The association between age and high-intensity treatment in traumatic brain injury patients: a CENTER-TBI study

IntroductionOlder age is associated with worse outcome after traumatic brain injury (TBI). Whether this association is entirely driven by frailty, or clinicians reluctance to give specific treatments to older patients is unclear. Therefore, we aimed to confirm the association between age and worse outcome, and to assess the association between age and received high-intensity treatment (HIT). MethodsWe included TBI patients aged 16 and older from the CENTER-TBI study. The association between age and HIT, and between age and outcome (the Glasgow Outcome Scale Extended (GOSE) at 6 months), was analyzed using multivariable ordinal and logistic regression respectively. In the overall cohort, HIT was defined as receiving emergency intracranial surgery, or ICU admission. In the subset of patients admitted to the ICU, HIT was defined as receiving metabolic suppression, intensive hypocapnia, hypothermia below 35 {degrees}C, decompressive craniectomy, or intracranial surgery not scheduled on admission. We adjusted for pre-injury health, injury severity (Glasgow Coma Scale (GCS) motor score and pupillary reactivity at baseline; major extracranial injury (MEI); Marshall CT classification), and in the subset of ICU patients for the median ICP before receiving any HIT. ResultsIn total, 4349 patients were included. Of these, 1999 patients (46%) were admitted to the ICU. The median age was 51 years. Every ten-year increase in age for patients over 65, was associated with worse outcome (OR = 0.6, CI = 0.5 - 0.7, OR in the subset of ICU patients = 0.5, CI = 0.3 - 0.5). Furthermore, every ten-year increase in age for patients over 65 was associated with a lower likelihood of receiving emergency intracranial surgery (OR = 0.4, CI = 0.3 - 0.6), and ICU admission (OR = 0.6, CI = 0.5 - 0.8). Similarly, in the subset of ICU patients, every ten-year increase in age for patients over 65, was associated with a lower likelihood of receiving neuromuscular blockade (OR = 0.6, CI = 0.4 - 0.9), intensive hypocapnia (OR = 0.2, CI = 0.1 - 0.9), decompressive craniectomy (OR = 0.4, CI = 0.2 - 0.8), and intracranial surgery (OR = 0.5, CI = 0.3 - 0.8). ConclusionOlder patients have poorer outcome, and were less likely to receive high-intensity treatments, independent of patient and injury characteristics. Clinicians should not withhold high-intensity treatments solely based on older age. Educating clinicians about this delicate topic, and performing further comparative effectiveness research focusing on older patients may improve diagnosis, treatments, and understanding of TBI outcomes in this group.