Poor prognostic factors in elderly patients aged 75 years old or older with mild traumatic brain injury

Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals

BACKGROUND

Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population.

METHODS

We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses.

FINDINGS

We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality.

CONCLUSIONS

In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population.

REVIEW REGISTRATION

PROSPERO CRD42022323231.

Concussion Management in Older People: A Scoping Review

OBJECTIVE

To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding.

CONTEXT

Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people.

DESIGN

Scoping review.

METHOD

A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed.

RESULTS

The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed.

CONCLUSION

Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.

Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage

INTRODUCTION

Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes.

METHOD

Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis.

RESULTS

During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15.

CONCLUSION

Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Systematic Review and Meta-analysis of Outcome after Mild Traumatic Brain Injury in Older People

OBJECTIVE

Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation.

METHODS

Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation.

RESULTS

By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery.

CONCLUSIONS

Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.

A cost-effectiveness and value of information analysis to inform future research of tranexamic acid for older adults experiencing mild traumatic brain injury

BACKGROUND

Tranexamic acid reduces head injury deaths in patients with CT scan evidence of intracranial bleeding after mild traumatic brain injury (TBI). However, the cost-effectiveness of tranexamic acid for people with mild TBI in the pre-hospital setting, prior to CT scanning, is uncertain. A large randomised controlled trial (CRASH-4) is planned to address this issue, but the economic justification for it has not been established. The aim of the analysis was to estimate the likelihood of tranexamic acid being cost-effective given current evidence, the treatment effects required for cost-effectiveness, and the expected value of performing further research.

METHODS

An early economic decision model compared usual care for mild TBI with and without tranexamic acid, for adults aged 70 and above. The evaluation was performed from a UK healthcare perspective over a lifetime time horizon, with costs reported in 2020 pounds (GBP) and outcomes reported as quality-adjusted life years (QALYs). All analyses used a £20,000 per QALY cost-effectiveness threshold.

RESULTS

In the base case analysis, tranexamic acid was associated with an incremental cost-effectiveness ratio of £4885 per QALY gained, but the likelihood of it being cost-effective was highly dependent on the all-cause mortality treatment effect. The value of perfect information was £22.4 million, and the value of perfect information for parameters that could be collected in a trial was £21.9 million. The all-cause mortality risk ratio for tranexamic acid and the functional outcomes following TBI had the most impact on cost-effectiveness.

CONCLUSIONS

There is a high degree of uncertainty in the cost-effectiveness of tranexamic acid for older adults experiencing mild TBI, meaning there is a high value of performing future research in the UK. The value in a global context is likely to be far higher.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Neurological deteriorations in mild brain injuries: the strategy of evaluation and management

PURPOSE

Most mild traumatic brain injuries (TBIs) can be treated conservatively. However, some patients deteriorate during observation. Therefore, we tried to evaluate the characteristics of deterioration and requirement for further management in mild TBI patients.

METHODS

From 1/1/2017 to 12/31/2017, patients with mild TBI and positive results on CT scans of the brain were retrospectively studied. Patients with and without neurological deteriorations were compared. The characteristics of mild TBI patients with further neurological deterioration or the requirement for interventions were delineated.

RESULTS

One hundred ninety-two patients were enrolled. Twenty-three (12.0%) had neurological deteriorations. The proportions of deterioration occurring within 24 h, 48 h and 72 h were 23.5, 41.2 and 58%, respectively. Deteriorated patients were significantly older than those without neurological deteriorations (69.7 vs. 60.2; p = 0.020). More associated extracranial injuries were observed in deteriorated patients [injury severity score (ISS): 20.2 vs. 15.9; p = 0.005). Significantly higher proportions of intraventricular hemorrhage (8.7 vs. 1.2%; p = 0.018) and multiple lesions (78.3 vs. 53.8%; p = 0.027) were observed on the CT scans of patients with neurological deteriorations. Subset analysis showed that deteriorated patients who required neurosurgical interventions (N = 7) had significantly more initial GCS defects (13 or 14) (71.4 vs. 12.5%; p = 0.005) and more initial decreased muscle power of extremities (85.7 vs. 18.8%; p = 0.002).

CONCLUSION

More attention should be given to mild TBI patients with older age, GCS defects, decreased muscle power of the extremities, multiple lesions on CT scans and other systemic injuries (high ISS). Most deteriorations occur within 72 h after trauma.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION

Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION

A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS

Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS

Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).