Head Injury in the Elderly: What Are the Outcomes of Neurosurgical Care?

doi:10.1016/j.wneu.2016.07.057

World Neurosurgery

Volume 94, October 2016, Pages 493-500

https://doi.org/10.1016/j.wneu.2016.07.057 Get rights and content

Background

Epidemiologic studies show that an increasing proportion of those presenting with head trauma are elderly. This study details the outcomes of elderly patients with head trauma admitted to a regional United Kingdom neurosurgical unit.

Methods

The notes and imaging were reviewed of all patients with head injury aged ≥75 years, admitted from 1 January 2007 to 31 December 2010, including mortality data up to at least 2 years after discharge. Outcomes comprised death as an inpatient, by 30 days and 1 year after discharge; Glasgow Outcome Score; discharge Glasgow Coma Scale (GCS) score; recurrence; readmission; reoperation; and complication.

Results

A total of 263 patients were admitted: 26 with acute subdural hematoma (ASDH); 175 with chronic subdural hematoma (CSDH); and 46 with mixed subdural collections (ACSDH). Sixteen patients had other head injury diagnoses.

Patients with ASDH had a significantly lower survival rate than did those with CSDH or ACSDH: the odds of inpatient death for patients with ASDH was 15.38 (vs. those with CSDH). For all subdural hematomas (SDHs), low American Society of Anesthesiologists score was an independent predictor of early death.

Death at 1 year was predicted by head injury severity measured by admission GCS score (P = 0.028), long anesthetic (P = 0.002), and the presence of bilateral SDH (P = 0.002).

Unfavorable Glasgow Outcome Scale score (1–3) was predicted by age greater than 85 years (P = 0.029); larger depth of subdural (P < 0.001); and presence of any complication (P = 0.003). Those aged greater than 90 years with presentation GCS score lower than 10 all had poor outcomes.

Conclusions

Most elderly patients admitted under neurosurgery after head injury have SDHs. Our results are better than many previously reported; however, the rate of death for those with ASDH is still high.

Introduction

The population of the world is ageing, with estimates that there will be almost 2 billion people older than 60 years by 2050.¹ The consequences of this situation challenge health care systems worldwide. Two-thirds of acute hospital admissions in the United Kingdom are older than 65 years,² and serious head injury among patients aged 70 years and older is associated with high mortality.³ Acute subdural hematomas (ASDHs) are 4 times larger in the elderly and produce twice the mass effect, compared with younger patients.⁴ Ritchie et al.⁵ reported that there were no favorable outcomes after head injury in patients older than 80 years with an initial Glasgow Coma Scale (GCS) score lower than 13, and that all those with an initial GCS score lower than 11 were either dead, vegetative, or required full nursing care on discharge. However, with the unprecedented increase in people living in good health into their 90s, it is increasingly difficult for the neurosurgeon to know when the benefits of intervention are outweighed by the harms of disability, prolonged hospital stay, and death in those who have a short life expectancy. We have an ethical duty to provide appropriate care to these patients, whose neurosurgical and rehabilitation care requires considerable resources. To inform this process and aid decision making, contemporaneous outcome studies for elderly patients with head injury are required to evaluate beneficence. We aimed to describe the demographics, risk factors, and outcomes of elderly patients with head injury admitted to a regional neurosurgical unit.

Our region covers Cornwall and most of Devon, in the south-west of the United Kingdom, which is a haven for the retired population; 19.6% of the population is 75 years old or older.⁶ Because of the stability of the local population, our unit is well placed for the study of regional referrals, with secure prospects of obtaining accurate and near complete outcome data. This, and the demographics of all elderly patients admitted to our neurosurgery unit, was further discussed in a previous study.⁷

The term “elderly” is variably defined in the literature, but for the purposes of this study, a cutoff age of 75 years was used.

Section snippets

Methods

A retrospective review was undertaken of the medical records and imaging of all patients aged 75 years and older, admitted for at least 1 night to the South West Neurosurgery Centre, United Kingdom, from 1 January 2007 to 31 December 2010. A minimum of 2 years' mortality data, up to 31 December 2012, were extracted from the Demographics Batch Service and the National Health Service Spine database. A description of the methods used and data collected for the entire cohort has previously been

Patient Characteristics

A total of 886 patients aged 75 years and older were admitted during the 4-year study period, of whom 877 had medical records that were available to review. The characteristics of the whole cohort have previously been reported.⁷ A total of 263 patients were admitted after a head injury, a rate of 66 cases per annum. Of these patients, scans were available for review in 255 and diagnoses confirmed; for the remaining 8 patients, the diagnoses documented in the notes were relied upon. The median

Discussion

This study identified 263 patients, aged 75 years and older, who were admitted to a regional neurosurgery unit with head injury, over a period of 4 years. As may be expected, most had sustained SDHs, with 175 at a chronic stage, 26 acutely presenting, and 46 appearing acute-on-chronic. Other diagnoses consisted of 6 predominantly contusional injuries, 2 fractures, 4 traumatic subarachnoid hemorrhages, 2 extradural hemorrhages, and 2 piercing foreign bodies.

In the past, there has been some

Conclusions

As stated by Chibbaro et al.,¹⁵ it is likely that there has been a slow evolution in the experience and attitudes of many neurosurgeons, to increasingly consider active, operative management in the treatment of the elderly patients with head injuries. The elderly population is extremely diverse, in terms of health, with some surviving into their 80s, independent, with few comorbidities. Neurosurgeons are seeing increasing proportions of patients referred and treated in their units.7, 9 We found

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Traumatic brain injury (TBI) is a diagnosis representing a diverse group of neurological traumas with short, intermediate, and long-term sequelae. Recovery from injury often involves multiple health professionals across the continuum of care. Telerehabilitation serves as an important modality for the delivery of these heterogeneous and often, highly specialized, services. This chapter discusses the current state of science for telerehabilitation in TBI. Where evidence is lacking in TBI, use cases from other diagnoses and disciplines are discussed and may serve as a template for future care in recovery from brain injury. In addition, this chapter discusses clinical caveats and special populations that may influence the use of telerehabilitation for people with TBI.
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The dire implications of this are illustrated by the disproportionately high mortality seen in these patients across the world [1–3]. Acute subdural haematoma (ASDH) is a particularly ominous traumatic pathology in this age group, with a 6-month mortality rate as high as 58% [4]. It is characterised by the accumulation of acute blood beneath the dura mater, causing mass effect on the brain, often featuring other signs of injury from the initial impact [5].
Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT.
A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included.
A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%.
EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.
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Male and female patients with benign conditions were equal in number with only the extra 2 female patients having malignant lesions. This showed that our elderly patients have mainly benign neurological pathologies which are amenable to neurosurgical intervention.[2,12,17] Multidisciplinary approach to patients’ care is very essential in the management of geriatric patients requiring neurosurgical procedure since most of them have comorbidities and are usually on multiple medications.[18]
Geriatric medicine is a growing specialty but the cut off age varies all over the world due to the variation in life expectancy. Neurosurgical procedures in this vulnerable age group pose remarkable challenges and require collaborative multidisplinary efforts to achieve optimal outcome. The aim of this review is to document preliminary outcomes of geriatric neurosurgery in our suburban community.
A review of a single neurosurgeon operative data of patients aged 60 years and above from July 2018 to June 2020. The pre-, intra- and post-operative data were prospectively collected and analyzed. The pre- and post-operative patients’ performance statuses were assessed using the Eastern Cooperative Oncology Group performance Status (ECOG PS). Institutional ethical approval was obtained and data obtained were collated, computed and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 20.
Twenty eight geriatric patients were operated by the first author over a period of twenty-four months. There were 16 (57.1%) females and 12(42.9%) males. The mean age was 69.2 ± 7.8 with age range 60 years to 92 years. Large proportion of our patients 20(71.4%) had comorbidities. Hypertension 18(64.3%) was the most common with four of them having coexisting diabetes mellitus. There was no incidence of surgical site infection and no perioperative mortality.
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Research has also shown that patients with TBI aged ≥70 years and admitted with a GCS score of 14 will have increased mortality compared with younger patients with a GCS score of 13.25 Whitehouse et al.26 found that improved neurosurgical outcomes were associated with head injury in the elderly but that those with acute SDH were less likely to do well. The 30-day mortality rate in acute vascular cases in the present series was comparable to that previously reported.20
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A total of 796 patients were included, of whom 622 were aged <80 years (group A) and 174 were aged >80 years (group B). Overall survival was 86.3% in group A and 79.9% in group B. The 30-day mortality between the elective (0.8%) and emergency (10.1%) patients was significantly different statistically (P < 0.001). Of the patients in groups A and B, 84.7% and 68.9% were discharged back to their usual residence, respectively. Logistic regression found emergency surgery to be an independent predictor of mortality.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleHead Injury in the Elderly: What Are the Outcomes of Neurosurgical Care?

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Patient Characteristics

Discussion

Conclusions

J Clin Neurosci

World Neurosurg

Surg Neurol

Continuity of Care for Older Hospital Patients: A Call for Action

Head injury in the elderly

Age Ageing

Acute subdural haematomas: an age-dependent clinical entity

J Neurosurg

Original Article
Head Injury in the Elderly: What Are the Outcomes of Neurosurgical Care?