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Why
should
injury
Injury
especially
to the
elderly
In
be worthy
of
discussion?
Aging
Trauma is the 7th leading cause of death in older adults.Why is trauma so much more “traumatic” for older people?
LET’S DISCUSS
Measurement of injury
How old age modifies clinical features &
management (i.e. fractures,
infection, confusion, host response)
How older trauma victims differ from
younger counterparts
Healthcare and Technology Advances
Enable elderly to be more active
Live in an environment that exposes them to many dangers
Older people who
sustain injuries are more likely to die as a result of
them, regardless
of the severity of
injury.
Despite the considerable proportion of trauma care
resources consumed by
the oldest people,
research is directed
towards needs of younger
ones.
Injury Measurement
Scoring systems grade severity
Most scales based on: extent of anatomical injuryphysiological disturbance
Abbreviated Injury Scale (1956)Injury by body region, 1 to 5
Injury Measurement
Injury Severity Score (ISS)High validityPrevalence of significant pre-existing
conditions increases elderly
Importance of intercurrent diseases in determining outcome after injury
Acute Physiology of Chronic Health Evaluation scale (APACHE)
Severity of illness & age related to survival
Injury MeasurementSimplified Acute Physiological Score (SAPS II)
Good predictor of short and long-term mortality in the elderly
Factors influencing mortality:Intrinsic: Age, severity of acute
illness, previous health status
Extrinsic: Medical environment,
quality healthcare factors
Measuring Recovery
Most outcome studies focus on survival
Little attention is given to quality of survival
Consider rates of change for function, disability & handicap
aggressive medical and
rehabilitation of elderly
trauma victims is justified
adequate intensive treatment
may improve outcome for
elderly
Recovery
FALLS IN OLDER ADULTS
Leading cause of injury
Leading cause injury-related mortality
Account for > 60% of the total causes of injury in the US
CAUSES OF FALLS IN OLDER ADULTS
Accidents
Due to common changes of aging
Environmental hazards
Cardiac Dysrhythmias
Orthostatic Hypotension
Dizziness, Vertigo
Syncope
Vertebral-basilar insuf.
Drugs
Other
MOTOR VEHICLE COLLISION OLDER ADULTS
More than 18% trauma-related deaths
Two-vehicle collisions at intersections
Risk is increased: changes in vision, hearing,
reaction times, acute and chronic medical
conditions, alteration in judgment
HOW AGE RAISES RISK
HEARTStiffening
decreased cardiac
contractility, stroke volume,
cardiac output
Decreased sensitivity to
catecholamines
inability to mount
tachycardia in stress
HOW AGE RAISES RISK
LUNGS
Rib fracture
may lead to splinting
hypoventilation
promoting atelectasis,
pneumonia, need for
ventilatory support
THORACIC TRAUMA IN OLDER PEOPLE
Aortic rupture
Mediastinal widening
Poorly defined aortic knob
80% die at the scene
20% may be stable on
presentation
THORACIC TRAUMA IN OLDER PEOPLE
Isolated chest injuries
2-3 times death risk
Rib fractures
Falls or blows to chest
Occult pneumothorax
Hemothorax
Pulmonary contusions
Prompt mechanical ventilation
HOW AGE RAISES RISK
BRAINLoses volume and the resultant space around the brain
increased dural vein fragility
reduced dural vein elasticity
more susceptible to subdural hematomas
HOW AGE RAISES RISK
SKIN
Atrophic, extremely delicate, easily injured
High risk complications from skin injury
wound infection
burns
HEAD INJURIES IN OLDER PEOPLE Modest increase incidence rates after 60
More common in men than in women
Can be devastating in older people
GCS less than 8 fatality rate of about 90%
Survivors long hospital stays
More severe neurological deficits
Reduced capacity of aging brain to recover
HEAD INJURIES IN OLDER
PEOPLE
AS THE BRAIN AGES…
Dura tightly adherent to skull
epidural hematomas uncommon
Progressive loss volume
Increased space around brain
Subdural hematomas or
intraparenchymal hemorrhage more common
emergent
management
of acute
subdural
hematoma is
critical
HOW AGE RAISES RISK
BONE
Most frequently injured
Osteoporosis
humerus, radius, hip
or pelvic fractures
longer periods of
immobility
HOW AGE RAISES RISK
SPINE
Degenerative spine
spinal fractures with
minor force
upper cervical injuries
odontoid fractures
central cord syndrome
more common
FALL-RELATED FRACTURES
Nature of the fall dictates
the nature of the fracture
Wrist, proximal humerusoutstretched armimply person was
moving reasonably fast at time of fall
Stationary position or during slow locomotion most likely
result proximal femoral
fractures
FALL-RELATED FRACTURES
Account for majority of cervical spine Fx
Frail may sustain long bone Fx
without a clear history of injury or falls
“minimal trauma fractures”
only precipitating factor is impaired
mobility
ABDOMINAL TRAUMA IN OLDER PEOPLE
Death rate visceral injuries around 80%
Intolerant of shock
Intolerant of unnecessary laparotomy
Management demands urgency
High degree of clinical expertise
MULTIPLE INJURIES IN OLDER PEOPLE
Visceral injuries without
fracture rare
Long bone
Must be stabilized early
Control blood loss
Reduce risk of fat
embolism
Enable early
mobilization
Bony injuries immediate life
threats
Skull fractures with brain
injury
Pelvic fractures
Massive bleeding from
lacerations to pelvic
venous plexus
Open pelvic fractures
death rate 80%
OLDER TRAUMA VICTIMS
Older accidental injury mostly women
Younger accidental injury mostly men
Old women out number old men
Thinner bones more likely to fracture
Occurrence of late deaths
Peak death rate femur 1 mo. after injury
Increased level for considerable time
Higher total of mortality late after injury
MAJOR TRAUMA OUTCOME STUDY, 1990
Retrospective study over 120,000 patients
US trauma centers, 10% were elderly
Purpose: set national norms in trauma
care and survival probability
Older increased likelihood of death
Older overrepresented unexpected deaths
APACHE III
Chronological age alone accounted for 3% of
variation in outcome
Acute physiological abnormalities accounted for
86%
Presence of shock has emerged as an enormously
potent predictive factor for negative outcome
Early invasive monitoring improves survival
It is not age that accounts for the poor outcome of
older trauma victims, but
factors that are strongly age
related.
Intrinsic Factors:
co-existing disease, under nutrition and
age-related changes in organs and
physiological systems…
…may contribute to
outcome directly by
limiting protective
responses or indirectly by confronting diagnostic
efforts.
Extrinsic Factors:
medication and the attitudes of
medical personnel may
have similar important
adverse effects.
Cardiac Output
30%
Average
Vital Capacity,
Renal Blood Flow
50%
Decline
Max Breathing Capacity, Oxygen Uptake
60-70%
Ages
30 to 80
Pharmacological Aspects Aging
Many drugs cause:hypotension & confusion,
predisposing falls, possible injury
Changes in the host: predispose drug toxicity, potential for interactions
More drugs higher reaction risk
Many drugs bind to proteinsSick old people often low albumin
Drugs that bind to albumin (warfarin) Higher concentrations of free drug
Pharmacological Aspects Aging
Many water-soluble drugs excreted by kidneysdeclines glomerular filtration, prolong
eliminationWater-soluble therapeutic concentration lower dose
(digoxin)
Pharmacodynamic Changes
Altered responsiveness to a drugIncreased sensitivity
Pharmacological Aspects Aging
Many drugs metabolized in liver
Considerable variations from: drug to drug & person to person
2012 AGS
Expert Panel
Beers Criteria
DISEASE PRESENTATION OLD AGE
Doctor may share patients’
views on aging
Wrongly attribute treatable
conditions to aging
Prevalence of disability
increases with age
DISEASE PRESENTATION OLD AGE
Traditional model for medical practice
Mainly from presentation younger people
Account abnormality to single diagnosis
Deviation from traditional model
Multiple diseases often co-exist
Atypical presentation of disease
Disease in one organ may precipitate decompensation in another
DISEASE PRESENTATION OLD AGE
Late or silent presentations
Disease one site limits symptoms at another
Disease often presents in advanced state
Misinterpret symptoms as aging
Mobility problems limit activity
– Dyspnea not occur until heart failure advanced
IMMUNOSUPPRESSIVE EFFECTS OF INJURY
Body’s response to
surgery & trauma
afferent nerve signals
from site of injury
Release
cytokines & circulating
stress hormones
Infective complications
account for most of the delayed deaths after injury
Infection should always be considered
when evaluating a patient whose condition has deteriorated
Hippocrates “old men have
little innate heat…for this reason too, the fevers of old men are less acute than
others, for the body is cold.”
An apparent afebrile state may
mask infection.
Changes in vital signs are less reliable indicators of instability in older adults.
Cause
Confusion
Consequence
Related to
Coincidental
Injury
CONFUSION AND INJURY IN OLD AGE
Whatever the relation confusion has a major impact on managementDelirium, ICD 10 some disturbance in:
ConsciousnessCognitionPsychomotor functionSleep-wake cycleEmotion
DELIRIUM
Children, old people very susceptible
Children – immaturity of CNS and of the cognitive and memory contents
Older – changes in Neuro…pathological, chemical, physiological, psychological
DELIRIUM IN OLD AGE
Pharmacologic agents that interfere with cholinergic function or sedation
Alcohol withdrawal
Sensory deprivation, the environment“talking across” increases confusion
Depression may masquerade as confusion
TRAUMA IN OLD AGE
“so healthy until now…”
“why all of a sudden, he was walking and independent, still driving to church every Sunday…”
“she was walking before she got here and isn’t leaving without walking out of here…”
Homeostenosis
ORTHOGERIATRIC UNITS
Identification, treatment of confusion
Effectiveness depends on
enthusiasm, resources, competence
Minimal disturbances
Minimal sedative medications
Nursing organization key to success
Nursing rehabilitation oriented
REFERENCES
Horan, M. A., & Little, R. A. (Eds.). (1998). Injury in the aging (First
ed.). New York, NY: Cambridge University Press.
Bartley, M. K. (2010). Handle older trauma patients with care. Nursing
2010, August, 24-29.
Cutugno, C. L. (2011). The ‘Graying’ of Trauma Care: Addressing
Traumatic Injury in Older Adults. American Journal of Nursing, Vol.
111, No. 11, 40-48.
http://www.modernmedicine.com
http://consultgerirn.org/
http://www.environmentalgeriatrics.org/#
http://www.cdc.gov/injury/wisqars/leading_causes_death.html