Traumatic brain injury in college students and the influence of alcohol consumption: A retrospective review from a rural state

INTRODUCTION

Traumatic brain injury (TBI) is a form of acquired brain injury resulting from an external mechanical force that causes an alteration in brain function. A TBI is not a single pathophysiological phenomenon; instead, it is a chronic progression of a disease resulting in structural and functional damage initiated by an initial injury event.^[1] Symptoms of a TBI can vary depending on the extent of the trauma and the resulting injury to the brain and can be permanent and debilitating. Even a mild TBI can have lasting cognitive, emotional, and functional impairment.^[1] TBI severity ranges from mild to moderate to severe. The Glasgow Coma Scale (GCS) can be used to classify clinical severity, with approximately 75–90% of all TBIs classified as mild TBIs.^[1] There is a peak in frequency of mild TBI seen in young adults during the 2^nd and 3^rd decade of life, around the time that young adults are of college-age.^[2]

A modifiable risk factor associated with TBI in young adults is alcohol consumption. Studies from Norway and Spain have shown that alcohol consumption was involved in 24–51% of all TBIs.^[3] Students are known to consume alcohol at higher rates when compared to non-college students of a similar age. Approximately 500,000 college students experience unintentional injuries under the influence of alcohol each year, and an estimated 1800 college students die each year from unintentional alcohol-related injuries.^[4] Despite the connection between alcohol and TBI, few studies examine the association between students consuming alcohol and TBI.

TBI is a leading cause of death and long-term disability in young adults, representing a significant socioeconomic and health-care burden.^[5] In 2010, TBI in hospital costs totaled $21.4 billion in the United States.^[6] The impact of a TBI can be costly for patients, their families, and the community. Financially, the cost of treatment for individuals suffering TBI varies according to the severity of illness, with per-patient costs ranging from $2,130 to $401,808.^[6] In a recent systematic review of international studies of TBI, van Dijck et al. reported median in-hospital costs per patient were $55,267.^[6] The purpose of this study is to understand better the prevalence and circumstances surrounding TBI and associated alcohol use in the college student population.

MATERIALS AND METHODS

RESULTS

Of the 636 charts reviewed for patients aged 18–26 admitted with a positive blood alcohol level and TBI, there were 186 students, 209 non-students, and 241 uncertain. This distribution is illustrated in [Figure 1]. The majority of both the student and non-student population was male. The student group was 80% male and 20% female, and the non-student group was 74% male and 26% female [Table 1]. A Chi-squared test was conducted. P-value 0.195 showed that the distributions of males and females were not statistically significantly different between the student and non-student groups. A two-sample test for equality of proportions was conducted and the 95% confidence interval (CI) for the difference in the proportions was (−15.57%, 3.700%).

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Figure 1:

Study population distribution.

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DISCUSSION

This study presents a novel analysis of the relationship between TBI, college students, and alcohol consumption. The significantly higher alcohol levels observed in college students with TBI compared to non-student young adults with TBI is consistent with the existing culture of college alcohol consumption.^[4,7] A recent study exploring the relationship between alcohol and several risk factors in college-aged students found a significant relationship between hazardous drinking and formal concussion diagnosis.^[8] Furthermore, Shore and Janssen found a dose-dependent relationship between concussion incidence and a multiple risk behaviors score, evaluating drinking, drug use, smoking, etc., in high school students.^[9] Our results are consistent with this literature, showing that the alcohol abuse that occurs on college campuses contributes to the global burden of TBI.^[6]

Our results illustrate that most of the student population who sustained a concussion under the influence of alcohol were male. Furthermore, males had significantly higher levels of alcohol than females. The current literature demonstrates that young adult males have greater risks of partaking in alcohol abuse or binge drinking behaviors than young adult females.^[2,10] The literature from Spain also showed that overall 51% of overall TBI were sustained under the influence of alcohol’ however, 54% of TBIs in males were sustained under the influence of alcohol.^[3] The results of the present study, taken into consideration with the presented literature, should be used to influence the target audience of deterrence policies for alcohol abuse in college. These policies could serve tremendous importance in lowering the burden of TBI, considering the literature has shown that pre-injury alcohol abuse and being male have been linked to increasing post-TBI alcohol abuse.^[11,12] This finding could be linked to the susceptibility of the ventromedial prefrontal cortex in closed head injury leading to reported increased impulsivity and aggression following TBIs.^[13] Thus, one danger of the increasing incidence of TBI in college students under the influence of alcohol is that the damage from the TBI can lead to further intensified alcohol abuse.

In terms of alcohol abuse in college-age students, several studies have found that underaged students drink less frequently than students over 21 years of age; however, underage students have more drinks per occasion and are more likely to drink to excess.^[14,15] In contrast, our results found that the study population under 21 did not have a significantly higher alcohol level than those aged over 21. Only 12% of the students in the study were under the age of 21; hence, a more extensive study population may yield different results. We did find that more students were under the age of 21 than non-students. A study by Wechsler et al. highlighted that access to alcohol for underage students is more accessible and cheaper on and around college campuses.^[15] Effective control of access to alcohol may be another approach to reduce the contribution of college aged students to the global burden of TBI.

These results should be considered bearing in mind the study’s limitations. A large group of patients could not be effectively categorized as students or non-students and had to be left out of the data analysis of the study. Another limitation was that the population studied was only patients seeking medical attention in the emergency department, which created a potential bias against patients with milder TBIs who did not seek medical attention. Injury severity is assessed as an overall score of injury, not specific to TBI. More research is indicated to assess the relationship between ISS, alcohol levels, and outcome. Finally, this is a single-center study, in a mostly rural state, and results in our patient population may not be generalizable to other centers, particularly as our patient population is not a racially diverse sample.

CONCLUSION

TBI represents a leading cause of long-term disability in young adults, yielding an enormous socioeconomic and health-care burden. Alcohol consumption continues to contribute to the incidence of TBI in students, with males having a higher prevalence of TBI and higher alcohol levels than females. We found alarmingly high alcohol levels for all the young people in the study; however, the student population had significantly higher alcohol levels than non-students, which could be contributed to the “party culture” and binge drinking associated with college life. Addressing the “party culture” and underage drinking could reduce the incidence of TBI among students. These results can be used to inform and better target harm reduction and alcohol awareness programs especially for young male students.