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

We read with great interest the article “Functional Decline and Loss of Independence After Traumatic Injury in Older Adults with Dementia” recently published in the Journal of the American Geriatrics Society [1]. The study provides important insight into long-term functional outcomes following traumatic injury in older adults with dementia. Given the increasing prevalence of dementia and the high burden of trauma-related morbidity in older adults, identifying factors associated with postinjury functional decline is highly relevant for geriatric clinical practice. We would like to appreciate this valuable study and make some contributions to the discussion. First of all, we think that the absence of information regarding dementia severity both at baseline and follow-up assessment is an important limitation. Functional trajectories in individuals with dementia are strongly influenced by disease stage, and patients with advanced dementia may already exhibit substantial functional dependence before trauma [2]. Without adjustment for baseline dementia severity, it may be difficult to distinguish trauma-related decline from the underlying progression of neurodegenerative disease. Second, although injury severity was assessed using the Injury Severity Score (ISS), this metric primarily reflects overall trauma burden and may not fully capture the differential functional impact of injuries involving specific anatomical regions. In older adults with dementia, the localization of trauma may be particularly relevant because diminished neurological and cognitive reserve increases vulnerability to central nervous system injuries. Even relatively mild head trauma may exacerbate cognitive impairment, balance disturbances, and functional dependency in individuals with underlying neurodegenerative disease [3, 4]. Evaluating functional outcomes according to injury location—particularly head and neck trauma—may therefore provide additional insight into the mechanisms contributing to functional decline in this population. There is a need for a scale assessing the location and the severity of the injury rather than the number of injured areas. Third, functional outcomes were evaluated through telephone interviews at 6 and 12 months with either patients or proxy respondents. While this approach is common in longitudinal geriatric research, it may introduce measurement bias. Individuals with dementia frequently demonstrate anosognosia, meaning reduced awareness of their functional limitations, which may affect the accuracy of self-reported outcomes [5]. In contrast, proxy respondents may unintentionally overestimate or underestimate functional impairment, a phenomenon widely recognized in studies relying on caregiver-reported data [6]. These factors may influence the reliability of reported functional decline and loss of independence. Follow-up assessment using an objective scale may give more insight about this issue in further studies. Finally, older trauma survivors frequently experience intercurrent conditions such as infections, metabolic disturbances, or delirium [7]. These time-varying clinical factors may complicate the causal interpretation of functional outcomes after trauma. Telephone interview may not be enough to address these issues. Analytical approaches that account for such factors—such as longitudinal modeling or repeated functional assessments—may help better distinguish trauma-related decline from the natural course of dementia and other clinical events. In conclusion, this study contributes valuable data on functional outcomes after traumatic injury in older adults with dementia. Incorporating injury location–specific analyses together with key clinical factors such as dementia severity and delirium may help further clarify the complex relationship between traumatic injury and long-term functional decline in this vulnerable population. We believe future studies focusing on these points can add more comprehensive information to the literature. All authors contributed to the conception, drafting, and critical revision of the manuscript and approved the final version for publication. The authors have nothing to report. No funding was received for this work, and no sponsor had any role in the design, methods, data collection, analysis, or preparation of the manuscript. The authors declare no conflicts of interest. This publication is linked to a related reply by Cohen and Herrera-Escobar. To view this article, visit https://doi.org/10.1111/jgs.70461.