The management of older adults presenting to the ED is oftentimes complicated by frailty and comorbid chronic conditions. Traumatic brain injury (TBI) has emerged as a leading cause of injury-related morbidity and mortality among adults aged 65 and older in the United States. Previous studies suggest there are differences in both the treatment and outcomes of TBI for older people when compared with younger individuals. Older age has long been thought of as a predictor of receiving more procedures and medications for treatment of TBI in the ED. It is also believed to be a predictor of poorer outcomes after treatment in the ED.
“Among older adults, falls are the leading cause of TBI,” says Lisa C. McGuire, PhD. “As age increases, the risk for hospitalization from TBI also rises. This could be due to the increased medical complexity of the patients presenting for treatment as well as other factors. As the U.S. population ages and continues to grow, there will be greater demand for emergency services to treat TBI in older Americans.”
To better understand the use of emergency services for TBI among older people, Dr. McGuire and colleagues conducted a study using nationally representative ED data to characterize these visits. The study, published in the August 2012 Western Journal of Emergency Medicine, also compared ED visits for TBI with those made by people younger than 65. In particular, the study team assessed triage immediacy, receipt of a head CT and/or head MRI, and hospital admission by type.
Assessing Use of ED Services for TBI
The number of ED visits for TBI is increasing among adults aged 65 and older, according to results from Dr. McGuire’s study. In 2006, the number of visits to EDs for TBI was nearly 1.6 million, but it rose to 1.7 million in 2007 and jumped to 2.1 million in 2008. During the 3-year study, an estimated 5.4 million total visits to U.S. EDs were for TBI, and about 15% of these visits were made by people older than 65. Of these individuals, the average age was 80.
Adults aged 65 and older presenting to the ED with TBI utilized more advanced care services than their younger counterparts (Table 1). Nearly three-fourths of visits for TBI in older adults received attention from a physician within 15 minutes of their arrival. Most of these patients—over 80%—received a head CT and/or MRI, and about 14% required admission to specialty care.
Older patients presenting to the ED with TBI were nearly four times more likely to receive a head CT or MRI when compared with younger patients presenting with these injuries (Table 2). They were also nine times more likely to be admitted to an ICU, a step-down unit, or to receive surgery. Admission to specialty care was also significantly higher for older adults than younger patients. Dr. McGuire adds that age was not a significant predictor in determining triage immediacy for visits, but it was an indicator for greater use of services. “This means that age could be used as a triage consideration in patients with head trauma presenting to EDs.”
Decreasing Falls & TBI Among Elderly
Considering the increasing incidence of TBI among older adults, as well as their higher likelihood of having comorbid chronic conditions and requiring additional healthcare services, Dr. McGuire recommends that efforts be made to identify these injuries as quickly as possible. “EDs should be aware that many older Americans who are prone to falling could be on antiplatelet and anticoagulant medications,” she says. “They are at substantial risk of sustaining life-threatening consequences from TBIs.”
Costs resulting from TBI can be considerable. Studies from the CDC have estimated that total costs from TBI among people aged 65 and older average more than $5 billion annually. Furthermore, older patients who have TBIs often become physically and financially dependent on others after their injury. “In addition to costs, patient quality of life can suffer greatly,” says Dr. McGuire. “One way to reduce this burden is to increase efforts to disseminate fall prevention educational materials to older patients. We also need to gain a better understanding of the scope and the impact of this phenomenon on EDs. This information will help optimize our management of TBI in older adults.”
Readings & Resources (click to view)
CDC. Falls – older adults. Available at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html.
Pearson WS, Sugarman DE, McGuire LC, Coronado VG. Emergency department visits for traumatic brain injury in older adults in the United States: 2006-08. Western J Emerg Med. 2012;13:289-293. Available at: http://escholarship.org/uc/item/5hk760x4.
Faul M, Xu L, Wald MM, et al. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
Bazarian JJ, McClung J, Cheng YT, et al. Emergency department management of mild traumatic brain injury in the USA. Emerg Med J. 2005;22:473-477.
Brazinova A, Mauritz W, Leitgeb J, et al. Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old. J Neurotrauma. 2010;27:1549-1555.
Brewer ES, Reznikov B, Liberman RF, et al. Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma. 2011;70:E1-E5.
Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma. 2004;56:1042-1048.
Frankel JE, Marwitz JH, Cifu DX, et al. A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay. Arch Phys Med Rehabil. 2006;87:57-62.
Testa JA, Malec JF, Moessner AM, et al. Outcomes after traumatic brain injury: effects of aging on recovery. Arch Phys Med Rehabil. 2005;86:1815-1823.