Don’t overestimate the Geriatric Conscious State (aka GCS is unreliable in the elderly)

kehoe2014-GCSelderlyHeader

We all know that elderly trauma patients tend to have worse outcomes, and that there is a high incidence of occult injury. A recent case of an elderly patient, who remained GCS 15 far longer than the significant intracranial injury on imaging predicted, prompted some discussion, and this study by Kehoe et al was raised. In this retrospective database review, they analysed the initial GCS for patients with isolated major head injury and showed that elderly patients (defined as ≥ 65 years old—controversial, I know) not only presented with higher GCS for the same grade injury, but also had worse outcomes with higher mortality and longer stays in hospital. The elderly group had higher rates of severe injury despite arising predominantly from lower risk mechanisms (86.4% due to "fall < 2m" vs 37.7% in the <65 year old group).

The elderly group had a higher mortality rate (22.4% vs 6.6%), despite eventual non-survivors presenting with a higher GCS (median of 11 vs 4.5)

Limitations

Being a retrospective study limits some of the data collected, in particular data on the type and size of injury identified. In addition, this was based on data from a single centre, and cases with incomplete data were excluded.

The higher mortality rate in the elderly group may reflect the increased impact of other injuries on outcomes (the definition of "isolated" head injury excluded only major injury elsewhere, but cumulative minor injuries may have an influence), as well as comorbidities and the lower neurosurgical procedure rate in the elderly group (although at 28.4%, this is still high).

The Bottom Line

It has been suggested that the elderly may have more "space" in the skull vault to allow for haematoma formation before GCS is impacted, but the key message here is:

Elderly patients may have severe anatomical traumatic brain injury with high ensuing mortality despite presenting with a near-normal GCS.

Maintain a high index of suspicion and be vigilant for deterioration in the elderly patient at risk of significant head injury or who has other risk factors such as anticoagulation.

 

Share your thoughts