Background

Traumatic injuries are important causes of morbidity and mortality in older adults, and older adults make up a growing proportion of trauma patients in emergency departments (EDs). Trauma systems and protocols that were developed in the United States over the last half-century were largely informed by advances from military medicine and primarily designed to serve younger adult patients. Although the general principles of trauma care for younger adults apply to elders, there are special considerations for the older trauma patient. This chapter highlights the epidemiology, pathophysiology, diagnosis, and management of trauma in older adults and focuses on decisions that may differ from those in younger adults.

Definition of Geriatric Trauma

There is no standard definition of “geriatric trauma”; studies include patients older than 45 to 65 years. Some studies further stratify the elderly population into those aged 65 to 80 or 85 years and the “oldest old,” those older than 80 or 85 years. The literature on trauma in older adults has several limitations. Older adults are frequently excluded from clinical trials, a limitation in considering high-risk interventions such as surgery or invasive hemodynamic monitoring. Furthermore, studies conducted via trauma databases include only trauma center patients evaluated by a trauma team; the results may not be generalizable to non–trauma center ED populations.

Demographics and Epidemiology

The U.S. population is aging, and the elderly are living more active lifestyles—which explains the dramatic rise in geriatric trauma. About one in eight Americans were aged 60 or older in 1994, whereas by 2030 one in five will be.¹ In 2008, U.S. adults aged 65 and older made more than 5.8 million ED visits for injuries, accounting for 30% of all visits by older adults and almost 14% of all injury-related ED visits.² Older trauma patients have increased morbidity and mortality owing to the severity of injury, comorbid disease, and the independent effects of age. In similar accidents, the elderly sustain more severe injuries than younger adults, a strong predictor of mortality. In 2009, unintentional injury was the ninth leading cause of death among those older than 65 years.³ Older adults are more likely to have significant underlying medical conditions that limit their physiologic response to injury and increase the risk of death after trauma, especially in less severe injuries.^4,5 Age is independently predictive of morbidity and mortality even when comorbidities and Injury Severity Score (ISS) are controlled for.^6,7

Age as a Triage Criterion

Age should be considered in determining criteria for transfer to a trauma center and for activation of trauma teams.⁸ Traditional triage criteria based on mechanism and vital signs miss many elders with major injuries.^9–12 Fewer older patients are transported to trauma centers despite meeting trauma center criteria,^9,13 and elders are less likely to be admitted to trauma centers than younger adults.¹⁴ In response, the Advanced Trauma Life Support (ATLS) program recommends that emergency medical services (EMS) transfer patients older than 55 years to a trauma center regardless of injury severity.¹⁵ Yet the effect of trauma center care on elders is not clear; although an early study showed that elderly patients with severe injuries have better outcomes when treated at a trauma center,¹⁶ a larger, more recent study of 69 hospitals in 14 states found no survival difference.¹⁷ At trauma centers, age is often a criterion for trauma team activation, and one study showed a trend toward decreased mortality after trauma team activation criteria were changed to include age older than 70 years.¹⁸

Mechanisms of Injury

Falls are the leading mechanism of injury and the leading cause of injury-related death in patients older than 65 years.¹⁹ In 2008, there were 2.1 million ED visits for falls among those 65 and older 10 times more common than motor vehicle collisions (MVCs).²⁰ Up to one third of elders sustain a significant fall each year, and serious injuries occur in up to a quarter.²¹ Most falls are from standing and occur at the elder’s place of residence.¹⁹ Risk factors for falling include (in decreasing relative risk) weakness, balance or gait deficit, visual deficit, mobility limitation, cognitive impairment, impaired functional status, and postural hypotension.²² Fractures are the most common injuries sustained by elders during falls, occurring in 5 to 10% of falls.²¹ Up to 10% of fallers sustain a major injury, with head injury being most frequent.²³ Although the height of the fall is associated with severity, falls from standing carry significant risk for older adults; same-level falls result in serious injury (ISS >15) 30% of the time in older patients, and peri-injury mortality from low falls is up to 10%.^23–25

MVCs and pedestrians struck by a motor vehicle are the second and third most frequent causes of trauma in older adults.6,19 Elders are more likely than younger adults to be involved in daytime crashes occurring close to home.²⁶ A detailed crash history is important, and single-vehicle crashes should raise the suspicion that a medical problem caused the crash (e.g., syncope). The mortality rate of older MVC victims is up to 21%.^19,27 Elders are more likely to be struck by a motor vehicle than younger pedestrians, because of poor eyesight, limited mobility, and slower reaction time. Pedestrians struck sustain significant injury patterns and have the highest fatality rate among injuries, 30 to 55%.¹⁹

Self-injury, elder abuse, and thermal injuries are less common but important injury patterns in the elderly population. Older adults have a lower likelihood of attempting self-injury but a higher likelihood of completing suicide attempts than any other age group, with men at higher risk. Thermal injuries such as burns and smoke inhalation occur more frequently and are more severe in older adults owing to decreased mobility and physiologic skin changes.²⁸ Elder abuse is a complex problem that can involve psychologic, social (e.g., financial), and physical abuse. Studies have identified that around 5% of elders self-report abuse in the previous month, although lower rates of physical abuse are reported to protective services.²⁹ All older adults with injuries should be asked if they feel safe at home and if there is anyone in their life who is threatening or injuring them.

Decreased Physiologic Reserve

A primary effect of aging on human physiology is decreased functional reserve, a progressive process seen in all organ systems. Older adults are less able to compensate for physiologic demands of hypovolemia and stress resulting from hemorrhage associated with trauma. Whereas older adults in a good state of health have sufficient reserves to accomplish activities of daily living, when they are stressed by acute trauma and the subsequent response to injury, the decrease in physiologic reserve can lead to tissue hypoperfusion and organ failure, a common cause of death in older trauma patients.

Comorbidities

Older adults are likely to have significant comorbidities at the time of injury. The percentage of the elderly population experiencing at least one of five chronic diseases (arthritis, cerebrovascular accident, chronic lower respiratory tract disease, coronary heart disease, and diabetes mellitus) varies from 15 to 47%, with only 33% of men and 25% of women having none of these comorbidities.³⁰

Effect of Medications

Medication use is common in older adults. A representative survey of community-dwelling U.S. adults (aged 57 through 85 years) showed that 81% used at least one prescription medication, and 29% used five or more prescription medications.³¹ Aspirin was the most common medication, used by 28% of older adults. Medications increase the likelihood of older adults getting into traumatic accidents (e.g., sedative hypnotics causing falls). Some, such as beta-blockers, affect the physiologic response to trauma. Medications’ effect on vital signs should be considered during the primary survey, and a full medication history should be taken early in the secondary survey.

Modifications to the Trauma Assessment of Older Adults

A systematic trauma assessment, as described in previous chapters, including a primary and secondary survey and concomitant resuscitation should be conducted in older adults. Yet many signs and symptoms of injury in the younger adult, such as hypotension, tachycardia, and pain, will be mild or absent in many older adults. Normal vital signs should not be reassuring, as significantly injured older adults often display delayed hemodynamic signs of injury.

Primary Assessment and Resuscitation