geriatric population. injury in aging (geriatrics) : how to handle older (geriatric) trauma victims...

Why

should

injury

Injury

especially

to the

elderly

In

be worthy

of

discussion?

Aging

Trauma is the 7th leading cause of death in older adults.Why is trauma so much more “traumatic” for older people?

LET’S DISCUSS

Measurement of injury

How old age modifies clinical features &

management (i.e. fractures,

infection, confusion, host response)

How older trauma victims differ from

younger counterparts

Healthcare and Technology Advances

Enable elderly to be more active

Live in an environment that exposes them to many dangers

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.

Injury Measurement

Scoring systems grade severity

Most scales based on: extent of anatomical injuryphysiological disturbance

Abbreviated Injury Scale (1956)Injury by body region, 1 to 5

Injury Measurement

Injury Severity Score (ISS)High validityPrevalence of significant pre-existing

conditions increases elderly

Importance of intercurrent diseases in determining outcome after injury

Acute Physiology of Chronic Health Evaluation scale (APACHE)

Severity of illness & age related to survival

Injury MeasurementSimplified Acute Physiological Score (SAPS II)

Good predictor of short and long-term mortality in the elderly

Factors influencing mortality:Intrinsic: Age, severity of acute

illness, previous health status

Extrinsic: Medical environment,

quality healthcare factors

Measuring Recovery

Most outcome studies focus on survival

Little attention is given to quality of survival

Consider rates of change for function, disability & handicap

aggressive medical and

rehabilitation of elderly

trauma victims is justified

adequate intensive treatment

may improve outcome for

elderly

Recovery

FALLS IN OLDER ADULTS

Leading cause of injury

Leading cause injury-related mortality

Account for > 60% of the total causes of injury in the US

CAUSES OF FALLS IN OLDER ADULTS

Accidents

Due to common changes of aging

Environmental hazards

Cardiac Dysrhythmias

Orthostatic Hypotension

Dizziness, Vertigo

Syncope

Vertebral-basilar insuf.

Drugs

Other

MOTOR VEHICLE COLLISION OLDER ADULTS

More than 18% trauma-related deaths

Two-vehicle collisions at intersections

Risk is increased: changes in vision, hearing,

reaction times, acute and chronic medical

conditions, alteration in judgment

HOW AGE RAISES RISK

HEARTStiffening

decreased cardiac

contractility, stroke volume,

cardiac output

Decreased sensitivity to

catecholamines

inability to mount

tachycardia in stress

HOW AGE RAISES RISK

LUNGS

Rib fracture

may lead to splinting

hypoventilation

promoting atelectasis,

pneumonia, need for

ventilatory support

THORACIC TRAUMA IN OLDER PEOPLE

Aortic rupture

Mediastinal widening

Poorly defined aortic knob

80% die at the scene

20% may be stable on

presentation

THORACIC TRAUMA IN OLDER PEOPLE

Isolated chest injuries

2-3 times death risk

Rib fractures

Falls or blows to chest

Occult pneumothorax

Hemothorax

Pulmonary contusions

Prompt mechanical ventilation

HOW AGE RAISES RISK

BRAINLoses volume and the resultant space around the brain

increased dural vein fragility

reduced dural vein elasticity

more susceptible to subdural hematomas

HOW AGE RAISES RISK

SKIN

Atrophic, extremely delicate, easily injured

High risk complications from skin injury

wound infection

burns

HEAD INJURIES IN OLDER PEOPLE Modest increase incidence rates after 60

More common in men than in women

Can be devastating in older people

GCS less than 8 fatality rate of about 90%

Survivors long hospital stays

More severe neurological deficits

Reduced capacity of aging brain to recover

HEAD INJURIES IN OLDER

PEOPLE

AS THE BRAIN AGES…

Dura tightly adherent to skull

epidural hematomas uncommon

Progressive loss volume

Increased space around brain

Subdural hematomas or

intraparenchymal hemorrhage more common

emergent

management

of acute

subdural

hematoma is

critical

HOW AGE RAISES RISK

BONE

Most frequently injured

Osteoporosis

humerus, radius, hip

or pelvic fractures

longer periods of

immobility

HOW AGE RAISES RISK

SPINE

Degenerative spine

spinal fractures with

minor force

upper cervical injuries

odontoid fractures

central cord syndrome

more common

FALL-RELATED FRACTURES

Nature of the fall dictates

the nature of the fracture

Wrist, proximal humerusoutstretched armimply person was

moving reasonably fast at time of fall

Stationary position or during slow locomotion most likely

result proximal femoral

fractures

FALL-RELATED FRACTURES

Account for majority of cervical spine Fx

Frail may sustain long bone Fx

without a clear history of injury or falls

“minimal trauma fractures”

only precipitating factor is impaired

mobility

ABDOMINAL TRAUMA IN OLDER PEOPLE

Death rate visceral injuries around 80%

Intolerant of shock

Intolerant of unnecessary laparotomy

Management demands urgency

High degree of clinical expertise

MULTIPLE INJURIES IN OLDER PEOPLE

Visceral injuries without

fracture rare

Long bone

Must be stabilized early

Control blood loss

Reduce risk of fat

embolism

Enable early

mobilization

Bony injuries immediate life

threats

Skull fractures with brain

injury

Pelvic fractures

Massive bleeding from

lacerations to pelvic

venous plexus

Open pelvic fractures

death rate 80%

OLDER TRAUMA VICTIMS

Older accidental injury mostly women

Younger accidental injury mostly men

Old women out number old men

Thinner bones more likely to fracture

Occurrence of late deaths

Peak death rate femur 1 mo. after injury

Increased level for considerable time

Higher total of mortality late after injury

MAJOR TRAUMA OUTCOME STUDY, 1990

Retrospective study over 120,000 patients

US trauma centers, 10% were elderly

Purpose: set national norms in trauma

care and survival probability

Older increased likelihood of death

Older overrepresented unexpected deaths

APACHE III

Chronological age alone accounted for 3% of

variation in outcome

Acute physiological abnormalities accounted for

86%

Presence of shock has emerged as an enormously

potent predictive factor for negative outcome

Early invasive monitoring improves survival

It is not age that accounts for the poor outcome of

older trauma victims, but

factors that are strongly age

related.

Intrinsic Factors:

co-existing disease, under nutrition and

age-related changes in organs and

physiological systems…

…may contribute to

outcome directly by

limiting protective

responses or indirectly by confronting diagnostic

efforts.

Extrinsic Factors:

medication and the attitudes of

medical personnel may

have similar important

adverse effects.

Cardiac Output

30%

Average

Vital Capacity,

Renal Blood Flow

50%

Decline

Max Breathing Capacity, Oxygen Uptake

60-70%

Ages

30 to 80

Pharmacological Aspects Aging

Many drugs cause:hypotension & confusion,

predisposing falls, possible injury

Changes in the host: predispose drug toxicity, potential for interactions

More drugs higher reaction risk

Many drugs bind to proteinsSick old people often low albumin

Drugs that bind to albumin (warfarin) Higher concentrations of free drug

Pharmacological Aspects Aging

Many water-soluble drugs excreted by kidneysdeclines glomerular filtration, prolong

eliminationWater-soluble therapeutic concentration lower dose

(digoxin)

Pharmacodynamic Changes

Altered responsiveness to a drugIncreased sensitivity

Pharmacological Aspects Aging

Many drugs metabolized in liver

Considerable variations from: drug to drug & person to person

2012 AGS

Expert Panel

Beers Criteria

DISEASE PRESENTATION OLD AGE

Doctor may share patients’

views on aging

Wrongly attribute treatable

conditions to aging

Prevalence of disability

increases with age

DISEASE PRESENTATION OLD AGE

Traditional model for medical practice

Mainly from presentation younger people

Account abnormality to single diagnosis

Deviation from traditional model

Multiple diseases often co-exist

Atypical presentation of disease

Disease in one organ may precipitate decompensation in another

DISEASE PRESENTATION OLD AGE

Late or silent presentations

Disease one site limits symptoms at another

Disease often presents in advanced state

Misinterpret symptoms as aging

Mobility problems limit activity

– Dyspnea not occur until heart failure advanced

IMMUNOSUPPRESSIVE EFFECTS OF INJURY

Body’s response to

surgery & trauma

afferent nerve signals

from site of injury

Release

cytokines & circulating

stress hormones

Infective complications

account for most of the delayed deaths after injury

Infection should always be considered

when evaluating a patient whose condition has deteriorated

Hippocrates “old men have

little innate heat…for this reason too, the fevers of old men are less acute than

others, for the body is cold.”

An apparent afebrile state may

mask infection.

Changes in vital signs are less reliable indicators of instability in older adults.

Cause

Confusion

Consequence

Related to

Coincidental

Injury

CONFUSION AND INJURY IN OLD AGE

Whatever the relation confusion has a major impact on managementDelirium, ICD 10 some disturbance in:

ConsciousnessCognitionPsychomotor functionSleep-wake cycleEmotion

DELIRIUM

Children, old people very susceptible

Children – immaturity of CNS and of the cognitive and memory contents

Older – changes in Neuro…pathological, chemical, physiological, psychological

DELIRIUM IN OLD AGE

Pharmacologic agents that interfere with cholinergic function or sedation

Alcohol withdrawal

Sensory deprivation, the environment“talking across” increases confusion

Depression may masquerade as confusion

TRAUMA IN OLD AGE

“so healthy until now…”

“why all of a sudden, he was walking and independent, still driving to church every Sunday…”

“she was walking before she got here and isn’t leaving without walking out of here…”

Homeostenosis

ORTHOGERIATRIC UNITS

Identification, treatment of confusion

Effectiveness depends on

enthusiasm, resources, competence

Minimal disturbances

Minimal sedative medications

Nursing organization key to success

Nursing rehabilitation oriented

REFERENCES

Horan, M. A., & Little, R. A. (Eds.). (1998). Injury in the aging (First

ed.). New York, NY: Cambridge University Press.

Bartley, M. K. (2010). Handle older trauma patients with care. Nursing

2010, August, 24-29.

Cutugno, C. L. (2011). The ‘Graying’ of Trauma Care: Addressing

Traumatic Injury in Older Adults. American Journal of Nursing, Vol.

111, No. 11, 40-48.

http://www.modernmedicine.com

http://consultgerirn.org/

http://www.environmentalgeriatrics.org/#

http://www.cdc.gov/injury/wisqars/leading_causes_death.html