Management of Concussion in the Geriatric Population

Initial Assessment and Triage

The American College of Emergency Physicians recommends early trauma protocol activation for geriatric patients (≥55 years) with suspected concussion, as they are at higher risk of mortality and are frequently under-triaged 1, 2
The Eastern Association for the Surgery of Trauma suggests using lower thresholds for trauma protocol activation in geriatric patients: heart rate >90 bpm and systolic blood pressure <110 mmHg 3, 4
Comprehensive frailty assessment using validated tools such as the Trauma-Specific Frailty Index is recommended to identify patients at highest risk of poor outcomes 1, 2, 4
Early blood gas analysis (arterial or venous) is recommended to assess baseline deficit or lactic acid levels 1
A low threshold for CT imaging in geriatric concussion patients is suggested, as the benefits outweigh the risks of contrast-induced nephropathy 1

The American Geriatrics Society recommends carefully assessing the patient's medication profile, particularly for beta-blockers, anticoagulants, and antiplatelet medications which can mask symptoms or increase bleeding risk 3, 4
Acetaminophen is recommended as the only medication immediately after injury, and only as recommended by a physician 5

Complete physical rest for the first 24-48 hours after concussion, followed by gradual return to activity, is recommended 5
Cognitive rest during the early recovery phase, especially in the first 24-48 hours, limiting activities requiring concentration, is suggested 5
Monitoring for neurological improvement within the first 72 hours is recommended, as failure to improve in Glasgow Coma Scale (GCS) within this timeframe is associated with poor functional outcomes 6, 7

A sub-symptom threshold aerobic exercise program with gradual increase in intensity is recommended after the initial rest period 8
Vestibular rehabilitation, including habituation exercises, adaptation exercises, and balance training, is suggested for patients with vestibular dysfunction contributing to headache 8
Spinal mobilization/manipulation is recommended for patients with concurrent neck pain and headache 8
Oculomotor vision treatment is suggested for patients with visual symptoms accompanying headache 8
Psychological treatment is recommended for emotional symptoms that may exacerbate headache 8

A stepwise return to activity protocol following the 24-48 hour rest period, with each step taking a minimum of 24 hours, is recommended 5
If symptoms recur during the return to activity protocol, returning to the previous asymptomatic level and trying to progress again after 24 hours of rest is suggested 5

Multidisciplinary management is recommended for symptoms persisting beyond 10 days 5
Recognition that 15-20% of concussion patients develop persistent post-concussion syndrome is important 5, 8
A multidisciplinary approach, including graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and possibly oculomotor vision treatment, is recommended for headaches persisting 1-2 months after concussion 8

Older patients often experience concussions from low-velocity mechanisms such as falls from standing height, according to the American Geriatrics Society 2
The odds of dying after geriatric trauma increase by 6.8% for each 1-year increase in age beyond 65, as reported by the Eastern Association for the Surgery of Trauma 2
Early involvement of palliative care teams is recommended for severely injured elderly patients to improve outcomes and reduce unnecessary interventions 6, 7
Older patients with traumatic brain injury have double the in-hospital mortality compared to younger patients and worse long-term outcomes, according to the Brain Injury Association of America 6

Monitoring for loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, and swelling or deformities of the scalp is recommended 5
Vigilance for signs of occult hypoperfusion in older patients is necessary, as "normal" blood pressure may actually represent hypotension in elderly patients with chronic hypertension, according to the American College of Emergency Physicians 2