Cognitive-communication difficulties due to traumatic brain injury sustained in adults 55 years and older: A survey of speech-language pathology professional practice in Australia

Abstract

Purpose

Limited research informs management of cognitive-communication difficulties following traumatic brain injury (TBI) in older adulthood. The purpose of this study was to understand the characteristics and practice of speech-language pathologists (SLPs) working with people who sustained TBI at ≥55 years and more specifically their management of cognitive-communication difficulties with this population. This included assessment and treatment practices, resource needs, barriers to practice, and impact to service delivery from COVID-19 restrictions.

Method

A cross-sectional survey-based design with non-probability sampling of SLPs working in Australia with adults with TBI was utilised. Descriptive statistics and content analysis were used for analysis of survey data.

Result

Fifty responses were eligible for inclusion. Participants predominantly worked in inpatient rehabilitation (48%), acute (40%), and community settings (36%). Service delivery to adults who sustained TBI at ≥55 years commonly included cognitive-communication management. Assessment and treatment trends are described. Most SLPs (74%) perceived barriers to cognitive-communication management, often relating to time and funding, that existed prior to the COVID-19 pandemic. Pandemic restrictions presented additional challenges.

Conclusion

Research relating to cognitive-communication difficulties following TBI in older adulthood is required to support evidence-based practice and inform services for older adults who sustain TBI.

Keywords:

• Cognitive-communication
• speech-language pathology
• traumatic brain injury
• older adults

Introduction

Traumatic brain injury (TBI) is complex in nature and can include both diffuse damage and focal injuries (Povlishock & Katz, 2005). Primary research studies into this complex condition have historically focused on younger adults with TBI (Gaastra et al., 2016). This is out of step with epidemiological trends that indicate TBI increases in older adulthood and places significant demands on healthcare systems (Centers for Disease Control and Prevention, 2019, 2021).

The Centers for Disease Control and Prevention (CDC) provides large-scale surveillance reports for TBI in the USA. Data from 2014 showed that individuals aged 75 years and older had the highest overall estimated incidence of emergency department care, hospitalisation, and death from TBI (CDC, 2019). This was followed by children 0–4 years and those aged 15–24 years (CDC, 2019). However, trends for hospitalisations with TBI indicate that TBI is also an issue of concern for individuals from early periods of older adulthood (CDC, 2019, 2021). Recent data from 2017 showed that adults aged 75 years and older had an estimated incidence of hospitalisation with TBI of 320.8 per 100 000 population, which was far in excess of all other age groups (CDC, 2021). Although not as pronounced, the next highest estimated rate of TBI related hospitalisation was seen in adults aged 65–74 years (102.7 per 100 000) followed by those aged 55–64 years (67.5 per 100 000; CDC, 2021). Further, single site research in Australia has shown a similar number of annual admissions of adults aged 55 years and older for inpatient rehabilitation with TBI to adults aged 18–54 years (Shorland et al., 2022).

It appears relatively common for older adults to be discharged home from inpatient settings following TBI (Hawley et al., 2017; Shorland et al., 2022). In comparison, not as many older adults are discharged into residential aged care following hospitalisation with TBI (Hawley et al., 2017; Shorland et al., 2022). However, discharge from acute care to residential aged care has been shown as more common for adults aged 85 years and older than those in earlier periods of older adulthood (Hawley et al., 2017). Given the prevalence and complexity of TBI in older adulthood, services for this population need to be considered across the continuum of care, including inpatient, community, and residential aged care settings.

Researchers emphasise the need for healthcare systems to direct rehabilitation resources towards the long-standing challenges of TBI, such as cognitive, communication, and behavioural difficulties (Ponsford et al., 2014). Difficulties with cognitive-communication are one of these long-standing challenges that can follow TBI. Impairments to cognitive processes, such as speed of processing, attention, memory, executive functioning, and social cognition may affect aspects of communication function (MacDonald, 2017). Cognitive-communication difficulties can impact upon aspects of everyday functioning, including social and professional communication (MacDonald, 2017). The exact incidence rate of post-TBI cognitive-communication difficulties is unclear. However, single site research has shown that 73% of rehabilitation inpatients with TBI who saw a speech-language pathologist (SLP) were identified as having cognitive-communication difficulties, with no significant difference in prevalence between younger and older adults (Shorland et al., 2022).

Despite the prevalence of TBI in older adult populations and post-TBI cognitive-communication difficulties having potential to affect adults of all ages, little is known about cognitive-communication outcome and management following TBI sustained by adults aged 55 years and older (Shorland et al., 2020). The shortage of research in this area presents challenges for clinicians aiming to deliver evidenced-based care to older adults following TBI, especially given the nuances of the TBI population who are injured in older adulthood (Shorland et al., 2020).

These age related nuances include the mechanisms and nature of TBI. Of all age groups, hospitalisation for TBI subsequent to falls has been shown to be most common in adults aged 75 years and older, followed by adults aged 65–74 years, and then those aged 55–64 years (CDC, 2021). In contrast, individuals aged 15–24 years and 25–34 years have the highest rates of hospitalisation with TBI secondary to motor vehicle accidents (CDC, 2021). In addition, research utilising MRI findings has indicated that TBI can have a more adverse impact on the brain in older than younger adults (Schönberger et al., 2009).

Research also suggests that younger and older adults who sustain TBI have different recovery trends and needs in rehabilitation. For example, research relating to acute inpatient rehabilitation admissions throughout the USA showed that adults aged 55 years and older had a similar mean functional improvement across their inpatient stay to adults aged 18–44 years who were matched for TBI severity. However, the older group improved at a slower pace and had a significantly more compromised level of functional performance on admission and discharge (Frankel et al., 2006).

When considering domain-specific outcome, age appears to have some influence on cognitive recovery following TBI. For example, older age was shown to be associated with poorer early recovery of executive functioning and processing speed in a relatively young cohort of adults (mean age = 35.2 years; SD = 15.0) with moderate to severe TBI (Rabinowitz et al., 2018). The authors of this study hypothesised that this may relate to the vulnerability of these cognitive functions due to natural ageing processes (Rabinowitz et al., 2018). Domain-specific cognitive change can commence from a young age within the context of healthy ageing (Salthouse, 2019). For example, processing speed shows a steady rate of decline from the third decade (Salthouse, 2019). Episodic memory and reasoning have been shown to decline in small increments from young adulthood, with more rapid drops in performance on cognitive assessments in these domains shown from the mid-sixties (Salthouse, 2019). Changes to communication processes, such as pragmatic language, can also be subject to change with healthy ageing (Messer, 2015). The potential influence of healthy ageing on premorbid cognition and communication is an important consideration for SLPs working with adults following TBI.

Premorbid neurological conditions can also become more of a consideration with increasing older age. For example, in a study of adults aged 65 years and older admitted to a UK trauma centre over a six-year period following TBI, 11% were reported to have dementia (Hawley et al., 2017). This type of finding is also noteworthy for SLPs working with individuals who sustain TBI in advancing older adulthood, as dementia and other neurological conditions can negatively impact communicative function.

SLPs have a pivotal role in supporting individuals with post-TBI cognitive-communication difficulty (Togher et al., 2014). SLPs in Australia work with adults with acquired brain injuries across domains that include cognitive-communication, motor speech, voice, language, swallowing, and counselling (Speech Pathology Australia, 2015). Australia’s health system is delivered through both public and private healthcare. The healthcare system includes acute and subacute hospitals, outpatient centres, and community health services (Australian Institute of Health and Welfare, 2018). SLPs work with adults with TBI across these sectors and settings. Research highlights that cognitive-communication clinical service delivery to TBI populations can be a challenging area of practice in which SLPs require additional education and resources (Behn et al., 2020; Frith et al., 2014; Morrow et al., 2020; Riedeman & Turkstra, 2018). Further, COVID-19 and pandemic related restrictions have added layers of consideration and complexity to speech-language pathology service delivery (Chadd et al., 2021) and to healthcare delivery to older adults (e.g. Brotto et al., 2021).

Given the age related differences of adults who sustain TBI and the limited research data to guide clinical practice with older adults with post-TBI cognitive-communication difficulties (Shorland et al., 2020), an important step in building the evidence base is to understand current SLP practice with adults of increasing older age. Gaining an understanding of which SLPs work with older adults following TBI, where they work in the care pathway, and how they deliver services to the older adult TBI population is needed to better understand how older adults are receiving support from SLPs following TBI. Drilling down to examine how post-TBI cognitive-communicative difficulties are managed with older adults, and the impact of COVID-19 on service provision, would also afford specific understanding and future direction in this unexplored area.

The aims of this study were to understand the characteristics and practice of SLPs who work in Australia with individuals who sustained TBI in older adulthood, and to examine how these SLPs manage post-TBI cognitive-communication difficulties with this population. The specific research questions in relation to SLPs who work in Australia with adults who sustained TBI in older adulthood were:

• What are their practice settings and characteristics?

• Which clinical services do they provide to this population?

• What are their practice patterns relating to the provisions of clinical services for cognitive-communication competence to this population?

• Do they identify any barriers to providing clinical services for cognitive-communication difficulties to this population?

•  ^ Did restrictions relating to COVID-19 impact on clinical service delivery to this population?

Method

A cross-sectional online anonymous survey-based design was used to investigate the characteristics and practice of SLPs working with older adults with TBI in Australia. Ethics approval for this study was obtained from the La Trobe University Human Ethics Committee (HEC20446).

Participants and recruitment

Given there is no national index of SLPs working in TBI in Australia, this survey was conducted using non-probability sampling (Fricker, 2017). Specifically, SLPs who worked in Australia with adults (≥18 years) with TBI as part of their clinical caseload within the 24 months prior to any COVID-19 restrictions in their state or territory were invited to participate in this voluntary online survey. During the survey open time, Australia was subject to COVID-19 restrictions. The nature and timing of restrictions varied between the states and territories. Given restrictions may have had an impact on clinical service provision, participants were asked to respond to the majority of questions in terms of their pre-COVID-19 practice so responses were not influenced by differing degrees of restrictions. At the end of the survey, participants were presented with questions relating to any changes to their management of post-TBI cognitive-communication difficulty with this population as a result of pandemic restrictions. We required participants to have had some experience working with people with TBI prior to COVID-19 restrictions in order that they could reflect on this practice.

To gain a broad representation of current practice and perceptions, the survey was open to SLPs working in any setting with no limits placed on years of experience or proportion of specific experience working with TBI populations. As is described below, for the purposes of this study responses were only included from participants who had provided speech-language pathology clinical services to at least one adult who was aged 55 years or older at the time of sustaining a TBI. Older adulthood is ill-defined in TBI research, as has been acknowledged within reviews of literature relating to post-TBI cognitive outcomes (e.g. An & Monette, 2018). The lower point of older adulthood was defined as 55 years in this study to gain a broad understanding of cognitive-communication service provision to adults who sustain TBI at periods of increasing older age. This focus from an early older age allowed consideration of trends across the peak incidence age groups for hospitalisation with TBI (CDC, 2021).

The survey was distributed with a generic survey link through advertisements in Speech Pathology Australia’s National eNews, and postings on relevant Google Groups (the Australasian Society for the Study of Brain Impairment’s Brain Impairment Clinician and Researcher Peer Network [BRAINSPaN]; Speech Pathology Email Chats [SPECS]) and social media platforms (e.g. Twitter). Email invitations were also distributed to clinical interest groups through coordinators and convenors (e.g. Speech Pathologists in Adult Rehabilitation [SPAR], and Psycholinguistics in Practice [PIP-SIG]) and through health care networks and clinicians working in the area of TBI across Australia.

Snowball sampling through the provision of a survey link for participants to forward on to other SLPs working with adults with TBI was used to further increase the distribution of the survey. The survey remained open for three months (November 2020–February 2021). Generic survey reminders were utilised during this time period. No incentives were provided for participation. No information was sought about who chose to complete the survey following distribution of the link and no identifying information or IP addresses were collected. Confidentiality measures meant the participation rate could not be ascertained.

Data collection – survey design

The survey was purposefully designed for this study. Survey questions regarding practice setting and sector were informed by literature relating to the Australian health care system and speech pathology scope of practice (e.g. Australian Institute of Health and Welfare, 2018; Speech Pathology Australia, 2015). Questions relating to speech-language pathology service delivery were informed by a review of the literature relating to SLP practice within the area of TBI and with older adult populations as well as evidence relating to management of cognitive-communication difficulties following TBI. This survey included questions on SLP practice patterns in swallowing, general counselling and support related to brain injury, and the broad area of communication management (e.g. motor speech, language, voice, and cognitive-communication) as well as specific questions relating to cognitive-communication management in order to place speech-language pathology service provision for cognitive-communication management in context.

The survey was built and managed with REDCap (Research Electronic Data Capture; Harris et al., 2009). REDCap is a secure, web-based application designed to support the collection of research data (Harris et al., 2009). To ensure quality of this survey, the design and reporting were based on recommendations in The Checklist for Reporting Results of Internet E-Surveys (Eysenbach, 2004). The survey was piloted on two members of the research team (JD and ROH; >15 years' research experience) and three SLPs not involved in the research who had experience working clinically across various settings with adults with acquired brain injury (8–13 years). Feedback was sought and minor adjustments made to instructions and questions to enhance ease of completion and clarity.

Online consent was obtained from participants and eligibility confirmed prior to commencement of the survey. The entire survey contained 29 questions and five main content sections; however, the number of questions presented to each participant depended on their individual responses. Adaptive questioning, or the presentation of additional questions based on a responder’s response to a previous question (Eysenbach, 2004), was used to streamline the survey experience. This was applied through online branching logic. The survey primarily included closed questions, with some open questions and a rating scale. All questions required a response in order for the participant to proceed to the next section, with the exception of open-ended free-text questions. Survey completion time was approximately 15 min; however, completion times were not recorded.

The survey included broad questions about SLP characteristics, qualifications, experience, and practice with adults with TBI. It then included questions on whether the participant had provided SLP clinical services to at least one adult who was aged 55 years or older at the time of sustaining a TBI within the 24 months prior to any COVID-19 restrictions; practice settings worked with this population; the proportion of this population on the participants’ TBI caseload; age ranges within this population seen; types of SLP clinical services provided to this population; and detail on assessment and treatment of cognitive-communication, as well as perceived resource needs and any barriers to this work. In addition, any impact of COVID-19 related restrictions on cognitive-communication service delivery was explored. Data relating to professional practice with adults who sustain TBI at 55 years and older are reported on in this study (see Supplementary Materials).

A definition of cognitive-communication difficulties was provided at the beginning of relevant survey sections. This was informed by literature relating to SLP practice and cognitive-communication difficulties (College of Audiologists and Speech-Language Pathologists of Ontario, 2015; MacDonald, 2017; Togher et al., 2013) and was as follows:

For the purposes of this survey cognitive-communication difficulties refer to a range of challenges with communication impacted by impaired cognition as a result of TBI. Impairments to cognitive processes, such as speed of processing, attention, memory, executive functioning and social cognition may affect areas of communication function including expression, comprehension, reading and writing. Difficulties could include, but are not limited to, challenges with pragmatic language functions, social communication, discourse level communication (spoken or written) and facial and vocal emotion recognition. For the purposes of this survey, cognitive-communication difficulties are not considered to include aphasia, apraxia or dysarthria.

Data analysis

Data were exported from REDCap into Microsoft Excel for data cleaning. Surveys were manually reviewed for any duplicate responses and checked for completeness. For the purposes of analysis, surveys were excluded if not completed far enough to indicate whether the participant had provided SLP clinical services to at least one adult who was aged 55 years or older at the time of sustaining a TBI within the 24 months prior to any COVID-19 restrictions in their state or territory, or if the participant indicated that they did not provide these services to anyone in this population within this timeframe.

Given the exploratory nature of this study, descriptive statistics were used (Scheel et al., 2021). This included counts, percentages, range, mean, and standard deviation to describe findings. Descriptive analysis was conducted in SPSS (IBM SPSS Statistics version 27; IBM Corp., Armonk, NY). Inductive content analysis (Kondracki et al., 2002) was used to analyse the free text responses that were appropriate for qualitative analysis. Meaningful units of text were coded and brought into categories by the first author. Analysis was reviewed by the other two members of the research team and team discussions were held to obtain consensus on analytical logic. Although content analysis was limited by the small amount of appropriate qualitative data generated by the survey, this method was used to augment descriptive findings.

Result

A total of 59 surveys were received. One survey was excluded as the participant had not worked with adults of any age with TBI during the 24 months prior to any COVID-19 related restrictions. Another survey was excluded as the participant had not worked with any adults aged 55 years or older at the time of sustaining a TBI during this timeframe. In addition, seven surveys were excluded as the participants did not complete the survey to the point of indicating if they had provided speech-language pathology services to the defined older adult TBI population.

The total number of responses eligible for inclusion was 50. This included 14 surveys where the participants did complete the survey until the required point for inclusion, but did not complete all subsequent questions relevant to their situation, and 36 fully completed surveys. The count for response rate (with the denominator being the total number of respondents for that question) along with percentages is presented in parentheses where appropriate. For some survey questions more than one response was possible (as indicated in Tables I–V). For this reason, total percentages reported may be greater than 100%.

Table I. Characteristics and practice settings of speech-language pathologists working with adults who sustain traumatic brain injury at ≥55 years (n = 50).

Variables	n (%)
Highest level of education obtained
Bachelor	19 (38.00%)
Postgraduate certificate/diploma	3 (6.00%)
Masters by coursework	24 (48.00%)
Masters by research	4 (8.00%)
PhD	0 (0.00%)
Years since graduated with speech-language pathology qualification
5 years or less	11 (22.00%)
6–10 years	14 (28.00%)
11–15 years	8 (16.00%)
16–20 years	10 (20.00%)
More than 20 years	7 (14.00%)
Years worked with adults with TBI as part of caseload
5 years or less	18 (36.00%)
6–10 years	15 (30.00%)
11–15 years	8 (16.00%)
16–20 years	5 (10.00%)
More than 20 years	4 (8.00%)
Practice settings with adults who sustained TBI at ≥55 years in the 24 months prior to any COVID-19 restrictions^a
Acute setting	20 (40.00%)
Inpatient rehabilitation	24 (48.00%)
Specialist brain injury unit	8 (16.00%)
Outpatient setting	8 (16.00%)
Community setting	18 (36.00%)
Residential aged care setting	7 (14.00%)
Other setting	0 (0.00%)
Two or more settings	26 (52.00%)
Sector^a
Public	37 (74.00%)
Private	12 (24.00%)
Other	1 (2.00%)
Geographical setting^a
Metropolitan (population of 100 000 or more)	41 (82.00%)
Regional/rural (population of 10 000–99 000)	13 (26.00%)
Remote	0 (0.00%)
Other	0 (0.00%)
State or territory majority of time spent working with adults who sustained TBI at ≥55 years in the 24 months prior to any COVID-19 restrictions
Australian Capital Territory	3 (6.00%)
New South Wales	8 (16.00%)
Northern Territory	6 (12.00%)
Queensland	7 (14.00%)
South Australia	2 (4.00%)
Tasmania	0 (0.00%)
Victoria	23 (46.00%)
Western Australia	1 (2.00%)

Note. TBI = traumatic brain injury.

^aSelection of multiple responses possible.

Table II. Clinical caseload trends for speech-language pathologists working with adults who sustain traumatic brain injury at ≥55 years (n = 50).

Approximate percentage of TBI caseload who sustained TBI at ≥55 years during the 24 months prior to any COVID-19 restrictions	n (%)
10% or less	21 (42.00%)
11–25%	12 (24.00%)
26–50%	13 (26.00%)
51–75%	2 (4.00%)
More than 75%	2 (4.00%)
Age ranges this included^a
55–64 years	44 (88.00%)
65–74 years	41 (82.00%)
75–84 years	27 (54.00%)
85–94 years	14 (28.00%)
95 years+	10 (20.00%)

Note. TBI = traumatic brain injury.

^aSelection of multiple responses possible.

Table III. Cognitive-communication assessment and treatment methods and approaches with adults who sustain traumatic brain injury at ≥55 years (n = 34).

Assessment methods^a (n = 34)	n (%)
Informal assessment based on interaction/discussion with person with TBI	32 (94.12%)
Formal structured tests or TBI test batteries	26 (76.47%)
Informal assessment based on observation of person with TBI and their everyday communication partners	25 (73.53%)
Informal assessment based on discussion with close others	24 (70.59%)
Rating scales (clinician, client, or close other completed)	20 (58.82%)
Discourse analysis	16 (47.06%)
Other	1 (2.94%)
I do not provide any cognitive-communication assessment to this population	0 (0.00%)
Treatment methods and approaches^a (n = 34)
Communication partner training	29 (85.29%)
Provision of education related to post-TBI cognitive-communication difficulties to communication partners	29 (85.29%)
Conversational and social skills treatments – individual therapy	27 (79.41%)
Provision of education related to post-TBI cognitive-communication difficulties to person with TBI	27 (79.41%)
Conversational and social skills treatments – with familiar and everyday communication partners	23 (67.65%)
Direct treatment of specific functions (e.g. restorative therapy for attention or word finding)	22 (64.71%)
Conversational and social skills treatment – group-based therapy	10 (29.41%)
Augmentative and alternative communication training	7 (20.59%)
Other treatment methods and approaches	2 (5.88%)
I do not provide any cognitive-communication treatment to this population	0 (0.00%)

Note. TBI = traumatic brain injury.

^aSelection of multiple responses possible.

Table IV. The five most commonly mentioned assessment tools utilised by speech-language pathologists who used rating scales, formal tests, and traumatic brain injury test batteries (n = 29).

Assessment tool	n (%)
LCQ	19 (65.52%)
FAVRES	16 (55.17%)^a
MCLA	12 (41.38%)^b
Mount Wilga High Level Language Test	11 (37.93%)^c
CLQT	9 (31.03%)

Note. LCQ = La Trobe Communication Questionnaire (Douglas et al., 2000); FAVRES = Functional Assessment of Verbal Reasoning and Executive Strategies (MacDonald, 2005); MCLA = Measure of Cognitive-Linguistic Abilities (Ellmo et al., 1995); Mount Wilga High Level Language Test (Christie et al., 1986); CLQT = Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001).

^a1/16 just used subtests of this tool; 2/16 only mentioned using the observational checklist within this tool as a rating scale.

^b2/12 specified using both the rating scales and test components of this tool.

^c1/11 usually just used subtests of this tool.

Table V. Barriers to practice and COVID-19 impacts (n = 34).

Barriers experienced to supporting adults with cognitive-communication difficulties due to TBI sustained at ≥55 years^a (n = 34)	n (%)
Limited experience working in the area of cognitive- communication with this population	3 (8.82%)
No access to a mentor or supervisor with experience managing post-TBI cognitive-communication with this population	2 (5.88%)
Older adults are not frequently referred to SLP for post-TBI cognitive-communication difficulties	6 (17.65%)
Time and/or funding restraints for management of post-TBI cognitive-communication difficulties in older adults	14 (41.18%)
No barriers to supporting this population	9 (26.47%)
Other	8 (23.53%)
Ways in which COVID-19 related restrictions impacted on SLP’s ability to manage post-TBI cognitive-communication with this older adult TBI population^a (n = 34)
A reduction in referrals received for older adults who have post-TBI cognitive-communication difficulties	6 (17.65%)
A move to telehealth services instead of face-to-face input for cognitive-communication difficulties for this population	15 (44.12%)
A deferral of services for cognitive-communication for this population	7 (20.59%)
Stopping services for cognitive-communication for this population (e.g. due to caseload prioritisation changes)	6 (17.65%)
An increase in services for cognitive-communication for this population	1 (2.94%)
No impact on management of cognitive-communication in this population	9 (26.47%)
Other	10 (29.41%)

Note. SLP = speech-language pathologist; TBI = traumatic brain injury.

^aSelection of multiple responses possible.

Characteristics of SLPs

Information on education, experience, practice settings of respondents who had worked with adults who sustained TBI at 55 years or older during the 24 months prior to any COVID-19 related restrictions in their state or territory, and their practice with this older adult TBI population is presented in Table I (n = 50). The most common responses were from SLPs who had graduated with their SLP qualification 6–10 years prior (14/50; 28%) and had 5 years or less experience working with adults with TBI (18/50; 36%). A total of 34% (17/50) had more than 10 years’ experience working with adults with TBI.

The provision of speech-language pathology services to adults who sustained TBI at 55 years or older occurred across the continuum of care; however, this was predominantly in inpatient rehabilitation (24/50; 48%), acute care (20/50; 40%), and community settings (18/50; 36%). Just over half of participants (26/50; 52%) worked with this population across two or more different settings.

Services were most commonly delivered through the public sector (37/50; 74%) and most participants provided services in metropolitan areas (41/50; 82%). Just over a quarter (13/50; 26%) provided services in regional or rural settings, with 8% (4/50) working across both metropolitan and regional or rural settings. No survey responses were received from SLPs working in remote settings. Participants were asked to indicate the state or territory where they had spent the majority of their time working with older adults who had sustained TBI in the 24 months prior to any COVID-19 restrictions. Most SLPs who responded worked in Victoria (46%), New South Wales (16%), or Queensland (14%). Tasmania was the only state or territory that was not represented.

Caseload trends

As detailed in Table II, adults who sustained TBI at 55 years or older represented 10% or less of most participants’ TBI caseload (21/50; 42%). For 12 (24%) participants this population represented 11–25% of their TBI caseload and for 13 (26%) participants this population represented 26–50% of their TBI caseload. It was rare for participants to have TBI caseloads that comprised more than 50% of individuals who sustained TBI at 55 years or older (4/50; 8%).

During the 24 months prior to any COVID-19 related restrictions, the majority of participants had patients or clients who were aged 55–64 years (44/50; 88%) and 65–74 years (41/50; 82%) when they sustained a TBI. More than half of the participants (27/50; 54%) had provided services to those who were 75–84 years when they sustained a TBI. Some had also provided services to those who were 85–94 years (14/50; 28%) and 95 years and older (10/50; 20%) at the time of sustaining a TBI.

Speech-language pathology services provided

Of the 46 SLPs who responded to this section, 44 (95.65%) indicated that they provided services for communication to adults who sustained TBI at 55 years or older during the 24 months prior to any COVID-19 restrictions. Of the 44 participants who indicated that they did provide services for communication to adults who sustained TBI at 55 years or older, 43 indicated that this included services for cognitive-communication difficulties.

A total of 38 (82.61%) provided services for swallowing and/or mealtime management. More than half provided general counselling or support related to brain injury (25/46; 54.35%). When considering these three speech pathology services, 13.04% (6/46) provided only one service, 41.30% (19/46) provided two services, and 45.65% (21/46) provided all these services to this population.

Seven SLPs indicated that they provided other services to this group, including anosmia assessment (1), input relating to cognition (2), disorders of consciousness (2), post-traumatic amnesia (2), tracheostomy (2), community engagement (1), family relationships (1), and return to work support (1).

Assessment and therapy trends

A total of 34 SLPs provided information about assessment and treatment of cognitive-communication difficulties in this population. The methods used to assess cognitive-communication difficulties in adults who sustain TBI at 55 years and older are shown in Table III. All respondents used some form of informal assessment with this population. It was particularly common to use informal assessment based on interaction or discussion with the person with TBI (32/34; 94.12%), with many utilising informal assessment based on discussion with close others (24/34; 70.59%) and observation of the person with TBI and their communication partners (25/34; 73.53%). Although informal assessment methods were common, the majority of SLPs indicated that they also used other assessment approaches including discourse analysis, rating scales, formal structured tests, or TBI test batteries (31/34; 91.18%). The majority of SLPs (25/34; 73.53%) indicated they used two or more assessment methods in addition to informal methods with this population.

Twenty-nine respondents also provided examples of the clinician rating scales, client or close other rating scales, formal structured tests, or TBI batteries that they used. Up to four tools could be listed for each of these categories using free text response. Responses across these categories were then compiled to obtain an overview of assessment tools being used with this population. The five assessment tools used by at least 30% of these participants across these categories can be seen in Table IV. The specific assessment tools reported as most frequently used were the La Trobe Communication Questionnaire (LCQ; Douglas et al., 2000); Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; MacDonald, 2005); Measure of Cognitive-Linguistic Abilities (MCLA; Ellmo et al., 1995); Mount Wilga High Level Language Test (Christie et al., 1986); and the Cognitive Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001).

The LCQ is a 30-item questionnaire or rating scale developed for use with adults with TBI that assesses perceived social communication with the option of a self- and a close other-report form (Douglas et al., 2000). Published normative data for 147 participants (age range 16–39 years; Douglas et al., 2000) and data for 88 adults with TBI (mean age = 32.26; SD = 12.12 years) is available for this tool (Douglas et al., 2007). The LCQ has established reliability and validity, and is recommended for use in psychosocial research following TBI (Honan et al., 2019). The FAVRES is an assessment of verbal reasoning, complex comprehension, discourse, and executive function conducted through functional tasks, which was developed for people with acquired brain injury (Macdonald & Johnson, 2005). Normative data for this tool is based on 101 healthy control participants aged 18–79 years and 52 participants with acquired brain injury (TBI and stroke) aged 19–64 years (Macdonald & Johnson, 2005).

The Mount Wilga High Level Language Test is a formal test of high-level language function (Christie et al., 1986). As pointed out in research focused on SLP assessment with TBI populations, this assessment is not norm referenced (Frith et al., 2014). There also does not appear to be any published data on the reliability or validity of this test. The MCLA is a formal test of cognitive linguistic function (Ellmo et al., 1995). This tool does not have normative data from an acquired brain injury population (Ellmo et al., 1995) and is no longer in publication. The CLQT is a criterion-referenced tool, which allows assessment across a range of cognitive and language domains and has been supported by studies that have included individuals with acquired brain injury (stroke, TBI, and Alzheimer’s disease) aged 18–89 years (Helm-Estabrooks, 2001).

Another 24 tools were mentioned by five (17.24%) or fewer of these 29 participants. However, collectively language screeners, including organisation-developed screening tools, were used by 24.14% (7/29) of participants.

As can be seen in Table III, SLPs also used a variety of treatment approaches with this population. The use of communication partner training was very common (29/34; 85.29%) as were conversational and social skills treatments delivered as individual therapy (27/34; 79.41%) or with familiar and everyday communication partners (23/34; 67.65%). However, conversational and social skills treatment delivered in a group was less common (10/34; 29.41%).

Most SLPs (31/34; 91.18%) provided education relating to post-TBI cognitive-communication difficulties. Education was provided both to the individual with TBI (27/34; 79.41%) and their communication partners (29/34; 85.29%). Clinicians who provided education (n = 31) typically utilised other treatment methods (96.77%; 30/31).

All participants (n = 34) identified at least two different treatment methods or approaches that they used. Sixteen SLPs identified six (8/34; 23.53%) or seven (8/34; 23.53%) different treatment methods or approaches that they used with this population.

Resources

Participants (n = 33) were also asked how well resourced they felt when providing speech-language pathology services for cognitive-communication to adults who sustain TBI at 55 years or older by placing a marker to their preferred point on a visual analogue scale coded 0–100. Three labels were presented on this sliding scale: “not well resourced” (far left of scale); “neither under-resourced nor well-resourced” (midpoint of scale); and “very well-resourced” (far right of scale). A wide range of results from 16 to 100 with an average of 59.55 (SD 24.44) were reported. Thirty percent of participants (10/33) indicated a score below the midpoint of the scale.

SLPs also had the option to list any additional resources that they would like, to support post-TBI cognitive-communication practice with adults who sustain TBI at 55 years or older. Fourteen participants identified resources, with some listing more than one. SLPs wanted more educational, assessment, and treatment resources (10); greater access to or funding for services and groups delivery (6); professional development (6); and further research (1).

Barriers

Participants (n = 34) were asked to indicate any barriers that they had experienced supporting adults with cognitive-communication difficulties due to TBI sustained at 55 years or older in the 24 months prior to any COVID-19 related restrictions. The majority of participants (25/34; 73.53%) reported experiencing one or more barriers, as can be seen in Table V. The most common barrier was time and/or funding restraints (14/34; 41.18%). One participant elaborated on their experience with client funding stating: “Funding has been an issue for my caseload. Older adults are not covered by NDIS [National Disability Insurance Scheme] and if not [covered by a road accident funding scheme] … [it is] very difficult to get funding.”

A lack of referrals for cognitive-communication management in this population was the next most frequently indicated barrier (6/34; 17.65%). This response was elaborated on further by one participant in free text at the end of the survey, who wrote: “Older TBI clients [do] not often transition through inpatient rehabilitation. As a result, they miss out on community referral, even if there is funding to support them, the aged care sector is not aware and doesn’t readily refer….”

Eight participants indicated that they had experienced other barriers. Issues identified included a lack of services for this population and the procedures of existing services. One participant described a lack of services in the residential aged care setting: “Many older adults with TBI are placed in nursing homes, where the support is not appropriate—lack of active engagement, deterioration of level of function.” Another participant described practice in relation to age: “while it’s not uncommon for us to see people over 55, it is less common to see people over 65… those that we do, tend to have clear vocational or family role/support aims.”

Impact of COVID-19

Participants were presented with questions relating to any changes to their management of cognitive-communication difficulties with this population as a result of pandemic restrictions, to ascertain if restrictions had presented any additional barriers to practice in this area. COVID related restrictions were reported to have an impact on SLP management of cognitive-communication difficulties with older adults in the majority of cases (25/34; 73.53%). As can be seen in Table V, the most commonly cited impact was a move to telehealth services (15/34; 44.12%). Twenty-one percent of SLPs (7/34) reported having to defer services for cognitive-communication difficulties for this population, 17.65% (6/34) had to stop services for cognitive-communication difficulties due to caseload prioritisation changes, and 17.65% (6/34) noted a reduction in referrals received for cognitive-communication difficulties in this population. Other COVID related impacts were also described by ten participants. Categories with corresponding participant comments can be seen in Table VI.

Table VI. Other COVID-19 related impacts (n = 10).

PPE challenges communication processes

Wearing of full PPE has meant that patients find it more difficult to recognise staff

Reduced engagement from patient due to new policies regarding wearing of masks

The impact of social distancing requirements on group and community intervention

Reduced ability to run group sessions adhering to social distancing/meeting room limits, etc.

Inability to provide group interventions

Communication groups stopped running

Unable to complete group therapy face-to-face

Community restrictions/social distancing

Barriers in residential aged care

Lack of access to face-to-face services for clients who are not appropriate for telehealth due to policies (i.e. nursing homes)

Limited access to aged care facilities, aged care unable to facilitate telehealth

Visitor limitations restrict communication management

More difficulty gaining insight into patient communication baseline. Reduced patient visitors meaning that it’s more difficult to contact patient family for collateral

Visiting limitations impacting communication partner training

Note. PPE = personal protective equipment.

Discussion

We aimed to understand the characteristics and practice of SLPs who work in Australia with individuals who sustain TBI at 55 years and older, and to examine how these SLPs manage post-TBI cognitive-communication difficulties with this population. Importantly, SLPs are providing cognitive-communication services to this population. However, survey findings suggest there are some systemic and resource-based challenges to the provision of care to these adults.

SLPs with a range of experience levels responded to this survey, including just over one third of participants with more than 10-years’ experience working with adults with TBI. Respondents also came from a variety of practice settings, with the largest number of participants working in inpatient rehabilitation, acute, and community settings. In-line with published trends for the profession, most participants worked in metropolitan areas (Health Workforce Australia, 2014).

Prior to COVID-19 restrictions, adults who sustained TBI at 55 years or older made up 25% or less of the TBI caseload of the majority of SLPs. Very few SLPs typically had more than 50% of this population on their TBI caseloads. The majority of respondents provided speech-language pathology services to those aged 55–74 years and just over half provided services to those aged 75–84 years. It was less common for adults aged 85 years and older to be seen.

These service delivery trends for SLPs raise the question about unmet need for this population given the disproportionately high rate of TBI from 75 years (CDC, 2019; 2021). A relatively small proportion of survey responses were received from SLPs working in residential aged care settings, where a greater proportion of adults of advanced older age with TBI may reside. Although further investigation is required to delineate these trends, the decline in SLP input for cognitive-communication as age increased may be influenced in part by a lack of SLPs supporting individuals with post-TBI cognitive-communication difficulties within residential aged care. Further investigation is also required to ascertain if trends are indicative of inconsistent referral patterns to rehabilitation services for adults aged 75 years and older who require this service intensity.

SLPs working in Australia reported providing a range of clinical services to individuals who sustain TBI in older adulthood. The vast majority (96%) of SLPs in this study provided services for communication and this almost always included work on cognitive-communication competence. To understand SLP practice in more detail, survey responses regarding cognitive-communication management with adults who sustain TBI at 55 years and older can be compared with TBI practice recommendations, whilst acknowledging that this comparison is limited by the lack of research evidence relating to cognitive-communication difficulties in adults who sustain TBI at 55 years or older that is available to inform any practice recommendations (Shorland et al., 2020). It is also acknowledged that, given the survey design and the number of participants working across multiple settings, these are general rather than setting specific practice trends.

SLPs working with adults who sustain TBI from 55 years onwards used multiple assessment methods to examine cognitive-communication function. Informal assessment was very common. However, informal processes seldom represented the sole assessment methods used with this population. Just over three quarters of respondents in this study used formal structured tests or TBI batteries, and 59% reported using rating scales. Many of these tools were standardised assessments, with clearly outlined methods for administration (Coelho et al., 2005; Turkstra, Coelho et al., 2005). Close to half of the SLPs who described their assessment approaches used discourse analysis. Recent advancements have seen an increased range of options for standardised assessment of discourse following TBI (Steel & Togher, 2019). However, in this study information was not sought on how discourse analysis was being conducted, therefore, this may have been in standardised or non-standardised ways.

In 2005, the Academy of Neurological Communication Disorders and Sciences Practice Guidelines Group provided guidance on the use of both standardised (Turkstra, Coelho, et al., 2005) and non-standardised (Coelho et al., 2005) assessment for people with TBI. It was recommended that clinicians take a considered approach to the use of standardised assessment and pair this with non-standardised methods, given that standardised assessment is not always able to capture the challenges faced by individuals with post-TBI cognitive-communication difficulties (Coelho et al., 2005). In addition, given that it is rare for social communication tools to include questions relating to a client’s goals, it has been suggested that clinicians can better understand an individual’s needs by interviewing clients about the personal salience of communication skills in conjunction with a published assessment tool (Sohlberg et al., 2019). Further, clinicians have been cautioned against the expectation that a single social communication assessment will yield a real-world representation of communicative performance (Douglas & Togher, 2017).

Although this survey does not allow an exact understanding of how assessment with older adults who have sustained TBI is being conducted, findings indicate that, in line with recommendations, a combination of both standardised and non-standardised assessment data are being used. This combination may represent a means of adhering to ecologically valid and client-centred practice when working with this population.

The five assessment tools utilised most commonly by SLPs who use rating scales, formal tests, or TBI batteries within their practice with older adults with TBI were the LCQ, FAVRES, MCLA, Mount Wilga High Level Language Test, and the CLQT. Cognitive-linguistic and high-level language assessments, such as The Mount Wilga High Level Language Test, MCLA, and CLQT have been reported as commonly used by SLPs working with broader adult TBI populations (Frith et al., 2014). However, in the context of a lack of published data of the Mount Wilga High Level Language Test, the applicability of this test to an older adult TBI population cannot be determined. Further, determining the applicability of the MCLA to an older adult TBI population is also limited given the lack of acquired brain injury-specific normative data. The LCQ and the FAVRES both consider communication from a functional perspective. Although applicability of the use of these tools would be based on an older adult’s specific age and context, they have been deemed to be among the 43% of currently available social communication assessments for adults with TBI that are ecologically grounded or relevant to authentic communication situations (Sohlberg et al., 2019).

An in-depth psychometric evaluation of these tools is beyond the scope of this study. Findings do indicate that a small range of standardised assessments are typically being used by clinicians working with people who sustain TBI in older adulthood. However, we do not know how these tools are being used with this population; although some SLPs are utilising certain subtests or components of tools, which may be a means of targeting the tool to the population. Further, it is possible, in the context of limitations to normative data, that some SLPs may be adopting a qualitative approach to assessment analysis with adults of advancing older age. Further targeted research is required to better delineate if clinicians are relying on some tools that may not be suitable for use with this population.

A range of treatment methods were used by SLPs working with people who sustain TBI in older adulthood. The most common methods utilised were communication partner training and provision of education related to post-TBI cognitive-communication difficulties to communication partners. This is in line with guidelines that specify that education and training of communication partners should be part of post-TBI cognitive-communication rehabilitation (Togher et al., 2014).

Survey-based research in the UK has shown that post-TBI communication partner training can be difficult to deliver in general, due to reasons such as time restraints and limited knowledge and training in this area (Behn et al., 2020). It is possible that similar issues existed for the participants who provided services to older adults with TBI in this study. Evidence related to communication partner training in TBI was considered in a recent systematic review (Behn et al., 2021). Across the seven studies that included people with TBI, participants ranged in age from 18 to 68 years, suggesting that individuals injured in older adulthood are typically underrepresented in this research area.

In terms of education provision, family members of those who sustain TBI have a need for information about the anticipated course of recovery of cognitive-communication disorders (Grayson et al., 2020). For many family members, this need is perceived to be unfulfilled or only partially fulfilled by speech-language pathology services (Grayson et al., 2020). SLPs working with older adults in this study were commonly providing education relating to cognitive-communication competence. These clinicians have a difficult task given that prognostication for this population is challenged by such limited research focus on this population (Shorland et al., 2020). Prognostication may also be challenged by the potential limitations of assessment tools with this population, suggested in this study.

International guidelines also recommend that person-centred input for social communication evaluated through social participation be provided as part of TBI cognitive-communication rehabilitation (Togher et al., 2014). The use of conversational and social skills treatments was common in this study. It cannot be determined whether, in line with recommendations (Togher et al., 2014), these treatment approaches were geared towards improving outcome in real-life contexts that were salient for individuals who sustain TBI in older adulthood. Findings do suggest that many SLPs were taking this type of approach, in that close to 70% of respondents delivered these treatments with familiar and everyday communication partners.

Participants varied in how well resourced they felt when working with older adult TBI populations; however, few felt very well resourced. When SLPs specified additional resources that they would like to manage this population, they reported access to more assessment, treatment, and educational resources; more professional development; and increased funding for services and groups for this population. The additional resources desired by SLPs to support practice align with the gaps that are evident within the areas of assessment and treatment. It is unclear if and how this sense of being under-resourced differs from similarly themed challenges faced by SLPs working with broader TBI populations (Behn et al., 2020; Morrow et al., 2020; Riedeman & Turkstra, 2018).

Almost three quarters of respondents had experienced barriers to supporting adults with cognitive-communication difficulties due to TBI sustained at 55 years or older when reflecting on their practice during the 24 months prior to any COVID-19 related restrictions. The most common barrier was time or funding restraints. It is unclear whether time resources were related to age, or if this was a universal problem relating to cognitive-communication management with the adult TBI population. Previous research involving SLPs working in acute hospital settings has indicated that time restraints can be a barrier to providing initial assessment to adults with TBI (Morrow et al., 2020). Further, swallowing and tracheostomy work are typically deemed a higher priority than cognitive-communication management in this setting (Morrow et al., 2020).

Healthcare funding is complex in Australia and an in-depth exploration of the impact of funding on service delivery is outside the scope of this study. However, in the context of TBI, there are several age-related factors that may influence access to funding schemes. An individual who sustains a TBI in a road accident may be eligible for funding for rehabilitation under their state or territory specific compensation scheme. However, given that falls rather than transport related accidents are the most prevalent cause of TBI in adults aged 55 years and older (CDC, 2021) these schemes may not be as applicable to the older adult new onset TBI population as compared to younger adults. In addition, the Australian National Disability Insurance Scheme (NDIS) is only available to adults entering this Scheme at 65 years or younger, with older adults with disability being subject to funding under aged care pathways (NDIS., 2020). Qualitative research conducted with professionals from national peak bodies, government agencies, and care providers to older adults with traumatic injury or disability has indicated shortfalls in the provision of services and supports for older adults with traumatic injury in Australia (Schwarzman et al., 2022). This research suggests that adults with traumatic injury who are funded through aged care pathways may receive lower-intensity input that does not necessarily meet the specific care needs of people with disability (Schwarzman et al., 2022).

A lack of referrals for management of post-TBI cognitive-communication difficulties in this population was reported as a barrier by some respondents. Further, there was concern that referrals for post-TBI cognitive-communication input are not typically initiated from residential aged care settings. This is supported by previous research where SLPs working in Australian residential aged care settings have reported that they are often referred clients solely for swallowing management (Bennett et al., 2015).

It is unclear if current services are designed to meet the needs of older adults who sustain TBI. Although many adults aged 55 years and older who sustain TBI may have traditional work or role based goals, it needs to be ascertained if the absence of these types of goals coupled with advancing age is a barrier to rehabilitation. Services need to be flexible to meet the needs of the diverse older adult TBI population and respond to a range of goals, such as: return to work; navigating an early forced retirement; needing to return to a parenting, grandparenting, or carer’s role; or wanting to successfully return to social activities specific to life stage.

Unsurprisingly, COVID-19 pandemic related restrictions added additional complexity to SLP management of cognitive-communication difficulties with people who sustain TBI in older adulthood for the majority of respondents. Moving to telehealth services as opposed to face-to-face services was the most commonly reported change and some SLPs also reported having to defer or stop services for cognitive-communication difficulties to this population. Others noted a reduction in referrals for this population. A movement to telephone and video consultations was also reported by SLPs during a heightened period of the pandemic in the UK (Chadd et al., 2021). Chadd et al.’s study also highlighted that many SLPs reported having clients who would normally receive SLP input missing out on input during this period and a large drop in referral rates for clients requiring communication input, with the same trend not observed with dysphagia referrals (Chadd et al., 2021).

Although many of the pandemic related impacts reported in this study may also be applicable to cognitive-communication management with younger adults, it is worth considering the additional complexity of these changes for an older adult TBI population. For example, the communicative impact of personal protective equipment (PPE), such as masks, may be greater on some adults of increasing older age, due to factors such as age-related decline in hearing acuity (Brotto et al., 2021).

Study limitations

Attempts were made to distribute the survey as widely as possible. However, the results from this non-probability sampling may be open to bias given those SLPs who elected to complete the survey may not represent the broader population of SLPs working with adults with TBI (Fricker, 2017). It should be noted that the majority of responses were from Victoria and may reflect the fact that the authors were also based in Victoria. Therefore, findings may not fully capture practice across Australia. Despite this potential for bias, this survey still has strong utility, as the perceptions of these practicing SLPs has allowed identification of pertinent issues related to clinical practice as well as hypothesis building for future research (Fricker, 2017; Scheel et al., 2021).

This study provides a descriptive overview of practice only. It has not been ascertained if factors such as experience and practice setting influence practice, perceived resource levels, and barriers to practice. Further, TBI severity was not asked about within the survey. Severity is an important variable that can shape approaches to management of post-TBI cognitive-communication difficulties. As an example, AAC was not frequently used; however, this is often only appropriate for those with severe communication difficulties (Togher et al., 2014). Chronicity of TBI was also not addressed. This is another variable that may influence the approach to the management of cognitive-communication difficulties.

Finally, when considering management of cognitive-communication difficulties following TBI the challenges of SLP practice in this area, irrespective of the age of the client, needs to be kept in mind. Other survey-based research provides evidence that the management of post-TBI cognitive-communication difficulties can be a demanding area of practice (Frith et al., 2014). SLPs have differing degrees of confidence and knowledge related to clinical practice in this area (Riedeman & Turkstra, 2018) and may be faced with limited time and resources to assess cognitive-communication competence in specific settings (Morrow et al., 2020). It is difficult to definitively ascertain the degree to which challenges relating to resources and management approaches taken are influenced by the established demands of SLP TBI practice as opposed to the challenges of supporting an older age at injury population.

Future directions

This study has helped illustrate how SLPs in Australia are working in this area of practice with adults who sustain TBI at 55 years and older. However, given that research evidence to support this area of practice is so limited (Shorland et al., 2020), we can only compare this practice with broad TBI cognitive-communication practice guidelines based on research with predominantly younger adults. Ultimately, research evidence on adults who sustain TBI in older adulthood that focuses on post-TBI cognitive-communication difficulties is required. Future research should include investigations that consider cognitive-communication outcome and management at more distinct stages of older adulthood so that a better understanding of age-based nuances in outcome can be appreciated.

Specifically, survey findings suggest the need for a critical analysis of the currently available tools for assessment of post-TBI cognitive-communication difficulties to determine suitability for older adults who sustain TBI. Such research also needs to capture other important variables that can affect communicative performance, such as education (Turkstra, Coelho, et al., 2005). The need for more normative data for older adults to allow meaningful TBI communication assessment was highlighted back in 2005 by Turkstra, Ylvisaker, et al. (2005). This research gap remains an issue and it must be addressed in order to optimise professional practice in this area.

A more nuanced understanding of management of cognitive-communication difficulties in this population is also required. For example, a general need for further research into post-TBI communication partner training has been identified (Behn et al., 2021). There should be greater inclusion of adults who sustain TBI at an older age and their communication partners in such research to support clinicians in delivering communication partner training to this population.

This survey-based research in this expansive unexplored area has yielded some broad findings. For example, 65% of respondents delivered direct treatment of specific functions, such as restorative therapy for attention or word finding. This finding likely represents a broad range of therapeutic approaches. It would be beneficial to investigate these trends in greater detail, including the efficacy for this practice with older adult TBI populations.

Models for dedicated research with older adults are emerging in post-TBI cognitive rehabilitation literature. For example, research has explored the efficacy of multimodal group therapy for executive functioning specifically for adults with TBI aged 55 years and older (Cisneros et al., 2021). Similar research into cognitive-communication treatment programs designed for older adults with TBI would support SLPs in delivering more targeted rehabilitation to older adults who sustain TBI.

SLP practice that is focused on an individual’s goals should capture meaningful cognitive-communication contexts, regardless of age. However, exploring the lived experience of sustaining TBI within older adulthood through qualitative research would help further inform this situation and direct SLP resources.

Conclusion

This survey provides critical insights into SLP assessment and management of cognitive-communication competence following TBI in older adulthood. Further research in relation to cognitive-communication difficulties in older adults after TBI will allow improved guidance and tools for SLPs working in this area, and support advocacy for appropriate supports and services for individuals who have cognitive-communication difficulties due to TBI sustained during older adulthood.

Acknowledgements

The authors thank the SLPs who assisted with the piloting of the survey and to all SLPs who responded to the survey. The authors also acknowledge the technological support relating to survey design provided by the La Trobe University Digital Research Team.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed at https://doi.org/10.1080/17549507.2023.2169352

Additional information

Funding

This work was supported by an Australian Government Research Training Program Scholarship.