Head injury in the elderly
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* Clare Mehta
* Karen Poole

Editor – I welcomed the review on head injury in the elderly1 for highlighting this growing issue. In addition to the excellent points made I would like to add the following. The first, and most important issue is that of terminology, which denotes diagnosis and has far reaching implications. The term ‘head injury’ should, in my opinion, be reserved for episodes of trauma to the head without resultant intracranial consequences eg scalp laceration. The consequences of head injury listed in Table 3 of the review all relate to intracranial complications (except skull fracture) and all can lead to, or are intrinsically, a form of brain injury. Use of the term acquired brain injury, traumatic brain injury or intracranial injury would highlight the potential severity of outcomes, and therefore help to reduce the variance in accurate assessment and appropriate management of brain injury in the elderly which currently exists. A similar argument has been made previously regarding the term concussion.2

Lack of identification of brain injury is an issue across all pathways and may be a particular problem in more vulnerable groups (including paediatric, elderly, learning disabled, substance misuse and offender populations). As a result, the right care may not be delivered at the right time. Inaccurate or missing codes mean that vast swathes of data are not collected, impeding efforts to characterise cohorts and outcomes, and plan for appropriate resourcing and service delivery.

Secondly, assessment of impairments and planning for follow-up and rehabilitation receives scant attention in the review. While I accept that the focus of the review is on acute management and anticoagulation management, I believe that the stated intention of the review is not fully met without more detail related to assessment of rehabilitation and care needs. Significant neurological impairments may result from acquired brain injury and can considerably affect function and safety.3–5 Cognitive impairment and balance are of particular note. Selected elderly individuals can achieve similar outcomes to younger patients with neurorehabilitation,6–8 while those who are not appropriate for rehabilitation require careful assessment and discharge planning, with environment and care needs appropriately supported.

*   © Royal College of Physicians 2019. All rights reserved.

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