Geriatric Trauma Michele M. Fowler D.O. OSU Medical Center Emergency Medicine

Background Elderly people account for 12-15% of U.S. population Elderly people account for 12-15% of U.S. population 10-14% of all trauma victims are > % of all trauma victims are >65 33% of all trauma $ is spent on elderly patients 33% of all trauma $ is spent on elderly patients Trauma care cost 3x as much for an elderly person compared to a younger person Trauma care cost 3x as much for an elderly person compared to a younger person

Definitions Elderly >65 years Elderly >65 years Young old and Old old Young old and Old old Chronological age is actual # of years lived Chronological age is actual # of years lived Physiologic age is actual functional capacity of patient’s organ systems Physiologic age is actual functional capacity of patient’s organ systems

Mechanisms Falls Falls Motor Vehicle Crashes (MVC) Motor Vehicle Crashes (MVC) Pedestrian vs. Motor Vehicle Pedestrian vs. Motor Vehicle Burns Burns Assaults Assaults

Falls Most common injury - 40% elderly trauma Most common injury - 40% elderly trauma 25% who fall sustain “serious injury” 25% who fall sustain “serious injury” Falls M=F but females are more likely to be injured Falls M=F but females are more likely to be injured Postural instability, vision and hearing, reaction time, meds Postural instability, vision and hearing, reaction time, meds Syncope vs Fall Syncope vs Fall Standing height falls Standing height falls

MVC 2 cars 2 cars Daytime Daytime Intersections Intersections Close to home Close to home 2 nd Highest fatal crash rate 2 nd Highest fatal crash rate Time to stop driving Time to stop driving

Auto-Ped 46% elderly trauma occurs at crosswalk 46% elderly trauma occurs at crosswalk Average crosswalk speed is 4ft/sec Average crosswalk speed is 4ft/sec Parking lots Parking lots

Pathophysiology of Geriatric Trauma Pre-existing diseases lead to more severe injuries Pre-existing diseases lead to more severe injuries Co-morbid diseases complicate recovery Co-morbid diseases complicate recovery Medications alter “normal” function and vital signs Medications alter “normal” function and vital signs Physiologic Age Physiologic Age Less dramatic physiologic response Less dramatic physiologic response Narrow limit of physiologic tolerance Narrow limit of physiologic tolerance

Cardiovascular Myocardial cells are replaced by fatty infiltration and amyloid deposits; heart becomes “stiff” Myocardial cells are replaced by fatty infiltration and amyloid deposits; heart becomes “stiff” Decreased Beta receptor # and sensitivity to catecholamines (decreases rate and contractile force) Decreased Beta receptor # and sensitivity to catecholamines (decreases rate and contractile force) Not able to increase cardiac output at important times Not able to increase cardiac output at important times

Cardiovascular Atherosclerotic disease is prevalent in elderly and can lead to “secondary injury” Atherosclerotic disease is prevalent in elderly and can lead to “secondary injury” Myocardial oxygen demand is increased during trauma and stress Myocardial oxygen demand is increased during trauma and stress Loss of elasticity of arteries decreases compliance and increases resistance Loss of elasticity of arteries decreases compliance and increases resistance Cardiac medications Cardiac medications Pacemakers Pacemakers

Pulmonary Chest wall and lungs not as compliant Chest wall and lungs not as compliant Respiratory muscles are weaker Respiratory muscles are weaker Loss of alveolar surface area leads to impaired gas exchange Loss of alveolar surface area leads to impaired gas exchange Spinal immobilization (collar and supine) Spinal immobilization (collar and supine) Impaired cough Impaired cough Rib fractures double mortality Rib fractures double mortality

“There are three signs of old age. The first is your loss of memory and the other two I forget.” “There are three signs of old age. The first is your loss of memory and the other two I forget.” Unknown

Central Nervous System Subdurals - Most common Subdurals - Most common Atrophy Atrophy Delayed accumulation of blood Delayed accumulation of blood Warfarin Warfarin Pre-existing dementia or strokes makes evaluation and recovery difficult Pre-existing dementia or strokes makes evaluation and recovery difficult

Renal By age 65 lose 40% of glomeruli By age 65 lose 40% of glomeruli Diminished renal blood flow Diminished renal blood flow Creatinine is misleading because of decreased muscle mass (CrCl is better) Creatinine is misleading because of decreased muscle mass (CrCl is better) Chronic dehydration Chronic dehydration Hypotension leads to ATN Hypotension leads to ATN Nephrotoxic agents (IV contrast and NSAIDS) Nephrotoxic agents (IV contrast and NSAIDS)

Metabolic, Nutrition and Immunity Caloric requirements decrease with age but nutrient demands remain constant Caloric requirements decrease with age but nutrient demands remain constant Elderly have less nutritional reserve Elderly have less nutritional reserve Glucose intolerance and diabetes Glucose intolerance and diabetes Catabolic response is same as with young people but catabolic protein loss is more significant with elderly Catabolic response is same as with young people but catabolic protein loss is more significant with elderly Increased risks of infection Increased risks of infection

Injuries Subdurals Subdurals Hip fractures Hip fractures Wrist fractures Wrist fractures Compression fractures Compression fractures Rib fractures Rib fractures Central cord syndrome Central cord syndrome Scalp lacerations Scalp lacerations

Subdurals Tear in bridging veins because of atrophy Tear in bridging veins because of atrophy Crescent shaped clot between the dura and arachnoid Crescent shaped clot between the dura and arachnoid Judicious use of CT for falls Judicious use of CT for falls Warfarin Warfarin Aggressive reversal of coagulopathy Aggressive reversal of coagulopathy

Central Cord Syndrome Cervical stenosis and spondylosis Cervical stenosis and spondylosis Hyperextension injuries Hyperextension injuries Central corticospinal and spinothalamic tracts Central corticospinal and spinothalamic tracts Upper extremities more commonly involved Upper extremities more commonly involved Good prognosis Good prognosis

Outcomes Mortality Mortality Young is 4-8% Young is 4-8% Elderly is 15-30% Elderly is 15-30% Improve survival by early invasive monitoring Improve survival by early invasive monitoring Prevention most important Prevention most important Withholding Care Withholding Care

Outcomes Occult hypotension and early recognition Occult hypotension and early recognition High Risk High Risk TBI TBI Multiple long bone fractures Multiple long bone fractures Auto vs. Pedestrian Auto vs. Pedestrian Initial systolic BP < 130 Initial systolic BP < 130

Prevention Safe environment (rugs, cords, lighting, etc) Safe environment (rugs, cords, lighting, etc) Home modifications (tubs, rails, etc) Home modifications (tubs, rails, etc) Medications (benzos and narcotics) Medications (benzos and narcotics) Driving Safety Driving Safety Not driving Not driving Strength and balance therapy Strength and balance therapy

How to Help Seniors Drive Safely Longer- 8 Functional Areas (AAA) Leg strength and flexibility Leg strength and flexibility Head and neck flexibility Head and neck flexibility High contrast visual acuity (signs/marks) High contrast visual acuity (signs/marks) Low visual acuity Low visual acuity Working Memory (directions and traffic rules) Visualization of missing info (recognize hazards) Visual search (find signs) Useful field of vision (peripheral threats)

“An ounce of prevention is worth a pound of cure.” Benjamin Franklin

Summary Poor prognosis for old people with traumatic injuries Poor prognosis for old people with traumatic injuries Significant injuries with minor accidents Significant injuries with minor accidents Warfarin is bad in trauma Warfarin is bad in trauma Judicious use of CT scans Judicious use of CT scans Early invasive monitoring Early invasive monitoring Prevention is the key Prevention is the key

“Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter.” Jack Benny