Models of Care

 

Following a head injury, it is typical that an individual remains in acute care long enough to monitor and manage basic systems (e.g., respiration), undergo surgery and/or complete a hospital-based rehabilitation program (Institute of Neurological Disorders and Stroke 2002). Following acute care, individuals may be required to complete further rehabilitation in a hospital-based or community setting. Depending on the severity of the injury, individuals could also be discharged home or to a long-term facility (Kim et al. 2006).

In acute care, older patients should be aggressively triaged (Kuhne et al. 2005), monitored closely (Selassie et al. 2005) and referred to senior medical staff (Zietlow et al. 1994). Mitra et al. (2008) emphasize that transition to intensive care units is extremely beneficial in optimizing good outcomes. Older adults that experience a head injury have a greater number of medical complications compared to younger individuals (Thompson et al. 2006) and typically have poorer long-term prognoses (Mosenthal et al. 2002). According to the Center for Disease Control and Prevention (2007), 79.1% of all individuals over the age of 65 years, who had sustained a severe head injury, had at least one co-morbid disease. Physicians should be wary of the overlap in symptoms between cognitive impairment and TBI to eliminate the potential for misdiagnosis (Flanagan et al. 2006). Seniors may be more at risk for further complications because of co-morbidities, frailty, previous head traumas, and medication interactions. Given the costs/resources required to care for older adults with TBI, the current demographic trends are concerning. It is important that treatments are unique and shifted towards older adults that have sustained a TBI, particularly due to the large number of older adults with TBI in the population (Kuhne et al. 2005; Cekic & Stein 2010).

ACUTE CARE

Length of Stay

After a brain injury occurs, a patient may transition through a typical care pathway consisting of acute care, intensive care unit management, inpatient rehabilitation, and outpatient rehabilitation or another support service (Khan et al. 2002). In Ontario in 2006, approximately 1-5% of all emergency department visits by individuals 60 or more years of age were for TBI. Additionally, 4-16% of all acute care inpatient hospital admissions by individuals 60 or more years were for a diagnosis of TBI (Colontonio et al. 2009). Length of stay in acute care varies widely depending on a multitude of factors including but not limited to injury severity, age at injury, geographical status and discharge disposition. Based on Canadian data, older adults stayed, on average, 15 days in acute care, in 2004. In comparison, those aged 0-19 years stayed for 5 days, those aged 20-39 years stayed for 11 days and those aged 40-59 years stayed for 13 days (Canadian Institute for Health Information 2006).

 

Intensive versus Conservative Treatment

There is much controversy as to whether older adults should be treated aggressively or conservatively in the acute care setting, especially for older individuals who have sustained very serious head injuries. For ethical reasons researchers have not specifically withheld acute care treatment to compare outcomes. Some studies have found that older patients that have sustained a TBI tend to receive more conservative acute care compared to younger patients (Lane et al. 2003; Thompson et al. 2008). Thompson et al. (2008) found that as age increased, a lower intensity of care was provided to older adults (e.g., transportation to a designated trauma center, intracranial pressure monitoring, specialty care assessments, surgical/medical specialty care, intensive care unit admission). Additionally, older individuals were more likely to have died at discharge compared to younger adults, after accounting for injury severity, co-morbidities, and gender. Higher mortality rates, in part, could be explained by less aggressive care being provided or a greater number of do not-resuscitate orders (Thompson et al. 2008). A multitude of studies have shown that older adults sustaining a brain injury are given a lower intensity of care which ultimately resulted in higher than expected mortality rates (Grant et al. 2000; Lane et al. 2003; Thompson et al. 2008).

 

 

Older adults are often treated more conservatively (less intensely) in acute care post-TBI.

 

 

Neurosurgical Care

After a particularly serious head injury, cerebral perfusion pressure (CPP) can build. Following brain trauma, it is important to maintain stable CPP to allow proper oxygen perfusion, waste removal and glucose delivery (Rao 2007). However, there is a general lack of studies assessing whether CPP guidelines are appropriate for elderly individuals. Age-specific factors such as co-morbid conditions including hypertension or diabetes mellitus and multiple medications may affect the cerebral response to injury and thus CPP (Thompson et al. 2006).

When CPP increases to dangerous levels, decompressive craniotomy is a procedure used to relieve pressure in the brain and results in significantly better management of uncontrollable intracranial hypertension (Jiang et al. 2005; Meier et al. 2005; Ucar et al. 2005; Aarabi et al. 2006). While good outcomes can be achieved in young trauma patients, whether the same outcomes could be obtained for older adults is controversial. A suggested age limit for performing decompressive craniotomy has been said to be 40-50 years of age (Skoglund & Nellgard 2005; Aarabi et al. 2006; Meier et al. 2006). However, surgery should still be recommended for young-old elderly patients with mild injuries (Jamjoom et al. 1992; Bouras et al. 2007). Mohindra et al. (2008) examined 45 older (70+ years) and 1,026 younger (20-40 years) individuals with TBI for outcomes after advanced trauma care, including surgery. The elderly group consistently showed greater rates of disability and mortality post-surgery (Mohindra et al. 2008). 

 

 

Decompressive craniotomy is typically not performed on patents older than 50 years, despite that a modest number of older adults have benefitted from the surgery.

 

 

Discharge Disposition

After an individual has stabilized in acute care and is well enough to leave, they may be discharged to a variety of settings based on their likelihood of improvement. Such settings may include inpatient rehabilitation, personal home with or without outpatient support services, long-term care or supportive housing. While Livingston et al. (2005) did not find any age-related differences in discharge disposition among their study sample, several researchers have found a discrepancy. Several studies have shown that older adults were less likely to return to their former living status (Rothweiler et al. 1998; Mosenthal et al. 2002; Utomo et al. 2009). Frankel et al. (2006) reported that only 80.8% of the older patients (55 years) with a TBI were discharged to the community compared to 94.3% of the younger patients with a TBI (<55 years). 

 

 

There appears to be a discrepancy in discharge destination between older and younger individuals post injury; a greater number of older adults are discharged to long term care facilities or nursing homes while younger adults often return home.

 

 

Rehabilitation

Goldstein (2005) wrote a special section on rehabilitation for TBI in the older adult population. Unlike the significant focus on rehabilitative efforts in children and young adults, very little has been done regarding the rehabilitative needs of older adults. A concern is whether a “good” outcome is even possible in older adults. As indicated previously, overall there is a linear relationship between severity of injury and outcome (Mosenthal et al. 2002). Rehabilitation efforts that are being used with elderly individuals have resulted from studies solely including a younger population. Age-related differences may interact to generate a very different set of circumstances requiring unique rehabilitative efforts. Extra-injury factors including depression and a deterioration of social functioning may exacerbate these differences.

 

 

The effectiveness of rehabilitation interventions specifically for the older TBI population have not been studied. 

 

 

Length of Stay

Older adults had significantly longer lengths of stay in rehabilitation, ranging from 27 to 56 days among older adults (40+ years), and 22 to 33 days among young patients (<40 years; Cifu et al. 1996; Frankel et al. 2006; Marquez de la Plata et al. 2008). Despite longer stays, and therefore greater total costs, there was no notable difference between age groups in terms of daily rehabilitation costs.

 

 

Older TBI patients stay a longer length of time in rehabilitation compared to younger TBI patients.

 

 

Conclusions

Overall, there is limited research conducted specifically examining older adults post TBI. The health care team must assess the individual to decide which choice of setting will be most beneficial (e.g., inpatient, outpatient or home therapies). Rehabilitation goals should be set in conjunction with the patient, caregiver and therapeutic team. While the ultimate goal is to return the patient to pre-morbid functioning, this may not always be possible and therefore goals should be realistic and aim for independence. Patients, caregivers and the support network should be aware that regardless of outcome, rehabilitation and recovery require extensive community support (Scherer 2000)