Geriatric Trauma: Senescence and the Inherent Risks that Predispose the Elderly Patient to Injury
January 1, 2000
Geriatric Trauma: Senescence and the Inherent Risks that Predispose the Elderly Patient to Injury
Author: Brian R. Plaisier, MD, FACS, Attending Surgeon, Trauma Service, Bronson Methodist Hospital, Kalamazoo, MI.
Peer Reviewer: Mark A. Malangoni, MD, Chair, Department of Surgery, MetroHealth Medical Center; Professor of Surgery, Case Western Reserve University, Cleveland, OH.
The population of the United States is "older" than at any time in history and is getting older. According to the U.S. Census Bureau, in 1997 the elderly (65 years and older) numbered 34,075,611 and composed 12.7% of the total U.S. population. By 2050 (using moderate estimates), the group number will be more than 80 million and will make up 20.4% of the total population.1 This dramatic increase in the number of elderly persons will put a much larger population at risk for injury. There is no doubt that the elder trauma patient presents emergency medicine physicians, trauma surgeons, and intensivists with a complex challenge. It is imperative that all understand how to treat the geriatric trauma patient.
The objectives of this review on geriatric trauma are to: 1) define the data regarding the increasing elderly population in the United States; 2) understand the mechanisms of injury in the elderly and compare these to younger patients; 3) appreciate the effects of the aging process and the unique risks imposed upon the elderly that predispose to injury; 4) recognize the effects of aging and comorbid factors in these patients; 5) know the priorities of the prehospital evaluation; 6) outline the primary survey; 7) understand the treatment principles related to certain specific injuries; 8) understand the principles related to outcomes; and 9) recognize the unique socioeconomic factors related to these patients after injury.
— Editor’s Note
The Aging Population
Data from the United States government show that the life expectancy of the U.S. population has reached 76.5 years—the highest at any time in U.S. history.1 In addition, the age-adjusted death rate reached a record low of 479.1 per 100,000 U.S. standard population.1 In the elderly (65 years and older), the decrease in death rates were reflected primarily in decreases in death from heart disease, cancer, and stroke. There has also been some impact due to decreased death from trauma for age groups 65-74 years and 75-84 years. (See Table 1.) However, for the age group 85 years and older, death rates due to trauma have not changed.
| Table 1. Death Rate for Geriatric Trauma Patients | |||
| Year | Age Group 65-74 years | 75-84 years | 35 years and over |
| 1997 | 46.4 * | 103.4 | 276.5 |
| 1996 | 47.0 | 102.0 | 276.2 |
| 1979 | 58.8 | 117.8 | 276.0 |
| * Rates based on annual basis per 100,000 population. | |||
| Modified from Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Reports from the Centers for Disease Control and Prevention. | |||
The dramatic increase in the elderly population will be due to the aging of the "baby-boom" generation (75 million babies born between 1946 and 1964).2 While projection assumptions vary, using the Census Bureau’s "Middle Series" projections (moderate fertility, mortality, and immigration assumptions) the elderly will make up 12.8% by 2000 and 20.4% by 2050.2
The oldest old (85 years and older) is a small but rapidly growing group. In 1900, 122,000 people were 85 years and older. From 1960 to 1994, this segment increased to 3.5 million (274%), compared with 100% for those age 65 and older, and 45% for the total population.2 Using middle series projections, the oldest old population in 1994 will double to 7 million in 2020 and double again to 14 million in 2040.
Trauma ranks as the fifth leading cause of death when considering all races, both sexes, and all ages.1 For those years 65 and older, trauma ranks seventh, although the rate per 100,000 is 92, compared with 35.7 for all age groups.1 Unlike younger age groups, there is relatively little variation in death rates between black and white races. These data indicate that an unprecedented number of elderly persons will be at risk for injury in the future. Due to longer life expectancy, it is likely that these patients will have more comorbid conditions as well, making it imperative that physicians be well versed in the care of the elderly trauma patient.
Risks in the Geriatric Patient
With senescence, protective senses are decreased in acuity, with a resultant increase in the risks of daily life. Compared with younger patients, the elderly are exposed to unique risks, including falling and hearing loss, that may predispose to injury. (See Table 2.)
| Table 2. Risk Factors for Injury in the Elderly | |||
| 1. Decreased visual acuity | |||
| 2. Hearing loss | |||
| 3. Poor coordination | |||
| 4. Gait disturbances | |||
| 5. Cognitive impairment | |||
| 6. Joint disease | |||
| 7. Syncope | |||
An important study to help identify risks in the elderly for falling was performed, prospectively evaluating 336 subjects 75 years old and older who were living in the community.3 One hundred eight subjects (32%) fell at least once in the one-year follow-up period. Risk factors for falls included sedative use, cognitive impairment, lower extremity disability, and foot problems. Serious injuries resulted in 24% of subjects, and 26% reported that they had curtailed activities such as shopping for fear of falling. The chance of falling increased linearly with the number of risk factors.
Another group performed a cross-sectional study to examine the relationship between poor visual acuity, eye disease, and falls.4 A detailed questionnaire and a visual examination were administered to 3299 individuals aged 49 years or older (2365 were 60 years old or older). Of these, 16.1% reported one fall within the prior 12 months. Of patients older than 65 years, 29.6% had reported one or more falls in the past 12 months. Increased age, female gender, psychotropic drug use, history of stroke, arthritis, and poor self-reported health status were all statistically associated with two or more falls. This study found a significant association between decreased visual acuity, reduced contrast sensitivity, and decreased visual fields.
Hearing loss is common in the elderly population.5 Decreased hearing, particularly when coupled with other impairments, may predispose to injury. Hearing loss, however, is often not recognized or is under-reported. In one study, while self-reported hearing impairment was 8.1% in men and 7.4% in women, the actual prevalence increased to 19.0% for both genders when speech audiometry was used.6 Impaired hearing was found to be associated with increased age, diabetes mellitus, low education level, poor self-reported health, and cognitive impairment. The authors concluded that these populations might be better served by increased attention to identifying hearing impairment.
The elderly driver also deserves special consideration. The number of elderly drivers has risen steadily over the years and will continue to rise.7 The skills for safe driving deteriorate with age. Cognitive impairment, psychomotor slowing, decreased strength, and decreased visual acuity all contribute to increased crash rates in the elderly. While the exposure to risk is lower in the elderly as a result of fewer miles driven per person, after adjusting for miles driven, the risk for crashes increases at approximately 70 years and does so dramatically after age 80.7 In a detailed study of older drivers, risk factors for crashes included a 40% reduction in useful visual field, a history of falling in the previous two years, and not taking beta-blocking drugs.8
Epidemiology of Geriatric Trauma
The incidence of geriatric trauma is relatively low, between 8% and 12.5% of the general trauma population.9-12 In younger age groups, males are greatly predominant.9,13 In the injured elderly, however, the male to female ratio is almost equivalent.
Several studies have examined mechanism of injury in the geriatric patient. In several series examining the total geriatric trauma population, falls were the most common cause of injury.13-18 The elderly often have numerous factors which predispose to falling, including dementia, poor vision, impaired sensation, gait disturbances, joint disease, medications, and syncope. The elderly are more likely to die as a result of a fall, usually due to comorbid factors or complications arising during hospitalization.19 For example, falls in the young usually occur from a significant height compared to the elderly, who usually fall from a standing height or down a few steps.20 The incidence of falls is far greater in the elderly compared to the young, with up to one-third of elderly falling within a one-year period.3,15
Even the low fall (< 20 feet) has been found to cause significant injuries. In one study evaluating 176 patients who sustained low falls, 34% had multisystem injuries, 46% sustained head injuries, and 28% incurred spinal column injuries.21 Although only 27% of patients were older than 60 years, this group accounted for one-half of the deaths.
It is not enough simply to provide care for the patient who has fallen; it is necessary to leave no stone unturned in investigating the cause of the fall. While an evaluation for the cause of a fall is beyond the scope of this article, attention should be directed to intrinsic (physiologic) causes such as syncope, medication effects, or poor vision and extrinsic (environmental) causes such as an unsafe home environment.
Motor Vehicle Crashes. Motor vehicle crashes (MVCs) are the second most common mechanism of injury.13,14,16-18,22,23 The incidence in several recent series ranges from 20% to 59%.13,14,16,22,23 The elderly are at risk for crashes due to visual disturbances, poor hearing, cognitive problems, decreased strength, poor coordination, and syncope. Elderly drivers are more likely to be involved in crashes during the day, in good weather, at intersections, and involving two vehicles and are more likely to be found culpable.7,24
The elderly are also more commonly involved in pedestrian/motor vehicle crashes when compared with younger counterparts, with this mechanism causing 9-25% of trauma in this age group.12,13,22,23,25 Schiller and colleagues found that pedestrian/motor vehicle crashes were the most lethal mechanism of injury, with a 53% case fatality rate.9 Holubowycz found that fatality rates increased with advancing age, with males 85 years old and older having the highest fatality rates.26
In comparison with younger patients involved in pedestrian/motor vehicle crashes, the elderly had a higher Injury Severity Scale (ISS) score; were more frequently admitted to the intensive care unit (ICU); had longer ICU and total hospital stays; and a significantly higher mortality rate.27 Sklar and associates found that elderly patients were more than twice as likely to die despite a lower overall injury rate and similar ISS when compared with other age groups.28 Changes associated with aging are an important contributor to these accidents, with one-third of the fatalities involving elderly pedestrians directly attributable to co-existing confusional states or impaired auditory or visual acuity.25
The incidence of penetrating trauma is generally low in this demographic group.15,18,29 Osler found that 6% of admissions for the elderly were due to penetrating wounds compared with 25% in a younger cohort.15 Finelli found that stab wounds made up 2.6% of injuries in patients 65 years and older and gunshot wounds comprised 5.5%.18
Ethanol intoxication typically increases the risk for injury. In trauma patients, ethanol use is highest among young males.26 In elderly trauma patients, approximately 10-14% are intoxicated upon hospital admission.9,15,30 This compares to nearly one-half that for younger trauma victims.9,15 In a study of MVCs, Rehm found that the elderly were only one-third as likely to be intoxicated compared with a younger cohort.24 Although the elderly are less likely to be intoxicated, blood should be assayed for ethanol to help evaluate for both subsequent risk of injury and to help identify alcohol abuse. Illicit drug use in the elderly trauma patient is distinctly uncommon.30
Recidivism. While trauma recidivism is well established in younger trauma patients, only one study has examined recidivism in the elderly.31 Older injured patients were matched for gender and age to uninjured elders and followed for the next five years. The injured group had twice the relative risk for a subsequent trauma admission when compared with the uninjured cohort. The risk of a subsequent admission increased with age, injury severity, and comorbid conditions. This study emphasizes the importance of assessing for risk factors that may predispose to subsequent injury.
The Effects of Aging and Comorbidity
Advancing age is associated with a gradual decline in organ function and an increase in comorbid disease. The prevalence of comorbid conditions reported in trauma patients is between 8.8% and 19.3%.32 In injured patients older than 65 years, however, the incidence climbs to 30%.33 In those 75 years of age, 69% had one or more pre-existing conditions.34 Problems due solely to senescence and diseases not associated with age may be difficult to distinguish from one another, but it is important to consider the physiologic changes of aging and all comorbidities concomitant with injury in this age group.
Cardiac Function. Cardiac function decreases with age. The walls of the heart become less compliant and the amount of collagen in the myocardium increases.35 Cardiac index decreases 1% per year with age and systemic vascular resistance rises 1% per year.35 Maximum heart rate is also reduced with age. In addition, the heart is less able to respond to the stress of injury as there is an age-related decrease in the effectiveness of adrenergic stimulation.36 The prevalence of hypertension also increases as a function of age. In the United States, 59.2% of white males aged 65-74 are hypertensive and this increases dramatically to 82.9% in elderly black females.37 The end result of these age-related changes is a decreased ability to respond to the stress of injury or critical illness.
Respiratory Function. There are numerous changes in respiratory function associated with increasing age. The chest wall becomes less compliant, and the elasticity of the lung decreases.35 The loss of compliance results in a greater dependence on diaphragmatic breathing.35 Although the number of alveoli remain constant with aging, atrophy results in decreased total surface area.35 Atrophy of the pseudociliated epithelium results in decreased ability to clear the tracheobronchial tree of secretions.33 The resulting increased work of breathing and decreased ability to manage secretions mandates a careful assessment of respiratory function.
The geriatric patient with a lung or chest wall injury must be given meticulous attention. Care must be paid to analgesia since without proper pain control, the patient will not be able to do the coughing and deep breathing necessary to maintain pulmonary hygiene. Incentive spirometry, percussion and postural drainage, and early ambulation are all vitally important to maximize respiratory function.
Renal Mass. Renal mass is rapidly lost after the age of 50, and a corresponding fall in glomerular filtration rate occurs beyond the age of 60 due to the loss of nephrons.35 Measurement of creatinine clearance becomes more important in the geriatric patient, since serum creatinine may be lowered as a result of decreased muscle mass, giving a false sense of security with respect to renal function. Age-related vascular changes result in a decreased percentage of blood flow to the older kidney.35 The kidney is less able to buffer a large acid load, as may be seen in response to hemorrhagic shock. As a result, management of fluids, electrolytes, and acid-base balance assumes high priority in the elderly.
Immune System. The function of the immune system is also impaired with age. Both cell-mediated and humoral responses are diminished with advanced age.33 Anergy is commonly seen in old age.38 The explanation for this phenomenon is not clear and there has been no conclusive link between anergy and mortality.38 There is an increased incidence of infections and multiple organ failure syndrome, however.35
Endocrine Function. Endocrine function decreases with age. The production and turnover of thyroid hormone species is significantly reduced, although the steady state concentrations of thyroid hormone is not significantly altered.39 However, tissue responsiveness to thyroid hormone is lessened, resulting in striking similarities between clinical hypothyroidism and the changes commonly seen in the elderly as a result of senescence.39
Normal adrenal function is critical in order to respond to the stress of injury and critical illness. Basal, circadian, and stimulated cortisol secretion remains intact with aging.40 There is an age-related decrease in the catabolism of cortisol, although this is compensated with a decrease in the rate of catabolism. Glucose intolerance, seen as part of the stress response due to injury and critical illness, increases in the elderly.44,45
There is evidence for age-related decrease in testosterone contributing to increased frailty in men older than age 50.41 The decrease in testosterone level is doubled in men older than age 70. Signs and symptoms include lack of energy and decreased strength that may increase the risk for injury. Testosterone replacement has been shown to increase muscle strength and give a more positive outlook on life, but there is no evidence as of yet that testosterone replacement therapy will prevent or reverse frailty in older men.41
Body Composition. Body composition changes with increasing age. Body weight reaches a plateau between 40 and 60 years followed by a progressive decline leading to decreased muscle mass and increased adipose stores.42 The reason for this is not entirely clear but may be related to a decrease in growth hormone secretion.43
Protein-energy malnutrition is common in the hospitalized elderly.46,47 In one study of elderly patients admitted from their homes to a geriatric ward, 75% were below the 50th percentile for normal weight and 38% were below the 10th percentile.48 Although there were no statistically significant differences between the undernourished and well-nourished groups with respect to mortality and discharge disposition, episodes of sepsis were more common in undernourished patients.
Comorbidity. The question of whether comorbid conditions are responsible for increased mortality after trauma in the elderly is not clear. There is agreement that the incidence of comorbidity in this population is high. In a study of geriatric patients admitted with femur fractures, 16% presented with a single comorbid condition, 45% presented with two comorbid conditions, 28% with three conditions, and 11% presented with four.49 Another group found an average of two preexisting medical problems in injured patients 75 years and older.50
Cardiovascular disease was the most common morbidity noted, with a prevalence of 33-46%.14,22,50 Other common, important comorbidities included pulmonary diseases and cancer.22,50
The question of whether preexisting disease contributes to poor outcome has not yet been conclusively answered. Smith and associates did not find comorbid conditions to be associated with adverse outcome.14 After controlling for age, however, Sacco and colleagues found that hepatic, cardiovascular, respiratory, renal, and diabetes adversely affected survival.51 Milzman and MacKenzie and associates found that mortality and length of stay increased as the number of preexisting conditions rose.34,52
While not unequivocally shown, it would appear that comorbidity does negatively affect the injured elder. When older patients are prepared for elective surgery, every attempt is made to optimize comorbid conditions. Unlike the context of elective surgery, there is little or no opportunity to prepare an injured patient to undergo an operation.
History and Prehospital Evaluation
The proper evaluation of a patient after an injury starts with an accurate history. The events must be carefully assessed, as important clues about the patient may be learned before an interview is even conducted. For example, a motor vehicle crash which occurs during daylight, on dry roads, and without skid marks should raise suspicion of an episode of syncope, cerebrovascular accident, or a cardiac dysrhythmia. The prehospital providers should be carefully questioned, as the description of the automobiles and the scene of the crash must be carefully assessed in order to understand the forces involved and in turn anticipate injuries.
Eyeglasses and hearing aids must be noted, as significant deficits may masquerade as alterations in level of consciousness. Dentures should be sought and removed since they may be a source of airway obstruction, and intubation will be needlessly difficult if false teeth are allowed to remain in place.
Medications must be carefully listed, as many of the elderly are on multiple medications. In one series, one-half of patients were on diuretics, 60% were on cardiac agents, 38% on psychotropic drugs, and 17% on anticoagulants.49 Diuretics and ß-blockers may increase the amount of physiologic compromise seen after hemorrhage. Any anticoagulants such as warfarin, low molecular weight heparin (LMWH) preparations, aspirin, or non-steroidal anti-inflammatory drugs (NSAIDs) must be stopped or reversed in patients who are at risk for hemorrhage or are to undergo urgent surgery or invasive procedures.
If the patient is unable to provide a complete history, the patient’s family and personal physician must be interviewed early after injury. These individuals will be able to provide valuable data regarding medical history, previous level of function, medications, results of recent diagnostic testing, and end-of-life wishes.
The elderly are clearly more fragile than their younger counterparts and have an increased likelihood of serious injury following even relatively minor mechanisms of injury.53 It is for this reason that the American College of Surgeons recommends that patients older than 55 years be triaged to a trauma center.54
Primary Survey: Airway and Breathing
Evaluation of the injured patient should be guided by the principles established in the Advanced Trauma Life Support Course from The American College of Surgeons.54 In the patient with significant injuries, there is no higher priority than the establishment of a definitive airway. This is best accomplished with an endotracheal tube by the oral route. Every patient with significant injury must be assumed to have a cervical spine injury until proven otherwise. Therefore, it is critical that inline stabilization of the neck be maintained during intubation of the trachea. One member of the trauma team should be dispatched to deal solely with inline stabilization.
If endotracheal intubation is required, perform this procedure under controlled circumstances before signs of respiratory failure are evident. All attempts should be made to avoid an emergent intubation, since a hurried procedure will increase the potential for errors.
Pre-oxygenation is important because the elderly are not tolerant of hypoxia.33 While opiates and benzodiazepines may help provide a more favorable situation for intubation, care must be taken with these drugs as hypotension may result with surprisingly small doses in hypovolemic patients. The largest tube possible should be used to decrease airway resistance and allow diagnostic or therapeutic bronchoscopy if it is indicated later.
Oropharyngeal bleeding or facial instability from maxillofacial trauma may impose significant difficulties during intubation. Ideally, personnel experienced with cricothyrotomy should be present for a surgical airway if attempts at intubation are unsuccessful.
After airway control, oxygenation and ventilation have next priority. The only exception to this would be the patient with a tension pneumothorax without airway compromise, since any delay in decompression could be fatal. Rapid evacuation of air or blood in the pleural space must be accomplished as soon as possible. Needle catheter decompression should be followed by tube thoracostomy. Large bore (36 French or greater) chest tubes should be used in the trauma patient. Oxygenation should be monitored continuously by pulse oximetry. In patients with a history of chronic obstructive pulmonary disease (COPD), adequate oxygenation may be difficult and result in a concomitant respiratory depression.
Circulation/Resuscitation
The search for blood loss must be swiftly done. All hemorrhage sources must be quickly identified and controlled for any hope of an acceptable outcome. Blood may be lost only in a finite number of locations: 1) externally; 2) pleural spaces; 3) sites of long bone fractures; 4) peritoneal cavity; and 5) pelvis/retroperitoneum. Large bore venous access may be rapidly obtained in the upper extremities. In cases of profound shock or if peripheral veins are not available, large bore (8.5 French or greater) central venous access, using percutaneous technique, should be obtained. The mainstay for intravascular volume replacement is lactated Ringer’s solution. Although normal saline may be used as a volume expander, there is the potential for hyperchloremic acidosis. In patients who may have decreased renal function, this sodium load may not be well tolerated. For patients with hemodynamic compromise, a 1 L bolus of lactated Ringer’s solution is given. If the patient does not respond positively (decreased pulse rate and increased blood pressure), a second liter bolus is indicated. If hemodynamic compromise persists, blood should be given. One must be wary of fluid overload in this population, as there may be a fine line between hypovolemia and cardiac failure.
Pulse rate and blood pressure are obtained early in the resuscitation. While shock is often defined as a systolic blood pressure less than 90 mmHg, it must be kept in mind that hypertension in the elderly is very prevalent. Therefore, a normal blood pressure for a young person may be distinctly low for an elder. One must be skeptical of a "normal" blood pressure in a geriatric patient and bleeding must be suspected until proven otherwise. Normally, pulse rate is a sensitive indicator of hypovolemia. However, elderly patients may be taking ß-blockers or calcium channel blockers and may not be able to generate an increase in pulse rate in response to hemorrhage, since aging results in a decreased response to endogenous catecholamines.
Criteria for hemodynamic monitoring are not clear in this population. The geriatric patient shares with the child a propensity to mask physiologic deficits with "normal" vital signs. DelGuerico and colleagues found significant physiologic compromise in geriatric patients who had been "cleared" for elective surgery.55 Among those who were not able to be optimized prior to surgery, all died postoperatively.
Scalea and colleagues found significant measurable hemodynamic compromise in elderly patients who were clinically stable after initial evaluation.56 Early invasive hemodynamic monitoring was carried out in patients believed to be at high risk for mortality, including those involved in a pedestrian vs. motor vehicle crash; with initial systolic blood pressure lower than 130 mmHg; with pH lower than 7.35; with multiple long bone fractures; and with head injury. Thirteen of 30 patients were found to be in cardiogenic shock and 54% died. The vital message from this important work is that a multiply injured geriatric patient may appear "stable" yet have a profound perfusion deficit from a dangerously low cardiac output. The early use of invasive hemodynamic monitoring can identify this deficit and may help improve survival.
Measurement of acid-base status, such as lactate levels and base deficits can assist in identifying patients who are in occult shock. Davis studied the utility of base deficit in patients 55 years and older.57 There was a significant association between an increase in base deficit and an increase in mortality. Compared with mortality in the younger cohort, mortality in the elderly was significantly increased for a given base deficit. The positive predictive value of base deficit for predicting severe injury was similar between young and old, but the negative predictive value was significantly better in younger patients. Therefore, while an elevated base deficit can identify unrecognized hemodynamic compromise and alert the physician to patients with underlying significant injury, a normal base deficit in older patients should not confer reassurance.
The elderly patient is more likely to present in shock than younger patients with similar trauma and injury severity scores.58 The above data indicate the importance of hemodynamic monitoring, measurement of acid-base status, and careful trending of vital signs rather than relying on a single set of "normal" vitals.59 Since the elderly patient is often unable to generate an augmented cardiac output in response to hemorrhage, early invasive hemodynamic monitoring and judicious use of vasoactive drugs (after appropriate fluid resuscitation) are recommended for any geriatric patient with significant injuries.56
Specific Injuries
Head/Face. There can be no doubt that brain injuries in the geriatric population result in significant mortality and poor outcomes.60-62 Day and coworkers found brain injuries the most common cause of a fatal outcome, and Osler and associates found brain injuries second to shock as a predictor of mortality.15,16 The principles for treatment of brain injuries are similar to those in younger patients.63 Rapid control of the airway and careful attention to oxygenation are critical. Early and liberal use of computed tomography is indicated.
With advancing age, the dura becomes more adherent to the skull, making epidural hematomas uncommon.59,63 However, age-related atrophy increases the potential for subdural hematomas. This is due to two possible reasons: 1) greater movement of the brain within the skull in response to deceleration, and 2) stretching of the parasagittal bridging veins, making them more prone to rupture. In addition, this increase in potential space due to atrophy may mask the early signs of mass effect from intracranial hematoma.
Pennings and associates compared elderly patients with a Glasgow Coma Scale (GCS) of 5 or less with a younger cohort.60 Falls predominated in the elderly, while MVCs were the most common mechanism of injury in the young. Twenty-one percent of the elderly survived to discharge, compared with 64% of the young. All of the deaths in the young group were believed to be due solely to the brain injury while one-third of the elderly deaths were due to complications. Of those patients surviving to discharge, only one (11%) of the elderly patients had a "favorable" outcome, compared with 59% of the younger patients. The charges for a favorable outcome averaged $1,540,971, compared with $154,155 for younger patients.
Another retrospective study of patients with subdural hematomas found an overall mortality rate of 31%.61 A GCS of less than 7, age 80 years old or older, acute hematoma (vs chronic hematoma), and the need for surgical intervention were all significantly associated with hospital mortality. These findings should help physicians in both clinical decision making and guidance to patients and families.
Facial fractures are common and well described in the young, but relatively little has been written about this problem in the elderly. Falcone and associates retrospectively compared a group of young patients (n = 201) with fractures of the facial skeleton with an elderly cohort (n = 45).64 Males made up 79% of the young group and 47% of the elderly group. Nasal fractures were the most common fracture in the elderly, mandible fractures were most common in the young. While the incidence of MVCs was similar, falls were far more common in the elderly and assaults distinctly uncommon when compared to the young. The young were far more likely to be intoxicated. The authors recommended application of the same management principles for both patient groups.
Marciani succinctly addresses surgical concerns in these patients.65 Established principles of maxillofacial repair may be applied to all trauma victims, irrespective of age. However, withholding or delaying treatment of facial fractures may be prudent if the trauma team judges that a complex and lengthy surgical procedure may be a threat to life. The surgeon must balance the risk of a surgical procedure with compromised form and function if the operation is not performed. Fractures that interfere with mastication are likely to be problematic if left untreated.
Chest. Injury to the chest wall accounts for significant morbidity and mortality. Rib fractures are the most common injury found.66,67 It should be remembered, however, that significant thoracic injuries may occur in the absence of bony injury.66 Shorr reviewed elderly patients with blunt chest trauma and compared them with a younger cohort.66 Fractures of the bony thorax are the most common injury seen, followed by hemopneumothorax. Complications occurred in 46% of patients, but the prevalence was no different than in the younger group. The most common complication was atelectasis, followed by pneumonia and acute respiratory distress syndrome (ARDS). Elderly mortality was 37%, which was statistically greater than the younger group.
In the elderly, a unique pattern of chest injury may be seen with lap-shoulder belts.68 While restraint use was associated with lower injury scores for all body regions in the younger group, the elderly group did not realize such benefits. The most pronounced difference was an increase in chest injuries in the elderly. Decreased compliance of the chest wall and lung may lead to this finding. It is important for treating physicians to be aware of this pattern of injury so as to aggressively anticipate chest injuries with their high potential for morbidity.
The approach to these patients must include meticulous hemodynamic monitoring and fluid management, liberal use of arterial blood gas assays, aggressive pulmonary toilet, and recognition of a high risk for morbidity and mortality. If careful attention is paid to these details, acceptable results may be obtained as in one series in which 90% of patients returned to independent life.67
Aortic Injury. Advances in the management of aortic lacerations have resulted in improved survival rates.69 Age has been shown to correlate directly with mortality in blunt aortic injury.69 The supine anteroposterior chest radiograph is a standard examination for any patient who has sustained significant injury. This injury should be suspected in any patient with a significant deceleration injury and a widened (> 8 cm) mediastinum on the chest radiograph. Evaluation of the mediastinum in the elderly patient may be more difficult than the younger patient since tortuosity of the thoracic aorta may mimic the widened mediastinum, which marks the mediastinal hemorrhage of a potential aortic disruption. Repeat anteroposterior (AP) chest radiographs with the patient in reverse Trendelenberg position may be helpful. Depending upon institutional protocols, computed tomography of the chest or aortography may be used to confirm the diagnosis.
Few studies have addressed this injury as it pertains to the elderly patient. Camp and associates performed a 20-year retrospective study to examine the effect of this injury in the elderly (³ 55 years) compared with younger patients.70 Seventy-seven percent of the cases occurred in the younger group. Although the elderly patients had a greater number of pre-morbid conditions and a higher injury severity score, there were no differences in the revised trauma score or the calculated probability of survival. There were no significant differences in the percentage receiving operations, although half of the elderly patients died in the operating room compared with none of the younger cohort. The mortality rate in the elderly group was 82.4%, compared with 12.1% in the young. In each group, six patients did not undergo operations; this was due to associated injuries in the young and co-morbid conditions in the elderly. The authors concluded that in the elderly, non-surgical therapy should be considered as the risks of operation in these patients outweigh the risks of conservative treatment. While citing the limitations of a retrospective study, it would seem that a careful consideration of the risks vs. benefits of surgery in these fragile patients is a must.
Abdomen. The abdominal cavity must be evaluated quickly as a potential source of hemorrhage in any trauma patient. Significant abdominal injuries are found in approximately one-third of elderly patients.22,71,72 In the patient who is awake and alert, physical examination may be helpful in providing evidence for injury. However, the elderly are not easy to evaluate, and it is recognized that the abdominal examination is often unreliable, making imaging techniques more important.32
Therefore, liberal use of computed tomography, diagnostic peritoneal lavage (DPL), or ultrasound is recommended, particularly in the elderly, since delays in the diagnosis of hemoperitoneum are not tolerated. Ultrasound and DPL are best applied in the setting of hemodynamic instability where the abdomen must be immediately ruled out as a source of hemorrhage. Computed tomography is the imaging modality of choice in patients with potential abdominal injury who are hemodynamically stable.58 Once intra-abdominal bleeding has been diagnosed, rapid, yet thoughtful attention must be given to methods to arrest hemorrhage.
In a study reviewing 177 elderly patients (> 60 years) with abdominal injuries, shock was present in 38 patients (21.4%) and 19 patients required immediate laparotomy.11 The most common injuries were abdominal contusion (28.8% of patients), followed by injury to the kidneys (27.6%), liver (14.1%), spleen (14.1%), and small intestine (9.6%). The mortality rate was 27.6%, and abdominal injuries were directly implicated in one-third of deaths.
The question concerning the safety of non-operative management of solid organ injuries in this age group has not yet been satisfactorily answered. Godley found that age was directly related to failure of non-operative management.73 Barone and associates evaluated data from a regional trauma quality assurance committee regarding management of splenic injuries in patients older than 55 years.74 Immediate surgery was undertaken in 10 patients, and non-operative management was attempted in 23. Four patients failed non-operative therapy (17%), and all had either hemoperitoneum or ISS higher than 17. While non-operative management may be undertaken with an "acceptable" failure rate, it is imperative that these patients are indeed carefully observed. Although abdominal injury in both the old and young patient is usually managed similarly, a greater sense of urgency and accuracy is mandatory in the elderly.59 While mortality is higher in elders for every body region injured, the difference is most marked for the abdomen (4.7 times mortality in 85+ age group compared with the 14-24 age group).18
Spine. Spinal injuries are very difficult to evaluate in the geriatric patient. Maintenance of cervical spine stabilization must have high priority in the initial management and resuscitation. A careful history from the patient or family will provide valuable information regarding the presence of previous neurologic deficits. Cognitive problems or brain injury may make the clinical evaluation of the spine equivocal if not impossible.
Pre-existing cervical spine pathology may predispose to spinal cord injuries, especially of the hyperextension type.75 In the elderly, this mechanism typically manifests as the central cord syndrome. This incomplete spinal cord injury (SCI) may be subtle and should be suspected in patients with upper greater than lower extremity weakness and sensory loss. In addition to incomplete SCI, other differences in older patients include a less significant mechanism of injury (such as a fall from standing), and a predominance of upper (C1 and C2) cervical spine injuries. Adequate views of the odontoid are mandatory. The radiographic evaluation may also be challenging due to the presence of degenerative changes. If plain radiographs are nondiagnostic, CT scans may be needed to exclude spinal injury.
Spinal injuries have greater morbidity in the elderly as compared with the young. DeVivo and associates examined the outcome of both elderly (³ 61 years) and young (age 16-30 years) patients.76 The elderly patients were twice as likely to develop pneumonia, nearly three times as like to develop gastrointestinal bleeding, and more than five times as likely to develop pulmonary emboli. Mortality at two years post-injury was 41% in the elderly and only 5% in the young.
Extremities. While usually not a direct threat to life, attention to extremity fractures is a matter of high priority, as ambulation and activities of daily living may be profoundly effected. Early mobilization in any trauma patient is important, but in the older age groups it cannot be overemphasized. Early fracture fixation should be accomplished as soon as life-threatening injuries are addressed.
One retrospective study examined timing of fixation of long bone and pelvic fractures.77 Of those undergoing fixation within 24 hours, mortality was 11% compared to 18% in those stabilized after 24 hours. Although the results were not statistically significant, early fixation was found to be safe in this age group.
Swanson and colleagues conducted a randomized trial of early intervention vs. standard care in elderly patients (³ 55 years) with proximal femur fractures.78 The groups were matched with respect to age, gender, pre-admission functional level, cognitive level, living arrangements, and social support. While "early" was not specifically defined, median time to surgery was one day for the early group and two days for the standard group. Rehabilitation began within 24 hours of surgery. Median length of stay was significantly reduced in the early intervention program. Mean functional level at discharge was significantly higher for the early group.
Injury Complications
Compared with younger patients, complications are more common in the geriatric patient.9,13,18 Champion and colleagues noted a complication rate of 33.4% in the elderly compared to 19.4% for the younger patients in their series.13 Schiller and coworkers found the rate of chest complications to be nearly twice that for younger patients.9 Likewise, dysrhythmias occurred five times more frequently in the elderly, and infectious complications were twice as common.
Complication rates are substantial, varying from 26% to 43%.14,22,23,79 Cardiovascular and pulmonary complications predominate in most series and are responsible for many deaths.22,23,79 Osler found that pneumonia and respiratory failure led to 50% of deaths.15 Infectious complications have also been found to cause substantial morbidity and mortality.14,22,77
Tornetta and colleagues reviewed multiply injured patients older than 60 years from four different institutions in an attempt to determine factors that contribute to complications.77 Injury severity score was found to be predictive of ARDS, pneumonia, sepsis, and gastrointestinal complications. Increased fluid requirements predicted myocardial infarction. The need for surgery and transfusion both predicted sepsis. ARDS, myocardial infarction, and sepsis were all significantly associated with mortality, having mortality rates of 81%, 62%, and 39%, respectively.
In a study of 31 geriatric trauma patient deaths, there were no potentially preventable complications among the five patients who died in the emergency department.88 Eight of 13 patients who died of multiple organ failure were deemed to be potentially preventable. The authors conclude that early ICU admission and aggressive critical care management may decrease mortality in high-risk patients by decreasing preventable complications.
For those who survive their initial injury, cardiovascular, pulmonary, and infectious complications are common and contribute significantly to mortality. The importance of detailed care cannot be overemphasized, as complications are a significant sequelae in this group of high-risk patients.
Mortality and Long-Term Outcome
As with many facets of geriatric trauma, the literature is not unanimous concerning the factors determining outcome after injury. In addition, an increasing amount of data seem to indicate that even though mortality and complication rates are higher than the younger cohort, a high percentage of survivors return to independence and that aggressive care in these patients is appropriate.22,23,50,81
There are significant differences in mortality rates between the young and old. Osler found that the elderly are more than five times as likely to die due to injury than a younger cohort after controlling for injury severity.15 The probability of death increased by 1% per year over the age of 65 years. Several other studies have also documented increased mortality rates in the elderly.9,13,18,26,58,82-84
Does injury severity correlate with mortality? Several series have shown that as severity of injury increases, the risk of mortality also increases.9,14,18,85-87 This is not a universal finding however.12,72 An anatomic scale such as ISS may not be the most sensitive tool to predict mortality in this group.
Increased age has also been shown to be predictive of mortality.18,29,79 Finelli and associates found that mortality increased markedly beginning at age 45 and up to 85 years, after which there was a slight decrease.18 Shabot studied elderly trauma patients and found that patients 75 years and older (oldest old) suffered a disproportionately high share of severe injuries (as measured by ISS) and displayed a greater amount of physiologic compromise than patients aged 65-74.29 Compared to the elderly patient, the oldest old had a longer length hospital stay, greater mortality, and were less likely to be discharged to home.
Numerous studies have examined long-term outcome in the elderly following injury. Oreskovich evaluated 100 multiply injured patients older than 70 years.72 Mean ISS was 19 and mortality was 15% at one year follow-up. The authors constructed a non-survivor profile: Required prehospital intubation (93% mortality), shock (100%), intubated more than five days (100%), and gram-negative sepsis (80%). ISS was not found to be predictive of mortality. At one year, only seven patients were independent, compared with 96 patients pre-injury.
There have been more recent analyses, however, that have shown a higher proportion of elderly returning to independence. Van Aalst and coworkers were one of the first groups of investigators to learn of the importance of aggressive care in the elderly, as long-term outcomes in these patients may be better than previously thought.81 Ninety-eight geriatric (age ³ 65 years) blunt trauma patients with ISS 16 or higher admitted over a five-year period were reviewed. After excluding patients who died or were lost to follow-up, 48 patients were surveyed regarding long-term outcome (mean = 2.82 years). While only 17% were able to reach their preinjury level of function, 67% were able to live independently. The 32 independent patients were compared with the patients who died and were dependent at follow-up. Factors associated with a poor outcome included: 1) GCS of 7 or higher; 2) age older than 75 years; 3) shock upon admission; 4) presence of head injury; and 5) sepsis. This study was one of the first to document that a significant proportion of elderly trauma patients do indeed return to independent life.
Other investigators have found high levels of post-discharge independence in the elderly.16,22,23,49,71,83 Day studied 118 patients with ISS higher than 15 who were older than 60 years, with a minimum-two year follow-up. Seventy-eight percent of patients were fully functional in activities of daily living, and 81% were living independently.16 Another study found that at two years after injury, 93.2% of elderly patients had returned home.83
Injury also appears to have long-term effects on survival. One study compared injured patients 66 years and older to an uninjured cohort and followed the subjects for five years.88 The overall, five-year risk for death among the injured cohort relative to the uninjured cohort was 1.7 after adjustment for age, gender, and comorbid conditions. These results indicate that the effects of trauma are not isolated to the immediate post-injury period. While the reason for this finding is not yet known, it does serve to emphasize the need for attention to long-term care and rehabilitation in these patients.
While the literature is not unanimous concerning factors which correlate with mortality or poor long-term outcome, there are several items that have generally been shown to be predictive. (See Table 3.) This is not to say that the presence of such factors should preclude aggressive care, but rather should help anticipate poor outcomes and mortality. These data will help the physician provide proper guidance to the families of critically ill geriatric patients.
| Table 3. Factors Commonly Associated with Mortality and Poor Outcome in the Geriatric Trauma Patient | |||
| 1. Advanced age | |||
| 2. Increasing severity of injury | |||
| 3. Shock | |||
| 4. Prolonged mechanical ventilation | |||
| 5. Male gender | |||
| 6. Significant head injury | |||
| 7. Sepsis | |||
Economic Concerns
Numerous investigators have noted the high cost of caring for the injured elder.10,15,45,58,87,89-93 Even though the elderly make up approximately 12% of the population, they consume about 25% of trauma-related health care resources.10 Covington and colleagues found that the elderly (³ 65 years) had longer hospital and ICU stays and had higher mean charges than a group of adults aged 15 to 64 years after controlling for injury severity.89 The authors conclude that a 10% reduction in transportation injuries and falls could save $3.5 million dollars in this population over three years.89
Several authors have noted poor reimbursement for care of the elderly. Sartorelli and associates reviewed the financial records of trauma patients and found older patients had significantly lower reimbursement rates compared to patients aged 17-64 years.92 The pediatric patients accounted for 19.6% of the trauma population but incurred only 12% of the total cost, whereas geriatric patients constituted 22.4 % of the trauma patients but accounted for 26% of the total cost.
Zietlow reviewed geriatric patients with multisystem trauma and ISS of 10 or higher. The reimbursement of all in-hospital care was 66% of the total cost. At follow-up, 22% of patients stated their hospitalization was a financial catastrophe.93
Finelli found that of the 469 DRG categories, only 96 were adjusted for age. Notably, head injuries are not adjusted for age. DRG payments resulted in a net loss of more than $2,000 per patient, with the loss in non-survivors averaging more than $10,000.18
Young examined reimbursement in trauma patients aged 18-64 years compared to patients 65 years and older.87 The elderly population had a significantly higher ISS. The cost per case was 13% lower in the elderly, and the reimbursement rate was 25% higher than the younger group. This resulted in an overall profit of $1700 per case in the elderly group and an average loss in excess of $4000 per case in the younger group. This is contrary to the studies cited above and the authors postulated three contributing factors: 1) extensive use of practice pathways on the authors’ trauma service; 2) withdrawal of support in older patients before a terminal stage of care could be reached; and 3) much higher rate of insurance coverage in the elderly group.
Elder Abuse
The discussion of geriatric trauma is not complete without considering elder abuse. It has been estimated that 1 million elderly persons are abused annually.94 Elder abuse not only includes physical violence, but also acts of neglect. These may include withholding food, medications, hygiene, or monetary or emotional support. There does not appear to be a consistent profile for the elderly person at risk for abuse, although it is believed that elders with disabilities or cognitive impairment are particularly vulnerable.94 Abusers may have a history of violence or substance abuse, but this is not a consistent finding.
A high index of suspicion is important since signs and symptoms of elder abuse may be attributed to chronic diseases. A meticulous history and physical examination should be undertaken and any unusual features should be noted. These may include delays in seeking treatment, coming to medical attention without the caregiver, a caregiver who dominates the conversation, and unkempt appearance of the elderly patient; unusual wounds such as multiple bruises, "glove and stocking" injuries, or genital injuries should arouse suspicion for abuse.94
Summary
Geriatric trauma patients present a complex challenge to emergency medicine physicians, nurses, trauma surgeons, and intensivists. The problem of geriatric trauma is even now just being realized. Demographics reveal that an unprecedented explosion of growth in the geriatric citizenry is just around the corner. This increase in the elder population will undoubtedly have a dramatic effect on trauma patient demographics. A review of the literature reveals that the geriatric trauma patient is indeed a unique individual. Much as the child is not just a little adult, the injured elder is not just a "grayer" adult. Knowledge of the altered response to trauma in the elderly along with prompt recognition of injury and appropriate, aggressive treatment is necessary to optimize outcome in this population. Although the injured elder is more likely to die than the younger patient, an aggressive treatment program will allow many geriatric patients to regain their preinjury independence. Attention to detail, while important for all trauma patients, must be heightened in the injured elder as the opportunity for good outcomes may be fleeting.
Unlike other physicians, the emergency medicine physician, trauma surgeon, and intensivist are not chosen by the patient or family; therefore, no opportunity exists for developing a relationship prior to the injury episode. It becomes ever so important for the treating physicians to communicate effectively among themselves, and together with the patient and the patient’s family regarding prognosis, treatment, and end-of-life decisions.
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Physician CME Questions
1. According to the Census Bureau, in 1997 the elderly made up what percentage of the U.S. population? In 2050 this proportion (using moderate estimates) is projected to be what percent?
A. 12.7%, 20.4%
B. 6%, 10%
C. 2.3%, 5.9%
D. 19%, 40.4%
2. Comorbidity in the geriatric trauma patient is:
A. found in approximately 30% of patients older than 65 years of age.
B. most commonly cardiovascular disease.
C. likely to increase mortality and length of stay with a greater number of comorbidities.
D. all of the above.
3. The important message from the work of Scalea in resuscitation of the geriatric trauma patient is:
A. All patients with ISS > 15 should receive a pulmonary artery catheter.
B. A multiply injured geriatric patient may appear "stable" yet have a profound perfusion deficit from a dangerously low cardiac output.
C. Dobutamine should be immediately administered if a low cardiac output is found.
D. Augmentation of cardiac output will ensure survival for all patients.
4. In the geriatric patient:
A. complications are less common than in the young.
B. cardiovascular and pulmonary complications predominate in most series.
C. development of complications is generally due to a failure to deliver proper care.
D. complications do not increase the risk of mortality.
5. Regarding mortality and long-term outcome in the geriatric patient:
A. all studies show that ISS correlates directly with mortality.
B. nearly all studies show that only about 10% return to independent life.
C. most studies show increased mortality compared to a younger cohort.
D. there is no scientific basis to justify aggressive care for these patients.
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