Mild Traumatic Brain Injury in the Geriatric

Population Cynthia Blank-Reid, RN, MSN, CEN

Trauma Clinical Nurse Specialist

Temple University Hospital

Philadelphia, PA

Definitions

• Geriatrics

• Mild traumatic brain injury

• Positive Outcome

Geriatric Trauma—Epidemiology

• 5th leading cause of death over age

• 25% of trauma deaths• Persons >65 = Fasting

growing age group

Epidemiology

Rapid growth in elderly population - 65 or older currently represent 12% (30 million)- expected to rise to 20% (52 million) by 2020- will be 22% of population by 2030

High rate of fatalities from trauma- 28% of fatalities in those over 65- 6 times more likely to die

Chronologic Age vs. Physiologic Age

Geriatric Mechanisms of Injury

• Falls

• Motor vehicle crashes

• Pedestrian struck by motor vehicle

• Assaults

• Co-morbid disease may be precipitating factor for injury

Risk Factors

• Poor visual acuity

• Poor visual attention

• Overload of information

• Impaired reaction time

• Slower gait

• Medication side effects and interactions

• Alcohol consumption

Higher Mortality

• Higher mortality rate due to:– Age-related deterioration– Decreased stress tolerance and physiologic

reserve– Greater complication risk– Pre-existing chronic disease– Pre-existing nutritional deficits

Anatomic/Physiologic Differences in the Older Adult Trauma Patient

Neurologic

Loss of neurons in cortex Cerebellum Hippocampus

Changes in neurotransmitter systems: Dopaminergic Cholinergic Catecholamines Glutamatergic

Neurologic

• Brain weight of decreases 6 to 7%

• Brain size decreases

• Cerebral blood flow declines 15 to 20%

• Nerve conduction slows up to 15%

Neurologic

Pupil size diminished pupillary light reflex Slowed motor reaction time Gait tends to be short-stepped and guarded Ankle jerk is lost Vibratory sense in legs is diminished

Neurologic

• Bridging veins susceptible to injury

• Higher incidence of coagulopathies and anticoagulation therapy

Respiratory

• Hypoxia

• Loss of pulmonary reserve

• Reduced cough reflex

• Blunt trauma: Although rib fractures are considered a minor injury, they are major in the elderly

Cardiovascular

• Atherosclerosis• History of hypertension• Cardiac output decreases

with aging• Elderly patients need early

hemodynamic monitoring

Musculoskeletal

• Hip fractures increase with age

• Femoral neck fractures occur spontaneously

• Arthritis limits mobility, flexibility

• Degenerative changes make radiographic diagnosis difficult

Renal

• Impaired ability to concentrate urine

• Decreased glomerular filtration rate

• Slight increases in blood urea nitrogen and creatinine expected; changes considered when using contrast media and certain drugs

Integumentary

• Skin provides less cushion against mechanical forces

• More susceptible to shearing-type forces

• Impaired ability to tamponade

• Loss of thermoregulatory ability

Additional Changes

• Inadequate nutrition and pre-existing malnutrition leads to weakened respiratory muscles and ventilatory fatigue

• Slowed peristalsis and gastric motility

• Decreased BMR

• Total body water is decreased in the elderly so patients are at greater risk for hypovolemia

Additional Changes

• Medication effects – Shock may be present with normal vital signs

• May have pre-existing anemia

Psychosocial

• End-of-life decisions

• Specific directions for withholding or withdrawing treatments

• Guidelines for making treatment decisions– Patient’s right to self-determination– Patient’s best interest– Benefits of treatment outweigh adverse outcomes

Geriatric Head Injury Pearls• With aging, the brain undergoes progressive

atrophy and decreases in size by 10% between ages 30 and 70

• Subtle changes in cognition and memory make evaluation of MS difficult

• Lower incidence of epidural hematomas • Higher incidence of subdural hematomas • The increased “dead space” within the skull

may delay symptoms of ICH• Low threshold for Head CT

Types of Mild Traumatic Brain Injury in the Elderly

Types of Mild Traumatic Brain Injury in the Elderly

• Concussion

• Contusion

• Epidural

• Subdural

• Skull Fractures

• Penetrating

So What Do You Do?

• Concussion

So What Do You Do?

• Contusion

So What Do You Do?

• Epidural

So What Do You Do?

• Subdural

So What Do You Do?

• Skull Fractures

So What Do You Do?

• Penetrating

Prognosis and Outcome

• Markers for poor prognosis at admission:

- Age > 75

- GCS of 7 or less

- Presence of shock on admission

- Severe head injury

- Development of Sepsis

Prognosis and Outcome

• Mortality rate of 15 to 30% for hospitalized patients

• Debate over ethics and cost-benefits of trauma care for elderly

• Conflicting data on ability to return to independent living

Nursing Care of the Geriatric Trauma Patient—Assessment

History

• Does the patient have pre-existing medical conditions?

• What medications does the patient take?

• What were the events that led up to the injury?

• What was the patient’s functional status/neurologic status before?

• Does the patient have advance directives?

Nursing Care of the Geriatric Trauma Patient—Assessment

Inspection• Mouth for loose teeth,

partial plates, dentures• Skin: look carefully

for pressure areas, ecchymosis

Palpation• Bony prominences of

spine

Nursing Care of the Geriatric Trauma Patient—Assessment

Auscultation• Apical heart rate and blood pressure• Abnormal heart sounds (valve disease, fluid

overload)• Tachycardia as a response to shock may not

be seen• A normal blood pressure may be indicative

of shock

Diagnostic Procedures

Laboratory Testing• Electrolytes• Cardiac enzymes,

troponin• Therapeutic drug

levels• Coagulation profiles

Other Studies• Electrocardiogram• Echocardiogram• Carotid ultrasound

Factors Complicating Assessment

• Presence of multiple pathologies– 85% have one chronic disease; 30% have three

or more– One system’s acute illness stresses other’s

reserve capacity– One disease’s symptoms may mask another’s– One disease’s treatment may mask another’s

symptoms

Nursing Care of the Geriatric Trauma Patient—Planning and Implementation

Interventions• Airway

– Remove dentures, partial plates– Carefully consider need to intubate

• Spinal immobilization– Pad bony prominences– Remove immobilization as soon as possible

• Breathing– Administer supplemental oxygen

Nursing Care of the Geriatric Trauma Patient—Planning and Implementation

Interventions• Circulation

– Consider early placement of pulmonary artery catheter

• Initiate laboratory studies early.• Keep patient warm• Administer medications in doses

recommended for older adults

Assessing for Maltreatment

• Higher risk for maltreatment

• High index of suspicion

• Inconsistent history, unexplained injuries

Assessing For Maltreatment

• Unexplained – Bruises or burns

– Fractures

– Head injury

– Malnutrition

– Dehydration

• Signs of confinement

Assessing For Maltreatment

• Lack of medical attention

• Caregiver disinterest• Unusual interaction

between patient and caregiver

• Evidence of over-medication

Evaluation and Ongoing Assessment

• Assess vital signs frequently.

• Monitor cardiovascular and pulmonary response to resuscitation.

• Monitor temperature frequently.

The Distractors

• All those things that get in the way of allowing us to genuinely believe that there could be a head injury.

Dementia/Altered Mental Status

• Distinguish between acute, chronic onset• Never assume acute dementia or altered mental

status is due to “senility”• Ask relatives, other caregivers what baseline

mental status is

Dementia/Altered Mental Status

• Head injury with subdural hematoma

• Alcohol, drug intoxication, withdrawal

• Tumor

• CNS Infections

• Electrolyte imbalances

• Cardiac failure

• Hypoglycemia

• Hypoxia

• Drug interactions

Possible Causes

Cerebrovascular Accident

• Emboli, thrombi more common• CVA/TIA signs often subtle—dizziness,

behavioral change, altered affect• Headache, especially if localized, is significant• TIAs common; 1/3 progress to CVA• Stroke-like symptoms may be delayed effect of

head trauma

Seizures

• All first time seizures in elderly are dangerous• Possible causes

CVA

Arrhythmias

Infection

Alcohol, drug withdrawal

Tumors

Head trauma

Hypoglycemia

Electrolyte imbalance

Syncope

• Morbidity, mortality higher

• Consider– Cardiogenic causes (MI, arrhythmias)– Transient ischemic attack– Drug effects (beta blockers, vasodilators)– Volume depletion

Depression

• Common problem

• May account for symptoms of “senility”

• Persons >65 account for 25% of all suicides

• Treat as immediate life threat!

Rehabilitation of the Geriatric Mild TBI Patient

• Will they qualify?• Will they be taken?• Will it matter?• Does it matter?• What works and what doesn’t work.

Tips and Pearls

• Assume limited physiologic reserves

• Minor injuries may be life-threatening

• “Stable” patients may quickly become unstable

• Low threshold for head, neck, and abdominal CT

• Early invasive hemodynamic monitoring

Tips and Pearls (cont.)

• Early, aggressive O2 and mechanical ventilation

• Overresuscitation is as detrimental as inadequate resuscitation

• Liberal use of blood transfusion • Consider patient’s environment and

social situation

Prevention

• Discharged patients:

- Home safety assessment

- Carefully review medications

- Suspend driver’s license?

Summary

• Aggressive treatment approach

• There is no such thing as a mild head injury or minor trauma with the elderly

• Consider triage to trauma center