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Mild Traumatic Brain Injury in the Geriatric Population

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Presentation on theme: "Mild Traumatic Brain Injury in the Geriatric Population"— Presentation transcript:

1 Mild Traumatic Brain Injury in the Geriatric Population
Cynthia Blank-Reid, RN, MSN, CEN Trauma Clinical Nurse Specialist Temple University Hospital Philadelphia, PA

2 Definitions Geriatrics Mild traumatic brain injury Positive Outcome

3 Geriatric Trauma—Epidemiology
5th leading cause of death over age 25% of trauma deaths Persons >65 = Fasting growing age group Slide 31 Our population is living longer and are more active due to advances in health care. 12.5% of the population is aged 65 or older. For this age group, trauma is the fifth leading cause of death. Older adults account for 25% of trauma deaths. The older adult trauma patient is more likely to die than a younger patient. This is often not because of the primary injury but because of secondary complications. An aggressive treatment approach needs to be initiated to prevent secondary complications from occurring. Seriously injured older adults are less likely to be taken to trauma centers for care. The American College of Surgeons has established guidelines to consider triaging trauma patients over 55 years of age to trauma centers.

4 Epidemiology Rapid growth in elderly population
- 65 or older currently represent 12% (30 million) - expected to rise to 20% (52 million) by 2020 - will be 22% of population by 2030 High rate of fatalities from trauma - 28% of fatalities in those over 65 - 6 times more likely to die Chronologic Age vs. Physiologic Age Although elderly are LESS likely to be involved in trauma compared to other age groups, they are MORE likely to have fatal outcomes when injured Physiologic age describes the actual functional capacity of the patients’ organs in the physiologic sense. Comorbid diseases such as DM, CAD, ESRD, arthritis and pulmonary diseases can decrease physio reserve, making it harder to recover. Physiologic reserve describes the various levels of functioning of the patients organ systems that allow them to compensate for traumatic injuries. Example: 65 yo w/DM, arthritis, and COPD may have less physio reserve and thus an older physio age than an 80 yo with no PMH

5 Geriatric Mechanisms of Injury
Falls Motor vehicle crashes Pedestrian struck by motor vehicle Assaults Co-morbid disease may be precipitating factor for injury Slide 32 Falls are the most common injury. Often these falls are from the same level. Changes in visual acuity, sensation, and proprioception may be contributing factors. Motor vehicle crashes are the second most common mechanism. Delayed reaction time as well as changes in visual acuity play a role. Pedestrians struck by a motor vehicle represent the third most common mechanism of injury. Alterations in mobility make it difficult to cross the street quickly. Hearing impairment and visual changes also make it more difficult to hear and see traffic. Co-morbid diseases can precipitate factors that result in injury. These factors include such things as syncope, postural hypotension, and cardiac dysrhythmias. Falling may be caused by dehydration, urinary tract infections, pneumonia, MI or side effects from medications. All these factors need to be considered and appropriate diagnostic testing ordered.

6 Risk Factors Poor visual acuity Poor visual attention
Overload of information Impaired reaction time Slower gait Medication side effects and interactions Alcohol consumption

7 Higher Mortality Higher mortality rate due to:
Age-related deterioration Decreased stress tolerance and physiologic reserve Greater complication risk Pre-existing chronic disease Pre-existing nutritional deficits

8 Anatomic/Physiologic Differences in the Older Adult Trauma Patient

9 Neurologic Loss of neurons in cortex Cerebellum Hippocampus
Changes in neurotransmitter systems: Dopaminergic Cholinergic Catecholamines Glutamatergic

10 Neurologic Brain weight of decreases 6 to 7% Brain size decreases
Cerebral blood flow declines 15 to 20% Nerve conduction slows up to 15%

11 Neurologic Pupil size diminished pupillary light reflex
Slowed motor reaction time Gait tends to be short-stepped and guarded Ankle jerk is lost Vibratory sense in legs is diminished

12 Neurologic Bridging veins susceptible to injury
Higher incidence of coagulopathies and anticoagulation therapy

13 Respiratory Hypoxia Loss of pulmonary reserve Reduced cough reflex
Blunt trauma: Although rib fractures are considered a minor injury, they are major in the elderly

14 Cardiovascular Atherosclerosis History of hypertension
Cardiac output decreases with aging Elderly patients need early hemodynamic monitoring

15 Musculoskeletal Hip fractures increase with age
Femoral neck fractures occur spontaneously Arthritis limits mobility, flexibility Degenerative changes make radiographic diagnosis difficult

16 Renal Impaired ability to concentrate urine
Decreased glomerular filtration rate Slight increases in blood urea nitrogen and creatinine expected; changes considered when using contrast media and certain drugs

17 Integumentary Skin provides less cushion against mechanical forces
More susceptible to shearing-type forces Impaired ability to tamponade Loss of thermoregulatory ability

18 Additional Changes Inadequate nutrition and pre-existing malnutrition leads to weakened respiratory muscles and ventilatory fatigue Slowed peristalsis and gastric motility Decreased BMR Total body water is decreased in the elderly so patients are at greater risk for hypovolemia

19 Additional Changes Medication effects May have pre-existing anemia
Shock may be present with normal vital signs May have pre-existing anemia Slide 34 Aging results in a loss of pulmonary reserve. There is decreased strength in the pulmonary muscles, and a reduced cough reflex. There may also be a long history of smoking. Any degree of hypoxemia may be detrimental to for the older adult. Supplemental oxygen must be administered to prevent hypoxia. The cardiovascular system is also not as responsive. The heart does not pump as effectively and atherosclerosis limits the ability of the vessels to respond in stress. For those patients on beta blockers, calcium channel blockers, or afterload reducing medications, the effect of these medications limits the heart’s response to shock. Shock may be present with normal vital signs. Heart rate may not increase to compensate for hypovolemia, or the increase is limited. The usual blood pressure may be hypertensive, creating a false sense of security for the nurse evaluating the patient whose blood pressure is within normal range. The patient may have pre-existing anemia. Blood transfusion should be considered early in the resuscitation to maintain the oxygen-carrying capacity of the blood. Early placement of pulmonary artery catheters and aggressive management of hemodynamic parameters in the older adult are recommended.

20 Psychosocial End-of-life decisions
Specific directions for withholding or withdrawing treatments Guidelines for making treatment decisions Patient’s right to self-determination Patient’s best interest Benefits of treatment outweigh adverse outcomes

21 Geriatric Head Injury Pearls
With aging, the brain undergoes progressive atrophy and decreases in size by 10% between ages 30 and 70 Subtle changes in cognition and memory make evaluation of MS difficult Lower incidence of epidural hematomas Higher incidence of subdural hematomas The increased “dead space” within the skull may delay symptoms of ICH Low threshold for Head CT Grave error to assume that altered MS is due to underlying dementia. Elderly have a lower incidence of epidural hematomas – attributed to relatively more dense fibrous bond between the dura mater and inner table of the skull. However there is a higher incidence of subdural hematomas in the elderly, b/c as brain mass decreases there are greater stretching and tension of the bridging veins.

22 Types of Mild Traumatic Brain Injury in the Elderly

23 Types of Mild Traumatic Brain Injury in the Elderly
Concussion Contusion Epidural Subdural Skull Fractures Penetrating

24 So What Do You Do? Concussion

25 So What Do You Do? Contusion

26 So What Do You Do? Epidural

27 So What Do You Do? Subdural

28 So What Do You Do? Skull Fractures

29 So What Do You Do? Penetrating

30 Prognosis and Outcome Markers for poor prognosis at admission:
- Age > 75 - GCS of 7 or less - Presence of shock on admission - Severe head injury - Development of Sepsis Arrange for a social worker to conduct a home safety assessment

31 Prognosis and Outcome Mortality rate of 15 to 30% for hospitalized patients Debate over ethics and cost-benefits of trauma care for elderly Conflicting data on ability to return to independent living Conflicting data – 12% vs. 57% returning to independent living Cost of hospitalized geriatric trauma patients 3 times greater for those over 65

32 Nursing Care of the Geriatric Trauma Patient—Assessment
History Does the patient have pre-existing medical conditions? What medications does the patient take? What were the events that led up to the injury? What was the patient’s functional status/neurologic status before? Does the patient have advance directives? Slide 36 History-taking in the older adult should include the following questions: Does the patient have pre-existing medical conditions? Often these can cause precipitating factors that lead to injury. What medications does the patient take? Ask specifically about anticoagulant/antiplatelet agents such as warfarin (coumadin), aspirin, or clopidogrel (plavix). Consider early initiation of clotting studies. What were the events that led up to the injury? Did the patient feel dizzy before the fall? Did he pass out or have palpitations? What was the patient’s neurologic status/ functional status prior to the injury? Did the patient live alone? Walk without assistive devices? Was someone else assisting with care? Does the patient have advance directives?

33 Nursing Care of the Geriatric Trauma Patient—Assessment
Inspection Mouth for loose teeth, partial plates, dentures Skin: look carefully for pressure areas, ecchymosis Palpation Bony prominences of spine Slide 37 When assessing the patient, the mouth should be inspected for loose teeth, partial plates, or dentures that may obstruct the airway. These should be removed. Skin should be observed carefully, looking for pressure areas, ecchymosis, or skin tears. Bony prominences should be padded. The bony prominences of the spine should be palpated for pain and tenderness as well as deformity. Remember that deformity may also be due to the aging process or pre-existing arthritis. The brittle spine fractures easily. Collaborate with the physician to determine need for imaging of the spine. NOTE TO INSTRUCTOR: Older adult having procedure done to skin

34 Nursing Care of the Geriatric Trauma Patient—Assessment
Auscultation Apical heart rate and blood pressure Abnormal heart sounds (valve disease, fluid overload) Tachycardia as a response to shock may not be seen A normal blood pressure may be indicative of shock Slide 38 Auscultate apical heart rate and blood pressure. Listen carefully for signs of fluid overload such as an S3. Additionally, note murmurs which may indicate valvular disease. Medications such as beta-blockers or cardiac glycosides may decrease the heart rate or limit the heart’s sympathetic response to hypovolemia. Tachycardia as a response to shock may not be seen in these patients. Hypertension is frequently seen in older adults. A normal blood pressure in the setting of trauma may be indicative of shock in the patient with a history of hypertension.

35 Diagnostic Procedures
Laboratory Testing Electrolytes Cardiac enzymes, troponin Therapeutic drug levels Coagulation profiles Other Studies Electrocardiogram Echocardiogram Carotid ultrasound Slide 39 An older patient’s injury may be the result of a reaction to other symptoms that presented before the injury. Diagnostic studies should be done to rule out other factors such as myocardial infarction, dysrhythmia, stroke or arterial insufficiency. Laboratory studies may include electrolytes, cardiac enzymes, therapeutic drug levels, and coagulation profiles (PT, PTT, INR). Other studies that may be appropriate include electrocardiogram, echocardiogram, and carotid ultrasound.

36 Factors Complicating Assessment
Presence of multiple pathologies 85% have one chronic disease; 30% have three or more One system’s acute illness stresses other’s reserve capacity One disease’s symptoms may mask another’s One disease’s treatment may mask another’s symptoms

37 Nursing Care of the Geriatric Trauma Patient—Planning and Implementation
Interventions Airway Remove dentures, partial plates Carefully consider need to intubate Spinal immobilization Pad bony prominences Remove immobilization as soon as possible Breathing Administer supplemental oxygen Slide 40 When intervening to control the airway in an older adult, remember to remove dentures and partial plates so they do not obstruct the airway. Carefully consider the need to intubate. Intubation increases the risk of pneumonia. Other alternatives may be implemented such as BiPap. For patients with spinal immobilization, bony prominences should be padded to reduce the risk of pressure ulcers. Remove splints, backboard, and cervical collar as soon as injuries are ruled out. In relationship to breathing, remember that the older adult cannot tolerate hypoxemia and supplemental oxygen should be administered to prevent hypoxia.

38 Nursing Care of the Geriatric Trauma Patient—Planning and Implementation
Interventions Circulation Consider early placement of pulmonary artery catheter Initiate laboratory studies early. Keep patient warm Administer medications in doses recommended for older adults Slide 41 Aggressive care of the elderly trauma patient is important. In the initial management, fluid resuscitation should not be withheld. Hemodynamic monitoring devices such as pulmonary artery catheters or central venous pressure monitoring can assist in determining appropriate fluid balance, adequacy of fluid resuscitation, and preventing fluid overload. Lab studies should be sent promptly after arrival. Special attention should be paid to those patients who are on medications for anticoagulation. Reversal of the anticoagulation may need to be initiated emergently prior to surgery. The older adult trauma patient is prone to hypothermia due to the changes of aging. Trauma rooms should be kept warm, wet clothes removed, and warm blankets applied. Temperature should be monitored closely during the resuscitative stage. Analgesics and medications should be given in doses recommended for older adults. Dosages may need to be decreased due to altered organ function.

39 Assessing for Maltreatment
Higher risk for maltreatment High index of suspicion Inconsistent history, unexplained injuries

40 Assessing For Maltreatment
Unexplained Bruises or burns Fractures Head injury Malnutrition Dehydration Signs of confinement

41 Assessing For Maltreatment
Lack of medical attention Caregiver disinterest Unusual interaction between patient and caregiver Evidence of over-medication

42 Evaluation and Ongoing Assessment
Assess vital signs frequently. Monitor cardiovascular and pulmonary response to resuscitation. Monitor temperature frequently. Slide 43 Patients from these special populations require frequent re-evaluation and ongoing assessment. Vital signs should be assessed frequently. For pregnant trauma patients, this includes fetal heart rate and monitoring of uterine activity. The cardiovascular and pulmonary response to resuscitation should be evaluated. Monitor temperature frequently especially in pediatrics and the older adult populations.

43 The Distractors All those things that get in the way of allowing us to genuinely believe that there could be a head injury.

44 Dementia/Altered Mental Status
Distinguish between acute, chronic onset Never assume acute dementia or altered mental status is due to “senility” Ask relatives, other caregivers what baseline mental status is

45 Dementia/Altered Mental Status
Possible Causes Head injury with subdural hematoma Alcohol, drug intoxication, withdrawal Tumor CNS Infections Electrolyte imbalances Cardiac failure Hypoglycemia Hypoxia Drug interactions

46 Cerebrovascular Accident
Emboli, thrombi more common CVA/TIA signs often subtle—dizziness, behavioral change, altered affect Headache, especially if localized, is significant TIAs common; 1/3 progress to CVA Stroke-like symptoms may be delayed effect of head trauma

47 Seizures All first time seizures in elderly are dangerous
Possible causes CVA Arrhythmias Infection Alcohol, drug withdrawal Tumors Head trauma Hypoglycemia Electrolyte imbalance

48 Syncope Morbidity, mortality higher Consider
Cardiogenic causes (MI, arrhythmias) Transient ischemic attack Drug effects (beta blockers, vasodilators) Volume depletion

49 Depression Common problem May account for symptoms of “senility”
Persons >65 account for 25% of all suicides Treat as immediate life threat!

50 Rehabilitation of the Geriatric Mild TBI Patient
Will they qualify? Will they be taken? Will it matter? Does it matter? What works and what doesn’t work.

51 Tips and Pearls Assume limited physiologic reserves
Minor injuries may be life-threatening “Stable” patients may quickly become unstable Low threshold for head, neck, and abdominal CT Early invasive hemodynamic monitoring One study (Scalea) demonstrated that trauma surgeons themselves frequently fail to recognize the severity of hemodynamic instability in geriatric patients – reducing the time to invasive monitoring from 5.5 to 2.2 hours, and recognizing and treating occult shock, survival rate went from 7 to 53%.

52 Tips and Pearls (cont.) Early, aggressive O2 and mechanical ventilation Overresuscitation is as detrimental as inadequate resuscitation Liberal use of blood transfusion Consider patient’s environment and social situation Transfusions will enhance oxygen delivery and help minimize ischemia. Administer crystalloid judiciously b/c diminished cardiac compliance can lead to CHF.

53 Prevention Discharged patients: - Home safety assessment
- Carefully review medications - Suspend driver’s license? Arrange for a social worker to conduct a home safety assessment

54 Summary Aggressive treatment approach
There is no such thing as a mild head injury or minor trauma with the elderly Consider triage to trauma center Slide 44 The care of special populations that have experienced trauma requires knowledge of their unique anatomic and physiologic differences. Trauma in pregnant, pediatric, and older adult patients must be treated differently. Assessment, intervention, and evaluation must be guided by the unique response to traumatic injury. It is recommended that nurses who care for pediatric patients attend the Emergency Nurses Association’s Emergency Nursing Pediatric Course (ENPC). For those interested in more education related to the care of older adults, it is recommended that nurses take the Geriatric Emergency Nursing Education (GENE) Course.

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