Jan. 05, 2018
It is a myth that treating geriatric trauma patients is just like treating any other injured patient.
The fact is that geriatric patients have unique vulnerabilities in acute illness or trauma, since as patients age, they do not have the same resources or reserves as younger people. They are more likely to experience delirium, and they are at higher risk of adverse drug events. Further, research indicates geriatric trauma patients are more likely to sustain significant injuries, even with lower forces of injury.
The United States is in the midst of significant population aging. Thus, it is increasingly important to know how to treat geriatric trauma patients. As geriatric patients are distinct from their younger counterparts, when they present with injuries at a trauma center, they require additional assessment. Some trauma centers have even developed trauma care for adults ages 60 and greater (G-60 trauma service).
A key question that arises in caring for geriatric patients is the definition of this population. Currently, this remains controversial, and boundaries for this group are an emerging area of geriatric literature.
"There is so much heterogeneity," says Donna M. Miller, M.D., a geriatrician and an internist at Mayo Clinic's campus in Rochester, Minnesota, whose patient pool is more than 50 percent over age 65. "Someone who's 90 can be much healthier than a 60-year-old. Chronological age often doesn't reflect physiological age. A patient's baseline functional status and degree of comorbidity is more important than numeric age alone in determining the risks of an adverse outcome in the setting of a major acute illness or trauma."
Common geriatric trauma cases
Though potential for trauma is present everywhere for geriatric patients, common mechanisms of injury are:
- Falls from standing height or less, such as from a wheelchair, bed or commode
- Motor vehicle crashes
- Other issues related to the physical environment of geriatric patients inside or outside the home
Older patients' presentations may also be more subtle than in younger patients, especially due to comorbid illnesses. "Atypical presentations are typical in geriatric patients," says Dr. Miller.
Though older adults are also more likely to present with frailty, there are not many specific treatments for this condition. Nonetheless, frailty or lack thereof is noteworthy, as research indicates frail patients have worse outcomes than those who are younger and heartier. As such, in all patients, but especially in those who are frail, it is important to consider patients' overall health and care goals so that their medical care plans align with their goals and preferences.
It's also important to note that geriatric trauma patients are more vulnerable to hospital-associated complications such as physical function decline, delirium and adverse drug events. Older adults also have higher mortality rates when hospitalized than their younger counterparts with a similar injury.
Recommendations for geriatric trauma care
Even if resources are limited, Dr. Miller encourages trauma practitioners to consider the following key steps when treating geriatric trauma patients:
Determine the mechanism of injury
Though this is important for all trauma patients, it can be especially important in geriatric patients for prevention of further injury. For example, if the patient sustained injuries from a fall, it's important to answer the question, "Why did the patient fall?" in order to identify and treat the modifiable fall risk factors that might prevent future falls and injury.
Review all medications
As geriatric patients are more likely than younger patients to have chronic illnesses, they are also likely to be taking more medications. A careful medication review is needed, therefore, to avoid interactions and for awareness of any side effects and susceptibilities due to the medications. Review should include over-the-counter medications and herbal supplements. Medications also often need revisiting for geriatric patients while in the hospital.
The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (Beers List) is useful for screening for potentially unnecessary medications. Another useful tool is the Screening Tool of Older Person's Prescriptions/Screening Tool to Alert Doctors to Right Treatment (STOPP/START), which suggest potential medications to stop or start. The objective, particularly in this more vulnerable population, is to reduce risk associated with inappropriate doses or types of medications for older adults.
Assess baseline health and functional status
When patients come into the trauma unit, it's useful to understand what their usual health looks like. This provides perspective in assessing whether patients' presentations are indicative of chronic or new problems. In addition, understanding what a day in their lives looks like when they are not in crisis is important, to provide thoughtful care for geriatric trauma patients. A patient's home environment and baseline independence or dependence in daily activities provides insights that influence hospital plans of care and early anticipation of discharge needs.
The prevalence of chronic cognitive impairment and dementia increases with age. Underlying cognitive problems can be a factor in the mechanism of injury, increase the risk of delirium or falls in the hospital, and impact discharge planning. One good, quick screening tool — literally taking only three minutes to conduct — for this assessment is the MINI-Cog, which involves just a clock draw and a three-item recall.
Conduct delirium screening
Delirium is an acute medical condition of confusion with underlying medical causes and serious consequences. It is common and preventable, and the diagnosis is often missed. The Confusion Assessment Method (CAM) is a rapid and reliable bedside tool for diagnosing delirium. William D. Freeman, M.D., addressed the diagnosis of patients with delirium in Evidence-Based Neurology: Management of Neurological Disorders: Second Edition in 2015.
Check orthostatic vital signs
In any older adult with a fall from standing height, practitioners should obtain orthostatic vital signs. Orthostatic hypotension is more common in geriatric patients and can cause falls or syncope. Intravascular volume status or cardiovascular medications may need to be adjusted to achieve an acceptable seated or standing blood pressure.
For general guidelines for treating older adults who have undergone trauma, Dr. Miller also recommends reviewing the American College of Surgeons' TQIP Best Practice Guidelines, a collection of resources with specifics on geriatric trauma care, massive transfusion, traumatic brain injury, orthopedic trauma and palliative care.
For more information
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatric Society.
Gallagher P, et al. STOPP (screening tool of older person's prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. International Journal of Clinical Pharmacology and Therapeutics. 2008;46:72.
Borson S. Mini-Cog: Screening for Cognitive Impairment in Older Adults.
Freeman WD. Delirium. Evidence-Based Neurology: Management of Neurological Disorders: Second Edition. 2015:75.
ACS TQIP Best Practice Guidelines. American College of Surgeons.