Older Adults

Older persons

People older than age 65 (older adults) can be considered a specific sub-set of the population for concussion assessment and treatment. This age group deserves particular attention for several reasons, including the difficulty in securing an initial concussion diagnosis due to lack of recognition for potential concussive events, increased likelihood of concomitant age-related issues and polypharmacy. 

The majority of concussions sustained in this age group are due to falls which are often not witnessed as the most likely place for falls to occur is at home1,2. This can make diagnosis more difficult if the patient cannot remember hitting their head or if they present with a more prominent injury which demands more immediate attention (e.g. a broken bone). Older adults are at an increased risk of falling due to a variety of factors such as age-related decline in cognition, vision issues, mobility issues, reduced reflex response and underlying neurodegenerative or pre-neurodegenerative disease symptoms.

Older age is a risk factor for prolonged concussion symptoms 3, 4, which can negatively impact quality of life and independence over time. 

Thus, it is important to consider older people in their health context and whether they may benefit from concussion rehabilitation with a geriatric focus. This section emphasises the need to successfully identify concussions and review concussion treatments that are appropriate for older adult’s symptoms. 

References supporting introduction:

  1. https://www.canada.ca/en/public-health/services/publications/healthy-living/surveillance-report-falls-older-adults-canada.html
  2. André S. Champagne, Xiaoquan Yao, Steven R. McFaull, Shikha Saxena, Kevin R. Gordon, Shelina Babul and Wendy Thompson. Health Reports: Self-reported concussions in Canada: A cross-sectional study. Release date: June 21, 2023. DOI: https://www.doi.org/10.25318/82-003-x202300700002-eng
  3. Sage NL, Chauny JM, Berthelot S, et al. Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury. J Neurotrauma. 2022;39(19-20):1349-1362.
  4. Langer LK, Alavinia SM, Lawrence DW, et al. Prediction of risk of prolonged postconcussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score. PLoS Med. 2021;18(7):e1003652.
13.1

Concussion should be suspected for all older persons presenting with a fall or other mechanism of injury that could plausibly cause a concussion.

A concussion could result “…from a transfer of mechanical energy to the brain from external forces resulting from the (1) head being struck with an object; (2) head striking a hard object or surface; (3) brain undergoing an acceleration/deceleration movement without direct contact between the head and an object or surface; and/or (4) forces generated from a blast or explosion.”1 Older people may be more susceptible to concussion from all mechanisms of injury and therefore presentation with any plausible mechanism of injury should be a flag for a healthcare provider to do assessment. 

 

Context references:

1. Silverberg ND, Iverson GL; ACRM Brain Injury Special Interest Group Mild TBI Task Force members, et al. The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Arch Phys Med Rehabil. 2023;104(8):1343-1355. 

Level of Evidence C
Last updated  
13.2

For older persons presenting with new onset cognitive impairment, concussion should be considered within the differential diagnosis. 

 

Where there has been evidence of head trauma such as bruising or other concussion-related symptoms such as headache, new onset balance impairment, or vision difficulties, concussion should be considered as a potential etiology for the change in status. In addition to cognition assessment, physical (e.g., headache, sleep) and emotional/psychological state should be assessed to determine if other issues are present or could be causing concussion-related signs and symptoms. Concussion should be diagnosed in the same manner as for younger patients. See Living Concussion Guidelines Diagnosis section. 

Level of Evidence C
Last updated  
13.3

For older persons presenting to the Emergency Department after a concussion, the need for immediate neuroimaging should be determined according to the Canadian CT Head Rule. 

The Canadian CT Head Rule remains the most relevant tool for determining the need for neuroimaging for older persons presenting to Emergency. In situations without CT capability (e.g., in some rural settings), the Falls Decision Rule1 may be useful. This decision rule indicates that no head CT is likely required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. 

 

Context references:

1. de Wit K, Mercuri M, Clayton N, et al. Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen. CMAJ. 2023, 195(47):E1614-E1621.

Level of Evidence B
Last updated  
13.4

Older persons taking vitamin K antagonist anticoagulants (e.g., warfarin) should undergo neuroimaging immediately after a concussion.

The original article establishing the Canadian CT Head Rule excluded people on anticoagulants.1 Since then, research has shown that people taking vitamin K antagonists are more likely to have a positive CT scan.2-5 Therefore, we recommend that people taking this class of antithrombotic be scanned. Research also indicates that people experiencing nausea, pain, headache, or dizziness may be at an increased likelihood of having a positive result on CT scan.6-12 People with any of these symptoms should receive extra consideration for a CT scan. See our table entitled “Positive Variable Associations with CT findings” for a full list of prognostic variables assessed in the literature. 

 

Context references:

1. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396.

2. Turcato G, Zannoni M, Zaboli A, et al. Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists. J Emerg Med. 2019;57(6):817-824. 

3. Riccardi A, Spinola B, Minuto P, et al. Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am J Emerg Med. 2017;35(9):1317-1319. 

4. Santing JAL, Lee YX, van der Naalt J, et al. Mild Traumatic Brain Injury in Elderly Patients Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis. J Neurotrauma. 2022;39(7-8):458-472.

5. Savioli G, Ceresa IF, Luzzi S, et al. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. Medicina. 2020;56(6):308.

6. Ibañez Pérez De La Blanca MA, Fernández Mondéjar E, Gómez Jimènez FJ, et al. Risk factors for intracranial lesions and mortality in older patients with mild traumatic brain injuries. Brain Inj. 2018;32(1):99-104. 

7. Sakkas A, Weiß C, Scheurer M, et al. Management of older adults after mild head trauma in an oral and maxillofacial surgery clinic. Eur Geriatr Med. 2023;14(3):603-613. 

8. Sakkas A, Weiß C, Wilde F, et al. Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit. Eur J Trauma Emerg Surg. 2024;50(1):157-172. 

9. Sakkas A, Weiß C, Wilde F, et al. Justification of Indication for Cranial CT Imaging after Mild Traumatic Brain Injury According to the Current National Guidelines. Diagnostics. 2023;13(11):1826. 

10. Sakkas A, Weiß C, Ebeling M, et al. Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis. J Clin Med. 2023;12(10):3563.

11. Aramvanitch K, Khachornwattanakul K, Vichiensanth P, et al. Age-appropriateness of decision for brain CT scan in elderly patients with mild traumatic brain injury. World J Emerg Med. 2023;14(3):227-230.

12. Park N, Barbieri G, Turcato G, et al. Multi-centric study for development and validation of a CT head rule for mild traumatic brain injury in direct oral anticoagulants: the HERO-M nomogram. BMC Emerg Med. 2023;23(1):122. 

Level of Evidence A
Last updated  
13.5

For persons sixty-five years of age and older, routine in-hospital observation periods or repeat CT scans (after an initial negative CT scan) are not recommended for persons presenting with concussion who are currently on antithrombotic medication (e.g., antiplatelet medication, direct oral anticoagulants, vitamin k antagonists). 

Level of Evidence A
Last updated  
13.6

Older persons diagnosed with concussion should have concussion symptoms managed similarly to other age groups. 

There is no specific evidence to suggest changing usual management practices for this age group. Therefore, what applies to younger adults also applies to older adults. Thus, there should be a focus on supporting older adults to be safely physically active and gradually return to regular activities and roles. However, it is important to note that older persons are more vulnerable and have unique needs (e.g., polypharmacy), so age needs to be taken into account in overall management. 

Level of Evidence C
Last updated  
13.7

For older persons diagnosed with concussion and concurrent geriatric health issues, referral to a geriatric assessment program (e.g., has geriatric expertise) is recommended. 

Examples of geriatric health issues include: polypharmacy, medications with relative contraindications in the elderly, frailty, multiple medical conditions, and cognition and mood issues. The clinic should have experience with older adults and have a geriatrician assigned to it. Also, fall prevention information should be provided to the patient and any caregivers. Interventions (e.g., physical rehabilitation) should be started to prevent any future falls. 

Level of Evidence C
Last updated