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

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Presentation on theme: "Mild Traumatic Brain Injury in the Geriatric Population Cynthia Blank-Reid, RN, MSN, CEN Trauma Clinical Nurse Specialist Temple University Hospital Philadelphia,"— 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 TraumaEpidemiology 5th leading cause of death over age 25% of trauma deaths Persons >65 = Fasting growing age group

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

5 Geriatric Mechanisms of Injury Falls Motor vehicle crashes Pedestrian struck by motor vehicle Assaults Co-morbid disease may be precipitating factor for injury

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 –Shock may be present with normal vital signs May have pre-existing anemia

20 Psychosocial End-of-life decisions Specific directions for withholding or withdrawing treatments Guidelines for making treatment decisions –Patients right to self-determination –Patients 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

22 Types of Mild Traumatic Brain Injury in the Elderly

23 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

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

32 Nursing Care of the Geriatric Trauma PatientAssessment 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 patients functional status/neurologic status before? Does the patient have advance directives?

33 Nursing Care of the Geriatric Trauma PatientAssessment Inspection Mouth for loose teeth, partial plates, dentures Skin: look carefully for pressure areas, ecchymosis Palpation Bony prominences of spine

34 Nursing Care of the Geriatric Trauma PatientAssessment 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

35 Diagnostic Procedures Laboratory Testing Electrolytes Cardiac enzymes, troponin Therapeutic drug levels Coagulation profiles Other Studies Electrocardiogram Echocardiogram Carotid ultrasound

36 Factors Complicating Assessment Presence of multiple pathologies –85% have one chronic disease; 30% have three or more –One systems acute illness stresses others reserve capacity –One diseases symptoms may mask anothers –One diseases treatment may mask anothers 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

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

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.

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 Head injury with subdural hematoma Alcohol, drug intoxication, withdrawal Tumor CNS Infections Electrolyte imbalances Cardiac failure Hypoglycemia Hypoxia Drug interactions Possible Causes

46 Cerebrovascular Accident Emboli, thrombi more common CVA/TIA signs often subtledizziness, 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 doesnt 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

52 Tips and Pearls (cont.) Early, aggressive O 2 and mechanical ventilation Overresuscitation is as detrimental as inadequate resuscitation Liberal use of blood transfusion Consider patients environment and social situation

53 Prevention Discharged patients: - Home safety assessment - Carefully review medications - Suspend drivers license?

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

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