Level 2 (mid-level) evidence

The Glasgow Coma Scale (GCS) is a simple and well-validated tool used to assess the degree of brain injury in patients with head trauma. The GCS is used not only as part of the patient assessment to help guide initial treatment and potential transfer to major trauma centers, but it also plays an important role in determining continued patient care and prognosis.

Previous reports have suggested that elderly adults with moderate-to-severe traumatic brain injury may have higher presenting GCS scores than younger adults (J Trauma. 2004;56[5]:1042-1048), but that study included only 44 patients aged ≥65 years.

A recent retrospective cohort study assessed the GCS scores of 561 patients with significant isolated traumatic brain injury, defined as a head Abbreviated Injury Scale (AIS) score of 3 to 5 and no additional injuries. About 57% of patients were aged ≥65 years. There were no significant differences in distribution of head AIS scores between those ≥65 years and those <65 years. Presenting GCS scores and survival rates were significantly different between elderly and younger patients, however (Table).

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Patients ≥65 years Patients <65 years P value
Severe GCS score (3-8) 9.8% 22.1% <0.001
Survival 77.6% 93.6% <0.001
Median GCS score in nonsurvivors 11 4.5 <0.01
Median GCS score in patients
with head AIS score 5 (critical injury)
14 13 <0.05

The results of this study suggest that GCS may be less accurate for predicting the extent of isolated traumatic brain injury in those aged ≥65 years compared with younger adults. This is consistent with current guidelines that recommend age >65 years as an indication to perform noncontrast head computed tomography in patients with no loss of consciousness or post-traumatic amnesia (Ann Emerg Med. 2008;52[6]:714-748; NICE Guidelines. 2014; Jan 22:CG176). Given the role of GCS in assessing and treating patients with traumatic brain injuries, it is important to consider these results when treating elderly patients with traumatic head injury.


  1. Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J. 2015;32(8):613-615. doi: 10.1136/emermed-2013-203488

Alan Ehrlich, MD, is a deputy editor for DynaMed, Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester. 

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