1. Robert D. Barraco, MD, MPH, FACS, FCCP Chief, Geriatric Trauma
ElderTrauma: 2012 Update
Robert D. Barraco, MD, MPH, FACS, FCCP
Chief, Geriatric Trauma
Lehigh Valley Health Network
Allentown, PA

2. Objectives
Describe the epidemiology and physiology of geriatric trauma and its impact on our system.
Discuss recent literature in the area of geriatric trauma.

3. NO ONE IN THIS ROOM IS GETTING YOUNGER
Committee Update
NO ONE IN THIS ROOM IS GETTING YOUNGER

5. Background Injury rates are rising
38% of inpatients were aged 65 years and over, 43% days of care
Those aged 75 years and over 24% of all inpatients
Source: NHDS

6. Epidemiology Trauma is the 5th leading cause of death in the elderly
In order of most to least common:
Falls
MVC
Pedestrian struck
Stab wounds
Gunshot wounds
others

7. Mechanism of Injury Falls Most common method of injury in the elderly
Most responsible for cause of death
By 2020, 47.8 billion dollars spent on the treatment of geriatric falls

8. Mechanism of Injury Motor Vehicle Crash
MVC are #1 cause of trauma related cause of death ages 65-74
In accidents involving elderly patients
80% were found to be at fault
18% syncopal episode was the inciting agent

9. Mecahnism of Injury Pedestrian struck by MV
Involves the elderly more than any other age group.
Cause
Confusion
Vision or hearing deficiency
Poor gait

10. Bodily Changes: Sunset or Sunrise?
Changes in all body systems
Less reserve
Relatively unable to compensate
Physical exam findings unreliable

11. Nervous System Sensory decline Motor decline Memory impairment
Impaired temperature/ blood pressure control
Sleep changes

12. Cardiovascular System
 Stretch of cardiac muscle
Atherosclerosis: Hardening of the arteries
Can’t compensate with heart rate
Fat in-growth of SA and AV nodes

13. Respiratory System Stiffening of chest wall and lung  Oxygen
 amount of air with maximal breath
 Work of respiratory muscles

14. Urologic System  Kidney failure  Drug clearance and processing
 Response to dehydration

15. GI System
Swallowing problems
Reflux
Diverticuli

16. Immune System  Cancer  Autoimmune disease like Rheumatoid Arthritis
 Infections/ complications

17. Endocrine System Reduced ability to respond to stress
Loss of glucose tolerance leads to diabetes

18. Bones, Joints and Muscles
 Muscle strength, endurance and size
Osteoporosis
 Fractures
 Joint disease
Osteoarthritis

19. These are general trends. Individual results may vary...
Please Remember:
These are general trends.
Individual results may vary...

23. Factors affecting outcome and mortality in Eldertrauma

24. 2001
Triage Issues
Parameters (End Points) for Resuscitation
2010
Correction of anti-coagulation
Age as indicator for trauma alert
Supraphysiologic Resucitation

25. What is “Elderly”? Level II
In general, where specific guidance is not otherwise given for the purposes of determining independent risk for adverse outcomes following trauma, patients >65 years of age can be considered as “elderly”.

26. Prehospital Triage and Activation
Level II
Injured patients with advanced age (>65) and pre-existing medical conditions (PEC’s) should lower the threshold for field triage directly to a designated/verified trauma center.

27. Prehospital Triage and Activation
Level III
A lower threshold for trauma activation should be utilized for injured patients>70 years age who are evaluated at trauma centers.
Elderly patients with at least one body system with an AIS>3 should be treated in designated trauma centers, preferably in ICU’s staffed by surgeon-intensivists.

28. Literature Support: Trauma Center Triage/Care

29. Effectiveness of Prehospital Trauma Triage…
Retrospective study
Three NJ counties with Level 1 trauma centers
18% undertriage in elderly men, 15% in elderly women
Age cutoff 65 years
J Emerg Nursing 2003; 29:109-15

30. Old Age as a Criterion for Trauma Activation
Retrospective review 7.5 years
Level 1 urban trauma center
25% of age 70 and over met one standard criteria
Mortality 50%, ICU 40%, OR 35%
75% not meet criteria
Mortality 16%, ICU 24%, OR 19%
Age 70 a stand alone criteria for activation
J Trauma 2001 Oct; 51(4): 754-6

31. Should Age be a Factor… NTDB review
At all levels of injury, patients older than 60 have 3 fold increased morbidity and 5 fold increased mortality with minor ISS (0-15), 2- and 4-fold with major ISS.
Minor ISS were often Level II activations
Suggests Level 1 activation age 60 and over
J Trauma Issue/Volume 69(1), July 2010, pp 88-92

32. More often required urgent craniotomy and orthopedic procedures
The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis
13,820 (27%) elderly patients.
Significantly less likely trauma team activation despite similar severity
More often required urgent craniotomy and orthopedic procedures
Undertriaged elderly patients had 4 times the mortality rate
Am J Surg. 197(5):571-4; discussion 574-5, 2009 May.

33. Undertriage of elderly trauma patients to state-designated trauma centers
Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center.
Arch Surg. 143(8):776-81; discussion 782, 2008 Aug.

34. Elderly Injury: A Profile of Trauma Experience in the Sunshine (Retirement) State
In the moderate and minor injury categories, TC survival was significantly better for both groups.
The proportion of NTC fatalities as potentially preventable is significantly higher than trauma centers.

35. Elderly Injury: A Profile of Trauma Experience in the Sunshine (Retirement) State
When the effects of all reported diagnoses are considered, potentially preventable mortality for patients with noninjury comorbidity is significantly lower in TC.
Moreover, by using “discharge to home” as an indicator of completeness of recovery, TCs seem to be significantly more effective than NTC
The Journal of Trauma: Issue: Volume 48(4), April 2000, pp

36. Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers
Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients.
J Trauma. 52(1):79-84, 2002 Jan.

37. Anticoagulation Level III
All elderly patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission.
All elderly patients with suspected head injury receiving daily anticoagulation should be evaluated with head CT as soon as possible after admission. 
Patients receiving warfarin with a post-traumatic intra-cranial hemorrhage should receive initiation of therapy to correct their INR toward a normal range within 2 hours of admission.

38. PTSF Geriatric Trauma Committee
Vision: Pennsylvania’s Trauma System will pioneer and excel in the care of the injured elderly.
Goals:
Evaluate/Examine Best Practices in Geriatric Trauma Care in the Commonwealth
Limit variation and improve outcomes through standardization of care
Discuss and resolve issues of importance to the care of the Geriatric Trauma Patient
Evidence-Based Reviews as available or create our own to guide care
Research to provide tools to change practice and provide the best care to our community
Trauma Systems approach to issues

39. Definition
Geriatric trauma will be defined in the Commonwealth of Pennsylvania as injured patients age 65 and over.

40. PTSF Geriatric Trauma Committee
On the agenda:
Best practices/usable protocols
Interfacility standard work:
Common protocols for clinical situations
Anticoagulant reversal
Syncope
Triage
Prevention Initiatives

41. Coumadin and CHI protocol: Non-trauma vs. Level 3/4
Mechanism for Head Injury and taking Coumadin:
Able to obtain stat head CT and read it?
Stat PT/INR/PTT
Type and Cross
Stat head CT with stat read
See Level 3-4 algorithm
Transfer to Level 1 or 2 trauma center
Yes No
Mechanism for Head Injury and taking Coumadin:
GCS < 14?
Stat PT/INR/PTT
Type and Cross
Obtain stat head CT with stat read
Transfer to Level 1 or 2 trauma center
Begin correction as able
Yes No
Injury on CT?
Admit, observe
Consider CT in AM

42. Geriatric Triage Research
No denominator
Need to see if numbers would overwhelm resources
Rich database of PCRs with PEHSC
Will look at data points for answers at state level
Will use locoregional EMS if needed

43. Geriatric Issues in Trauma Care

44. Frailty

45. AAST 2011
PREDICTORS OF CRITICAL CARE RELATED COMPLICATIONS IN COLECTOMY PATIENTS USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM: EXPLORING FRAILTY AND AGGRESSIVE
LAPAROSCOPIC APPROACHES.
ARE THE FRAIL DESTINED TO FAIL?: FRAILTY INDEX AS A PREDICTOR OF SURGICAL MORBIDITY AND MORTALITY IN THE ELDERLY

46. Surgery in the Elderly
21% of those over age 60 will undergo surgery and anesthesia as compared with only 12 percent of those aged 45 to 60 years by 2030
20% of all open heart surgery >70

47. Surgery in the Elderly Overall risk steadily declining
Heart disease mortality 3-5%
Heart attack 1-4%
CHF 4-10%
Lungs most common: 15-45%

48. Frailty Unintentional weight loss (10 pounds or more in a year)
General feeling of exhaustion
Weakness (as measured by grip strength)
Slow walking speed
Low levels of physical activity.

49. Trauma in the Elderly: Frailty
Frailty Scales: Measure thinking, functionality and general health status.
Higher scores were associated in increased complications and decreased chance of being discharged to home.

50. VES-13 The VES-13 relies on patient self-report.
VES-13 is function-based.
In the national sample of elders, a score of 3+ identified 32% of individuals as vulnerable.
This vulnerable group had four times the risk of death or functional decline when compared to elders scoring 3 or less.

52. Frailty Outcomes
Increasing frailty was associated with postoperative complications, increased length of hospitalization and inability to be discharged home independent of age.
EFS scores of 3 or less were associated with a lower risk of having a complication and a higher chance of being discharged home.
EFS scores exceeding 7 were associated with increased complications and a lower chance of being discharged home.

54. Cardiac evaluation Diagnostic testing in at risk patients
EKG, Stress, Cath
Assign risk, NOT CLEAR
Recommendations
Statins, Beta blockers
Perioperative monitoring

55. Putting it all together…

56. Preoperative Risk Assessment
What is missing?
Medications
Frailty evaluation
Optimization beyond Cardiac
Utilizing VES-13 as part of preop screen to undergo Comprehensive Geriatric Assessment, more accurate prognostication and optimization
Journal of the American College of Surgeons Recommendations

57. Models of Care: CGA
Geriatrics-focused interdisciplinary management of older adults can be grouped into 2 models of care:
Geriatric evaluation and management (GEM), in which the interdisciplinary team actively follows up on the patient and directs medical care
Comprehensive geriatric assessment (CGA), in which the consultative interdisciplinary team makes specific recommendations to the patient’s primary care provider rather than directly implementing care

58. Nurses Improving Care for Hospitalized Elders
Using nurse practitioners to implement best practice care for the elderly during hospitalization: the NICHE journey at the University of Virginia Medical Center
Nurses Improving Care for Hospitalized Elders
These include the Geriatric Resource Nurse model, the Acute Care of the Elderly model, and, most recently, the Geriatric Consultation Service model.
Critical Care Nursing Clinics of North America. 19(3):321-37, vii, 2007 Sep.

59. NICHE Models at UVA
Nurse practitioners (NPs) with geriatric expertise have provided the leadership in implementing these initiatives to achieve the goal of improving geriatric care delivery within the health system.
Each NP functions in a broad role that is tailored to meet the needs of the patients and staff and includes the role components of clinician, educator, team leader, and care coordinator.

60. Models of Care: ACE Geriatrician-led interdisciplinary team approach
Improve functional status, reduce acute care hospital days and readmission, and lower mortality rate in hospitalized acutely ill frail older patients
Acute Care of the Elderly (ACE) unit
More homelike environment
Patient-centered care that includes plans for preventing disability and iatrogenic illness, and comprehensive discharge planning and management

61. Models of Care: ACE
ACE Units bring evidence-based practices to hospital care
Better patient outcomes
Better staff retention
Geriatric Resource Nurses are a relatively low-cost option for putting aging knowledge across units and clinics.

62. Models of Care: ACE
Geriatrics expertise, when coupled with high-margin procedures can lead to better patient outcomes and shorter stays in hospital.
Better margins
Better downstream revenues
Competitive edge in recruiting patients

63. Treatment
Exercise and geriatric interdisciplinary assessment and treatment models improve outcomes

64. Delirium

65. Delirium: History
First century AD - mental disorders during fever or head trauma
Current - transient, reversible syndrome that is acute and fluctuating, and which occurs in the setting of a medical condition

66. Delirium: Epidemiology
Incidence - 14–56% of all hospitalized elderly patients.
Postoperative delirium - in 15–53% of surgical patients over the age of 65
70–87% of elderly in the ICU
At least 20% of the hospitalized patients over 65 each year in the US experience complications due to delirium

67. Delirium: Factors Potentially modifiable risk factors
Sensory impairment (hearing or vision)
Immobilization (catheters or restraints)
Medications
Acute neurological diseases
Intercurrent illness
Metabolic derangement
Surgery
Environment
Pain
Emotional distress
Sustained sleep deprivation
Nonmodifiable risk factors
Dementia or cognitive impairment
Advancing age (>65 years)
History of delirium, stroke, neurological disease, falls or gait disorder
Multiple comorbidities
Male sex
Chronic renal or hepatic disease

68. Diagnosing Delirium

69. CAM and CAM-ICU
Form
Algorithm
Video
Website: icudelirium.org

70. Delirium: Imaging
CT scan: marked cortical atrophy in the prefrontal cortex, temporoparietal cortex, and fusiform and lingual gyri in the nondominant hemisphere, and atrophy of deep structures,
Reflect a state of increased vulnerability of the brain to any insult

71. Delirium: Prevention 30–40% of cases of delirium are preventable
Beers Criteria drugs should be avoided
The Hospital Elder Life Program (HELP) uses tested delirium prevention strategies to improve overall quality of hospital care.

72. Inappropriate Medications in the Elderly
30 percent of hospital admissions in elderly patients may be linked to drug-related problems or toxicity
Overall human and economic consequences of medication-related problems vastly exceed the findings of the Institute of Medicine (IOM) on deaths from medical errors
In 2000, it is estimated that medication-related problems caused 106 000 deaths annually at a cost of $85 billion.
Fifth leading cause of death in the United States

73. Beers Criteria
The Beers List: Potentially Inappropriate Medications for the Elderly
CBC News In Depth: Drugs seniors should avoid - The Beers criteria

74. Delirium: Prevention
In a controlled trial that evaluated HELP, delirium developed in 9.9% of the intervention group, compared with 15.0% of the usual-care group
The HELP interventions can also effectively reduce the total number of episodes and days of delirium
Proactive geriatric consultation reduces risk of delirium after acute hip fracture by 40%

75. Delirium: Treatment Reorientation and behavioral intervention.
Caregivers should use clear instructions and make frequent eye contact with patients.
Sensory impairments, such as vision and hearing loss, should be minimized
Physical restraints should be avoided because they lead to greater risk of injury and prolongation of delirium

76. Delirium: Treatment An environment with minimal noise at night
Nonpharmacological sleep protocol
First, a glass of warm milk or herbal tea
Second, relaxation tapes or relaxing music
Third, back massage
Reduced the use of sleeping medications from 54% to 31%

77. treatment Nat Rev Neurol doi:10.1038/nrneurol.2009.24
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and
treatment Nat Rev Neurol doi: /nrneurol

78. Summary
Delirium is a serious cause and complication of hospitalization in elderly patients and should be considered to be a medical emergency until proven otherwise.
Potential to markedly affect the overall outcome and prognosis of severely ill patients, as well as substantially increasing health-care utilization and costs.

79. “ The alleviation of suffering is the warrant of medicine and its test of adequacy…it is a test that contemporary medicine fails despite the brilliance of its science and its awesome technical power” Eric J. Cassell, J Clin Ethics. 1991; 2(2): 81-82

80. What is Palliative Care?
Good patient care
Caring for terminally-ill patients and their families
Aggressive symptom management
Primary goal
Communication
Spirituality

81. Curative vs. Palliative Models
Primary goal is cure
Object is disease
Symptoms treated as clues
Measurable data
Devalue subjective
Therapy indicated if cures or slows
Patient’s body different from mind
Death is failure
Primary goal relief of suffering
Object is patient/family
Symptoms treated as entities in themselves
Subjective is valued; patient’s experience
Therapy if relieve suffering
Patient a complex of physical, emotional, social and spiritual
Live fully and comfortably till death a success

82. What Palliative Care is Not…
End-of-Life Care
Withdrawal of Care
Do not Treat
Giving up

83. “ A medicine that embodies an acceptance of death would represent a great change in the common conception, and might set the stage for viewing the care of dying people not as an afterthought when all else has failed but as one part of the ends of medicine.” Daniel Callahan, from The Troubled Dream of Life

84. Five Basic Palliative Care Interventions
Control Pain and other Distressing Physical Symptoms
Alleviate Psychosocial Problems
Communicate Effectively
Empathic Presence
Foster Hope

85. “We are a culture that denies death…therefore we are all walking towards death backwards! It is better to turn around.” Michael Meade

86. Geriatric Trauma Data: LVH CC

87. Beers’ Criteria Medications
Preliminary data
Compared one year prior to implementation to 4 and 6 years after
7.6% reduction in patients discharged on Beers’ meds
20.8% increase in patients taken off Beers’ meds

88. Geriatric Trauma Data LVH CC11
13.7
10.4
ISS
10.6
11.3

89. Geriatric Mortality Comparison 2006-2009
Alive
Dead
LVHN
ISS 13.7
3811
212 (5.6%)
State (adjusted)
ISS 12.5
32047
1931 (8.5%)

90. Thank you

91. Contact Information:

92. Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol doi: /nrneurol

93. REFS Not Frail 0–5 Apparently Vulnerable 6–7 Mild Frailty 8–9
Frailty domain
Item
0 Point
1 Point
2 Points
Cognition
Please imagine that this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’
No errors
Minor spacing errors
Other errors
General health status
In the past year, how many times have you been admitted to a hospital?
1–2 ≥2
In general, how would you describe your health?
Excellent/Very good/Good
Fair
Poor
Functional independence
With how many of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)
0–1
2–4
5–8
Social support
When you need help, can you count on someone who is willing and able to meet your needs?
Always
Sometimes
Never
Medication use
Do you use five or more different prescription medications on a regular basis? No
Yes
At times, do you forget to take your prescription medications?
Nutrition
Have you recently lost weight such that your clothing has become looser?
Mood
Do you often feel sad or depressed?
Continence
Do you have a problem with losing control of urine when you don't want to?
Self-reported performance
Two weeks ago were you able to:
(1) Do heavy work around the house like washing windows, walls or floors without help?
(2) Walk up and down stairs to the second floor without help?
(3) Walk 1 km without help?
REFS
Not Frail 0–5
Apparently Vulnerable 6–7
Mild Frailty 8–9
 Moderate Frailty
10–11
Severe Frailty
12–18

94. Importance of a Comprehensive Geriatric Assessment in Prediction of Complications Following Thoracic Surgery in Elderly Patients
Dependence for the performance of ADLs and impaired cognitive conditions are important predictors of postoperative complications, especially when the operation time is long. CGA is necessary in addition to the conventional cardiopulmonary functional assessment in elderly patients.

95. Geriatric Trauma Data Query
January 1, July 30, 2011

96. Geriatric Trauma Data
Queried EMS patient care reports for patients age 65 and older with the following reported causes of injury:
Fall
Pedestrian Struck
Motor Vehicle Accident
27,009 Records Returned

99. 22144 (82%) Records Reported GCS Score
Percentage of Total Reported

102. Geriatric Standards Requirement Level 1 Level 2 Level 3
Interdisciplinary care E D
Geriatrician as liaison
Internist/family medicine/rehab medicine interested in geriatrics as liaison
Geriatric Resource Nurse
(1 FTE if >1000/yr)
Geriatric PI
Palliative Care program
Geriatric Education
E (may be internal)
Geriatric prevention
Geriatric Trauma Chief

103. Relationships between various etiological factors in delirium
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol doi: /nrneurol

104. Hospice and Palliative Care
Comfort and Dignity
PACE outpt
ACE inpt
CGA and TX
Frailty screen
Exercise TX
Symptom Management
Patient Centered Goals
Concordance between patient, caregiver, Healthcare team