Trauma in Elders handout - cdn.ymaws.com · Acute Care Practice Stacey Maguire, PT, DPT, Neurologic...

Trauma In Elders:Applying Evidence to Acute Care Practice

Stacey Maguire, PT, DPT, Neurologic Certified SpecialistLaura Driscoll, PT, DPT, Geriatric Certified Specialist

Shannon Stillwell, PT, DPT, Geriatric Certified Specialist

Disclosures

• The presenters have no potential conflicts of interest to report.

Learning Objectives

• Recall how the aging process leads to physiological changes that compromise the ability of elders to respond to the stress of injury.

• Explain the PT’s role in reviewing medications and recognizing psychosocial issues and their potential impact upon health, impairments, functional limitations, and disabilities.

• Apply a hypothesis driven examination strategy to initial evaluation of an elder after trauma in the hospital setting.

• Appreciate the risk factors for development of delirium, as well as tests for screening and interventions to delirium.

• Create therapeutic interventions of proper intensity to address a variety of common impairments in elders who have been hospitalized after trauma.

• Recognize the value of utilizing standardized tests and outcome measures to help drive clinical decision making.

• Understand the value of developing a patient-centered discharge plan.

Why Geriatric Trauma?

Epidemiology

• Those aged 65 or over.

• The most rapidly growing segment of the population.

• By 2050, this number of geriatric individuals is expected to grow to 2 billion.

• Living longer and leading more active lifestyles.(Tieland, 2017)

Geriatric trauma

Why does trauma happen in older adults?• Leading causes:

• #1 Falls• #2 Motor vehicle accidents

What makes elders unique?• Elders are more susceptible to injury.

• Pre-existent comorbidities• Pre-existent impairments in body structure and function

• Traditional trauma outcomes are not applicable to elders.(Gaebel, 2017; Brooks, 2017)

Geriatric traumaElders are less likely to receive care in trauma centers.• Under triaged = Adverse Outcomes

How prevalent is trauma in elders?• 9th leading cause of death amongst the elderly, BUT:

• 35% of trauma healthcare expenditures(Gaebel, 2017; Brooks, 2017)

What Are the Physiological Changesthat Make Elders Vulnerable?

Physiological Changes

• Connective Tissue Changes• Decreased water content• Increased stiffness• Decreased strength• Decreased cross sectional area and volume

• Joint Structure and Function Changes• Limited healing• High load activities/occupations = OA• Decreased water content in discs• Increased stiffness and decreased ROM

(Guccione, 2011)

• Boney Changes• Increased osteoclast activity, decreased osteoblast

activity• Decreased ability to absorb load• Increased risk of fracture with age

• Muscular Changes• Atrophy of muscle à muscles mass replaced with fat• Steady decline of strength• Slowing of contractile properties

• Type II fast twitch atrophy faster than Type I slow twitch• Decreased force production

• Sarcopenia(Guccione, 2011)

• Cardiovascular Changes• Stiffer myocardium = Decreased pump effectiveness

• Decreased cardiac output• Loss of heart rate variability• Cardiac function declines by 50% by the time we are 80

• Pulmonary Changes• Anatomic, muscular and connective tissue changes • Ineffective pulmonary system• Decreased ability to fight off post-operative complication

• Neurological Changes• Cortical atrophy• Plaque build up

(Sharma, 2006; Vigorito, 2014)

• Other Systyems• Endocrine Changes

• Decreased VitaminD• Decreased Estrogen and Testosterone• Increased Insulin resistance

• Malnutrition• Altered Drug Metabolism

(Guccione, 2011)

So what does this mean for Elders?

Physiological Frailty Phenotype

• Weight Loss

• Exhaustion

• Physical Activity

• Walk Time

• Grip Strength(Bellal, 2014; Fried, 2001)

Application to PT

ICF Model

• Impairments in body functions and structures:

• ROM• Strength/Force Production• Joint Mobility/Integrity• Posture• Endurance

• Activity Restrictions• Impaired Balance• Impaired Gait• Impaired ADLs

• Participation Restrictions• Family roles• Occupational roles• Leisure roles• Loss of independence

Mrs M.• 87 year old female admitted s/p fall down stairs• Found down by her sister

• + Loss of consciousness

• Sustained several injuries• Non-displaced fractures of maxillary wall• L orbital floor fracture, small L subdural hematoma• L 8th and 9th rib fractures.

• Hypotensive on admission

• Found to have urinary tract infection

Past medical/surgical history

• Ventricular arrhythmia s/p pacemaker placement• Mitral regurgitation• Coronary artery disease s/p stents 2014• Congestive heart failure (ischemic cardiomyopathy with reduced

ejection fraction: 25%)• Hypertension• Hyperlipidemia • Gallstone pancreatitis s/p laparoscopic cholecystectomy • Hard of hearing in right ear• s/p hysterectomy • s/p back surgeries (unknown)

Imaging

• Head CT: small acute L subdural hematoma without evidence of midline shift. Non-displaced fractures of maxillary wall, L orbital floor fracture.

• Chest XR: L posterolateral 8th and 9th rib fractures

Labs

• Positive Urine Culture (Klebsiella Oxytoca)

Test Name Value Reference RangeWBC 8.7 4.0-10.0 K/uLHgb 8.0* 11.2-15.7 g/dLHct 25.4 34-35%Plts 242 150-400Cr 1.3* 0.4-1.1 mg/dLBUN 30* mg/dL

What do we want to learn about Mrs M?

Patient Interview

• Social and Work History

• Living Situation

• Baseline functional and activity level

• Detailed information regarding falls: frequency, symptomatology, situational information

• Medications and management

• Screening for psychosocial considerations (depression, neglect, abuse)

Social / Functional History

• Retired. Previously employed in various jobs. Enjoys crafting.

• Widowed. Lives with son and daughter-in-law. Enjoys time with her twin, who lives in Maine.

• Two story home with 10 steps to enter with bilateral railings.

• Baseline independent ambulation without assistive device. Independent in ADLs. Family assist with IADLs. Independent medication management. Drives short distances. Sedentary.

• +hard of hearing R ear (doesn’t use hearing aide), no visual aides

• History of falls, usually about 2/year, but reports 2 in past 2 weeks.

Patient Interview







“Physical Therapist patient/client management integrates an understanding of a patient’s/client’s prescription and nonprescription medication regimen with consideration of it’s impact upon health, impairments, functional limitations, and disabilities.” https://www.apta.org/uploadedFiles/APTAorg/Payment/Medicare/Coding_and_Billing/Home_Health/Comments/Statement_MedicationManagement_102610.pdf

APTA Position Statement

Why is medication management an important consideration with elders?

POLYPHARMACY

• The use of multiple medications by a patient

• Varying definitions of number of medications (range 5-10)

• In a 2003 survey 46% of Medicare beneficiaries were taking 5 or more medications

(Fried et al, 2014)

AGE-RELATED CHANGES

•Increased distribution

•Natural decline of renal and hepatic function

•Larger drug storage and decreased clearance = increased plasma concentrations

•Increased sensitivity

Consequences of Polypharmacy

• Increased health care costs

• Adverse drug reactions

• Drug interactions

• Non-adherence

• Cognitive Impairments

• Falls

• Urinary incontinence

• Poor nutrition

• Functional decline

Polypharmacy and falls

Kojima et al, 2012: • Followed 172 patients for two years and documented fall

occurrence (by self report).• Falls were associated with older age, osteoporosis, number of

comorbid conditions and number of medications. • Number of medications (5 or more) was independent

predictor of falls.

American Geriatric SocietyBeers Criteria:

Potentially inappropriate medications

• Anticonvulsants

• Antipsychotics

• Benzodiazepines

• Eszopiclone, Zaleplon, Zolpidem (Nonbenzodiazepine Hypnotic Agents)

• Tricyclic Antidepressant Agents (TCAs)

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Opioids (excludes pain management due to recent fracture or joint replacement)

(American Geriatrics Society 2015 Beers Criteria Update Expert Panel)

Mrs M: Home Medications

• Plavix 75 daily

• Atorvastatin 20mg daily

• Metoprolol 100mg twice daily

• Losartan 50mg daily

• Ranexa 500mg SR q12hours

• Spironolactone 25mg daily

• Lasix 40mg daily

• Lantanoprost 0.005% eye drops, both eyes q HS

Patient Interview







Depression

> 1 in 10 elders in the US has depression.• This frequency increases in elders with chronic illness.

(Steffens, 2009)

Associated with poor physical performance• 970 non-depressed elders in Italy, followed for 4 years• Associated identified between poor performance at baseline

and the development of depression(Veronese et al, 2017)

Attitudes and beliefs about depression in elders

• 58% believe it is a normal part of aging.

• 38% believe it is a health problem.

• 42% would seek help from a health professional.(http://www.mentalhealthamerica.net/conditions/depression-older-adults-more-facts)

Hypothesis-driven exam

• Targeted impairment-level testing• Standardized outcome measures

• Goals:o Make a clear connection from Pathology to Activity to

Participation.o Determine etiology of falls.

What are the priorities of her physical exam?

IMPAIRMENT LEVEL TESTING: Cognition

• Alert and oriented to self, birthdate, place, date and situation.

• Follows all simple and 2 step commands with single verbal cue.

Is this enough?

Impairment level testing: cognition

(Ahmed, 2014)

Risk factors for delirium among older people in acute hospital medical units

Delirium: Definition

Core features of DSM-IV criteria:1. Disturbance of consciousness with reduced ability to sustain, or

shift attention

2. Change in cognition or development of a perceptual disturbance

not better explained by a pre-existing condition

3. Disturbance develops over a short period of time and tends to

fluctuate during course of the day

Epidemiology

More than 7 million hospitalized Americans experience delirium each year

Clinical Variants

Mixed

Hyperactive Hypoactive

Restless/agitatedAggressive/hyper-reactiveAutonomic arousal15-47% of cases

Lethargic/drowsyApathetic/inactiveQuiet/confusedOften escapes diagnosisOften mistaken for depression19-71% of cases

43-56% of cases

DELIRIUM: LONG TERM EFFECTS

• Neurocognitive sequelae following critical illness:• Common• May be permanent • Associated with impaired ADLs/QOL and inability to return to work

• Evidence from 10 cohorts suggest 25 to 78% survivors experience neurocognitive impairments

• In patients with ARDS the prevalence of neurocognitive impairment may be as high as:

• 78% at d/c • 46% at one year• 25% at 6 years

Hopkins, R et al 2005

Confusion Assessment Method (CAM)

IMPAIRMENT LEVEL TESTING: Hemodynamic Response Considerations

• Goal directed: What are you looking for?• Positional Tolerance • Activity Tolerance • Pulmonary Tolerance

• Assessing a baseline is crucial.• Consider the position of the patient.

Mrs. M’s Vital signs

Heart Rate Blood Pressure Respiratory Rate SpO2

Rest, Supine 80 112/46 16 98% 2L NC

Rest, Sitting 88 100/54 28 92% RA

Rest, Standing 92 92/48 28 92% RA

Ambulation, Standing

96 100/52 24 86% RA, 94% 2L NC

Recovery 80 110/52 16 96% 2L NC

Integumentary

• Bilateral LE 2+ pitting edema distal to knee to foot

• Bilateral LE hypertrophic toe nails

• Bruising noted throughout L thorax and under chin

Functional Performance

• Bed mobility: MinA with use of bed rail • Sit to stand: minA, required multiple attempts• Ambulation: 50’x2 with RW and CGA, seated

break• Decreased step length and cadence with wide base of

support • Flexed posture with inability to achieve full hip

extension

• Stand to Sit: minA 2/2 poor eccentric control

Musculoskeletal findings

Posture• Flexed trunk with increased thoracic kyphosis, scapular protraction

Strength• Bilateral UEs grossly 3+/5, limited by pain from rib fractures• Bilateral LEs 4/5, suspect B hip extensors weakness which were

observed to be weak with both ambulation and stand to sit

ROM• WFL bilateral UEs/LEs except bilateral ankle DF to neutral only

Sensation• Denies paresthesias, bilateral great toe proprioception intact

Pain

INTENSITY

• 7/10 rest

• 9/10 mobility/deep breaths

• 8/10 recovery

LOCATION

• L thorax

QUALITY

• Constant, worst with deep breaths and mobility

• Sharp, aching

Pulmonary Exam

• Gas Exchange: impaired with ambulation, requires supplemental O2 via nasal cannula

• Ventilation: impaired with incentive spirometer noted to 500mL • Thoracic Excursion: impaired, decreased excursion L > R• Cough Strength/Effectiveness: weak, congested cough, non-

productive of sputum• Auscultation: crackles noted throughout posterior lungs,

diminished L > R

What does all of this information mean?

Physiological Frailty Phenotype

Initial interventions

Interventions

Interdisciplinary Care

Coordination Exercise Prevention Advocacy

Medication changesPain controlPsychosocial Concerns

Targeted therexPulmonary careFunctional mobilityBalance

DeliriumPNAFalls

D/C dispositionRehab needs after d/cLong term outcomesPatient’s values

Physical therapy intervention: Exercise

Exercise Considerations

• MODE

• FREQUENCY

• INTENSITY

• DURATIONExercise

Exercise Intensity

• Overload stimulus is key• 60-80% of 1 rep maximum• At least one set• 2-3x/week • Intersperse strengthening with aerobic exercises and motor

learning activities• Continual re-assessment• Consider Rate of Perceived Exertion (RPE) use, especially in

the hospital setting

(Guccione, 2011; Avers, 2009)Exercise

What does this mean in the Hospital Setting?

• Prescribe therapeutic exercise of adequate intensity

• Use RPE• Target weak muscles that will improve

function• Utilize your rehab aides and other ancillary staff• Empower your patients to perform their exercise

programs independently

Exercise

How do we intervene for pulmonary deficits?

Thoracic Trauma Interventions

• Main goal is to prevent pneumonia (PNA) and other complications

• Pain control• Pulmonary hygiene

• Splinted Coughing• Deep breathing• Chest wall excursion• Incentive Spirometer use• Advocate for frequent walking with nursing

(Shulzhenko, 2017; Winters, 2009)Exercise

Advocate for optimal medical management

Evidenced Based Intervention: Advocate for Optimal pain management

• Increased pain means decreased likelihood of discharge home.

(Brotemarkle, 2015)

• Scheduled acetaminophen if appropriate.(Inouye, 2015)

• Adequate pain control reduces delirium.(American Geriatrics Society, 2015)


Coordination

Interventions to Address Medication management

• Patient/Caregiver Education: • Timing• Understanding of effects • Management • Empower to advocate for changes if indicated

• Medication Reconciliation: • Consider Beers Criteria and discuss high risk medications • Advocate for Pharmacist or Geriatrician involvement (Pellegrin, 2017)

• Communicate suspected medication effects and impact on patient presentation Interdisciplinary

Care Coordination

Evidence Based Interventions: Advocate for Geriatrics consultation

• Involvement of geriatricians has been associated with:

• Lower rates of delirium and discharge to long term care.

(Lenartowicz, 2012)• A reduction in hospital-acquired complications such as

functional decline, falls, delirium, and death. (Fallon, 2006)

• Better recovery of function over the year following injury.

(Tillou, 2014) Interdisciplinary Care

Coordination

Address psychosocial issues

• Advocate for social work consult: • Emotional support and coping• Possible facilitation of outpatient follow up

with mental health services


Coordination

Minimize risk of delirium

Delirium is preventable in 30–40% of cases

(Sidiqqi, 2016)

Evidence Based Intervention: Best Practice Statement from the American Geriatrics Society

• Sensory enhancement• Mobility enhancement • Orientation protocols • Cognitive stimulation• Nutritional and fluid repletion enhancement• Sleep• Medication review • Minimization of restraints and tethers

(Inouye, 2015)Prevention

Discharge Planning

Evidence Based Interventions: Discharge Planning

• 30% of patients reported having received < 1 day advance notice of discharge.

(Horwitz, 2013)

• Poorly coordinated transitions of care can lead to:• Adverse medication events• Patient and caregiver dissatisfaction• Functional decline

(Jeffs, 2017)

Advocacy

Functional Performance

Activity Initial Evaluation Hospital Day 5

Bed Mobility Min A with bed rail Min A (without rail)

Sit to Stand Min A Independent

Ambulation 50’x2 with RW and CGA

Decreased step length and cadence with wide base of support

Stooped posture with inability to achieve full hip extension

150’ with RW, S

Improved but still with deviations present

Gait Speed: 0.67m/s

DGI: 17/24

Stand to Sit Min A Independent

Stairs N/A Flight of stairs with step-to pattern and S

Ongoing evidence based examination: Value of standardized tests and outcome measures

• Inform discharge recommendations (Bland, 2014)

• Evidence-based approach (Jette, 2003)

• Quantify observations (Potter, 2011; Sullivan, 2011)

• Improve continuity of care between settings (Thier, 2006)

• Identification of impairments (Guide to Physical Therapist Practice)

• Establish a baseline (Guide to Physical Therapist Practice)

How Do You Select an Appropriate Standardized Test or Outcome Measure?

• Feasibility of use in setting• Valid and reliable for population• Identify impairments central to patient presentation • Functional prognosis/Discharge disposition• Responsiveness to change

Mrs M’s Results

Comfortable Walking Speed• Pt demonstrated a comfortable

walking speed of 0.67m/s over 10m using a RW.

Dynamic Gait Index• Pt scored a 17/24.

How do we make a decision?

DISCHARGE PLANNING:PATIENT CENTERED PRACTICE

• “Physical therapists should account for patient’s sense of identity, goals, history, and social context in order to engage in a process of communication and deliberation with the patient, with the goal of maximizing patient autonomy and developing a patient-centered care plan that call can accept.”

• For action to qualify as autonomous, a substantial degree of understanding is required. (Hunt, 2011)

Advocacy

Discharge planning

• Optimal care of the injured older adult does not end with

acute care

• Proper rehab is important to maximize functional outcomes

• Trauma admissions to SNF doubled from 2003-2009

• (Ayoung-Chee, 2013)

• Recent legislation enforcing joint hospital – SNF

responsibility for outcomes and associated costs may

intensify the focus on patient selection for SNF (Burke, 2017)

Advocacy

Discharge planning: Home vs. Rehab

• Values• Safety• Amount and Intensity of Therapy• Functional Outcomes

Advocacy

Discharge planning: Drivers

• Advances in medical care and changes in payer reimbursement lead to decreased LOS and expedited D/C

• SNF becomes a safety net• Knowledge deficit re: SNF practices, quality and patient

outcomes• Lack of standardized evaluation process or clear primary

decision maker• (Burke, 2017)

Advocacy

Evidence to support disposition

HOME REHAB

Impairments in body functions & structures:

• Exercise• Pulmonary

Activity Restrictions• Balance• Mobility• ADL

Participation Restrictions• Family role

Health Condition• Medication changes• UTI treatment

Personal Factors• Depression screen• Delirium prevention• Patient’s goals

Environmental Factors• Family assistance• Home set up AdvocacyPrevention


CoordinationExercise

In Conclusion…

• Consider age related changes and how they affect the performance and care of older adults

• Consider impact of medications and the PT role in management• Maximize examinations by performing strategic hypothesis-

driven exams• Maximize interventions with knowledge of pathophysiology and

application of evidence• Perform patient-centered discharge planning

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