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Seniors are at highest risk for death and disability from TBI, but the condition is often under-recognized. Stepped-up identification and treatment are needed.

By Erin Mattingly

Most of us know the famous—or maybe infamous—“I’ve fallen and I can’t get up” commercial for an emergency device the wearer can use to call emergency services if they fall.

The common assumption among viewers is likely that the woman broke her hip or sustained another type of orthopedic injury. But traumatic brain injury (TBI) is also a possibility—and because the cognitive communication effects of TBI can sometimes mirror the symptoms of typical aging, that possibility could, unfortunately, be overlooked.

If an older adult has recently experienced a fall or other cause of a blow to the head, it’s critical to assess immediately for cognitive communication difficulties and provide treatment if warranted. A delay in assessment increases the risk of misdiagnosing TBI-related difficulties as symptoms of typical aging, which do not usually result in a diagnosis that supports the need for cognitive communication treatment.


It’s important that the public and we, as speech-language pathologists, are aware of the likelihood of TBI in older (at least 65) adults following falls and from other causes, so that older adults receive appropriate treatment for cognitive communication impairment resulting from TBI (including mild TBI or concussion).

The rate of TBI-related death and disability in older adults is higher than in any other age group: Falls are the leading causes of TBI in this population, followed by motor vehicle accidents. Older adults most often fall on level surfaces (trip on uneven flooring, slip on rugs, slide in socks), not up or down the stairs. This risk profile is important to emphasize when educating clients on fall prevention and when engaging with multidisciplinary partners, such as occupational therapists (OTs) and physical therapists (PTs).

The progressive changes of typical aging may include cognitive, sensory, and motor changes, all associated with increased TBI risk. For example, vision changes might cause an older adult to miss seeing a grandchild’s toy on the floor; balance changes make a fall more likely if they trip on it.

Side effects of medications for conditions like diabetes, high blood pressure, and high cholesterol may also magnify TBI impacts. Anticoagulants, for instance, may raise the risk of brain hemorrhage in cases of head injury from a fall.

Assessment and treatment

There is no specific evidence-based TBI assessment or treatment protocol for older adults that differs from that of adults in general. TBI assessment should follow the same evidence-based protocol, typically including standardized, informal, and functional observation.

Functional observation is critical to assessment: Clinicians can often learn more from watching a patient in their natural environment than from tests.

Begin with education, then lead the client into the specific therapy tasks and coaching. Develop treatment goals with the patient, if possible, based on assessment results and the patient’s interests and aspirations. And, as much as possible, address social isolation by incorporating community reintegration and social interaction (see “Relearning Work Skills … at Work” ).

In a group facility

In skilled nursing or assisted living facilities, use a patient’s personal items and activities for functional treatment. For example, gather a patient’s morning routine items—such as soap, toothbrush, toothpaste, shampoo—and ask your patient to place these items in the order they would use them. Or collaborate with nursing or other staff to observe how patients typically sequence these items.

Later reinforce compensatory strategies to correctly sequence the steps: Do they remember the sequence of getting dressed? Can they find the dining room? These areas of function can informally contribute to your assessment and guide treatment.

In an outpatient setting

If possible, take your patient out into the community—on errands to the grocery store, for example, or the cleaners. If getting out of the clinic isn’t an option, ask the patient to bring in goal-related tasks or items to work on. If they want to cook, for example, have them bring in a recipe and work on sequencing and using supports like reminders and timers.

Interprofessional practice

Multidisciplinary treatment allows different team members, with their own unique relationships with the patient, to address different functional areas. Co-treatment can be especially beneficial if appropriate. For example, in a residential facility, you might plan a cooking task with your patient and the OT. You and your patient can work on planning the menu, making a grocery list, and reviewing recipe steps—incorporating memory, attention, problem-solving, and executive function. Your OT teammate might address safety aspects of the cooking activity and help the patient apply visual, fine-motor, and other skills during the task.

Outpatient co-treatment with a PT might include a community re-entry task of going out to lunch. If the goal is to improve attention and memory in the community (with a SMART—specific, measurable, achievable, relevant, timely—focus of course!), have the patient plan where to go to lunch, pick their order, and remember their order (with or without a compensatory strategy, depending on their goal). The PT may choose to focus on mobility, looking at function while ambulating in the community; you, as the SLP, can consider whether the patient remembers ambulatory safety precautions (for example, does the patient remember to lock the wheelchair brakes before trying to transfer or stand up?).

Be part of the solution

Because there is limited evidence supporting assessment and treatment for older adults with TBI, investigate the possibility  of contributing to research. Reach out to local universities and/or hospitals to ask about relevant studies and opportunities to get involved, read the latest research in this area (see ASHA’s evidence mapsjournals, and Practice Portal), write case studies about unique patients and interventions, and share research ideas with your colleagues.  Be part of the solution to getting our older patients the treatment, and recovery, they need.

Erin Mattingly, MA, CCC-SLP (she/her/hers), is a strategic consultant, traumatic brain injury (TBI) subject-matter expert, and the senior director of strategic development at Loyal Source Government Services. She is an affiliate of ASHA Special Interest Group 2, Neurogenic Communication


Mattingly, E., & Roth, C. R. (2022). Traumatic brain injury in older adults: Epidemiology, etiology, rehabilitation, and outcomesPerspectives of the ASHA Special Interest Groups, 7(4), 1166–1181.

New International TBI Treatment Guidelines Update 2014 Recommendations
By Leanne Togher

Newly revised international guidelines for the management of TBI-related cognitive-communication and social cognition disorders—INCOG 2.0 (International Cognitive Rehabilitation Guidelines)—address cultural and emotional considerations, group treatment, and telehealth.

The recommendations update initial guidelines published in 2014 by an expert multidisciplinary international panel. INCOG 2.0 includes 26 new papers since 2014 and expert consensus regarding best practices. It also includes a decision-making algorithm and an audit tool to aid review of clinical practice.

The five updated and four new recommendations include:

Cognitive-communication (CC) #1: Levels of communication competence and characteristics may vary as a function of communication partners, the environment, and personal factors. INCOG 2.0 adds physical, sensory, and psychosocial variables as factors to consider.

CC #2: Ensure rehabilitation programs are culturally responsive, and consider the person’s pre-injury variables (for example, gender identity, cultural-linguistic background—including Native, first, and preferred languages—literacy, and language proficiency). INCOG 2.0 adds the importance of cultural awareness and culturally appropriate communication resources to assist health care interactions.

CC #3 (new): Staff should receive cultural competence training.

CC #4: Includes new evidence for recommended cognitive communication interventions, including communication partner training, communication strategy and metacognitive awareness training, and education of the patient and close others. INCOG 2.0 adds communication coping treatment; focus on confidence, self-esteem, and identity; and education about CC disorders for patients and close others.

CC #5: Individualized, goal- and outcome-oriented treatment should be appropriate to the context of the person, including where they live, study, and work. INCOG 2.0 adds goal-attainment scaling to measure personally relevant progress.

CC #6: Recommends augmentative and alternative communication (AAC) for people with severe communication disability, in combination with training for family members, caregivers, and other communication partners. INCOG 2.0 recommends routinely offering AAC within the context of the person’s everyday environment.

CC #7 (new): Clinicians are advised to consider group therapy to remediate social communication impairments.

CC #8 (new): Telerehabilitation is efficacious, feasible, and acceptable for communication partner training.

Social Cognition #1 (new): Consider evaluating aspects of social cognition, including emotion perception, theory of mind, and emotional empathy. Interventions to improve these aspects are recommended; however, computerized social cognition treatments are not recommended, given the lack of evidence of generalization to real-life acitivites.

Leanne Togher, PhD, CPSP, is a speech pathologist and director of the Acquired Brain Injury Communication Lab and professor of communication disorders following traumatic brain injury at the University of Sydney. A member of the INCOG 2.0 expert panel, she is the first author on the group’s recommendations for cognitive-communication and social cognition disorders. She is an international affiliate of ASHA Special Interest Group 2, Neurogenic Communication Disorders.

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