Nov. 06, 2021
Donna M. Miller, M.D., a hospitalist and geriatrician at Mayo Clinic's campus in Rochester, Minnesota, suggests the analogy of a slinky when considering the impact of trauma on geriatric patients compared with younger patients.
"A slinky that's not old or frail can stretch and still go back to its perfect self," she says. "In geriatrics, when you twist the slinky, it may be difficult or impossible to get back to its former self again. The reserve to spring back from acute stressors is lower."
A traumatic injury increases the risk of mortality for older adults more than for younger counterparts. The risk of morbidity for older adults experiencing trauma is often less recognized, however, says Dr. Miller. She also explains that advancing age, especially if coupled with frailty, is akin to walking a tightrope. "Even a low-impact acute stressor — like a fall from standing height — can really push you off the wire," she says. "You don't have the same capacity to handle it as a younger person."
Falls are problematic for older adults, often resulting in injuries such as rib fractures. When coupled with hospitalization and new medications, the risk of additional adversity goes up. Both uncontrolled pain and medication side effects can make walking around more difficult, and the patient's risk of delirium or of a repeat fall increases. "This one-moment event with a trip and fall ends up becoming a 2- to 3-monthlong affair from which to recover," says Dr. Miller.
Falls are a major category of traumatic injury for older adults. They typically are caused by the combined effects of underlying medical and situational risk factors, according to Dr. Miller. Falls may involve events such as slipping in the bathroom, off a curb or on the stairs. Motor vehicle crashes also are a major source of traumatic injury for older adults.
Older adult population and trauma risk
As the older adult population — age 65-plus — increases, so will the volume of older patients who experience trauma. Dr. Miller is quick to acknowledge not all geriatric patients are alike: She's cared for a 95-year-old patient who's functionally robust, and a 67-year-old with cognitive issues who's functionally dependent. The key is determining who is at the highest risk of adverse outcomes in the hospital.
"We generally don't do a great job identifying vulnerable older adults unless we use formal screening tools," she says.
This population is at greater trauma risk than younger counterparts because of frailty, medical comorbidities, vision impairment, osteoporosis and polypharmacy, says Dr. Miller. Frailty also correlates with poor prognostic outcomes post-trauma. Polypharmacy plus frailty and other comorbidities increase the likelihood of needing a higher care level.
Trauma and geriatric care provider collaboration
At Mayo Clinic, trauma professionals consult Dr. Miller and geriatrician colleagues to collaborate in the hospital care of older adults with advanced age who are frail, have multiple medical comorbidities or have trauma related to falls. An American College of Surgeons Trauma Quality Programs geriatrics initiative prompted this collaboration. The geriatricians are cognizant of older adult-specific issues upon hospitalization, such as the high risk of delirium, functional decline and other medical issues.
Focus areas for geriatric patients seen in trauma
Dr. Miller encourages trauma providers to focus on the four Ms of age friendly health care — what matters, mentation, mobility and medications — from the Institute for Healthcare Improvement:
- It's important to understand each older adult's individual care goals.
- Identifying cognitive impairment or delirium risk is crucial in geriatric care, especially since 25% to 50% of older patients become delirious during hospitalization. This population also has risk of undiagnosed dementia. Patients with cognitive impairment commonly have more unsteady gaits and higher fall risk.
- It's critical that geriatric patients hospitalized post-trauma get out of bed and walk. Meanwhile, patient safety is key when patients ambulate in the hospital: Fall prevention is paramount.
- The first crucial task a geriatrician completes with older adult patients is a medication review. This review is important, given that polypharmacy and adverse drug events are very common in older adults. Medications may be a key factor leading to the patient's injury. The STOPP/START criteria help care providers to identify potentially inappropriate medications and optimize prescribing practices.
Dr. Miller recommends a "start low, go slow" approach to prescribing new medications to hospitalized geriatric patients. Older adults are more prone to side effects because they metabolize medications differently than younger patients. Blood pressure medications, diuretics, central-acting pain medications and anticoagulants particularly need careful, slow adjustment.
"If we could do well with the four Ms, we'd be strides ahead of the U.S. health care system today," she says.
For more information
What is an age-friendly health system? Institute for Healthcare Improvement.
O'Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age and Ageing. 2015;44:213.