Markenzie Jean-baptiste

4/20/2020

Head Injury- What are the specific concerns in the elderly acutely (assessment and diagnosis) and long term (prognosis and management)?

Assessment

There are unique challenges in assessing geriatric patients with traumatic brain injuries(TBI) because of age-related issues like variable baseline cognitive function and impaired memory. Many geriatric patients have comorbid diseases and medications that can affect there cognitive state and there is a risk of delayed intracranial bleeding from anticoagulant use.

 

Things to consider in elderly patients with head trauma:

Risk of bleeding — Nearly 10 percent of older adult patients presenting with head trauma are taking warfarin, and a significant percentage take other anticoagulants or antiplatelet agents. The rate of intracranial hemorrhage in asymptomatic head injury patients on warfarin approaches 15 percent in some studies according to up to date. Intracranial hemorrhage can also occur with minimal trauma.

Cognitive Disorders– The evaluation and diagnosis of mild head injuries is challenging in older persons with pre-existing dementia or cognitive disorders. Because mild traumatic brain injuries includes any alteration of consciousness, a pre-existing alteration in consciousness can complicate the diagnosis of geriatric patients. Common symptoms of brain injury like balance impairment, depression, and cognitive deficits may be misattributed to other causes. This is especially when elderly patients experience a fall that was not witnessed by anyone.

Glasgow Coma Scale(GCS)– Mild and moderate TBI are often difficult to assess clinically during the first hours after injury because neurological examinations such as the Glasgow Coma Scale are of restricted value in elderly patients. This is because significant intracranial injury may be present even in geriatric patients with a normal or relatively high GCS score. With older age,  brain atrophies occurs and creates more space within the cranial vault for blood to accumulate before symptoms appear. Therefore, elderly people can have significant hemorrhage into their brain and not show signs of deterioration.

 

Diagnoses

Non-contrast Computed tomography (CT) of head:  is the most preferred initial imaging modality to evaluate acute TBI in the elderly. It can reveal traumatic intracranial injuries such as contusions, brain lacerations, and hemorrhage leading to the formation of hematoma in the extradural, subarachnoid, subdural, or intracerebral compartments within the head. The American College of Emergency Physicians recommends a head CT scan for any patient age 65 years or older who presents with mild head injury.

• According to UptoDate, when determining the need for imaging, all well validated clinical practice guidelines should not be used to assess older adults for CT scan. All of them specifically exclude older patients (>60 years in the New Orleans Criteria, >65 years in the Canadian rule and NEXUS II).
• Many of these guidelines use the GCS to determine if imaging is indicated but as mentioned before, GCS may be less accurate in geriatric patients.

Though head CT is widely used, it does have low sensitivity to diffuse brain damage and exposed patients to radiation. Brain MRI is more sensitive than head CT for the detection of intracranial hemorrhage and can provide information on the extent of diffuse injuries. However, it’s widespread application is restricted by cost, the limited availability of MRI in many centers, and the difficulty of performing it in physiologically unstable patients and in those with pacemakers.

 

Management

According to UptoDate, admission or transfer to a trauma center is appropriate for patients over the age of 65 with head trauma and any alteration in mental status or other sign of injury. Transfer to a trauma center should not be delayed in order to complete imaging studies.

• Reversal of anticoagulation should be performed as soon as the need is recognized, as the rate and volume of bleeding are among the most important determinants of morbidity and mortality from intracranial hemorrhage. For patients on warfarin who sustained a closed head injury but whose initial CT scan shows no acute intracranial hemorrhage, a 12-hour period of observation with reassessment every two hours is suggested.
• Analgesia— Pain control is essential to the management of injured older adults. Failure to provide analgesia increases the risk of delirium in this population. There are some challenges with treatment in elderly patients. Tricyclic anti-depressants are commonly used in the treatment of post-traumatic headache, but it may lead to complications in elderly patients due to the anticholinergic side effects( ex: urinary retention, constipation, dry eyes, confusion, heart rhythm disturbance). Medications commonly used to treat muscle spasticity may lead to sedation which can increase risk of fall. In particular, benzodiazepines and typical anti-psychotics such as haloperidol should be avoided due to evidence that they impair recovery from TBI.

Long Term Management and Prognosis

Older age is associated with poorer outcome following TBI including higher mortality and increased functional disability.

• According to large retrospective studies, older adult patients with severe traumatic brain injury (defined as a sustained Glasgow Coma Scale [GCS] <9) have at least an 80 percent likelihood of death or major disability leading to placement in a long-term care facility.

Fall prevention- is highly important in the recovery from TBI. This is of even greater consequence among elderly patients with intracranial hemorrhage or recent craniectomy, in whom a repeat fall can be disastrous. There is a need to address polypharmacy due to increased risk of negative side effect such as sedation and confusion which can increase risk of fall .Home assessment and modifications may be indicated near the time of discharge in order for patients to be able to live comfortably due to possible changes in ADL’s and IADL’s.

Multidisciplinary approach– may be needed due to complexity of injury- Acute inpatient rehabilitation facilities offer physical therapy, occupational therapy, speech therapy, rehabilitation nursing, and neuropsychological services. Physical Therapy is needed to address any physical weakness, coordination impairment, or vestibular dysfunction.

Neuropsychological testing- can be used in the detection and classification of cognitive and behavioral symptoms. The data can help clinicians make recommendations regarding activities of daily living especially if there is  concern about cognitive or behavioral disturbances affecting function. If the results of testing suggest a possible diagnosis of Chronic traumatic encephalopathy (CTE) or other neurodegenerative disease, then repeat testing will usually be recommended after 6–12 months to monitor for further decline or to check for treatment effects. Neuropsychological testing can also be useful for identifying psychiatric disturbances such as depression and anxiety, which are common after TBI and are known to affect recovery. In so, psychotherapy, counseling, and/or psychopharmacological treatments may be recommended.

 

Sources:

• https://www.ncbi.nlm.nih.gov/pubmed/25856357
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625036/
• https://www-uptodate-com.york.ezproxy.cuny.edu/contents/geriatric-trauma-initial-evaluation-and-management?search=head%20trauma%20adult&source=search_result&selectedTitle=7~150&usage_type=default&display_rank=7#H3512287
• https://www-uptodate-com.york.ezproxy.cuny.edu/contents/falls-in-older-persons-risk-factors-and-patient-evaluation?search=head%20trauma%20elderly&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H29
• https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=953&sectionid=53375684#1100069607
• https://www-uptodate-com.york.ezproxy.cuny.edu/contents/subdural-hematoma-in-adults-etiology-clinical-features-and-diagnosis?search=head%20trauma%20older%20adult&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H11