The results of this study demonstrate an increased level of advanced care for older persons presenting to an ED with TBI. Persons 65 years of age and older were more likely to receive a head CT and/or MRI in the ED and to be admitted to either the ICU, step-down unit, or have surgery after presenting to the ED with TBI compared to younger persons. It is important to note that age was not a statistically significant predictive factor in determining the triage immediacy for visits, but still was an indicator for increased services. This could point to a possible opportunity to use age as a triage consideration in patients with head trauma presenting to an ED. Visits for head trauma were triaged as requiring immediate or urgent attention regardless of age. However, age could be a surrogate for anticoagulant use and should be further studied. In addition to these findings, our results also suggest that the numbers of ED visits for TBI are increasing.
Among older adults, falls are the leading cause of head injuries resulting in TBI. As the U.S. population continues to age and rapidly grow, falls resulting in injury will become an even more important public health issue.14
Falls from ground level are common in older populations, resulting in significant morbidity and mortality.15
Furthermore, due to the increased use of anticoagulants in this population, complications from falls can have deleterious outcomes such as subdural hematomas resulting in death.9–16
Even minor head injuries in older patients result in a higher incidence of intracranial hemorrhage due to the use of antiplatelet and anticoagulant medications and could be a plausible explanation for the increased ICU, step-down unit, or emergent surgery rates found in this study.17
Therefore, quick identification of this type of injury is important in older populations.
Age can also be related to the trajectory of recovery for those suffering from TBI, and can result in higher costs for care. Patients 65 years of age and older require greater levels of inpatient rehabilitation and do not progress as quickly with rehabilitation as do younger patients.18
Rehabilitation charges for older patients were significantly higher compared to younger patients, as was total length of stay for inpatient rehabilitation services after TBI, due to more severe injuries.19–20
To better understand the relationship of age on use of services, we examined age as a continuous variable and found that each year of age contributed to increased use of services (p<.01).
Costs from TBI can be considerable. Finkelstein et al21
have suggested that the lifetime costs for TBI in the U.S. in 2000 dollars was $60.4 billion. Data from the CDC Web-based Injury Statistics Query and Reporting System (WISQARS) estimates that total 2005 costs from TBI among persons 65 years of age and older were over $5 billion.22
Older patients suffering from TBI have also been found to become physically and financially dependent on others after injury and suffer significant decreases in independence.23
This suggests that there an increase in medical costs for TBI in the inpatient and outpatient setting, but in costs at a societal and personal level due to a loss of both physical and mental functionality. It has been proposed that a reduction in societal costs, which appear to be the most significant contributor of cost, could be achieved through widespread adoption of the Brain Trauma Foundation (BTF) treatment guidelines that address treatment of patients with severe TBI who account for approximately 10% of all TBIs.24
The main limitation of this study was the small sample size. We took the data used for these analyses from the NHAMCSED sample, which collects data from the ED during a four-week period in selected hospitals with just three admission diagnoses. The total sample size for each collected year of data was no greater than 35,000 records. With the overall incidence of TBI for each year, this limited the likelihood of collecting information on TBIs within the four-week sampling period of the survey. Therefore, a complete characterization of each ED visit for TBI that described all procedures was not possible. However, by combining three years of data, robust estimates of overall visits by age, sex and race were possible, as well as several descriptors of the visit, including triage immediacy, receipt of a head CT and/or MRI and admission to the hospital. Furthermore, by using this dataset, national estimates were possible. To the authors’ knowledge, this is the first presentation of this level of data for older persons presenting with TBI to an ED.
A second limitation of this study was that there was no measurement of GCS collected in the dataset. Use of this scale is a commonly used measure of severity for head injury. Even so, this study demonstrates that older persons presenting to an ED with diagnosed TBI potentially require higher acuity treatment compared to younger persons, which could be indicative of a more deleterious GCS measure. Furthermore, antiplatelet and anticoagulant use was not collected in this database, preventing comparisons with prior studies on these medications.
A final limitation was our inability to determine the specific reason for increased triage immediacy, receipt of head CT and/or MRI or admission to the hospital for each of these cases from this data. Both age and comorbidities could be the driving factors that would require additional service provision. This study only searched for a diagnosis of TBI among the three listed diagnoses on admission to the ED. However, it is reasonable to believe that complications, such as increased risk of subdural hematomas and the increased frailty of older persons, are most likely the driving forces behind the outcomes examined in this study.