Evaluation and Care of the Geriatric Patient

Educational Objectives

The goal of this program is to improve management of trauma in older patients. After hearing and assimilating this program, the clinician will be better able to:

1. Identify common signs of trauma in older patients.
2. Modify management of traumatic injuries in older patients based on age-related changes in physiology.
3. Implement recent guidelines for field triage of older patients with trauma.

Summary

Epidemiology of geriatric trauma: the geriatric population (≥65 yr of age) in the United States is growing; unintentional injury is the seventh leading cause of death in this age group; the top 2 mechanisms of injury are falls and motor vehicle collisions (MVCs); hip and femur fractures account for >25% of injuries, and traumatic brain injury (TBI) accounts for ≈10%; >50% of patients are treated at nontrauma centers; reasons for this include inadequate training of prehospital providers in the triage of older patients, perception that sending older patients to a trauma center is not worth the expense, unfamiliarity with the protocol, feeling unwelcome when bringing older patients to trauma centers, and perception that older patients receive better care at the community hospital; data from the Centers for Disease Control and Prevention (CDC) show age >65 yr confers an increased risk for hospitalization with traumatic brain injury and mortality, with the risk increasing further with older age

Physiologic changes in older patients: older patients are at increased risk for trauma, particularly from ground-level falls; incidence of delirium, dementia, and impairments in vision and hearing are increased; decreased number of myocytes reduces contractility of the heart and responsiveness to catecholamines (blunted heart rate [HR] and blood pressure response to stress); stiffer arteries increase afterload and can cause chronic left ventricular hypertrophy; older patients tend to have slightly higher systolic blood pressures (SBPs) at baseline; tachycardia with hypotension is an indicator of significant injury in younger patients, but use of β-blockers (more prevalent in older patients) may blunt this response; older patients tend to have decreased muscle mass in the chest wall and lower elasticity of the lungs, with decreased functional residual capacity and gas exchange; the combination of a decreased cough reflex, poorer clearing of secretions, and increased colonization of microorganisms in the oropharynx results in poorer oxygen exchange

Complications: if rib fractures or other traumatic injuries that cause pain are present, patients do not cough and clear secretions as effectively, which increases the risk for aspiration and pneumonia; reduced kidney mass decreases glomerular filtration rate by ≈45% from 50 to 80 yr of age (basic metabolic panel may be normal); ability to concentrate urine (which requires dosing adjustments for renally excreted medications) and compensate for volume overload are decreased (susceptible to the effects of crystalloid or blood); skin tears and muscle injury are more likely; decreased muscle mass affects balance, especially when combined with decreased physical function; bones are thinner and more brittle, thus increasing risk for fractures; underlying degenerative changes of the spine and joints are likely

Triage for trauma patients: patients with high Injury Severity Scores have better outcomes when treated at trauma centers; Field Triage Guidelines recommend a level of undertriage of <5% (defined as patients who are severely injured but do not go to or are not activated at the trauma center; they have significant injuries, but there is a delay in diagnosis and treatment); the rate of overtriage may be ≤35% (unnecessary use of resources, eg, minor injuries that receive full activation of the trauma team or unnecessary transfer to a trauma hospital); a retrospective review found that ≈50% of patients >65 yr of age are undertriaged (vs 17.8% of younger patients); mortality increases when older patients have a HR >110 beats/min or SBP <110 mm Hg; activation criteria should be different than for younger patients

Field Triage Guidelines: published in 2011 to help field providers determine whether trauma patients should go to a trauma center or community hospital; they noted that low-impact mechanisms can create significant injury in elderly patients; the most recent guidelines published in 2021 simplified the algorithm and designated red criteria that identify patients at high risk for serious injury that warrants transportation to a trauma center

Red criteria: include age >65 yr with SBP <110 mm Hg; an older patient with a HR higher than their SBP should be transferred to a trauma center; transfer to a trauma center is generally preferred for patients who meet yellow criteria (however, potential delays in transport to trauma centers should be accounted for when making this decision); low-level falls with significant head trauma or use of anticoagulants are considered yellow criteria in older patients, and transfer to a trauma center is preferred if one is nearby

Management at the trauma center: perform a primary survey (airway, breathing, circulation, disability, and exposure); in the secondary survey, obtain a detailed medication list (β-blockers and anticoagulants are significant concerns); consider medical causes of trauma, particularly when triaging a low mechanism of injury; eg, a fall from standing in a patient with hypotension may result in a catastrophic head bleed or rib fractures with a hemothorax or spleen injury, or it may have been caused by confusion secondary to urosepsis or a myocardial infarction; patients may be in shock with normal vital signs; measurements of lactic acid or arterial blood gases to assess for a base deficit may reveal occult hypoperfusion; check a urinalysis; use computed tomography liberally; the risk of radiation to an 85 yr old is negligible, and missing an injury is far more threatening to survival

Admission orders: have a low threshold for a higher level of care; eg, if the patient appears fine to go home, consider observation instead; if they appear to need a general bed, they might need an intermediate unit; involve geriatric specialists if available; provide medications that the patient has been taking, eg, benzodiazepines should be given to prevent withdrawal for patients with chronic use; follow protocols for anticoagulation reversal; the Beers Criteria list includes which medications to avoid, use with caution, and use renal dosing

Geriatric protocols: a protocol that addresses the unique physiology and most frequent injuries and complications improves outcomes for older patients; the American College of Surgeons Trauma Quality Improvement Program published best practice guidelines; delirium precautions are vital; monitor volume status; use aggressive pulmonary hygiene and aspiration precautions; bowel regimens are important, particularly if patients are on opioids, and help prevent delirium; prevention of pressure ulcers and early mobilization are important

Goals of care: ask patients about their preferences; be open and honest; inform patients about the risk for complications, mortality, and functional decline after injury; low-level traumas frequently result in significant functional decline, particularly with multiple falls; inquire whether the patient has advanced directives and a health care power of attorney; use the palliative care team liberally (if available); explore online resources to explain end-of-life care to patients; plan a family meeting ≤72 hr to talk about the patient’s trajectory, expectations about outcome, and goals of care; repeat this discussion any time a deterioration in the patient’s condition occurs

Readings

Chang DC, Bass RR, Cornwell EE, et al. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg. 2008;143(8):776-782. doi:10.1001/archsurg.143.8.776; Newgard CD, Fischer PE, Gestring M, et al. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg. 2022;93(2): e49-e60; Fakhry SM, Shen Y, Garland JM, et al. The burden of geriatric traumatic brain injury on trauma systems: Analysis of 348,800 Medicare inpatient claims [published online ahead of print, 2022 Nov 4]. J Am Geriatr Soc. 2022. doi:10.1111/jgs.18114; Jang SH, Kwon YH, Lee SJ. Tachycardia in a patient with mild traumatic brain injury. Clin Auton Res. 2020;30(1):87-89. doi:10.1007/s10286-019-00646-4; Lucke JA, Mooijaart SP, Heeren P, et al. Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine. Eur Geriatr Med. 2022;13(2):309-317. doi:10.1007/s41999-021-00578-1; Lupton JR, Davis-O'Reilly C, Jungbauer RM, et al. Under-triage and over-triage using the field triage guidelines for injured patients: A systematic review. Prehosp Emerg Care. 2023;27(1):38-45.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Trisler was recorded at the Trauma Symposium: Current Trends in Trauma Care, held October 28, 2022, in Greenville, NC, and presented by Brody School of Medicine at East Carolina University/Eastern Area Health Education Center. For information about upcoming CME activities from this presenter, please visit cme.ecu.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

EM400801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.