Elderly at a Crossroads: Rehabilitation and Hospice Outcomes in Small Traumatic Brain Injuries

Background: Traumatic brain injury (TBI) in older adults is a growing public health concern, yet outcome research has primarily focused on moderate-to-severe injuries or aggregated severity groups. Small-volume intracranial lesions, subdural hematomas (SDH ≤ 8mm), epidural hematomas (EDH ≤ 8mm), and cerebral contusions (≤ 2cm), are often classified as mild, but this may underestimate the functional burden in aging populations. Evidence is lacking on discharge outcomes in patients with isolated small-volume TBIs, particularly across age strata.Objective: To evaluate age-related differences in hospital discharge disposition, specifically to rehabilitation or hospice care, among adults aged ≥40 years with isolated, small-volume blunt TBIs, stratified by TBI type and age group.Methods: A retrospective cohort study was conducted using American College of Surgeons-Trauma Quality Programs-Participant Use Files (ACS-TQIP-PUF) data (2017-2022). Adults ≥40 years with isolated blunt TBIs, without skull fractures or polytrauma, were included. Lesion size was defined radiographically via abbreviated injury scale codes. Logistic regression models assessed associations between age group (middle-aged [40-64] vs. elderly [≥65]) and discharge disposition, adjusting for TBI subtype, comorbidities, injury severity, and facility factors.Results: Among 135,343 patients with isolated small-volume TBIs, elderly individuals were more likely to be discharged to rehabilitation (EDH: OR 1.601, 95% CI 1.234-2.076, P <0.001) and hospice care (SDH: OR 2.184, 95% CI 1.630-2.927, P <0.001) compared to middle-aged patients. These age-based differences persisted across TBI subtypes.Conclusion: Despite being classified as "mild" by volume, small TBIs are associated with significant discharge care needs among older adults. Elderly patients face markedly higher odds of requiring rehabilitation or end-of-life care. These findings challenge traditional severity frameworks and highlight the need for age-adapted discharge planning in the context of small-volume intracranial injuries.