Impact of Cognitive Status at Skilled Nursing Facility Admission on Days Spent at Home Over the Year Following Traumatic Brain Injury Among Older Adults.

OBJECTIVES: Older adults have the highest rates of traumatic brain injury (TBI)-related hospitalizations and deaths. Cognitive impairment is an acute consequence of TBI and may limit participation in rehabilitation. Older adults discharged to skilled nursing facilities (SNFs) after TBI may be particularly vulnerable to poor recovery. We examined whether cognitive status at SNF admission was associated with recovery in days spent at home (DAH) during the year following TBI hospitalization. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A 20% sample of Medicare beneficiaries aged 65 and older hospitalized with TBI from 2017 to 2020 and discharged to an SNF linked to assessment data from the Minimum Data Set. METHODS: Cognitive status was evaluated using the Brief Interview for Mental Status (BIMS), present in the Minimum Data Set. BIMS 13 to 15 was categorized as not impaired, BIMS 8 to 12 as moderate impairment, and BIMS 0 to 7 as severe cognitive impairment. DAH were defined as days not spent in a facility or deceased. Negative binomial regression was used to model the adjusted association between BIMS category and DAH. RESULTS: Of 14,395 adults aged ≥65 years hospitalized with TBI and discharged to an SNF, 47.1% were cognitively intact, 30.2% had moderate cognitive impairment, and 22.7% had severe impairment. In adjusted models, compared with cognitively intact individuals, those with moderate [rate ratio, 0.82; 95% CI, 0.78-0.87] and severe (rate ratio, 0.64; 95% CI, 0.60-0.68) cognitive impairment had significantly fewer days at home during the year following TBI. CONCLUSIONS AND IMPLICATIONS: Cognitive impairment at SNF admission was associated with fewer DAH following TBI hospitalization, with a dose-response relationship across levels of impairment. Cognitive status at SNF admission appears to be an important marker of recovery trajectory following TBI. Future studies should investigate whether targeted rehabilitation interventions based on BIMS at SNF admission could improve recovery following TBI.