Stroke Incidence Following Traumatic Brain Injury in Older Adults

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Stroke Incidence Following Traumatic Brain Injury in Older Adults

Jennifer S. Albrecht, PhD,¹ Xinggang Liu, MD, PhD,¹ Gordon S. Smith, MB, ChB, MPH,^2,3 Mona Baumgarten, PhD,² Gail B. Rattinger, PharmD, PhD,⁴ Steven R. Gambert, MD,⁵ Patricia Langenberg, PhD,² and Ilene H. Zuckerman, PharmD, PhD^1,2

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Abstract

Objective

Following traumatic brain injury (TBI), older adults are at increased risk of hemorrhagic and thromboembolic events, but it is unclear whether the increased risk continues after hospital discharge. We estimated incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among adults ≥65 and compared them with pre-TBI rates.

Participants

16,936 Medicare beneficiaries aged ≥65 with a diagnosis of TBI in any position on an inpatient claim between 6/1/2006 and 12/31/2009 who survived to hospital discharge.

Design

Retrospective analysis of a random 5% sample of Medicare claims data

Main Measures

Hemorrhagic stroke was defined as ICD-9 codes 430.xx-432.xx. Ischemic stroke was defined as ICD-9 codes 433.xx-435.xx, 437.0x, and 437.1x.

Results

There was a six-fold increase in the rate of hemorrhagic stroke following TBI compared to the pre-TBI period (adjusted Rate Ratio (RR) 6.5; 95% Confidence Interval (CI) 5.3, 7.8), controlling for age and sex. A smaller increase in the rate of ischemic stroke was observed (adjusted RR 1.3; 95% CI 1.2, 1.4).

Conclusion

Future studies should investigate causes of increased stroke risk post-TBI as well as effective treatments to reduce stroke risk and improve outcomes post-TBI among older adults.

Keywords: Traumatic brain injury, Hemorrhagic stroke, Ischemic stroke, Older adults

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Introduction

Traumatic brain injury (TBI) is a significant health problem among older adults that results in 142,000 emergency department visits, 81,500 hospitalizations, and 14,300 deaths annually in the United States.¹

Older adults have poor short-term outcomes following TBI including higher in-hospital mortality rates and lower functional abilities at hospital discharge compared to younger patients with similar TBI injury severity.^2-4 Mild TBI, which can result in a period of transient confusion, disorientation, or impaired consciousness and accounts for more than 75% of TBI cases, is also associated with higher mortality in older versus younger adults.^5,6

Older adults also experience poor long-term outcomes following TBI. Compared to younger patients with TBI, older adults have greater disability in physical and cognitive functioning up to one year after hospital discharge.^7-10 This leads to increased hospitalizations and nursing home stays among older adults, and results in high one-year treatment costs.¹¹ One study estimated average per-patient treatment costs in the first year following TBI among adults aged ≥55 to be $80,000, and the lifetime cost of TBI among older adults due to persistent disability and the risk of long-term sequelae is likely much greater.^11-16

Stroke can cause increased disability among older adults post-TBI. Older adults are at increased risk of both intracranial hemorrhage and thromboembolic events during hospitalization for TBI.^17,18 However, it is unclear whether the increased risk continues during the year after hospital discharge. The aim of this study was to estimate incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among Medicare beneficiaries aged ≥65 and compare them with pre-TBI rates.