Concussion Care for Older Adults and Seniors
Learn how to provide concussion care to older adults and seniors from the initial assessment to returning them to their everyday activities.
Based on a presentation given by Dr. Christina B. Kunec, PsyD, Director at Stamford Health Concussion Center, at the 2021 Concussion Care Virtual Conference.
16% of Americans are age 65 and older, which is approximately 56 million people, or 1 in 6 Americans. They make up more than 25% of physician visits, 35% of all hospital stays, and 34% of all prescriptions.
The number of individuals aged 65 and older is growing, partly as a result of declining death rates. In the population aged 65 and older, approximately 56% are women. Baby Boomers are one of the largest generations in the U.S. and by 2030 all will be 65 or older, which equates to 1 in 5 Americans, or approximately 73 million people. Older adults are projected to outnumber children for the first time in U.S. history.
As the older population grows larger, it will also become more diverse. Programs and services for older adults will need to address the needs of a more diverse population, placing greater demands on the healthcare system.
Data from 2013 tells us that more than 1 in 200 individuals ages 65-74 years, and more than 1 in 50 individuals ages 75 years and older, experience a TBI-related emergency department (ED) visit, hospitalization, or death each year. In 2013 adults ages 75 years and older accounted for over 25% of TBI-related deaths and approximately 30% of hospitalizations in the U.S. The incidence of TBI-related ED visits, hospitalizations, and deaths are increasing amongst older adults. From 2007-2013 TBI-related ED visits amongst ages 75 years and older doubled and TBI-related hospitalizations increased more than 25%. The rapid rise in TBI-related hospital visits among this oldest segment of the U.S. population exceeded population growth during this timeframe.
From 2008-2017 all TBI-related deaths increased significantly by 17%. Older adults were most at risk, especially those 75 years of age and older.
Despite the high incidence, older adults may be less likely to seek medical attention for a TBI and are also less likely to be accurately diagnosed even though medical attention is sought. These findings suggest that TBI incidence among older adults likely exceed published reports.
#1. Falls: For ages 65-74, falls account for approximately 55% of TBIs, but for ages 75-85 falls account for approximately 75% of TBIs.
#2. Motor vehicle accidents (MVAs): MVAs account for a greater percentage of TBIs in individuals ages 55-64, but this percentage decreases as individuals get older, likely due to less drivers. For ages 75 and older, MVAs account for less than 20% of TBIs.
#3. Unknown causes: As much as 20% of TBIs in older adults are from unknown causes.
#4. Assaults: Assaults account for 1% of TBIs in older adults.
Falls
Approximately 30% of older adults fall annually and 85% occur in the home. Approximately 8% of individuals aged 65 and older visit the ED each year because of a fall-related injury and 25% of those result in inpatient admission.
Most falls are caused by a combination of risk factors, so the more risk factors a person has, the greater their chances of falling.
Fall risk factors include:
- History of falls
- Certain medications (e.g. sedatives, tranquilizers, hypotensives)
- Visual impairment
- Cognitive impairment
- Diabetes
- Balance / gait difficulties
- Lower extremity weakness
- Depression / anxiety
- Vitamin D deficiency
- Arthritis
- Age 80+
- Female gender
- Physical inactivity
Physically active older adults are at an elevated risk for specific sport-related falls from activities such as skiing or biking. Adults ages 55-64 years old have the highest incidence of skiing-related TBI.
Decreased neck strength and slower neck muscle activation are significant predictors for sports related concussion (SRC). Older adults experience age-related declines to neck muscle strength and muscle activation. This may result in the inability of older adults to control their head during a fall, which results in greater impact force being transmitted to the brain, increasing the risk of sustaining a TBI.
Motor Vehicle Accidents (MVAs)
There are more than 45 million licensed drivers ages 65 and older in the U.S. That’s 1 in 5 drivers. This has increased 60% since 2000. Each day, more than 20 older adults are killed and almost 700 are injured in motor vehicle accidents. Drivers ages 75 and older tend to have a higher MVA death rate. Older adults are also more than twice as likely to report having a medical condition that makes it difficult to drive.
There are certain risk factors for greater mortality and injury in motor vehicle accidents involving drivers and pedestrians who are older including:
- Vision problems
- Slower reflexes
- Decreased bone density
- Cognitive impairment
- Comorbid conditions
- Frailty
- Cognitive impairment
- Alcohol use
- Medication use
Older adults tend to have more symptoms at baseline and certain comorbid conditions that mimic concussion symptoms such as diabetes and hypertension. It’s important to distinguish which symptoms onset after the head injury, which may have been there before the injury occured, and identify which baseline symptoms were exacerbated after the head injury. Since older adults tend to under-report symptoms, it may be beneficial to have a loved one present to corroborate the information the patient is giving.
Older adults are also more at risk of persistent cognitive difficulties than younger adults. Certain pre-existing conditions put the older adult patients at a greater risk for secondary complications and longer rehabilitation stays. Older adults may lack insight into their cognitive limitations making it difficult to separate what part of cognitive impairment is pre-existing versus what is due to the TBI. Additionally, older adults are less likely to report affective symptoms due to the fear of stigma.
You should obtain the mechanism of injury (MOI) and determine if pre-existing health conditions contributed to the head injury or if it was purely mechanical. Depending on the nature of the injury, there may be an increased chance for other orthopedic injuries which may limit assessment.
Mortality rates for older adults with TBI are also substantially higher than those for their younger counterparts. Therefore, it can be more difficult to assess these individuals and diagnose what exactly is going on.
Despite older age being an independent predictor of worse outcome from TBI, there are no evidence-based guidelines for the clinical management of older adults following a TBI. This is due in part to limited research focus on older adults with TBI in general, since most research is conducted on younger populations, specifically athletes. Older adults, particularly those with pre-existing functional impairment or multiple comorbidities, are often excluded from TBI research altogether. The lack of research is concerning because older adults are at a greater risk of poor outcomes following concussion compared to younger adults, especially those who are hospitalized after their head injury.
Seeing different types of concussion patients
Before the pandemic, most sports medicine clinics saw predominantly student-athletes with head injuries from their sport. When the pandemic temporarily halted sporting events, clinics started to see more non-sports related head injuries.
Dealing with older injuries
The pandemic made many individuals reluctant to seek medical care for head injuries. As a result, patients may now be presenting with head injuries that are now several months to a year old.
Making telemedicine work for your practice
Telemedicine has become a great tool that has allowed healthcare providers to keep in touch with patients when they can’t come into the clinic. However, it’s important to remember that older adults may not be as technologically savvy to do a telehealth visit, particularly for computerized testing. They may say they are comfortable using a computer for minor things, but things like making sure they have the right web browser, managing pop-up blockers, sharing their screen, may be challenging and anxiety provoking.
When using telemedicine for older patients, it’s a good idea to provide written instructions beforehand that walk them through the process. Depending on your telemedicine platform, this may include how the visit will go, what links they need to click on, how to make a login, etc.
It’s also important to allow for extra time for telemedicine visits, so you can walk patients through the process. You may recommend that someone in their household be available to help in case they have difficulties.
It’s important to be flexible. If there are technical issues, or the patient is overwhelmed with the process, you may need to adjust what you’re doing that day.
Addressing increased anxiety
Some clinics’ COVID-19 policies may prevent them from having a loved one with them during their office visits. This may increase anxiety as many older adults rely on a spouse or child to help them report about their conditions and help them remember treatment recommendations. Also, it’s important to consider that concussion symptoms overlap those of “pandemic fatigue”.
Older adults are different from their younger counterparts in how they present and they have unique needs.
More chronic health conditions
65% of older adults have multiple chronic health conditions such as heart disease, hypertension, stroke, asthma, COPD, cancer, diabetes, and arthritis. They also have more functional limitations. In 2018, approximately 22% of the population aged 65 and older reported having a disability, as defined by having a lot of difficulty in at least one of the following functional domains: Vision, hearing, mobility, communication, cognitive, or self-care.
More vague or non-specific symptoms
Symptoms in this population may include changes in appetite or mood, self-neglect, and incontinence in some cases.
Tendency to under-report
This population tends to not be as forthcoming with their symptoms whether it be due to past bad experiences, fear of creating a burden, denial, or fear of being institutionalized.
More mental health concerns
1 in 4 older adults experience a behavioral health problem such as depression, anxiety, or substance abuse. There is also a greater rate of divorce in this age group, which may contribute to isolation.
Older adults and seniors may be experiencing changing social roles associated with retirement and they may be experiencing other losses in their life. They’re also going through many age-related changes that can be cognitive, visual, auditory, or physical in nature.
Additionally, you must consider their environment and circumstances outside of your office including their living situation, transportation, and general safety.
Living situation:
Do they live alone, with a spouse, or in a multi-family house?
Are they caring for their grandchildren or spouse?
Transportation:
Do they drive?
Do you think they should refrain from driving?
Do they have a ride to their appointments?
General safety:
What was the level of functioning prior to the concussion and how has it been impacted?
Are they able to keep up with household tasks such as cooking, housekeeping, laundry?
Are they able to manage household finances?
Are they able to manage their medical conditions like making their appointments and remembering to take their medications?
Do they have someone to help with tasks they’re unable to perform?
With older patients, it’s important to allow for more time so you can do a thorough clinical interview and perform any necessary testing. An initial evaluation with an older adult may take up to 2 hours. You may want to designate specific days or times in your schedule to see older adults so you don’t feel rushed. Older adults may have more difficulty reporting their medical history, so it’s helpful to review their medical records ahead of time if possible.
The Clinical Interview
At a minimum, your clinical interview should include the following:
- Ask about their biopsychosocial history
- Determine their pre-injury physical activity level
- Determine the mechanism of injury (MOI)
- Obtain medical history
- Obtain information about initial signs and symptoms
- Ask about current symptoms including length and severity
The Concussion Assessment
When conducting any assessment, it’s important to explain the reason for the assessment, your role as the clinician, as well as what you’re asking them to do. You want to do everything you can to encourage their maximum level of performance and alleviate any anxiety they might be experiencing.
It’s also important to consider other factors that may influence their performance and the outcome of testing including:
- Arthritis
- Vision / hearing impairment
- Impaired motor skills
- Medication
- Fatigue
- Lack of understanding / confusion about the instructions
- Lack of cooperation / effort
- Affective symptoms
- Literacy (including computer literacy)
ImPACT
ImPACT has normative data available for ages up to 80, which helps clinicians streamline how they see older patients. Previously, they relied on paper and pencil testing, which is time-consuming and cognitively taxing for the patient. The main caveat to using ImPACT for older adults is making sure the individual is computer literate enough to successfully complete computerized testing. Healthcare provider supervision is important to provide extra clarification. Again, allow for more time for older adults to complete the test.
VOMS
VOMS was designed for use with patients ages 9-40. So when using VOMS with patients outside of this age range, it’s noted that interpretation may vary. While convergence generally remains stable with age, accommodation does decline. If convergence is much farther out than 7 cm, ask questions to figure out what may be causing the abnormality.
Is this causing distress?
Are you having symptoms associated with visual work?
Is there any functional impairment associated with it?
In most cases where there is abnormal convergence beyond 7-8 cm, there’s usually some eye strain and headache associated with it and reports of problems using the computer often corroborate that.
BESS
BESS has normative data available for up to ages 69. However, this population did not have significant medical, neurological, or lower extremity problems that might affect balance.
Treatment Plan / Recommendations
Change your mindset in terms of your expectations and how you approach recommendations. It’s important to consider comorbid conditions and how they may complicate recovery, but also how they may complicate or take priority in treatment.
Recognize there’s big variability and individual differences regarding health, activity level, medical knowledge, and social support. Some individuals may have more difficulty navigating resources. In most cases, it’s more challenging to get them active. Also, more older adults tend to be hospitalized.
Older adults may require more guidance when going over your recommendations.
- Educate them by explaining what a concussion is and what is happening in their brain.
- Avoid medical jargon.
- Provide written materials or handouts.
- Offer them work accommodations.
- Provide clear instructions.
- Set clear expectations about recovery and symptoms.
Emphasize the importance of a routine schedule with regard to sleep, nutrition, hydration, stress management, and physical activity.
The level of physical activity will need to be adjusted based on their pre-injury physical activity levels. You may recommend they take short walks accompanied by someone else and involve your physical therapists to help with the exertion component.
It’s also important to remember that sleep changes in this population. Older adults receive less deep sleep and they have more difficulty maintaining sleep. Their sleep tends to be less efficient and more fragmented. Their internal biological clock shifts to earlier bed and wake times. They may also be taking medications that tend to disrupt sleep.
There are serious consequences to poor sleep including:
- Difficulty sustaining attention / slower reaction time
- Decreased ability to complete daily tasks
- Increased impairments in concentration and memory
- Higher occurrence of mood and anxiety related symptoms
- Increased pain
- Adverse effect on relationships
Emphasize the importance of sleep, but understand that in general this is an area in which older adults may struggle. Poor sleep can contribute to and exacerbate concussion symptoms.
Concussion Clinical Profiles
Concussions can be classified into one or more clinical profiles which helps inform clinical care and treatment recommendations.
There are 5 clinical profiles:
- Migraine
- Vestibular
- Ocular
- Cognitive
- Anxiety / Mood
There are 2 clinical modifiers which can impact any of the concussion profiles:
- Cervical
- Sleep
Different treatments may be recommended based on the primary concussion profile(s) and modifiers.
Headache / Migraine:
- Behavioral recommendations
- Neurology
Vestibular:
- Vestibular therapy
- Reduce exposure to busy environments initially, then gradually expose back
Vision:
- Occupational therapy
- Ophthalmology / Optometry
Cognitive Fatigue:
- Physical activity
- Neurology
- Cognitive speech therapy
Anxiety / Mood:
- Psychotherapy
- Psychiatry
- Physical activity
There are a number of barriers or other post-injury factors that may impede recovery in the older adult population.
Insurance: Their insurance may limit providers they can see and the number of visits, which may require out of pocket costs. Think about who you want to refer to and whether those providers see older adults and accept their insurance.
Transportation: Does the patient drive? If not, are they able to get a ride to appointments?
Tendency not to self-advocate: You may need to take a more active role in this area and facilitate communication with other treatment providers. Get releases to speak with them to ensure everybody’s on the same page.
Other medical conditions that impede the recovery model: Older adults may have orthopedic conditions that may limit their ability to get physically active. They may also be in treatment for other conditions that are stressful or time-consuming, which may limit their ability to initiate your recommended treatments.
Lack of education about the course of treatment: Sometimes older adults have a tendency to not want to ask questions. So make sure they understand your recommendations.
Role of mood and anxiety: Many older adults have a tendency to not report affective symptoms due to concerns about stigma. However, many of them do have fear of sustaining another injury, particularly falling again. They may also have concerns about normal age-related cognitive decline and may have anxiety that they are developing dementia. Educate them about the lack of a causal link between concussion and Alzheimer's and explain how concentration and memory problems are common with concussion and are not necessarily indicative of dementia.
Bonus: Cognitive Impairment Screening
94% of physicians agree that it’s important to regularly screen all individuals ages 65 and older for cognitive impairments. After older patients are fully recovered from their concussion, you may suggest they return for regular cognitive screening to keep an eye on age-related cognitive decline and identify early signs of dementia. Cognitive Impairment Screener (CIS)™ is a 10-minute computerized test that can help you confidently identify individuals who need further assessment for neurocognitive deficits and mental illnesses.
CITATIONS:
U.S. Census Bureau, 2020
CDC, 2020
Older Americans 2020: Key Indicators of Well-Being – 8th report prepared by the Federal Interagency Forum on Aging-Related Statistics, 2020
Gardner et al., 2018; Thompson et al., 2006
Wood et al., 2019
Ancoli-Israel & Cooke, 2005
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