Is It Dementia or a Brain Bleed? Chronic Subdural Hematoma in the Elderly

The "Rapid Aging" Trap

I recently saw a 78-year-old patient brought in by his worried daughter. "Doctor," she said, "Dad was fine last month. But in the last few weeks, he's become forgetful, he's dragging his feet, and he sleeps all day. We think he has rapid dementia."

An MRI revealed the truth: it wasn't Alzheimer's. It was a large collection of old blood pressing on his brain—a Chronic Subdural Hematoma (cSDH).

He underwent a simple 30-minute procedure to drain the fluid. Two days later, he was chatting normally, walking without support, and asking when he could go home.

This condition is often called "Reversible Dementia," and it is one of the most common—and missed—neurosurgical emergencies in the elderly.

What is a Chronic Subdural Hematoma?

A Chronic Subdural Hematoma is a slow accumulation of blood and fluid on the surface of the brain, just beneath the protective outer covering (dura).

Unlike a sudden "brain hemorrhage" that happens instantly after a crash, a cSDH oozes slowly.

• The Cause: As we age, our brains shrink slightly. This stretches the tiny "bridging veins" connecting the brain to the skull.
• The Trigger: A minor jerk or bump—like hitting your head on a car door or slipping in the bathroom—can tear these stretched veins.
• The Slow Leak: Blood leaks out drop by drop. Over weeks, this collection grows, increasing pressure on the brain.

The "Forgotten" Injury

The most dangerous part of cSDH is the delay. Symptoms often don't appear until 2 to 6 weeks after the injury.

By the time the confusion starts, the patient (and their family) has often completely forgotten about the minor bump they had a month ago. In about 30% of cases, patients don't recall any injury at all.

Symptoms: Is it Dementia or a Brain Bleed?

Because the blood accumulates over the frontal and parietal lobes (areas controlling personality, movement, and thinking), the symptoms look terrifyingly similar to dementia or a stroke.

Watch for these signs in elderly parents:

1. Fluctuating Confusion: They seem fine in the morning but very confused by evening.
2. Gait Disturbance: Walking with small shuffling steps, dragging one leg, or frequent falls.
3. Headache: Often a dull, constant ache that is worse in the mornings.
4. Drowsiness: Sleeping much more than usual or being hard to wake up.
5. Weakness: Mild weakness in one arm or leg (hemiparesis).

Comparison: cSDH vs. Dementia vs. Stroke

How We Diagnose It

If an elderly person shows a sudden decline in mental function or balance, a CT Scan of the Brain is mandatory. A CT scan will instantly show the crescent-shaped collection of blood pressing on the brain. It is a quick, non-invasive test that gives us the answer immediately.

The Fix: Burr Hole Evacuation

The treatment for a symptomatic chronic subdural hematoma is one of the most successful procedures in neurosurgery: Burr Hole Evacuation.

This is not open brain surgery.

• Minimally Invasive: We make one or two small holes (size of a dime) in the skull.
• Drainage: The old, liquefied blood is washed out with saline. A small drain may be left in place for 24 hours.
• Anesthesia: It can often be done under Local Anesthesia or Sedation, making it safe even for 80+ year olds with heart conditions.

Recovery and Outlook

The recovery is often gratifyingly fast.

• Immediate: Headache usually vanishes right after surgery.
• 24-48 Hours: Confusion clears, and strength returns as the brain expands back to its normal shape.
• Discharge: Most patients go home within 2-3 days.

Note on Blood Thinners: Many elderly patients are on blood thinners (Ecosprin, Clopidogrel, Warfarin) for heart issues. These drugs make them more prone to bleeding. If your parent is on blood thinners and has a fall, the risk of cSDH is higher. We manage this by temporarily stopping the medication or giving reversal agents before surgery.

When to Seek Urgent Care

Do not wait if you notice:

• Sudden inability to speak clearly.
• Inability to wake the patient up.
• Severe vomiting or seizure.
• Weakness on one side of the body.

These signs indicate the pressure is critically high, and immediate Brain Bleed Evacuation is needed to prevent permanent coma.

Conclusion

Aging brings many changes, but sudden confusion or balance loss is not a normal part of aging. It is a medical emergency.

If your parent has "suddenly aged" in the last few weeks, ask yourself: Did they have a minor fall last month? A simple scan could reveal a treatable problem. Don't let a "reversible dementia" go untreated.

Worried about a head injury? Learn more about our Brain Surgery Services or read about Neuroplasticity and Recovery after brain injury.