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Geriatric traumatic brain injury: An old challenge
Traumatismo craneoencefálico en el anciano: un viejo reto
J.A. Llompart-Pou
, J. Pérez-Bárcena
Corresponding author
Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Llompart-Pou, J. Pérez-Bárcena" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Llompart-Pou" "email" => array:1 [ 0 => "juanantonio.llompart@ssib.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Pérez-Bárcena" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Traumatismo craneoencefálico en el anciano: un viejo reto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Up to one-quarter of trauma admissions to the intensive care unit (ICU) correspond to patients over 65 years.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> It is expected that the progressive aging of the population will double the number of geriatric trauma admissions in the next decades.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Ground-level falls constitute the leading mechanism of injury because of decreased vision and hearing, slower reflexes, poorer balance, impaired motor and cognitive function, decreased muscle mass, strength, bone density and joint flexibility.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2,3</span></a> Despite these conditions, geriatric patients are currently undergoing more recreational activities.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Specifically, traumatic brain injury (TBI) represents the major challenge. The central nervous system may be impaired because of cortical atrophy and plaque buildup in the cerebrovascular vessels, making the brain a more susceptible area to traumatic injury.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Subdural hematomas are common.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Geriatric TBI patients have greater morbidity and mortality compared with younger counterparts.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2,5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Specific problems</span><p id="par0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Under-triage: This is one of the major concerns in the attention of geriatric trauma patients<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> and constitutes a modifiable factor. Mortality of these patients decreases when they are transferred to trauma centers with a high volume of geriatric trauma patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Underlying reasons of under-triage include low-energy mechanisms of injury, unconscious age bias, unreliability of vital signs, the use of medications that blunt the physiologic response to injury and the lack of specific triaging scores.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Unreliability of clinical scales: Due to the increment in the subarachnoid space, the performance of clinical scales such as the Glasgow Coma Scale (GCS) is poor. In this context, prompt evaluation, a high index of suspicion and a low threshold to perform repeated cranial tomography (CT) scans even with subtle clinical changes is mandatory.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2,5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Use of antiplatelets and anticoagulants: According to the results of <span class="elsevierStyleItalic">RETRAUCI</span>, the use of antiplatelets or anticoagulants in trauma patients admitted to the ICUs of our environment reaches half of the patients over 75 years-old.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> The use of clopidogrel and anticoagulants is associated with progression of intracranial hemorrhages and poorer outcomes.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> The use of direct anticoagulants does not seem to be associated with worst prognosis when compared to warfarin.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">How can we improve outcomes of geriatric TBI?</span><p id="par0035" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Appropriate evaluation of comorbidity and frailty: Age itself is not an accurate indicator of the ability of the geriatric patient to respond to injury. Traditional vital signs and conventional severity scores do not work well in this population. Frailty refers to a decreased physiologic reserve in multiple organ systems which leads to an impaired ability to withstand physiological stress. Frailty can be evaluated using the 15-variable Trauma-specific Frailty Index<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> and may help to determine the optimal hospital and treatment for geriatric trauma patients, since frail patients are at higher risk of poor outcomes following trauma.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Prompt evaluation and reversal of anticoagulation: Ivascu et al. published an aggressive protocol for TBI patients on prior anticoagulant treatment. By performing a rapid CT scan of the head and correction of INR to less than 1.6 within 4<span class="elsevierStyleHsp" style=""></span>h of admission, they obtained a 75% decrease in mortality for posttraumatic intracranial hemorrhage in geriatric patients.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Another controversial topic is when to resume anticoagulation therapy in patients who presented TBI. In a large-retrospective study, Albrecht et al. reported that restarting warfarin following discharge was associated with a 51% increased risk of hemorrhagic events and a 23% reduction in thrombotic events over the following year.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> No recommendations on the exact moment after TBI to restart anticoagulation can be made in the light of the current evidence and must be considered on an individual basis.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Biomarkers constitute a promising tool in the initial management of TBI patients, since they could help to identify patients more likely to present complications or die. Whilst the number of biomarkers available is increasing, to date, no specific one has been developed for geriatric TBI patients.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> The aging process and comorbid conditions can affect biomarker production, distribution, metabolism and clearance.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13,14</span></a> We believe that this is a potential area of improvement in the care of geriatric TBI patients.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Design of prospective multicenter studies in geriatric patients: Geriatric patients are usually excluded from multicenter studies evaluating neuroprotective agents in TBI. In addition, classic prognostic models do not take into consideration comorbidities. Future studies will determine whether incorporating comorbidities, baseline function or measures of frailty into these models will improve their prognostic value.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Rehabilitation: Evidence suggests that intensive inpatient rehabilitation greatly benefits geriatric TBI patients.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Unfortunately, geriatric patients are less likely to receive rehabilitation compared with younger patients.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Preventive measures: Interventions to reduce frailty in the community, including exercise, nutrition, cognitive training, geriatric assessment and management and prehabilitation are potentially effective to improve the ability to prevent and recover from injuries.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> A more restrictive use of antiplatelets and anticoagulants in the community in patients with high risk of falls must be also considered.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">How must the intensivist face geriatric TBI?</span><p id="par0070" class="elsevierStylePara elsevierViewall">Classical studies showed an ominous prognosis in geriatric severe TBI patients. No patient with admission GCS less than 9 had good 6-month outcomes. Mortality achieved 80% in this group.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Therefore, logical concerns about futility surrounded the ICU care of these patients. Routine use of neuromonitoring is controversial. Czosnyka et al. showed that older patients had lower intracranial pressure and therefore higher cerebral perfusion pressure, combined with worse vascular pressure reactivity and autoregulation.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> Neurosurgical interventions and modern neurointensive care have improved outcomes geriatric TBI.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> In our opinion, aggressive initial treatment is mandatory. After a reasonable time-frame and taking into account the comorbidities and frailty, limitation of life-sustaining therapies and palliative care must be considered in non-responding patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary, the management of geriatric TBI patients constitutes a challenge for intensivists. New prognostic models including baseline conditions, appropriate triaging and prompt reversal of anticoagulation may improve outcome. Aggressive neurosurgical and neurointensive care can achieve better outcomes than expected. Limitation of life-sustaining therapies and palliative care must be considered.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contribution</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Juan Antonio Llompart-Pou:</span> Reviewed literature. Wrote the first and final drafts of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Jon Pérez-Bárcena:</span> Reviewed literature. Critical review of the first draft. Gave final approval of the submitted version.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest related to this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Specific problems" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "How can we improve outcomes of geriatric TBI?" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "How must the intensivist face geriatric TBI?" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contribution" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-08" "fechaAceptado" => "2018-02-18" "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "en representación del Grupo de Trabajo de Trauma y Neurointensivismo SEMICYUC. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 17 | 27 |
| 2024 October | 44 | 37 | 81 |
| 2024 September | 47 | 25 | 72 |
| 2024 August | 47 | 41 | 88 |
| 2024 July | 37 | 23 | 60 |
| 2024 June | 42 | 53 | 95 |
| 2024 May | 41 | 38 | 79 |
| 2024 April | 49 | 43 | 92 |
| 2024 March | 30 | 20 | 50 |
| 2024 February | 30 | 34 | 64 |
| 2024 January | 23 | 30 | 53 |
| 2023 December | 44 | 38 | 82 |
| 2023 November | 67 | 38 | 105 |
| 2023 October | 49 | 20 | 69 |
| 2023 September | 48 | 38 | 86 |
| 2023 August | 39 | 15 | 54 |
| 2023 July | 60 | 27 | 87 |
| 2023 June | 42 | 17 | 59 |
| 2023 May | 54 | 30 | 84 |
| 2023 April | 46 | 30 | 76 |
| 2023 March | 85 | 30 | 115 |
| 2023 February | 60 | 39 | 99 |
| 2023 January | 46 | 18 | 64 |
| 2022 December | 61 | 28 | 89 |
| 2022 November | 56 | 32 | 88 |
| 2022 October | 79 | 40 | 119 |
| 2022 September | 47 | 66 | 113 |
| 2022 August | 50 | 48 | 98 |
| 2022 July | 41 | 57 | 98 |
| 2022 June | 37 | 24 | 61 |
| 2022 May | 50 | 31 | 81 |
| 2022 April | 37 | 32 | 69 |
| 2022 March | 51 | 64 | 115 |
| 2022 February | 56 | 37 | 93 |
| 2022 January | 73 | 40 | 113 |
| 2021 December | 59 | 48 | 107 |
| 2021 November | 52 | 27 | 79 |
| 2021 October | 64 | 64 | 128 |
| 2021 September | 40 | 31 | 71 |
| 2021 August | 49 | 46 | 95 |
| 2021 July | 28 | 29 | 57 |
| 2021 June | 42 | 37 | 79 |
| 2021 May | 82 | 49 | 131 |
| 2021 April | 237 | 117 | 354 |
| 2021 March | 138 | 37 | 175 |
| 2021 February | 131 | 31 | 162 |
| 2021 January | 96 | 22 | 118 |
| 2020 December | 67 | 16 | 83 |
| 2020 November | 68 | 12 | 80 |
| 2020 October | 43 | 28 | 71 |
| 2020 September | 35 | 17 | 52 |
| 2020 August | 28 | 19 | 47 |
| 2020 July | 45 | 17 | 62 |
| 2020 June | 29 | 20 | 49 |
| 2020 May | 30 | 15 | 45 |
| 2020 April | 24 | 11 | 35 |
| 2020 March | 20 | 10 | 30 |
| 2020 February | 58 | 27 | 85 |
| 2020 January | 25 | 19 | 44 |
| 2019 December | 27 | 26 | 53 |
| 2019 November | 22 | 20 | 42 |
| 2019 October | 19 | 12 | 31 |
| 2019 September | 25 | 25 | 50 |
| 2019 August | 32 | 24 | 56 |
| 2019 July | 30 | 22 | 52 |
| 2019 June | 16 | 7 | 23 |
| 2019 May | 29 | 29 | 58 |
| 2019 April | 3 | 10 | 13 |
| 2019 March | 0 | 5 | 5 |
| 2019 February | 1 | 13 | 14 |
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