Head injury sequelae can be devastating for a geriatric client and affect nearly every component of the quality of life, including self-care, employment and leisure activities. Poor recovery outcomes may warrant institutional placement if caregiving demands exceed available resources in the home environment. Fall prevention strategies for older clients are essential in preventing head injury. Geriatric individuals generally sustain falls secondary to either intrinsic or extrinsic causes. For example, intrinsic causes include sensory changes or vestibular pathology that impede effective balance modulation. Environmental barriers and obstacles resulting in trips and slips are included in the extrinsic category. Appropriate balance measures such as the Berg Balance Scale (Berg et al., 1992) or Timed Up and Go Test (Posiadlo & Richardson, 1991) can assist in identifying those clients most at risk for falling.

Head injuries may be characterized as either open or closed; open head injuries involve open penetration to the skull. The initial site of impact following a traumatic insult to the brain is known as the coup injury. A rebound effect often occurs in the cranium following the initial impact and causes a contre-coup injury (Fig. 26.2). Patients may also sustain additional complications because of skull fractures or hematomas. Skull fractures vary from relatively nonthreatening simple linear fractures to those with extensive comminuting fragments that require cranioplasty procedures (Fig. 26.3). Additionally, patients can incur complications such as internal organ damage or both spinal and extremity fractures. Patients may undergo extensive intensive care monitoring because of uncontrolled intracranial pressure or resultant seizure activity.

Initial trauma assessments are performed using the Glasgow Coma Scale (GCS). Composed of three divisions, this instrument assesses three areas of function in individuals following head injury: motor performance, eye opening and verbal response (Table 26.1) (Teasdale & Jennett, 1974). Scores from 13 to 15 designate mild injury; from 9 to 12, moderate injury; and from 3 to 8, severe TBI. The rehabilitation team members should be aware of the initial GCS score and subsequent complications at the time of injury so that any examination or intervention activities can be adjusted. Patients’ prognostic functional recovery can be predicted by the initial FIM score, duration of post-traumatic amnesia and initial GCS score (Sandhaug et al., 2010).

Interventions for the geriatric client with a TBI include integrated strategies for both cognitive and neuromuscular impairments. Following recovery from a head injury, patients may be classified according to behavior associated with the Rancho Los Amigos Levels of Cognitive Function. Consisting of eight stages, this classification scheme illustrates progressive improvement from minimally responsive behavior to near full cognitive recovery (Table 26.2). This tool has been widely used to track such outcomes as patients’ functional recovery and hospital length of stay (Fakhry et al., 2004).