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Trauma i n the Ol der Adul t

Epidemiology and Evolving Geriatric Trauma


Principles
Stephanie Bonne, MD, Douglas J.E. Schuerer, MD*
There is little debate that the worlds population continues to age,
1,2
and as such there
are increasing numbers of older patients presenting with traumatic injuries than in the
past. The current population of both the United States and the developed world is
aging, creating a new subset of patients with trauma, the geriatric patient with trauma.
If we are to study this population, we must quantitatively define it. In the case of
trauma, recent data suggest that mortality as adjusted for injury severity scale (ISS)
increases at the age of 70 years, defining the population older than 70 as distinct
from those younger than 70 years, and making the age of 70 the cutoff at which to
consider a patient with trauma elderly or geriatric.
3
This notion is distinct from
Advanced Trauma Life Support (ATLS) teaching, which recommends transport to
a trauma center of any patient older than 55 years, or the Eastern Association for
the Surgery of Trauma (EAST) guidelines, which recommend considering any patient
Washington University in St Louis, 660 South Euclid Avenue, Campus Box 8109, St Louis, MO
63110, USA
* Corresponding author.
E-mail address: schuererd@wudosis.wustl.edu
KEYWORDS

Geriatric

Trauma

Fractures

Falls
KEY POINTS
From the initial time of injury, the overall experience of an elderly person who sustains
a traumatic injury can be very different from that of a younger patient with trauma, and
special consideration should be made to properly triage and treat the geriatric patient
with trauma.
Once a traumatic event occurs, there are several comorbidities that complicate recovery
from the trauma. Greater than 50% of the geriatric trauma population has underlying
hypertension, and greater than 30% have heart disease.
The widespread use of medications and polypharmacy adds to the challenge of evaluating
and treating the elderly patient with trauma. Older patients may be using medications,
such as b-blockers, that will mask abnormal vital signs, or may have pacemakers in place,
which can further confound the primary survey.
Clin Geriatr Med 29 (2013) 137150
http://dx.doi.org/10.1016/j.cger.2012.10.008 geriatric.theclinics.com
0749-0690/13/$ see front matter 2013 Elsevier Inc. All rights reserved.
older than 65 years as elderly.
4,5
Although there is no consensus on an age cutoff for
a patient with trauma to be considered elderly, the age of 65 is most often used when
considering a patient elderly or geriatric in the trauma literature. It is well recog-
nized that the geriatric trauma population requires special consideration with regard
to diagnosis and treatment, and it is important for the trauma clinician to be aware
of the special needs of these patients.
EPIDEMIOLOGY
By 2050, it is expected that there will be nearly 90 million adults older than 65 years
living in the United States, representing more than one-fifth of the population.
6
In addi-
tion to the increase in the volume of the geriatric population, one can expect more
injuries to occur in this population as they continue to live more independent and
active lifestyles. At present, patients older than 65 years account for 23% of all trauma
admissions, and trauma represents the fifth leading cause of death in this popula-
tion.
7,8
Because of the high prevalence of multiple comorbidities in the elderly, there
is an increased likelihood of death or severe disability following trauma.
8
Up to one-
third of all patients presenting with an ISS greater than 15 can be expected to die
before leaving the hospital.
9
In addition, the economic costs, as well as the societal
cost and loss of life, are higher following trauma to an elderly patient. Falls are the
leading cause of trauma in the elderly. There is approximately a one-third risk of fall
for geriatric adults each year.
10
With an average hospital cost of $18,000 (United
States, 2012) per fall, and further costs associated with long-term nursing care
following trauma, the economic implication of all trauma, but specifically of standing
level falls, to the elderly is astonishing.
11,12
Looking forward, the social and economic
implications of the expected increase in geriatric trauma cannot be overlooked, and
clinicians must continue to strive toward a more standardized and evidence-based
approach to the diagnosis and treatment of these patients.
MECHANISMS OF GERIATRIC TRAUMA
Several factors place the geriatric population at particular risk for traumatic events,
and for subsequent delayed recovery from trauma. Conditions that predispose
patients to incurring trauma are seen in higher prevalence in the older population.
Weakness or generalized deconditioning resulting from chronic illnesses can lead to
an increased rate of falls or other accidents in these patients. Loss of visual acuity,
balance and gait instability, slowed reaction times, and cognitive impairments are
also important disabilities that may lead to an increased incidence of traumatic events
in the elderly. Often these issues are not recognized before trauma, and cognitive
dysfunction can be seen up to 35% of the time in the geriatric visitor to the emergency
department, but is only recognized 6%of the time.
13
Trauma itself is also an increased
risk factor for future traumas, with elderly patients who have sustained trauma in the
past being 3 times more likely to have a future traumatic event.
14
Because this partic-
ular constellation of problems is seen in the elderly, prevention of geriatric trauma
should be addressed by all clinicians caring for a geriatric patient. Trauma prevention
in patients who are at high risk because of the aforementioned disabilities should be
addressed by the geriatric primary care physician (Fig. 1).
The mechanisms of trauma are not unique to this particular population, but
because geriatric trauma presents at such a higher rate than in the younger popula-
tion, they can be considered to be different mechanisms than those observed
younger patients with trauma. Unlike their younger counterparts, elderly patients
with trauma usually sustain blunt trauma rather than penetrating trauma. Falls
Bonne & Schuerer 138
account for nearly three-quarters of all traumas in the geriatric population, with motor
vehicle accidents accounting for nearly all of the remaining 25% of injuries. Pene-
trating trauma and other mechanisms make up only 4% of total trauma in the geriatric
population.
9
Among the elderly patients who fall, nearly 90% experience simple falls,
such as falls from standing. Despite being simple mechanisms, the multiple comor-
bidities in the elderly population, along with the need for rehabilitation, make falls
a significant medical and economic event in the life of these patients.
15
Falls associ-
ated with blunt cerebral injury and long bone fractures lead to the greatest morbidity
and mortality.
7,8
About one-quarter of all elderly victims of motor vehicle accidents
sustain chest trauma, such as flail chest and rib fractures, which can complicate
preexisting cardiopulmonary disease and lead to pneumonia or respiratory failure,
complications which are known to have particularly high morbidity and mortality.
16
Car accidents also cause mortality at almost double the rate for the elderly as for their
younger counterparts when adjusted for injury severity.
16
Finally, although pene-
trating trauma remains rare in the elderly population, it is associated with higher
morbidity, longer stays in the intensive care unit (ICU), and longer overall hospital
stays when compared with younger patients.
17
When caring for a geriatric patient
with trauma after a fall or motor vehicle accident, it is important to be aware of the
most likely injuries and injury patterns, reviewed herein. These injury patterns may
vary from those seen to arise from the same mechanism in a younger patient, so it
is important to be aware of the particular injury patterns seen in the elderly so that
occult injuries are not missed.
TRIAGE AND EVALUATION OF THE GERIATRIC PATIENT WITH TRAUMA
From the initial time of injury, the overall experience of an elderly person who sustains
a traumatic injury can be very different from that of a younger patient with trauma, and
special consideration should be given to proper triage and treatment of the geriatric
patient with trauma. Nursing homes or assisted care facilities, where elderly patients
often reside, are a unique location, where health care workers are available and may
attempt to treat a traumatic event on site. However, this can actually delay the trauma
evaluation of a patient who might otherwise be taken to an emergency department
sooner if they reside in the community. Likewise, families or other laypersons may
Fig. 1. Pie chart of injury mechanism in the elderly patient. MVC, motor vehicle accident.
Trauma in the Older Adult 139
underestimate the severity of a traumatic event to their elderly family member,
because the mechanism may seem trivial or their loved one may not initially show
signs and symptoms of having a major underlying injury. Once the emergency medical
services (EMS) system is activated, it is critical for the emergency responder to appro-
priately evaluate and triage the patient. For nearly 20 years it has been recognized that
elderly patients are consistently undertriaged to major trauma centers, possibly
because emergency responders do not recognize potential major injuries or are not
fully aware of all the potential comorbidities in the elderly patient, or because of poten-
tial age bias on the part of the responders.
18,19
Undertriage is particularly troublesome
because trauma outcomes with regard to both morbidity and mortality have been
shown to be improved when the geriatric patient is taken immediately to a high-
level trauma center.
20
In addition to undertriage, it has been shown that geriatric
patients who are transferred to a trauma center but do not meet trauma activation
criteria on initial evaluation, will often have occult injuries, or their comorbid conditions
will act in synergy with their traumatic event to lead to higher morbidities for that partic-
ular injury.
21,22
When adjusted for injury severity, geriatric patients have consistently
higher levels of morbidity and mortality across all levels of injury.
23
This fact has led
many trauma surgeons to advocate for age alone to be a criterion for activation of
the trauma system and transfer to a Level 1 trauma center, although the age that
should be the threshold for such activation is debated.
21,23
Level 1 trauma centers
can be identified at www.traumamaps.org. Current guidelines suggest that age alone,
in the absence of any diagnosable injury, is insufficient for activation of the trauma
team; however, the threshold for activation should be lower in patients who show
hemodynamic instability or any potentially life-threatening injuries, such as severe
fractures, abdominal trauma, or chest trauma.
3
In addition to improved outcomes
from immediate evaluation at a higher-level trauma center, geriatric patients may
also benefit from a dedicated geriatric trauma service, which may be increasingly
found at higher-level trauma centers or academic centers (Fig. 2).
24
Once an elderly patient arrives at a trauma center, the staff must be careful to eval-
uate the geriatric patient as is appropriate for their advancing age. Vital signs and
physical examination can be deceptive in these patients, who may exhibit examination
characteristics very different from those of younger patients. Although the ATLS
protocol should be followed for geriatric patients just as it is for younger patients, there
are some differences in the normal physiology of elderly patients that will make their
evaluation and treatment more challenging. Even among patients who are not taking
Fig. 2. Algorithm for field triage of the elderly patient with trauma. Current triage guide-
lines suggest transfer to a trauma center provides optimal care. Those with obvious injury
or relative hypotension (low normal blood pressure but very low for patients with preexist-
ing hypertension) should be triaged to a higher-level trauma center, depending on state
regulations.
Bonne & Schuerer 140
confounding medications, vital signs can be falsely reassuring. Increased mortality
has been shown among elderly patients with heart rates greater than 90 beats/min
and systolic blood pressure less than 110 mm Hg, whereas the same increase in
mortality is not seen until 130 beats/min and 95 mm Hg in younger patients.
25
Elderly
patients also subjectively report less pain for the same severity of injury than do their
younger counterparts, potentially masking injuries or falsely reassuring staff that an
injury is less severe than it actually is.
26
Mental status examinations and Glasgow
Coma Scale (GCS) scoring can be particularly difficult in the geriatric patient, who
may have preexisting cognitive deficits, hearing impairment, or other factors that
can confound these examinations.
27
Clinical neurologic examination has also been
shown to be unreliable in detecting significant hemorrhage in patients with minor
head trauma.
28
The difficulty in using normal clinical judgment and assessment in
elderly patients has led many emergency medicine and trauma surgeons to advocate
for a low threshold of reliability in ancillary studies on the geriatric patient with
trauma.
27
COMORBIDITIES IN GERIATRIC TRAUMA
Once a traumatic event occurs, several comorbidities complicate recovery from the
trauma. Greater than 50% of the geriatric trauma population has underlying hyperten-
sion, and greater than 30% has heart disease.
7
Other conditions that can complicate
evaluation and management of the patient with trauma include diabetes, previous
cerebrovascular events, chronic obstructive pulmonary disease (COPD), dementia,
arrhythmias, and endocrine disorders; all of which are present in greater than 10%
of the geriatric trauma population.
7
Other common diseases in the elderly, such as
community-acquired infections, cancers, and chronic renal failure, also lead to
increased risk of poor outcomes following trauma.
9,29
The comorbid conditions that
confer the highest risk of mortality in the geriatric population are hepatic disease, renal
insufficiency, and cancer.
30
The presence of congestive heart failure, particularly in
patients who take b-blockers or are anticoagulated, can confer a 5- to 10-fold
increased risk of death following trauma.
31
Because the geriatric population is gener-
ally less healthy at baseline, they are at increased risk of certain types of trauma and at
increased risk of in-hospital complications once a trauma has occurred. Comorbid
conditions, therefore, become a major factor in the evaluation and treatment of the
elderly patient with trauma. Closely related to this are the medications a patient with
trauma may be taking for the aforementioned comorbidities.
The widespread use of medications and polypharmacy adds to the challenge of
evaluating and treating the elderly patient with trauma. Older patients may be using
medications, such as b-blockers, that will mask abnormal vital signs, or may have
pacemakers in place, which can further confound the primary survey. Preinjury
b-blocker use does confer an increased risk of mortality, particularly when con-
founded with warfarin or other cardiac medications.
27
This risk may be due to under-
recognition of tachycardia owing to b-blocker use, conferring a falsely reassuring
clinical picture. In the secondary survey, geriatric patients may bleed more rapidly
from seemingly minor wounds because of widespread use of anticoagulants and anti-
platelet agents. Because falls and head trauma comprise such a large percentage of
total trauma in the elderly, anticoagulation becomes a significant problem that the
emergency or trauma clinician can expect to encounter often.
In addition to cardiac medications and anticoagulation, other medications can
confound the treatment of trauma. Steroids, often prescribed for COPD in the
elderly, can cause reduced wound healing or can lead to clinical adrenal
Trauma in the Older Adult 141
insufficiency in the critically ill patient, and have been shown independently to lead
to a 1.6- to 5-fold increased incidence of death in the geriatric trauma population.
26
Antipsychotics may render neurologic examinations unreliable, and antidopaminer-
gic agents used for Parkinson disease may change the neurologic examination of
the extremities. Eye drops or systemic medications taken for glaucoma may alter
the pupillary examination, as may corneal or other eye implants. It is crucial to docu-
ment the pupillary examination on arrival, and document any ophthalmologic history
to avoid confusion among care providers during the patients hospitalization. In
addition to taking into account the patients home medications when evaluating
the patient, it is important to consider which home medications are necessary to
continue during the stay in hospital. Patients may exhibit adverse effects to the
sudden discontinuation of antidepressants, antipsychotic agents, and in particular
to antidopaminergic agents. In short, the polypharmacy seen more often in the
elderly must be carefully considered, from the point of initial evaluation through
the entire treatment course of the geriatric patient, so as not to miss occult injuries
or to cause additional clinical problems by discontinuing a chronic medication
(Table 1).
PATTERNS OF INJURY AND SPECIFIC INJURIES
In addition to global considerations of geriatric patients, there are special consider-
ations for each injury. In the case of head-injured patients, there is a linear relationship
Table 1
Physiologic and functional preexisting differences in the older adult
Organ System Normal
Potential Differences in the Older
Patient
Vital signs Increased mortality if HR >130
beats/min or SBP <95 mm Hg
Increased mortality if HR >90 beats/min
or SBP <110 mm Hg
Neurologic No baseline deficits Baseline deficits (dementia, stroke,
hearing loss)
Report less pain for equivalent injuries,
potentially limiting injury discovery
Cardiovascular No baseline deficits, no
hypertension
No cardiac medications
Baseline hypertension
Medications that affect blood pressure
and heart rate (b-blocker, calcium-
channel blocker, amiodarone)
History of heart failure
Pulmonary Normal functional residual
capacity
Potential smoker
Decreased functional residual capacity
Chronic obstructive pulmonary disease
Renal Normal renal function Decreased glomerular filtration rate
Coagulation Normal coagulation status On blood-thinning medications
including ASA, warfarin, and platelet
inhibitors
Skeletal Normal bone density Osteoporosis, leading to easier fracture
rate
Medications Minimal medications Polypharmacy that can change mental,
hemodynamic, renal, and
coagulation status
Abbreviations: ASA, acetylsalicylic acid; HR, heart rate; SBP, systolic blood pressure.
Bonne & Schuerer 142
between age and mortality following head injury, such that even within the population
older than 65 there is increased risk of death with increasing age.
32
Among those
patients who do not die from their head trauma, poor outcomes are common and
also increase with increasing age.
33
These patients may present with a very mild
mechanism for head injury or may have few hard neurologic signs, such as neurologic
deficits, weakness, or altered mental status, on initial evaluation, but may still have
very significant underlying subdural or epidural hematomas.
34
The widespread use
of anticoagulation in the elderly population has led to a large body of literature evalu-
ating the effects of anticoagulation on the patient with trauma. Some studies have
shown an increased risk of mortality with warfarin use in all patients with trauma,
whereas other students show that in the absence of head trauma, warfarin use
does not lead to increased mortality in the patient with trauma.
31,35
However, if the
elderly patient with head trauma is taking warfarin, there is a significantly increased
risk of fatal intracranial hemorrhage.
31
Patients who are anticoagulated on arrival,
particularly those with head trauma, should be rapidly corrected, and there should
be a low threshold to repeat brain imaging with any clinical neurologic change.
36
The GCS is an unreliable clinical tool in this scenario, and rapid and repeated use of
computed tomography (CT) of the head becomes the essential means of identifying
increased intracranial pressure in this scenario.
37
In the case where medical history
is unavailable or unreliable, there should be a low threshold for the use of head CT
in the elderly population, because of both the high prevalence of occult injuries and
the rising prevalence of anticoagulant use.
34
Common rules such as the NEXUS-II
specifically rule out patients older than 65 when determining who does not need
a CT.
38
Even with use of intracranial pressure (ICP) monitoring and careful pharmaco-
logic management of ICP, elderly patients have poorer autoregulatory mechanisms,
which subsequently lead to a 30% decrease in the Glasgow Outcome Score after
head injury in comparison with their younger counterparts.
39
In the case of cervical spine injuries, elderly patients have mechanisms and risks for
spine injury similar to those of their younger counterparts; however, the prevalence of
cervical stenosis or degenerative spine disease is more common in this population.
Also, there is little need to consider future cancer risk from radiation in the elderly
patient. Common predictors of cervical spine injury include focal neurologic deficits,
concomitant head injury, and high energy mechanism. Although similar predictors
are seen in the younger population, the older population requires its own risk stratifi-
cation to guide clinicians to suspect cervical spine fractures, because an apparently
lesser injury can be so much more devastating in the older population.
40
One can
expect a lower energy mechanism, such as a fall fromstanding, to cause greater injury
to an elderly patient, because of the higher likelihood that the patient has preexisting
degenerative spine disease or cervical stenosis. Also, because the elderly patient is
most likely a victim of blunt trauma, most will require cervical spine evaluation. Early
spine evaluation, a low threshold for involvement of a spine service, and the careful
use of cervical spine immobilization are all essential in ensuring that a low energy
mechanism does not become a devastating neurologic injury.
Thoracic trauma in the elderly is most likely to be blunt, and most likely to be from
a motor vehicle accident. Fractures that might seemclinically insignificant in a younger
patient, such as isolated rib fractures or clavicle fractures, may represent significant
force and be associated with significantly higher morbidity in elderly patients.
8
Rib
fractures in the elderly can be particularly worrisome, because of the increased
morbidity and mortality associated with as few as 3 or fewer nondisplaced rib frac-
tures. In addition, the increase in number of rib fractures increases the rate of compli-
cations.
41
Elderly patients are likely to develop pulmonary contusions or pneumonia
Trauma in the Older Adult 143
from rib fractures, even isolated rib fractures.
42
Pneumonia following a rib fracture can
be a devastating complication for an elderly patient who, at baseline, does not have
the pulmonary reserve and ability to generate a forceful cough that a younger patient
may have. It is essential to aggressively manage rib fractures in elderly patients,
including, when indicated, epidural anesthesia and rib fixation. Pain control will help
with pulmonary toilet and use of incentive spirometry (IS). Admission should be
strongly considered if more than 2 rib fractures and/or IS use is found to be poor
despite analgesia.
Abdominal trauma in the geriatric patient does not differ significantly from abdom-
inal trauma in the younger patient. The same mechanisms and grades of solid organ
injury apply to the older adult. Early experience with operative management for blunt
abdominal trauma in the geriatric population showed poor outcomes; however, more
recent studies have shown that operative management is possible and, in fact, pref-
erable to nonoperative management based on age criteria alone, likely attributable
in part to improved perioperative care and improved surgical optimization.
43,44
In
fact, a patient older than 55 years will be more likely than their younger counterparts
to fail nonoperative management of blunt splenic trauma.
45
Of course, in cases of
penetrating abdominal trauma or bowel injury, operative exploration must be per-
formed regardless of age criteria.
Much like the other injuries discussed, pelvic fractures in the elderly have a higher
incidence of complications and mortality than in the younger population. The injury
pattern of pelvic fractures in the geriatric population tends to be different to that in
the younger population, specifically with a higher incidence of lateral compression
fractures.
46
These fractures are more likely to cause hemorrhage that requires inter-
vention, such as angiography.
47
The trauma surgeon should be aware that the elderly
patient with a pelvic fracture may have pelvic bleeding that often otherwise goes
unrecognized both clinically and radiographically on simple radiographic or CT exam-
inations.
48
In addition, older age and concomitant long bone fracture, often seen in the
elderly, impart a higher likelihood of finding occult bleeding with angiography.
49
Some
investigators therefore advocate the liberal use of angiography in the geriatric popu-
lation, regardless of hemodynamic stability, because of the very high incidence of
occult bleeding.
The treatment of extremity orthopedic injuries among the elderly does not vary sig-
nificantly from treatment of the younger population. The evaluation of concomitant
neurovascular injury and the treatments of surgery, splinting, and reduction are
largely the same as for the younger population. The exception is the long bone femur
fracture, or hip fracture. This fracture was formerly considered a fatal event for the
elderly osteoporotic patient, but with advances in pinning and plating, this is no
longer true. The incidence of this injury remains high, however, as more women
live well past menopause and experience osteoporosis, among other risk factors.
50
Low bone density imparts an increased risk for all types of long bone fractures, but
particularly for hip fractures. It is also important to consider the surgical risk of
a patient in whom operative fixation may be indicated. Should the elderly patient
have multiple surgical risk factors, it may be more prudent for the orthopedic surgeon
to simply splint or cast a fracture rather than expose the patient to the risk of anes-
thesia. This approach needs to be carefully considered in juxtaposition to the
patients functional goals and outcomes, and the potential risks of deep vein throm-
bosis or occupational deconditioning if the patient is unable to use the extremity for
a period of time. Although orthopedic management may not be drastically different
for the elderly patient with trauma, careful medical management must be considered
for the geriatric patient (Fig. 3).
Bonne & Schuerer 144
INTENSIVE CARE MANAGEMENT OF GERIATRIC PATIENTS WITH TRAUMA
Once a patients management course has been set, or their injuries have been defini-
tively managed, the patient may require a course of treatment in the ICU. Intensive
care medicine for the elderly patient, and specifically the elderly patient with trauma,
differs from that for younger patients. Patients older than 65 years have a significantly
greater mortality rate when matched for injury severity and comorbidities. This situation
actually leads to decreased use of ICU resources, as many elderly patients will die
before reaching the ICU and thus use little or no ICU resources.
51
Once resuscitation
has begun, it is clear that the geriatric population has less physiologic reserve and
therefore requires more rapid, yet judicious, treatment.
52
In addition, patients who
BRAIN
Baseline defects
Dementia
Stroke
Less pain reporting
SDH more likely due to cerebral atrophy
Vision changes
Figure of specific concerns for the older trauma patient
EAR
Hearing loss
LUNGS
Emphysema (potentially
creating pneumothorax)
Decreased functional
residual capacity COPD
KIDNEY/BLADDER
Decreased glomerular
filtration rate
Increased UTI
CARDIOVASCULAR
Baseline hypertension
Baseline heart failure
Cardiac medications
Heart rate control
Blood pressure control
Anticoagulation
GLOBAL
Polypharmacy
Diabetes mellitus
Psychiatric medications
Beta-Blockers
Ca Channel Blockers
Anticoagulation
Platelet inhibitors
Blood thinners
NECK
Osteophytes
Arthritis
More difficult intubation
Easier to fracture
spinal column
SKELETAL
Osteoporosis
More frequent fracture
Fractures with minimal
energy injury
Fig. 3. Specific concerns for the older trauma patient.
Trauma in the Older Adult 145
are stable on initial evaluation will often have measureable hemodynamic compromise
when invasive monitoring has been performed.
53
This occult hemodynamic compro-
mise can present a unique challenge to the clinician who does not retain a high index
of suspicion. Renal function in the elderly patient will differ from that in the younger
patient owing to decreased renal blood flow and declining renal mass, therefore urine
output alone is a poor clinical indicator of resuscitation. Creatinine clearance also
becomes a much more important marker of renal function because creatinine alone
can be deceptive in the elderly patient with lower muscle mass.
54
Although there has
been insufficient evidence to suggest the routine use of pulmonary artery catheters in
this population, the judicious use of invasive monitoring is warranted in the patient
with an unclear clinical picture. Newer studies have shown a benefit to elderly patients
who receive pulmonary artery catheter monitoring, and this monitoring has been
shown to be lowrisk.
55,56
Even though there are no specific end points for resuscitation
in these patients, the optimization of cardiac index and the use of base deficit as a mea-
sure of the status of resuscitation may be useful to the clinician.
57
It remains the clini-
cians choice to place an invasive line in a patient who is thought to warrant one;
however, it canbebeneficial inguidingtheresuscitationof theolder patient withtrauma.
In addition to the hemodynamic changes seen in the elderly, the pulmonary
mechanics of the elderly individual vary significantly from those of younger patients,
leading to challenges in ventilator management in the older population. Elderly
patients with trauma have a distinct increase in the vulnerability to pulmonary compli-
cations after trauma, owing to the decrease in their pulmonary reserve.
58
The ability of
a nonventilated older patient to compensate for metabolic disturbances is decreased,
which may cloud the clinical picture for the clinician because the patient may have
a normal respiratory rate while becoming progressively hypoxic and hypercarbic.
59
In addition, when matched for injury severity, elderly patients are more likely to
develop nosocomial infections, such as pneumonia, which in turn lead to longer length
of stay in the ICU and hospital, and a higher mortality.
60
To reduce these complica-
tions, early and aggressive treatment of injuries, pulmonary toilet, pain control, and
early mobilization must be implemented to give such fragile patients the best oppor-
tunity for a good outcome.
It is known that elderly patients have a higher morbidity and mortality following
trauma than younger patients, which may lead to different recommendations regard-
ing continuing care and withdrawal of care by clinicians. Elderly patients may not have
the reserve to survive a long hospitalization following trauma, nor may they be able to
participate in intensive rehabilitation following neurologic or orthopedic injuries. These
patients may be intubated, sedated, confused, or delirious following their injuries, and
therefore may be unable to participate in conversations regarding their goals of care.
The discussion a clinician has with the patients family must therefore take into consid-
eration the increased length of stay, increased complications, and long recovery time
associated with an elderly patient following trauma.
61
Because the majority of these
patients will survive their injuries, a frank discussion of rehabilitation expectations,
disposition, and other outcomes besides mortality is key to patient and family under-
standing of the severity of injury.
62
THE TRAUMA TEAM FOR GERIATRIC PATIENTS
The unique difficulties of caring for the patient with trauma have led to the develop-
ment of trauma teams for geriatric patients at many institutions. While still awaiting
good data, the concept is to treat this population as a distinct specialty. In the past
such patients may have end up with the orthopedic, medicine, or trauma service.
Bonne & Schuerer 146
Although each specialty does its part well, often it may not as accurately address the
other medical issues. For instance, the medical practitioner will likely address the
cardiac problems, but may not as aggressively treat a few rib fractures. In such a situ-
ation the patient would benefit from a traumatologist as well.
To improve on the old system, a trauma team for geriatric patients should be staffed
with interested individuals from each of the disciplines, along with mid-level providers
to bring the consistency needed in treating these individuals. Protocols to address
well-proven strategies should be written, created, and followed. Early involvement
with anesthesia and prevetted anesthesia workups should take place, limiting delays
to the operating room for unnecessarily thorough medical clearance. These teams
should be led by geriatric traumatologists, who have experience in leading a multidis-
ciplinary team, and should include orthopedic surgeons and neurosurgeons, geriatri-
cians, dedicated therapists, social workers, dieticians, and others, all experienced in
treating and appropriately dispositioning such patients. While an inpatient, home
health could also perform evaluation of fall hazards to help prevent future injuries.
In short, the team approach used in the ICU should be used to improve patient
outcomes.
OUTCOMES IN GERIATRIC TRAUMA
As geriatric patients are studied, improvement in care of their trauma can be expected.
Although geriatric patients have a higher mortality owing to multiple factors already
discussed, the patients who do survive will eventually achieve some level of functional
outcome following trauma. Their comorbidities, while playing a role in their survival
and recovery, do not appear to affect their overall outcome.
63
For example, although
geriatric brain-injured patients have a longer recovery time and require more inpatient
care, they will generally improve in functional status and eventually reach the same
rehabilitation goals as their younger counterparts.
64
These results, however, are age
dependent, with geriatric patients older than 80 years having poorer functional
outcomes than those aged 65 to 80.
65
There are also promising results regarding
long-term survival following trauma, with long-term survival of several years after
trauma for geriatric patients who are discharged from hospital.
66
Such lead data
should inspire optimism in the clinician caring for the geriatric patient with trauma,
who can be confident that in most patients, survival and functional outcomes will be
good should the patient survive hospitalization. The effort spent, therefore, in caring
for and rehabilitating the older patient with trauma is not in vain, and provides good
quality of life and longer quality time for these patients.
Future research that will likely yield improvement for the elderly patient must focus
on early recognition of instability and on falls, which make up approximately 75% of
trauma in elderly patients. Efforts in early recognition have included triaging the elderly
to trauma centers, but proof that this prospectively improves survival is not yet avail-
able. Also, research that helps EMS recognition of relative hypotension, and thus
triages the patient appropriately, may improve survival. However, research that works
toward reducing the incidence of falls, especially recurrent falls, and determining risk
of falls of this population, will begin to address the single largest reason for injury in this
population.
In conclusion, elderly patients with trauma must be triaged, evaluated, and treated
differently to their younger counterparts. We must learn, as we did with children, that
older adults have unique physiologic and structural differences that leave them at an
increased risk of mortality from even minor trauma. Early recognition of these differ-
ences can lead to a better mortality rate and a more productive recovery after trauma.
Trauma in the Older Adult 147
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