol. 2020;11:112.

22. Holveck CA, Wick JY. Addressing the shortage of geriatric specialists. Consult Pharm. 2018;33(3):130-138.

23. Langlois JA, Brown-Rutland W, Thomas KE. Traumatic brain injury in the United States; emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention website. https://stacks.cdc.gov/view/cdc/12294. Published January 2006.