The Consequences of a Lack of Health Care Proxy in Individuals 65 and Older Following Traumatic Brain Injury

Introduction: In patients with traumatic brain injury (TBI), the presence of a healthcare proxy (HCP) may play a significant role in facilitating timely care and improving outcomes. This study explores the impact of lacking an HCP at admission and/or preoperatively on overall hospital course, and outcomes in operative TBI patients 65 and older.

Methods: A retrospective analysis of demographic, clinical, and outcomes data was conducted for TBI patients treated from 2015–2021 at a large safety-net hospital. Individuals aged 65 and older treated operatively for TBI were included.

Results: Of the 74 patients that were included, HCP designation was present in 53 (71.6%). Patients with HCPs were significantly older, with a median age of 77 vs. 72 in patients without HCPs (p=0.03). Of the patients without a HCP, 39.1% arrived with a GCS < 8 compared to 22.6% with HCPs although the difference was not significant (p=0.053). There was no difference in GOSE at discharge between the two groups (p=0.07). Mortality was notably lower among patients with HCPs, with 77.4% surviving compared to 47.6% without HCPs (p=0.01). Patients with HCPs had significantly shorter hospital length of stay (LOS) (median 9 days) compared to patients without HCPs (median 15 days) (p < 0.01). Additionally, patients with mild (p=0.02) and moderate (p < 0.01) GCS at presentation that didn’t have an HCP were significantly likelier to have a LOS >15 days. Patients with HCPs were also more likely to be discharged home or to rehabilitation (p=0.03), attend follow-up appointments post-discharge (p < 0.01), achieve mRS < 3 (p < 0.01), and experience good (GOSE 7-8)/moderate (GOSE 5-6) recovery (p=0.049). After multivariate analysis both mortality (OR 9.9 CI95% 1.7-29.5) and LOS >15 days (OR 7.1 CI95% 2.2-44.3) remained significant.

Conclusion : Despite no significant difference in GCS at presentation, operative TBI patients without an HCP aged 65 and older had higher rates of mortality, and longer LOS than those with an HCP. Patients in this age range should be encouraged to designate an HCP.