Traumatic Brain Injury in the Geriatric Patient

This chapter includes an accompanying lecture presentation that has been prepared by the authors: .

Key Concepts

Although older adults now have the highest and fastest rising incidence of traumatic brain injury (TBI), the vast majority of TBI research to date has been done in younger adults, whose mechanisms of injury, presentation, and outcomes differ markedly from those of older adults.
Diagnosis, management, and prognosis of TBI in older adults is complicated by high rates of preexisting medical and neurological conditions, as well as functional and cognitive disabilities.
Nearly all trauma head CT guidelines and validation studies recommend that any adult ≥ 60 to 65 years of age with suspected TBI undergo a head CT, even in the setting of mild TBI and normal Glasgow Coma Scale (GCS) score.
Many older adults, even those with moderate-to-severe TBI, can achieve good recovery.
Recovery trajectories are often slower in older patients, requiring more extended inpatient or outpatient rehabilitation to achieve the same level of recovery as in younger patients. Neurosurgeons should aggressively advocate for early and sustained rehabilitation services for their patients.
Discharge considerations include patient/family education on TBI sequelae, medication reconciliation and polypharmacy reduction, home safety evaluation, social support, level of impairment in activities of daily living (ADLs) and instrumental ADLs (IADLs), need for home health services, medical equipment, rehabilitation services, and coordination of follow-up care.
The American College of Surgeons Trauma Quality Improvement Program Geriatric Trauma Management Guidelines emphasize the importance of measuring preexisting comorbidities, functional status, and physical frailty in all geriatric trauma patients to guide prognostication; management guidelines specific to geriatric TBI are needed.

Geriatric TBI is a significant yet largely silent epidemic in the United States and around the world. Although older adults have the highest rates of TBI-related hospitalization and death, they are more likely to be triaged to non-trauma centers for treatment. This is because the markedly different clinical presentations of TBI in older adults compared with younger patients complicate the initial diagnosis and management. In the geriatric TBI patient, diagnostic and management decisions must be guided not only by the acute injury, but also by pre-injury health status, including pre-injury cognitive impairment, physical frailty, medical comorbidities, polypharmacy, and social-environmental factors. Although older adults with TBI experience higher mortality, slower recovery trajectories, and poorer outcomes compared with younger patients with TBI, many experience good recovery, even including those with severe TBI who undergo surgical management. There are few geriatric-specific TBI guidelines to assist with complex management decisions and to determine which subset of older adults will benefit from aggressive management and rehabilitation. Although more research is needed in the field of geriatric TBI to optimally tailor diagnosis and management, here we present a summary of current evidence and key clinical considerations that may be useful to health care providers caring for this population. First, we present the epidemiology of geriatric TBI and describe three important factors to consider in the geriatric TBI patient. Next, we review acute diagnosis and management, discharge planning, and short- and long-term outcomes following geriatric TBI. We end with two case studies that illustrate key clinical considerations in geriatric TBI. For important further reading, we point readers to several selected review articles, also listed in Suggested Readings at the end of the chapter.

Epidemiology

As of 2013, the Centers for Disease Control and Prevention (CDC) reported that older adults have the highest and fastest rising incidence of TBI compared with all other age groups ( Fig. 40.1 ), ^, now exceeding the incidence in infants and toddlers. From 2006 to 2014, TBI-related emergency department (ED) visits doubled, and TBI-related hospitalizations increased by more than 25% in older adults. A shocking 1 in 50 US adults ≥75 years of age sustained a TBI-related ED visit, hospitalization, or death in 2013 and again in 2014. ^, In 2014, adults ≥65 years of age accounted for nearly one-half (46%) of all TBI-related hospitalizations. Older adults are less likely than younger people to present to medical attention for a TBI and also are less likely to be correctly diagnosed (and appropriately triaged) once they do present, particularly in the setting of concomitant polytrauma.

Figure 40.1, Annual incidence of traumatic brain injury (TBI) emergency department (ED) visits, hospitalizations, and deaths for 2002 to 2013 by age.

The majority of TBIs in older adults are caused by low-level falls. Etiology and risk factors for fall-related TBI in older adults include frailty, gait difficulties, chronic comorbidities, systemic infections, impaired cognition, polypharmacy, history of previous falls or previous TBI, and environmental factors. This difference in mechanism contributes to the age-related differences in intracranial lesions, with subdural hemorrhage being more common in older adults.

Preexisting Conditions, Frailty, and Polypharmacy

Preexisting Conditions

Among older adults presenting with TBI, 99% have at least one preexisting comorbid condition and most have several, with Alzheimer disease and related dementias, depression, diabetes, cardiovascular disease, and pulmonary disease being most common. Atrial fibrillation is present in up to 29% of older adults with TBI; thus, pre-injury anticoagulant and antiplatelet use are common. ^, Preexisting cognitive impairment and acute-onset delirium make TBI diagnosis in the geriatric patient particularly challenging. Furthermore, preexisting conditions and resulting polypharmacy may also independently contribute to the patient’s risk for repeat falls and subsequent injuries. ^,

Frailty

Consistent with studies conducted in other geriatric trauma patients, self-rated health and frailty ^, are emerging as key predictors of outcome in geriatric TBI, independent of age and acute injury characteristics. There are several tools available for assessing baseline/pre-injury frailty in older adults, two of which have been shown to predict outcome specifically in geriatric trauma. The Trauma-Specific Frailty Index (TSFI; Table 40.1 ) was found to predict in-hospital complications, death, or discharge to a nursing facility in geriatric trauma. The Groningen Frailty Indicator (GFI; Box 40.1 ) was found to predict functional outcome (e.g., Glasgow Outcome Scale—Extended [GOSE]) 2 to 3 years postinjury in geriatric mild TBI. Nonetheless, this is an area where additional research in geriatric TBI populations is needed.

TABLE 40.1

Trauma-Specific Frailty Index (TSFI)

15-Variable Trauma-Specific Frailty Index
Comorbidities
Cancer History	□ Yes (1)	□ No (0)
Coronary Heart Disease	□ MI (1)	□ CABG (0.75)	□ PCI (0.5)	□ Medication (0.25)	□ None (0)
Dementia	□ Severe (1)	□ Moderate (0.5)	□ Mild (0.25)	□ No (0)

Daily Activities
Help with grooming	□ Yes (1)	□ No (0)
Help managing money	□ Yes (1)	□ No (0)
Help doing housework	□ Yes (1)	□ No (0)
Help toileting	□ Yes (1)	□ No (0)
Help walking	□ Wheelchair (1)	□ Walker (0.75)	□ Cane (0.5)	□ No (0)

Health Attitude
Feel less useful	□ Most time (1)	□ Sometimes (0.5)	□ Never (0.25)
Feel sad	□ Most time (1)	□ Sometimes (0.5)	□ Never (0.25)
Feel effort to do everything	□ Most time (1)	□ Sometimes (0.5)	□ Never (0.25)
Falls	□ Within last month (1)	□ Present not in last month (0.5)	□ None (0.25)
Feel lonely	□ Most time (1)	□ Sometimes (0.5)	□ Never (0.25)

Function
Sexually Active	□ Yes (1)	□ No (0)

Nutrition
Albumin	□ Yes <3(1)	□ >3(0)
Score _________ TSFI: Score/15 _________ Interpretation: Frail is defined as TSFI > 0.25.

CABG, Coronary artery bypass graft; MI, myocardial infarction; PCI, percutaneous coronary intervention.

BOX 40.1

Groningen Frailty Indicator (GFI)

From Steverink N, Slaets J, Schuurmans H, Lis M. Measuring frailty: Developing and testing the GFI (Groningen Frailty Indicator). Gerontologist. 2001; 41(Special Issue 1): 236–237.

Physical Domain

Are you able to carry out these tasks single-handedly and without any help? (The use of help resources, such as a walking stick, walking frame, or wheelchair, is considered to be independent.)

1.
Shopping □ Yes □ No
2.
Walking around outside (around the house or to the neighbor’s) □ Yes □ No
3.
Dressing and undressing □ Yes □ No
4.
Going to the toilet □ Yes □ No
5.
What mark do you give yourself for physical fitness? (enter a value between 1 and 10): ____________
6.
Do you experience problems in daily life because of poor vision? □ Yes □ No
7.
Do you experience problems in daily life because of being hard of hearing? □ Yes □ No
8.
Have you lost a lot of weight in the past 6 months? (3 kg in 1 month or 6 kg in 2 months) □ Yes □ No
9.
Do you take 4 or more different types of medicine? □ Yes □ No

Cognitive Domain

10.
Do you have any complaints about your memory? □ Yes (consistently) □ Sometimes □ No

Social Domain

11.
Do you have ever experienced an emptiness around you? □ Yes (consistently) □ Sometimes □ No
12.
Do you long for other people (to socialize with)? □ Yes (consistently) □ Sometimes □ No
13.
Do you feel abandoned? □ Yes (consistently) □ Sometimes □ No

Psychological Domain

14.
In the past 4 weeks, did you feel downhearted or sad? □ Yes (consistently) □ Sometimes □ No
15.
In the past 4 weeks, did you feel anxious or nervous? □ Yes (consistently) □ Sometimes □ No

Scoring:

Questions 1–4: → Yes = 0; no = 1
Question 5: → 0–6 = 1; 7–10 = 0
Questions 6–9: → No = 0; yes = 1
Question 10: → No = 0; sometimes = 0; yes (consistently) = 1
Questions 11–15: → Yes (consistently) = 1; sometimes = 1; no = 0

Total score: _____

Interpretation: Frail is defined as a score > 3.

Polypharmacy

Psychotropic and sedating medications such as opioids, antipsychotics, sedatives, anxiolytics, hypnotics, antidepressants, and anticholinergics may increase morbidity, mortality, and fall risk in older adult patients. ^, ^, The Beers criteria for potentially inappropriate medication use in older adults may be useful for informing targeted discontinuation or replacement of particularly high-risk medications, as illustrated in Case Study 40.1 . ^, An analysis of Medicare beneficiaries ≥ 65 years of age who were hospitalized for TBI found that the prevalence of psychotropic medication use before TBI was high (>40%) and increased post-TBI. Despite this, there is evidence that newly diagnosed older adults with depression, anxiety, or posttraumatic stress disorder (PTSD) are less likely to receive indicated pharmacologic treatment. ^, Thus, polypharmacy reduction must be carefully weighed against appropriate treatment of both preexisting and TBI-related conditions. A geriatrics consult can be very valuable for guiding appropriate polypharmacy reduction and age-appropriate treatment of preexisting and TBI-related conditions.

Acute Diagnostic and Management Considerations

Clinical Assessment

The Glasgow Coma Scale (GCS) is the most widely used clinical assessment tool for initial determination of TBI severity. However, increasing evidence suggests that this instrument is inadequate for assessment of geriatric TBI because: (1) older adults with preexisting cognitive impairment may have an abnormal GCS at baseline ; (2) comorbid medical conditions or medication side effects may further lower the score and confound accurate diagnosis ; and (3) TBI severity is frequently underestimated by the GCS in part because age-related cerebral atrophy may allow substantial hemorrhage expansion before producing

Case Study 40.1

A 76-year-old female patient with a history of asthma, osteoporosis, breast cancer status postmastectomy, chronic pain on opioids, and a history of three falls within the past year was brought by ambulance after a ground-level fall with head trauma. She endorsed loss of consciousness, denied posttraumatic amnesia, and had a Glasgow Coma Scale score of 15 on arrival. Her head CT was negative for intracranial trauma but positive for acute T11, T12, and L1 compression fractures, which were deemed nonoperable. At pre-injury baseline, the patient lived alone and was fully independent with activities of daily living (ADLs) (e.g., dressing, bathing, feeding, transferring) and instrumental ADLs (IADLs) (e.g., finances, medications, shopping, appointments).

Because of the patient’s history of frequent falls of uncertain etiology, she was admitted for a syncope evaluation. Her 48-hour telemetry was unremarkable. The patient was discharged to a skilled nursing facility but was rehospitalized for Clostridioides difficile colitis 8 days after discharge, which was successfully treated without further complications. During this repeat hospitalization, she was counseled about the risks associated with polypharmacy and chronic opioid use. She decided to electively discontinue opioids upon discharge.

At 3 months postinjury, the patient complained of ongoing headaches as well as difficulty with concentration and memory, which affected daily life. By 12 months postinjury, the headaches and cognitive symptoms fully resolved, she returned home, was fully independent in all ADLs and IADLs, and reported no further falls since the time of her traumatic brain injury (TBI) 1 year earlier. She additionally reported being opioid free for almost 1 year and in retrospect attributes her falls to the effects of opioids.

Key Considerations

This patient had a fall-related mild TBI, likely resulting from chronic opioid use. With cessation of opioids, her fall frequency went from four per year down to zero. She ultimately experienced a complete recovery from her mild TBI.
Application of Beers criteria to eliminate polypharmacy can significantly reduce fall risk and risk for re-injury after geriatric TBI.
This patient’s initial hospitalization for TBI was a missed opportunity to provide counseling about polypharmacy and risks associated with chronic opioid use; luckily, this counseling was delivered during her repeat hospitalization for colitis.

clinically apparent symptoms. Abnormal GCS scores may also be more commonly misattributed to preexisting conditions in older versus younger adults, leading to delays in care, as demonstrated in Case Study 40.2 . When interpreting an abnormal GCS in an older adult patient, it is critically important to quickly establish the pre-injury baseline cognitive, sensory, and motor function of the patient through all available sources.

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