Clinical Geriatrics

This article is the fifth in a continuing series on trauma care and the older adult. The series discusses the growing problem of trauma in the elderly, including its causes and possible ways to prevent it, care in the acute stages, and manifestations and treatment strategies when trauma involves the torso, spine, brain, and hip. Authors include skilled experts in the trauma field representing various specialties at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and the University of Maryland School of Medicine.

Introduction
Within the last 100 years, the elderly population has experienced the fastest rate of growth in the United States. From 1900 to 1994, the number of Americans age 65 and older increased elevenfold from 3 million to 33 million. By 2050, it is expected that this number will increase to 80 million.¹ The prevalence of active, elderly Americans has had a profound impact on the American healthcare system, and trauma is certainly no exception. Unlike the conventional disease processes that affect the geriatric population, trauma has a unique and complex pathophysiology that significantly increases an elderly patient’s morbidity and mortality as compared to a younger patient. With this in mind, physicians must be able to properly identify and triage the elderly trauma patient, recognize the shock state that may not be apparent at bedside evaluation, and resuscitate the patient to proper end points so that potential complications are minimized.

Diagnosis and Treatment
Adequate resuscitation of the trauma patient begins with appropriate triage. We define triage as the practice of prioritizing care based on the patient’s injuries and the available medical resources. Studies have demonstrated that the elderly trauma patient often experiences undertriage, when the patient’s injuries are underestimated by the medical system, and the patient is transferred to a facility that does not have the essential resources required for definitive care. Multiple institutions have examined this trend in geriatric trauma care, with the conclusion that there is a tendency to undertriage elderly patients because their underlying comorbidities and decreased physiologic reserve are not appreciated.² For instance, blood pressure and heart rate may not be the most sensitive indicators of physiologic distress in the elderly patient, given a likely history of hypertension and beta blockade use. These typical physiologic parameters are less reliable in the pre-hospital evaluation of the elderly patient and, as a result, an occult shock state may go unrecognized. This concept is clearly illustrated by Phillips et al,³ who examined a state-wide trauma system’s criteria for triage and its outcomes among the elderly trauma population. The Florida Trauma Triage Study demonstrated an undertriage rate of 71% when pre-hospital staff used standard physiologic criteria in the assessment of trauma patients older than age 55 years.³ In addition, the study found that the older the patient, the higher the rate of undertriage, with patients older than age 85 years experiencing an undertriage rate of 82%. The majority of injuries included motor vehicle accidents and low-velocity falls; however, the trends illustrate that a seemingly stable geriatric patient is more likely to have significant physiologic abnormalities that are subtle and may be appreciated only by evaluation of specific resuscitation end points.

With patterns of field triage in mind, one should also consider whether there should be a preferential transfer of elderly trauma patients to designated trauma centers. Meldon and colleagues⁴ performed a cohort retrospective study examining elderly patients over age 80 who were treated at Level I and Level II trauma centers versus those treated at local acute care hospitals.