Reply to: Comments on “Functional Outcomes After Trauma in Older Adults With Dementia”

Thank you for the opportunity to write a reply to the commentary published by Kuran et al. on our original research published in the Journal of the American Geriatrics Society [1]. We value the appreciation of our work and its contributions to the literature, as traumatic injury among older adults with dementia remains a significant clinical and research priority. The authors raised several insightful points related to our methodology and measurement that help contextualize our results. We agree that the absence of information regarding dementia severity is an important limitation. Because this study relied on institutional trauma registry data, which is designed for tracking information related to operative procedures, complications, and discharge outcomes, we were unable to access more detailed measures of cognitive impairment experienced. The authors point out that distinguishing trauma-related decline from the underlying progression of dementia is challenging. Our study was informed by intersectionality theory, which suggests that co-occurring vulnerabilities may interact in multiplicative, rather than additive, ways [2]. While both dementia and traumatic injury independently contribute to functional decline [3-5], this paper is framed under the assumption that their intersection may amplify risk beyond what either condition confers alone. Although this was not the original goal of our paper, we believe there is significance in this conceptual framing. Further, the authors highlight the limitations of the Injury Severity Score (ISS), which reflects the overall burden of trauma and may obscure important differences in body-region-specific injury patterns. We agree that this is a potentially important area of investigation, as certain injuries may potentially accelerate underlying neurodegenerative or neuroinflammatory processes implicated in dementia [3]. To explore this further, we conducted additional analyses using the Abbreviated Injury Scale (AIS), which provides injury severity by anatomical region. We found that the only significant difference between patients with and without dementia was in severe extremity injury (extremity AIS ≥ 3) (57.7 vs. 50.3%, p = 0.015). Despite the authors' concerns, we did not find differences between groups in severe head–neck injury rates (head/neck AIS ≥ 3) (28.9 vs. 28.3%, p = 0.828). Including interaction terms between dementia and severe extremity injury in our multivariable models, we observed significant effect modification. Patients with both dementia and severe extremity injury had increased odds of functional decline (OR 2.3, 1.6–3.4, p < 0.001), though this was not significant for loss of community living (OR 2.3, 0.8–7.0, p = 0.144). While ISS remains an imperfect measure for research, given its main clinical use in mortality prediction, it remains widely used in trauma settings and alternatives to this measure better aligned with functional outcomes are limited. Finally, the commentary raises concerns related to our long-term follow-up approach. We acknowledge the reduced ability for individuals with dementia to accurately appraise their own health status, which explains the overwhelming majority of patients in this group having their interviews completed by a family caregiver (78.7%). While the authors point out the potential for bias, caregiver report is often the primary source of functional assessment in this population in real-world clinical settings and reflects the information available to clinicians making decisions about care, discharge planning, and prognosis. Objective Clinician Reported Outcomes (CROs), on the other hand, are not feasible within the trauma setting where follow-up rates beyond the acute recovery period are minimal [6]. The FORTE study represents one of the most robust available data sources for studying long-term patient-reported outcomes after traumatic injury in the United States. Unfortunately, trauma care is not treated as a chronic disease state, and as a result, longitudinal follow-up with repeated functional assessments is uncommon. We believe there is a critical need to treat traumatic injury, particularly in older adult populations, as a chronic condition to better align care delivery and research with the realities of recovery, which often extends well beyond the acute hospitalization period [7]. We are encouraged by models such as ortho-geriatric clinics [8], the Trauma Medical Home model [9], and other combined efforts that represent important steps forward in geriatric trauma care and research. Continued investment in and evaluation of these models will be critical to better understand and address the complex needs of older adults with dementia who experience traumatic injury. J.E.C. contributed to conceptualization, formal analysis, and writing of the original draft. J.P.H.-E. provided supervision and contributed to critical review and editing of the manuscript. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a reply article by Kuran et al. To view this article, visit https://doi.org/10.1111/jgs.70462.