Geriatric Trauma Care: Integrating Geriatric Medicine Consultation Within a Trauma Service

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Citation:

Pages 38 - 42

Authors:

Peter A. DeGolia, MD, CMD, Erin L. Rader, MSN, RN, CNS, Joel R. Peerless, MD, FCCP, FCCM, Lorraine C.
Mion, PhD, RN, FAAN, James W. Campbell, MD, MS, AGSF, and William F. Fallon, Jr., MD, MBA, FACS

Author Affiliations:

Dr. DeGolia is Associate Professor, Department of Family Medicine, School of Medicine, Case Western Reserve University, and Director, Center for Geriatric Medicine, University Hospitals Case Medical Center; Ms. Rader is a Clinical Faculty member, Francis Payne Bolton School of Nursing, Case Western Reserve University, and Advanced Practice Nurse, Department of Family Medicine and Geriatrics, MetroHealth Medical Center; Dr. Peerless is Associate Professor, Departments of Surgery, Anesthesiology, and Medicine, School of Medicine, Case Western Reserve University, and Director, Surgical Critical Care, MetroHealth Medical Center, Cleveland, OH; Dr. Mion is the Independent Foundation Professor of Nursing, School of Nursing, Vanderbilt University, Nashville, TN; Dr. Campbell is Professor, Department of Family Medicine, School of Medicine, Case Western Reserve University, and Chairman of Family Medicine/Director of Geriatrics, MetroHealth Medical Center, Cleveland, OH; and Dr. Fallon is Associate Professor of Surgery, Department of Surgery, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, and Chairman, Surgery, Director, Trauma Services, Summa Health System, Akron City Hospital, Akron, OH.

Introduction

Human aging and its impact on individuals and society will transcend all specialties of medicine and become the unprecedented focus of the 21st century. The U.S. population age 65 years and older is anticipated to grow from 12% in 2000 to 20% in 2030. This represents an increase from 35 million to 72 million older adults. Moreover, the fastest growing cohort among older adults is the 85-and-older group, increasing at three to four times that of the general U.S. population. Clinical and ethical issues related to the care of older adults, particularly in trauma care, will become more prominent as the population ages. With fewer disabilities and more active lifestyles than in previous generations, today’s older adults are at increased risk for injury. Currently, this older population accounts for 12% of all U.S. trauma cases. By 2050, 40% of all trauma patients will be age 65 years or older.1

Despite accounting for approximately one-tenth of the trauma patient population, older adults consume one-third of all trauma healthcare resources.2 Even when controlling for the type and severity of injury, older adults consume greater healthcare resources as compared with younger adults. Older trauma patients, even with minor levels of injury with an Injury Severity Score (ISS) lower than 9 (scale ranges from 1 to 75, mild to severe), also have higher mortality rates as compared with younger patients at each level of trauma severity.3,4 The oldest-old (≥ 80 yr) have the highest mortality rates.5

In-hospital complications occur at rates of 33% among geriatric trauma patients as compared with 19% for younger adults, with cardiovascular events (23%) and pneumonia (22%) being most common.4 Older trauma patients have longer hospital lengths of stay (mean, 9.2 ± 9.6 days) as compared with younger patients (mean, 8.3 ± 10.0 days), although their admission rates to the Intensive Care Unit (ICU) are lower (36.7% vs 45.5%). Thus, early identification and management of new or existing medical issues that complicate recovery may improve trauma outcomes in older patients. The higher morbidity and mortality among older adults are a reflection of preexisting medical conditions, altered responses to apparently minor injuries, and atypical physiologic signs of injury. These differences define the unique problems of assessment and management of the injured geriatric patient. Although 32% of all this population’s trauma deaths are thought to be associated with preventable complications, 62% of deaths are caused by multiple organ failure or sepsis.6

Trauma Service and Older Adults

The three primary mechanisms of injury in older adults are falls, motor vehicle collisions (MVCs), and pedestrian MVCs. Falls, the most common mechanism of injury, are responsible for significant morbidity, mortality, and medical cost7; MVC and pedestrian MVC injuries rank second and third. Head injuries caused by falls and pedestrian MVC often include subdural hematomas due to fragile bridging veins and increased distance between the dura and brain parenchyma. This increased intracranial distance and the generalized cerebral atrophy that occurs with aging lessen the increase in intracranial pressure and result in only subtle neurologic changes that are often overlooked. Pelvic, spine, and extremity fractures associated with osteoporosis are especially common in older women. Pelvic fractures are the most serious skeletal injury in older patients, yet unsatisfactory functional outcomes can result from any type of extremity fracture, regardless of the type of treatment.8

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