Screening for Concussions in Older Adult Patients

By Brittani Hollinger, PT, DPT
Physical Therapist, Central Pennsylvania

Many of our older adult patients have a history of falls or have fallen recently. This frequently leads to a direct referral for PT/OT/SLP services to address any deficit areas that may be contributing to these incidents. Your physical exam is likely to include assessments of strength, endurance, balance, vestibular function, sensation, hearing, vision, cognition, and the status of their living environment. While physical therapists are proficient at determining impairments across the International Classification Functioning (ICF) model, I think we fall short when it comes to concussion in geriatrics: does your screening include, or is it specific to concussion? 

Failure to assess equates to failure to address. If we miss even a single piece of the puzzle, we fail to provide our patients with a complete and well-rounded plan of care (POC). In turn, that poses the potential for readmission to caseload, hospitalization, injury, decline, and in some cases, even death. So, how exactly do we proceed in assessing a concussion after our older adult has fallen? Let’s break things down and start by answering a few questions.

What is a Concussion?

A concussion, or mild TBI, is a consequence of a mechanism of injury (MOI) that causes brain tissue to come in contact with the inside of the skull. This typically occurs at both the initial collision site and directly opposite the initial site of impact, termed coup-contrecoup, respectively. Loss of consciousness may or may not occur. 

Please note that imaging cannot detect a concussion, however may be warranted to determine the presence of hemorrhaging.

What Are the Signs and Symptoms of a Concussion?

Due to the vast intricacies and complexities of our brains, it is no surprise that associated signs and symptoms are diffuse and vary greatly between individuals. Potential difficulties/changes can be seen in one or more of the following:

• Hearing
• Vision
• Balance/equilibrium
• Concentration
• Memory
• Mood
• Learning disabilities (i.e. ADD, ADHD)
• Psychological involvement (i.e. stress, anxiety)
• Sleep

Other common complaints include:

• Headache
• Nausea
• Vomiting
• Light sensitivity
• Noise sensitivity
• Fogginess
• Confusion
• Mental fatigue
• Blurry/double vision
• Ringing in the ears
• Irritability
• Dizziness
• Lightheadedness
• Floating
• Spinning
• Motion sickness
• Emotional lability

To summarize, one can expect both central and peripheral nervous system involvement.

When Do I Assess for a Concussion?

Concussion screening should be initiated following any MOI/event that results in rapid or sudden acceleration/deceleration of the head. Let us recall that this includes:

• Fall (with or without head impact)
• Direct trauma to the head
• Whiplash injury
• MVA

Once you have determined that screening is warranted, what should you do next? 

Purposeful Questioning

Like any other evaluative process, focused and purposeful questioning is vital to fully understand the incident at hand to ensure proper diagnosis and whether or not a referral is required. 

The following questions should be considered (note that these directly coincide with our potential/anticipated signs and symptoms from above):

• Can you tell me about the incident itself and the events that led up to it?
• Did you lose consciousness? (associated with increased recovery time)
• Did you experience amnesia?
• Did you experience any nausea, fogginess, or a headache immediately following? (the presence of any one of these is associated with increased recovery time)
• Are there any prior concussions that you are aware of? When? (be aware of post-concussion syndrome and/or second impact syndrome, especially if they are falling frequently)
• Any changes in hearing (e.g. tinnitus, aural fullness) or vision (e.g. blurriness, diplopia, oscillopsia)?
• Do you have any learning disabilities or mood disorders such as ADD/ADHD or anxiety? (this becomes a point of education whereas the expected outcome would be to experience heightened associated symptomology if history is positive for any one of the aforementioned conditions)
• Do you have a history of headaches/migraines?
• Are there any changes in your balance? (if so, have them describe when the imbalance occurs/gets worse: Spontaneous? Movement induced? Position-related? Worse with fatigue? Worse in the dark? Worse inside versus outside? Flat versus uneven surfaces?)
• ADL/participation impacts?

 

While this is not an all-encompassing list, using these questions will give you a detailed picture of what is likely occurring, and subsequently, will allow you to funnel your focus to what’s most important/potential areas of treatment.

How to Begin Your Physical Exam

It is important to “clear” the cervical spine prior to a true concussion-related examination in order to assess for red flags and ensure safety when proceeding to hands-on testing.

1. Cervical ROM

Assess for pain or restrictions in all directions — most notably with rotation secondary to eventual head thrust testing. Positive results are a relative contraindication. If you are unsure whether it is safe to proceed, err on the side of caution and rely on your clinical judgment.

2. VBI Testing

Although rare, proceed with caution in individuals with known luminal narrowing as testing position can potentially result in CVA. Instruct your patient to keep their eyes open and stare at a single point/object while counting backward from 20 to adequately assess for the presence of the 5 Ds and 3 Ns once in the appropriate testing position.

• 5 Ds: dizziness, dysphasia, dysarthria, diplopia, drop attacks
• 3 Ns: nausea, numbness, nystagmus

Ask your patient directly regarding subjective symptoms from above (e.g. nausea), in which case the presence of even a single sign or symptom warrants a referral to PCP/cardiology for imaging to determine if blood flow to the brain is compromised

3. Ligamentous Testing

This will help determine if the SC is at risk for injury:

• Modified Sharp Purser (atlantoaxial instability due to a compromised transverse ligament)
• Alar ligament test (upper cervical spine instability)

Positive results warrant a referral. And remember, new/increased difficulty swallowing or a sensation of having a lump in the throat is a red flag.

Assessing Concussion-Related Deficits

Once you’ve successfully cleared the C-spine, it’s time to determine impairments related to your patient’s mild TBI. The following is a list of tests that can be utilized to determine whether a treat, refer, or treat and refer approach is appropriate:

• Resting gaze (assess for symmetry, presence of tropia, pupil size)
• Spontaneous nystagmus
• Fixed-gaze nystagmus (fast phase of nystagmus beats towards the intact side and intensifies when looking in the direction of the intact- ‘Alexander’s Law’)
• H-test (include diagonals for combined movements)
• Convergence (complete at least 3 trials secondary to impact of fatigue where 6+cm is considered to be abnormal; *true impairment indicates double vision was experienced, simple blurring of the image does not equate to a positive test result- ensure your patient understands this difference prior to testing)
• Saccades (all directions including combined motions via diagonals)
• Smooth pursuit (all directions including combined motions via diagonals)
• Head-shaking nystagmus (ensure the head is flexed 30 degrees to properly orient horizontal canals)
• Cover-Uncover/Alternate Cover Test, as known as ‘Test of Skew’ (assesses for phoria)
• VOR Cancellation
• Head thrust (can be performed with various biases (i.e. thrust into the direction of the desired canal) including translational forces to determine SSC versus otolith involvement)
• VOR 
• SVA versus DVA (1-2 line difference is considered normal, 3-4 line difference may indicate unilateral vestibular involvement, 5+ line difference may indicate B involvement)
• Dix-Hallpike/Roll Test (multi-canal involvement may be present!)
• Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)
• Functional Gait Assessment (FGA)

As you’re assessing for concussion-related deficits, remember:

• Direction-changing or pure vertical nystagmus is a red flag and immediate referral is warranted.
• Note speed, accuracy, dysmetria, saccadic corrections, physical endurance, and reported eye fatigue/other symptomology with oculomotor testing.
• Lack of objective findings during positional testing (i.e. Dix-Hallpike) with reproduction of subjective symptoms is considered a positive test result and should be treated as though nystagmus was observed.
• Dix-Hallpike should be completed at least twice under the circumstance that initial testing produces a negative result due to the potential for false negatives.
• Movement restrictions following BPPV treatment is no longer required, as once thought.
• Older adults tend to experience “dizziness” or vertigo associated with BPPV differently, frequently describing their symptoms as feeling “imbalanced.”
• Increased symptomatology is normal and expected with concussion rehab, however an increase or onset of a HA with exertion warrants cessation of the current task/exercise.
• Pending on the amount of time transpired since the MOI, the CNS is capable of overriding nystagmus in room light, which may indicate a need for Frenzel goggles or a referral to a clinician/clinic with access to such equipment.
• Many folks find themselves in the ER s/p fall for a number of reasons. Many claim that medical staff ruled out a concussion, however, if you inquire further about their experience you may be shocked by the rarity in their report of medical personnel. assessing their eyes. This is a MUST, or else how do you truly know? The answer is that you don’t. Assess your patient’s oculomotor function. It’s more likely than not that you will find deficits.

Are symptoms not adding up? Have you completed your neuro exam (i.e. coordination, sensation, reflexes, tone, CNs)?

How Do I Treat My Patient’s Concussion?

Most PTs are familiar with the ever-increasing requirements for baseline testing in athletics, such as the King-Devick Test, SCAT-2, etc., to more easily diagnose the presence of a concussion in such a high-risk population. Considering the setting in which we treat, this luxury is typically not at our disposal. But not to worry! Treatment is foundationally the same as any other impairment. 

For example, you determine through MMT that a patient has a weak bicep muscle, so what do you do? You load the tissue and perform bicep curls. It would be nice to know their PLOF bicep strength, but it is not necessarily required to achieve strength gains. Concussion-related deficits work the same. An issue with gaze stabilization? Initiate VOR. Impaired convergence/accommodation? Utilize Brock string. Postural instability? Trial VSR exercises. Loose otoconia? Determine the canal and complete the associated maneuver. Or maybe habituation is warranted.

Keep your treatment simple. Instruct and assist your patient in addressing their impairments found on examination. To review, this is likely to include oculomotor function, vestibular rehab, management of BPPV, dynamic balance, and/or gaze stability, etc.

Educating Your Patients on Concussions

Let us not forget that every well-rounded PoC includes education. It is imperative to ensure your patient understands:

• Only under rare circumstances should they be lying in bed in the dark without any stimulation.
• Appropriate graded exposure with reintegrating their typical activities/exercise.
• Modifications to movements and/or movement intensity.
• Limiting screen time.
• Reducing mental exertion/stimulation (this includes watching TV/listening to music!)
• Donning sunglasses/hats outdoors to reduce light exposure.
• Actively listening to their body’s responses/reactions to treatment/daily life, meaning they are physically adjusting accordingly, not simply identifying an increase in symptoms or what appears to be a regression.
• Anticipation of worsening symptomatology (within reason!) in order for healing to occur.

Finally, have fun by upgrading interventions:

• Increase performance time and speed
• Progress to standing
• Transition to a compliant surface
• Place them in a visually stimulating environment
• Combine exercises
• Incorporate dynamic gait patterns

You know what to do, just reach into your bag of tools!

What if My Patient is Presenting with Acute Dizziness?

If they are stable, perform the HINTS exam, otherwise, a 911 call is likely appropriate. If you are concerned that something more serious is at play, such as a CVA, perform the HINTS exam first to determine whether their complaints are of central origin. This screening tool has greater utility than imaging under acute circumstances. You may even save someone’s life.

1. HINTS: Head Impulse, Nystagmus, Test of Skew (Cover/Uncover Test)
2. An INFARCT is of concern if the following results are obtained: Impulse Negative, Fast-phase Alternating, Refixation on Cover Test. The rationale for this assessment include:

• Negative impulse testing (head thrust) indicates the reduced likelihood of peripheral involvement.
• Direction-changing nystagmus increases the likelihood/indicative of central involvement.
• Ocular refixation upon covering or uncovering the eye increases the likelihood of central origin.

Call 911 if ‘INFARCT’ results are acquired upon assessment.

Reminder: Older adults inherently experience normal/typical age-related changes in vision, hearing, and oculomotor function, not to mention the impact of comorbid conditions. Despite this, and as discussed previously, baseline assessment is a “nice-to-know” not a “need-to-know.” That means if your older adult is presenting with VOR deficits, for example, VOR exercises are indicated.

Now, get out there and help our older adults live better, longer!