Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

Background

The probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors.

Methods

Patients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable.

Results

Two hundred twenty patients with mean age 70 years (median 69; range 60–87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5–8), unfavorable outcome 27% (GOSE 2–4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age (p < 0.05), multiple injuries (p < 0.05), GCS M ≤ 3 on admission (p < 0.05), and mechanical ventilation (p < 0.001).

Conclusions

Overall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

Content Validity of an Assessment Tool to Identify Home Fall Hazards: The Westmead Home Safety Assessment

Identifying hazards in the homes of elderly people adequately is of central importance to reducing the risk of falls; however, no assessment tool has demonstrated validity in the area of, or focuses specifically on, home fall hazards. Content validity was undertaken to develop further and refine the Westmead Home Safety Assessment (WeHSA).

A list of stimulus attributes was generated from an extensive literature review and contributed to an expert review by providing a descriptive scheme of the tool's domain of interest. A content analysis of the literature and the expert review process established the tool as having a high degree of content validity and an overall content validity index of 0.80. The rigorous process ensured that the items in the tool were complete and relevant to the focus of the assessment and helped to guide manual development. The WeHSA provides a meaningful tool to enhance therapists' ability to observe and judge hazards.

Types of Hazards in the Homes of Elderly People

This study describes the type and range of hazards found in the homes of elderly persons (n=257) referred to the occupational therapy department of a city teaching hospital. Homes were assessed using an abbreviated version of the Westmead Home Safety Assessment. The most commonly found hazards were in internal traffic ways (48%), the bathroom (40%), and access areas to and from the home (38%). Hazardous mats, pathways, and bathroom and toilet floor surfaces were the most commonly found individual hazards. Mildly cognitively impaired persons were found to have increased exposure to hazards in traffic ways; women were found to have more bed light hazards and people living with others were more likely to have a pet that may pose a risk of the elderly person falling. Otherwise, characteristics of people were generally not found to be associated with increased exposure to any particular type of hazard. We recommend further and more detailed investigation of home hazards, including in the homes of the well elderly.

Age-related striatal dopaminergic denervation and severity of a slip perturbation

BACKGROUND

Striatal dopamine activity declines with normal aging. Age-related striatal dopaminergic denervation (SDD) has been implicated in standing balance and unperturbed gait. The goal of this study was to analyze the association between the degree of SDD and the magnitude of an unexpected slip perturbation induced during gait.

METHODS

Fifty healthy participants aged 20-86 years old underwent dopamine transporter positron emission tomography to classify SDD severity as mild, moderate, or severe. Participants also walked on a floor that was unexpectedly contaminated with a glycerol solution for gait testing. The magnitude of a slip was quantified using the peak slip velocity (PSV), measured at the slipping foot. Data were analyzed for both fast (greater than 1.2 m/s) and slow walkers as gait speed correlated with slip severity. All data analyses were age adjusted.

RESULTS

Greater severity of dopaminergic denervation in the caudate nucleus was correlated with higher PSV (p < .01) but only in the fast speed walking group. The relationship between SDD in the putamen and slip severity was not statistically significant in fast and slow walkers.

CONCLUSIONS

Age-related SDD may impact the ability to recover from large perturbations during walking in individuals who typically walk fast. This effect, prominent in the caudate nucleus, may implicate a role of cognitive frontostriatal pathways in the executive control of gait when balance is challenged by large perturbations. Finally, a cautious gait behavior present in slow walkers may explain the apparent lack of involvement of striatal dopaminergic pathways in postural responses to slips.

Footwear and Falls in the Home Among Older Individuals in the MOBILIZE Boston Study

BACKGROUND: Whether certain types of footwear, such as slippers, socks without shoes, and going barefoot, increase the risk for falls among the elderly is uncertain. Our purpose was to examine the relationship between footwear and falls within the home in MOBILIZE Boston, a prospective cohort study of falls etiology among non-institutionalized women and men, mainly aged 70 years and older, from the Boston MA, USA area. METHODS: The 765 participants were from households randomly selected from town lists. They were followed for a median of 27.5 months. At baseline, participants were administered a questionnaire that included questions on footwear usually worn, and were given a comprehensive examination that included measurement of many risk factors for falls. During follow-up participants were asked to record each day whether they had fallen; those reporting falls were asked about their footwear when they fell. RESULTS: At the time of in-home falls, 51.9% of people were barefoot, wearing socks without shoes, or wearing slippers; 10.1% of people reported that their usual footwear was one of these types. Among those who fell in their own home, the adjusted odds ratio for a serious injury among those who were shoeless or wearing slippers compared to those who were wearing other shoes at the time of the fall was 2.27 (95% confidence interval 1.21-4.24). CONCLUSIONS: It may be advisable for older individuals to wear shoes in their home whenever possible to minimize the risk of falling. Further research is needed to identify optimal footwear for falls prevention.

The epidemiology of falls and syncope

Falls, syncope, and the associated complications are among the most serious problems that face the elderly population. The most common underlying causes and risk factors for falls include muscle weakness, gait and balance problems, visual impairment, cognitive impairment, depression, functional decline, and particular medications (especially in the presence of environmental hazards). Studies have identified the relative risks for these factors that enable a fairly accurate prediction of who is at high risk for falls and what areas to target for falls-prevention activity. Causes and risk factors for syncope have not been studied as well in the older population. The most serious types of syncope have underlying cardiac etiologies but they cause less than 25% of the reported cases. The largest category of syncope (approximately 40%) is syncope of unknown etiology, which defies careful diagnostic evaluation but seems to be fairly benign. The epidemiology of these syndromes can provide extremely helpful insights for developing falls-prevention strategies.

Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam

The objective of this study was to identify easily measurable predictors for falls, recurrent falls, and fractures using a population-based prospective cohort study of 1469 elderly, born before 1931, in three regions of the Netherlands. The baseline at-home interview was in 1992. In 1995, falls experienced in the preceding year and fractures over the preceding 38-month period were registered. In a period of 1 year, 32% of the participants fell at least once, and 15% fell two or more times. The rate of recurrent falls was similar in men and women up until the age of 75 years. The total number of fractures was 85, including 23 wrist fractures, 12 hip fractures, and 9 humerus fractures. The incidence density per 1000 person-years for any fracture was 25.1 (95% confidence interval [CI], 18.9-31.4) for women and 8.2 (95% CI, 4.5-12.0) for men, respectively. Multiple logistic regression identified urinary incontinence, impaired mobility, use of analgetics, and use of antiepileptic drugs as the predictors most strongly associated with recurrent falls. Female gender, living alone, past fractures, inactivity, body height, and use of analgetics proved to be the predictors most strongly associated with fractures. The probabilities of recurrent falls were 4.7% (95% CI, 2.9-7.5%) to 59. 2% (95% CI, 24.1-86.9%) with zero to four predictors, respectively. The probability of fractures ranged from 0.0% (95% CI, 0.0-0.4%) without any of the identified predictors to 12.9% (95% CI, 4.4-32. 2%) with all six predictors present. Our study shows that the risk of recurrent falls and of fractures can be predicted using up to, respectively, four and six easily measurable predictors. This study emphasizes the importance of impaired mobility and inactivity as predictors for falls and fractures.

Falls reported among elderly Norwegians living at home

BACKGROUND AND PURPOSE

Norway has the highest reported incidence of hip fractures in western Europe. Little is known about the epidemiology of falls in Norway where the winter season is long and dark. The objective of this work was to study reported falls and their consequences among elderly Norwegians living at home.

METHODS

A cross-sectional design was used for the study. Interviews were performed in the homes of 431 subjects, aged 67-97 years, living at home. Information on falling was gathered through six questions: whether the subject had fallen during the last six months, and if so, how many falls they had, where the last fall occurred, its perceived reason, the activity the subject had been engaged in when the fall occurred, and the resulting injury.

RESULTS

In all, 24.1% of subjects reported falling during the last six months, and 9.5% had suffered more than one fall. Falls were most frequently linked to external events (63.1%). Outdoor falls were more frequent (59.0%; 95% CI = 51.2-82.0) than indoor falls. Older subjects were associated with more frequent indoor falls (p < 0.05), but gender was not significant. Fifty-one per cent of subjects had fallen while walking and 53% had suffered an injury from the last fall. In 13.4% of the women and 16.2% of the men, the last fall had resulted in a fracture.

CONCLUSIONS

Compared to the results of other studies from industrialized Western countries, a similar crude fall rate, similar frequency and similar type of injury were found. However, in contrast to other studies, no gender difference was observed with regard to falling, place of falling and fracture rate.