• Vikas N Vattipally, Kathleen R Ran, Oishika Das, Carlos A Aude, Ganiat A Giwa, Jordina Rincon-Torroella, Risheng Xu, James P Byrne, Susanne Muehlschlegel, Jose I Suarez, Debraj Mukherjee, Judy Huang, Tej D Azad, and Chetan Bettegowda.
• Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA. vvattip1@jhmi.edu.
• Neurocrit Care. 2025 Jan 16.

BackgroundTraumatic brain injury (TBI) is a significant cause of morbidity and mortality in the older adult population, and palliative care consultation can assist in goals-of-care discussions. However, patterns of hospital care delivered before consultation are understudied for older adult patients with TBI. The objective of this study was to identify demographic and clinical drivers of preconsultation care intensity in this population.MethodsWe retrospectively identified older adult (≥ 75 years) patients admitted at our institution who experienced a traumatic fall leading to TBI, neurosurgical consultation, and palliative care consultation. Therapy intensity level (TIL) scores were assigned from interventions administered before consultation. We constructed a multivariable linear regression model for associations with preconsultation TIL. Then, to evaluate associations between demographic and clinical drivers and preconsultation care intensity with consideration for the complex interplay between variables, we employed structural equation modeling in a separate model.ResultsA total of 122 patients were included (median age 85 years; 46% female). In the original multivariable model, patients who identified as Asian (β = 1.4; P = 0.04) or multiracial/other race (β = 2.9; P = 0.006) had higher preconsultation TIL scores. Increasing midline shift (MLS) was also associated with increased care intensity in this model (β = 0.20 per mm; P < 0.001). With structural equation modeling, demographic factors driving increased preconsultation care intensity included female sex (β = 0.110; P = 0.049) and Black (β = 0.118 per mm; P = 0.01) or multiracial/other (β = 0.201; P = 0.005) race, whereas clinical factors driving decreased care intensity were MLS (β = - 1.219 per mm; P < 0.001) and abnormal pupillary reactivity (β = - 0.425; P < 0.001).ConclusionsDemographic factors such as sex and race were associated with differential prepalliative care consultation care intensity. Although MLS was associated with increased care intensity in the original multivariable model, when considering complex interactions between variables, greater injury severity drove decreased care intensity potentially due to perceptions of medical futility. These findings serve to inform discussions about disparities and clinical considerations surrounding palliative care for older adult patients with TBI.© 2025. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.

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