Geriatric traumatic brain injury – What we know and what we don’t

The issue of geriatric trauma is a significant and growing concern among trauma surgeons. The outcomes of geriatric patients with traumatic brain injury are worse than younger cohorts and the number of traumatic brain injury (TBI)-related hospitalizations and fatalities in elderly patients will continue to increase as the world’s population ages. Although guidelines for the treatment of TBI have been established, they do not address the challenges of managing TBI in older patients. Issues of anticoagulation reversal, confounding of clinical exam by premorbid conditions, and optimal timing and frequency of imaging remain poorly studied. Additionally, current guidelines for optimal management of blood pressure, intracranial monitoring, cerebral perfusion pressure and operative management fail to address the unique concerns in the geriatric patient. Prognostication of acceptable outcomes in older patients with TBI is more challenging compared to younger cohorts and require early palliative care approaches targeted to the geriatric patient. Geriatric-specific research is sorely needed in nearly all aspects of TBI care. Given the paucity of data available, this non-systematic review seeks to outline the unique considerations of the geriatric patient with TBI and highlight what is currently unknown about the best way to care for elderly patients with TBI

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS: We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS: Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of \u3c9 \u3e(OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION: Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III