Pam Wills-Mertz, RN

April 25, 2015

Disclosures:None

Objectives:Definition of geriatric, discussion of epidemiologyDiscussion of age-related changes that can mask

the severity of traumatic injuryDiscussion of how co-morbid conditions can change

outcomesDiscussion of the risks of medication use in geriatric

traumaDiscussion of common MOIDiscussion of field triage

What is old?

Aging is:.... the normal, predictable, and irreversible changes

of various organ systems over the passage of time that ultimately lead to death ….

Age is a state of mind…

So, what is old, elderly, geriatric?

Chronological age v. physiological age65 is a societal and social norm65 per EAST55 per ACS-COT, TNCC, PHTLSMortality increases at 45 in males

Epidemiology:

Average American life span has increased by almost 30 years in the past century1900 = 47 years old2000 = 76 years oldClimbing…..

By 2050, people over age 64 will make up over 20% of the US population Today it is 12%

So…

Why? How?Baby boomersMedical advancesActive lifestyle

More risk? Less risk?

Unique Characteristics:

Age-related changes in anatomy and physiology

Pre-existing diseases and co-morbidities

MedicationsPossibility of elder

maltreatment

Age-related Changes:↓ Brain mass

Eye disease

↓ Depth of perception

↓ Discrimination of colors

↓ Pupillary response

↓ Respiratory vital capacity

↓ Renal function

2- to 3-inch loss in height

Impaired blood flow to lower leg(s)

↓ Degeneration of the joints

Total body water

Nerve damage (peripheral neuropathy)

Stroke

Diminished hearing

↓Sense of smell and taste

↓Saliva production

↓Esophageal activity

↓Cardiac stroke volume and rate

Heart disease and high blood pressure

Kidney disease

↓Gastric secretions

↓Number of body cells

↓Elasticity of skin, thinning of epidermis

15 – 30% body fat

Older people

who sustain

injuries are more likely to die as a result of

them, regardless

of the severity of

injury.

Despite the considerable proportion of trauma care resources

consumed by the oldest people,

research is directed towards needs of

younger ones.

More facts:Young trauma victims are maleOlder trauma victims are female

Thinner bonesMore likely to fracture

MortalityPeak 1 month s/p femurHigher mortality after injuryA considerable time25% die within one year

Cardiovascular:

Less Effective PumpMinimal ReserveMedication EffectsIschemia/HypoxiaArrhythmiasCautious with fluids

Renal:

Functional ChangesLoss of Surface AreaDiminished Renal Blood

FlowProgressive Decline in

filtration function

Respiratory:Lungs

Decreased elasticityDecreased alveolar number and

functionDecreased baseline p02Diminished respiratory reserve

MusculoskeletalKyphosisDecreased Chest Wall Strength Increased Chest Wall Rigidity

Infectious Risks Increased Bacterial ColonizationDecreased Force of CoughDecreased Clearance Rate

Central Nervous System:(Functional Changes)AuditoryCognition

acquisition of new datamemory - short and long

term

ProprioceptionVisual Acuity

glare intolerancecolor perceptionvisual fields

Nervous System:Structural Changes

10% Reduction in Brain Weight

Loss/Degeneration of Neurons

Cerebral AtrophyCerebrovascular Changes

Confounding FactorsBrain/Skull RelationshipCervical SpineAltered “Baseline” Mental

Status

Quick Tip:

A complete interview and careful inspection of the head is essential.

Also, review medications for anticoagulants and ask about the use of aspirin, vitamin E, gingko biloba or other substances that may contribute to intracranial bleeding.More to come…..

Musculoskeletal:

Structural ChangesDecreased MassDegeneration of

Remaining MuscleDegeneration of Joint

CartilageOsteoporosis

Functional ChangesStrengthRange of MotionMobilityPainFracture-ProneGait

Consider this: Hospitalizations of older adults for trauma-related

injuries occur at twice the rate of the general population

The mortality rate of older trauma victims has been estimated at 6 times that of younger victims when statistically controlling for severity of injury 1/3 with an ISS > 15 will die

Older adults account for 33% of all healthcare resources spent on trauma and for 25% of injury fatalities

Morbidity & Mortality:Trauma -- 5th Leading Cause of Death

Elderly account for 12% of overall traumasBut… make up 28% of ALL trauma deaths

Physiologic changes impact morbidity & mortality Medications impact morbidity & mortality

Trauma Risk Factors:Poor visual acuityPoor visual attention Overload of informationImpaired reaction timesLimited neck rotationsSlower gaitMedication side effects Alcohol consumption

Medications:Psychotropic Medications

AntidepressantsSedatives

AntihypertensivesBeta-BlockersCalcium Channel BlockersDiuretics (volume depleted)

Anticoagulants & AntiplateletsCoumadin, AspirinPlavix

Anticoagulants & Antiplatelets:Warfarin (Coumadin)Enoxaparin (Lovenox)Dalteparin (Fragmin)Tinzaparin (Innohep)Bivalirudin (Angiomax)Aragtroban (Acova)Dabigatran (Pradaxa)Fondaparinux (Arixtra)Rivaroxaban (Xarelto)Apixaban (Eliquis)

AspirinDipyridamole

(Persantine)ASA-dipyridamole

(Aggrenox)Clopidogrel (Plavix)Prasugrel (Effient)Ticagrelor (Brilinta)Eptifibade (Integrillin)Tirofiban (Aggrestat)

Reversible:Coumadin (Warfarin)

Falls are #1:

Falls Facts:Most Common Injury > 75 YearsInjuries to head, pelvis & lower extremities are most

common90% are falls from standing

60% are at home

Neurosensory Changesaltered vision, hearing & memory cause impaired

obstacle avoidancePostural Instability

prone to loss of balance increased postural sway slowed central processing

Physiologic

DisabilitiesEnvironmental

Hazards

Behavioral

Alterations

Falls:Environmental Factors

poor lightingnew furniturenon-secured rugsloose railingsstairs

Syncopecerebral hypo perfusionseizuredysrhythmiahypoglycemia

Orthostatic Hypotensiondehydrationmedications

Gait Changespropensity to trip or

stumblefeet not picked up as highmen

wide-based

women narrow-based

Falls:

One out of every three persons over 65 years old will fall in any given year.

These falls result in fractures, admissions to the hospital, loss of the ability to live alone and death.

Women are more likely then men to sustain injuries from falls because they have less muscle mass and a greater likelihood of having osteoporosis.

Fast Facts:

One half of all elderly who sustain a fall find themselves unable to return home independently

Many older adults reduce their activity after a fall and report a fear of falling again

MVC’s are #2:

MVC Facts:

Crashes are more likely in older versus younger drivers under normal driving conditions.

The highest death rate for victims of motor vehicle crashes occurs in the lower age range of elderly (55-64 years old) followed closely by those over 74.

Left Turns:

The most common kind of crash older drivers have is when turning left into oncoming traffic.

More MVC Facts:Close to HomeDaylight HoursGood WeatherCauses

Error in Perception Pathophysiology of aging and presence

of acute and chronic medical conditions Altered Reaction Time

Abuse, Neglect, & Suicide:Older adults are more likely to be victims of abuse or

maltreatment if they are dependent or demented.Mandated reportersBe suspicious

Elderly persons over 65 account for more than 18% of all suicides.Growing problemUnder acknowledged

Obtaining a History:Simplify!

Time to respond One questionUse simple sentences.Be patient.

Personalize…Use touch, tone of voice

and eye contact to maintain attention and focus.

Make allowances for likely problems with vision and hearing.

Show, not tell.Have the patient show

you the site of pain or discomfort.

Ask the individual to take your hand and place it over any painful area.

Field Response:Decompensation may

occur rapidly and without warningReduce field

stabilization time Serial vital signs and

monitoring “110 is the new 90”Increased mortality with

SBP < 110 and HR >90

Field Response:Arthritic changes

increase potential complicationsProtect the cervical

spineBeware the “face plant”

Cervical Spine:Cervical Spine Injuries

Just as in young trauma Need rigid collar

Higher instance for Central Cord syndrome Due to age related narrowing of cervical canal and vascular

disease of spinal arteries Causes deficit of upper extremity strength and sensation

Field Response:Aging tends to increase

upper airway secretionsMicro aspiration is

commonAssist with airway

secretionsUse suctioning and

airway adjuncts as indicated

Dentures!

Field Response:Changes of aging increase the

risk of compromised oxygenationMonitor airway and

ventilatory effortOxygenate early and

liberally in the absence of COPD

Normal PO2 may be compromised due to normal agingMaintain O2 saturation

>90%

Field Response:The elderly may have “room for rent” within the

cranium due to loss of brain mass.Elevate head 15 to 30 degreesAssume the worstFear anticoagulationWork with their neuro baselinePitfalls

Dementia Prior CVA

General Approach:

Pre-hospital Imperative to understand past medical history and

events leading to injury Elderly have shown to be under-triaged Comorbidities often are the inciting cause of injury

Thoracic Injuries:Chest

Rib fractures are the most common injury Rib fractures double mortality

3 point restraint belts have shown to cause significant chest trauma

EKG remains the most sensitive method to predict short-term cardiac complications

Abdomen / Pelvis:Abdomen

In face of multi-system injuries, exam is unreliable Recommend liberal use of diagnostics

PelvisFractures are significant for high mortalitySignificant blood loss

Extremities:Extremity Trauma

Like all other fractures in elderly Little impact necessary for fracture Overall isolated extremity injuries are tolerated well by the

elderly Femur is the exception

Liberal radiological diagnostics recommended

Pain Management:Myth: Elderly patients experience less painRealities:

Acute and chronic pain is common in the elderly.Pain in the elderly is often under diagnosed and

under treated.Pain is often responsible for agitation, delirium and

depression.

More on Pain:Narcotics - elderly are more sensitive to pain

relieving aspects. MSO4 - still gold standard. Altered pharmacodynamics

NSAIDs - side effects more severe and common in elderly.

Cutungo, C. (2011).

End of Life Decisions:

When is enough, enough?Advanced DirectivesDNRTreatment in patient’s best interestBenefits of treatment must outweigh

consequencesTrauma is a game changer

Summary / Recommendations:Advanced age is associated with increased mortality

at all injury levels.Higher ISS for comparable mechanism of injury.Fewer physiologic abnormalities than expected for

injuriesPEC are associated with worse outcomes for each

level of injury

Summary / Recommendations:

Elderly trauma victims should be triaged to trauma centersLower threshold for activation of the trauma team for

elderly trauma patientsHigher index of suspicion Studies support the geriatric trauma specialty

The physiologic, mental and psychologic effects of aging can influence how you provide trauma care.

In the case of both intentional and unintentional injury, knowing the special needs of the geriatric trauma patient can help you avoid further injury and greatly increase the patient’s chance of survival.

Conclusion:

Thank you!!