Geriatric Trauma

1
Geriatric Trauma

• Alan Sori, MD
• St. Josephs Regional Medical Center
• Paterson, NJ

2
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

3
What is Geriatric Trauma?

• No. 5 cause of death for age gt 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

4
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?

5
Geriatric Bias

• Documented bias in medical care
• Rehabilitation placement.
• Breast cancer management.
• Thrombolytics.
• Trauma triage.
• Therapeutic Nihilism

6
Epidemiology

• Age gt 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

7
Epidemiology

• gt65 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.

8
Geriatric Recidivists

• Washington state Medicare population.
• gt 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
9
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
10
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.

11
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

12
Pulmonary System

• Decreased functional reserve.
• Thoracic cage - more brittle, stiff.
• Decreased compliance
• Increased work of breathing.
• Dec. alveolar ventilation
• Inc. V/Q mismatch.

13
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.

14
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.

15
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.

16
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

17
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 gt65.
• Increased incidence of penetrating trauma, elder
  abuse.

18
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
19
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.

20
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
21
Falls

• Falls 159 / 333 adms- age 65 (48)
• 83 falls age lt 65 (7 total)
• ISS gt 15 50(32) elderly, 12 (15) young.
• Falls are 2/3 of all elderly w ISS gt 15
• Same level w ISS gt15 - 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
22
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.

23
MVA- Driver Characteristics

• I year period - Level 1 trauma center
• 84 drivers age gt60
• 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
24
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.

25
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.

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Mortality -Factors

• Consistent
• TS (lt 7)
• SBP lt 90
• Shock
• RR lt 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
27
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.

28
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
29
Triage

• Philips - Florida- statewide
• Overtriage 7.5, undertriage - 71
• Triage tool identified only 103 / 355 major
  trauma patients.
• lt 65 - 11 / 33.
• Triage guidelines were most sensitive to GSW and
  least sensitive to falls.

J. Trauma 1996 40(2) p 278
30
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 (lt 65- 15, gt65- 56)
• Non TC deaths- elderly with ISS 1- 9

J. Trauma 1995 39(5) p 922 1999 46(1) p 168
31
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.

32
Brain Injury and the Elderly

• GCS lt 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 787 J. Trauma 1996
41(6) p 957
33
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
34
In younger patients, nature often saves the day
after minor surgical errors. In the aged, every
error is a major danger in life.
35
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.

36
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
37
Initial Evaluation

• History
• PMH
• Premorbid functioning
• Medications
• Drug - drug interactions, cause of injury
• PMD

38
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 lt 1L/min

39
Resuscitation

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

40
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
41
Resuscitation

• 1985- 60 elderly trauma patients at Kings County
  - 44 mortality, 85 in high risk.
• Ped vs MVA, SBP lt 130, acidosis (pH lt 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
42
Resuscitation

• CI lt 3.5 L / min or MVO2sat lt 60
• Fluids, blood, inotropes, afterload reducing
  agents.
• Hct- 35
• CI gt 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
43
Therapeutics

• Imaging.
• Early and often.
• Early tracheostomy?
• Pain management
• Epidurals ?
• Vena cava filters ?

44
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.

45
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.

46
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
47
Outcomes

• vanAalst - 98 pts age 65 with ISS gt16
• 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
48
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
49
Outcomes

• Why the big difference between Oreskovich and
  vanAalst / DeMaria?
• Falls- 66 falls vs lt40
• 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)

50
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
51
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.

52
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.

53
Summary / Recommendations

• Aggressive hemodynamic monitoring and
  resuscitation may be beneficial in the elderly
  trauma patient.
• Shock, BD lt -6
• AIS gt 3, high risk mechanism of injury
• Uncertain cardiac or volume status
• Optimize cardiac output and O2 delivery.

54
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 lt 8 TS lt 7 RR lt 10