The impact of preinjury anticoagulation therapy in the older adult patient experiencing a traumatic brain injury: a systematic review

Abstract

Background The use of anticoagulants to manage acute and chronic medical conditions is a frequently-prescribed therapy to promote positive patient outcomes. What is known is that anticoagulant therapy may have detrimental effects, especially among older adult trauma patients. Early identification by the healthcare provider is essential to support rapid therapeutic intervention. Further research is indicated to establish clear, evidence-based guidelines regarding the care of the trauma patient on pre-injury anticoagulants. Objective The objective of this systematic review was to determine the effect of pre-injury anticoagulation therapy in the older adult patient who experiences a traumatic brain injury. Inclusion criteria Types of participants The review considered studies that included all patients aged 65 years or older, regardless of gender or ethnicity, who have experienced a traumatic brain injury. Types of intervention(s)/phenomena of interest The review included studies that compared the use of prescribed anticoagulant medication prior to the traumatic brain injury to non-use of prescription anticoagulant medication therapy. Types of studies The review included cohort studies, comparative case-control studies, and other comparative studies and case series/report studies which met all inclusion criteria. Types of outcomes The review considered studies that included the following outcome measure: all causes of mortality before patients are discharged from the acute care setting. Search strategy A three-step search strategy was utilized to find both published and unpublished studies in the English language only. No time frame was indicated. An initial limited search of MEDLINE, CINAHL and OVID was undertaken followed by an analysis of the text words contained in the title and abstract, and the index terms used to describe the article. A second search using all identified keywords and index terms was undertaken across all included databases. Lastly, the reference list of all identified reports and articles was searched for additional studies. Methodological quality The reviewers utilized the Joanna Briggs Institute Critical Appraisal Checklist for comparable Cohort/Case Control Studies to assess methodological quality. Data collection Data was extracted using the Joanna Briggs Institute Data Extraction Form for Comparable Cohort and Case Control studies. Data synthesis Results were analyzed using the System for the Unified Management, Assessment and Review of Information (SUMARI) software from the Joanna Briggs Institute. Three retrospective cohort studies were included in the final analysis. Results indicated a statistically-significant (p=0.0001) reduction in acute care mortality prior to discharge when non-anticoagulated older adult trauma patients experienced a traumatic brain injury. Results Synthesis of data indicated a statistically-significant (p=0.0001) reduction in mortality in the acute care setting prior to discharge when patients were not taking anticoagulants pre-injury. Conclusions Based on the results of this review, the use of pre-injury anticoagulant therapy demonstrates increase mortality in the older adult trauma patient diagnosed with a traumatic brain injury. Although anticoagulant therapy is prescribed to treat acute and chronic medical conditions, the need to identify this fragile population early in the course of treatment is imperative to support positive patient outcomes, and to decrease acute care mortality. Implications for practice Emergency and trauma care providers will realize a clinically-significant reduction in acute care mortality for trauma patients identified as taking pre-injury anticoagulants. The impact on practice includes early identification during the triage process. Healthcare providers not only need to identify patients on anticoagulants, but if they are therapeutic or non-therapeutic with their International Normalized Ratio (INR) at the time of injury. The need for standardized intervention(s) will impact patient outcomes as a whole.