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trauma in the elderly; geriatric trauma

Etiology: - falls in the elderly - hip fracture (more common in women) - falls associated with syncope may be recurrent [5] - head injury is often associated with facial trauma [5] - automobile accidents Epidemiology: - trauma increases in mortality rate at ages 55, 77, & 82 years - RR vs age < 55 years, 55-76 (RR=2.42), 77-81 (RR=4.70), >=82 (RR=6.43) - contributing factors include morbidities, dementia, female [1] Pathology: - low physiological reserve & the altered response to injury* * see age-related physiological changes Clinical significance: - variables of age, injury severity score, & 24-hour transfusion are components of a multivariate model to predict 1-year mortality [3] - the frailty index is an independent predictor of in-hospital complications & adverse discharge disposition in geriatric trauma patients [4] - mechanism of injury, vital signs on presentation, comorbidities, & medications are also associated with in-hospital complications, longer length of stay, & adverse discharge disposition in elderly trauma patients [4] - systolic blood pressure & resiratory rate most significant vital signs [4] - falling from standing & sustaining sufficiency injury to warrant hospitalization is a marker for frailty & comorbidities [7] Complications: - see Complications section of hospitalization - trauma associated with anticoagulant or anti-platelet agent use increases risk of bleeding - a delay may be observed in bleeding associated with head injury [5] - older adults are more likely than adults < 55 years to be discharged to a skilled nursing facility Management: - triage: - transfer to trauma center* - systolic BP < 90 mm Hg, < 100 mm Hg if > 70 years - pedestrian hit by motor vehicle & > 70 years [6] - geriatric trauma pathway [7] - goals include prevention of postoperative complications, especially postoperative dilerium & minimizing length of hospital stay - a multidisciplinary team with representation from: - trauma surgery - anesthesiology - geriatric medicine - emergency department - critical care - nursing - physical therapy & occupational therapy - speech pathology & language pathology - case management - social work - pharmacy - nutrition - transitional care - quality - patient family advisory council - having anesthesiology as part of the multidisciplinary team is necessary for optimal geriatric pain management [7] - geriatric medicine - comprehensive geriatric assessment - confusion assessment method every shift - identify & manage comorbidities - see Management section of hospitalization for general guidelines - see Management section of hip fracture for specific recommendations * older patients more likely to require surgery & intensive care after trauma than younger patients [6]

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geriatrics

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trauma

References

  1. Fakhry SM, Morse JL, Garland JM et al REDEFINING GERIATRIC TRAUMA. 55 IS THE NEW 65 J Trauma Acute Care Surg. 2021. Jan 6 AAST Poster Not indexed in PubMed https://journals.lww.com/jtrauma/Abstract/9000/REDEFINING_GERIATRIC_TRAUMA__55_IS_THE_NEW_65.97616.aspx
  2. Horst MA, Morgan ME, Vernon TM et al The geriatric trauma patient: A neglected individual in a mature trauma system. J Trauma Acute Care Surg. 2020 Jul;89(1):192-198 PMID: 32118822 https://journals.lww.com/jtrauma/Abstract/2020/07000/The_geriatric_trauma_patient__A_neglected.30.aspx
  3. Ross SW, Adeyemi FM, Zhou M et al One-year mortality in geriatric trauma patients: Improving upon the geriatric trauma outcomes score utilizing the social security death index. J Trauma Acute Care Surg. 2019 November 87(5):1148-1155 PMID: 31318764 https://journals.lww.com/jtrauma/Abstract/2019/11000/One_year_mortality_in_geriatric_trauma_patients_.20.aspx
  4. Joseph B, Pandit V, Zangbar B et al Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surg. 2014 Aug;149(8):766-72. PMID: 24920308 https://jamanetwork.com/journals/jamasurgery/fullarticle/1879845
  5. Gioffre-Florio M, Murabito LM, Visalli C, Pergolizzi FP, Fama F Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. G Chir. 2018 Jan-Feb;39(1):35-40. PMID: 29549679 PMCID: PMC5902142 Free PMC article
  6. Ichwan B et al. Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults. Ann Emerg Med 2014 Jun 5 PMID: 24908590
  7. Park C, Bharija A, Mesias M et al Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury. JAMA Surg. 2022 Aug 1;157(8):676-683 PMID: 35675065 PMCID: PMC9178494 (available on 2023-06-08) - Zhao B, Xing H, Ma W Implementation of a Geriatric Trauma Clinical Pathway. JAMA Surg. Published online October 5, 2022. https://jamanetwork.com/journals/jamasurgery/fullarticle/2797093 - Park C, Staudenmayer K Implementation of a Geriatric Trauma Clinical Pathway- Reply JAMA Surg. Published online October 5, 2022. https://jamanetwork.com/journals/jamasurgery/fullarticle/2797091
  8. Kregel HR, Pedroza C, Sunez F et al The geriatric trauma hospitalist service: An analysis of a management strategy for injured older adults. J Am Geriatr Soc. 2024 Sep;72(9):2752-2758. PMID: 38970303 PMCID: PMC11368630 (available on 2025-09-01)