Jimmy Carter’s Head Injury: Emblem of Impending Health Crisis

Former President Jimmy Carter, 95, successfully underwent a procedure to reduce brain swelling caused by a subdural hematoma. The brain hemorrhage was caused by recent falls the former president sustained last month. In October, Carter fell in his Georgia home, hitting his head and requiring 14 stitches above his eyebrow. Despite this, he went on to Nashville to start work on a new Habitat for Humanity home, building wooden support structures for the project.

Two weeks later, the former president was admitted to the hospital for observation and treatment of a minor pelvic fracture. Details about what symptoms led to his current hospitalization were not given, and no definite discharge date was announced, according to a Nov. 12 statement from the Carter Center.

Carter was previously diagnosed with metastatic melanoma that had spread to his liver and brain. He underwent a single course of radiation therapy and four rounds of pembrolizumab (Keytruda). He was declared “tumor-free” in December 2015.

Falls in the Elderly: An Impending Health Crisis?

According to the CDC, falls are serious and costly:

• One out of five falls causes a serious injury such as broken bones or a head injury.
• Each year, 3 million older people (ages >65) are treated in emergency departments for fall injuries.
• Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.
• Each year at least 300,000 older people are hospitalized for hip fractures.
• More than 95% of hip fractures are caused by falling, usually by falling sideways.
• Falls are the most common cause of traumatic brain injuries (TBI).
• In 2015, medical costs for falls totaled more than $50 billion. Medicare and Medicaid shouldered 75% of these costs.

As the Baby Boomer generation ages, the number of people over age 65 will reach 71 million by 2030 and will represent 20% of the population.

Risk Factors for Falls in the Elderly

Several community-based studies for risk factors have found the following factors as significant for falls in the elderly:

• Lower body weakness
• Past history of a fall
• Difficulties with walking and balance
• Use of medicines, such as tranquilizers, sedatives, or antidepressants. Some over-the-counter medicines can affect balance.
• Vision problems
• Cognitive impairment
• History of stroke
• Orthostatic hypotension
• Foot pain or poor footwear
• Home hazards or dangers such as broken or uneven steps and throw rugs or clutter that can be tripped over

Traumatic Brain Injury in the Elderly

Trauma is the seventh leading cause of death in those over 65, with a significant amount of those being traumatic brain injuries (TBIs). Falls (28%), motor vehicle accidents (20%), and other events such as pedestrian strikes (19%) account for many of these TBIs. Most falls occur from ground level, in or around the home.

The most common TBIs in the elderly include subdural, contusional, and intracerebral hematomas.

Several specific factors make the elderly population at increased risk for TBI and make assessment and treatment more challenging. These include:

Physiologic and physiologic brain changes

• Brain shrinkage: As we age, our brain volume naturally decreases. Brain volume is maximal at about age 35 and slowly decreases at 0.2%-0.5% per year. By age 60-80, volume is reduced approximately 6%-11%. There is a corresponding expansion of the subdural space and increasing brain mobility within the cranium.
• Blood vessels, in general, become more fragile with age. Bridging veins connect the dura to the brain surface. As they adhere to the dura, with brain shrinkage, these veins can be stretched and are more vulnerable to injury. This can lead to subdural hematomas.
• Researchers have found that cerebral arterial autoregulation and vasoreactivity to pCO2 or metabolic changes is impaired in the elderly. This makes them more vulnerable to decreases in cerebral blood flow and metabolic changes after a TBI.

Pre-injury factors

• As mentioned above, many prevalent preexisting medical conditions increase the risk of falls in the elderly. Any medical condition that impairs balance, proprioception, vision, or blood pressure increases the risk of a fall and subsequent TBI. Side effects of prescribed medications can also increase the risk of falls.

• Impaired cognitive dysfunction, either age-related decline or dementia, can make the assessment of a patient brought in after a fall more difficult to assess for TBI. Those with short-term memory loss may not remember that they were injured or whether they hit their head. It may be difficult to assess whether there is an additional decrease in their disorientation.
• Many elderly patients are on anticoagulants, as preventive treatments for stroke, pulmonary embolism or deep vein thrombosis, or atrial fibrillation. Otherwise seemingly minor injuries can have more serious consequences in these patients.

“Talk and deteriorate”

• Karibe, et al. noted that for the first 48 hours after injury, the death rate for all age groups is nearly the same. However, after this, the elderly show a progressive increase in the death rate, which levels off at about 35%. This is more than the survival rate of 60%-80% in other age groups. This delayed deterioration, sometimes called “talk and deteriorate,” is more common in the elderly, occurring in 20%-30% of elderly patients with TBI. Talk and deteriorate “is often induced by delayed hyperemia/hyperperfusion, delayed traumatic intracerebral hematoma, delayed expansion of subdural hematoma, or delayed aggravation of traumatic contusional edema.” In addition, the enlarged subdural space (as mentioned above) may temporarily buffer an increase in intracranial pressure, leading to later clinical deterioration.

Sensitivity to medications used in the rehabilitation of TBI

• The management of symptoms associated with TBI can be more difficult in the elderly. In general, the elderly tend to be more sensitive to any medication that acts centrally. For example, medications used to treat muscle spasticity can cause increased drowsiness in the elderly. Filer and Harris suggested that “benzodiazepines and typical antipsychotics such as haloperidol should be avoided due to evidence that they impair recovery from TBI.”
• In addition, tricyclics, often used to treat post-TBI headaches, can have anticholinergic side effects which can cause complications.

Given the potential rise in falls and TBIs as our population ages, providers who care for the elderly need to make fall prevention a major part of their patient educations goals. One tool being studied is the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. It is a multifactorial approach to fall prevention that includes screening for fall risk, assessing modifiable risk factors, and prescribing evidence-based interventions to reduce risk. A copy of the care plan is available at STEADI Coordinated Care Plan.

https://www.medpagetoday.com/blogs/celebritydiagnosis/83484