Introduction

You have probably heard the word concussion before, but just what is a concussion?

Concussions are a common form of mild traumatic brain injury (mTBI) caused by a forceful blow or jolt to the head, disturbing the function of the brain. 

Approximately 42 million people worldwide suffer a concussion every year, making it the most common form of brain injury.³ In adults, the condition is generally caused by sports and road traffic accidents, and individuals often make a complete recovery. However, it is commonly caused by falls in individuals over the age of 65, and is. associated with increased care needs and mortality.¹ Older adults are at greater risk of harm and diagnosis can be complicated by co-occurring conditions. It is therefore important to understand the risks, symptoms and recovery to identify and treat the condition.

Understanding concussions

Definition of concussion

Concussions are defined as mild traumatic brain injuries that result in alterations in mental state. A concussion is a “traumatically induced transient disturbance of brain function.”² They are characterised by lightheadedness, headache, nausea and vomiting within 24-72 hours of a head injury. This may be accompanied by cognitive deficits such as loss of consciousness, poor concentration and difficulty remembering new information. Repeated concussions can result in degeneration of brain tissue.⁴

Causes of concussions 

Concussions occur due to direct or indirect injury to the head. It has also been found that indirect traumatic injuries to some parts of the body can result in concussions. 

Some common causes of concussions include:

• Motor vehicle accidents 
• Sports injuries
• Falls
• Assaults 

In older adults, falls are the leading cause of TBI, accounting for 51% of cases.⁵ Falls are regarded as a major threat to the health of older adults and can reduce the individual’s ability to remain independent.⁶

The second most common cause of TBI is motor vehicle crashes (MVCs), although this only makes up 9% of cases, as high-impact accidents are more likely to cause fatality in elderly individuals.¹ Assaults account for 1% of concussions in older adults, and all other known causes account for 17%, although more than 21% of TBIs in older adults are from unknown causes.⁵

Risk factors for concussion in the elderly

Age-related changes in the brain

Older adults are particularly vulnerable to concussion due to age-related changes in the brain. The brain shrinks with age, and blood flow decreases, making it more susceptible to injury even from minor trauma. Additionally, there is decreased muscle mass and issues with balance which increase the risk of falls, leading to concussions.

As individuals age, the covering of the brain becomes more adherent to the skull. Ageing is also associated with systemic changes such as cerebrovascular atherosclerosis, where the arteries supplying blood to the brain harden and narrow due to plaque buildup. This may increase the risk of injury, or increase the likelihood of repeated concussion.⁵ Older adults also have decreased free radical clearance, which can lead to increased oxidative stress. This may increase the risk of brain inflammation and oedema in concussion.⁵

Co-occurring conditions 

Older individuals are more likely to have chronic medical conditions such as hypertension (high blood pressure) and diabetes mellitus.⁶ Individuals are therefore more likely to take aspirin and anticoagulant therapies such as warfarin, which increases the likelihood of bleeding and increased mortality following a concussion.⁷

Recent studies have also shown that Alzheimer’s disease and dementia are associated with an increased risk of concussion due to an increased risk of falls.⁸ This is due to increased mobility issues, balance and muscle weakness. Individuals may also struggle to communicate their needs, so may be less able to identify symptoms, and medication may cause drowsiness or hypotension (low blood pressure). 

Symptoms of concussion in older adults

Concussion can present in many different ways in elderly individuals, so may often be mistaken or overlooked. Symptoms may not appear until 72 hours after a fall.

Some common symptoms that older adults may present with include: 

• Headache
• Vomiting
• Double or fuzzy vision
• Feeling groggy, foggy or sluggish
• Confusion

However, there are also a range of atypical symptoms that they may present with which may be mistaken for other conditions:

• Depression 
• Changes in sleeping patterns
• Nausea
• Impairments in balance
• Dizziness
• Photosensitivity 
• Concentration or memory problems 
• Irritability
• Anxiety
• Insomnia

It is important to watch out for these symptoms and see your GP or phone 111, to ensure that the diagnosis is made accurately and promptly.

If the individual experiences any of the following since a fall or knock to the head, phone 999 or attend A&E:

• Increased drowsiness
• Severe headache or neck pain that gets worse over time
• Bruising near eyes/ears
• Fluid or bleeding from ears
• Seizure
• Vomiting

Diagnosis 

Diagnosing concussion in older adults requires careful evaluation by a multidisciplinary team of healthcare professionals. Neurological exams and cognitive assessments are the first step in assessing the patient’s condition. Additionally, imaging studies such as computed tomography scan (CT scan) and magnetic resonance imaging (MRI) may be used to assess the extent of brain injury. 

Challenges in diagnosing concussion in the elderly

Elderly individuals are more likely to have other health conditions which can overshadow the symptoms of a concussion, such as memory impairments or balance issues. As such, their symptoms may be overlooked which can delay the diagnosis and intervention and can lead to increased morbidity and mortality.

Treatment and recovery

Treatment is usually supportive. Patients are advised to rest, medications are offered for pain management, and constant monitoring is done for complications such as bleeding or swelling in the brain. In severe cases, surgery may be necessary to relieve pressure on the brain.

Recovery from concussion in older adults may be slower and more challenging than in younger individuals. 

Rehabilitation programs tailored to the specific needs of older adults, including physical therapy, occupational therapy, and cognitive rehabilitation, can help improve outcomes and restore function.

Supportive care from family members and caregivers is also essential for promoting recovery and ensuring a safe return to daily activities. 

Lifestyle changes that may reduce the risk of falls such as home adaptations or employment of a carer may also be necessary.

Impact and complications

The impact of concussion on older adults can have a significant impact on cognitive function, mobility, and overall quality of life. The effects of this mild traumatic brain injury can vary between individuals and may be short-term or long-term.

In the short term, concussions can lead to cognitive impairment, difficulty with balance and coordination, and increased risk of future falls. 

Long-term complications may include post-concussion syndrome. This occurs when symptoms persist long after the injury and can last weeks to months. 

Post-concussion syndrome is characterised by:

• Persistent headache 
• Nausea 
• Depression
• Tinnitus
• Sensitivity to light and sound
• Visual changes: Double or blurred vision.

In addition, repeated concussions can lead to an increased risk of neurodegenerative diseases such as Alzheimer's disease.

Prevention strategies

Preventing concussions in the elderly requires a multifaceted approach that may involve:

• Fall prevention measures: such as removing tripping hazards from the home and installing handrails and grab bars, can help reduce the risk of head injuries
• Medication review: visit your general practitioner to review medications regularly. This can help to minimise the use of drugs that increase the risk of drowsiness, dizziness or bleeding
• Education and awareness campaigns: aimed at caregivers and older adults can help promote safety and reduce the incidence of concussions

Prevention of falls is essential to prevent repeat concussions, which can lead to chronic traumatic encephalopathy (CTE).

FAQs

What happens when an elderly person gets a concussion?

Concussions are considered mild traumatic brain injury. When this occurs, elderly individuals can suffer from cognitive impairments and alterations in their mental status. This may present as memory difficulties, loss of consciousness, confusion and/or irritability.

What are the red flags of a concussion?

The following signs require immediate medical attention: intractable vomiting, severe headaches, one-sided neurologic deficits, sustained loss of consciousness, seizures, deterioration of mental status, and worsening symptoms. Phone 999 or go to the nearest A&E if you notice any of these signs.

What do you do when an elderly person hits their head?

Keep the individual still and don’t allow any rapid movements. Monitor for bleeding and any changes in their level of consciousness or breathing. Visit A&E if they demonstrate any of the red flag signs above.

Can concussion cause dementia in the elderly?

Concussions, especially if severe or recurrent, have been found to increase the risk of developing dementia.⁸

How do you treat an elderly concussion?

Treatment usually involves rest, sleep, lifestyle modifications and pain management.

Summary

Concussions also referred to as mild Traumatic Brain Injuries (mTBIs), pose a significant threat to the health and well-being of older adults. Understanding the unique risks, symptoms, and recovery process of concussions in the elderly is essential for healthcare providers, caregivers, and older adults themselves. 

By implementing preventive measures, improving diagnosis and treatment, and providing comprehensive rehabilitation services, we can minimise the impact of concussions on the elderly population and promote healthy ageing for all.