Management of mild brain trauma in the elderly: Literature review

Key-words:

Brain trauma - elderly - head injury - head trauma - mild brain trauma

Introduction

The world population is aging. It is estimated that almost two billion people will be older than 60 years by 2050.[[1]] In the USA, in 2030, one in five residents is expected to be 65 years or older with a projection to doubling the current number in 2050.[[2]] A similar trend has been observed in Canada.[[3]]

As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions,[[4]] causing a challenge for the health-care system worldwide.

Traumatic brain injury (TBI) represents a major cause of mortality and morbidity which involves globally more than 10 million individuals annually,[[5]] with no substantial differences in the incidence between low- and high-income countries.[[6]]

Since TBI used to be prevalent in young people, nowadays, we are witnessing in a shift in the epidemiology of TBI toward the elderly.[[5]] This is the result of mainly two factors: first, the aging of population as seen above; second, the decrease of traffic accidents due to the improvement of traffic safety which allowed falls to become the most important cause of TBI. Moreover, falls account for over 65% of TBI-related hospital admissions in the elderly.[[7]]

Epidemiologic studies show that the majority of TBI in older patients is mild with an incidence ranging from 60% to 80%.[[3]],[[8]],[[9]]

Mild TBI (mTBI) is defined by the Neurotraumatology Committee of the World Federation of Neurosurgical Societies as a head injury presenting with Initial Glasgow Coma Score (GCS) of 14 or 15.[[10]] History of loss of consciousness (LoC) and posttraumatic amnesia may be or not be present. Consider 65 years as a cutoff for the elderly is widely accepted in the international literature, mostly after the report of Mosenthal et al. which demonstrates the age 65 and more to be a predictor of increased mortality after TBI.[[11]]

This cohort of patients represents a challenge for clinicians because of the unique physiologic and clinical factors, including frailty, chronic health diseases and polypharmacy, which make them more prone to primary and secondary injury following TBI, regardless of severity.

Frailty is defined as a syndrome of decreased reserves (energy, physical ability, cognition, and health) that gives rise to vulnerability in times of acute stress.[[12]] It has been calculated that about 7% of the people older than 65 years and 20% older than 80 years have frailty syndrome.[[12]]

Despite what was discussed above, the researcher in the last 15 years does not seem to have found interest in exploring a common address for the management of mTBI in the elderly.

In 2004, the World Health Organization instituted a task force on mTBI with the scope of finding methodological issues and research recommendations.[[13]] After 10 years, the main research priorities included focus on the elderly and the development of validated clinical prediction rules for the prognosis.[[14]]

In 2015, the American Association for the Surgery of Trauma performed a member survey disclosing that 65% of the participants thought that geriatric trauma patients are undertriaged and not transferred appropriately to the higher levels of care. Reported concerns were the lack of uniformly accepted protocols, primarily for mTBI.[[15]]

More recently, a group from the University of Cambridge completed an extensive epidemiologic literature review with the conclusion that though increased admissions of elderly patients following TBI there was little or no evidence of corresponding increase of age of patients recruited for TBI in studies around the world.[[16]]

Finally, in a large cohort study including about 6000 mTBI older patients, Cheng et al. concluded that mTBI is an independent significant risk factor of death in the elderly and emphasized the need for head injury prevention and research.[[17]]

The aim of this review is to point out the state of the art of the literature focused on mTBI in the elderly with the scope of delineating specific and practice rules for the management and to define the lacking areas of research.

Methods

This literature review study was conducted in accordance to the recommendations outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement during the reporting of the current study's findings.[[18]] A literature search using PubMed was performed for English human studies published in the last 15 years using the following keywords: “traumatic brain injury AND elderly” and “head injury AND elderly.” The literature search was conducted on March 6, 2019.

Study selection

Studies were included if they met focus on mTBI in the elderly defined as people aged >65 years. The exclusion criteria were as follows: (1) animal studies and case reports, (2) studies focusing on severe and/or moderate TBI, (3) studies focusing on pediatric patients, (4) studies that had reported data without distinction of age and trauma severity, (5) clinical trial still in progress, and (6) full-text reports unavailable on-line.

Each retrieved article was screened for eligibility by two independent reviewers (FM and GT) first at the title and abstract level, and then full-text level if potentially relevant. The references of the included articles had been also evaluated and articles that met our criteria had been comprised in the review [[Figure 1]].

Figure 1: Flow diagram for studies identification and selection process

Results

A total of 388 studies were identified, and after duplicates exclusion, 359 unique abstracts were screened. Abstracts were evaluated by the first author (FM), and 148 potentially relevant articles were selected for full-text review and subsequently obtained and assessed for eligibility by two authors (FM and GT). Additional 15 full-text articles were identified through references. Finally, a total of 68 articles met all eligibility criteria and were selected for the review.

Quality assessment was achieved categorizing each study by level of evidence (LoE), according to the framework proposed by Sauaia et al. for the surgical research.[[19]] We found 10 prospective prognostic and diagnostic studies (LoE I); 4 prospective therapeutic/care management studies (LoE II); 3 prospective prognostic and epidemiological studies (LoE II); 31 retrospective prognostic studies and 2 prognostic case-control studies (LoE III); one therapeutic case–control study and one retrospective epidemiological study (LoE III); 2 epidemiological studies (LoE IV–V) and 3 prognostic studies (LoE V). We collected three systematic reviews of predominantly level II studies with no negative criteria (LoE II); 4 systematic reviews with up to two negative criteria (LoE III); 4 reviews (LoE IV). Overall, we collected 29% high-quality studies (LoE I or II) and 71% low-quality studies (LoE III or V). Studies were published between 1997 and 2018.

Extensive reading of the selected articles permitted to identify the major concerns of the recent literature about mTBI in the elderly to be discussed on. A total of 8 focused on epidemiology. Risk factors were reported in six articles. Thirty-five addressed the management of mTBI whom a total of 25 focusing patients on anticoagulation/antiplatelet (AP) therapy, and one described seizure therapy. Outcome and mortality were analyzed by 19 papers. All studies and their main characteristics are presented in [[Table 1]] [Appendix A].

Table 1: Characteristics of selected studies

Table 1: Contd...

Only 8 studies (11,76%) were designed to assess exclusively elder mTBI patients, with the rest presenting mixed cohorts for age and severity. Due to the high heterogeneity of the topics found, statistical analysis was not performed.

Discussion

The aging of the world population and the increase in life expectancy subject both emergency and neurosurgery departments to everyday challenges related to the management of TBI in the elderly. This is especially true for those with a mild trauma because it is estimated that 82% of older patients hospitalized for mTBI return to independent living after completing the medical, surgical, and physical treatments.[[11]] Triage and appropriate treatment should be uniformed to obtain the better results in terms of outcome for patients and cost-effectiveness for health-care system. As most of the international literature is focused on younger patients or severe TBI, and nonspecific guidelines exist, older mTBI patients are often undertriaged and the entity of trauma may be underestimated.

The results of our literature review were grouped and evaluated according to the major concerns emerged.

Risk factors for traumatic brain injury and prevention

Mechanisms accounting for TBI in the elderly may be the same of younger people. Nonetheless, most of TBI in the elderly are attributable to falls either from standing or from heights,[[9]],[[20]],[[21]],[[22]],[[23]] accounting for over 80% of TBI hospitalizations and in-hospital mortality.[[21]]

Mild cognitive impairment or dementias, comorbidities, ambulation with assistance, and polypharmacy have been demonstrated as the risk factors for falls in older adults and subsequent admission for fall-related TBI (fr-TBI).[[9]],[[20]],[[21]]

However, even in the absence of comorbidities, older age is associated with an increased risk of falls due to physiologic age-related deterioration of physical functions in balance, vision and hearing, physical strength, gait, and dexterity.[[21]],[[22]]

Finally, older adults are particularly susceptible to suffering iatrogenic effects of medications because of the increased risk of polypharmacy, defined as the simultaneous use of multiple medications such as anticoagulants (ACs), psychotropics, and sedatives, defined as “fall risk-increasing drugs.”[[22]],[[24]] Polypharmacy represents a relevant problem as it has been shown that more than 20% of older Americans receive at least one inappropriate drug.[[25]] Physicians must carefully weigh the risk-benefit ratio when making decisions to prescribe medication such as AC therapy to patients who are at a high risk of falling.[[26]] The Prevention of Falls in the Elderly Trial demonstrated the fundamental role of falls prevention with appropriate interventions, including the following: exercise programs aimed at improving strength and balance; vision assessments to correct poor eyesight; educational programs to encourage safer behavior among patients and families; periodic medication review to eliminate unnecessary medications or mitigate iatrogenic effects.[[27]]

However, there is some controversy in the literature regarding the optimal combination of these interventions, and the best prevention strategy for fr-TBI in the elderly has still to be elucidated.[[21]],[[26]]

Admission versus observation

The overall assessment of a geriatric mTBI patient requests an interdisciplinary collaboration to improve diagnosis and treatment of underlying comorbidities, management of medications, and to address the most appropriate care setting.[[4]]

It is estimated that 65% of annually visited TBI elderly patients in the emergency departments require admission,[[28]] thus establishing the guidelines to define the criteria for observation and discharge is mandatory.

Mild head trauma in older population is not as mild as in younger patients. Several studies showed a discrepancy of observed GCS between the elderly and young patients with similar anatomic severity of TBI, with geriatric TBI having better GCS than younger patients.[[29]],[[30]] This creates a false idea that the elderly could tolerate equivalent injuries better, leading to underestimate the entity of TBI. The mechanisms behind this phenomenon are unknown, but they are certainly related to comorbidities and differences in physiological response to injury.

Although LoC has a strong predictive value for intracranial hemorrhage (ICH),[[31]] most older patients with mTBI who require surgical intervention do not have a history of LoC.[[32]] These data suggest that GCS and neurology examination alone cannot reliably exclude significant intracranial pathology in the elderly with mTBI. Given the lack of validated clinical evidence for identifying mTBI older patients who can be managed without cranial computed tomography (CT), radiological evaluation is always needed,[[33]],[[34]],[[35]]

Clinical observation is also often involved because it has been showed that 80% of patients in need of neurosurgical intervention can be identified by worsening of symptoms during the first 6 h.[[36]]

Admission criteria to a trauma center are strongly correlated with the presence of co-injuries, clotting disorders, and preexistent diseases. The role of anticoagulation/AP therapy is discussed further in this section. Certainly, elderly patients on anticoagulation and documented intracranial pathology should be admitted to the neurosurgical department.[[28]] In case of normal CT and elevated international normalized ratio (INR), mTBI patients should be observed for 12–24 h,[[37]] and those with normal INR and CT, and no other associated injury, may be discharged and followed-up at home by a care provider.[[28]]

Several authors suggested that most of observed patients can be safely discharged without a second CT scan, in the absence of clinical impairment, due to the low rates of delayed ICH occurring after 24 h from trauma.[[38]],[[39]],[[40]],[[41]],[[42]],[[43]]

Finally, coinjuries and chronic diseases are considered the positive predictors of worse outcome and mortality when associated to mTBI in the elderly, claiming admition to a trauma center.[[1]]

A comprehensive flow chart for the management is provided in [[Figure 2]].

Figure 2: Flowchart for management of mild traumatic brain injury in elderly patients. Co-injuries and anticoagulant therapy must be combined (GCS: Glasgow Coma Score; CT: Computed tomography; LoE: Level of evidence)

The role of anticoagulation/antiplatelet therapy

Anticoagulants (ACs), APs, and the more recent direct oral anticoagulants (DOACs) are frequently used among the elderly. This trend, together with the high risk of falling, determines a difficult dilemma for clinicians who have to balance the risk of ICH with thromboembolic complications. Therefore, benefits may not always outweigh the risks. Even though an ICH may also occur in patients not taking any ACs or APs medications,[[44]] it is well known that long-term oral anticoagulation is an independent risk factor for both immediate and delayed ICH, and it is significantly associated with worse outcome and higher mortality.[[45]],[[46]] Risk's classification for ICH requiring surgery according with GCS score and clinical manifestations is resumed in [[Table 2]].[[44]] The management of these older mTBI patients is still largely debated in the literature and a common strategy has not yet been achieved. ACs drugs like warfarin are associated with the higher increased risk for ICH in the setting of TBI[[47]] and with elevated chances of ICH progression in the follow-up period.[[48]] Conversely, DOACs have a considerably lower rate of development of ICH compared to warfarin[[49]],[[50]] and lesser chances of ICH progression.[[48]] These data support the safer profile of DOACs than ACs, suggesting that they should be used as first choice in older patients with high risk of falling. However, warfarin and DOACs users have similar mortality rates,[[48]] reflecting the fact that every effort to prevent falls should be accomplished in patients who need ACs or DOACs therapy. APs use also confer a slight increase rate of ICH,[[47]],[[51]] particularly clopidogrel more than aspirin,[[41]] but they are not associated with higher mortality if not used in combination.[[48]] Part of the management of mTBI elderly patients on ACs or APs therapy involves the need of discontinuation and/or reversal of these drugs. In case of ICH at the initial CT scan, prompt reversal of warfarin with fresh frozen plasma demonstrated to be effective in decreasing ICH progression and mortality.[[52]] Furthermre, APs and DOACs should be discontinued in this setting, but potential drawbacks are the inability to rapidly reverse DOACs, as an antidote is not always available, and that platelet transfusion is not associated with benefit in mortality and outcome in case of aspirin or clopidogrel usage.[[53]] Patients on ACs or APs therapy with initial normal CT scan have a cumulative incidence of delayed ICH very low (<1%), and there is no evidence that their therapy must be reversed or discontinued.[[41]] Nevertheless, supratherapeutic INR levels should be taken back to therapeutic range in all mTBI patients. When neurosurgical intervention for ICH is needed, ACs or DOACs reversal may facilitate clot evacuation and limit recurrences. A flowchart for a proposed management based on our review is provided in [[Figure 3]]. Despite this extensive literature search, no clear indications are emerged on when to restart ACs or APs medications if discontinued after a mTBI.

Table 2: Stratification of risk of hematoma requiring neurosurgical intervention

Figure 3: Flowchart for management of anticoagulant/antiplatelet therapy in mild traumatic brain injury elderly patients (ACs: Anticoagulants; APs: Antiplatelets; DOACs: Direct oral anticoagulants; INR: International normalized ratio; ICH: Intracranial hemorrhage; mTBI: Mild traumatic brain injury; CT: Computed tomography; LoE: Level of evidence)

Seizure risk and prophylaxis

TBI is known to contribute to 4%–9% of all epilepsy cases, particularly mTBI is associated to a double risk for seizures in the general population.[[54]] Related TBI epilepsy is defined as at least one seizure occurring 7 days or later after the trauma; isolated seizure occurring in the first 7 days is considered as acute symptom.[[54]]

New onset seizures in older patients are often focal and can differ for semiology from younger patients. Subtle and noncharacteristic symptoms lead to delayed diagnosis and include syncope, memory problems, confusional episodes, or mental status changes.[[55]] Only one report matches our inclusion criteria. In this large prospective case–control study, Mahler et al. assessed a cumulative relative risk of 2.5 in mTBI patients older than 65 years, which increased six times with a brain contusion. Conversely, an isolated skull fracture was not associated with an increased risk.[[54]] Based on these few data, seizure prophylaxis cannot be recommended in all cases, but physicians should be aware of the subtle and noncharacteristic symptoms to promptly confirm the diagnosis with an electroencephalogram and to start therapy if needed.

Outcome

Long-term impact of mTBI on the patient, their family and society cannot be underestimated. It is mainly associated with loss of independence and cognitive decline secondary to the trauma. The high impact for the health-care systems is also reflected by the prolonged hospitalization and the needing for rehabilitative therapy. In the acute settings at the time of hospitalization, literature data showed that 45% of mTBI elderly patients could be discharged at home, 38% need physical or cognitive rehabilitation, and 8% need a long-term placement.[[56]] Mortality is still high, reported as about 8%,[[46]],[[56]],[[57]],[[58]] and it has a strong and linear correlation with age. Moreover, 23% of discharged mTBI elderly patients have severe disability.[[11]] It is possible that these discouraging reports may have led to an undertreatment for these patients in the last years. However, there are suggestions that outcome may be improved with more invasive monitoring and aggressive care.[[58]],[[59]] Furthermore, a recent prospective study demonstrates that elderly TBI patients benefit from highly specialized rehabilitation, and it fails to prove inferiority regarding the younger age group.[[60]] Furthermore, for patients who need neurosurgical intervention, evidence that craniotomy will negatively affect outcome is lacking. When operated, mTBI elderly patients show a more favorable outcome than who do not undergo surgery.[[56]],[[61]] Our review supports the idea that age should not be the sole factor for limiting care in mTBI patients. Physicians should be aware that older patients with mTBI deserve prompt and aggressive care and rehabilitation, as they can respond similarly to younger patients. However, the retrospective nature of this supporting data must be reinforced by more prospective studies.

Limitations

This study is mainly subject to the classical limitation of all reviews: the overall quality of the studies included. The majority of studies presented level II or less, and only 6 studies (8%) were LoE I. Moreover, there is a high heterogeneity in the literature focused on elderly TBI patients, and very few articles consider primarily mTBI. This made it necessary to carry out a research work oriented in extracting data that could involve some bias in patients' selection and outcome results. Finally, the obtained data were not suitable for meta-analysis to reach the evidence of a systematic review and the given recommendations are only based directly on the LoE of the studies selected.

Conclusion

Assuming that life expectancy is constantly increasing as well as the world population over the age of 65 years, reduction in mortality and morbidity should be the aim of managing patients with TBI in this cohort. Since severe TBI still represents a challenge in both young and older people, current outcome data from mTBI in elderly show a condition that cannot be sustained in the future by families, society, and health-care systems.

There is a strong need for more research on geriatric mTBI addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies based on the identification of patients who have chance of unfavorable outcome despite mild trauma.

Age alone should not limit care in these patients because they can have a good outcome if properly treated.

Appendix A

Complete references for Table 1 (alphabetic order)

1. Adams SD, Holcomb JB. Geriatric trauma. Curr Opin Crit Care 2015;21:520–526 doi:10.1097/MCC.3041773041770246.

2. Batey M, Hecht J, Callahan C, Wahl W. Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly. Surgery 2018;164:814-9.

3. Beynon C, Potzy A, Sakowitz OW, Unterberg AW. Rivaroxaban and intracranial haemorrhage after mild traumatic brain injury: A dangerous combination? Clin Neurol Neurosurg 2015;136:73-8.

4. Bouras T, Stranjalis G, Korfias S, Andrianakis I, Pitaridis M, Sakas DE. Head injury mortality in a geriatric population: differentiating an “edge” age group with better potential for benefit than older poor-prognosis patients. J Neurotrauma 2007;24:1355-61.

5. Brousseau AA, Emond M, Sirois MJ, Daoust R, Griffith LE, Lang E, et al. Comparison of functional outcomes in elderly who have sustained a minor trauma with or without head injury: A prospective multicenter cohort study. CJEM 2017;19:329-37.

6. Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am 2007;25:837-60.

7. Campiglio L, Bianchi F, Cattalini C, Belvedere D, Rosci CE, Casellato CL, et al. Mild brain injury and anticoagulants: Less is enough. Neurol Clin Pract 2017;7:296-305.

8. Cetty L, Abdin E, Vaingankar JA, Jeyagurunathan A, Chua BY, Picco L, et al. Prevalence and correlates of traumatic brain injury (TBI) in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study. Int Psychogeriatr 2017;29:1899-907.

9. Cheng PL, Lin HY, Lee YK, Hsu CY, Lee CC, Su YC. Higher mortality rates among the elderly with mild traumatic brain injury: A nationwide cohort study. Scand J Trauma Resusc Emerg Med 2014;22:7.

10. Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK; Consortium ftSCPR. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surg 2018;153:570.

11. Clement CM, Stiell IG, Schull MJ, Rowe BH, Brison R, Lee JS, et al. Clinical features of head injury patients presenting with a glasgow coma scale score of 15 and who require neurosurgical intervention. Ann Emerg Med 2006;48:245-51.

12. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma 2006;60:553-7.

13. Collins CE, Witkowski ER, Flahive JM, Anderson FA, Santry HP. Effect of preinjury warfarin use on outcomes after head trauma in medicare beneficiaries. Am J Surg 2014;208:544-9.e541.

14. Cruise CM, Sasson N, Lee MH. Rehabilitation outcomes in the older adult. Clin Geriatr Med 2006;22:257-67,de Guise E, LeBlanc J, Dagher J, Tinawi S, Lamoureux J, Marcoux J, et al. Traumatic brain injury in the elderly: A level 1 trauma centre study. Brain Inj 2015;29:558-64.

15. Depreitere B, Meyfroidt G, Roosen G, Ceuppens J, Grandas FG. Traumatic brain injury in the elderly: A significant phenomenon. Acta Neurochir Suppl 2012;114:289-94.

16. Evans D, Pester J, Vera L, Jeanmonod D, Jeanmonod R. Elderly fall patients triaged to the trauma bay: Age, injury patterns, and mortality risk. Am J Emerg Med 2015;33:1635-8.

17. Filer W, Harris M. Falls and traumatic brain injury among older adults. N C Med J 2015;76:111-4.

18. Flaada JT, Leibson CL, Mandrekar JN, Diehl N, Perkins PK, Brown AW, et al. Relative risk of mortality after traumatic brain injury: A population-based study of the role of age and injury severity. J Neurotrauma 2007;24:435-45.

19. Flanagan SR, Hibbard MR, Gordon WA. The impact of age on traumatic brain injury. Phys Med Rehabil Clin N Am 2005;16:163-77.

20. Franko J, Kish KJ, O'Connell BG, Subramanian S, Yuschak JV. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma 2006;61:107-10.

21. Fu WW, Fu TS, Jing R, McFaull SR, Cusimano MD. Predictors of falls and mortality among elderly adults with traumatic brain injury: A nationwide, population-based study. PLoS One 2017;12:e0175868.

22. Gaastra B, Longworth A, Matta B, Snelson C, Whitehouse T, Murphy N, et al. The ageing population is neglected in research studies of traumatic brain injury. Br J Neurosurg 2016;30:221-6.

23. Gangavati AS, Kiely DK, Kulchycki LK, Wolfe RE, Mottley JL, et al. Prevalence and characteristics of traumatic intracranial hemorrhage in elderly fallers presenting to the emergency department without focal findings: Intracranial hemorrhage in elderly fallers. J Am Geriatr Soc 2009;57:1470-4.

24. Grandhi R, Harrison G, Voronovich Z, Bauer J, Chen SH, Nicholas D, et al. Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients: . J Trauma Acute Care Surg 2015;78:614-21.

25. Haring RS, Narang K, Canner JK, Asemota AO, George BP, Selvarajah S, et al. Traumatic brain injury in the elderly: Morbidity and mortality trends and risk factors. J Surg Res 2015;195:1-9.

26. Haydel M. Management of mild traumatic brain injury in the emergency department. Emerg Med Pract 2012;14:1-24.

27. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100-5.

28. Helmes E, Ostbye T, Steenhuis RE. Incremental contribution of reported previous head injury to the prediction of diagnosis and cognitive functioning in older adults. Brain Inj 2011;25:338-47.

29. Herou E, Romner B, Tomasevic G. Acute traumatic brain injury: Mortality in the elderly. World Neurosurg 2015;83:996-1001.

30. Howard JL 2nd, Cipolle MD, Horvat SA, Sabella VM, Reed JF 3rd, Fulda G, et al. Preinjury warfarin worsens outcome in elderly patients who fall from standing. J Trauma 2009;66:1518-22.

31. Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma 2005;59:1131-7.

32. Jagoda AS, Bazarian JJ, Bruns JJ, Cantrill SV, Gean AD, Howard PK, et al. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008;52:714-48.

33. Jiang JY. Head trauma in China. Injury 2013;44:1453-7.

34. Julien J, Alsideiri G, Marcoux J, Hasen M, Correa JA, Feyz M, et al. Antithrombotic agents intake prior to injury does not affect outcome after a traumatic brain injury in hospitalized elderly patients. J Clin Neurosci 2017;38:122-5.

35. Kaen A, Jimenez-Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010;68:895-8.

36. Karibe H, Hayashi T, Narisawa A, Kameyama M, Nakagawa A, Tominaga T. Clinical characteristics and outcome in elderly patients with traumatic brain injury: For establishment of management strategy. Neurol Med Chir (Tokyo) 2017;57:418-25.

37. Kim DY, Kobayashi L, Barmparas G, Fortlage D, Curry T, Coimbra R. Venous thromboembolism in the elderly: The result of comorbid conditions or a consequence of injury? J Trauma Acute Care Surg 2012;72:1286-91.

38. Krishnamoorthy V, Distelhorst JT, Vavilala MS, Thompson H. Traumatic brain injury in the elderly: Burden, risk factors, and prevention. J Trauma Nurs 2015;22:204-8.

39. Kristman VL, Borg J, Godbolt AK, Salmi LR, Cancelliere C, Carroll LJ, et al. Methodological issues and research recommendations for prognosis after mild traumatic brain injury: Results of the international collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil 2014;95:S265-77.

40. Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M, et al. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma 2004;56:802-7.

41. LeBlanc J, de Guise E, Gosselin N, Feyz M. Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury. Brain Inj 2006;20:779-90.

42. Levin HS, Goldstein FC, MacKenzie EJ. Depression as a secondary condition following mild and moderate traumatic brain injury. Semin Clin Neuropsychiatry 1997;2:207-15.

43. Li J, Brown J, Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet 2001;357:771-2.

44. Mahler B, Carlsson S, Andersson T, Adelöw C, Ahlbom A, Tomson T. Unprovoked seizures after traumatic brain injury: A population-based case-control study. Epilepsia 2015;56:1438-44.

45. Mann N, Welch K, Martin A, Subichin M, Wietecha K, Birmingham LE, et al. Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emerg Med 2018;18:27.

46. Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann Emerg Med 2012;59:451-5.

47. Menzel JC. Depression in the elderly after traumatic brain injury: A systematic review. Brain Inj 2008;22:375-80.

48. Miller J, Lieberman L, Nahab B, Hurst G, Gardner-Gray J, Lewandowski A, et al. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review. J Trauma Acute Care Surg 2015;79:310-3.

49. Moore MM, Pasquale MD, Badellino M. Impact of age and anticoagulation: Need for neurosurgical intervention in trauma patients with mild traumatic brain injury. J Trauma Acute Care Surg 2012;73:126-30.

50. Mosenthal AC, Livingston DH, Lavery RF, Knudson MM, Lee S, Morabito D, 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;56:1042-8.

51. Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.

52. e467.Parra MW, Zucker L, Johnson ES, Gullett D, Avila C, Wichner ZA, et al. Dabigatran bleed risk with closed head injuries: Are we prepared? J Neurosurg 2013;119:760-5.

53. Pedersen AR, Severinsen K, Nielsen JF. The effect of age on rehabilitation outcome after traumatic brain injury assessed by the functional independence measure (FIM). Neurorehabil Neural Repair 2015;29:299-307.

54. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma 2007;63:525-30.

55. Riccardi A, Frumento F, Guiddo G, Spinola MB, Corti L, Minuto P, et al. Minor head injury in the elderly at very low risk: A retrospective study of 6 years in an Emergency Department (ED). Am J Emerg Med 2013;31:37-41.

56. Riccardi A, Spinola B, Minuto P, Ghinatti M, Guiddo G, Malerba M, et al. Intracranial complications after minor head injury (MHI) in patients taking Vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am J Emerg Med 2017;35:1317-9.

57. Salottolo K, Levy AS, Slone DS, Mains CW, Bar-Or D. The effect of age on Glasgow coma scale score in patients with traumatic brain injury. JAMA Surg 2014;149:727.

58. Scantling D, Fischer C, Gruner R, Teichman A, McCracken B, Eakins J. The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy. Eur J Trauma Emerg Surg 2017;43:741-6.

59. Shimoda K, Maeda T, Tado M, Yoshino A, Katayama Y, Bullock MR. Outcome and surgical management for geriatric traumatic brain injury: Analysis of 888 cases registered in the Japan Neurotrauma Data Bank. World Neurosurg 2014;82:1300-6.

60. Stapert S, Houx P, de Kruijk J, Ponds R, Jolles J. Neurocognitive fitness in the sub-acute stage after mild TBI: the effect of age. Brain Inj 2006;20:161-5.

61. Stocchetti N, Paterno R, Citerio G, Beretta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma 2012;29:1119-25.

62. Susman M, DiRusso SM, Sullivan T, Risucci D, Nealon P, Cuff S, et al. Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 2002;53:219-23.

63. Swap C. Risk of delayed intracerebral hemorrhage in anticoagulated patients after minor head trauma: The role of repeat cranial computed tomography. Perm J 2016;20:?14-6.

64. [doi:10.7812/TPP/15-095].Teo DB, Wong HC, Yeo AW, Lai YW, Choo EL, Merchant RA. Characteristics of fall-related traumatic brain injury in older adults. Int Med J 2018;48:1048-55.

65. Tseng JH, Tseng MY, Liu AJ, Lin WH, Hu HY, Hsiao SH. Risk factors for chronic subdural hematoma after a minor head injury in the elderly: A population-based study. Biomed Res Int 2014. pii: 218646.

66. Van den Brand CL, Karger LB, Nijman ST, Hunink MG, Patka P, Jellema K. Traumatic brain injury in the Netherlands, trends in emergency department visits, hospitalization and mortality between 1998 and 2012. Eur J Emerg Med 2018;25:355-61.

67. Werman HA, Erskine T, Caterino J, Riebe JF, Valasek T; Board MotTCotSoOE. Development of statewide geriatric patients trauma triage criteria. Prehosp Disaster Med 2011;26:170-9.

• References

• 1 Werman HA, Erskine T, Caterino J, Riebe JF, Valasek T, Members of the Trauma Committee of the State of Ohio EMS Board. Development of statewide geriatric patients trauma triage criteria. Prehosp Disaster Med 2011;26:170-9.
• 2 Bruns J Jr., Hauser WA. The epidemiology of traumatic brain injury: A review. Epilepsia 2003;44:2-10.
• 3 de Guise E, LeBlanc J, Dagher J, Tinawi S, Lamoureux J, Marcoux J, et al. Traumatic brain injury in the elderly: A level 1 trauma centre study. Brain INJ 2015;29:558-64.
• 4 Adams SD, Holcomb JB. Geriatric trauma. Curr Opin Crit Care 2015;21:520-526 doi:10.1097/MCC.3041773041770246.
• 5 van den Brand CL, Karger LB, Nijman ST, Hunink MG, Patka P, Jellema K. Traumatic brain injury in the Netherlands, trends in emergency department visits, hospitalization and mortality between 1998 and 2012. Eur J Emerg Med 2018;25:355-61.
• 6 Cetty L, Abdin E, Vaingankar JA, Jeyagurunathan A, Chua BY, Picco L, et al. Prevalence and correlates of traumatic brain injury (TBI) in older adults: Results from the Well being of the Singapore Elderly (WiSE) study. Int Psychogeriatr 2017;29:1899-907.
• 7 Haring RS, Narang K, Canner JK, Asemota AO, George BP, Selvarajah S, et al. Traumatic brain injury in the elderly: Morbidity and mortality trends and risk factors. J Surg Res 2015;195:1-9.
• 8 Jiang JY. Head trauma in China. Injury 2013;44:1453-57.
• 9 Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochir (Wien) 2006;148:255 68; discussion 268.
• 10 Servadei F, Teasdale G, Merry G, Societies NCotWFoN. Defining acute mild head injury in adults: A proposal based on prognostic factors, diagnosis, and management. J Neurotrauma 2001;18:657-64.
• 11 Mosenthal AC, Livingston DH, Lavery RF, Knudson MM, Lee S, Morabito D, 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;56:1042-8.
• 12 Polidoro A, Dornbusch T, Vestri A, Di Bona S, Alessandri C. Frailty and disability in the elderly: A diagnostic dilemma. Arch Gerontol Geriatr 2011;52:e75-78.
• 13 Carroll L, Cassidy JD, Holm L, Kraus J, Coronado V. Methodological issues and research recommendations for mild traumatic brain injury: The who collaborating centre task force on mild traumatic brain injury. J Rehabil Med 2004;36:113-25.
• 14 Kristman VL, Borg J, Godbolt AK, Salmi LR, Cancelliere C, Carroll LJ, et al. Methodological issues and research recommendations for prognosis after mild traumatic brain injury: Results of the international collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil 2014;95:S265-77.
• 15 Kozar RA, Arbabi S, Stein DM, Shackford SR, Barraco RD, Biffl WL, et al. Injury in the aged: Geriatric trauma care at the crossroads. J Trauma Acute Care Surg 2015;78:1197-209.
• 16 Gaastra B, Longworth A, Matta B, Snelson C, Whitehouse T, Murphy N, et al. The ageing population is neglected in research studies of traumatic brain injury. Br J Neurosurg 2016;30:221-6.
• 17 Cheng PL, Lin HY, Lee YK, Hsu CY, Lee CC, Su YC. Higher mortality rates among the elderly with mild traumatic brain injury: A nationwide cohort study. Scand J Trauma Resusc Emerg Med 2014;22:7.
• 18 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol 2009;62:e1-34.
• 19 Sauaia A, Moore EE, Crebs JL, Maier RV, Hoyt DB, Shackford SR. Evidence level of individual studies: A proposed framework for surgical research. J Trauma Acute Care Surg 2012;72:1484-90.
• 20 Evans D, Pester J, Vera L, Jeanmonod D, Jeanmonod R. Elderly fall patients triaged to the trauma bay: Age, injury patterns, and mortality risk. Am J Emerg Med 2015;33:1635-8.
• 21 Fu WW, Fu TS, Jing R, McFaull SR, Cusimano MD. Predictors of falls and mortality among elderly adults with traumatic brain injury: A nationwide, population based study. PLoS One 2017;12:e0175868.
• 22 Karibe H, Hayashi T, Narisawa A, Kameyama M, Nakagawa A, Tominaga T. Clinical characteristics and outcome in elderly patients with traumatic brain injury: For establishment of management strategy. Neurol Med Chir (Tokyo) 2017;57:418-25.
• 23 Ramanathan DM, McWilliams N, Schatz P, Hillary FG. Epidemiological shifts in elderly traumatic brain injury: 18 year trends in Pennsylvania. J Neurotrauma 2012;29:1371-8.
• 24 Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007;5:345-51.
• 25 Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, et al. Potentially inappropriate medication use in the community dwelling elderly: Findings from the 19.
• 26 Krishnamoorthy V, Distelhorst JT, Vavilala MS, Thompson H. Traumatic brain injury in the elderly: Burden, risk factors, and prevention. J Trauma Nurs 2015;22:204-08.
• 27 Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): A randomised controlled trial. Lancet (London, England) 1999;353:93-7.
• 28 Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am 2007;25:837-60.
• 29 Rau CS, Wu SC, Chen YC, Chien PC, Hsieh HY, Kuo PJ, et al. Effect of age on glasgow coma scale in patients with moderate and severe traumatic brain injury: An approach with propensity score matched population. Int J Environ Res Public Health 2017;14:1378. doi:10.3390/ijerph1411137.
• 30 Salottolo K, Levy AS, Slone DS, Mains CW, Bar Or D. The effect of age on Glasgow coma scale score in patients with traumatic brain injury. JAMA Surg 2014;149:727.
• 31 Mack LR, Chan SB, Silva JC, Hogan TM. The use of head computed tomography in elderly patients sustaining minor head trauma. J Emerg Med 2003;24:157-62.
• 32 Gangavati AS, Kiely DK, Kulchycki LK, Wolfe RE, Mottley JL, Kelly SP, et al. Prevalence and characteristics of traumatic intracranial hemorrhage in elderly fallers presenting to the emergency department without focal findings: Intracranial hemorrhage in elderly fallers. J Am Geriatr Soc 2009;57:1470-4.
• 33 Jagoda AS, Bazarian JJ, Bruns JJ, Cantrill SV, Gean AD, Howard PK, et al. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008;52:714-48.
• 34 Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, et al. External validation of the Canadian CT head rule and the new Orleans criteria for CT scanning in patients with minor head injury. JAMA 2005;294:1519-25.
• 35 Vos PE, Alekseenko Y, Battistin L, Ehler E, Gerstenbrand F, Muresanu DF, et al. Societies EFoN. Mild traumatic brain injury. Eur J Neurol 2012;19:191-8.
• 36 Clement CM, Stiell IG, Schull MJ, Rowe BH, Brison R, Lee JS, et al. Clinical features of head injury patients presenting with a glasgow coma scale score of 15 and who require neurosurgical intervention. Ann Emerg Med 2006;48:245-51.
• 37 Itshayek E, Rosenthal G, Fraifeld S, Perez Sanchez X, Cohen JE, Spektor S. Delayed posttraumatic acute subdural hematoma in elderly patients on anticoagulation. Neurosurgery 2006;58:A851-6.
• 38 Campiglio L, Bianchi F, Cattalini C, Belvedere D, Rosci CE, Casellato CL, et al. Mild brain injury and anticoagulants: Less is enough. Neurol Clin Pract 2017;7:296-305.
• 39 Kaen A, Jimenez Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010;68:895-8.
• 40 Miller J, Lieberman L, Nahab B, Hurst G, Gardner Gray J, Lewandowski A. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review. J Trauma Acute Care Surg 2015;79:310-3.
• 41 Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.e467.
• 42 Scantling D, Fischer C, Gruner R, Teichman A, McCracken B, Eakins J. The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy. Eur J Trauma Emerg Surg 2017;43:741-6.
• 43 Swap C. Risk of delayed intracerebral hemorrhage in anticoagulated patients after minor head trauma: The role of repeat cranial computed tomography. Perm J 2016; 20:14-6. doi: 10.7812/TPP/15-095.
• 44 Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK, Consortium ft SC. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surg 2018;153:570.
• 45 Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma 2007;63:525-30.
• 46 Ritchie PD, Cameron PA, Ugoni AM, Kaye AH. A study of the functional outcome and mortality in elderly patients with head injuries. J Clin Neurosci 2000;7:301-4.
• 47 Collins CE, Witkowski ER, Flahive JM, Anderson FA, Santry HP. Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries. Am J Surg 2014;208:544-9.e541.
• 48 Scotti P, Séguin C, Lo BW, de Guise E, Troquet JM, Marcoux J. Antithrombotic agents and traumatic brain injury in the elderly population: Hemorrhage patterns and outcomes. J Neurosurg 2019; 5:1-10.
• 49 Kobayashi L, Barmparas G, Bosarge P, Brown CV, Bukur M, Carrick MM, et al.Group AMPOSoTPoNOAS. Novel oral anticoagulants and trauma: The results of a prospective American Association for the Surgery of Trauma Multi Institutional Trial. J Trauma Acute Care Surg 2017;82:827-35.
• 50 Riccardi A, Spinola B, Minuto P, Ghinatti M, Guiddo G, Malerba M, et al. Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am J Emerg Med 2017;35:1317-9.
• 51 Julien J, Alsideiri G, Marcoux J, Hasen M, Correa JA, Feyz M, et al. Antithrombotic agents intake prior to injury does not affect outcome after a traumatic brain injury in hospitalized elderly patients. J Clin Neurosci 2017;38:122-5.
• 52 Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma 2005;59:1131-7.
• 53 Grandhi R, Harrison G, Voronovich Z, Bauer J, Chen SH, Nicholas D, et al. Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients. J Trauma Acute Care Surg 2015;78:614-21.
• 54 Mahler B, Carlsson S, Andersson T, Adelöw C, Ahlbom A, Tomson T. Unprovoked seizures after traumatic brain injury: A population based case control study. Epilepsia 2015;56:1438-44.
• 55 Motika PV, Spencer DC. Treatment of epilepsy in the elderly. Curr Neurol Neurosci Rep 2016;16:96. doi:10.1007/s11910-016-0696-8.
• 56 Lai Fung L, Wai Man L, Wong HT, Yuen WK, Leung GK. Outcome after operative intervention for traumatic brain injuries in the elderly. Asian J Neurosurg 2017;12:37.
• 57 Flaada JT, Leibson CL, Mandrekar JN, Diehl N, Perkins PK, Brown AW, et al. Relative risk of mortality after traumatic brain injury: A population based study of the role of age and injury severity. J Neurotrauma 2007;24:435-45.
• 58 Susman M, DiRusso SM, Sullivan T, Risucci D, Nealon P, Cuff S, et al. Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 2002;53:219-23; discussion 223-4.
• 59 Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, et al. Geriatric blunt multiple trauma: Improved survival with early invasive monitoring. J Trauma 1990;30:129 34; discussion 134-6.
• 60 Pedersen AR, Severinsen K, Nielsen JF. The effect of age on rehabilitation outcome after traumatic brain injury assessed by the functional independence measure (FIM). Neurorehabil Neural Repair 2015;29:299-307.
• 61 Shimoda K, Maeda T, Tado M, Yoshino A, Katayama Y, Bullock MR. Outcome and surgical management for geriatric traumatic brain injury: Analysis of 888 cases registered in the Japan Neurotrauma Data Bank. World Neurosurg 2014;82:1300-6.