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 Table of Contents  
Year : 2020  |  Volume : 53  |  Issue : 2  |  Page : 55-63

One-year results in elderly patients with severe head injury

1 Division of Traumatology, Department of Surgery, Chi Mei Medical Center, Liouying, Taiwan
2 Department of Nursing, Chang Jung Christian University, Tainan, Taiwan
3 Department of Surgery, Chi Mei Medical Center, Liouying, Taiwan
4 Division of Urology, Department of Surgery, Chi Mei Medical Center, Liouying; Department of Information Management, National Chung Cheng University, Chiayi, Taiwan

Date of Submission18-Sep-2019
Date of Decision11-Nov-2019
Date of Acceptance30-Jan-2020
Date of Web Publication23-Apr-2020

Correspondence Address:
Dr. Chih-Cheng Lu
Division of Urology, Department of Surgery, Chi Mei Medical Center, Liouying, No. 201, Taikang, Liouying, Tainan 73657
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_74_19

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Background: This study explored the outcome of older adults with severe head injury after 1-year follow-up.
Materials and Methods: Data were collected from the hospital medical information system. The patients who suffered from severe head injury met with the disease classification system, traumatic statistics, with or without brain surgery, and patient medical records of a regional teaching hospital were included in the study. Patients were followed with telephone contact 1 year after discharge. The Glasgow Outcome Scale and the Functional Independence Measure were used as tools for prognostic evaluation. This study protocol was approved by the institutional review board of the hospital.
Results: Patients who were 65 years of age and older diagnosed with severe head injury (Injury Severity Score 2 ≥16) were included. Between January 2009 and September 2015, a total of 142 patients were collected with 88 men (62%) and 54 women (38%). The mean age was 76.6 ± 6.6 years. Head injury was caused by traffic accidents for 73 patients (51.4%) and by falls for 69 patients (48.6%). There were 122 patients with subdural hemorrhage, 82 with intracerebral hemorrhage, 71 with subarachnoid hemorrhage, and 11 with epidural hemorrhage. Forty-one patients (28.9%) had simple head injury and 101 patients had multiple head injuries. The mean Glasgow Coma Scale was 5.4 ± 1.9, and the mean ISS was 24.3 ± 9.2. Thirty-eight patients (26.8%) refused surgery and 104 patients (73.2%) underwent brain surgery. Among 142 patients, 70 (49.3%) died and 72 (50.7%) survived, with 16 patients (11.3%) classified as good condition and 126 (88.7%) as poor condition. After 1 year, those who underwent brain surgery had a better prognosis than those who refused surgery (P = 0.01).
Conclusion: Older adults with severe head injuries often face disability, a vegetative state, or death. In this study, those who underwent brain surgery had better survival, and 27.6% (16/58) of those who survived were able to live independently after 1 year.

Keywords: Brain surgery, head injury, older adults, outcome

How to cite this article:
Lin MH, Suen LJ, Chang CH, Tsai TC, Lu CC. One-year results in elderly patients with severe head injury. Formos J Surg 2020;53:55-63

How to cite this URL:
Lin MH, Suen LJ, Chang CH, Tsai TC, Lu CC. One-year results in elderly patients with severe head injury. Formos J Surg [serial online] 2020 [cited 2021 Jan 19];53:55-63. Available from: https://www.e-fjs.org/text.asp?2020/53/2/55/283125

  Introduction Top

Head injury is an important medical, social, and economic issue. The rate of survival after head injury has improved as a result of advances in medical science and care technology, but physiological, cognitive, and kinesthesiological disability and rehabilitation problems remain. Enabling patients to resume normal independent living requires humane care. Sequelae remain during 3–4 months after hospital discharge. The physical, psychological, and social problems caused by these sequelae cannot be ignored. The surgical choices by patients' family members for treating severe head injury also determine the physical and mental health of the main caregivers in the future; family burden and loss of national productivity often result. The overall social cost has far-reaching implications and merits discussion and attention.[1],[2]

After treatment for head injury caused by a fall or a traffic accident, some elderly patients recover well, but others are left with physical or cognitive disabilities. Although the prognosis of falls in elderly patients is being studied, only half a year of follow-up and the details of discharge care have been tracked.[3],[4] The 1-year prognosis after discharge with severe head injury has not been discussed in detail. In this study, we explored basic conditions, injury severity, the decision of whether to receive brain surgery, status upon discharge, and 1-year prognosis in elderly patients with severe head injury. To provide for a clinical care reference, we discuss patients' recovery status 1 year after hospitalization.

  Methods Top

Research design

This study was a secondary data analysis. We sampled data from patients in an injury registration database, which included information from standardized questionnaires about traumatic brain injury and the medical records of a teaching hospital. Typical discharge diagnoses included cranial hemorrhage, subdural hemorrhage, epidural hematoma, subarachnoid hemorrhage, diffuse nerve injury, and other neurological complications. The dataset includes cases of head injuries (code S00–S09 according to the tenth edition of the International Classification of Diseases) and trauma, standardized admission and discharge information, and information from telephone follow-ups conducted 1 year after discharge. Data from January 2009 to September 2015 were collected.

Inclusion and exclusion criteria

Inclusion criteria for this study were age of 65 years or older; a severe head injury resulting from a fall or motor vehicle accident; admission to the intensive care unit; a body Injury Severity Score (ISS) of 16 or higher and a head area ISS of 16, according to surgeons' medical discharge diagnosis; and a recommendation of neurosurgery.

Exclusion criteria included falls and motor vehicle accidents secondary to stroke. Diagnosis of stroke was based on physicians' diagnosis, discharge diagnosis, clinical presentation, and a neurological evaluation. A total of 142 patients were included in the study.

Data collection

The principal investigator retrieved data using a standardized form developed by the trauma center of the teaching hospital and conducted 1-year follow-up telephone interviews. For institutionalized patients or those unable to complete the survey, caregivers were asked to respond on behalf of the patients.


Demographics, comorbidity, and injury characteristics

Basic demographic data included gender and age (all the patients were 65 years of age or older). Comorbidity was defined as preinjury chronic conditions, and the number of conditions was added up for each patient. The injury characteristics included mechanism of injury (fall or traffic accident) and type (intracranial hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage) and number of head injuries. The Glasgow Coma Scale (GCS) score and ISSs were measured when the patient first entered the emergency department.

Severity of head injury

The ISS was used to assess the severity of injury in six body regions, each of which was assigned an Abbreviated Injury Scale score. The squares of the three highest scores (from the three most severely injured body regions) were added together to yield ISS. The highest possible score for the head-and-neck region is 4, and so severe head injury was defined as a total ISS of 16.[5],[6],[7]

Level of consciousness

The GCS is the neurological instrument most commonly used for evaluating level of consciousness, and it was used in this study to assess the severity of the patient's head injury.[8] A total score of 15 points is considered normal; 13–14 points, indicative of mild impairment of consciousness; 9–12 points, indicative of moderate impairment of consciousness; and 3–8 points, indicative of severe impairment of consciousness or coma. The literature suggests that GCS score is an important indicator of prognosis, and a GCS score of 8 points or lower is often associated with a poor outcome in hospitalized patients with a head injury.

Outcome evaluation of severe head injury

The original Glasgow Outcome Scale (GOS) has five categories of prognosis. We used the extended GOS (GOS-E), which has eight such categories: in order of poor to good outcome, death, vegetative state, lower severe disability, upper severe disability, lower moderate disability, upper moderate disability, lower good recovery, and upper good recovery.[9],[10],[11] These eight categories of the GOS-E were combined into two groups: the first four were categories indicating “poor prognosis” and the other four were categories indicating “good prognosis.” The GOS-E was used to follow-up with patients a year after discharge.

Brain surgery decision

The patient's or family members' decision to accept the physician's recommendation for immediate surgery was documented.

Discharge condition

Discharge condition was classified as institutional care, transfer to a respiratory care unit, nursing care at home, or care by a domestic helper or family at home.

Status 1 year after hospitalization

The GOS-E was administered again for the 1-year follow-up.

Living function evaluation

The Functional Independence Measure (FIM), modified form, was used to evaluate living function. The FIM includes 18 items that constitute three assessments of recovery from head injury (locomotion, feeding, and verbal expression); scores range from 18 to 126.[12],[13],[14] Full dependence and partial dependence with need for assistance were classified as having a “poor prognosis,” and independence and independence with need for some assistance were classified as having a “good prognosis.”

Ethical considerations

The institutional review board (IRB) approved the study and confirmed that it is in compliance with the principles of research ethics (IRB number 10512-L04). The IRB agreed that the survey used in this study does not necessitate patient consent.

Statistical method

After the data were collected and the integrity of the data confirmed, the results were coded for statistical analysis.

Results of the descriptive statistical analysis were expressed as means and standard deviations (SDs). Chi-square and t-tests were used to conduct inferential statistical analysis and to investigate differences between the groups; a P level of < 0.05 was considered significant. The statistical analysis was performed with SPSS 18 for Windows (SPSS Inc., Chicago, IL, USA) and Microsoft Office Excel 2007 (Microsoft Corp., Redmond, WA, USA).

  Results Top

Of the 142 patients with severe head injury [Table 1], 88 (62%) were men and 54 (38%) were women. The mean age was 76.6 years (SD = 6.6 years), and 67 patients (47.2%) were between the ages of 65 and 75 years. Eighty-three patients (58.5%) had one or two chronic diseases. The head injury was caused by a traffic accident in 73 patients (51.4%) and by falling in 69 patients (48.6%). Forty-one patients (28.9%) had a single head injury, and the other 101 patients (71.1%) had two or more head injuries. The mean GCS score was 5.4 (SD = 1.9), and the mean ISS was 24.3 (SD = 9.2). One hundred four patients (73.2%) agreed to undergo brain surgery; the other 38 (26.8%) refused.
Table 1: Demographics of the patients (n=142)

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Sixty patients, of whom 32 (53.3%) were men and 28 (46.7%) were women, remained alive 1 year after discharge [Table 2]. The mean age of this group was 75.2 years (SD = 6.1 years), and 34 (56.7%) were between the ages of 65 and 75. Thirty-four patients (56.7%) had one or two chronic diseases. The head injury was caused by a traffic accident in 35 patients (58.3%) and by a fall in 25 (41.7%). Thirteen (21.7%) had a single head injury, and the other 47 (73.3%) had two or more head injuries. The mean GCS score was 5.5 (SD = 2.1), and the mean ISS was 21.9 (SD = 5.3). The recommendation of brain surgery was accepted for 58 (96.7%) and not accepted for 2 (3.3%).
Table 2: Demographics of the patients after 1 year (n=60)

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Of the 60 survivors, 18 (30.0%) were in a vegetative state, 26 (43.3%) were severely disabled, 4 (6.7%) were moderately disabled, and 12 (20.0%) experienced a good recovery. According to the FIM evaluation 1 year after discharge, 16 (26.7%) had a good prognosis for locomotion, 17 (28.3%) for feeding, and 23 (38.3%) for verbal expression. Total dependence characterized 48.3%–50% of the patients.

[Table 3] lists the GOS-E status of patients at discharge. Among the 142 patients, the good prognosis and poor prognosis groups showed no statistical difference in age, number of chronic diseases, cause of injury, type of injury, GCS score, or ISS. The gender difference was significant (χ2 = 4.6, P = 0.03): A greater percentage of female patients were in the good prognosis group. Those who underwent brain surgery had a significantly better prognosis than did those for whom surgery was refused (χ2 = 6.6, P = 0.01).
Table 3: Analysis of Glasgow Outcome Scale of status at discharge (n=142)

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[Table 4] lists the GOS-E status of patients after 1 year. Among the 60 patients who survived the 1st year, those in the good prognosis and poor prognosis groups showed no statistical difference in age, gender, number of chronic diseases, cause of injury, type of injury, GCS score, or ISS. Only two patients for whom surgery was refused were alive a year later, and both had a poor prognosis. A number of patients in these two categories were too small to perform a Chi-square or other meaningful statistical test.
Table 4: Analysis of Glasgow Outcome Scale of status after 1 year (n=60)

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Health status at discharge was significantly correlated with prognosis 1 year after discharge (χ2 = 46.1, P < 0.001). Of the 15 patients with moderate disability or good recovery at discharge, 14 (93.3%) had a good prognosis 1 year later. In contrast, of the 45 patients who were in a persistent vegetative state or had severe disability at discharge, only 2 (4.4%) had a good prognosis 1 year later.

[Table 5], [Table 6], [Table 7] present FIM scores for locomotion, feeding, and verbal expression, respectively, 1 year after discharge. These three aspects of function were not significantly correlated with age, gender, the number of chronic diseases, cause of injury, type of injury, GCS score, or ISS. As mentioned previously, only two patients who refused surgery survived for a year, and none had good locomotion, feeding, or verbal expression. Again, a number of participants in the good and poor prognosis groups were too small to perform a meaningful statistical test.
Table 5: Analysis of locomotion of Functional Independence Measure after 1 year (n=60)

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Table 6: Analysis of feeding of Functional Independence Measure after 1 year (n=60)

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Table 7: Analysis of expression of Functional Independence Measure after 1 year (n=60)

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The Chi-square test showed significant correlations between the status at discharge and all three aspects of FIM 1 year after discharge: for locomotion, χ2 = 28.7, P < 0.001; for feeding, χ2 = 28.6, P < 0.001; and for verbal expression, χ2 = 26.0, P < 0.001.

  Discussion Top

According to foreign literature, age can be predictive of the prognosis of elderly patients with head injury. Head injury has increasingly occurred with age; the incidence is highest among people older than 85. The older the patient, the worse the prognosis.[15] According to our data, the mean age of the patients at the time of head injury was 76 years. When the data were grouped by age interval, the age cohort with the worst prognosis was patients aged 86–95 years. Sixteen patients with head injury had a poor prognosis, and those aged 86–95 had the worst results 1 year after discharge. Our data confirmed that the oldest patients had the worst prognosis.

Domestic research has demonstrated that the ratio of male to female patients with head injury is 2:1;[16] the survival rate among men with head injuries is higher than that of affected women, and women are more severely incapacitated.[4] Our results showed that head injuries occurred in a similar ratio of men to women (approximately 2:1), but the prognosis was better in women. We speculated that the reason for the different results may be related to the presence of more male participants in our study.

Some investigators have pointed out that elderly people tend to have chronic diseases, and head injury may lead to injury-related complications of those diseases. Elderly patients may have many adverse reactions and complications because of the aging of the body and some chronic diseases; severe injury could worsen the prospects of recovery.[17] The results of this study showed that there was no significant difference in recovery from chronic diseases and in prognosis. Of the 142 participants, 46 did not have chronic diseases, whereas 96 had at least one or two chronic diseases. Because of the sizes of our samples, we could not effectively estimate the prognosis.

Domestic research indicates that 50% of head injuries are related to traffic accidents,[16] and foreign literature indicates that falling is the main cause of death in elderly people with head injury.[15] In our study, 73 patients sustained head injuries in traffic accidents and 69 in falls; in neither group was the rate of recovery by the time of discharge good: of those injured in traffic accidents, only 9.6% recovered well, and of those injured in falls, only 13% recovered well. After 1 year of tracking, the rates of recovery in both the groups were 11.0%, a rate similar to that in foreign research.

Head injury associated with multiple cranial hemorrhages has a high mortality rate. For affected patients, physicians often recommend emergency surgery. However, because of the severity of head injury in elderly patients, family members are less willing to subject the patients to surgery, and the prognosis is, therefore, not ideal.

Foreign literature mentions that the lower the GCS score in a patient with a head injury, the worse the prognosis is. A GCS score of <8 points is predictive of death.[18] The data collected in this study were from patients with severe head injury, in whom the GCS scores were mostly 3–8. The data revealed that regardless of the GCS scores, the rate of recovery was also very low, so we could not effectively compare the difference between the two.

Foreign studies have pointed out that the severity of injury can be used to predict prognosis. An ISS of 16–24 was representative of severe head injury, and scores higher than 24 represented extremely severe injury; the higher the ISS, the worse the prognosis.[6] The results of this study showed that the ISS was significantly correlated with language prognosis; in patients with a good language prognosis, the mean ISS was 20.4 (SD = 4.5), and in those with a poor language prognosis, the mean ISS was 23.0 (SD = 5.5).

Of the 142 people in this study, 104 (73.2%) underwent open brain surgery, and surgery was refused in 38 who refused surgery. The prognosis of patients who did not undergo surgery was poor, which indicates that surgery produced better results than did no surgery. At the time of discharge, 50.7% had survived and 49.3% had died; 37.5% of survivors were transferred to nursing homes.

The proportion of patients with good prognoses at the time of discharge and 1 year after discharge was only 11.3%; the remaining 88.7% of survivors had a poor prognosis. Physical, cognitive, and kinesthesiological disability on discharge became a family care burden, which was a consideration in families' decision about surgery. The data showed that for patients who underwent surgery, care after discharge affected the patient's prognosis. According to domestic research, the effects of injury continue at least 3–4 months after discharge,[2] and 6 months after discharge of elderly patients with head injury, nearly 80% had died, 16% had severe disabilities, 3% were in a vegetative state, and 1% had moderate disability.[15] In our study, the prognosis was assessed a full year later; although there was progress in some patients, the number and rate of recovery were still not satisfactory.

In our study, the 60 survivors were assessed with regard to locomotion, feeding, and verbal expression. In other studies, only 11.7% of patients were completely independent with regard to locomotion, 23.3% were completely independent with regard to feeding, and up to 38.3% had completely recovered verbal expression. In contrast, 48.3%–50.0% were completely dependent with regard to those three abilities, and our findings were similar.

The results of this study showed that age, gender, undergoing brain surgery, injury severity index, and status when discharged from the hospital are all significant factors in prognosis 1 year after the injury.

This study had some limitations. First, the institute collected information on head injury at a teaching hospital in Southern Taiwan, and only representative cases were selected. There were no other hospital materials, and our patients might not have been representative of the national population of patients with head injury. Second, this study tracked patients' prognosis for only 1 year after discharge. We, therefore, could not estimate whether recovery was better or worse 2 or 3 years after injury.

  Conclusion Top

Severe head injury in elderly people often leads to severe disability, vegetative states, and death; with brain surgery, the rate of survival is higher, and the chances of restoring independent living are approximately 20%. However, complications such as inhospital infection affect recovery. Therefore, regardless of whether head injury is treated according to physicians' advice, the care after discharge affects prognosis. Family members face the problems of follow-up care. About 80% of the patients need the assistance of others, and this is a major challenge for family members.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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