Modification of Glasgow Coma Scale for Injured Elders

The Glasgow Coma Scale (GCS) is a score that is used to assess mental status, particularly in the evaluation of injured persons. It is frequently used to determine if a patient should be transported to a trauma center.

Here is the GCS scoring system:

This scale evaluates the degree of coma by determining the best motor, verbal, and eye-opening response to standardized stimuli.

• Spontaneous: 4
• To voice: 3
• To pain: 2
• None:  

Verbal Response

• Oriented: 5
• Confused: 4
• Inappropriate words: 3
• Incomprehensible words: 2
• None: 1

Motor Response

• Obeys command: 6
• Localizes pain: 5
• Withdraw (pain): 4
• Flexion (pain): 3
• Extension (pain): 2
• None: 1

The total numeric score that a person can achieve is 15. In an article published  in the journal Academic Emergency Medicine entitled “Modification of Glasgow Coma Scale Criteria for Injured Elders” (2011;18:1014-1021), Jeffrey Caterino MD and colleagues concluded that changing the emergency medical services (EMS) trauma triage cutoff for elders from a GCS of 13 to a GCS of 14 improved the score’s ability to predict “clinically relevant” trauma outcomes. In other words, a decline in GCS from 15 to 14 was associated with increased mortality, a finding that has not been observed in younger adults. Furthermore, elders with a GCS of 14 had greater odds of mortality and traumatic brain injury than did non-elder adults with a GCS of 13. 

What is the application of this to caring for patients in the outdoors? An elder is defined as a person 65 years of age or older. My interpretation is that elders are more sensitive to injuries, at least to those that influence the GCS as it is currently determined. The test remains a “rough cut” scoring system, such that if it is determined that a patient has lost only one point on the test (that is, he or she is not 100% normal by the criteria listed above), there is now an important increase in risk for traumatic brain injury or death. If an injured elder does not open their eyes spontaneously, is not fully oriented and without any confusion, or does not fully obey commands, then consideration should be given to a possible serious problem and the patient treated and transported appropriately to a high level of trauma care.