Head trauma in the new millennium: Elderly patients

Dear Editor:

It was with great interest that we read the recently published article by Giner et al.¹ on the clinical characteristics of severe head trauma in the new millennium in a Spanish reference centre. The authors report that progressive population ageing is associated with such epidemiological changes as an increase in the percentage of female patients, a predominance of low-energy falls as the cause of trauma, and concomitant use of anticoagulants; these findings are consistent with results from similar studies² and multi-centre trauma registries conducted in our setting.³

Elderly patients represent approximately 25% of all intensive care unit (ICU) admissions due to trauma; this percentage is expected to increase in the coming years. In elderly patients, cortical atrophy and accumulation of atheromatous plaques in cerebral blood vessels make the brain particularly susceptible to traumatic injury,⁴ and especially subdural haematoma, as reported by Giner et al.¹

Although the elderly population is under-triaged in reference centres, recent years have brought increasing awareness of this problem and the need for intensive treatment to revert anticoagulation, evacuate treatable masses, and monitor and treat these patients as we would younger neurocritical care patients.^4–6 Ivascu et al.⁷ analysed the impact of an aggressive anticoagulation reversal protocol for patients previously treated with cumarinics. Achieving INR below 1.6 within 4 hours of head trauma resulted in a 75% decrease in mortality associated with traumatic intracerebral haemorrhage in elderly patients. Furthermore, neurosurgery interventions and multimodal management at ICUs have improved prognosis in some series of elderly patients with severe head trauma, achieving good neurological outcomes in 55% of patients aged between 70 and 79 years.⁸ In our setting, a recent study including traumatology patients aged ≥ 80 years and attended at Spanish ICUs showed that head trauma is the main determinant of outcomes.⁵ However, the mortality rate was much lower than that expected according to scores on the head section of the Abbreviated Injury Scale.⁵ We therefore believe that the initial treatment in this population must be aggressive; if no clinical improvement is observed after a reasonable period, limitation of life-sustaining treatment (LLST) may be considered.⁹ LLST is a common practice, applied to nearly 25% of elderly patients with severe trauma in our setting.¹⁰ The results reported by Giner et al.,¹ with an increase in the percentages of patients undergoing decompressive craniectomy or intracranial pressure monitoring during the second period analysed despite their older mean age, support the idea of more active treatment.

However, their results also reveal a statistically significant difference in early mortality between the 2 periods analysed (14.7% vs 30.9%; P = .004). To better interpret these data, it may be interesting to determine how many of the patients who died in each period received LLST measures or were admitted as part of an intensive care protocol oriented toward organ donation.

Comprehensive, multidisciplinary management of elderly patients with head trauma constitutes a challenge; predictive models and specific treatment guidelines should be developed to improve prognosis of these patients.¹¹

Conflicts of interest

The authors have no conflicts of interest to declare.