Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.
Geriatric trauma is an increasingly prevalent and historically under-triaged presentation in emergency medicine.
Geriatric trauma patients deserve special consideration due to baseline physiologic differences and unique injury patterns.
Geriatric trauma patients should have comprehensive evaluations, including assessment of baseline function, medications, and access to care.
Geriatric trauma is a rapidly evolving area of interest in emergency medicine (EM). As the population ages, emergency physicians (EPs) can expect to see a surge in geriatric patients presenting with all common chief complaints, in particular trauma. Geriatric patients are defined as any patients 65 years of age or older. The geriatric population continues to grow, with 69 million Americans anticipated to be older than 65 by 2030. The incidence of geriatric trauma will rise with this growth. , More than 1 million geriatric patients experience trauma annually, and this number will continue to increase.
As of 2011, the average age of a trauma patient discharged from the hospital in the United States is 59, up from 54 in 2000. The latest data suggest geriatric patients represent 30.75% of all trauma patients. Older adults who experience trauma have worse clinical outcomes compared with younger patients. The traumatic case fatality rate increases significantly after age 65; trauma patients between ages 35 and 44 have an expected case fatality rate of 3.35, whereas those ages 75 to 84 have a rate of 6.66. Even if a traumatic injury does not cause immediate death or serious injury, geriatric patients who experience traumatic injuries have an increased mortality within the next 12 months.
The most common mechanism for trauma in older patients is falls. Ground-level falls account for approximately 2.1 million emergency department (ED) visits per year. Geriatric patients have a mortality of 7% to 11% after falls and have increased incidence of hospital and intensive care unit (ICU) admission compared with younger patients. The case fatality rate for geriatric patients who fall ranges from 4.04 (ages 65–74) to 8.11 (ages >84). Although ground-level falls are much more prevalent than other mechanisms of trauma in geriatric patients, other mechanisms typically seen include motor vehicle accidents, pedestrians struck by a vehicle, injuries related to other forms of transport, firearm injuries, and lacerations/penetrating injuries.
This article outlines common presentations for trauma in older adults, management strategies, and special circumstances that should be considered.
Age-related changes in older adults
The geriatric population has more comorbidities than younger populations. Special consideration should be taken when determining normal vital signs in the setting of trauma, given physiologic changes of aging as well as increase in comorbidities. Many geriatric patients are on medications for cardiac conditions, such as β-blockers, which may slow their heart rate artificially or blunt a physiologic tachycardic response to stress or hemorrhage. Additionally, many patients have chronic hypertension that may or may not be controlled with medications. It is crucial to obtain an accurate medication list for these patients as well as to determine when they last took each medication. Physicians who remain cognizant of these vital sign nuances can avoid the pitfalls of being falsely reassured by the lack of tachycardia or a normal blood pressure (for example, a systolic blood pressure of 110 mm Hg when a patient’s baseline is 160 mm Hg). Further information can be found in Table 1 .
|Vital Sign||Special Considerations in Geriatric Population||Concerning Values in Geriatric Patient||Traditional Trauma Activation Vitals|
Geriatric trauma patients present a challenge from a physiologic perspective. Generally, geriatric patients with preexisting conditions have higher morbidity and are more likely to die within 5 years of a traumatic injury. EPs must consider comorbidities, medications, and baseline functional status (eg, ambulatory ability and cognitive deficits) carefully when evaluating geriatric patients.
Generally, geriatric patients are more likely to be considered frail than their younger counterparts. Frailty, defined as the age-associated decline in physiologic function across multiple organ systems, makes patients both more likely to experience trauma (in particular falls) and to have poor outcomes after a trauma. ,
From a neurologic perspective, geriatric patients are more likely to have neurocognitive impairments, such as dementia, which could influence the accuracy of a medical history. They are more likely to have had prior cerebrovascular accidents, often with residual neurologic deficits. This can make it challenging to accurately assess for new deficits from a traumatic injury. Geriatric patients are more likely to be on anticoagulants or antiplatelets and also have decreased brain volume, making intracranial bleeds more prevalent and often more difficult to manage.
From a cardiopulmonary perspective, geriatric patients are much more likely to be on medications that alter hemodynamics. Additionally, they have a higher incidence of baseline cardiovascular disease. Blunt cardiac injury has a higher mortality in patients with existing cardiac conditions. Physiologically, older adults have a decline in overall respiratory function, including decreased functional residual capacity, and a higher incidence of pulmonary comorbidities, such as chronic obstructive pulmonary disease, with associated decrease in lung compliance. As a result, injuries that may not have significant implications in younger patients, such as rib fractures and pulmonary contusions, have a larger impact on geriatric patients. The most common posttraumatic hospital complication is pneumonia, which can have delayed resolution in patients with poor baseline pulmonary function.
Geriatric patients are more prone to musculoskeletal injuries compared with younger patients because they are more likely to be deconditioned and also have bone pathology, such as osteoporosis. They are more likely to suffer fractures and dislocations from minor trauma. Orthopedic injuries that may have minimal impact on the lives of younger patients can have a profound impact on functional independence, and even mortality, of geriatric patients.
Outcomes for geriatric patients who experience head injuries unequivocally are worse than in younger patients. Traumatic brain injuries (TBIs) predominantly are caused by ground-level falls and are a leading cause of mortality in geriatric patients. Studies show a mortality of up to 74% in patients older than 65. Mortality for geriatric head injury patients with a Glasgow Coma Scale score less than 8 is extremely high, and in some studies a low Glasgow Coma Scale score is thought to be predictive of death. , Recovery from serious head injuries often is delayed and results in worse cognitive and psychosocial function in older adults compared with their younger counterparts.
As patients age, the incidence of subdural hematoma after a head injury increases significantly. This is due partly to the inherent changes in vasculature and white matter in geriatric patients and exacerbated by the increased prevalence of antiplatelet and anticoagulant therapy in this population. Geriatric patients on anticoagulation may have a delayed presentation of intracranial hemorrhage, necessitating a longer period of observation after their injury. Historically, there has been controversy surrounding observation, repeat neurologic examinations, and repeat head imaging. Current data suggest head computed tomography (CT) at the time of presentation is sufficient for patients with a normal neurologic examination, patients with therapeutic/subtherapeutic international normalized ratio (INR) (if on warfarin), and for those taking novel oral anticoagulants. For those patients with a supratherapeutic INR, further observation likely is necessary; however, there remains no consensus on whether serial neurologic examinations are sufficient or if repeat imaging is warranted.
If there is an acute intracranial hemorrhage, the patient should be resuscitated as needed and evaluated by a neurosurgeon, and reversal of anticoagulation (if present) should be initiated. If the head CT is unremarkable and the patient otherwise is safe for discharge, the EP frequently is tasked with the decision on whether to continue or hold anticoagulation, particularly in patients with frequent falls. There are studies suggesting that patients with frequent falls do not have an increased risk of major bleeding, thus making it safe to continue anticoagulation. Other studies show that there are increased rates of intracranial hemorrhage in patients with frequent falls; however, there are no differences between patients on warfarin and those on aspirin only. Additionally, within this study those in the warfarin group showed that the drug was protective against stroke, intracranial hemorrhage, myocardial infarction (MI), and death. Finally, there are data to suggest that patients on warfarin would need to fall 295 times in a year for the risk of fall-related intracranial hemorrhage would outweigh the benefit of the warfarin itself.
Although these data suggest that continuing anticoagulation is safe for patients, in particular those with multiple stroke risk factors, it is prudent for EPs to evaluate each patient individually. This can be done by considering the underlying pathology being addressed with warfarin and making a calculated risk-benefit assessment using previously validated clinical decision rules when possible. The CHA 2 DS 2 -VASc score assesses the risk of stroke for patients with atrial fibrillation, a common reason for anticoagulation in the geriatric population. The risk of stroke given by this score can be weighed against the risk of major bleeding while taking anticoagulation, which can be calculated by the HAS-BLED score. If the risk of stroke exceeds the risk of major bleeding, then anticoagulation may be favored, even in light of fall risk.
Geriatric patients are more likely to have baseline spinal pathology, such as arthritis, osteoporosis, stenosis, or disk disease, than younger patients. These comorbidities predispose patients to more severe cervical (C)-spine injuries from lesser impact trauma. Although young patients have the highest risk of C-spine injury at C4-7 (the most mobile portion of the C-spine), geriatric patients have increased spinal rigidity and are more likely to suffer from injuries to odontoid and C2. Therefore, C-spine imaging often is warranted in geriatric patients with blunt trauma that may have affected the C-spine. Notably, 50% of C-spine injuries in geriatric patients are unstable, so the risk of missing this diagnosis, particularly after a low-impact trauma, is very high. Many radiologists recommend that any geriatric trauma patient who has a mechanism or findings severe enough to consider a head CT also should undergo cervical spine imaging.
Evaluation of C-spine injuries in geriatric patients generally should be done with cross-sectional imaging as opposed to plain films. When using clinical decision-making tools to determine whether these patients need a C-spine CT, EPs often look to Canadian C-spine and National Emergency X-Radiography Utilization Study (NEXUS) rules ( Box 1 ). Based on the Canadian C-spine rule, patients 65 and older are not considered low risk enough to forego imaging; therefore, limiting the utility of this tool in geriatric patients. On the other hand, the NEXUS criteria do not include age as a risk-stratifying factor, allowing its usage in older adults. A subgroup analysis of approximately 3000 older adults included in the original NEXUS study reveals a sensitivity of 100% (CI, 97.1%–100%) in older adults for clinically significant C-spine injury. Given the lack of a robust external validation of NEXUS, however, specifically in geriatric patients, some clinicians are hesitant to utilize this tool in older adults and prefer liberal imaging. For those patients who do receive a CT scan, EPs may be challenged with having to “clear the C-spine” after the negative imaging in patients with cognitive impairment. There is literature suggesting that magnetic resonance imaging (MRI) to evaluate for occult C-spine injury in blunt trauma can change management up to 6% of the time ; however, other data suggest that the incidence of occult C-spine injuries in this setting is as low as 0.12%, even in obtunded patients. This likely is due to the high quality of modern CT scanners. Furthermore, another systematic review recommends removing the C-collar after negative high-quality CT scan alone (a guideline put forth by the Eastern Association for the Surgery of Trauma). None of these studies addresses older adults in particular, which may make this information unclear, and the decision to remove a C-collar without confirmatory MRI a difficult one. Further issues surround the use of C-collars, which have been shown to cause discomfort, tissue breakdown, increased aspiration risk, and worsened delirium. It is helpful to involve the family in the discussion around the removal of the C-collar after CT scan alone versus obtaining an MRI as well as to consider the patient’s wishes, underlying functional status, and goals of care. Finally, if a patient must be sedated for MRI, the EP needs to consider the risks of sedative administration versus the likelihood of advanced imaging changing management.
C-spine imaging is recommended unless all the following criteria are met:
No posterior midline C-spine tenderness
No evidence of intoxication
Normal level of alertness
No focal neurologic deficit
No painful distracting injuries
Vertebral fractures are some of the most common osteoporotic fractures in geriatric patients. They are most common from T10 down into the lumbar spine. Recent studies suggest that most of the fractures are nonoperative and that spine immobilization can lead to worse outcomes. Therefore, early ambulation with a supportive brace often is indicated for vertebral fractures without neurologic compromise in geriatric patients. ,
Geriatric patients who suffer from blunt trauma often sustain rib fractures. Age is one of the strongest predictors of mortality after rib fractures. Rib fractures are a surrogate for major trauma, because 90% of patients with rib fractures have other traumatic injuries. Geriatric patients with rib fractures have double the mortality rates of young patients with rib fractures and this number increases proportionally with each additional rib fracture. Additionally, the risk of pneumonia, hypoventilation, pneumothorax, and respiratory failure increases with the number of fractured ribs in geriatric patients. In older patients who suffer from rib fractures, up to 34% subsequently develop pneumonia, which significantly increases risk of mortality. As a result of this, geriatric patients with multiple rib fractures usually benefit from inpatient management.
Multiple studies have demonstrated that appropriate analgesia lowers the risk of poor outcomes in geriatric patients with rib fractures, and many trauma centers have specific “rib fracture protocols” to manage pain ( Table 2 ). These protocols include multimodal analgesia in addition to pulmonary therapy, such as incentive spirometer. One study in 2005 found that epidural analgesia reduces mortality in patients with multiple rib fractures. Although rib fractures in geriatric patients historically have been managed conservatively, there has been recent advocacy for operative management, particularly for rib plating. Studies on rib plating and fracture fixation thus far have demonstrated lower mortality, decreased posttraumatic complications, and shorter rehabilitation periods than patients managed conservatively.