Aug. 21, 2018
If Grandpa slips on the bathroom rug and falls, it may not sound like a big deal. According to Steven E. Brooks, M.D., and others in research published in Surgical Clinics of North America in 2017, however, if Grandpa is age 65 or older — the U.S. Census Bureau's definition of elderly — it may well be a grave incident. Grandpa's skeletal system may be more fragile, he may have chronic conditions such as rheumatoid arthritis or diabetes, his heart may be weaker, and he may take multiple medications. In short, his resilience is not the same as in a younger patient.
"Even with what we'd call a relatively minor mechanism of injury or lower speed conditions, injuries are much more significant for geriatric patients," says Scott P. Zietlow, M.D., Mayo Clinic trauma surgeon in Rochester, Minnesota, and a medical director of Mayo Clinic Medical Transport. "With the same injury in a 75-year-old versus a 25-year-old, the mortality rate doubles."
The most common mechanisms of injury for geriatric patients include, in descending order:
- Falls, frequently down stairs or from standing height
- Motor vehicle accidents
- Pedestrian accidents with a motor vehicle
Distinctive aspects of geriatric resuscitation
As geriatric patients lack the physiological reserve of their younger counterparts, with every organ less injury tolerant, resuscitating geriatric patients after traumatic injury is also distinct. Beyond the issues indicated in the above case, other issues the team should recognize in resuscitating a geriatric patient include blood pressure, heart rate, exsanguination risk and other subtle signs.
Compared with younger patients, geriatric patients are less tolerant of low blood pressure — they may need the care of a trauma center sooner and to receive resuscitation more quickly than patients under age 65.
The heart rate may not pick up to compensate for traumatic injury in geriatric patients, thus recovery is not as robust as in nongeriatric counterparts.
Because geriatric patients often are prescribed anticoagulants, bleeding is far more serious and poses a higher exsanguination risk. This is a particular issue with head injuries, as anticoagulative agents increase internal bleeding, which can necessitate surgery and pose further challenges in returning to baseline post-injury.
Indications that geriatric patients are deteriorating may be difficult to perceive, yet they warrant earlier and greater attention than do those in younger patients. The appearance of geriatric patients may fool care providers into thinking their statuses are more positive than they are, and sudden changes may occur.
Though the need for resuscitation post-traumatic injury is greater in geriatric patients than in younger patients, the anatomy and physiology of geriatric patients can't tolerate overly aggressive resuscitation.
"It's a Goldilocks kind of thing with resuscitating elderly patients — can't be too hot or too cold, but just right," says Dr. Zietlow. "Resuscitation needs to be aggressive enough to provide the best outcomes but gentle enough not to damage their bodies."
Establishing care goals also is critical. It's important for the trauma team to know what geriatric patients might want: How aggressive would they want their resuscitation to be?
Dr. Zietlow often suggests decisions such as these — trying to determine the right thing to do in resuscitating geriatric patients absent their personal care goals — become clearer if the team thinks along these lines: If this was my father or grandfather, what would I want done for him?
Transfer and admission
Though there's a tendency not to transport a geriatric patient with a low mechanism of injury — considering it overkill — transferring the patient often is merited. Geriatric patients require transfer more frequently and there should be a low threshold for transporting them to a higher care level.
The geriatric population also has higher admission rates. This is because conditions such as rib fractures in which a younger patient might be sent home after seeing the trauma team may warrant admission for older patients.
Uniquenesses beyond resuscitation
Once admitted to the hospital, geriatric patients require significant resources. According to Dr. Zietlow, while geriatric patients represent 10 to 15 percent of trauma's patient population, they consume about one-third of trauma resources. Their physicians more frequently send them to the ICU for further heart and lung monitoring, and hospital stays tend to be longer.
Challenges for geriatric patients — compared with those of patients under age 65 — extend beyond initial resuscitation as they seek to return to normal life after traumatic injury. Challenges include slow healing, additional rehabilitation and medication reconciliation.
Geriatric patients suffering fractures heal more slowly. In addition, extremity and spinal fractures are common in this patient population, which can markedly affect patients' ability to return to self-care and often require transitional facilities. Underlying chronic conditions also can delay restoration of previous health status post-injury.
Older adults require more rehabilitation to return to independent functioning, yet at the same time often are not offered as extensive inpatient and outpatient rehab as are younger patients because of payer or availability issues.
Because geriatric patients use more prescription medicines than younger patients do, a trauma visit often requires reassessment of the patient's entire medication regimen to ensure continued suitability.
Despite more challenges with getting back to baseline and independent living after trauma, the majority of geriatric patients do so, says Dr. Zietlow.
"We know a lot of elderly folks who are doing fantastic — it's not all doom and gloom," he says.
As the number of people in the U.S. over age 65 grows exponentially, with those over age 80 as possibly the fastest growing segment, knowing what to expect and how to care for geriatric patients undergoing trauma from resuscitation and beyond is imperative, says Dr. Zietlow.
For more information
Statistical Brief: Sixty-Five Plus in the United States. U.S. Census Bureau. Accessed July 11, 2018.
Brooks SE, et al. Evidence-based care of geriatric trauma patients. Surgical Clinics of North America. 2017;97:1157.