Neurotrauma

Traumatic brain injuries (TBIs) are a significant contributor of morbidity and mortality in the elderly. In a study by Haring et al. between 2000 and 2010, patients aged 65 to 69 accounted for 13.0 percent of all TBI-related hospitalizations, and patients older than age 85 accounted for 30.3 percent of all admissions. Overall mortality in this population was 11.4 percent over this study period [19]. Common injuries include subarachnoid, subdural, and epidural hemorrhages. This is due to the more adherent dura, cerebral atrophy, and cerebrovascular atherosclerosis seen during the aging process. Confounding these data are the patients who present with intracranial bleeds prior to a traumatic injury (fall, MVC, etc.), which may be mistriaged as TBIs. In addition to age-related physiologic and anatomic factors, a major contributor to TBI outcomes is the use of anticoagulants in this patient population [20]. Further confounding this issue is the rapid adoption of the use of direct oral anticoagulants (DOACs) in the elderly population. The inability to monitor the degree of anticoagulation and limited options for reversal of these agents make the management of TBI patients receiving these agents difficult. Prothrombin complex concentrate (PCC) use for the reversal of warfarin rapidly reverses coagulopathy and decrease the progression of intracranial hemorrhage, but reversal agents for DOACs are still under development and poorly studied [21,22]. Idarcizumab (Praxbind) was approved in 2015 by the Food and Drug Administration (FDA) for the reversal of dabigatran, and other agents such as andexanet alfa show promise in reversing the effects of factor Xa inhibitors [23].

Spinal Trauma

Spine trauma is a significant contributor to morbidity and mortality in the elderly. Cervical spinal fractures are among the top five fractures in elderly patients. Fractures in this population are associated with a significant rate of high cervical fractures with dens involvement. Fortunately, neurologic involvement is still infrequent [24]. Management of these fractures in the elderly is debatable. High rates of surgical complications and mortality with surgical treatment are weighed against the high rate of nonunion in older patients with cervical spine injuries treated nonoperatively with rigid cervical collars [25]. Lower spinal compression fractures are extremely common in the elderly population. Greater than one-fourth of postmenopausal women have vertebral compression fractures due to inadequate accumulation of bone mass in childhood and early adulthood and resorption after menopause. Nonoperative management, including analgesia, bracing, and physical therapy, is effective in the majority of cases, with surgery reserved for chronic, severe pain, instability, or neurologic compromise [26].

Thoracic Trauma

Elderly patients are especially susceptible to pulmonary complications after blunt thoracic trauma. Rib fractures are associated with poor outcomes. Elderly patients who sustain rib fractures have increased ventilator days, intensive care unit (ICU) and hospital lengths of stay, and rates of pneumonia and twice the mortality and thoracic morbidity than their younger counterparts. Each additional rib fracture increases mortality by 19 percent and risk of pneumonia by 27 percent [27]. Additional factors contributing to poorer outcomes in these elderly patients include decreased physiologic reserves and preexisting comorbidities but require further study [28]. Optimal pain control and pulmonary toileting are essential to optimize outcomes in these patients. In elderly patients, use of epidural analgesia over intravenous narcotic analgesia decreases morbidity, as well as hospital length of stays and overall hospital costs, but may be associated with increased deep venous thrombosis [29–31]. Frequent treatment with anticoagulants further complicates the placement of epidural and paravertebral catheters for analgesia.

Abdominal Trauma

Most intra-abdominal solid-organ injuries are managed nonoperatively. Specifically, the majority of hepatic and splenic injuries are managed with observation, with angioembolization and surgery reserved for those with active bleeding or hemodynamic instability. Risks of splenectomy include morbidity from laparotomy as well as the risk of postsplenectomy sepsis, although the true risk is unknown. Initial concerns regarding advanced age (defined as older than age 55) being a predictor of failure in nonoperative management of splenic injury have not borne out; therefore, advanced age should not be used as the sole determinant in the decision to pursue nonoperative management [32–35]. Improved imaging and interventional techniques have shown good results in the management of both liver and spleen injuries without surgical exploration. However, overall mortality for patients managed both operatively or nonoperatively is elevated compared with their younger counterparts [36]. Therefore, decision making regarding operative versus nonoperative management of solid-organ injury is based on hemodynamic status and transfusion requirements. Patients who are hemodynamically appropriate or respond rapidly to volume resuscitation are appropriate candidates for a trial of nonoperative management. These candidates require close hemodynamic monitoring, serial examinations, and hematocrit determinations. Patient who continue to have hemodynamic instability or have ongoing transfusion requirements should be managed surgically or with angiography and angioembolization.

Thermal Injury

For unclear reasons, elderly patient do particularly poorly after sustaining burn injuries [37]. The LD₅₀ for burn size for patients older than age 65 has remained at 35 percent, whereas gains have in made in younger patients [38,39]. This relationship appears to be linear, however, without a clear inflection point and relates to preexisting conditions as opposed to age alone. Likely higher rates of preexisting pulmonary disease, immobility, and decreased pulmonary reserve contribute to this finding. Elderly patients have longer lengths of stays and higher rates of multisystem organ failure but not infections or sepsis. This may be explained by alterations in the inflammatory response (metabolic, glycemic, immune, wound healing) in the aging population and requires a multimodal approach [40].

Musculoskeletal Trauma

Elderly patients are at particular risk of morbidity and mortality secondary to musculoskeletal trauma. Increased risk of falls, relative skeletal fragility, degenerative joint disease, stress fractures, periprosthetic fractures, and pathologic fractures contribute to increased rates and poorer outcomes. In patients older than age 80, those with hip fractures suffer up to three times the annual mortality compared with those without hip fractures [41]. This difference in outcomes is likely due to preexisting medical comorbidities, lower bone mineral density, and less muscular mass.

Orthopedic injuries should be managed in the safest and most expedient manner. While early operative fixation (<24 hours from injury) has been shown to be beneficial in younger patients, failure to manage preexisting conditions leads to higher mortality in the elderly population [42,43]. Medical consultation, optimization of medications, and stabilization of medical condition prior to repair of orthopedic injuries (up to 72 hours) leads to better outcomes with no increase in 30-day or long-term mortality, infectious complications, myocardial infarction, or thromboembolism. Perioperative antibiotics should address coverage of Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus, and Staphylococcus epidermis in institutions with high rates of colonization. Thromboembolic prophylaxis is an area of controversy, but current American College of Chest Physicians (ACCP) guidelines recommend use of low-molecular-weight heparin, fondaparinux, low-dose unfractionated heparin, a vitamin K antagonist, aspirin, or intermittent leg compression devices in the perioperative period [44]. Ultimately, risk of surgery must be weighed against optimizing the best chance of return to pretrauma functional status and quality of life.

Resuscitation Goals

Cardiovascular aging contributes to the difficulties in compensating for stress and increased demands after shock and trauma. Diminished cardiac output with decreased maximal heart rate, in addition to common use of antihypertensive and heart rate–controlling medications, makes the diagnosis of shock and hypoperfusion challenging in this population. In a prospective, randomized trial of elderly hip fracture patients, early use of invasive monitoring with pulmonary artery catheters was shown to decrease mortality rates [51]. Increased base deficit (−6 mEq/liter or less) or lactic academia (>2.2 mg/dl) has been shown to be associated with increased mortality [52,53]. Early use of pulmonary artery catheters to guide resuscitation to target cardiac indices or oxygen consumption may be beneficial in optimizing outcomes, but recent intraoperative studies suggest that goal-directed resuscitation appears to be less effective in elderly patients [54,55].

Contribution of Frailty to Outcome

Research involving the geriatric trauma population is difficult to interpret. There is a lack of consensus on the definition and characteristics of geriatric trauma patients and a lack of randomized, prospective, controlled trials examining this age group specifically. The overall mortality rate for elderly trauma patients is approximately 15 percent [56]. This rate increases in a linear fashion with increasing age until age 84, after which rates decline [57]. Research does support that advanced age alone is not a predictor of poor outcomes, and advanced age should not be used as the sole criterion for denying or limiting care [58]. Excellent outcomes are possible because most geriatric trauma patients return home, and up to 85 percent will return to independent function [59,60].

The presence and severity of preexisting conditions are major determinants of outcomes after trauma [61,62]. A combination of factors including preexisting conditions, medications, nutritional status, functional ability, and general state of health contributes to the ability to survive and recover from traumatic injury. Up to 38 percent of geriatric trauma patients are frail, with an increased risk of fractures and discharge to an institution. Increasing frailty is a risk factor for postoperative morbidity, mortality, and hospital length of stay [63–66]. In geriatric trauma patients, preinjury frailty assessment, using one of a number of available tools, may be a useful predictor of postinjury functional status and mortality [67]. The Trauma-Specific Frailty Index (TSFI) uses a scale based on 50 variables associated with poorer outcomes, has been validated in a trial of 200 patients, and is a fast and reliable tool for use in trauma patients [68]. Routine assessment of pretrauma status may be a useful tool in early determination of postdischarge needs and functional recovery. While posttrauma ambulation is a significant predictor of outcomes, pretrauma ambulation status is a predictor of long-term survivorship in the elderly with hip fractures [69]. Use of tools such as the Geriatric Trauma Outcome Score {age + [2.5 × Injury Severity Score (ISS)] + 22 (if transfused packed red blood cells)} may provide a more accurate estimation of mortality after trauma [70]. Use of these scores can assist practitioners in discussions with families in determining treatments and goals of care and may help to identify patients in need of early involvement of palliative care services.

While most patients do return to independent living, a significant proportion experiences diminution in quality of life across multiple domains [71]. On average, elderly patients experience the equivalent of loss of one activity of daily living (ADL) 1 year after their injury [72]. This predisposes them to further loss of function, independence, and death. A multidisciplinary approach is required in the management of these complex patients. Early geriatric consultation can improve functional recovery after trauma injury in older patients [73].

Optimal care of these patients requires not only appropriate management of their traumatic injuries but also prevention of further injury and harm. One-third of patients over age 65 suffer a fall annually, and one-third of those either returned to the emergency department or died within 1 year [74,75]. Risk factors for additional falls include prior falls, independent living, use of walking aids, depression, cognitive deficits, and use of greater than six medications. Screening and identification of these risk factors in elderly patients may be an opportunity for intervention to prevent further falls in the future. Targeted educational programs addressing these factors prevent recurrent injury and falls and may benefit long-term outcomes [76].

Special Considerations

Elderly abuse is a common and underreported cause of significant morbidity and mortality in the elderly population. It is estimated that 10 percent of older adults are victims of abuse, but fewer than 1 in 24 cases are ever reported to the authorities [77,78]. Abuse occurs in many forms, including physical, sexual, emotional, psychological, neglect, and financial exploitation. In physical abuse, the most common injuries involve blunt trauma with fists or household objects and are reported as “falls” [79]. Injuries to the upper extremities, face, and neck are uncommon following ground-level falls but are common in victims of elder abuse [80]. Healthcare providers must maintain a low threshold for suspicion of elder abuse in order to intervene early in this vulnerable population.