Evidence-Based Care of Geriatric Trauma Patients

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Key points

  • The doubling of the geriatric population over the next 20 years will challenge the existing health care system.

  • Care of geriatric trauma patients will be of paramount importance to the health care discussion in America.

  • Geriatric trauma patients warrant special consideration because of altered physiology and decreased ability to tolerate the stresses imposed by trauma.

  • In spite of increased risk for worsened outcomes, geriatric trauma patients are less likely to be triaged to a designated trauma

Introduction: why geriatric trauma?

The United States is experiencing an exponential increase in its older adults unlike any that has ever occurred. With the aging of the baby boomer generation, the geriatric, commonly defined as those aged 65 and older, are the most rapidly growing segment of the US population.1 According to the Census Bureau this age group will nearly double in 2 decades, from 39.6 million in 2009 to 72.1 million in the year 2030.2, 3 Although trauma is the number one cause of death in those aged 44 years and

Physiology in geriatric trauma patients

The evolution of clinical care in geriatric trauma originated with a dramatic shift in thought process about the physiology of the geriatric. In 1984 Harborview Medical Center published a review of 100 trauma patients older than 70 years that reported an 85% survival rate but noted that 88% did not return to their previous level of independence. The article stated that, “…what impact preexisting disease has on survival following injury has not been adequately studied.”13 In a 1986 study, Horst

Preexisting conditions: comorbidities and chronic illness

Geriatric trauma patients may have many or all of the comorbidities that portend poorer outcomes in trauma:

  • Decreased vision and hearing

  • Slower reflexes

  • Poorer balance

  • Impaired motor and/or cognitive function

  • Decreased muscle mass and/or strength

  • Decreased bone density

  • Decreased joint flexibility

Additionally, 80% of geriatric trauma patients have at least 1 or more chronic diseases, such as hypertension, arthritis, heart disease, pulmonary disease, cancer, diabetes, or history of stroke.4 These

Central nervous system changes in the geriatric

The central nervous system in geriatric patients may be impaired because of cortical atrophy and plaque buildup in the cerebrovascular vessels. Clinical implications include decrements in all 5 sensations in addition to cognitive decline. Decreased cerebellar function and associated worsening of balance add to risk of falls.4 The combination of polypharmacy and acute injury may exacerbate agitation and delirium in geriatric trauma patients.16

Cardiovascular changes with aging

Geriatric patients have altered cardiovascular physiology, with cardiac function declining by 50% between 20 and 80 years of age.17 Patients in this age group will experience 30% of all myocardial infarctions and 60% of all associated deaths.18 The cardiac muscle and conductive pathways are replaced with fat and fibrous tissue, predisposing the heart to arrhythmias. This stiffer heart is also more likely to have diastolic dysfunction, or inadequate ability to relax, decreasing its effectiveness

Pulmonary and thoracic changes with aging

Geriatric patients are particularly vulnerable to pulmonary disease. Lower respiratory tract pathology is the third leading cause of death and significant disability in persons aged 65 and older.22 Anatomic changes of the geriatric include kyphosis, or narrowing of the intervertebral disc spaces, leading to narrowing of the intercostal spaces and altering the angle and insertion of intercostal muscles.23 Decreasing skeletal muscle mass and strength, loss of type II fast twitch muscle fibers,

Renal changes in the geriatric

Anatomic changes of the renal parenchyma include glomerulosclerosis, a gradual replacement of glomerular tissue with fibrous tissue, causing a loss of 30% to 50% of cortical glomeruli by 70 years of age.26 Additionally, intimal thickening of both the afferent and efferent renal arterioles occurs secondary to atherosclerosis and atrophy of smooth muscle media.27 Perhaps the most profound renal anatomic change with aging is the decreased ability to preserve the renovascular reflex, termed

Gastrointestinal system in the geriatric

Nutritional status of geriatric trauma patients is integral in predicting surgical risk. Malnutrition has been associated with increased postoperative morbidity, perioperative mortality, hospital length of stay (LOS), and decreased quality of life.30, 31, 32 Unfortunately, malnutrition is reportedly as high as 40% to 50% in hospital and nursing home settings.33 Fortunately, these are modifiable risk factors when nutritional interventions are applied smartly. Recommended interventions include a

Mechanisms of injury in the geriatric

Ground-level falls (GLFs), accounted for 2.1 million ED visits among those aged 65 years and older in 2008.11 This staggering figure is almost 10 times more common than motor vehicle crashes, the second leading cause of trauma in older adults.35 Nearly 1 in 3 geriatric persons will have a GLF each year, and emergency medical services will respond to between 5 and 10 times more calls than for motor vehicle crashes.36 Six percent of GLF patients will sustain a fracture, and 10% to 30% of these

Traumatic Brain Injury

Traumatic brain injury (TBI) is an epidemic problem in the geriatric trauma population, prompting more than 80,000 ED visits each year.17, 38 Geriatric TBI patients have greater morbidity and mortality compared with younger TBI patients.39 The aging baby boomer generation has increased the prevalence of atrial fibrillation and other conditions requiring anticoagulation. In 2004, there were 31 million outpatient prescriptions for warfarin in the United States, a 45% increase from the prior

Orthopedic injuries

Orthopedic fractures confer significant risk to the geriatric population. In a 2015 study of more than 25,000 US geriatric trauma patients in 127 hospitals, Maxwell and colleagues65 found that 56% had a major operative procedure. Thirty-six percent of patients had femoral neck fractures, the most common injury. Eighteen percent of the patients fractured either the neck or trunk. Twenty-one percent had either lower extremity fractures or upper extremity fractures. Fractures of the hip, spine,

Abdominal injuries

Although blunt trauma management has become increasingly nonoperative in hemodynamically stable patients, geriatric trauma patients warrant careful consideration. For example, in case of a splenic injury, older patients are more likely to fail nonoperative management.71 Additionally, geriatric trauma patients compensate differently during acute hemorrhage (see physiology section earlier). University of Southern California studied penetrating trauma in the geriatric trauma population and found

Critical care triage and intensive care unit delirium management

Because preventable complications in the geriatric dramatically worsen outcomes, improving triage by placing appropriate geriatric patients in the intensive care unit (ICU) may be the first step in morbidity and mortality improvement. A study of more than 22,500 trauma patients (including more than 7100 geriatric trauma patients) revealed that geriatric patients had significantly lower ICU admission rates compared with younger patients with similar injury severity.73 Studies at both Baltimore

Creation of a dedicated geriatric trauma unit

Mangram and colleagues82, 83 published 1 year of data following creation of a geriatric trauma unit for patients aged 60 years and older. The G-60 unit, as it was named, showed improvement in multiple morbidities, such as pneumonia, respiratory failure, and urinary tract infection. The G-60 also demonstrated mortality improvement.82, 83 Decreases were seen in ED LOS, average ED to operative management time, surgical critical care unit LOS, and average hospital LOS.82, 83 In spite of dramatic

Triage

Although geriatric trauma patients are at greater risk for adverse outcomes when compared with younger counterparts, they are actually less likely to receive care at trauma centers.75, 85, 86 A retrospective 10-year study in Maryland of more than 26,000 patients showed that undertriage was significantly more likely in patients older than 65 years.37 This finding is in spite of evidence that when surgical intensivists lead critical care in trauma centers, in-hospital mortality is greatly reduced.

Ethical decisions in geriatric trauma

Complex ethical dilemmas are often the rule rather than the exception in caring for geriatric trauma patients. Futility provides some of these dilemmas, such as in the case of an 89-year-old, frail woman after a GLF, devastating subdural hematoma, and 72-hour history of GCS less than 8 whose family members want everything done. Other dilemmas are created when treatments for acute trauma exacerbate preexisting conditions and create myriad of unwanted side effects, such as in the case of a

Autonomy

Autonomy is the ability of a person to make a decision freely. Accomplishing this requires informing, rather than coercing, patients. Patients must have the capacity to reasonably comprehend their options and also rationally use the information. Such capacity may be compromised in the geriatric population.

Dementia is the most common cognitive disorder of the geriatric and can affect patients’ ability to make autonomous decisions. Evaluating capacity is not always straightforward. Determining

Communication when caring for geriatric trauma patients

Communication is paramount in uncovering patients’ definition of a meaningful outcome. Communication inadequacies in health care commonly generate ethical consults in clinical care.100 Surgeons are susceptible to having inadequate or poor end-of-life conversations because of time constraints, inadequate communication training, the complexity of clinical prognostication, and a tendency to overestimate prognosis.92 Cooper defines 9 elements for structured communication with patients in an

Geriatrics Service Consultation

Geriatric consultation services provide a specialized approach to care of geriatric patients. The consultants may help navigate the unique problems posed to geriatric patients and provide a more complete approach to their care. The addition of a geriatric consult service may lead to more effective in-hospital care and better outcomes.91, 97

Lenartowicz and colleagues91 studied a compulsory geriatric consult service for trauma patients older than 60 years and found that, consistent with prior

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      In addition to comorbidities and chronic illness leading to hospitalization in the ICU, elderly patients are also more susceptible to complications from trauma (including low energy mechanisms), requiring critical care. Elderly patients may have underlying decreased vision and hearing, slower reflexes, and impaired cognitive function that increase the risk of delirium in the ICU.35 A higher level of vigilance to compensate for these decreased senses is critical in preventing and treating delirium in older patients.

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    The authors have no commercial relationships or financial interests to disclose.

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