Resilience in Older Adults Following Mild-to-Moderate Traumatic Brain Injury (TBI)

Abstract

Abstract Resilience in Older Adults Following Mild-to-Moderate Traumatic Brain Injury (TBI) Premgamon Kuntajak Chair of the Supervisory CommitteeHilaire J. Thompson Department of Biobehavioral Nursing and Health Informatics Background: Traumatic brain injury (TBI) in older adults is associated with prolonged recovery and poorer functional, cognitive, and psychosocial outcomes. Resilience may support positive adaptation to TBI and its chronic sequelae; however, the concept remains unclear in this population, and evidence on the multilevel factors that foster resilience and its relationship to health outcomes in older adults with TBI remains understudied. Purpose: This dissertation aimed to (1) clarify the concept of resilience in older adults with TBI, (2) identify multilevel factors associated with resilience and examine its associations with health outcomes, and (3) explore how older adults experience these multilevel factors in shaping resilience postinjury. Methods: A concept analysis using Walker and Avant's method was conducted, examining 23 peer-reviewed articles. A convergent mixed-methods study enrolled adults aged ≥ 55 years one year after hospitalization for mild-to-moderate TBI at a Level I trauma center. Quantitative measures included resilience (25-item Connor-Davidson Resilience Scale; CD-RISC-25), spirituality (Spirituality Perspective Scale; SPS), social support (Medical Outcomes Study Social Support; MOS-SSS), built environment (Social Vulnerability Index; SVI), subjective health-related quality of life (36 Item Short Form Survey Instrument; SF-36), and Objective functional outcomes measured (Glasgow Outcome Scale-Extended; GOSE). Semi-structured interviews were thematically analyzed; extreme-case sampling was used to compare the lowest (Q1; n = 15) and highest (Q4; n = 13) resilience quartiles. The two datasets were then integrated. Results: Resilience in older adults with TBI is defined as a dynamic, developmental, and continuous process of positive adaptation that harnesses personal and socioecological resources in response to TBI and its situational and cumulative effects. The mixed-methods study enrolled 57 older adults with TBI. In quantitative analyses (n=57), both spirituality (β = 0.45, 95% CI [0.23, 0.67], p < .001) and social support (β = 0.26, 95% CI [0.09, 0.42], p = .003) were significantly and positively associated with resilience after adjusting for sex. Higher resilience was associated with better physical and mental health-related quality of life (PCS: β = 0.23, 95% CI [0.03, 0.43], p = .025; MCS: β = 0.25, 95% CI [0.07, 0.42], p = .006). In qualitative thematic analysis (n=26), resilience was shaped by cognitive appraisal of the injury and its sequelae, mobilizing lived experience to construct meaning and grow through adversity, engaging with multilayered social support and upstream structural factors to facilitate recovery, and cultivating a positive outlook and goal attainment. In the mixed-methods analysis (n=28), the integrated findings confirmed as well as expanded on how multilevel factors shape resilience across the highest (Q4) and lowest (Q1) resilience quartiles. For spirituality, Q4 had significantly higher spirituality scores than Q1 on both Spiritual Beliefs (10.1 points higher, 95% CI [3.10, 17.1], t(21.8) = 2.99, p = .007) and Spiritual Behaviors (6.60 points higher, 95% CI [1.83, 11.4], t(23.8) = 2.86, p = .009). The two groups were distinguished by spiritual communal embeddedness, which supported cognitive appraisal of injury and extended social support networks. For social support, Q4 had higher social support than Q1 across all MOS-SSS subscales, with the largest statistically significant difference on emotional support (24.7 points higher, 95% CI [9.64, 39.8], t(23.8) = 3.38, p = .002). The availability of tangible and emotional support distinguished the two groups. For the built environment, although Q4 resided in census tracts with slightly lower SVI than those residing in Q1, this difference was not statistically significant (mean difference = -0.07, 95% CI [-0.30, 0.15]), t(25.9) = -0.67, p = .507). The two groups were distinguished by patient-provider relationships and active engagement in care, which supported continuity of care and recovery. Conclusion: Resilience in older adults with TBI emerges through a dynamic interplay across nested levels of individual, interpersonal, and structural resources rather than residing at any single level. Goal attainment and lived experience represent novel, population-specific resources that clinicians can target to foster recovery.