Traumatic Brain Injury (TBI) among all injury types is considered to be the most severe in terms of clinical management and often has life-altering consequences, which makes it a major public health problem globally (Puvanachandra and Hyder, 2009). The incidence rate of TBI has increased by about 10% over the last 3 decades (Guan et al., 2023). In 2019, an estimated 49 million people endured TBI of all causes worldwide (Guan et al., 2023). TBI also results in high rates of mortality, morbidity, and it often leads to lifelong permanent disability (Gardner et al., 2018). It accounts for seven million YLD’s (Year loss in disability) annually, estimated in 2019 (Guan et al., 2023). Furthermore, injuries to the brain create substantial economic difficulties and compromise the quality of life for the affected individual and family members and burden the healthcare system for a nation at large. The direct and indirect costs associated with TBI related deaths were estimated to be around 1.1 billion in the USA (Humphreys and Wood, 2013). In addition to creating high personal and social burdens, TBI consumes a high volume of healthcare resources both at the acute and rehabilitation stages (Humphreys and Wood, 2013). The treatment and recovery process for TBI can be very difficult and lengthy. Often a multi-system approach that targets both the physical and psychological damages incurred in such an incident is needed for a meaningful and sustainable recovery.

The burden of TBI is particularly predominant in low- and middle-income countries (LMIC’s) which deal with a large number of these cases and have inadequate and under-resourced healthcare infrastructures to provide acute care for these individuals and manage the long-term health consequences (Hyder et al., 2007). LMICs have a higher incidence rate of TBI compared to an estimated global incidence rate (Bryan-Hancock and Harrison, 2010) and a review article by Puvanachandra and Hyder reports that the Southeast Asian and Western Pacific countries face the highest overall burden of TBI (Puvanachandra and Hyder, 2009). Yet, there is a lack of evidence from these regions that identify the risk factors and consequences of TBI (Bryan-Hancock and Harrison, 2010). LMIC’s generally have a weaker social safety net and almost non-existent supportive systems to look after the TBI patients after they survive and try to integrate back to society. Further, the economies of the LMICs are primarily based on manufacturing, transportation, construction and agriculture which make the risk of sustaining TBI high at the same time make it very difficult for the TBI victims to reintegrate into the labour force. This calls for epidemiological and preventive research on TBI specific to LMICs as the evidence from the high-income countries may not be applicable there. Since TBI incidents are mostly preventable, data on epidemiological profile and pattern of TBI in LMICs are vital for the development and implementation of region and context specific prevention programs (Puvanachandra and Hyder, 2009).

The old age population has been identified previously as the second most vulnerable group for TBI, preceded by younger adults (Goodman and Englander, 1992). Studies reveal a bimodal trend where young adults and older adults have the highest rate of TBI in all levels of severities (Bruns and Hauser, 2003). With the fast growing worldwide aging population, the incidence of TBI is rising in this population group, which has increased by two-fold in the past 18 years according to one study (Mak et al., 2012). In many Western countries, the epidemiology of TBI is evolving with a growing proportion of critically ill older TBI patients admitted to Intensive Care Units (Stocchetti et al., 2012). The risk factors and consequences of TBI among older patients are likely different from younger patients. Age alone contributes to the increased risks of hospital admission following TBI (Peschman et al., 2011). For older patients, even mild TBI poses a significant mortality risk (Cheng et al., 2014). Further, older adults also have a greater need for long-term care and rehabilitation services in comparison to young and middle-aged patients (LeBlanc et al., 2006). Moreover, the financial burden for TBI treatment of older patients is also higher than in other age groups (Chan et al., 2009). For this group of the population, prompt admission and comprehensive management are even more important to have a better treatment outcome along with the quality of life (Papa et al., 2012).

Although older adults are a particularly vulnerable group, evidence on TBI among them remains scarce (Mak et al., 2012), especially in LMICs. The few research studies that have been conducted on TBI in the LMICs such as India, Sub-Saharan Africa, including Bangladesh, did not provide much information on older population-who are the most vulnerable (Agrawal et al., 2016; Tran et al., 2015; Hossain et al., 2018). A study in India’s Level-1 trauma centre reports higher mortality rates among >50 aged patients due to head injury, but no further substantial information has been provided on this group (Agrawal et al., 2016). Another study on a tertiary healthcare centre of Uganda which tried to explore the distribution and characteristics of TBI had very few old-age patients and therefore their vulnerability picture could not be depicted in the study (Tran et al., 2015). Similarly, In Bangladesh, there is a lack of age-specific TBI research. Since the lifestyle and health status are different in older adults than young people (Rahman et al., 2021a; Tasnim et al., 2024), risk factors and characteristics of the victims should be explored in-depth to develop and implement age-specific prevention programs and offer a better and may be a different clinical management plan for them. The current study was conducted to provide a comprehensive picture of TBI among older patients by investigating the causes, clinical characteristics, outcomes, and health-seeking behaviors of this population. Additionally, it investigated the association of clinical characteristics and sociodemographic profiles with health outcomes among this population.

The original cohort consisted of 659 TBI patients recruited over a 3-month study period, of whom 117 (17.8%) were aged 60 years and above and were included in this analysis. The following sections present the data for TBI patients aged 60 years and above from this cohort.

Although TBI research has expanded over the years, older adults remain underrepresented despite being a highly vulnerable group (Gardner et al., 2018). In Bangladesh, where injury rates are high, understanding TBI is particularly important as it is among the most severe forms of injury. This study is the first in Bangladesh to focus on older adults with TBI and one of the few from LMICs. It offers a comprehensive overview of the burden, key characteristics, associated risk factors, and health-seeking behaviors in this population.

Analyzing data from patients aged 60 and above within a larger cohort, the study found that approximately two out of every 10 TBI cases involved older adults. Likewise, studies in US found that older patients consist about 20% of the total TBI patients, and accounts for about 40% of the deaths due to TBI (Peschman et al., 2011; Waltzman et al., 2022). This implies a significant burden for older population group in Bangladesh which makes up 7.5% of its’ total population (Barikdar et al., 2016). Males are identified as predominant sufferer from TBI in general as culturally men are more exposed to outer world and responsible for wage earning in the family. The Bangladesh Health and Injury Survey (BHIS), 2016 also found that males, across all age groups, experienced head injuries more frequently than females. (Hossain et al., 2018).

The study also shows income to be significantly associated with the mortality outcome in older TBI patients. Similar findings are shared by several previous studies which tried to explore the impact of socio-economic status on the outcome of TBI patients (Haines et al., 2019; McQuistion et al., 2020). Even having treated with uniform treatment protocols in a public healthcare facility, older adults of low economic status experience poorer outcome; this may be explained by the presence of co-morbidities, poor nutritional status, inadequate hygiene and weak immunity in this group of people (Dhandapani et al., 2012). Beyond healthcare access and comorbidities, emerging research also suggests a biological underpinning linking low SES with worse neurocognitive and recovery outcomes after brain injury. Chronic psychosocial stress, often embedded in poverty, is associated with elevated levels of glucocorticoids and neuroinflammatory markers such as IL-6 and TNF-α, which are known to exacerbate neural injury and impede recovery after TBI (Muscatell et al., 2020). The concept of “psychosocial defeat”, common among individuals in structurally disadvantaged contexts, is implicated in chronic microglial activation and prolonged neuroinflammation, potentially worsening outcomes following neurotrauma (Kraynak et al., 2018).

Road traffic injuries were the predominant cause of TBI among older adults which is not a surprise for a country where road accidents claim on average about 12,000 lives annually (Alam, 2018; Rahman and Rahman, 2019). Another hospital-based survey in DMCH and a national survey on injury also found RTI to be responsible for majority of TBI among all ages in Bangladesh (Hossain et al., 2018; Mondol et al., 2013). The study also examined the role of older adults in RTIs, finding that most were pedestrians who lacked access to safe options such as footpaths, footbridges, or designated crosswalks. Similar findings have been reported in a North American rehabilitation clinic study, which identified pedestrian accidents as a common cause of TBI among older individuals (Goodman and Englander, 1992).

Falls were the second most common cause of TBI among older people in Bangladesh, accounting for about one-fourth of cases. In contrast, most studies from high-income countries identify falls as the leading cause of geriatric TBI (Goodman and Englander, 1992; Mak et al., 2012), highlighting a distinct pattern in LMICs. In an agricultural country like Bangladesh, falling from tree during fruit harvesting season is a big concern, and the study depicts similar picture as majority of the falls from height occurred by falling from the trees. Additionally, the study shows about 10% of the incidents occurred in home environment. This is important as older adults spend a considerable amount of time in home and it is generally considered to be a safe space for them. The incidents in home mostly occurred by falling or tripping on the ground and primarily took place in the bathroom. This suggests a lack of understanding and information about protective measures, which is also supported by the fact that none of the older adults used any safety measures such as gripping aid or anti-slip mat during those incidents. The mechanism of fall in older TBI patients in Bangladesh differ considerably from developed country scenario where most of the fall related injury results from sports or physical exercise related activities such as falls while skiing or bi-cycle riding (Gardner et al., 2018; Chehuen Neto et al., 2018). Although different in mechanism, the causes and nature of fall incidents in Bangladesh suggest that they are also largely preventable with proper awareness and prevention strategies (Rahman et al., 2021b). To prevent the fall incidents among older group, awareness regarding household risk factors such as low lighting, slippery floors, obstacles, long clothes, etc., and the practice of using safety tools such as anti-slip mat, safety bars, safety shoes and walking aid sticks can be beneficial (Chehuen Neto et al., 2018).

Older patients were found to have substantial adverse outcome both in terms of mortality and morbidity following TBI. CRASH (Corticosteroid Randomization after Significant Head Injury) data on global incidents also identified old age group as most vulnerable but evidence for Bangladesh was unavailable till date (Biswas et al., 2017). Several other studies also confer that outcome in old age group following TBI is worse than that of other age groups (LeBlanc et al., 2006; Papa et al., 2012). Advanced age is a recognized predictor of poor TBI outcomes, and our findings align with this evidence. Biological factors such as reduced neuroplasticity, diminished neurogenesis, and impaired cortical remapping limit recovery in older adults (Orr et al., 2015). Aging brains are also more susceptible to secondary injury mechanisms, including oxidative stress and mitochondrial dysfunction, which worsen prognosis even in mild TBI (Shively et al., 2012). These factors, combined with the lack of age-specific rehabilitation services in LMICs such as Bangladesh, underscore the urgent need for tailored geriatric TBI care and long-term management strategies.

About half of the older patients had moderate problem in all the five domains of EQ-5D-3L during discharge. Further, although more than half of the older respondents had moderate to severe difficulty in mobility at the time of discharge, no rehabilitative management or physiotherapy was given to them. Difficulty in movement and the need for intensive rehabilitative management for older TBI patients is also suggested by several other studies focusing outcome in geriatric patients (Goodman and Englander, 1992; LeBlanc et al., 2006; Alam, 2018). No psychosocial counselling was provided to any of the patients either despite about half of them had some to severe form of anxiety or depression. Similarly, a research report on geriatric TBI showed that depression is prevalent in around 50% of older TBI patients and often has a major effect on their quality of life (Papa et al., 2012). This also supports the fact that rehabilitation and psychosocial supports are generally unavailable for patients in most healthcare facilities of Bangladesh, even in a tertiary care centre, despite having a substantial demand (Mamin and Hayes, 2018; Islam, 2015).

This study also showed that health condition of older TBI patients at admission assessed by GCS ranking, length of lack of consciousness and PTA have independent influence on mortality. Further statistical analysis could not be performed due to the study’s small sample size. Comparable findings have been shared by other studies which also identified GCS score, length of coma and severity of injury as predictors of outcome in older TBI patients (Goodman and Englander, 1992; Stocchetti et al., 2012; Chan et al., 2009).

Moreover, older patients were primarily referred from their nearest secondary or primary healthcare facilities without receiving any prior treatment. The transportation and referral process eventually cause a long delay between injury and initiation of treatment. Waiting time in an overloaded public healthcare facility further delayed the initiation of treatment to more than 24 h in about one-fifth of older patients which have serious implications as prompt treatment in initial hours is vital after a head injury (Ashadullah et al., 2017). Nearly none of them received any first aid care either. All of these point towards an inadequate emergency care and a lack of trained first aid response team at root level or rural level where two-thirds of the country’s total population reside. Since there is a dearth of information regarding TBI among old age population in resource poor settings, these findings could not be compared with similar research.

Road Traffic Injuries (RTIs) and falls are the leading causes of TBI in Bangladesh, disproportionately affecting older males from low socio-economic backgrounds. Including general road safety measures, specific safety programs such as educating the older group on safe pedestrian’s strategies and local collision hotspots, and make them aware on their functional limitations and physical vulnerability that needs to be considered while using road, is critical to prevent RTI in this group. Preventive measures in home regarding fall of older adults can be largely beneficial as well. The association of poor socio-economic condition with mortality among older TBI patients demands further in-depth research and actions such as increase awareness building in this group. In a resource-poor setting like Bangladesh where healthcare system is mostly overburdened, the value of predictive clinical status for outcome at admission needs to be further explored for proper triage and prompt case management. Aggressive treatment needs to be ensured in this older population group with separate geriatric ward, tailored treatment protocol, dedicated institution and management facility which is currently minimal to missing in Bangladesh. Mostly, primary and secondary healthcare facilities of rural Bangladesh need to be upgraded with appropriate emergency services to address TBI and a timely referral system should be in place. Comprehensive multi-system approach targeted to the old age group is essential to reduce this preventable burden of traumatic brain injury in Bangladesh.