Aging After Brain Injury: BrainLine Talks with Dr. Steven Flanagan

Aging After Brain Injury: BrainLine Talks with Dr. Steven Flanagan

BrainLine sat down with Dr. Steven Flanagan to talk about the issues of aging after a traumatic brain injury. Dr. Flanagan is professor and chairman of the Department of Rehabilitation Medicine, New York University School of Medicine, and the medical director of the Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center.

Are there any increased risks as people age after a brain injury?

We think the answer is yes. Although aging after a brain injury has not been terribly well studied to date, some research, including a study conducted in 2008 by the Institute of Medicine, has suggested that people with brain injury are at an increased risk of seizures. We have also found that people with poorly controlled seizures are at a higher risk of dying at an earlier age than people without brain injury-related seizures.

Studies also suggest that the more physically disabled a person is post-injury, the more likely he is to have a shorter life span. This is common sense. For example, if a person has trouble swallowing or can’t exercise at all post-injury, he will more likely have medical complications earlier on in life than someone who can move around, stay physically healthy, and swallow without problems.

Medical evidence also suggests that after a moderate or severe brain injury, a person is more likely to develop Parkinson’s disease or Parkinson-like symptoms. The same is true for the development of dementia. That being said, the medical evidence to date shows an association between brain injury and these problems, not a direct cause and effect.

For people with a mild brain injury, there is little evidence of any association between brain injury and developing Parkinson’s or early-onset dementia.

Are there symptoms to watch for? If so, which ones in particular?

That is a tough question because everyone is different. Symptoms can differ across the board but can include anything from depression to problems with balance. But if a person has more significant physical or cognitive problems that resulted from a moderate or severe brain injury, he should get checked by his doctor on a regular basis, meaning once or twice a year; and his doctor should be someone who specializes in or has experience with traumatic brain injury.

People with what’s called “complicated mild brain injury” — a mild brain injury with symptoms that don’t resolve quickly or that remain chronic — should also check in with their doctor periodically.

What can people do to protect their health after a brain injury? Are there long-term health problems that may crop up?

This is an important question because people who live with long-term effects from brain injury often forget that they have other parts of their bodies to look after. Everyone — with or without a brain injury — should do “upkeep” tests like pap smears and mammograms for women, prostate exams for men, colonoscopies at 50 years old, cholesterol checks, and so forth. They should also maintain a good diet and fitness regimen.

It’s easy for people with brain injury to focus solely on their brain and the long-term issues that persist from their injury; however, it’s crucial not to forget about the rest of the body.

A person with brain injury should also make sure his doctor keeps signs and symptoms of Parkinson’s disease and early-onset dementia on the radar screen. Again, brain injury is not a cause of these other diseases, rather an association.

How does a brain injury affect cognitive issues as a person ages?

This has not been well studied at all and is difficult to answer. Some studies suggest that people with moderate to severe brain injury have accelerated cognitive decline as they age. But, again, this has not been proven.

Ideally, we need to have a long-term study that looks at how brain injury affects cognition as a person gets older. For example, if we could study the cognitive skills of people with brain injury versus those without brain injury at 30 years of age and then at 60 years of age, we would probably learn a great deal. However, that kind of study is almost impossible because it is hard to follow people for so many years.

That said, people with brain injury, especially those with long-term cognitive issues, should stay in touch with their doctor, preferably a physician knowledgeable about brain injury.

How does a brain injury affect physical issues as a person ages?

Folks with brain injury who have chronic problems with balance, for example, may need to schedule periodic sessions with a physical therapist or an occupational therapist. Sometimes these “tune ups” bring people back to a safer level of function. As we get older, our sensory system changes, more so for people who may have had their sensory system disrupted or damaged from a brain injury. Therefore, we need to pay more attention to how we move and do things. Balance can get worse and our bones and muscles weaker, making it harder to move safely through the world. So, getting a therapy here and there can be incredibly helpful not just physically but also emotionally, for one’s self-confidence.

How does a brain injury affect emotional or behavioral issues as a person ages?

Behavioral problems are part of what separates people with brain injury from others in rehabilitation medicine. Many behavioral and emotional problems that are a result of a brain injury can be chronic, and the severity of these problems can fluctuate over time. Depression is a significant risk. Anxiety and other mood disorders can also persist. People who have a hard time multitasking or concentrating tend to be vulnerable to frustration, anger, and depression.

We are not sure if the risk of these types of emotional or behavioral issues ever goes away entirely after a brain injury. Data show, for example, that there is an increased risk of depression for people with brain injury even years after an injury.

What do you tell people who are concerned about developing Alzheimer’s disease or early-onset dementia after a brain injury?

We definitely don’t know all the answers about Alzheimer’s disease, especially as it relates to brain injury. There is ongoing research on many fronts related to Alzheimer’s, but, to date, we don’t have any definitive answers. However, studies suggest that there is an association between genetics and developing the disease and between brain injury and developing the disease. Again, there is an association with severe brain injury, not a cause and effect. That is an important distinction.

It’s important to remember that most people in general do not get Alzheimer’s. The best thing to do is to stay focused on staying physically active, socializing with supportive friends and family, getting out and staying involved in the world, and keeping our minds sharp and engaged.

More and more studies are being conducted about contact sports and progressive brain injury. What is chronic traumatic encephalopathy, and what should we be doing to protect young athletes?

For years, we have known about a type of neurodegenerative disease that may affect amateur and professional boxers, known as dementia pugilistica. Symptoms and signs of dementia pugilistica can develop progressively over a long period of time. Chronic traumatic encephalopathy, or CTE, may be similar and may be seen in more and more athletes who play contact sports like football or ice hockey. How much can the brain take, after all? It makes sense that a football player who is hit time and time again and who suffers multiple concussions could develop some sort of neurological trauma. The research that is being done on CTE is important, but it needs to be followed up with more research.

I think the increased awareness about traumatic brain injury is very helpful as is the awareness that a person doesn’t have to lose consciousness to sustain a concussion. This awareness will help everyone — from young athletes and coaches to soldiers serving in Iraq and Afghanistan. Everyone, including healthcare professionals at all levels, needs to know that brain injury is not necessarily a benign event and sometimes symptoms do not go away.

How long do you follow up with a patient after a brain injury?

For most of my patients, they remain my patients for life. I never discharge them. For those with moderate to severe brain injury, once their active rehab or restorative therapy is over, I follow up with them approximately one to two times a year. When they are still in rehab, I am actively involved and check in with them about once a month or so.

For my patients with mild brain injury — unless they make a full recovery and are symptom-free within the first three months post-injury — I also follow up with them once or twice a year.

I find it important to follow up once or twice a year with patients to make sure the therapy and/or medications are still appropriate for them. For example, a patient may no longer need the same amount of an anti-depressant or a sleep aide as his life settles back into a new normal. Or maybe a patient needs more physical therapy for balance or strength. Recovery is a life-long endeavor for many people with brain injury, and we want to make sure they are getting the right care at every step along the way.

What type of long-term medical follow-up do you recommend for people with brain injury? Which specialists should they see, and how often?

When necessary, I refer my patients to specialists like endocrinologists, psychiatrists, or neurologists. I also make sure that all my patients have a primary care doctor to ensure that they are doing the “regular” health maintenance checks like cholesterol tests, pap smears, and colonoscopies.

Why is long-term follow up important for people with brain injury?

In a nutshell, long-term follow up is important for people with brain injury because they can be more susceptible to the effects of aging, like depression or physical and cognitive changes that naturally come with age.

Does having a brain injury put a person at greater risk for other health problems? Of dying at a younger age?

Depending on the severity of the injury and the associated long-term consequences, some people may be at risk for certain health problems. Certainly, if people are less physically active or emotionally unhealthy, they are more susceptible to age-related effects — from problems with balance to depression. The stronger people’s bodies, minds, and spirits are — whether they have a brain injury or not — the more effectively they will postpone the effects of aging … and enjoy life.

Dr. Steven Flanagan is professor and chairman of the Department of Rehabilitation Medicine, New York University School of Medicine, and the medical director of the Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center. He has served on medical advisory boards of many national and international committees and has presented at scientific meetings both nationally and internationally, most notably on topics pertaining to brain injury rehabilitation.

Posted on BrainLine December 22, 2009. Reviewed July 27, 2018.


Comments (115)

Dr. Flanagan states that "...for most patient they remain my patients for life. I never discharge them." He should add to that,"....unless their insurance runs out and they're too hell bent on recovery that they refuse to apply for SSI or Medicaid." I suffered a TBI in June of 1988. I was in a coma for 5 days, in the hospital of S.I. for a month, and treated at the Rusk Institute/NYU Medical Center for about 5 to 10 years or so. Pardon me for my bad memory of exact details due to TBI. I had a excellent memory before my accident, but I lost that along with many other things. I do remember that I used to go there every day for a long time. I use to see all kinds of doctors and therapists. There was Dr. Ahn, the head neurosurgeon I think, then Dr. Protomastro, Dr. Kaplan. And therapists including Dora Blacker and Bob something or another, (forgive me for messing up the names a little bit, there were other doctors and therapists I seen, but my memory fails me. It was a long time ago, and I was mentally Lost in Space at that time) I thank them for their help, and I did come a long way when I was treated there. I also made a couple of friends in group therapy sessions that I still keep in touch with till this day. But except for maybe a email or two from Dr. Promastro (Who was the best!) I think, No staff at Rusk has ever contacted me. What it seemed to me that once my insurance ran out, I was just told that there was nothing more they could do for me, there's the exit, good luck and goodbye!
It's so interesting to read other people's experiences and recovery observations regarding TBI. I was 17, in a car accident, thrown into rock ledge face first. Massive hematoma at base of brain, 25 burr holes drilled into head (yes, they shaved my long, long hair!) 5 weeks in a coma, paralasis on my left side, left eye nerve damage (legally blind in left eye)and I lack a visual focal point, so I see two of everything. My biggest challenge was denial. I simply didn't want to be disabled. Luckily, in about 5 years I recovered to a relatively normal 22 year old. Graduated college 4 times, married, had kids, opened a business. Fast forward to 57, I'm divorced, unemployed, on disability, and struggling. It's difficult to concentrate, difficult to read, difficult to write. My memory is amazing, and I practice memory challenges. I see the diminishing ability I have with multi-tasking, concentration, learning new things. I'm very healthy, take zero meds. I do supplement my diet with Fish oil, vitamin D, magnesium, and Lysine. My balance is a little skewed, but I manage. My email:, and I welcome anyone to contact me with questions or share ideas, experiences. HUGS>Melanie
Thank you so much for this Q&A Session. How I wish my father had you for a doctor. My father's doctor discharged him as soon as he completed rehab. It would be so nice to have a doctor that stuck by him and made an effort to prevent "back sliding". The idea of letting a person "backslide" when therapy stops for lack of mark-able progress is giving up. I have studied, research and collaborated with other well educated people. The consensus is those with TBI can prevent and/or slow the loss of progress as long as therapy is continued and on-going. Telling a grown man with tbi to exercise daily for his own good and him actually doing it are two different things. Again thank you for this article!!
I had my first major tbi at 18 mos. it impacted my vision, as a child I was always called irritable and was made fun of a lot. The appeared to be no concern about head injuries and the effect they have on the brain. At 34 yrs I had my second major head injury. Again, not much concern was taken. I did have a good Dr. and was referred to a neurologist. It wasn't until decades later that I was given the correct anti-depressants and sleep medication. My current doctor does not seem to be able to connect the dots between my health problems and the tbi. It is good to see there is a place to turn. After, many years of complaining about feeling tired I asked my doctor to check my thyroid. His tests came back as normal. I almost had to demand to see an endo doctor. His tests show my thyroid was not working correctly. I tried to explain the head injury and if my health problems were caused by the injury. No one seemed to hear me. Now, I have the correct medication and I am slowly getting some energy back. I have arthritis in several places and had to have a knee replacement, which good have been avoided if I was given the hormones I needed. So thank you, for bringing the tbi out in the open. Now, if I could get my family to understand, I would be much happier.
I'm a Vietnam vet and for years after the service I'd get what I thought and was treated for, were "sinus Headaches" but have since been defined as migraines.I hit a mine driving a tank in Vietnam and have a slight hearing loss.In the last 2 years or so I have been having daily migraines and have gone through a pyramid of medications,one of which,gabapentin temporarily took my memory away to the point psychological tests determined that it appeared I had a lesion in the right hemisphere of my brain. I also had a colloid cyste removed from the foremon of munro in 2003. I'm wondering if these migraines could be delayed TBI symptoms and where do I go from here.
I am 23 post injury and I had questions this is and will be very informative about my injury.
I myself am a 33 year TBI; accident on 12/06/1978; comatose for 5 weeks; Author of the book, How I Became A Fearless Woman.
A family member is now 27 years post severe traumatic brain injury (incl. 72 hrs in coma, seizures, a second hospitalization, dilanton therapy, etc). While I continue to urge appropriate medical followup, I am witness a serious LACK of such by medical professionals. There has been NO MRI since the original injury in 1984, there has been NO referrals for specialist care, and no provision of resource materials. Now 27 years post injury and manifesting various commonly identified behavioral issues such as cognitive decline, suicial ideation, peristent depression, lack of ability to multitask, frequent agitation, my family member has also lost marriage relationship, home of 17 years & ability to work full time. The greatest irony here is HIPPA laws prevent the family physican from hearing/discussing my concerns while my family member remains hindered and even medically neglected as congitive declines hinder persuit of necessary followup. More antidepressants and sleep meds are the only prescriptions given. I am enormously concerned and I do not understand this system or the lack of appropriate treatment.
My husband was 50 when he had his colloid cyst resection. He's now 52 and has cognitive deficits from permanent brain damage. He goes to a psychiatrist for mood and sleep disorders. It is trial and error with the medication and what does/doesn't work. I stumbled upon this article and found it to be most helpful and supportive. I have had people tell me to put him in an institution. I think these people are wrong. He has good quality of life in his home with me being in the community and having his friends and family around.
im 42 and my TBI happened at 16...i feel that the lack of awareness on my part; playing rugby in college (a few concussion), multiple car accident, drug n alcohol abuse; may have a more significant impact to my future than i imagined. Honestly speaking i never thought i'd still be alive today and never really managed to create a map for my life. Thanks to this article i am more aware of my situation for the future.
I had a severe TBI 22-years ago and find word finding problems getting worse and concentration. IT just made sense to me when I got hurt that the natural aging process and the confusion that goes along with getting older would come harder and sooner. I am 52 years old now, my physichiatrist prescribed valproic acid for me to help me cope with my 9-year old son and it has made a signifacant difference in my ability to think which lowers my frustration. This has made it possible for me to be the father I am trying to be. With out the research common sense tells us if we have the cognitive ability of a 60-year old at 30 becasue of a TBI. I remeber the first time I drove a car at he rahab hopital, I was as confused at the intersection just like my 60-year old father.
I came across this site seeking answers some kind of movement forward. I read this one gal being 53 and 17 months since her tbi occurrence, I was thinking how close in age we are and the same months have passed since this happening to us. I'm 54 and now its been also 17-months. The truth is the Doctors say 70% is a good comeback, well since I'm always in pursuit to ce day one I have said NO you see I want 110% :)
It has almost been 18 months since my major TBI. I have not been to a doctor for a year now. I keep looking for answers. I am healthy! I am 53 years old & stay happy running! I am also looking for answers. Please send me any tips to keep me getting better. What should I be doing?
similar to the 1st comment I too have had two incidents of brain injury - the 1st a car accident at 17 and the 2nd meningitis when I was 52. I am very fortunate in that I have a loving family and am gainfully employed. I too get frustrated now and then. I would be interested in talking to the person who wrote the 1st comment and had 2 incidents of TBI.
I found this article interesting in that my husband has suffered two headinjuries in his life, at 19 and then again at 39. He is now 61. We have had little support so it is interesting to read things from time to time. He is happy enough but I find things quite frustrating at times!!