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Maiga AW, Ho V, Morris RS, Kodadek LM, Puzio TJ, Tominaga GT, Tabata-Kelly M, Cooper Z. Palliative care in acute care surgery: research challenges and opportunities. Trauma Surg Acute Care Open 2025; 10:e001615. [PMID: 40124208 PMCID: PMC11927415 DOI: 10.1136/tsaco-2024-001615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 02/08/2025] [Indexed: 03/25/2025] Open
Abstract
Palliative care includes effective communication, relief of suffering and symptom management with an underlying goal of improving the quality of life for patients with serious illness and their families. Best practice palliative care is delivered in parallel with life-sustaining or life-prolonging care. Palliative care affirms life and regards death as a normal process, intends neither to hasten death nor to postpone death and includes but is not limited to end-of-life care. Palliative care encompasses both primary palliative care (which can and should be incorporated into the practice of acute care surgery) and specialty palliative care (consultation with a fellowship-trained palliative care provider). Acute care surgeons routinely care for individuals who may benefit from palliative care. Patients exposed to traumatic injury, emergency surgical conditions, major burns and/or critical surgical illness are more likely to be experiencing a serious illness than other hospitalized patients. Palliative care research is urgently needed in acute care surgery. At present, minimal high-quality research is available to guide selection of palliative care interventions. This narrative review summarizes the current state of research challenges and opportunities to address palliative care in acute care surgery. Palliative care research in acute care surgery can rely on either primary data collection or secondary and administrative data. Each approach has its advantages and limitations, which we will review in this article.
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Affiliation(s)
- Amelia W Maiga
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Vanessa Ho
- Division of Trauma, Critical Care, Emergency General Surgery, and Burns, Department of Surgery, MetroHealth, Cleveland, Ohio, USA
| | | | - Lisa M Kodadek
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Thaddeus J Puzio
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gail T Tominaga
- Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Masami Tabata-Kelly
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Corriero A, Fornaciari A, Terrazzino S, Zangari R, Izzi A, Peluso L, Savi M, Faso C, Cavallini L, Polato M, Vitali E, Schuind S, Taccone FS, Bogossian EG. The impact of age and intensity of treatment on the outcome of traumatic brain injury. Front Neurol 2024; 15:1471209. [PMID: 39650242 PMCID: PMC11621102 DOI: 10.3389/fneur.2024.1471209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 11/08/2024] [Indexed: 12/11/2024] Open
Abstract
Background Approximately one-third of trauma-related deaths are due to traumatic brain injury (TBI), particularly among young adults and elderly patients. Management strategies may vary across different age groups, potentially influencing short-term neurological outcomes. This study aims to investigate age-related disparities in treatment approaches and 3-month neurological outcomes among TBI patients. Methods We conducted a retrospective study on TBI patients requiring Intensive Care Unit (ICU) admission from January 1, 2015, to January 1, 2024, in a tertiary University hospital. Patient demographics, major comorbidities, ICU admission parameters, interventions and ICU complications were collected. An unfavorable neurological outcome at 3 months (UO) was defined as a Glasgow Outcome Scale (GOS) score of 1-3. A high therapy intensity level (TIL) was defined as a TIL basic of 3-4. A multivariable logistic regression model and a Cox proportional Hazard Regression model were used to assess the association of age and TIL with neurological outcome and mortality. A sensitivity analysis on low TIL (0-2) and high TIL subgroups was also conducted. Results We enrolled 604 TBI patients, of which 240 (40%) had UO. The highest prevalence of UO was found in patients aged ≥80 years (53/94, 56%), followed by patients aged 50-79 years (104/255, 41%). The age group 35-49 years had the lowest rate of UO (38/127, 30%). Older patients (age ≥ 80 years) received less frequently high TIL than others (p = 0.03). In the multivariable analysis, age ≥ 80 years [OR: 3.42 (95% CI 1.72-6.81)] was independently associated with UO, while age ≥ 80 years [HR 5.42 (95% CI 3.00-9.79)] and age 50-79 years [HR 2.03, (95% CI 1.19-3.48)] were independently associated with mortality. Although there was no interaction between age groups and TIL on outcome, an exploratory analysis showed that in the high TIL subgroup of patients, age had no independent impact on the outcome, whereas, in the low TIL group, age ≥ 80 years was independently associated with UO [OR: 3.65 (95% CI: 1.64-8.14)]. Conclusion Older age, especially in the setting of low intensity treatment, may impact short-term neurological outcome of traumatic brain-injured patients.
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Affiliation(s)
- Alberto Corriero
- Department of Interdisciplinary Medicine-Intensive Care Unit Section, University of Bari Aldo Moro, Bari, Italy
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anna Fornaciari
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Samuel Terrazzino
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Rossella Zangari
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Antonio Izzi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- UOC Anesthesia and Intensive Care II, IRCCS Casa Sollievo Della Sofferenza Viale Cappuccini, San Giovanni Rotondo, Italy
| | - Lorenzo Peluso
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Milan, Italy
- Department of Anesthesia and Intensive Care, Humanitas Gavazzeni, Bergamo, Italy
| | - Marzia Savi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Chiara Faso
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laura Cavallini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Martina Polato
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eva Vitali
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Flores-Sandoval C, MacKenzie HM, McIntyre A, Sait M, Teasell R, Bateman EA. Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury. Arch Gerontol Geriatr 2024; 125:105488. [PMID: 38776698 DOI: 10.1016/j.archger.2024.105488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition. METHOD Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines. RESULTS 64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %). CONCLUSION Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.
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Affiliation(s)
| | - Heather M MacKenzie
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
| | - Amanda McIntyre
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Muskan Sait
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; University College Cork, Ireland
| | - Robert Teasell
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada.
| | - Emma A Bateman
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
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Ma Z, He Z, Li Z, Gong R, Hui J, Weng W, Wu X, Yang C, Jiang J, Xie L, Feng J. Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res Rev 2024; 99:102376. [PMID: 38972601 DOI: 10.1016/j.arr.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population. METHODS We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses. FINDINGS We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality. CONCLUSIONS In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population. REVIEW REGISTRATION PROSPERO CRD42022323231.
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Affiliation(s)
- Zixuan Ma
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhenghui He
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhifan Li
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Ru Gong
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Jiyuan Hui
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Weiji Weng
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Xiang Wu
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Chun Yang
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Jiyao Jiang
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Junfeng Feng
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China.
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Lafiatoglou P, Ellis-Hill C, Gouva M, Ploumis A, Mantzoukas S. Older adults' lived experiences of physical rehabilitation for acquired brain injury and their perceptions of well-being: A qualitative phenomenological study. J Clin Nurs 2024; 33:1134-1149. [PMID: 38014630 DOI: 10.1111/jocn.16939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
AIM To explore the experiences of older adults (65+) living with acquired brain injury regarding their sense of well-being during physical rehabilitation within the Greek Healthcare System. BACKGROUND With the increasing ageing population and the life-changing effects of acquired brain injury, there is a need to focus on care for older people and their potential to live well. Rehabilitation systems deserve greater attention, especially in improving the well-being of those who are using them. DESIGN A qualitative study design with a hermeneutic phenomenological approach was used. METHODS Fourteen older adults living with acquired brain injury and undergoing physical rehabilitation in Greece were purposively sampled. Semi-structured interviews were conducted to collect data and were thematically analysed using van Manen's and Clarke and Braun's methods. The COREQ checklist was followed. RESULTS Four themes emerged from the analysis: (1) Challenges of new life situation, (2) Seeking emotional and practical support through social interaction, (3) Identifying contextual processes of rehabilitation, (4) Realising the new self. CONCLUSIONS The subjective experiences, intersubjective relations and contextual conditions influence the sense of well-being among older adults living with acquired brain injury, thus impacting the realisation of their new self. The study makes the notion of well-being a more tangible concept by relating it to the degree of adaptation to the new situation and the potential for older adults to create a future whilst living with acquired brain injury. RELEVANCE FOR CLINICAL PRACTICE Identifying the factors that impact older adults' sense of well-being during rehabilitation can guide healthcare professionals in enhancing the quality of care offered and providing more dignified and humanising care. PATIENT OR PUBLIC CONTRIBUTION Older adults living with acquired brain injury were involved in the study as participants providing the research data.
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Affiliation(s)
- Panagiota Lafiatoglou
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Mary Gouva
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Avraam Ploumis
- Department of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Stefanos Mantzoukas
- Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
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Ghneim MH, Broderick M, Stein DM. Dementia and Depression Among Older Adults Following Traumatic Brain Injury. ADVANCES IN NEUROBIOLOGY 2024; 42:99-118. [PMID: 39432039 DOI: 10.1007/978-3-031-69832-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2024]
Abstract
Traumatic brain injuries are increasingly common in older adults and represent a substantial source of morbidity and mortality for this population. In addition to the impact from the primary insult, TBI can lead to a variety of chronic neurocognitive conditions including dementia, depression, and sleep disturbances. When caused by TBI, these conditions differ importantly from their non-TBI-related counterparts. Much about how TBI relates to the development of these conditions is unknown, and more research is needed to further elucidate optimal treatment strategies.
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Affiliation(s)
- Mira H Ghneim
- R Adams Cowley Shock Trauma, The University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Meaghan Broderick
- R Adams Cowley Shock Trauma, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma, The University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Ratha Krishnan R, Ting SWX, Teo WS, Lim CJ, Chua KSG. Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups. Life (Basel) 2023; 13:2047. [PMID: 37895429 PMCID: PMC10608274 DOI: 10.3390/life13102047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/18/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.
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Affiliation(s)
- Rathi Ratha Krishnan
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
| | - Samuel Wen Xuan Ting
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Wee Shen Teo
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health, Singapore 737628, Singapore
| | - Karen Sui Geok Chua
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Institute of Rehabilitation Excellence, Tan Tock Seng Hospital Rehabilitation Centre, Singapore 307382, Singapore
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9
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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10
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Halter M, Jarman H, Moss P, Kulnik ST, Baramova D, Gavalova L, Cole E, Crouch R, Baxter M. Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review. BMJ Open 2023; 13:e066329. [PMID: 36810176 PMCID: PMC9944672 DOI: 10.1136/bmjopen-2022-066329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/15/2022] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma. SETTING Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched. INCLUDED ARTICLES Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone. METHODS Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken. OUTCOME MEASURES Any outcomes reported for patients, staff or care system. RESULTS 17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury. CONCLUSIONS This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.
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Affiliation(s)
- Mary Halter
- Faculty of Health, Social Care and Education, Kingston University and St George's University of London, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Phil Moss
- Emergency department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Stefan Tino Kulnik
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Desislava Baramova
- Emergency Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Lucia Gavalova
- Faculty of Health, Social Care and Education, Kingston University and St George's University of London, London, UK
| | - Elaine Cole
- Trauma Sciences, Queen Mary University of London, London, UK
| | - Robert Crouch
- Health Sciences, University of Southampton, Southampton, UK
| | - Mark Baxter
- Geriatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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11
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Hsieh CT, Yen TL, Chen YH, Jan JS, Teng RD, Yang CH, Sun JM. Aging-Associated Thyroid Dysfunction Contributes to Oxidative Stress and Worsened Functional Outcomes Following Traumatic Brain Injury. Antioxidants (Basel) 2023; 12:antiox12020217. [PMID: 36829776 PMCID: PMC9952686 DOI: 10.3390/antiox12020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
The incidence of traumatic brain injury (TBI) increases dramatically with advanced age and accumulating evidence indicates that age is one of the important predictors of an unfavorable prognosis after brain trauma. Unfortunately, thus far, evidence-based effective therapeutics for geriatric TBI is limited. By using middle-aged animals, we first confirm that there is an age-related change in TBI susceptibility manifested by increased inflammatory events, neuronal death and impaired functional outcomes in motor and cognitive behaviors. Since thyroid hormones function as endogenous regulators of oxidative stress, we postulate that age-related thyroid dysfunction could be a crucial pathology in the increased TBI severity. By surgically removing the thyroid glands, which recapitulates the age-related increase in TBI-susceptible phenotypes, we provide direct evidence showing that endogenous thyroid hormone-dependent compensatory regulation of antioxidant events modulates individual TBI susceptibility, which is abolished in aged or thyroidectomized individuals. The antioxidant capacity of melatonin is well-known, and we found acute melatonin treatment but not liothyronine (T3) supplementation improved the TBI-susceptible phenotypes of oxidative stress, excitotoxic neuronal loss and promotes functional recovery in the aged individuals with thyroid dysfunction. Our study suggests that monitoring thyroid function and acute administration of melatonin could be feasible therapeutics in the management of geriatric-TBI in clinic.
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Affiliation(s)
- Cheng-Ta Hsieh
- Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City 22174, Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu 300044, Taiwan
- Department of Medicine, School of Medicine, Fu Jen Catholic University, New Taipei City 24205, Taiwan
| | - Ting-Lin Yen
- Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei 110, Taiwan
- Department of Medical Research, Cathay General Hospital, Taipei 22174, Taiwan
| | - Yu-Hao Chen
- Chung-Jen Junior College of Nursing, Health Sciences and Management, Chia-Yi City 62241, Taiwan
- Section of Neurosurgery, Department of Surgery, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi City 600, Taiwan
- Department of Biotechnology, Asia University, Taichung City 41354, Taiwan
| | - Jing-Shiun Jan
- Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei 110, Taiwan
| | - Ruei-Dun Teng
- Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei 110, Taiwan
| | - Chih-Hao Yang
- Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei 110, Taiwan
| | - Jui-Ming Sun
- Section of Neurosurgery, Department of Surgery, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi City 600, Taiwan
- Department of Biotechnology, Asia University, Taichung City 41354, Taiwan
- Correspondence:
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12
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Launey Y, Coquet A, Lasocki S, Dahyot-Fizelier C, Huet O, Le Pabic E, Roquilly A, Seguin P. Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study. BMC Geriatr 2022; 22:1004. [PMID: 36585608 PMCID: PMC9801582 DOI: 10.1186/s12877-022-03651-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/24/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Changes in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI. METHODS This was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5. RESULTS Among the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04-1.14), male sex (OR 2.94, CI95% 1.70-5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13-1.29), injury severity score (ISS; OR 1.04, CI95% 1.02-1.06) and use of osmotherapy (OR 2.42, CI95% 1.26-4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74-0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74-0.84]). CONCLUSIONS Among intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.
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Affiliation(s)
- Y Launey
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - A Coquet
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - S Lasocki
- grid.411147.60000 0004 0472 0283Département d’Anesthésie Réanimation, CHU de Angers, Angers, France
| | - C Dahyot-Fizelier
- grid.411162.10000 0000 9336 4276Département d’Anesthésie Réanimation, CHU de Poitiers, Poitiers, France
| | - O Huet
- grid.411766.30000 0004 0472 3249Département d’Anesthésie Réanimation, CHU de Brest, Brest, France
| | - E Le Pabic
- grid.411154.40000 0001 2175 0984Centre d’Investigation Clinique, CHU de Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
| | - A Roquilly
- grid.277151.70000 0004 0472 0371Département d’Anesthésie Réanimation, CHU de Nantes, Nantes, France
| | - P Seguin
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
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13
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Blumenfeld A, Sang HI, Baird R, Brenden M, Bjordahl P. 79 is the new 70: Left digit bias in craniotomy. Am J Surg 2022; 224:1442-1444. [PMID: 36283882 DOI: 10.1016/j.amjsurg.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/31/2022] [Accepted: 10/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Left digit bias is the psychological phenomenon in which the difference between values is perceived as larger due to the value of the first digit. For example, an 80 year old may be perceived as much older than a 79 year old. We sought to determine if left digit bias is present in craniotomy for elderly patients with traumatic brain injury. METHODS Patients aged 69, 70, 79, and 80 with traumatic brain injury and an abbreviated injury scale severity of a minimum of 3 were included from the National Trauma Data Bank from the years 2012-2019. 38,908 patients were included. A Chi-squared Test was performed to compare the percentage of patients undergoing craniotomy. RESULTS 79 year olds had higher craniotomy rates than 80 year olds (7.8% vs 6.4%, P < 0.001). There was no difference in craniotomy rates between 69 and 70 year olds (8.2% vs 7.8%, P < 0.2622). CONCLUSION This study suggests the presence of left digit bias in the decision to perform a craniotomy in patients aged 79 vs 80 with traumatic brain injury.
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Affiliation(s)
- Allison Blumenfeld
- University of South Dakota Sanford School of Medicine General Surgery Residency, Health Science Center, 1400 W 22nd St, Sioux Falls, SD, 57105, USA
| | - Hilla I Sang
- Sanford Research, 2301 E 60th St, Sioux Falls, South Dakota, 57104, USA
| | - Rebecca Baird
- Sanford Research, 2301 E 60th St, Sioux Falls, South Dakota, 57104, USA
| | - Misty Brenden
- Sanford USD Medical Center, 1305 W 18th St, Sioux Falls, South Dakota, 57117, USA
| | - Paul Bjordahl
- Sanford USD Medical Center, 1305 W 18th St, Sioux Falls, South Dakota, 57117, USA.
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Nevalainen N, Luoto TM, Iverson GL, Mattila VM, Huttunen TT. Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018. Acta Neurochir (Wien) 2022; 164:625-633. [PMID: 35119493 PMCID: PMC8913452 DOI: 10.1007/s00701-022-05140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/24/2022] [Indexed: 11/25/2022]
Abstract
Background A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population. Methods The data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified. Results The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period. Conclusions The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.
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Affiliation(s)
- Nea Nevalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Teemu M. Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, USA
- Spaulding Rehabilitation Hospital and Spaulding Research Institute, Boston, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA USA
| | - Ville M. Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
- Coxa Joint Replacement Hospital, Tampere, Finland
| | - Tuomas T. Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardio-Thoracic Surgery, Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland
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16
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Tverdal C, Aarhus M, Rønning P, Skaansar O, Skogen K, Andelic N, Helseth E. Incidence of emergency neurosurgical TBI procedures: a population-based study. BMC Emerg Med 2022; 22:1. [PMID: 34991477 PMCID: PMC8734328 DOI: 10.1186/s12873-021-00561-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/28/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures. METHODS Oslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry - Neurosurgery over a five-year period (2015-2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures. RESULTS A total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability. CONCLUSIONS The incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.
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Affiliation(s)
- Cathrine Tverdal
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway.
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Ola Skaansar
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Karoline Skogen
- Department of Neuroradiology, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
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17
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Zebrowski AM, Hsu JY, Holena DN, Wiebe DJ, Carr BG. Developing a measure of overall intensity of injury care: A latent class analysis. J Trauma Acute Care Surg 2022; 92:193-200. [PMID: 34225349 PMCID: PMC8692337 DOI: 10.1097/ta.0000000000003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization. METHODS We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored. RESULTS A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay. CONCLUSION This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. LEVEL OF EVIDENCE For prognostic/epidemiological studies, level III.
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Affiliation(s)
- Alexis M. Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jesse Y. Hsu
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel N. Holena
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Surgery, Division of Traumatology, Perelman School of Medicine, University of Pennsylvania
| | - Douglas J. Wiebe
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
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18
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Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit. World Neurosurg 2021; 158:e441-e450. [PMID: 34767994 DOI: 10.1016/j.wneu.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207). METHODS Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge. RESULTS Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes. CONCLUSIONS Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
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19
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Lafiatoglou P, Ellis-Hill C, Gouva M, Ploumis A, Mantzoukas S. A systematic review of the qualitative literature on older individuals' experiences of care and well-being during physical rehabilitation for acquired brain injury. J Adv Nurs 2021; 78:377-394. [PMID: 34397112 PMCID: PMC9291982 DOI: 10.1111/jan.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/24/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022]
Abstract
Aims To acquire an in‐depth understanding of how older individuals diagnosed with acquired brain injury (ABI) experience their well‐being and care when undergoing physical rehabilitation. Design Systematic literature review. Data sources The electronic databases of PubMed, CINAHL, APA PsycInfo, ASSIA and SCOPUS were searched from 2005 to 2020. Extensive reference checking was also conducted. Review methods A systematic review was conducted following PRISMA guidelines, including predominantly qualitative studies. Studies’ quality was appraised using the critical apraisal skills programme (CASP) tool. Results Seventeen studies met the inclusion criteria. Following methods of thematic synthesis, four overarching interpretive themes were identified: (a) Rehabilitation processes and their impact on older individuals’ well‐being; (b) Identity and embodiment concerns of older individuals during rehabilitation; (c) Institutional factors affecting older individuals’ care and well‐being experiences; and (d) Older individuals’ participation in creative activities as part of rehabilitation. Conclusion Organizational and structural care deficiencies as well as health disparities can adversely impact older individuals’ autonomous decision‐making and goal‐setting potentials. The discrepancy between older individuals’ expectations and the reality of returning home along with the illusionary wish to return to a perceived normality, can further negatively affect older individuals’ sense of well‐being. Constructive communication, emotional support, family involvement in rehabilitation and creating a stimulating, enriching social environment can humanize and facilitate older individuals’ adjustment to their new reality following ABI. Impact There is a lack of qualitative research on older individuals’ ABI rehabilitation experiences, especially traumatic brain injury incidents. Further study should consider patients’ concerns over their involvement in decision‐making and goal setting about their care. Overall, this review reveals the need to examine further the significance of humanizing care and the factors that affect older individuals’ sense of well‐being.
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Affiliation(s)
| | | | - Mary Gouva
- Department of Nursing, University of Ioannina, Ioannina, Greece
| | - Avraam Ploumis
- Department of Medicine, University of Ioannina, Ioannina, Greece
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20
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Sokas C, Lee KC, Sturgeon D, Streid J, Lipsitz SR, Weissman JS, Kim DH, Cooper Z. Preoperative Frailty Status and Intensity of End-of-Life Care Among Older Adults After Emergency Surgery. J Pain Symptom Manage 2021; 62:66-74.e3. [PMID: 33212144 PMCID: PMC8124083 DOI: 10.1016/j.jpainsymman.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022]
Abstract
CONTEXT Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population. OBJECTIVES We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year. METHODS This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization. RESULTS Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents. CONCLUSION While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.
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Affiliation(s)
- Claire Sokas
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Daniel Sturgeon
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Stuart R Lipsitz
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joel S Weissman
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dae H Kim
- Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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21
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Gavrila Laic RA, Bogaert L, Vander Sloten J, Depreitere B. Functional outcome, dependency and well-being after traumatic brain injury in the elderly population: A systematic review and meta-analysis. BRAIN AND SPINE 2021; 1:100849. [PMID: 36247393 PMCID: PMC9560680 DOI: 10.1016/j.bas.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022]
Abstract
Introduction Traumatic brain injury (TBI) rates in the elderly are increasing worldwide, mainly due to fall accidents. However, TBI's impact on elderly patients' lives has not been thoroughly investigated. Research question This systematic review and meta-analysis aims at describing post-TBI incidence of functional decline, dependency, nursing home admission, reduced quality of life and depression in the elderly. Materials and methods A systematic literature search was performed in PubMed, EMBASE, Web Of Science, BIOSIS, Current Contents Connect, Data Citation Index, MEDLINE, SciELO, Cochrane library and CINAHL. Study selection was conducted by two independent reviewers. Meta-analysis was performed using a random-effects model. Results Twenty-seven studies were included in the qualitative synthesis and twenty-five in a random-effects meta-analysis. The prevalence of unfavorable functional outcomes after TBI was 65.2% (95% CI: 51.1–78.0). Admission to a nursing home had a pooled prevalence of 28.5% (95% CI: 17.1–41.6) and dependency rates ranged between 16.9% and 74.0%. A reduced quality of life was documented throughout follow-up with SF12/36 scores between 35.3 and 52.3/100.2.6–4.8% of the patients with mild TBI reported depressive symptoms. A large heterogeneity was found among studies for functional outcomes and discharge destination. Discussion and conclusion In conclusion, elderly patients have a significant risk for functional decline, dependency, nursing home admission and low quality of life following TBI. Moreover, more severe injuries lead to worse outcomes. These findings are important to provide accurate patient and family counseling, set realistic treatment targets and aim at relevant outcome variables in prognostic models for TBI in elderly patients.
Traumatic Brain Injury in the elderly has a major impact on functional outcomes. Traumatic Brain Injury in elderly leads to dependency and nursing home admission. Elderly patients have a lower quality of life after Traumatic Brain Injury. Older age and injury severity are risk factors for poor functional outcome.
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22
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Llompart-Pou JA, Pérez-Bárcena J, Barea-Mendoza JA, Chico-Fernández M. [Head trauma in the new millennium: elderly patients]. Neurologia 2020; 35:673-674. [PMID: 31899018 DOI: 10.1016/j.nrl.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/19/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, España.
| | - J Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, España
| | - J A Barea-Mendoza
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - M Chico-Fernández
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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23
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Head trauma in the new millennium: Elderly patients. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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25
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Skaansar O, Tverdal C, Rønning PA, Skogen K, Brommeland T, Røise O, Aarhus M, Andelic N, Helseth E. Traumatic brain injury-the effects of patient age on treatment intensity and mortality. BMC Neurol 2020; 20:376. [PMID: 33069218 PMCID: PMC7568018 DOI: 10.1186/s12883-020-01943-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI. Methods Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression. Results A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity. Conclusion The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.
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Affiliation(s)
- Ola Skaansar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Cathrine Tverdal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Olav Røise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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Stranjalis G, Komaitis S, Kalyvas AV, Drosos E, Stavrinou LC, Koutsarnakis C, Kalamatianos T. Recent trends (2010-2018) in traumatic brain injury in Greece: Results on 2042 patients. Injury 2020; 51:2033-2039. [PMID: 32536530 DOI: 10.1016/j.injury.2020.05.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/10/2020] [Accepted: 05/29/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recent analysis on the epidemiology of traumatic brain injury (TBI) within Europe indicates an increase in fall-related injuries and in the incidence of hospitalization among older adults as well as a decrease in contribution of road traffic accidents (RTA). Given the paucity of recent national data, we analyzed TBI-related admissions from the Athens Head Trauma Registry during the largest part of the past decade (2010-2018), a period marked by a profound national socioeconomic crisis. METHODS Demographic and clinical data of admitted TBI patients were collected and analyzed statistically. RESULTS The mean age of patients (N=2042, 68% men) was 59 years (median 64 years). Patient age showed an upward trend across the study period. Most cases were mild, while moderate and severe injuries were indicated in, 11% and 20%, respectively. Falls were the predominant cause of injury (46% of cases), followed by RTA (38%). An upward trend in the frequency of fall-related injury was apparent across the study period; RTA-related injury frequency displayed a downward trend during the second part of the study period. Assault-related injury accounted for 6%. Surgery took place in 11% of cases. In-hospital mortality (IHM) was 21%. Fall-related mortality contributed to 56% of total IHM; RTA-related mortality contributed to 30%. The mean length of hospital stay was 13 days (median: 5 days). CONCLUSIONS The present findings suggest a shift in the epidemiologic profile of TBI patients in Greece with a rise in the proportion of elderly patients, a concomitant increase in fall-related injuries and a reduction in RTA-related injury. They also highlight fall-related injury as the predominant cause of IHM. Our results point towards the urgent need for the intensification of fall prevention strategies, continuing medical education as well as public information campaigns on the risks of geriatric fall-related injury.
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Affiliation(s)
- George Stranjalis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Spyridon Komaitis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Aristotelis V Kalyvas
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Evangelos Drosos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Lampis C Stavrinou
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Christos Koutsarnakis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Theodosis Kalamatianos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece.
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Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care. J Surg Res 2020; 246:224-230. [DOI: 10.1016/j.jss.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 01/24/2023]
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Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older. Neurosurg Rev 2019; 43:1305-1314. [PMID: 31414197 DOI: 10.1007/s10143-019-01159-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/13/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury ScaleHead (AIS) ≥ 3, and an AISNon-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AISHead of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.
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Stretti F, Klinzing S, Ehlers U, Steiger P, Schuepbach R, Krones T, Brandi G. Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital. Anesth Analg 2019; 127:698-703. [PMID: 29649031 DOI: 10.1213/ane.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.
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Affiliation(s)
- Federica Stretti
- From the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | | | | | | | - Tanja Krones
- Clinical Ethics, University Hospital of Zurich, Zurich, Switzerland
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Mehta C, Poole K. Head injury in the elderly. Clin Med (Lond) 2019; 19:262-263. [PMID: 31092530 PMCID: PMC6542216 DOI: 10.7861/clinmedicine.19-3-262b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Clare Mehta
- Sussex Rehabilitation Centre, Sussex Community NHS Foundation Trust and Brighton and Sussex University Hospitals Trust
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio AM, Diaz-Arrastia R, Okonkwo DO. Recovery Trajectories and Long-Term Outcomes in Traumatic Brain Injury: A Secondary Analysis of the Phase 3 Citicoline Brain Injury Treatment Clinical Trial. World Neurosurg 2019; 125:e909-e915. [PMID: 30763755 DOI: 10.1016/j.wneu.2019.01.207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospects for recovery after traumatic brain injury (TBI) are often underestimated, potentially leading to withdrawal of care in the comatose TBI patient who may ultimately have a favorable outcome with aggressive care. Outcomes and trajectories of recovery in a large series of patients with TBI were evaluated at 30, 90, and 180 days postinjury. METHODS A secondary analysis of the phase 3 Citicoline Brain Injury Treatment (COBRIT) trial was performed analyzing recovery trajectories and long-term outcomes at 30, 90, and 180 days postinjury. A Glasgow Outcome Scale-Extended (GOS-E) score of 5 or higher was considered favorable. Pearson χ2 analysis was used, and a P value of 0.05 was considered significant. A locally weighted, polynomial regression model was used to model recovery trajectories in a nonlinear fashion. RESULTS Subjects with TBI in the COBRIT trial had high rates of favorable outcome (57% of severe TBI, 86% of moderate TBI, and 93% of complicated mild TBI) at 6-month follow-up. These favorable outcomes often converted from high rates of unfavorable outcome at initial 1-month follow-up (85% of severe TBI, 57% of moderate TBI, and 21% of complicated mild TBI). Recovery trajectories had not plateaued at 6 months, suggesting that further improvement occurs beyond 6 months postinjury. CONCLUSIONS In this secondary analysis of the COBRIT trial, most patients had favorable outcomes by the GOS-E at 6 months postinjury in all complicated mild and moderate TBI groups, with over half of patients with severe TBI achieving a favorable outcome as well. Of subjects in a vegetative state (GOS-E score 2) at 1 month postinjury, 18% improved to a favorable outcome by 6 months postinjury. There was substantial improvement in all groups from 1 to 6 months, and this improvement may continue beyond 6 months. Clinical trials in TBI should consider recovery curves with repeated measures to assess outcomes because arbitrary single-moment outcome determination likely underestimates treatment effect in TBI care.
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Affiliation(s)
- Ross C Puffer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John K Yue
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Matthew Mesley
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Jane Sharpless
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Anita L Fetzick
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ava M Puccio
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI. RECENT FINDINGS Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired. SUMMARY Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.
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Lilley EJ, Lee KC, Scott JW, Krumrei NJ, Haider AH, Salim A, Gupta R, Cooper Z. The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge. J Trauma Acute Care Surg 2018; 85:992-998. [PMID: 29851910 PMCID: PMC6202158 DOI: 10.1097/ta.0000000000002000] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Affiliation(s)
- Elizabeth J Lilley
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts (E.J.L., K.C.L., J.W.S., A.H.H., A.S., Z.C.); Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (E.J.L., N.J.K., R.G.); Department of Surgery, University of California San Diego, La Jolla, California (K.C.L.); and Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., Z.C.)
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Peters ME, Gardner RC. Traumatic brain injury in older adults: do we need a different approach? Concussion 2018; 3:CNC56. [PMID: 30370057 PMCID: PMC6199670 DOI: 10.2217/cnc-2018-0001] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/12/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
- Matthew E Peters
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.,Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Raquel C Gardner
- Department of Neurology, University of California San Francisco, CA, 94143, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, 94121, USA.,Department of Neurology, University of California San Francisco, CA, 94143, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, 94121, USA
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Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older Medicare patients with moderate to severe traumatic brain injury. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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Lilley EJ, Scott JW, Weissman JS, Krasnova A, Salim A, Haider AH, Cooper Z. End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals. JAMA Surg 2018; 153:44-50. [PMID: 28975244 PMCID: PMC5833626 DOI: 10.1001/jamasurg.2017.3148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/21/2017] [Indexed: 01/19/2023]
Abstract
Importance More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.
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Affiliation(s)
- Elizabeth J. Lilley
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - John W. Scott
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Anna Krasnova
- The Center for Surgery and Public Health, Boston, Massachusetts
| | - Ali Salim
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Adil H. Haider
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Deputy Editor, JAMA Surgery
| | - Zara Cooper
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Schumacher R, Müri RM, Walder B. Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review. Curr Neurol Neurosci Rep 2017; 17:92. [PMID: 28986740 DOI: 10.1007/s11910-017-0801-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond. RECENT FINDINGS The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.
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Affiliation(s)
- Rahel Schumacher
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - René M Müri
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
- Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland
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Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
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Carpenter CR, Arendts G, Hullick C, Nagaraj G, Cooper Z, Burkett E. Major trauma in the older patient: Evolving trauma care beyond management of bumps and bruises. Emerg Med Australas 2017; 29:450-455. [DOI: 10.1111/1742-6723.12785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/19/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
| | - Glenn Arendts
- Department of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
- Harry Perkins Institute for Medical Research, Centre for Clinical Research in Emergency Medicine; Perth Western Australia Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital; Newcastle New South Wales Australia
- Department of Emergency Medicine; Faculty of Health and Medicine, The University of Newcastle; Newcastle New South Wales Australia
| | - Guruprasad Nagaraj
- Department of Emergency Medicine; Liverpool Hospital; Liverpool New South Wales Australia
- Department of Emergency Medicine, School of Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital; Harvard University School of Medicine; Boston Massachusetts USA
| | - Ellen Burkett
- Princess Alexandra Hospital; Brisbane Queensland Australia
- Department of Emergency Medicine; School of Medicine, The University of Queensland; Brisbane Queensland Australia
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