Geriatric Trauma Patient
April 29, 2022 - read ≈ 16 min
Christine Wu, MD
Department of Trauma, Burn, Surgical Critical Care Brigham and Women’s Hospital, Boston, MA, USA
Zara Cooper, MD, MSc
Department of Trauma, Burn, Surgical Critical Care Brigham and Women’s Hospital, Boston, MA, USA
With a rapidly aging population, increasing numbers of older adults sustain trauma. Most injuries are due to falls, but more older adults are also suffering from motor vehicle crashes, assaults, and burns. Age-related anatomic and physiologic changes alter older trauma patients’ clinical presentations and blunt their physiologic response to injury. As people age, their adaptive and homeostatic mechanisms change, contributing to a decreased physiologic reserve and reduced metabolic response to injury.
Thus, seemingly minor injuries can be lethal and older injured patients are at greater risk for prolonged hospitalization, worsening disability, and functional dependence. Moreover, trauma is associated with increased mortality, relative to other non-injured older adults, for years after injury. Multidisciplinary and appropriate evaluation and management of older patients is necessary to improve clinical outcomes.
Accurate evaluation of the geriatric trauma patient can be particularly challenging due to comorbidities, medications that alter the normal physiologic response to injury, occult injury, and preexisting cognitive impairment or delirium.
With age, there is a progressive loss of cardiac myocytes leading to a decline in cardiac function, decreased sensitivity to catecholamines, and reduced compensatory capacity. In addition, atherosclerotic changes in the arteries and fibrotic changes to the heart result in impaired blood flow to tissues and organs and a less resilient, stiffer heart, respectively. In the setting of hypovolemia, older patients are less able to compensate with tachycardia and an increase in cardiac output, and so systemic vascular resistance increases in response.
As older individuals are more likely to have an elevated baseline blood pressure, a blood pressure in what is generally considered the normal range can actually be indicative of relative hypotension for these patients. Furthermore, older patients often take cardiovascular medications such as beta blockers, calcium channel blockers, and other antihypertensive agents. These medications physiologically block the improvement of cardiac contractility and blunt the expectant, reflexive tachycardia as a response to stress, injury, and shock.
The pulmonary changes that occur with age include reduced thoracic muscle mass and decreased elastic recoil of the lungs, leading to decreased chest wall compliance, reduced functional residual capacity, and impaired gas exchange. Additionally, older patients have a decreased cough reflex and decreased mucociliary epithelial function. In the setting of injury, these patients are more susceptible to atelectasis, hospital-acquired or ventilator-associated pneumonia, and prolonged ventilatory support.
Rib fractures are a very common injury in older trauma patients, oftentimes from a ground-level fall. In comparison to younger patients, older patients with rib fractures are at a higher risk for morbidity and mortality. Increasing age and number of rib fractures are associated with an increase in complications and negative outcomes, including increased ICU length of stay, total length of stay, ventilatory days, and pulmonary complications. In patients 65 years and older, each additional rib fracture is associated with an increased risk of pneumonia by 27% and increased mortality rate by 19%.
With age, the glomerular filtration rate decreases with a loss in renal mass. Older patients have impaired renal tubule reabsorption and secretion, resulting in challenges with medication clearance and fluid balance. In general, extra attention needs to be focused on dosing renally excreted drugs appropriately as well as monitoring for signs of volume overload. Because of these factors, older patients are at greater risk for acute kidney injury and volume and electrolyte derangements while hospitalized.
Older people have a loss of muscle mass, accompanied by skeletal degeneration such as osteoporosis and osteoarthritis. They are at increased risk for skeletal fractures, particularly of the vertebrae, ribs, pelvis, hip, and distal extremities. Females are at greater risk due to lower bone density. Upper cervical injuries are among the most common types of fractures in older patients, and 3 injuries specific to these patients and anatomic region include: central cord syndrome, cervical extension or distraction injuries, and odontoid fractures.
Compared to young patients with similar injuries, older patients with pelvic fractures are more likely to require a blood transfusion and are at an increased risk of death. In addition, skin changes with aging include thinner epidermis, decreased vascularity, and increased skin dryness. These skin changes can impair wound healing for patients who suffer traumatic injury or who undergo any sort of operative intervention.
In the field, severity of injury is often underestimated in geriatric trauma patients. Late recognition of significant injuries can contribute to poor outcomes, and thus, Center for Disease Control (CDC) guidelines advise a lower threshold to transfer to a trauma center above age 55, and trauma centers may consider age-related criteria for trauma team activations.
Preexisting medical conditions (ie. cirrhosis, COPD, ischemic heart disease, diabetes mellitus, congenital coagulopathy, dementia or cognitive impairment), as well as regular administration of certain medications (ie. anticoagulants, antiplatelets, antihypertensives), can significantly affect initial evaluation and care. It is important to identify these comorbidities and reconcile home medications in order to facilitate appropriate patient care.
Primary and secondary surveys should be conducted in standard fashion for all trauma patients regardless of age. However, certain conditions and criteria should be considered in geriatric patients. In regards to airway, older patients can have a loss of protective airway reflexes, have arthritic changes leading to difficult mouth opening, and be edentulous making bag-mask ventilation more challenging.
Patients may have preexisting respiratory disease, in addition to age-related changes of the respiratory system, that can result in limited respiratory reserve and an increased work of breathing. Early administration of supplemental high flow oxygen is important, and aggressive airway management including intubation may be necessary.
The typically concerning vital signs for younger patients are different with older patients due to age-related changes to the cardiovascular system and common preexisting medical conditions such as hypertension and the use of antihypertensive medications. These factors present challenges to triaging and treating geriatric patients. Older patients with baseline hypertension may seemingly have a blood pressure within normal limits that is truly a relative hypotensive state.
As such, traditional normal vital signs are inadequate in identifying shock in older patients. For instance, younger patients are at increased mortality for heart rate >130 bpm and systolic blood pressure <95 mm Hg, while comparable increased mortality in older patients is seen when heart rate >90 bpm and systolic blood pressure <110 mm Hg. As such, for patients over the age of 65, a systolic blood pressure of 110 mm Hg should be used as the criterion to transport the patient to a trauma center, rather than the standard 90 mm Hg.
Despite having vital signs in the standard normal range, older patients have a limited capacity to compensate, and the expected cardiovascular response to hypovolemia is not as apparent. Patients may, in fact, be hemorrhaging or have tissue hypoperfusion. It is important to ensure early resuscitative efforts and serial monitoring of clinical parameters and laboratory values of shock and tissue perfusion such as mental status, serum lactate, base deficit, and urine output. Initial vital signs may be misleading, and so it is necessary to trend vital signs and carefully investigate any signs of hemorrhage or significant injury.
Resuscitation can be done in a similar manner as other patients by fluid and blood administration. However, the balance between hypoperfusion and volume overload must be considered during and after resuscitation, as large-volume resuscitation can be detrimental in older patients with limited cardiovascular reserve.
The disability assessment and neurologic exam can be challenging to accurately evaluate in older patients who may have blunted sensation, altered cognition, and baseline dementia. Additionally, the use of sedatives and analgesia in the acute trauma setting can complicate a patient’s mental status examination. A high index of suspicion is necessary for older patients with any mechanism or signs of head trauma.
A noncontrast head CT for all patients 65 years or older with a mild head injury is necessary based on American College of Emergency Physicians recommendations. Cerebral atrophy results in loss of intracranial volume, which allows for more space for blood to accumulate prior to the development and demonstration of mass effect or midline shift, thus, masking early signs of intracranial hemorrhage.
An aggressive approach to evaluating and monitoring older patients is important given that they often lack the classic physiologic responses to shock. Early diagnostic testing with cardiac monitoring, ultrasound, and CT imaging is crucial. Ultrasound can be used as a non-invasive, real-time evaluation for peritoneal free fluid concerning for hemoperitoneum and solid organ injury, as well as for rapid echocardiographic assessment to evaluate cardiac dysfunction, hemodynamics, and resuscitation.
Frailty is a well-recognized marker of progressively declining physiologic reserve and associated increasing vulnerability in older patients. This syndrome is marked by fatigue, muscle wasting and weakness, functional disability, comorbidity, and inability to withstand physiologic insults such as surgery or trauma.
In comparison to non-frail patients, frail patients are at greater risk for in-hospital complications, loss of function, discharge to skilled nursing facilities, and readmission for repeat trauma or death within 6 months after discharge. These vulnerable patients would benefit from geriatric-centered interdisciplinary evaluation and care. The inclusion of geriatric specialists and geriatric care processes focused on improving mobility, minimizing polypharmacy, recognizing dementia and cognitive impairment, avoiding delirium, and aligning treatment with the patient’s overall health goals can reduce patient complications, delirium, hospital length of stay, and readmission.
Traumatic Brain Injury
Older age is known to be associated with poor outcomes after a traumatic brain injury (TBI). Goal-directed TBI treatment, as directed by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) guidelines, include maintaining adequate oxygenation and normocapnia, monitoring intracranial pressure, monitoring blood pressure and mean arterial pressure closely to avoid hypotension, maintaining normothermia, and keeping glucose levels and electrolytes within normal range particularly sodium levels.
Geriatric patients more commonly take anticoagulant and antiplatelet medications, placing them at higher risk for intracranial hemorrhage and worse outcomes in comparison to younger patients. Early identification of these medications and any traumatic hemorrhage— not limited to the brain — is of utmost importance to provide appropriate intervention including correction of therapeutic anticoagulation.
For patients with supratherapeutic anticoagulation levels necessitating reversal, the effects of prothrombin complex concentrate (PCC) occurs within minutes of administration. As such, PCC is often recommended over fresh frozen plasma (FFP), which takes hours and greater fluid volume to administer. Other agents used to reverse anticoagulation include vitamin K and cryoprecipitate. Patients on regular anticoagulants with a negative head CT after injury should have a follow-up CT prior to discharge to ensure occult injury is not missed.
For older patients with TBI, important outcomes to consider and improve include patients’ functional outcome and independence, cognitive function, and quality of life. Careful identification of a patient’s pre-injury neurologic baseline from family is important in order to recognize deficits in neurologic evaluations and allow appropriate prognostic decision-making. It is more likely that older patients will require additional rehabilitation at the time of discharge for longer periods of recovery.
Rib fractures in older patients can lead to significant morbidity and mortality. As older patients are less able to tolerate rib fractures, important factors must be kept in consideration when caring for these patients, including adequate pain management, possible need for intubation and prolonged ventilatory support, reducing risks of pneumonia, and ICU level of care. Early recognition of respiratory failure and aggressive supportive measures are necessary to reduce morbidity and mortality in these patients. Patients with respiratory insufficiency requiring rapid sequence intubation may need doses of induction agents that are reduced between 20-40% to minimize risks of cardiovascular depression.
Adequate analgesia by multimodal pain therapy should be initiated early and monitored closely to reduce morbidity and mortality associated with poorly controlled pain. This multimodal approach will be determined by patient comorbidities and response to therapy, but can include regional analgesia, acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentin, lidocaine patches, and judicious use of opioids, rather than opioids alone. Neuraxial blocks for multiple rib fractures can provide superior pain relief, reduce opioid use, and decrease hospital length of stay.
As the cardiovascular response to hypovolemia may not be as apparent in older patients, this also suggests that hemodynamic stability may not be a reliable indicator for an attempt at nonoperative management of older patients with solid organ injuries. This must be kept in consideration during evaluation and management decision-making for these patients. There appears to be a trend toward an increased failure rate of nonoperative management with increasing grade of solid organ injury in geriatric trauma patients.
Early surgical intervention is still recommended for suspected solid organ injury, hemodynamic instability, and concerning abdominal exam. Overall, both operative and nonoperative management of abdominal injury is associated with higher mortality for older patients.
Hip and Pelvic Fractures
The prognosis for older patients with a hip fractures is poor, with 1-year mortality rates of 20-30%. Significant challenges exist in the management of older patients with hip and pelvic fractures including fracture management in the acute phase, timing of operative intervention, and functional outcome. These patients are at a higher risk for substantial bleeding requiring blood transfusion, angioembolization, and ICU admission. Mortality for older patients with pelvic fractures can be up to 20.5%, in comparison to mortality rate of 6.2% for younger patients.
While hip and pelvic fractures are the most common fractures in adults over the age of 65, distal radius and proximal humerus fractures are the second and third most common fractures in these patients. Decision-making surrounding operative timing is dependent on other injuries, clinical and physiologic status, and the extent of the orthopedic operation planned. Operative fracture fixation should be performed as early as possible once life-threatening injuries have been addressed. This will also allow for early physical mobilization and can improve clinical outcomes.
For a given burn size, older patients are at risk for higher morbidity and mortality than younger patients. This is largely due to impaired mobility and diminished senses, which result in deeper and more extensive burns. Inhalation injuries are poorly tolerated and add significantly to patient morbidity and poor survival.
Various formulas (ex. rule of tens, Parkland, modified Brooke) and algorithms (ex. Baux score) use factors such as patient age, weight, and burn total body surface area to guide fluid resuscitation and predict percent mortality, respectively. As older age is a negative predictor of survival for burn patients, it is important to establish realistic expectations and have goals of care discussions with patients and their families to determine the most appropriate approach to burn management.
Palliative and End-of-Life Care
Palliative care takes on a multidisciplinary, patient-centered approach targeted at improving the quality of life for patients with serious illnesses, as well as their families, while concentrating efforts on their physical, mental, emotional, and spiritual well-being. Parallel delivery of palliative care alongside and integrated with trauma care is critical and can be associated with shorter hospitalization, decreased cost of care, and reduced non-beneficial care at the end of life without affecting rate of mortality.
Older, and especially frail, patients are at greater risk of adverse outcomes to injury in comparison to younger and non-frail patients. These patients should trigger additional assessments and care practices related to palliative care. Important components of palliative care include identifying a health care proxy, advance care planning, pain and symptom management, goals of care discussion, and family support. Goals of care discussions are particularly imperative for subsequent decision-making surrounding the extent of life-sustaining interventions desired and protocols related with withdrawal of care to ensure they are aligned with the patient’s goals.
- Trauma teams are encountering more older patients. Geriatric trauma patients experience worse clinical outcomes during the acute phase as well as long-term survival in comparison to a younger group.
- Multiple age-related anatomic and physiologic changes contribute to older trauma patients’ increased susceptibility and decreased ability to compensate to the stress of injury. As compared to younger patients, low impact mechanisms of trauma may lead to significant injury in older patients.
- Clinicians caring for older trauma patients should be aware of the additional hazards associated with baseline comorbidity, frailty, functional impairment, polypharmacy, anticoagulation, and antihypertensives.
- Early recognition of critically ill and injured older patients is of paramount importance to perform timely interventions, optimize outcomes, and improve survival. Close monitoring of vital signs, mental status, and reassessment of additional areas of concern are essential. Field triage should reflect a low threshold to transfer older adults to a high level of care.
- Geriatric-focused interdisciplinary care focused on improving mobility, recognizing cognitive impairment, avoiding delirium and hazardous medications, and aligning treatment with the patient’s overall health goals provides comprehensive care for older patients and improves outcomes.
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