What is the impact of advanced age on outcomes following traumatic head injury?

From the Guidelines

Older adults generally have worse outcomes from head injuries compared to younger individuals, primarily due to age-related physiological changes, comorbidities, and polypharmacy, which increase the risk of bleeding, disability, and mortality. This is supported by the 2023 WSES guidelines on the management of trauma in elderly and frail patients, which highlights the importance of considering age-related physiological changes, such as brain atrophy, thinner blood vessels, and reduced cognitive reserve, when evaluating elderly patients with head injuries 1. Additionally, the guidelines emphasize the need to maintain a lower threshold for neuroimaging, even with seemingly minor trauma, and to consider the patient's comorbidities, such as diabetes, hypertension, and previous strokes, which can further complicate recovery 1.

Some key points to consider when evaluating elderly patients with head injuries include:

• Age-related physiological changes, such as brain atrophy and thinner blood vessels, which increase the risk of bleeding and disability
• Comorbidities, such as diabetes, hypertension, and previous strokes, which can further complicate recovery
• Polypharmacy, which can increase the risk of bleeding and other complications
• The need for a lower threshold for neuroimaging, even with seemingly minor trauma
• The importance of early rehabilitation, including physical, occupational, and speech therapy, to maximize functional recovery

The 2023 WSES guidelines also highlight the importance of considering frailty and cognitive function when evaluating elderly patients with head injuries, as these factors can significantly impact outcomes 1. Furthermore, the guidelines emphasize the need for a multidisciplinary approach to care, including early involvement of palliative care teams and shared decision-making, to improve outcomes and reduce medical futility 1.

In terms of specific management strategies, the guidelines recommend:

• Early activation of tailored trauma protocols for elderly trauma patients
• Focused triage and early assessment of frailty and cognitive function
• Consideration of alternative predictors of mortality, such as serum lactate level and base deficit
• Use of scoring systems, such as the Geriatric Trauma Outcome Score (GTOS) and the quick Elderly Mortality After Trauma (qEMAT), to predict in-hospital mortality and guide management decisions 1

Overall, the management of elderly patients with head injuries requires a comprehensive and multidisciplinary approach, taking into account the patient's age-related physiological changes, comorbidities, and polypharmacy, as well as their frailty and cognitive function. By prioritizing early evaluation, tailored management, and multidisciplinary care, clinicians can improve outcomes and reduce morbidity and mortality in this vulnerable population.

From the Research

Impact of Advanced Age on Outcomes Following Traumatic Head Injury

• Advanced age is associated with worse outcomes after traumatic head injury, with older adults being more likely to experience adverse outcomes due to comorbidities and frailty 2.
• The severity of traumatic brain injury in older adults can be underestimated due to a delay in the development of mass effect and symptoms of intracranial haemorrhage 2.
• Older adults are frequently frail and multi-morbid, with many having indications for anticoagulation and antiplatelet agents, which can increase the risk of haemorrhagic complications 3.
• The use of anticoagulant and antiplatelet medication is common among older adults presenting with head injury, with 116 patients taking these medications in one study, but only 37 (31.9%) receiving a head CT scan 4.

Clinical Management and Outcomes

• Clinical management of head injury in older adults is challenging due to comorbidities, and practising evidence-based clinical management and following guidelines is important 4.
• Determining the role of surgery and interrupted anticoagulation requires careful personalised risk assessment, taking into account the opposing risks and the evidence base in both surgery and medicine 3.
• Older age is associated with worse outcomes after traumatic brain injury, but premorbid health is an important predictor, and good outcomes are achievable 2.
• Decision making should be multidisciplinary, transparent, personalised, and inclusive of patients and relatives, avoiding unsubstantiated nihilism and early withdrawal decisions based on age alone 2.

Seizure Prophylaxis and Traumatic Brain Injury

• Seizure prophylaxis is an important consideration in the management of traumatic brain injury, with anticonvulsants such as phenytoin and levetiracetam being used to prevent post-traumatic seizures 5, 6.
• Phenytoin has been shown to reach therapeutic levels in the cerebrospinal fluid quickly, but has a large side-effect profile, while levetiracetam has a better side effect profile but may not reach therapeutic levels as quickly 5.
• The choice of anticonvulsant for seizure prophylaxis in traumatic brain injury patients should be based on individual patient factors and the availability of medications 6.