TBI in the elderly. Andras Buki M.D., Ph.D.,D.Sc. Department of Neurosurgery, Medical Faculty of Pecs University, Pecs, Hungary, H-7624

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HALLGATÓBARÁT KORSZERŰSÍTÉSE A VIDÉKI KÉPZŐHELYEK

1 TBI in the elderly Andras Buki M.D., Ph.D.,D.Sc. Department of Neurosurgery, Medical Faculty of Pecs University, Pecs, Hungary, H-7624 AZ ÉLETTUDOMÁNYI- KLINIKAI FELSŐOKTATÁS GYAKORLATORIENTÁLT ÉS HALLGATÓBARÁT KORSZERŰSÍTÉSE A VIDÉKI KÉPZŐHELYEK NEMZETKÖZI VERSENYKÉPESSÉGÉNEK ERŐSÍTÉSÉRE TÁMOP C-13/1/KONV

2 Ironically, the field of geriatric trauma is still in its infancy

3 Geriatric traumatic brain injury - Differences I. Definition: Elderly y Super elderly 80+ y Male/female ratio ~2x prevalence Functional loss of sensory organs: Altered perception Longer reaction time Medications side effects: Dizzines Vertigo Blackouts Etiology: fall

4 Geriatric traumatic brain injury - Differences II. Frequent cerebral atrophy SDH Warfarin/coumarin treatment + platelet aggregation inhibitors Higher proportion of altered hemostasis Medications often without clear indication! Alcohol induced coagulopathy Comorbidities reduced physiological reserve Decreased capacity of scavange mediators of oxidative stress

5 OR Pecs Severe TBI Database , 308 cases Coagulopathy - Age 60 5, * 4,0 3,0 2,0 1,0 1,079 1,002 0,935 1,049 1,374 0,433 0,0 Gender Age GCS on admission Alcohol Primary coagulopathy Secondary coagulopathy OP

6 TBI-Care for the elderly - Substantially worse outcome despite of intensive treatment Lack of enthusiasm in treatment Self fulfilling prophecy

7 Outcome of gtbi Stochetti: probability of unfavorable outcome was six times higher above 59y cut off point is 69y: favorable outcome was still possible without extreme additional burden of severely disabled survivors. (J Neurotrauma Apr)

8 Observations were similar regardless of injury severity!

9 Early ICU costs are higher for young TBI-victims In elderly patients funtional changes occur later in the rehab phase Charges are particularly high in the rehab phase for the geriatric population

10 Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age associated with longer length of hospital stay (p = 0.014), higher rate of complications (OR 5.74, 95% CI ), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI ). No statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status.

11 Outcome of gtbi Worse outcome state of the art surgical therapy + rehabilitation - ~equal outcome

13 Major limitation of TBI care in Hungary and Eastern Europe High- or middle income countries. Low or lower-middle income level health care systems.

14 Therapeutic decisions based on expert opinion Reorganisation of emergency care/ambulance high proportion of secondary/terciary referrals Lack of reliable regional epidemiology reports no quality assurance Almost complete absence of state of the art complex neurorehabilitation centres poor long term outcome

15 Results I. Hungarian nationwide survey Data collection Total number of cases 267 Overall in hospital mortality Over 54% Age group Number of cases Gender Male (%) 29 (69.05%) 7 (58.33%) Female (%) 13 (30.95%) 5 (41.67%) Fall (%) 27 (64.29%) 9 (75.00%) Mechanism of injury Road traffic accident (%) 9 (21.43%) 2 (16.67%) Other (%) 6 (14.29%) 1 (8.33%) In hospital mortality N (%) 31 (73.81%) 10 (83.33%)

16 Results II. Pécs severe head injury database Data collection Total number of cases 414 Overall in hospital mortality 46.14% Age group Number of cases Gender Male (%) 80 (70.80%) 13 (38.24%) Female (%) 33 (29.20%) 21 (61.76%) Fall (%) 84 (74.34%) 31 (91.18%) Mechanism of injury Road traffic accident (%) 13 (11.50%) 1 (2.94%) Other (%) 16 (14.16%) 2 (5.88%) In hospital mortality N (%) 68 (60.18%) 27 (79.41%)

17 Number of cases Treatment modality Compliance with guidelines /II /I. Drain+ Drain-

18 Age Compliance with guidelines % 76.47% % % % 23.53% drain+ drain-

19 Mortality Mortality - Age Compliance with guidelines 90% 80% 80.43% 70% 60% 50% 40% 40.00% 41.03% 50.00% 58.73% 30% 27.59% 20% 10% 0% Drain+ Drain-

20 Mortality Treatment modality Compliance with guidelines 70% 60% 50% 60.87% 50.96% 46.18% 47.46% 53.01% 40% 40.47% 30% 20% 10% 0% Mortality Mortality standardized for age Mortality standardized for age and GCS on admission Drain+ Drain-

21 Conclusions The geriatric population is growing; thereby, gtbi is more frequent. Every attempt should be made to achieve similar outcome results as it is feasible in the younger population. Higher than expected mortality rates in Eastern Europe are associated with the fact that the functioning and efficacy of the health care system does not keep pace with the development of the economy. Enforcement of guideline compliance may make a difference in the care of the gtbi population worldwide, particularly in this region.

22 Thank You!

ecompressive craniectomy in TBI

ecompressive craniectomy in TBI Andras Buki M.D., Ph.D.,D.Sc. Department of Neurosurgery, Medical Faculty of Pecs University, Pecs, Hungary, H-7624 AZ ÉLETTUDOMÁNYI- KLINIKAI FELSŐOKTATÁS GYAKORLATORIENTÁLT