Management of Traumatic Brain Injury in the Older Adult

Blessen C. Eapen, Carlos A. Jaramillo, and David X. Cifu

INTRODUCTION

This chapter will review the general aspects of traumatic brain injury (TBI) rehabilitation of the older adult (aged 65 and older).

Normal age-related changes of the brain include:

• Brain atrophy (deceased brain volume and weight)

• Increased bridging vein fragility

• Increased adherence of dura to skull

• Decreased cerebral autoregulation and cerebral perfusion reactivity

These neuroanatomical and neurophysiologic changes make the elderly brain more susceptible to TBI and its complications.

DEMOGRAPHICS

The U.S. Census Bureau estimates that adults over 65 years of age will represent nearly 20% of the total population in 2030 and may include some 83 million individuals by 2050 [1]. From 1997 to 2007, those over 65 years of age were at greatest risk of TBI, with rates higher for males than for females and with the highest rates of TBI-related hospitalization and death occurring in those 75 years of age and older [2].

ETIOLOGY

The most common causes of TBI in older adults are [2]:

1. Falls

2. Traffic-related events (e.g., motor vehicle crashes [MVCs] and pedestrian struck)

3. Assault

Falls, which are typically low velocity injuries, result in focal brain injuries, most commonly subdural hematomas (SDH) and/or focal cortical contusions [3]. Elders on anticoagulation/antiplatelet agents have a higher likelihood of having intracerebral hemorrhage. MVCs may result in diffuse axonal injury (DAI), focal contusions, or SDH [4]. Pedestrian motor vehicle collisions frequently occur at crosswalks and in parking lots. These accidents result in DAI, SDH, or focal contusions but can also involve skeletal trauma and visceral injuries. Assaults and violent acts, although rare, are increasing among elderly people, and may result in focal contusions, skull fractures with SDH, epidural hematomas (EDH), and intracranial bone or bullet fragments.

RISK FACTORS

Falls

• Chronic: neurological disease (cerebrovascular accident, Parkinson’s disease), diabetes (sensory impairment), dementia, visual impairments (glaucoma, cataracts), musculoskeletal disease

• Short term: episodic postural hypotension, acute illness, alcohol use, medication effects, polypharmacy

• Activity related: tripping while walking, descending stairs, climbing ladders

• Environmental: poor lighting, nonsecure throw rugs, or ill-fitting shoes

• Slow reaction time and walking pace can also predispose older adults to motor vehicle accidents and pedestrian accidents, respectively [5,6]

Traffic-Related Events

Older drivers have a higher rate of fatality per mile driven compared with those between the ages 30 and 69, with the highest rates among drivers over the age of 85. The higher rates of serious injury and fatality among older adults involved in MVCs appears to be related to age-related susceptibility to serious injury and medical comorbidities, which complicates recovery from injury [7].

CLINICAL PRESENTATION

When compared with younger individuals, older adults more often have an initial Glasgow Coma Scale score of 13 to 15 (i.e., mild TBI), with a time from onset of injury to following commands usually at 1 day or less. SDH is also more common in older adults than in younger individuals. Elderly individuals are particularly vulnerable to SDH because bridging veins become more susceptible to shearing forces as the brain naturally atrophies with advancing age.

Morbidity

TBI in the older adult often results in a higher morbidity because of concomitant medical problems. A brain injury physician should be involved from initial hospitalization to assist in minimizing secondary complications such as pressure ulcers, contractures, deep venous thromboembolisms, cardiac deconditioning, aspiration precautions, and bowel/bladder management, in addition to assessing medical comorbidities, such as cardiovascular disease, diabetes, neuromuscular disease, and dementia, which may have challenged function before injury.

Common Comorbid Complications

• Fractures—affect weight-bearing status and need for assistance.

• Cardiopulmonary complications—low ejection fraction and vital capacity can affect ability to participate in rehabilitation and live independently.

• Pain—can be preinjury neuropathic, musculoskeletal or vascular pain, or postinjury pain caused by trauma. Regardless of cause, pain must be assessed and treated appropriately. Care must be taken when choosing pain medications given the physiologic differences in drug metabolism between elderly patients and young adults. For example, opioids may easily lead to delirium and nonsteroidal anti-inflammatory drugs (NSAIDs) may further compromise renal function.

• Swallowing—may be compromised from injury or preexisting pathology (e.g., cerebrovascular accident), resulting in need for alternative feeding methods or modified diet.

• Polypharmacy—specific to older adults who may be on multiple preinjury medications and may have difficulty managing medication administration instructions.

• Deep venous thrombosis prophylaxis and treatment—need to consider both optimal timing of initiating prophylaxis as well as whether fall risk mitigates against starting therapeutic anticoagulation.

TREATMENT

Rehabilitation

The rehabilitation approach to an older adult with TBI requires an understanding of preinjury level of function, medical comorbidities, cognitive impairments, and behavioral issues. In addition to a thorough medical review, a detailed review of the elder’s social support network is critical. This is a key factor to help the rehabilitation team set goals that are realistic for the patient’s anticipated discharge environment. Specific areas of focus in a rehabilitation program for the older adult are discussed in the following sections.

Medication Management

The majority of the population above 65 years of age takes at least one prescription medication daily, with a majority taking over five medications [8]. Therefore, concern must be given to polypharmacy, which will likely complicate care on discharge and could lead to adverse events and outcomes. This is especially important in elderly patients who will likely have age-related decline in hepatic and renal drug clearance.

Medications may change during the acute and chronic recovery periods. Therefore, educating the patient and caregivers on proper medication timing and dosing is important when transitioning a patient through the acute phase to rehabilitation, and eventually to discharge from a hospital setting.

Bladder and Bowel Continence

Normal aging may affect bladder function because of prostate hypertrophy (in men), pelvic relaxation (in women), decreased bladder capacity with urinary frequency, and decreased capability to suppress bladder contractions at low volumes, resulting in urinary urgency [9]. TBI can result in urinary incontinence related to an inability to sense bladder fullness, an inability to suppress the pontine micturition center’s automatic emptying at key volumes, or increased frequency caused by a urinary tract infection. Assessment of preinjury voiding patterns is helpful in discerning underlying pathology, independent of the effects of TBI.

As with the bladder, bowel routines are typically disrupted during hospitalization. In the older adult, disruption of the bowel routine can become a preoccupation unless properly addressed. Assessing preinjury bowel routine is the first step in establishing goals. Continence should be a significant focus of rehabilitation efforts in older adults, because this can determine an individual’s independence and level of caregiver burden.

Sensory Health

Vision

Normal aging is associated with changes in visual acuity and refractive power, decrements in extraocular motion, increases in intraocular pressure, decreased tear secretion, and decreased corneal and lens function. These conditions could be compounded by additional visual disturbances after head injury and put the patient at increased risk for falls. Identifying visual changes due to TBI as well as preexisting visual problems is essential to the rehabilitation process.

Hearing

Normal aging is associated with high-frequency hearing loss and signal distortion at higher frequencies, difficulty localizing signals needed for binaural hearing, and difficulty understanding speech in unfavorable listening conditions. Traumatic injuries can result in disruption of the ossicular chain, or cranial nerve VIII becoming selectively damaged. Preinjury hearing aids may be less effective, which can hinder the accurate communication needed to help older adults through the rehabilitation process.

Smell

Normal aging is associated with decreased sense of smell and is associated with decreased appetite and poor nutritional intake in the elderly. This is important to consider because the olfactory nerve is the most frequently injured cranial nerve after a TBI and further disruption of smell may affect an individual’s appetite. Decreased smell may also negatively affect the ability to detect burning objects. Home evaluation should include appropriate placement of smoke detectors.

Taste

Normal aging is accompanied by the loss of lingual papillae, decreased saliva volume, and relative decrement of taste acuity. Loss of smell caused by a TBI may further impair the sense of taste, which can result in poor oral intake.

Touch, Vibration, Joint Position Sense

Position sense diminishes with age; this may be accelerated by the presence of peripheral neuropathy, which should be evaluated and treated/managed. This is concerning after TBI in the elderly because impaired balance is a common occurrence. Compensation techniques and assistive devices may help an individual adapt to these impairments [10].

Behavior and Cognition

Dementia affects 3% to 11% of community-dwelling adults above the age of 65, and 20% to 50% of adults above the age of 85. Preinjury cognition and behavior need to be assessed in order to set appropriate and realistic rehabilitation goals. Neurostimulants, typically used to address arousal and attention after TBI, should be prescribed with caution in elderly patients because of age-related changes in drug metabolism [11].

Sleep Disturbance

Normalizing the sleep–wake cycle is important after a TBI to optimize recovery. Behavioral and environmental modifications are usually first-line interventions. In considering medication management, note the following considerations specific to older adults: (a) diphenhydramine should not be used owing to the risk for urinary retention and cognitive worsening; (b) benzodiazepines should be avoided due to paradoxical reactions in elderly people; and (c) tricyclic antidepressants can cause postural hypotension and urinary retention, and are poorly tolerated.

Sexuality

Sexuality is commonly ignored in older adults, but at any age sexuality gives one a sense of self, and capacity to show love and affection and maintain intimate relationships. Normal aging can result in physiologic changes to the vaginal mucosa, erectile function, and orgasmic performance. Sexual desire may change (increase or decrease) after TBI; therefore, it is important to screen for sexual and relationship concerns in older adults and educate patients and families about changes. Sildenafil, tadalafil, and vardenafil are usually contraindicated in older adults because of frequently occurring comorbid cardiac conditions, such as coronary artery disease and hypertension [12].

Safety

Home evaluations by rehabilitation team members are important to assess safety risks in the home, to prevent future injury secondary to falls or wandering. Home assessments help with determining functional goals during the rehabilitation process, durable medical equipment needs, and the need for home modifications.

Substance Abuse

Substance abuse, and unhealthy alcohol use in particular, is common among elderly adults in the United States [13]. Illicit and improperly used substances including alcohol may significantly complicate recovery from a brain injury by interacting with prescribed medications, slowing central nervous system (CNS) healing, and impairing motor function. This puts the patient at risk for falls and other adverse events. Therefore, screening for substance abuse in older adults is important for improving long-term outcomes and safety. An aggressive, tailored treatment program for substance abuse in the older adult is important if these issues are identified, and family education is a key component of treatment.

Community Reintegration

Rehabilitation programs should focus on physical, cognitive, and behavioral deficits after brain injury while promoting social reintegration and improved quality of life. Community mobility can often be a concern and the rehabilitation program should focus on route finding, negotiating different terrains, and appropriate use of public transportation. This can help with an individual’s ability to resume leisure activities and minimize feelings of isolation.

Elder Abuse

Elder abuse has been increasing in prevalence, especially among those with poor social support. Not only physical abuse, but also emotional (e.g., neglect) and financial abuse are increasing. The importance of understanding a person’s social support and providing family education after a TBI cannot be emphasized enough [14]. Identifying an abusive environment will require sensitivity to these issues and interaction with the patient’s social support network regularly during the rehabilitation process.

AGING WITH TBI

The normal aging process is associated with declines in certain cognitive abilities, such as processing speed and some aspects of memory, language, visuospatial function, and executive function. After TBI, there can be an earlier onset of Alzheimer’s dementia in a subpopulation of those already susceptible to it [15]. In addition, repeated TBIs appear to predispose individuals to accelerated degeneration of the brain, most classically seen in chronic traumatic encephalopathy [16]. Neuropsychological impairments after a TBI in the older adult often parallel the changes seen with normal aging, with diminished ability to attend, concentrate, and recall, although long-term recall is more often affected due to aging as opposed to TBI.

OUTCOME

Data from the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model systems from 1995 to 2002 revealed that when compared with individuals aged 50 years or younger, individuals aged 55 years and older had only a 5-day longer rehabilitation length of stay and marginally higher costs of care, but demonstrated greater disability as measured on the Disability Rating Scale and Functional Independence Measure, and a decreased percentage of return to a private residence at discharge. On the Supervision Rating Scale, individuals aged 65 and above have demonstrated the need for a higher degree of supervision for their day-to-day care 1-year postinjury [17].

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