Geriatric Trauma

Alan Sori, MD

St. Joseph’s Regional Medical Center

Paterson, NJ

Patients

65 yo female falls on a bus – severe brain injury In ICU – found to have a prolonged QT interval Echo – severe cardiomyopathy Needs an ICD

75 yo male falls- two broken ribs. Multiple medical co-morbidities Develops pneumonia, dies two weeks after injury

What is Geriatric Trauma?

No. 5 cause of death for age > 65. Mortality in most series averages 15 to 30%.

4 to 5 X mortality of younger patients. Mortality start to increase at age 45 for males.

ACS - MTOS

Geriatric Trauma - Questions

What is old? Does age matter and what age?

– Physiology of aging.

Triage of elderly trauma victims. Injury patterns and physiologic responses.

What is the optimal resuscitation of the older trauma patient?

Outcomes in the elderly trauma patient?

Geriatric Bias

Documented bias in medical care: Rehabilitation placement. Breast cancer management. Thrombolytics. Trauma triage.

“Therapeutic Nihilism”

Epidemiology

Age > 65: 12.5% population (30 million) 2020 - 52 Million (20% population) At age 85 life expectancy is 5 to 7 years.

– Better health and increased activities.

65+ are hospitalized for trauma at 2X the rate of younger patients

– 25% of all trauma deaths

ICU beds – 15% of all hospital beds and 30% of hospital costs

Epidemiology

>65 use 33% of all health care dollars and 25% of all trauma care money.

Medicare - DRG based- grossly underpays hospital costs for trauma, esp. in the elderly Avg. reimbursement 40 to 65% of total hospital

costs.– Increased age and ISS - worse reimbursement.

Geriatric Recidivists

Washington state Medicare population. > 65 injured - 2X more likely to be admitted with a

new injury than uninjured person in next 24 months.

ISS 16 to 24 - new injury risk 4x normal population.

Inc risk in patients with COPD, liver disease, age.

J. Trauma 1996: 41(6) p. 952

Physiology of Aging

Aging is the progressive loss of individual organ function. Gradual and continuous. Not directly related to age. Significant age related mortality differences are

apparent by age 40 in males. Co-morbidities: 15% at age 35, 70% at 75.

J. Trauma 1990: 30(12) p. 1476

Physiology of Aging

The extent of physiologic alterations and he onset of those alterations are highly variable.

Most elderly well compensated for changes

in aging but have very limited physiologic reserve that becomes evident during times of stress or illness.

Cardiovascular

Most prominently affected. Myocardial degeneration:

– Inelastic heart - decreased cardiac output.– Diastolic dysfunction.

Altered conduction system– Maximal HR decreases

Beta adrenergic receptor function decrease. Coronary artery disease. Hypertension - Meds

Pulmonary System

Decreased functional reserve. Thoracic cage - more brittle, stiff.

Decreased compliance Increased work of breathing. Dec. alveolar ventilation Inc. V/Q mismatch.

Renal System

40 to 50% nephron loss by age 65. RBF decreases to 50% Dec. GFR, CrClr. Serum creatinine - poor indicator of renal function. Dec ADH sens, dec. thirst - chronic dehydration.

Musculoskeletal

Dec. muscle mass and strength. Progressive deterioration of cartilage and

ligaments starts at age 30.

Age related bone loss. Dec. reaction times. Widened, unsteady gate.

Misc.

Glucose intolerance. Dec. LBM, BMR, need for calories.

Need for other nutrients unchanged. Vit A, Vit C, Zinc deficiencies. Immune senescence

T cell and B cell function.

Misc.

Thyroid hormone dec, tissue response decreases. Increased intra-cranial space - atrophy.

– Increased movement of brain during injury.– Increased risk of subdural hematomas.

Decreased cognitive ability, memory and judgment.

– Senescence of senses

Etiology of Trauma

Age 65 to 75 - MVCs - most common Elderly have the highest rate of accidents / miles driven

Age 75+ - falls number one. MV vs Pedestrians Suicide - biphasic incidence

Increasing incidence in males >65. Increased incidence of penetrating trauma, elder

abuse.

Falls

Most common mechanism overall. 65+: 30 % sustain a fall each year requiring

medical treatment 85+: 50 % fall each year 40% of all nursing home admissions related to

falls. Most falls are single level or low bilevel.

J. Am. Geriatric Soc. 1986: 34 p 119

Falls

Risk Factors Dementia, visual impairments Lower extremity and foot diseases Gait and balance problems. Meds, med. problems, postural hypotension, neuro-

muscular disease. Usual falls - ladders, roofs, stairs

Injury patterns are more severe for all levels of falls.

Falls

Population based study: 336 people – average age 78

– 108 (32%) fell in past year– 48% - once, 29% - twice, 25% - three + – 77% falls at home.

Risk factors:– sedative use - Palmomental reflex– Cognitive impairment - Foot problems– LE disability - Balance / gait

NEJM 1988: 319(26) p.1701

Falls

Falls: 159 / 333 adms- age 65+ (48%) 83 falls age < 65 (7% total) ISS > 15: 50(32%) elderly, 12 (15%) young.

– Falls are 2/3 of all elderly w ISS > 15– Same level w ISS >15 - old (30%), young (4%).

Fall deaths: 11 (7%), younger - 4%– 11/20 deaths overall due to falls (55%)

J. Trauma 2001: 50(1) p. 116

MVCs

Age 75+ - second highest crash rate Highest accident rate per miles driven.

– Highest fatal accident rate.

Changes in perception, judgment, decision making ability and reaction times.

MV vs pedestrians: Most severe of all elderly injuries.

– Highest fatalities

Majority occur in cross walks.

MVA- Driver Characteristics

I year period - Level 1 trauma center 84 drivers age >60

– 67/ 84 (80%) - at fault according to police. Running stop signs, red lights, failure to yield - most common

– 35 ( 42%) - single car crash.– Daytime- 80%– Good weather - 95%– ETOH - 5%– Low speed / intersections common

Am.Surgeon 1995: 61(5) p. 935

Elderly Abuse

Estimated 1 million cases / year. Physical violence

– May not be as apparent as child abuse.

Emotional abuse– Threats of abandonment or institutionalization.

Material exploitation. Neglect (may be unintentional)

– Dehydration / malnutrition, mental status changes.

Elderly Abuse

2020 elderly - 3.7 % reported abuse 2.2% physical, 1.1 % emotional

– 2/3 spouse, 1/3 adult child

Risk Factors Physical frailty and cognitive impairment. Living with abuser

– Substance abusers, mental disease.

Adult kids who are financially dependent.

Mortality -Factors

Consistent TS (< 7) SBP < 90 Shock RR < 10 Head injury Base deficit

Less Consistent ISS Male sex Ped vs MV Non trauma center

admission PEC Pulmonary complications

J. Trauma 1998: 45(5) p 873, J. Trauma 1990: 30(12) p 1476 J. Trauma 1999: 46(4) p 702 CCM 1986: 14(8) p 681 Arch. Surg 1994: 129(4) p 448, J. Trauma 2002: 52(1) p 79

Pre Existing Conditions

Elderly patients are more likely to have underlying medical problems that affect survival. PECs may affect survival independent of age or

injury severity. May be underlying cause of an injury. Need to be treated aggressively. Coumadin does not adversely effect mort.

PECs

Hepatic* Renal*

– ARF as a complication is the most lethal.

Cancer* CHF COPD Diabetes Dementia

J. Trauma 1992: 32(2) p 236 1998: 45(4) p 805 2002: 52(2) p 242

Triage

Philips - Florida- statewide Overtriage 7.5%, undertriage - 71%

– Triage tool identified only 103 / 355 major trauma patients.

– < 65 - 11% / 33%.– Triage guidelines were most sensitive to GSW and

least sensitive to falls.

J. Trauma 1996: 40(2) p 278

Triage Compliance studies:

MD - statewide study– Injury factors- high compliance– Physiology, mechanism - poor.– 15- 54 - 2X more likely to be triaged to a TC.– Compliance decreases with increasing age.

Portland - city wide study– Undertriage- 21% (< 65- 15%, >65- 56%)– Non TC deaths- elderly with ISS 1- 9

J. Trauma 1995: 39(5) p 922; 1999: 46(1) p 168

Brain Injury and the Elderly

Age related mortality increases sharply at age 60+. Prognosis depend on initial severity and age. Subdural, contusions and SAH more likely.

– Epidural, skull fractures - uncommon.– 2 or 3 injuries common on CT scan

High incidence of associated injuries- chest most common, cspine, upper extremities.

Brain Injury and the Elderly

GCS < 7 - high mortality, survivors are all severely disabled or PVS.

Death rate is biphasic. Early from head injury, late from MSOF

Arch.Surg. 1993: 128(7) p 787J. Trauma 1996: 41(6) p 957

Rib Fractures

Very common injury in elderly- due to brittle rib cage

Most commonly due to MV vs peds, MVCs. Compared to younger patients

– ISS same– Increased mortality, ICU days, LOS, Vent days.– Mortality increased at 5 ribs fxs. (35% vs 10%)– Mortality decreased with epidural use.

J. Trauma 2000: 48(6) p 1040

“In younger patients, nature oftensaves the day after minor surgical errors. In the aged, every erroris a major danger in life.”

Aging and Surgery

1921: Oschner Herniorraphy was not indicated in patients greater

than age 50. Currently - age 65+ in general surgery:

1/3 of all operative cases. 50% of all surgical emergencies. 75% of all operative deaths.

Surgical Risks

148 patients for elective surgery - all cleared by internists- had preop swan.

– 20 had normal physiology - no mortality.

– 94 had mild to moderate dysfunction - 8.5% operative mortality.

– 34 had severe dysfunction 7 had lesser ops- survived. 8 had scheduled surgery- all died.

Preop evaluation did not correlate with physiologic parameters

JAMA 1980: 243(13) p 1350

Initial Evaluation

History PMH Premorbid functioning Medications

– Drug - drug interactions, cause of injury

PMD

Initial Evaluation

Physical Exam: Elderly patients have less dramatic physiologic

response to injury.

Don't be fooled by a patient that appears to be stable and minimally injured.

– 80 yo female in MVA, no bleeding, poor perfusion status but BP, HR ok. Swan- CI of < 1L/min

Resuscitation

Very little literature on trauma resuscitation in elderly patients. Contradictory Not very current Need for better studies

Avoid “therapeutic nihilism”

Preop Monitoring

70 patients with hip fractures randomized to preop monitoring and optimization

with SG catheter– Nonmonitored- 67 (40 to 89)– Monitored - 78 ( 40 to 95)– No difference in premorbid conditions.

Mortality was 2.9% vs 29%– Cause of deaths not listed– Operation was at 3.5 days vs 7 days

J. Trauma 1985: 25(4) p. 309

Resuscitation

1985- 60 elderly trauma patients at King’s County - 44% mortality, 85% in high risk.

– Ped vs MVA, SBP < 130, acidosis (pH < 7.3), head injury, multiple fractures.

1986 - invasive monitoring - ED to ICU was 5.5 hours - 93% mortality

1987 - Monitoring early before diagnostic workup - ED to ICU- 47% mortality

J. Trauma 1990: 30(2) p. 129

Resuscitation

CI < 3.5 L / min or MVO2sat < 60 %– Fluids, blood, inotropes, afterload reducing agents.– Hct- 35%– CI > 4L / min.

Increased mortality ISS not calculated. No group comparisons available. Hayes, MA: NEJM: 1994 330(24) p 1717

J. Trauma 1990: 30(2) p. 129

Therapeutics

Imaging. Early and often.

Early tracheostomy? Pain management

Epidurals ? Vena cava filters ?

Pain Management

Myth: Elderly patients experience less pain Realities:

Acute and chronic pain is common in the elderly. Pain in the elderly is often under diagnosed and

under treated. Pain is often responsible for agitation, delirium

and depression.

Pain Management

Narcotics - elderly are more sensitive to pain relieving aspects.

– MSO4 - still gold standard.– Altered pharmacodynamics - inc. half life.– Need bowel regimen with narcotics.– Avoid Darvon (propoxyphene), Talwin (pentazocine),

Demerol (meperidine) and long acting drugs.

NSAIDs - side effects more severe and common in elderly.

Outcomes

Oreskovich: 100 patients over 60 over a 2 year period at a Level 1 trauma center.

– age 74 Falls 64%– Independent- 94% MVC 8 %– Home assistance- 6% MVC vs Ped 9 %– ISS - 19 Burns 13%– Mortality- 15% Assaults - 4%

Discharge: – Independent 8 %, Home assist. 20%, NH 72%

J.Trauma 1984: 24(7) p. 565

Outcomes

vanAalst - 98 pts age 65+ with ISS >16 48 alive 1 to 6 yrs later (49%) Assessed independence and functionality.

– Ind / Maintained - 8– Ind / declined - 24– Moderately dependent - 10– Custodial - 6

J. Trauma 1991: 31(8) p. 1096

Outcomes

DeMaria - 63 patients, 97 % independent Discharge:

– 33% independent, 37 home but dependent– 19 (30%) to NH– 12/19 NH patients went to home after 3-4 months.– Age 80 + survivors , n = 12.

4 required permanent NH 8 home independent or with assistance.

J. Trauma 1987: 27(11) p. 1200

Outcomes

Why the big difference between Oreskovich and vanAalst / DeMaria? Falls- 66% falls vs <40%

– Falls are a marker of severe underlying cardiac, pulmonary and neurologic diseases.

– Death may often be preceded by a cluster of falls.– No 1 cause of NH admissions (40%)

Outcomes

Battista - 23% mortality / 93 independent– 47% of survivors dead at 2.5 years– 83% of those alive at home alone or with family.– 10% retirement home, 4% at NH.

Shapiro - 22% mortality– 53% home– 14% home assistance– 20% rehab– 8% NH

J. Trauma 1998: 44(4) p.618, Am. Surg. 1994: 60(9) p.696

Summary / Recommendations

Advanced age is associated with increased mortality at all injury levels. Elderly have higher ISS for comparable

mechanism of injury. There may be fewer physiologic abnormalities

than expected for injuries. PEC are associated with worse outcomes for

each level of injury.

Summary / Recommendations

Elderly trauma victims should be triaged to trauma centers There should be a lower threshold for activation of

the trauma team for elderly trauma patients. Blood gas analysis should be obtained for any

patient with a significant injury or mechanism.

Summary / Recommendations

Aggressive hemodynamic monitoring and resuscitation may be beneficial in the elderly trauma patient. Shock, BD < -6 AIS > 3, high risk mechanism of injury Uncertain cardiac or volume status

Optimize cardiac output and O2 delivery.

Recommendations

Advanced age alone is NOT a predictor of poor outcome and should NOT be used as a factor to deny or limit care. Up to 85% of survivors may return to independent

living. Limiting care may be considered when:

GCS < 8 TS < 7 RR < 10