What is the management of a concussion in the geriatric population?

Management of Concussion in the Geriatric Population

The management of concussion in geriatric patients requires specialized care with early trauma protocol activation, careful assessment of frailty, and a gradual return to activity approach, with exercise therapy being particularly beneficial for recovery.

Initial Assessment and Triage

• Early trauma protocol activation is essential for geriatric patients (≥55 years) with suspected concussion, as they are at higher risk of mortality and are frequently under-triaged 1
• Use lower thresholds for trauma protocol activation in geriatric patients: heart rate >90 bpm and systolic blood pressure <110 mmHg 1
• Perform comprehensive frailty assessment using validated tools such as the Trauma-Specific Frailty Index to identify patients at highest risk of poor outcomes 1
• Conduct early blood gas analysis (arterial or venous) to assess baseline deficit or lactic acid levels 1
• Maintain a low threshold for CT imaging in geriatric concussion patients, as the benefits outweigh the risks of contrast-induced nephropathy 1

Medication Management

• Carefully assess the patient's medication profile, particularly for beta-blockers, anticoagulants, and antiplatelet medications which can mask symptoms or increase bleeding risk 1
• Avoid medications except acetaminophen immediately after injury, and only as recommended by a physician 2
• Do not allow return to normal activities while the patient is taking medications for concussion symptoms 2

Early Management (First 24-72 Hours)

• Implement complete physical rest for the first 24-48 hours after concussion, followed by gradual return to activity 2
• Provide cognitive rest during the early recovery phase, especially in the first 24-48 hours, limiting activities requiring concentration 2
• Monitor for neurological improvement within the first 72 hours, as failure to improve in Glasgow Coma Scale (GCS) within this timeframe is associated with poor functional outcomes 1
• Avoid both excessive exertion and prolonged avoidance of exercise, as both extremes have negative consequences 3

Rehabilitation Approach

• After the initial rest period, implement a sub-symptom threshold aerobic exercise program with gradual increase in intensity 4, 5
• Consider vestibular rehabilitation for patients with vestibular dysfunction contributing to headache, including habituation exercises, adaptation exercises, and balance training 4
• Implement spinal mobilization/manipulation for patients with concurrent neck pain and headache 4
• Consider oculomotor vision treatment for patients with visual symptoms accompanying headache 4
• Offer psychological treatment for emotional symptoms that may exacerbate headache 4

Return to Activity Protocol

• Implement a stepwise return to activity protocol following the 24-48 hour rest period, with each step taking a minimum of 24 hours 2
• If symptoms recur during the return to activity protocol, return to the previous asymptomatic level and try to progress again after 24 hours of rest 2
• Moderate levels of cognitive and physical exertion appear to demonstrate improved outcomes compared to minimal or excessive activity 5

Management of Persistent Symptoms

• For symptoms persisting beyond 10 days, implement multidisciplinary management 2
• Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 4, 2
• For headaches persisting 1-2 months after concussion, use a multidisciplinary approach including graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and possibly oculomotor vision treatment 4

Special Considerations for Geriatric Patients

• Recognize that older patients often experience concussions from low-velocity mechanisms such as falls from standing height 1
• Be aware that for each 1-year increase in age beyond 65, the odds of dying after geriatric trauma increase by 6.8% 1
• Consider early involvement of palliative care teams for severely injured elderly patients to improve outcomes and reduce unnecessary interventions 1
• Note that older patients with traumatic brain injury have double the in-hospital mortality compared to younger patients and worse long-term outcomes 1, 6

Warning Signs Requiring Immediate Medical Attention

• Monitor for loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, and swelling or deformities of the scalp 2
• Be vigilant for signs of occult hypoperfusion in older patients, as "normal" blood pressure may actually represent hypotension in elderly patients with chronic hypertension 1