The Long-Term Impact of Severe TBI Among Older Adults
Following severe traumatic brain injury (TBI), mortality is highly likely among adults aged 65 years or older.
According to a new study1, of the 540 older adults who had been hospitalized with severe TBI over the 10-year study period, 428 patients (79%) died in-hospital and 456 patients (84%) died 6 months after injury.
Among those who survived, recovering to functional independence was uncommon. Of the 277 patients who had not been admitted to an intensive care unit (ICU), only 1 patient (0.4%) was functionally independent at 6 months. And of the 263 patients who had been admitted to an ICU, only 32 patients (12%) were functionally independent after 6 months.
The outcome proportions did not change over 2 years of follow-up.
Consultant360 reached out to the study’s lead author Matthew J. Maiden, PhD, who is a member of the ICU at Australia’s Geelong Hospital and Royal Adelaide Hospital, so that he can provide additional insight into these findings, as well as into how the results could influence the management of severe TBI in older adults.
Consultant360: What prompted your team to conduct this study?
Matthew Maiden: There were 2 main reasons that prompted us to conduct this study. As a medical retrieval doctor flying out to transfer older adults with severe TBI from their hometown in a rural/regional area to a metropolitan hospital, I wondered whether we were doing the patients—and their families—any favors. As an intensive care specialist, I was uncertain how to best advise patients’ families regarding the extent of patient recovery. This was particularly the case when clinicians and patient-surrogate decision makers advocated that patients should receive long-term ICU support.
C360: Your team’s findings showed that there is a very high mortality rate among older adults with severe TBI and that few recover to functional independence. How should this knowledge impact the way clinicians manage TBI immediately following the injury, as well as for the long term?
MM: In older adults with severe TBI managed in the ICU, few recover to functional independence. There are very few predictors of outcome, and there is no further recovery beyond 6 months among survivors. This is very important to understand, particularly as these patients are unconscious and unable to consent to treatment. While our study does not directly recommend how to treat these patients, it does allow more-informed decision making. Older adults may have expressed directives of how they would like to be treated when faced with a prognosis where death or permanent dependence is the likely outcome. Short- and long-term management decisions should be based on goals of care as expressed by the patient in an advanced care directive or by his or her surrogate decision maker.
C360: According to your team’s study, patients who are admitted to the ICU may be more likely to survive and/or gain functional independence following severe TBI compared with patients who are not admitted to the ICU. How should clinicians decide whether an older patient with TBI should be admitted to the ICU?
MM: The decision to admit an older adult with severe TBI to the ICU should be made collaboratively with the ICU specialist, the neurosurgeon, the patient’s surrogate decision maker, and a general practitioner (if available). The decision should be based on what treatment the patient would be willing to undergo given a low likelihood of recovery to functional independence.
C360: How do your findings highlight the need for improvement or standardization in the management of TBI among older patients?
MM: Our findings highlight the need for patient-centered discussions when deciding how to best manage severe TBI in older adults. Clinicians and families may advocate for neurosurgical interventions and ICU support, but this may not align with what the patient would have wanted. We also highlight the importance of ongoing monitoring of the treatment and outcomes of older adults with severe TBI. These patients are usually excluded from clinical trials, and comprehensive registry data will provide future insights to determine how these patients are best treated.
C360: What steps can clinicians take—or what conversations should they have with patients—to help prevent such injuries among their older patients?
MM: Given the extent of mortality and morbidity we observed, strategies to prevent TBI among older adults are likely to be more effective at maintaining functional independence than hospital treatment of severe TBI. Preventive strategies should focus on falls from standing height, which are clearly the most common cause of TBI in older adults.
Reference:
- Maiden MJ, Cameron PA, Rosenfeld JV, Cooper DJ, McLellan S, Gabbe BJ. Long-term outcomes after severe traumatic brain injury in older adults: a registry-based cohort study. Am J Respir Crit Care Med. 2020;201(2):167-177. https://doi.org/10.1164/rccm.201903-0673OC.