Geriatric Trauma

1. Geriatric Trauma Alan Sori, MD St. Joseph’s 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 > 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 > 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 • >65 use 33% of all health care dollars and 25% of all trauma care money. • Medicare - DRG based- grossly underpays hospital costs for trauma, esp. in the elderly • Avg. reimbursement 40 to 65% of total hospital costs. • Increased age and ISS - worse reimbursement.

8. Geriatric Recidivists • Washington state Medicare population. • > 65 injured - 2X more likely to be admitted with a new injury than uninjured person in next 24 months. • ISS 16 to 24 - new injury risk 4x normal population. • Inc risk in patients with COPD, liver disease, age. J. Trauma 1996: 41(6) p. 952

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 >65. • 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 < 65 (7% total) • ISS > 15: 50(32%) elderly, 12 (15%) young. • Falls are 2/3 of all elderly w ISS > 15 • Same level w ISS >15 - old (30%), young (4%). • Fall deaths: 11 (7%), younger - 4% • 11/20 deaths overall due to falls (55%) J. Trauma 2001: 50(1) p. 116

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 >60 • 67/ 84 (80%) - at fault according to police. • Running stop signs, red lights, failure to yield - most common • 35 ( 42%) - single car crash. • Daytime- 80% • Good weather - 95% • ETOH - 5% • Low speed / intersections common Am.Surgeon 1995: 61(5) p. 935

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.

26. Consistent TS (< 7) SBP < 90 Shock RR < 10 Head injury Base deficit Less Consistent ISS Male sex Ped vs MV Non trauma center admission PEC Pulmonary complications Mortality -Factors 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. • < 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% (< 65- 15%, >65- 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 < 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 < 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 King’s County - 44% mortality, 85% in high risk. • Ped vs MVA, SBP < 130, acidosis (pH < 7.3), head injury, multiple fractures. • 1986 - invasive monitoring - ED to ICU was 5.5 hours - 93% mortality • 1987 - Monitoring early before diagnostic workup - ED to ICU- 47% mortality J. Trauma 1990: 30(2) p. 129

42. Resuscitation • CI < 3.5 L / min or MVO2sat < 60 % • Fluids, blood, inotropes, afterload reducing agents. • Hct- 35% • CI > 4L / min. • Increased mortality • ISS not calculated. • No group comparisons available. • Hayes, MA: NEJM: 1994 330(24) p 1717 J. Trauma 1990: 30(2) p. 129

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 >16 • 48 alive 1 to 6 yrs later (49%) • Assessed independence and functionality. • Ind / Maintained - 8 • Ind / declined - 24 • Moderately dependent - 10 • Custodial - 6 J. Trauma 1991: 31(8) p. 1096

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 <40% • Falls are a marker of severe underlying cardiac, pulmonary and neurologic diseases. • Death may often be preceded by a cluster of falls. • No 1 cause of NH admissions (40%)

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