Concussions in Older Adults
Concussions are often more dangerous and take longer to recover from in elders. These injuries are more dangerous than in younger populations because of the higher risk for brain bleeds and because older adults are more likely to fall if they have had a previous head injury. Elders also have the highest traumatic brain injury (TBI) hospitalization rates when compared to other age groups, with falls being the leading cause of all TBIs in the United States. These risks are influenced by the prevalence of medication and other health problems that may be present in older people.
A Personal Story
Patient experiences suggest that healthcare professionals sometimes operate with a lack of urgency in treating elderly concussions, in addition to not being familiar with current concussion management protocols. We spoke with the daughter of an elderly patient whose mother sustained a concussion after a fall. After the first concussion, her mother fell repeatedly over the following months. The daughter suspects that her mother sustained multiple more concussions from the falls.
These falls may have been preventable, but their doctor did not give any advice for preventing future falls. Further, her healthcare providers did not schedule or even discuss a follow-up appointment following the first concussion, even though the mother was still symptomatic. The daughter describes the dismissive attitudes of the professionals her mother had received care from: “There is just this thing about, well, she's old. The doctor will say things like, ‘Well, she'll probably die in three to five years.’"
In the event of an older person sustaining a concussion, elders, caretakers, and healthcare professionals need to be aware of strategies to optimize the quality of concussion management. This article has guidelines for anyone impacted by concussions in elders, including how to ensure the best management and treatment, how to reduce the risk for future health problems, and stigmas and myths to look out for.
Concussions in Older People–Background
What is a Concussion?
A concussion is a mild traumatic brain injury that can occur when the head, neck, or body experiences a blow, resulting in an impulsive force being transmitted to the brain that causes the brain tissue to stretch, compress, and twist inside the skull.
This tissue movement causes a cascade of temporary chemical changes in the brain and can stretch and damage brain cells—often on a level that is too small to see on standard imaging tests. These chemical and physical changes cause symptoms that can affect how a person thinks, feels, acts, learns and sleeps.
Increased Risk
One of the main reasons why elderly concussions are particularly concerning is because older people are most at risk of developing a concussion—on par with adolescents, who are far more active. Recovery is also more difficult because the healing process in older people is not as effective. As we age, our brain tissue becomes less adaptable and less able to repair from injury. For these reasons, it is crucial that preventative measures are taken to reduce the likelihood of a future concussion in an elder. It is also necessary to know how to navigate the healthcare system to find the best treatment options. Below, we provide guidelines for concussion prevention and for receiving the best treatment. We also discuss how the high prevalence of comorbidities might make treatment and diagnosis more difficult for healthcare providers.
How to Get Help
Concussion rehabilitation can be a long and arduous process, especially for older adults who are more likely to have a longer recovery timeline than younger adults. For many, this process is made harder by navigating a confusing healthcare system. Patients and caretakers should know how to navigate a system that is often not up-to-date on the best practices. We have provided guidelines and questions to ask healthcare providers to receive the best care.
If a concussion is suspected, the first step should be to look out for red-flag symptoms. Elders who sustain a concussion are at an elevated risk of developing a brain bleed or other complication that would generate one or more of the red flag symptoms shown below. If you or a loved one notices signs of one of these symptoms, go to the emergency room immediately.
Symptoms from Cattonline
If there are any signs or symptoms of a concussion that are not red-flag: see a doctor as soon as possible, and definitely within 48 hours. Note that during the first medical visit, an examination of the neck should occur as the cervical spine might be injured. If headache, neck pain, or dizziness are present in the first medical appointment, Concussion Alliance recommends asking for a referral to get an appointment with a cervicovestibular rehabilitation specialist. The 6th Consensus statement on concussion in sport recommends this rehabilitation if any of these symptoms are present at 10 days, so Concussion Alliance recommends starting the referral process early in case it’s difficult to find a specialist.
For those that visit the emergency room, less than half are discharged with guidance or suggestions for a follow up visit. After going to the emergency room, the first step should be to book an appointment with your primary care physician as soon as possible. The physician may not know the most up-to-date concussion care information or proper referral pathways, so the most important thing in that visit is to ask for a referral to an outpatient rehabilitation center. Rehab centers are recommended for elders since they are equipped with an interdisciplinary team that is specialized in treating brain injuries and can treat unique concussion symptoms. Outpatient rehabilitation clinics are the best setting one can find to care for a concussion because they staff multidisciplinary teams that are usually trained and experienced working with all severity of TBIs. Oftentimes sleep specialists, physical therapists, occupational therapists, and many more specialists are either in close proximity or already work together in these centers to develop tailored, multidisciplinary treatment plans.
Physiatrists or Neurologists are often the first point of care at a rehab center; they will determine what types of treatments are appropriate and refer to one or more specialists at the rehab center. Physiatrists are trained to manage multidisciplinary care teams to optimize each patient’s unique treatment plan. Rehab centers generally take medicare. Learn more here.
For more specific symptoms to look out for when waiting for an appointment with outside care, please see the Guidelines for Recovery page. If symptoms persist for longer than four weeks, please seek care for persisting symptoms depending on which form of therapy is best for you. There are many different pathways for rehabilitating a concussion in an elder, so it is important to speak openly with your healthcare provider or the physiatrist you see in an outpatient setting.
Prevention
Since elders are at a higher risk of getting concussions, preventative measures are vital to ensure future health and safety. A major reason why concussions are common in older people is because of the increased incidence of falls. One study found that 90% of head injuries in older adults are caused by ground-level falls (falling to the ground when standing or sitting at ground-level).
What you can do for your Body
Exercise:
One of the most effective measures to prevent the risk of falls is to exercise regularly. One might think the opposite: that exercise makes falls more likely for older adults due to the increased physically dangerous activity. However, evidence suggests that exercise interventions actually decrease falls by 23% in older people. This is likely because consistent exercise can improve balance, coordination, strength, and confidence. However, despite the role of exercise in reducing falls, it is crucial that older adults are doing safe, but effective exercises. This means avoiding high-risk exercises like running on a treadmill and using heavy weights. An all-encompassing exercise routine would implement gait, balance, strength, flexibility, and endurance training. The strength and coordination improvements from these exercises make it easier for the brain and muscles to balance and stabilize a person in the event of tripping or stumbling. Older people with little experience exercising might need to implement an exercise program more gradually and start at a lower level of activity, but physically training the mind and body is very effective for reducing falls. Talk to your doctor or medical provider about creating an exercise plan directed at fall prevention.
Medication:
Medication is another important variable to consider in fall prevention. There is a litany of medications that are essential to combat other ailments that come with age, but many have side effects that can heighten the risk of falling and suffering a concussion. One common side effect is a sudden drop in blood pressure, which can cause lightheadedness, dizziness, and fainting; all of which can cause someone to fall. We spoke with Dr. Elizabeth Sandel, MD, about this problem:
“Some people are on medications that can cause impairments, side effects that create impairments, dizziness, lightheadedness, what's called orthostatic hypotension. So, your blood pressure drops, one's blood pressure can drop on standing up, and some people are on maybe too much of an antihypertensive, too high a dose…They may have to have reductions in the dose if they start to have lower blood pressure.”
Alcohol:
Another important factor that may reduce falls is limiting alcohol consumption. Higher alcohol consumption is associated with more falls. It is well known that alcohol impairs balance, which puts one at risk of falling. It is also important to note that elders process alcohol differently than younger adults. Older people have higher blood alcohol levels than younger people after the same amount of drinks, and it takes longer to eliminate alcohol from their bodies.
What you can do in your Home Environment
In combination with safe exercise and medication side-effect awareness, there are many at-home modifications that can reduce the risk of falls.
Dr. Elizabeth Sandel provided a list of everyday items to look out for. “Within the home, one of the main things is rugs…that's one of the main things that can be a problem for tripping and falling. The other thing is lighting. So, as vision dims for a lot of older people, there's the recommendation to use motion detector lights, so when an older person gets up in the middle of the night, the light goes on.” Not all older adults are in the financial position to be able to afford motion-detected lighting systems, but simply purchasing a nightlight to keep in places like the bathroom, where falls are especially common, can prevent future injuries. The CDC recommends other safeguards to prevent falls, such as: “remove things you can trip over,” “use non-slip mats in the bathtub”, and “wear well-fitting shoes with good support.”
Occupational therapists can help safeguard the at-home environment. Dr. Elizabeth Sandel recommends seeking one out: “they're the people that really can help to make the home safer. You can ask your primary care doctor…‘I want an occupational therapy home evaluation.’” Falls are the leading cause of concussion in elders by far, and although not all risk factors can be avoided, planning how to avoid common tripping hazards is a crucial step to take in reducing fall risk.
Comorbidities
Comorbidities are the simultaneous presence of two or more medical conditions in a patient at once. Concussions in older adults are especially concerning due to this population’s higher rate of pre-existing medical conditions, which may exacerbate a concussion. Furthermore, medical professionals may miss signs of concussion that overlap with other pre-existing or co-occurring conditions. Oftentimes, concussions can worsen pre-existing conditions.
Studies have shown that concussions may be associated with an increased risk of developing health issues such as strokes. A recent study by researchers Holly Elser et al. has found that the number of head injuries sustained is associated with an increased risk of ischemic stroke, but interestingly there was no connection between head injury severity and risk of stroke. Thus, those who suffer repeated head traumas are potentially at a greater risk of strokes than those who may have suffered from a greater impact fewer times. This research suggests that reporting falls, especially those that become repetitive, sooner rather than later is extremely important. However, while suffering from multiple head traumas or concussions may increase the risk of a stroke in the future, it is only one of many controllable factors associated with stroke risk. Elser et al.’s study also found that it is especially important when speaking with medical practitioners to discuss “healthy diet and exercise practices, which are proven to reduce stroke risk, as well as manage other risk factors with medication, including high blood pressure and high blood cholesterol.” Self care through exercise and dieting are crucial to decreasing your risk of developing many medical conditions that could precede or follow a concussion in the future.
However, older adults may already be on strict diets, on certain medications, or have restricted mobility due to other health conditions. Some medications, in particular, can play a role in making symptoms of concussion worse for older adults. Not only does the risk of concussion increase, but once one is suffered, these same medications can complicate recovery processes.
The daughter of an 87-year-old concussion patient recently spoke with us on the dangers of falls caused by side effects of medications: “So she fell at home and because at that time she was living alone, unassisted, it's unclear exactly what happened, but… we believe because that's where the blood was, that she gashed her head, her forehead on the edge of a desk…At that time, I believe she was also taking Ambien at night occasionally…and so I think it was probably an Ambien-related fall.” Ambien is one of many such medications with side effects including dizziness, headaches, and drowsiness. If you or a loved one is on medication that may have similar side effects, please have a discussion with your medical provider on whether there are any alternative medications that may not carry as many risks.
Some people may not be close to others who can help them immediately in the case of a fall. Luckily for the previously mentioned story, the 87-year-old concussion patient “was wearing, it's called a lifeline or something, but a necklace…which triggered a response” and was swiftly taken to the hospital to receive treatment. You or a loved one can consider setting up personalized care in the case of an emergency through one of these services.
What Should Caretakers Do?
Caretakers are an instrumental resource in monitoring older adults by noticing shifts in cognition, energy, or capacity, especially following a fall. By recounting signs or symptoms that the patient may not mention or providers may not notice, caretakers can be vital advocates for a thorough diagnostic procedure in the exam room. Not only can they notice changes the elder themself may not have noticed, but they also provide essential support, such as coordinating medical care, taking charge of medication routines, and being a resource for social support.
Providing social support is a critical part of taking care of anyone with a concussion. Social interaction is extremely important, especially for elders who have limited mobility or are having cognitive or memory issues due to a concussion. The 87-year-old concussion patient previously mentioned has multiple caretakers looking after them; according to their daughter, “[the caretakers have] become very fond of [them] and I think they're… loving relationships. And even on days, sometimes [they] will say, ‘well, all we did was chat…’ but [they enjoy] it.”
Caretakers, especially if they are in a full-time role, are a major source of socialization for elders suffering from concussions, and being able to care for them in a caring manner has a significant positive impact on the lives of older adults with concussions. Research demonstrates the need for social support in youth following concussion. Helena Kita et al.’s study on social support for concussed youth found that “Support provided by close friends, [other] youth with personal concussion history, and parents mitigated different challenges in recovery.” Caretakers must provide the same form of support for older adults who have suffered a concussion, as social interactions can provide cognitive stimulation and support for difficulties navigating symptoms.
Mental Health and Stigma
Even if elders safeguard their home as best as they can, concussions still occur. If they suspect a concussion, most people seek medical care from trained professionals. This is not always the case for elders. Researchers Erica Kornblith et al. conducted a study on the incidence of TBI in patients who were 65 or older over an 18 year period, in which they found that “older adults who experience falls, the largest segment of US citizens experiencing incident TBI, are also the least likely to seek care.”
Kornblith et al.'s study emphasizes the need to normalize helping all patients regardless of age, race, or any other factor. Although existing literature suggests that males, non-Whites, and people with lower socio-economic status may be more likely to be diagnosed with TBI, this study found an “increased rate of TBI was associated with healthy, wealthy, White female individuals.” These results may be skewed by which participants are willing (or able) to seek medical care, as the researchers pointed out that “lower resourced” and marginalized communities tend to distrust medical care. People from these communities may be less likely to seek medical care and, subsequently, not receive an official TBI diagnosis.
In addition, lower resourced individuals and those in racial and ethnic minorities may be even less likely to seek care due to multiple factors, including but not limited to insurance coverage, healthcare costs, and “the racial and ethnic microaggressions that commonly occur in the medical setting.” These microaggressions from medical professionals make patients less likely to visit their doctor and be honest during their visit, thus adding to a stigma that is far too common in older generations—which is to hide one’s pain, whether that be physical or mental.
The stigma surrounding older populations when it comes to opening up about mental or physical health struggles is a serious deterrent to reaching out to medical professionals or even loved ones for aid. Stigmatization of falls, in particular, is difficult to navigate, as these patients have to navigate internalized stigmas around falling and externalized stigmas affecting healthcare professionals’ perceptions of their severity. In a 2015 study, Annaletchumy Loganathan et al. found that healthcare professionals (HCPs) “perceived that older people normalized falls, felt stigmatized, were fatalistic, as well as in denial regarding falls-related advice. HCPs themselves trivialized falls and lacked the skills to manage falls.” When healthcare professionals allow implicit biases to affect their assessment of patients, they further isolate elders in need of help.
The mental health of older populations in particular is neglected far too often due to a whole host of factors, including generational trauma, isolation, and stigma associated with falls. If you or a loved one is having trouble with mental health following a concussion, please see Concussion Alliance’s Mental Health page to learn more on how to support or be supported.