Introduction

Traumatic brain injury (TBI) is the leading cause of death and disability in the first four decades and estimated to become the third most frequent cause of morbidity in 10 years. The worldwide prevalence of TBI of various severities is about 1,000/100,000 inhabitants; in the United States alone more than 5 million people live with disabilities following TBI [1, 2].

Most of the efforts in TBI research and care have been focused on the socioeconomic burden TBI puts on societies due to its predominance among young, active individuals.

Preventive measures such as increasing road traffic safety as well as aggressive medical/intensive care unit (ICU) treatment of victims of TBI were primarily aimed to reduce mortality in the active population. While these efforts resulted in a decreased occurrence and mortality of TBI among young individuals, a solid and constant rise of incidence was detected in the elderly.

Such an increased incidence is primarily explained by the rapid aging of populations: in Canada in the last four decades, life expectancy has increased with more than 10 years; thereby the population over age 65 years will be duplicated in the forthcoming two decades [3••].

The estimated incidence of TBI in the elderly is about 200/100,000 inhabitants, which is about twice as much as that of the general population. As Ferrel et al. [4] point out, this number can be higher because many of the falls (the leading cause of injury in the elderly) occur in nursing homes and most probably remain unreported.

The growing magnitude of geriatric head injury raises various questions and concerns including efficacy and cost-efficiency issues, the problem of targeted and tailored therapy based on pathophysiological traits of the elderly, as well as the withdrawal of care.

This review intends to provide a comprehensive, meticulous analysis of geriatric head injury primarily focusing on special features associated with the care provided in Eastern European countries.

Why Does Geriatric Brain Injury Differ?

The definition of geriatric brain injury is somewhat arbitrary; most reports refer to elderly patients over age 65 years and some identify a group of the “super elderly” over age 80 years [3••, 5].

Most researchers think that geriatric TBI (gTBI) should be considered a separate entity because of its unique features. Most of the publications report on worse outcome in this patient population [4, 6–8, 9••] while some claim that results can approximate that of younger individuals [10••].

The population of gTBI patients is unique from various aspects. While the frequency of injury is almost double in comparison with the general population, with increasing age the male predominance is disappearing (partially, due to the simultaneous, stepwise increase in the proportion of females in the geriatric population) [8, 11, 12].

Incidence of TBI is higher, primarily due to physiological alterations associated with aging. Merely, the organs of senses do not function properly; thereby, not only the perception but also the reaction time is altered. Medications that are frequently consumed for hypertension, Parkinson’s disease, and depression produce side effects that make this population more prone to injury, causing dizziness, vertigo, and blackouts [3••, 13, 14•].

This is one explanation for the more frequent occurrence of falls among the elderly while in the younger population motor vehicular accidents are dominating [15].

Once the injury occurs, physiological alterations associated with aging also define the faith of the patient as well as the characteristics of TBI.

Falls predominantly lead to inertial, deceleration type of diffuse brain injury conjoined by focal hits (impact-injury) [4, 5, 11].

The dura is rather tightly attached to the tabula interna of the skull; thereby, extradural hematomas are less frequent while cerebral atrophy leads to increased stretch of the bridging veins, making them more prone to rupture upon deceleration ending up in more common accordance of subdural collections/hematomas [4, 16].

Engorgement of traumatically evoked intracranial hematomas can be explained by frequent use of medications targeting components of the hemostatic machinery. Warfarin and coumarin treatment is associated with worse outcome but also inhibitors of platelet aggregation have a reputation for exaggerating intracranial bleedings [17, 18].

Rigidity of the cervical spine makes the occipitocervical junction more prone to injury; thereby, upper cervical (C) spine injuries relatively more frequently accompany gTBI than subaxial C-spine fractures [19, 20]. Similarly reduced flexibility of the cranial-cranio-cervical structures as well as reduced turgor of the soft tissues around, including that of the cervical muscles, may account for the surprisingly high incidence of positive computed tomography (CT) findings, reaching to more than 10 % of minor head injuries in the elderly [21].

Not surprisingly, current diagnostic and management protocols advise more liberal use of CT, particularly in the elderly population [19, 22, 23].

While generally the reduced physiological reserve in association with (and also due to) comorbidities diminishes the chances of survival and quality of life following gTBI [24, 25], at the subcellular level, a major drawback of the advanced age is the decreased capacity to scavenge mediators of the oxidative stress [16].

As it has been alluded to before, generally gTBI is believed to be associated with poor outcome or, at least, a reduced chance for good functional and neurocognitive results in comparison with TBI occurring in the general population. However, recent studies have pointed out that state-of-the-art neurosurgical care including multimodal monitoring at the neurosurgical ICU can make a difference, and the outcome of gTBI can be comparable with that of younger patients [9••, 10••, 26, 27].

Specifically, Lau et al. [10••] assessed survival of gTBI patients over age 80 years who have undergone emergency craniotomies and found remarkably similar chances to younger TBI victims for these “super elderly” patients to survive the injury as well as to reach the premorbid baseline quality of life.

The Price of Extended Lifespan

The investigations here described harbor a critical element that is the cost-benefit ratio.

While the scientific society as well as clinicians are dedicated and devoted to provide the best possible care worldwide we should be candid and admit that decisions about treatment intensity are affected by cultural and economic differences not necessarily reflected in official therapeutic guidelines and protocols. Such an approach can appear in under-triage to larger centers, withheld or withdrawal of care, or simply by noncompliance with guidelines and/or extreme shift in age-related mortality figures [26–29]. This is particularly true for countries and health care systems harboring limited resources (vide infra).

Via a detailed review of the literature, one may identify the “extremes” of survival rate and quality-of-life expectations ranging from 8 % survival rate in the general geriatric trauma population [26, 27] to series with outcome results comparable to that of the general population [10••].

Due to the heterogeneity of this group of patients, it is rather difficult to identify those factors facilitating better outcome in gTBI; nevertheless, the role of age within this subset of head-injured patients is rather obvious. Some epidemiological studies characterized that age has a longitudinal effect on survival [30].

Nevertheless, on the basis of various trials, it is hard to draw a clear age zone indicative of poor outcome and extreme costs associated with therapeutic efforts. Yet, a relative well-delineated difference appears between those who have sustained their TBI under ages 70–75 years and the ones over this age zone.

Stocchetti et al. [9••] recently reported on a database of 1366 patients between 19 and 94 years of age where the probability of unfavorable outcome was six times higher above the age of 59 years than in the younger population. Their “cut off point” appeared to be 69 years, where favorable outcome was still possible without extreme additional burden of severely disabled survivors.

When Bouras et al. [31] stratified their 1929 elderly patients into three groups by age, they have found that the group over 75 years did not benefit from ICU treatment, and had a significantly lower chance to survive the surgical intervention [31]. Utomo and coworkers [32••] also found that gTBI patients had significantly worse outcome over the age of 75 years.

Although the role of age is obviously important in outcome prediction we do not have any reason to decide about the intensity of care and the activity of the caregivers merely on the basis of this very information. Although Leblanc et al. [33] in a retrospective analysis of a Canadian cohort of 684 TBI patients aged 60–99 years reported on significantly worse outcome in comparison with younger patients regardless of injury severity, still more than 80 % of survivors of mild and 50 % of severe TBI returned home or have been transferred to rehabilitation following the acute care.

Similar figures are well known for the geriatric population in the general trauma literature [28], also highlighting the importance of active multidisciplinary treatment of the elderly.

In a recent paper assessing the outcome of gTBI patients over the age of 65 years and a first available Glasgow Coma Score (GCS) of 4 or less, Brazinova et al. highlighted that favorable outcome in this subgroup of patients is still feasible: 11 % of their patients reached this level at 12 months postinjury [34••].

Nevertheless, with rising age, the cost efficiency of treatment is obviously decreasing. The results that could be achieved in severely head-injured patients over age 65 years can be very disappointing: in the report of Utomo et al. [32••], none of the patients under a GCS of less than 9 had a favorable outcome at 6 months postinjury and most of them passed away.

The remarkable surgical results by Lau et al. [10••] alluded to before in the population over age 80 years were achieved via significantly more frequent and serious complications including infections and longer hospital stay in a setting where direct cost associated with craniotomy for TBI itself costs more than $15,000 USD [10••].

Outcome Prediction in Geriatric Traumatic Brain Injury

Identification of independent predictors of outcome in gTBI is of ample importance not only to aid informing and consenting the relatives but also to serve quality control issues that is the audit of care. To this end, in the general trauma literature, the Injury Severity Score (ISS) proved to be a significant predictor of outcome in the geriatric population [24, 35].

Similarly, the GCS, and particularly its motor score, is closely associated with outcome, a finding also corroborated at gTBI [3••, 32••]. Data from general trauma care (in a series where about 80 % of the enrolled cases were head injured) indicate C-spine injury to be an independent predictor of poor outcome [3••].

Another study found that poor outcome following gTBI was associated with the actual age, GCS, and injury type while patients under 75 years and/or with a systolic blood pressure of 131–150 mmHg had a significantly higher chance for favorable outcome [32••].

Brazinova et al. [34••] identified female sex, at least partially open basal cisterns, less severe injury, intracranial pressure (ICP) monitoring, and surgery to be associated with favorable outcome in gTBI of extreme severity (first available GCS under 5) [34••].

Of the premorbid conditions, the issue of altered hemostasis is of ample importance, a problem primarily associated with medications frequently used for the elderly [36, 37•].

Current consensus in the literature is that regardless of injury severity, prognostic factors should be used to aid decision making and consenting, but individual decisions on treatment and particularly withdrawal of care should not be justified exclusively on the basis of prognostic factors, mainly because we are far away from stone-carved guidelines in this matter.

Traumatic Brain Injury in Eastern Europe: Neurotrauma Care

Although spiritually and traditionally most of the Eastern European countries, including Hungary, consider themselves as historic building blocks of Europe, these countries are definitely handicapped as far as their health care system is considered.

While most of them do belong to high- or middle-income countries, their health care system is rather characterized by features of lower-middle income or low income countries.

A major cause of this is that the health care sector itself had not been included into negotiations as a topic before these countries have joined the united Europe.

In this region, neurotrauma care is traditionally characterized by decisions primarily based on expert opinion while scientific evidence-based guidelines, even if they are distributed, are not necessarily welcome and particularly not followed by health care providers. This leads to inequality of care and an unacceptably high mortality and morbidity of TBI that, because of the lack of any central audit of care, remains unrecognized and unpunished [38–41].

Most of these countries are in the beginning of reorganization/restructuring their health care systems, including emergency care as well as organization of the trauma system. To this end, the number of secondary or even tertiary transfers, limited availability of facilities dedicated to neurorehabilitation, as well as a lack of the audit of care and application of quality assurance visits and checks are considered burning problems [39, 42].

Due to these features, the region provides an excellent opportunity to test the efficacy of evidence-based guidelines to make a change in the outcome of TBI. This case was elegantly demonstrated with the TBI-Trac program headed by Jamshid Ghajar and founded by the Soros Foundation in the late 1990s. The success of this program itself led to a change in the field of neurotrauma in Eastern Europe, facilitating the dissemination of guidelines, spreading the word against the hopelessness of head injury, and recruiting young neurosurgeons to make a difference in neurotrauma care [43, 44].

Traumatic Brain Injury in Eastern Europe: The Actual Care

Probably due to the difficulties alluded to before, only a handful of epidemiological reports and reviews address the burden of TBI on societies in Eastern Europe and data regarding gTBI are particularly scant.

In Slovenia, the annual death toll of TBI is about 244/2 million, with 6205 hospitalizations, and the ratio of mild to moderate to severe TBI is about 80:15:5, respectively [45•] .

In Hungary, results extrapolated from a 3-month prospective data collection indicate 14,000 admissions annually, with 71.3 % mild, 19.4 % moderate, and 9.4 % severe TBI cases [39].

In Latvia, the incidence of moderate TBI to severe TBI is about 8 per 10,000 inhabitants; these two groups constitute more than 30 % of all TBI cases [43].

The most detailed research on TBI epidemiology in Eastern Europe has been conducted by the International Neurotrauma Research Organization (INRO) [42]. This seminal work compared TBI care in Austria, a “high-income” (HI) country, Slovakia and Croatia as “upper middle income” countries, and Bosnia-Herzegovina and the Former Yugoslav Republic of Macedonia considered “lower middle income” (LMI) countries. The authors claim that chances for application of guidelines (such as obeying the indications for ICP monitoring) decrease, while chances for violation of therapeutic standards (such as steroid use for TBI) increase with decreasing wealth. Similarly, the chances for serious complications, particularly those of infections as well as odds for considerable percentage of delayed mortality increase with poverty. The actual mortality proved to be more than 13 % above the “expected” rate in these LMI countries.

Unfortunately, this study also did not provide details on the mortality rate of the elderly, although the authors state that exclusion of cases with GCS 3 and over 65 years of age would have reduced the mortality from 42 %–55 % to around 20 %. These mortality figures are quite similar to those defined in the Hungarian prospective data collection (vide infra).

An intriguing finding of this study was the inequality of care, which has already been described in an analysis of patients receiving treatment for subdural hematoma in Hungary between various regions of the country [38]. While in the Hungarian analysis the significant between-center difference reaching 2.5-fold in favorable outcome was primarily due to substantially different extent of application of therapeutic guidelines and protocols, the INRO paper explained between-country differences with economic reasons.

Inequality of care has been described previously in Western Europe as well, yet differences appeared significant only in comparison with US outcome data. As Mauritz et al. [42] point out, this must be due to the fact that Hukkelhoven et al.’s [46] data exclusively derived from HI countries.

More recent studies also indicate that inequality of TBI care could be detected in an analysis of European and US centers too, but with a far pronounced difference in the former region (3.3-fold difference in the odds of unfavorable outcome between the centers in Europe versus 2.4 in the US) [47•].

Traumatic Brain Injury in Hungary: Emphasis on Geriatric Care

In the past decade, three epidemiological surveys analyzed the care of the head injured in Hungary revealing strikingly similar results to the previously detailed studies that have involved Eastern European cases [38–40]. The most comprehensive of these investigations utilized a nationwide network of study coordinators and controlled enrollment with feedback from the National Insurance Service [39]. On the basis of this information, the authors achieved coverage of close to 80 % of all TBI patients enrolled in a 3-month period in the country. In all, 267 cases were considered where post-resuscitation GCS was under 9 on admission (severe TBI [sTBI]) or the patient deteriorated to reach the criteria of sTBI.

The other relevant source of information is the Pécs Severe TBI Database (sTBID) representing a comprehensive data repository on all patients consecutively admitted to the Department of Neurosurgery of Pécs University. This repository contained data elements from 305 TBI patients admitted between July 2002 and December 2008 either having post-resuscitation GCS under 9 on admission or deteriorating to meet the criteria of sTBI.

It is of note that none of these sources excluded cases with blown pupils and/or GCS 3.

We have identified 70 patients belonging to the “elderly” and 23 to the “super elderly” category from the Pécs sTBID, while 42 and 12 patients were enrolled to these respective groups in the nationwide survey (Table 1).

Table 1 Comparison of demographic data derived from the Pécs Severe Traumatic Brain Injury Database and the nationwide survey of TBI in Hungary [40]
Full size table

In concordance with previously described findings, an overwhelming majority of these injuries were caused by falls. Both databases reflected the relatively high Hungarian in-hospital mortality of sTBI (44.26 % vs 47.94 %). The mortality was about 20 % higher for the elderly and more than 30 % higher in case of the “super” elderly group, with a constantly but only slightly lower mortality rate detected at all groups in the database deriving from the clinical center.

While these mortality figures do not seem to be devastating, it is of note that long-term follow-up of Hungarian sTBI cases indicate an unexpectedly high incidence of late postinjury mortality, most probably associated with the lack of appropriate step-down units and dedicated neurorehabilitation facilities.

Univariate logistic regression analysis of the Pécs sTBID revealed that in-hospital mortality in concordance with data from the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) collaboration were significantly associated with first available blood glucose level (Table 2) [48]. Although the effect of coagulopathy/altered hemostasis was close to significant, this factor in light of other factors defining outcome did not appear that important in this age group as it was supposed.

Table 2 Univariate logistic regression analysis of the Pécs Severe Traumatic Brain Injury Database focusing on elderly/super elderly patients
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As far as monitoring and treatment is considered, it is of note that ICP over 20 mmHg and cerebral perfusion pressure (CPP) under 60 mmHg proved to be associated with outcome. The finding that ICP monitoring via ventriculostomy catheter (“drain”) had a protective effect on in-hospital mortality is also associated with intent-to-treat issues reflecting the willingness to heal potential survivors according to scientific evidence-based guidelines. This is also reflected in the fact that 41 of the 70 elderly (58 %) and 8 of the “super” elderly patients (35 %) received a ventricular catheter for ICP monitoring.

Intriguingly, the length of stay at the ICU as well as occurrence of septic complication or a meningitis/ventriculitis (due to prolonged application of a ventricular catheter) was associated with lower in-hospital mortality, only revealing the fact that those who lived up to the stage when they got severe infectious complications were already through their critical neuro-ICU phase and had a better chance to recover or at least leave the hospital alive.

While significant attempts were made to disseminate evidence-based guidelines for the treatment of the head injured in Hungary in the early 2000s, the actual care of TBI did not change substantially. Although intensive care specialists in the late 1990s have already published their national guidelines [40], in 2002 only every fifth sTBI patient received an ICP monitor and less than 50 % has undergone invasive monitoring of their blood pressure [39].

Preliminary data indicate that the care for the head injured have not improved in the past few years either: analysis of 7000 patient records collected in 10 years, provided by the National Insurance Service, indicate that every second Hungarian TBI patient operated for TBI of various severity died within 6 months.

Not surprisingly, the trend that has been observed in detailed analysis of the IMPACT and CRASH (Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage) data, that predictive models may overestimate the real outcome of sTBI in “low income” (LI) countries, is also demonstrated in Hungary, although it should be considered a “high/middle income” country [49••, 50].

On the basis of these epidemiological studies in Eastern Europe, a clear gap can be identified between the economic background and the quality of TBI care provided by the health care system. Unfortunately, this is particularly true for the geriatric population, where outcome results appear particularly disappointing. The striking controversy between educating, training our physicians to provide state-of-the-art care without making available the necessary resources, and a properly organized structure of health care raises various concerns not only about the actual care but also the future of healing in this region.

While the system is not changed substantially, care for gTBI will be either negativistic with saving resources for younger individuals (under-triage, withheld of care) or will be focused on state-of-the-art, expensive but short acute care, with discharging our gTBI patients to institutions where there is a high chance for their secondary, subacute mortality without a hope to get appropriate neurorehabilitation. Both approaches lead to devastation and burnout of medical personnel either with observing the gTBI cases passing away with minimal care or recognizing the vanity of contemporary ICU strategies in lack of state-of-the-art rehabilitation.

A new European Union–funded nationwide project that is underway to establish step-down units to provide neurorehabilitation in the subacute phase postinjury may represent the light at the end of the rather dark tunnel of TBI care for the region.

Conclusions

The geriatric population is growing; thereby, gTBI is more frequent. These cases frequently harbor a difficult medical history and represent a challenge for care providers.

Results diverge, yet every attempt should be made to achieve similar outcome results as it is feasible in the younger population. This is not a cost-efficient yet rather demanding task particularly in Eastern Europe, where operations and efficacy of the health care system does not keep pace with the development of the economy. Distribution of scientific evidence-based guidelines and treatment protocols as well as enforcement of guideline compliance may make a difference in the care of the gTBI population worldwide, particularly in this region.