GREAT ADVANCES in emergency trauma treatment over the past 30 years have changed the landscape of brain injury survival. In our professional lifetime, as the baby boomers have matured and created a large, new class of aging individuals, increased survival rates in catastrophic brain injury have created a parallel new class of individuals aging with brain trauma. We are witnessing both the graying of America and the graying of brain injury in America.
Such a large new group of aging people with severe disabilities raises sobering public health issues, ethical quandaries, workplace problems, quality-of-life questions, and conundrums regarding public expenditures and moral priorities in the United States. It is not surprising that researchers have paid increased attention to the various aspects and implications of aging with brain injury. Dr Wayne Gordon and his colleagues have contributed heavily to this literature. The efforts of Dr Tina Trudel and her associates on the Long Term Issues Task Force of the Brain Injury Special Interest Group of the American Congress of Rehabilitation Medicine have been groundbreaking as well. Also, these groups are by no means the only research teams looking at brain injury and aging.
The articles included in this special issue offer an eclectic sampling of research in this area. Various medical aspects of aging with brain injury are presented including inquiries into the cognitive functioning of the elderly, Alzheimer's populations, and traumatic brain injury (TBI) groups.1 Research presented here is focused as a study of the impact of APOE ε4 on cognition and brain injury2 and as broad examination of the progression of symptoms and treatment of people in Singapore as they age with brain trauma.3 Finally, there is a practical foray into the serious issue of falling and prevention of falling in the TBI population, which is relevant to any aging population, including the population aging with brain injury.4
Three of the research pieces in this special issue converge on significant points that have broad applicability for practitioners in the field. The articles by Breed and colleagues,1 Ashman and colleagues,2 and Yap and Chua3 all point to the ability of individuals aging with brain injury to benefit from continued rehabilitation. Breed and her colleagues and Ashman and her associates stress the cognitive gains that are still possible in this population, whereas Yap and Chua look into physical factors as well. These findings are important to those of us in various arenas of treatment for the aging of populations with brain injury because we are often confronted with questions about why we persist in our rehabilitation efforts with long-term clients.
Breed et al and Yap and Chua also concur that as individuals without brain injury grow older, they are more likely to sustain brain trauma from falls than from any other cause.
The high incidence of falls underscores the importance of the Centers for Disease Control and Prevention's (CDC's) program to prevent falling in older adults. This most recent CDC venture in this area, Help Seniors Live Better, Longer: Prevent Brain Injury,4 is a highly attractive, clear, and imaginative initiative.
In their article, Breed et al compare a sample of persons aging with TBI, persons with Alzheimer's disease, and a cohort of similar aged adults with no disability. They offer highly detailed analyses of how aging with TBI affects many areas of cognition. Dr Breed and her associates highlight areas where individuals aging with TBI have relative strengths and weaknesses when acquiring new information. To the discerning practitioner, this article provides clues as to which types of cognitive interventions may be more likely to bear fruit with these individuals. This piece can effectively supplement the vast amount of data on cognitive interventions offered by the Cognitive Rehabilitation Task Force of the Brain Injury Interdisciplinary Special Interest Group of American Congress of Rehabilitation.
Also in this issue, Ashman and colleagues examine the potential effect of the APOE ε4 genetic marker on cognitive decline in an aging of the population with brain injury. In addition, the authors look at the role of both aging and TBI in cognitive decline, an inquiry that is of great interest but rare in the literature. On another interesting note, although Ashman and her colleagues found obvious differences in cognitive abilities between the TBI group and the “no disability” group, they found no difference between the 2 groups in the rate of decline, at least, during a 2- to 5-year follow-up interval. Studies of possible decline beyond the 5-year period have yet to be done. Finally, as in the article of Breed et al, Ashman and colleagues offer therapists some practical guidance regarding promising avenues of intervention for this population, particularly in domains involving visual memory.
Yap and Chua contribute an international perspective to this issue. The authors analyze a large cohort of older individuals (55 years and older) with TBI who were admitted to a rehabilitation hospital in Singapore over a 4-year period. In addition to the previously mentioned results regarding the efficacy of continued rehabilitation for many older people with brain injury, the authors provide revealing descriptive information. It is interesting how the demographics both differ from and are similar to western populations. It is also certain that, if possible, the graying of brain injury in China is an even more urgent economic, medical, rehabilitation, and ethical challenge than in America, because the population of older people is growing at a more accelerated rate than in the West, this within a culture that places such a high premium on taking care of one's elders.
I would like to make one final personal point. This topical issue began under the mentorship of both Drs Nathaniel Mayer and Mitchell Rosenthal and continued under skilled leadership of Dr John Corrigan, subsequent to the untimely passing of Mitch Rosenthal. It is so sad that we had to conclude the project without the skill, wit, brilliance, grace, and gentle good humor of the late Dr Rosenthal.
Thomas Felicetti, PhD
Executive Director, Beechwood Rehabilitation Services, Division of Woods Services, Langhorne, Pennsylvania
1. Breed S, Sacks A, Ashman TA, Gordon WA, Dahlman K, Spielman L. Cognitive functioning among individuals with traumatic brain injury, Alzheimer's disease, and no cognitive impairments. J Head Trauma Rehabil.
2. Ashman TA, Cantor JB, Gordon WA, et al. A comparison of cognitive functioning in older adults with and without traumatic brain injury. J Head Trauma Rehabil.
3. Yap SGM, Chua KSG. Rehabilitation outcomes in elderly patients with traumatic brain injury in Singapore. J Head Trauma Rehabil.
4. Sarmiento K, Langlois JA, Mitchko J. “Help seniors live better, longer: prevent brain injury.” An overview of CDC's education initiative to prevent fall-related TBI among older adults. J Head Trauma Rehabil.