Evaluation and Management of the Elderly Trauma Patient

Courtney Sommer, MD, MPHMarch 10, 2016

Projected US Population growth

North Carolina Statistics

2015 US Census

Trauma 4th leading cause of death in US

National Vital Statistics Report 2013http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf

NTDB Annual report 2015

Leading causes of accidental death

All Ages > 65 years old1. MVC2. Poisoning3. Falls4. Homicide firearm

1. Falls2. MVC3. Unspecified4. Suffocation

Older people fall

NTDB Annual report 2015

NTDB Annual report 2015

Falls in the elderly

• Frequent problem▫ 1/3 of people > 65 fall every year▫ ½ of institutionalized individuals fall every year▫ ½ of those that fall do so repeatedly

• 71% of falls have an associated injury▫ Femur, hip, cervical spine, arm, pelvis fractures

• Injury out of proportion to mechanism▫ Frailty, baseline health decline▫ Prolonged hospitalization (33% stay >10+ days)

High morbidity and mortality

http://www.nytimes.com/2014/11/04/science/a-tiny-stumble-a-life-upended.html

http://www.nytimes.com/interactive/2014/11/03/health/bracing-for-the-falls-of-an-aging-nation.html

Co-morbidities

• 66% of patients over 65 years old will have co-morbidities at time of trauma• 60% HTN• 10% Respiratory

disease• 22% DM• 9% CHF

• Compared to 4.6% of those under 55 years

Bergeron J Trauma 2004NTDB, TQIP

Hip fractures

• 5-8 fold increased risk for all-cause mortality within 3 months

• Progressive decline in health, leading to persistent increasing annual mortality– 20% at 5 years vs same age, no fracture

Haentjens Ann Intern Med 2010Ioannidis CMAJ 2009

Co-morbidities

Altered physiology in the elderly

What is “elderly”?

• No consensus in the literature

– Medicare – > 65 y

– Literature ranges 45-85 yr

• Individuals have a wide range of functional status despite similar chronologic age

Central Nervous System

• 15-20% loss of brain volume from 5th-10th decade

• Elderly brain occupies less space in the skull• More potential subdural space – 3x more likely• Epidural hemorrhage less likely

• Significant tissue injury with minor trauma▫ Worse outcomes than younger patients 1 year later

Cagetti Br J Neurosurg 1992Livingston J Trauma 2005

Central Nervous System

• GCS less reliable due to chronic disease– Dementia– Hearing impairment– Fluctuating baseline– Physiologic reasons?

• GCS actually more likely to be higher with same degree of injury (head AIS) compared with younger patients

Salottolo JAMA Surg 2014Kehoe Emerg Med J 2016

Cardiovascular System

• Thickened valves and vessel walls contribute to hypertension and cardiac arrhythmias

• Coronary artery disease makes vessels and heart less responsive, and there is increased risk of demand ischemia

• Do poorly with too much or too little fluid

Cardiovascular System

• Decreased maximal heart rate, stroke volume, and cardiac output– Max heart rate (220-age)

• Increased Systolic BP and SVR at rest– “Normal” BP may be relative hypotension– Can still be in shock

Hematologic system (anticoagulants!)

• Significant head bleeds with minor trauma– Mortality doubles after first ground level fall when on oral

anticoagulants for afib (3 6%)

Inui J Trauma ACS 2014Bolt Injury 2015

Respiratory system

• Decreased alveolar surface area – 4% per decade after age 30

• Impaired gas exchange by 0.5% per year

• Pre-existing pulmonary disease, decreased pulmonary reserve

Carpo Pulm Disease & Disorders 1998

Renal system

• Progressive decrease in functioning nephrons• 1%/yr after > 40yo• Maximal concentration in 80 yo is only 70% of 30 yo

• Creatinine clearance skewed by loss of muscle mass

• Diuretics create baseline dehydration

Medication pharmacokinetics

• Absorption– Transdermal, Intramuscular, Gastrointestinal

• Clearance altered (renal, hepatic)

• Volume of distribution– Hydrophilic vs Lipophilic

Musculo-Skeletal System

• Decrease in lean body mass▫ 4% per decade after 25 yo▫ 10% per decade after 50 yo▫ Increase in adipose tissue

• Osteoporosis – loss of up to 60% of trabecular bone mass and 35% cortical bone mass

• Increased risk fractures of vertebral body, hip, humerusand forearm

Moore EE TraumaATLS manual

Cervical Spine fractures

• Osteoporosis & Degenerative changes

• C1-C2 vertebrae more frequently injured

• Younger patients injure C4-C7

Rib fractures

• Increased chest wall rigidity & osteoporosis• Multiple rib fractures (>4)

– Morbidity (Pneumonia, atelectasis, ALI, ARDS)– Mortality

• Increasing age associated with increased morbidity– 45 years

Bulger J Trauma 2000Holcomb J Am Coll Surg 2003

Abdominal injury

• More likely to sustain bowel and mesenteric injuries• May not manifest peritoneal signs on exam• Localize pain poorly• “Damage control” is not futile

Trauma, MooreNewell J Trauma 2010

Skin

• Atrophy of subcutaneous fat, 20% loss of dermal thickness– Pressure ulcers develop

within 2 hours– Skin prone to breakdown

• Microcirculation is impaired affecting medication absorption

Moore EE TraumaATLS manual

Endocrine System

• Increasing Insulin resistance– >50y: “normal” fasting Glc up 10mg/dL decade

• Adrenal function– Aldosterone levels 30% lower in 70+ yo

• Increased hypothyroidism

Immunologic System

• Immunity is altered and has an impaired ability to respond to infection

• Less able to tolerate infection and more prone to progress to multiple organ system failure

Montecino-Rodriquez J Clin Invest 2013

Thermoregulation System

• Less responsive thermoregulatory mechanisms– more likely to develop hypothermia

• Less effective compensation – shivering, cutaneous vasoconstriction

Sleep habits

• Dampened circadian rhythm amplitude– Advance sleep phase syndrome

• Low level light exposure during daytime• Inactivity• Physical and psychiatric illness

– OSA– RLS– GERD

• Meds we use to treat!

www.sleepfoundation.org

Beers Criteria

• Over 75 drugs / drug classes• List of medications to use with caution in the

elderly due to increased side effects

J Am Geriatr Soc 63:2227–2246 2015

Elderly Abuse

• Under recognized, under reported– Estimated 1 in 6 cases reported

“Any willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment

resulting in physical harm, pain, mental anguish, or other willful deprivation by a caretaker of goods or

services that are necessary to avoid physical harm, mental anguish, or mental illness”

Getting old is rough!

Different care is needed

TriageER/Resuscitation

ICU issuesAge vs Function

DNR status

Geriatric Trauma Patients

• Elderly are less likely to be involved in trauma, but are more likely to have fatal outcomes when injured

• The mechanism is not as impressive as the injury or the outcome– Undertriaged, underdiagnosed, undertreated

Triage Issues

• Pre-hospital– Risk for undertriage was significantly higher among those older

than 65 years (49.9 vs. 17.8%)

– Improved survival at designated Level I trauma centers• 8% vs 56% survival in 80+ year old patients• Data variable here, may not be true for all “elderly”

– Trauma centers that have a higher volume of geriatric trauma patients have better outcomes

Chang Arch Surg 2008Staudenmayer JACS 2013

Demetriades j Trauma 2001

Trauma Team Activation

• Standard activation criteria fail to identify the severely injured geriatric patient– 63% of severely injured did not meet HD criteria

• Shock Index a better predictor of mortality than traditional Vital Signs– SI = HR/SBP– Modified with >55y: Age x Shock Index

ZarZaur J Trauma 2010

ABC’s – as always

• Airway– Cervical arthritis, arthritis of TMJ, limited mobility– Dentition, Nasopharyngeal friability

• Breathing– COPD/CO2 retention: hypoxemic respiratory drive, permissive

hypercarbia– Rib fractures – higher mortality– Pulmonary contusions – poor reserve

ATLS manual

Circulation

• Decreased maximum HR (220-age)– Masks volume loss

• Decreased catecholamine response– More frequent arrhythmias

• Pre-hospital medications• Similar fluid requirements, but…

– May be volume contracted from diuretics– Baseline CHF may be exacerbated

ATLS manual

Frequent Orthopedic injuries

Treatment goals

• Least invasive, most definitive procedure

• Early mobilization

• Regional blocks for pain– Femoral nerve and fascia

ilaca blocks

– Limit systemic narcotics

– Prolonged inactivity limits functional outcome, which impacts survival

Delirium

“An acute change in cognitionnot explained by preexisting

or evolving dementia”

• Often unrecognized / under diagnosed– Affects 7-10% older patients in the ED– Affects 43% of elderly ICU patients

Han Emerg Med Clin N Am 2010

Elderly Delirium in the ICU

• Longer ICU and hospital stays

• Higher rates of mortality

• Hypoactive delirium most common: 68%

• Increased mortality @ 6mo

Robinson Arch Surg 2011

CAM-ICU RASS• Fluctuations in mental

status• Inattention• Disorganized thinking• Altered level of

consciousness (RASS)

• Agitation - sedation scale• Activity level used to

determine delirium motor subtype– 0 to -3: Hypoactive– 1 to 4: Hyperactive– Mixed – both seen

Pandharipande Intens Care Med 2007

Delirium scales/screening

Nutrition in the elderly

• Often baseline malnutrition on admission

• Decreased caloric needs with less lean body mass, but increased requirements due to inefficient utilization of calories

• Difficult to meet caloric goals– Very frequently have dysphagia

ATLS manualCahill Crit Care Med 2010

Early inpatient rehabilitation

• Weakness associated with impaired function▫ Muscle wasting highest in first 2-3 weeks of ICU

• Early exercise therapy in the ICU▫ Decreased ICU and hospital LOS▫ Improved exercise capacity, strength and perception of function

at hospital discharge▫ Reduced mortality

“Up and About gets them OUT!

Morris Crit Care Med 2008Burtin Crit Care Med 2009Killewich JACS 2006

End of life issues

• Elder patients more likely to be “DNR” at time of death• Withdrawal/withhold life support chosen in 80% of

trauma deaths > 65 yrs old• Withdrawal of care represents a significant contribution

to trauma center mortality rates– Most should not be considered failure of treatment

Sise J Trauma ACS 2012

How old is old?

• Extreme variation in functionality of individuals of the same age

• We need better functional assessments that correlate with overall health status

• Frailty is better marker• No single frailty scale validated in trauma population• Recent review

• 32 assessment tools• Very few found to be objective, feasible, and useful in trauma

population

DOI: 10.1097/TA.0000000000000981

Frailty

What can we do?

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What can we do?

Resources

• TQIP guidelines– https://www.facs.org/~/media/files/quality%20programs/trau

ma/tqip/geriatric%20guide%20tqip.ashx

• EAST guidelines– https://www.east.org/education/practice-management-

guidelines/geriatric-trauma,-evaluation-and-management-of

• G 60 Conference

Resources

Page 55

Does age matter?• Injury• Resuscitation• Hospital Care• Discharge

Conclusion

• Elderly are physiologically different and have different patterns of injury

• Early and proper diagnosis and intervention, without causing of harm, yields outcomes similar to younger patients

• Early and aggressive rehabilitation improves outcomes

Questions?

Questions?