NICE Head Injury Guidelines for Elderly Patients
While the provided evidence does not include specific NICE guidelines, the most recent and highest-quality international trauma guidelines strongly recommend a low threshold for CT head imaging in all elderly patients (≥55-65 years) with head trauma, with imaging indicated even for seemingly minor mechanisms like ground-level falls, particularly given the high risk of occult intracranial injury and poor outcomes in this population. 1, 2
Age Threshold and Risk Stratification
Elderly patients should be defined as ≥55 years old for trauma protocol activation purposes, with careful evaluation to avoid under-triage and mortality risk. 1 The odds of dying after geriatric trauma increase by 6.8% for each 1-year increase in age beyond 65. 2, 3
Key Risk Factors Requiring Immediate Attention:
- Frailty assessment is mandatory in all elderly trauma patients using validated tools like the Trauma-Specific Frailty Index or Geriatric Trauma Outcome Score (GTOS). 1, 2
- Comprehensive medication history, particularly anticoagulants, antiplatelet agents, and beta-blockers that can mask symptoms. 1, 2
- Mechanism of injury assessment, noting that ground-level falls account for 69.6% of elderly head injuries but still carry significant risk. 4
Triage and Initial Assessment
Lower thresholds for trauma protocol activation must be used: heart rate >90 bpm and systolic blood pressure <110 mmHg (not the standard 120 mmHg). 1, 2 This is critical because "normal" blood pressure may represent hypotension in elderly patients with chronic hypertension. 2
Mandatory Initial Workup:
- Early blood gas analysis (arterial or venous) for baseline base-deficit or lactic acid assessment. 1, 2
- Vital signs monitoring including heart rate, blood pressure, respiratory rate, urinary output, and mental status. 1
- Serial base deficit and lactate levels as markers of occult hypoperfusion. 1
CT Head Imaging Indications
A low threshold for CT head imaging is strongly recommended in all geriatric trauma patients, as the diagnostic yield outweighs the risk of contrast-induced nephropathy given the dramatic effects of under-triage. 1, 2
Absolute Indications for CT Head (Any ONE of the following):
- Age ≥60-65 years with ANY additional risk factor. 2, 5
- Loss of consciousness or post-traumatic amnesia. 2, 5
- Glasgow Coma Scale (GCS) <15. 2, 5
- Focal neurologic deficit. 2, 5, 6
- Headache or vomiting. 2, 5
- Physical evidence of trauma above the clavicle. 2, 5
- Signs of basilar skull fracture. 2, 5
- Post-traumatic seizure. 2, 5
- Any anticoagulant therapy (warfarin, NOACs) or antiplatelet agents (clopidogrel, dual therapy) - regardless of symptom severity. 2, 5
- Drug or alcohol intoxication. 2, 5
Critical Anticoagulation Considerations:
- Warfarin increases relative risk of significant intracranial injury by 1.88-fold. 5
- Dual antiplatelet therapy increases risk by 2.88-fold. 5
- Aspirin monotherapy alone does NOT significantly increase risk (RR 1.29, not statistically significant), though caution is advised in patients >65 years. 5
- NOACs carry lower hemorrhage risk than warfarin (2.6% vs 10.2%) but still warrant imaging. 5
Timing of CT Imaging:
Optimal detection occurs when CT is performed ≥5 hours post-trauma, but do not delay imaging if high-risk features are present. 5, 6
Common Pitfalls to Avoid
Clinical evaluation is unreliable in elderly patients - 14.8% of patients with significant injuries present with occult findings (no high-risk criteria beyond age). 2, 4 Studies show that 21-30% of elderly patients with intracranial injury have GCS of 15, no neurologic symptoms, and no anticoagulation. 4, 7
Ground-level falls are deceptively dangerous: While accounting for most injuries (69.6%), they still result in significant intracranial hemorrhage in 8.9% of elderly patients. 4 Subdural hematomas and subarachnoid hemorrhages are the most frequent injury patterns. 4
Coagulation Management
Rapid recognition and correction of coagulation disorders is mandatory, whether related to trauma or chronic medication intake. 1 Meticulous triage criteria should emphasize drug history to guide early coagulative support. 1
Follow-up Imaging:
If initial CT shows intracranial hemorrhage in anticoagulated patients, repeat imaging is indicated as these patients have 3-fold increased risk of hemorrhage progression (26% vs 9%). 5
Monitoring and Resuscitation
Serial monitoring in a dedicated intensive geriatric care unit is recommended, including:
- Base deficit and lactate assessments for occult hypoperfusion. 1
- Continuous vital parameter trends (heart rate, blood pressure, respiratory rate, urinary output). 1
- Mental status monitoring. 1
- Point-of-care ultrasound (POCUS) for cardiac function and blood volume assessment if skills are available. 1
Failure to improve in GCS within the first 72 hours is associated with poor functional outcomes. 2
Outcomes and Prognosis
Outcomes after neurosurgical intervention are poor: Only 16.4% of elderly patients requiring neurosurgical intervention return home, 32.1% require extended facility care, and 41.8% die from their injuries. 4 Older patients with traumatic brain injury have double the in-hospital mortality compared to younger patients. 2
Early involvement of palliative care teams is recommended for severely injured elderly patients to improve outcomes and reduce unnecessary interventions. 2
Discharge Criteria and Follow-up
Elderly patients without loss of consciousness, amnesia, anticoagulation, or other high-risk features do not require routine head CT. 5 However, provide clear written and verbal discharge instructions about warning signs: worsening headache, repeated vomiting, altered mental status, seizures, visual changes, and swelling or deformities of the scalp. 2, 5
Consider fall risk assessment and anticoagulation risk-benefit evaluation for outpatient follow-up. 5