Within the next 15 years, 1 in 5 Americans will be over age 65. $34 billion will be spent yearly on trauma care of this age group. This section covers situations in trauma unique to the geriatric population, who are often under-triaged and have significant injuries underestimated. Topics covered include age-related pathophysiological changes, underlying existing medical conditions and certain daily medications that increase the risk of serious injury in elderly trauma patients. Diagnostic evaluation of this group requires liberal testing, imaging, and a multidisciplinary team approach. Topics germane to geriatric trauma including hypothermia, elder abuse, and depression and suicide are also covered.
Key points
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Geriatric trauma patients are a unique patient population that require individualized assessment and management strategies.
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Changing pathophysiology, increased incidence of co-morbid conditions and the use of anticoagulant medications augment the impact of trauma on geriatric patients.
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Geriatric trauma patients are often under triaged therefore a high index of suspicion should be maintained even with seemingly minor mechanisms of injury.
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Use of diagnostic imaging for geriatric trauma patients should be liberal.
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Elderly patients are at high risk of suicide and elder abuse.
Introduction
Epidemiology
The population of the United States is aging. By 2030, 1 in 5 Americans will be more than 65 years old and by 2050 the US Census projects that the population aged 65 years and older will double and approximately 4.5% of the population will be more than 85 years old. By then, geriatric patients will make up nearly 40% of all trauma cases.
In 2013, unintentional injury was the eighth leading of cause of death in older patients, with an estimated 25,000 deaths related to falls. Trauma in the elderly costs more than $34 billion in direct medical costs every year. Approximately three-quarters of the total cost is related to traumatic brain injury (TBI) and injuries to the lower extremities, including hip fractures.
The care of elderly patients with trauma presents a unique set of challenges. The combination of comorbid health conditions, prescribed medications, and frailty makes older patients more vulnerable to trauma and subsequent complications, including infections, pneumonia, venous thromboembolism, and multisystem organ failure. Patients more than 65 years old are twice as likely to die compared with younger patients with similar injury severity score (ISS). Studies suggest that mortality increases 6.8% for every year beyond age 65 years. Elderly patients are undertriaged a significant portion of the time and are more likely to go to a nontrauma center than younger patients. Some investigators recommend that any patient older than 70 years with trauma should be transported to a trauma center regardless of their ISS.
This article addresses the challenge of treating geriatric patients with trauma, covering differences in anatomy and physiology, triage and resuscitations, as well as addressing some special situations, including elder abuse, hypothermia, and suicide.
Geriatric Anatomy and Physiology
Frailty, aging versus underlying disease
Mortality after trauma increases with age starting as young as age 40 years. However, chronologic age has been shown to be less important in trauma than frailty. Frailty is defined as impairment of function of multiple systems that increases the susceptibility to physical and physiologic stressors. Frailty is difficult to quantify because the index tools are long and time consuming, making them difficult to apply in the emergency setting. The patient’s baseline functional status and evidence of sarcopenia may be considered as surrogate markers of frailty. Frail patients with poor functional status and multiple comorbidities have been shown to have worse outcomes after trauma.
Head and neck
Traumatic brain injury is the leading cause of traumatic death in the elderly. The brain shrinks over time. Decreasing brain volume causes stretching of the bridging veins, making them more susceptible to tearing and bleeding from the shearing forces in trauma. Furthermore, cerebrovascular autoregulation and free radical clearance are impaired with age. This process contributes not only to worsened brain injury in elderly patients but to delayed recovery. Elderly patients are at higher risk for significant intracranial injury in minor head trauma, and have more frequent bleeds and severity of intracranial hemorrhage (ICH) if taking oral anticoagulants. It is important to note that the clinical decision rules designed to decrease the use of computed tomography (CT) brain in minor head trauma have all found increased significant findings on CT in the elderly. Therefore, although use of clinical judgment is advised in determining the need for advanced imaging in patients more than 65 years old with minor head injury, the clinician should have a lower threshold to CT scan this population. Similarly, the same 2 research groups (NEXUS II c-spine, Canadian c-spine) excluded elderly patients from the low-risk decision rule because of higher numbers of significant fractures in this population.
Chest
Cardiac
Heart disease may affect outcomes of elderly patients with trauma through diminished cardiac reserve. Patients with a history of congestive heart failure (CHF), and those on warfarin or β-blockers are at higher risk of poor outcomes after trauma. The exact mechanism and physiology related to worse outcomes in CHF are not entirely understood and there are no clear studies to guide management in the emergency department (ED). It is thought that the decreased reserve is related to structural and functional cardiac changes of aging and a significant reduction in cardiac function during the stress of trauma. During evaluation of a geriatric patient with trauma the clinician should take a careful cardiac and medication history. Hypotension and poor cardiac output should be treated with inotropic and chronotropic medications and consideration of balloon pump in severe cases.
Pulmonary
The mechanics and physiology of breathing change with age. Increased chest wall rigidity and worsening kyphosis may lead to impaired respiratory muscle insertion mechanics, and when combined with a weakened diaphragm may lead to decreased fraction of expiratory volume in 1 second (FEV 1 ) and decreased vital capacity, and result in an overall decline in respiratory reserve. Elderly patients may also have impaired lung function from underlying chronic obstructive pulmonary disease, pulmonary fibrosis, or scarring. In addition, geriatric patients have a significantly lower diffusing lung capacity for carbon monoxide and decreased partial pressure of oxygen, which may explain why elderly patients can have significant hypoxia at lower levels of physiologic stress. These physiologic changes make elderly patients with trauma more susceptible to the stresses of acute blood loss and fluid resuscitation.
Abdomen
Liver and kidney disease
Underlying hepatic and renal disease increase mortality in elderly patients with trauma. The ability of the liver to withstand injury decreases with age. Furthermore, cirrhosis increases the susceptibility to ischemic and reperfusion injuries, the risk of hemorrhage, posttrauma complications, and mortality. Elderly patients also have an increased incidence of kidney disease, which may make them more prone to contrast-induced nephropathy (CIN). A recent study suggests that elderly patients with normal renal function are not at increased risk of CIN compared with younger patients. Oral hypoglycemic medications can increase the risk of CIN, so it is important to communicate this with radiology, and to limit scans with contrast to only those patients who need them, to avoid iatrogenic harm. A normal creatinine level should be interpreted with caution because elderly patients typically have less muscle mass, therefore a high normal value may reflect acute kidney injury or chronic kidney disease.
Musculoskeletal
Fragile bones and skin
Aging causes several normal, expected physiologic changes to both muscle and bone, making elderly patients more susceptible to fractures even in the absence of underlying osteoporosis. Aging bones are more easily fractured with minor trauma, for example in falls from standing. In addition to weaker bones, older patients have a loss of muscle mass leading to sarcopenia and a subsequently decreased structural support that protects younger patients from injury. Sarcopenia is one of the defining characteristics of frailty syndrome. As frailty increases, functional decline ensues, leading to decreased mobility and deconditioning, increasing the risk of falls and injury. Given the increased risk of musculoskeletal injury in the elderly, emergency practitioners should have a low threshold of obtaining plain film radiographs. Elderly patients who are unable to walk after the trauma should undergo advanced imaging such as CT or magnetic resonance imaging (MRI) of the hip even with normal radiographs. MRI is more sensitive (100%) for occult fracture but is more time consuming and expensive than CT (sensitivity 87%). One group of investigators suggests an algorithm whereby patients with an initial negative radiograph who have a low-energy mechanism of injury and who are at high risk of osteoporosis undergo MRI, and others CT.
History: Mechanism of Injury
Falls
Falls are the leading cause of trauma-related mortality in the elderly, and the rate of falls is increasing. Women and white people are most likely to fall. Elderly patients who fall are more likely to have complications of the fall, be hospitalized, be admitted to the intensive care unit, and subsequently require discharge to a rehabilitation facility.
Mortality
The overall estimated mortality of geriatric patients after a fall is between 7% and 11%. The strongest predictor of mortality is increased age. After admission for a fall, the 1-year mortality may be as high as 33% with a 44% 1-year readmission rate. The elderly are less likely to die as a direct result of the trauma and more likely to die from secondary complications. TBI is the most common direct cause of death from a fall.
Risk factors
Frailty and comorbidities both contribute to the risk of falling and the subsequent sequelae of the fall. The pattern of injury is directly related to the mechanism. Falls are often multifactorial and the exact cause may be difficult to determine in an emergency setting. Recent data suggest that many of these patients may have occult infections.
Several risk factors for falling have been identified in the geriatric population ( Table 1 ). Older women who have had previous falls are at the greatest risk. Slowed gait and reaction times contribute significantly to falling. Decreased reaction times may be a consequence of underlying arthritis, poor vision, sarcopenia, and chronic medication use. Pain is also a contributor because it may lead to a fear of moving. Muscles weaken from subsequent lack of physical activity, leading to poor gait and deconditioning. Interventions to treat pain, to address the fear of falling, and improve balance have been shown to decrease the risk of falls.
| Acute Illness | Chronic Medical Condition | Environmental Factors | Other |
|---|---|---|---|
| New medications Syncope Dysrhythmias CVA, TIA Acute MI Seizure Acute renal failure Infection Hypoglycemia AAA Dehydration Acute fractures | Osteoporosis Osteoarthritis CVA Ischemic heart disease Anemia DM HTN Gait or balance impairment Visual impairment Depression Polypharmacy Parkinson disease Dementia | Rugs Lighting Stairs Bathtubs/showers Footwear Walking aids Uneven ground Weather Pets | Older age Female Alcohol or drug use Elder abuse |
Motor vehicle collision
As the population ages there will be more elderly drivers on the roads, with an estimated 25 million drivers more than 65 years of age in 2012. Geriatric patients account for 17% of all motor vehicle crash (MVC) fatalities. Emergency providers can expect to see an increased proportion of geriatric patients with MVC injuries in the future. Older patients are more likely to have more severe injuries at low speeds and to be admitted to the intensive care unit. Elderly patients have a higher mortality, higher cost of admission, and higher use of acute rehabilitation facilities after an MVC.
Pedestrian struck
Geriatric patients account for approximately 20% to 30% of pedestrians struck and killed by a motor vehicle. Decreased visual acuity, decreased reaction times, difficulty ambulating, as well as impaired judgment place elderly patients at increased risk of being struck. Older pedestrians who are hit by a motor vehicle have a higher incidence of severe injury and death compared with younger patients. Even with seemingly minor or low-energy trauma, the concern for serious injury in elderly patients should remain high.
Clinical work-up
Triage/history of present illness
Geriatric patients with trauma are frequently undertriaged both in the prehospital setting and in the ED. The literature suggests that general prehospital triage guidelines are ineffective for elderly patients. Vital signs are unreliable, underlying comorbidities are common, and the use of certain medications can mask the physiologic effect of the trauma or exacerbate it. Certain risk factors may lead to undertriage, including age, female sex, and a fall-related injury. Even minor deviations from normal vital signs are associated with increased risk of death. Tachycardia with a heart rate (HR) greater than 150 beats per minute has a mortality of almost 70%. Similarly, a systolic blood pressure of 90 mm Hg carries a 30% mortality. Even small changes in mental status are associated with worse outcomes. Studies have shown that geriatric patients with a Glasgow Coma Scale (GCS) score of 14 have a significantly higher mortality and are at higher risk of TBI compared with younger adults with a similar GCS. Elderly patients with trauma should be evaluated at a trauma center and the trauma team should be activated.
Injury severity score: is it helpful in trauma evaluation?
Use of the ISS in the triage of patients with trauma is common practice. However, its applicability to elderly patients is debated. One recent study supporting its use found that an ISS greater than or equal to 16 and specific injury patterns including brain, chest, and abdomen-pelvic injuries were associated with a significant increase in mortality.
It is important to take a careful history. Certain underlying disease processes affect clinical outcomes in geriatric patients with multitrauma. These factors include heart disease, peripheral arterial disease, coagulation disorders, malignancy, and obesity.
Past medical history/medications and reversal agents
When taking the history, it is important to note any conditions that uniquely affect the geriatric patient with trauma, as discussed earlier. Elderly patients are more likely to be on medications before their traumatic event. β-Blocker and oral anticoagulant (OAC) use is common. The effect of β-blockers on posttraumatic vital signs is debated. Isolated use of β-blockers did not have a significant impact on presenting vital signs. Only patients taking a combination of β-blockers, calcium channel blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor binding agent showed blunted hemodynamic responses to trauma. Medications, especially antihypertensive and sedatives, may also increase the risk of trauma, in particular falls.
Oral anticoagulants are prescribed for many common conditions, including atrial fibrillation, stroke, thromboembolism, and medical management after cardiac revascularization. Some of the more common agents include warfarin, rivaroxaban, apixaban, dabigatran, clopidogrel, and aspirin.
Patients who are on OACs and subsequently fall are at greater risk of dying. This effect is most significant in patients with head injuries, specifically skull fractures, and intracranial hemorrhage, but is also higher with intra-abdominal injuries. The mortality effect of OAC seems to increase after age 70 years and is irrespective of different anticoagulation regimens. Rapid reversal of international normalized ratio (INR) in the setting of intracranial hemorrhage slows progression of the bleed and reduces mortality.
Initial Management and Resuscitation
Initial resuscitation should begin with the basic ABCs (airway, breathing, and circulation) as in any other patient with trauma. All patients with trauma should be placed on supplemental oxygen to preoxygenate and for apneic oxygenation should endotracheal intubation become necessary. Geriatric patients have higher Mallampati scores, increased rigidity of the cervical spine, and poor dentition, all of which may make bag-valve mask ventilation and endotracheal intubation more difficult. The changes associated with decreased functional reserve also affect intubation and mechanical ventilation.
Furthermore, elderly patients may have associated degenerative changes of the jaw, which may make complete opening of the mouth difficult. If intubation is required, rapid sequence intubation medicine doses should be adjusted accordingly. Benzodiazepines and etomidate doses should be reduced by approximately 20% to 40% to decrease their hemodynamic effects. Ketamine is less prone to cause hypotension but should be used with caution in patients with ischemic heart disease because it increases myocardial oxygen demand. The secondary survey should include complete exposure of the patient and a quick neurologic assessment. The physical examination may be more difficult in elderly patients. The abdominal examination may be unreliable because of decreased pain perception, cognitive decline, or minimization by the patient. In addition, their neurologic examination may be complicated by underlying dementia or altered mental status from other causes, such as infection or stroke, all of which may have contributed to the trauma. Given the risk of serious injury even with minor trauma, liberal use of CT scans is appropriate.
Do-not-resuscitate status
During resuscitation it is critical to consider the patient’s wishes for resuscitation and to consider the possible futility of such resuscitation. Certain risk factors, including hypotension, age greater than 74 years, and higher ISS, increase the risk of mortality but do not predict mortality. Age alone should never be used as the sole determinant to limit care.
Assessment for unstable patients
Aggressive resuscitation should be initiated in all unstable patients with trauma. Any patient with persistently abnormal vital signs or not responsive to resuscitation efforts, and those who have evidence of active hemorrhage or deteriorating mental status, should be considered unstable. Seemingly stable geriatric patients with trauma should be thoroughly evaluated for occult life-threatening injuries. A serum lactate level and base deficit should be obtained in elderly patients with trauma because abnormal values indicate impending deterioration and may predict mortality. However, normal values should not be used to rule out serious injury. Serum lactate and base deficit values should be repeated after initial resuscitation and persistently abnormal values should be investigated further.
Hemodynamic monitoring in elderly patients with trauma is essential. Slight changes in HR or blood pressure may signify unrecognized injury and should be investigated thoroughly. Pulmonary artery catheters are being replaced by ultrasonography and echocardiography and studies suggest that the data obtained from the two are comparable.
Reversing anticoagulants
Current guidelines recommend assessing the patient’s INR and activated partial thromboplastin time and prothrombin time and to rapidly reverse any abnormalities. Patients with increased INR may benefit from rapid reversal with fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) and vitamin K. Note that normalization of prothrombin time or INR does not always correlate with decreased bleeding. The newer anticoagulants rivaroxaban, apixaban, and dabigatran do not yet have proven reversal agents; however, some studies show that PCC may be a reasonable choice with life-threatening bleeding ( Table 2 ). Clinical trials are ongoing, investigating the use of monoclonal antibody reversal agents for rivaroxaban, apixaban, and edoxaban. The US Food and Drug Administration recently approved idarucizumab, a monoclonal antibody, for reversal of dabigatran in the setting of an acute bleed.
| Anticoagulant Agent | Mechanism of Action | Potential Reversal Agent |
|---|---|---|
| Warfarin | Vitamin K antagonist | FFP, PCC, vitamin K |
| Dabigatran | Direct thrombin inhibitor | Idarucizumab |
| Rivaroxaban | Factor Xa direct inhibitor | PCC |
| Apixaban | Factor Xa direct inhibitor | PCC |
| Enoxaparin | Anti–thrombin III inhibitor | Protamine (partially effective) |
| Heparin | Anti–thrombin III inhibitor | Protamine |
Diagnostic Evaluation
A thorough assessment of whether the fall was related to a neurologic or cardiac event is critical, because these events are more common in the elderly population. The circumstances surrounding the event, including environmental factors, substance use, acute or chronic medical conditions, medications, and the patient’s baseline functional capacity, should also be investigated. Determining the events surrounding the fall or trauma can help with appropriate disposition of the patient. An electrocardiogram should be done in all elderly patients with trauma. Use of plain films or CT scanning of the affected organ systems should be liberal. Long bones easily fracture, and older patients do not always experience the same degree of pain relative to the severity of injury. A FAST (focused abdominal sonogram in trauma) examination is quick and easy to perform and should be performed in elderly patients with trauma with moderate to severe mechanisms.
Geriatric patients presenting with multisystem trauma pose a challenge to emergency department providers. As discussed previously, vital signs can be unreliable in the elderly and their physiologic response to trauma variable. In addition, plain film radiography has poor sensitivity to rule out serious injury in patients with multisystem trauma. When there is evidence of multisystem involvement patients should undergo whole-body CT. Other studies advocate the use of whole-body CT in older patients with any concerning mechanism of injury or for those who present with a distracting injury.
Head injuries
TBI is the fifth leading cause of death in the elderly. Most TBIs are the result of low-impact, ground-level falls. Geriatric patients are more likely to have more severe TBI and longer hospital admissions, and are more likely to die or be discharged to subacute nursing facilities after a head injury compared with young patients. Patients more than 65 years of age with a GCS of 14 have a mortality of 10% to 15% compared with zero in younger patients with similar injuries. The American College of Emergency Physicians recommends that any patients more than 60 years of age with loss of consciousness or who are taking an OAC should undergo brain CT. Repeat brain CT imaging should be reserved for patients with a change in their neurologic examination or for those patients who cannot reliably be examined. Patients taking oral anticoagulants who have minor trauma and a normal brain CT may be safely discharged because the risk of delayed bleeding is low. Patients should be given clear return instructions.
Cervical spine injuries
Similarly, elderly patients are at a significantly increased risk of cervical spine fractures after trauma. Those more than 64 years of age are twice as likely to have a cervical spine injury (CSI) as younger patients with the same mechanism of injury. As a result of degenerative changes and stiffening of the lower cervical spine, elderly patients are at increased risk of higher CSI (C1–C2 and odontoid fractures vs C6–C7). Application of the NEXUS decision rule in the elderly has been debated because geriatric patients may have CSI with lower-energy mechanisms of injury. Several studies have shown that the NEXUS criteria perform equally well in patients more than 80 years old. However, given the increased risk of CSI, it is recommend that a CT scan of the cervical spine be obtained if CT brain is ordered because the risk of concomitant CSI is about 5%. Other studies recommend obtaining a CT scan of the cervical spine and brain regardless of the mechanism of injury in geriatric patients.
Thoracic trauma
Blunt thoracic trauma in the elderly carries a significant risk of complications and mortality, even with isolated rib fractures. The most common complications include pneumonia and pulmonary contusions. The risk of mortality after a rib fracture is proportional to the number of fractured ribs and may serve as a predictor of trauma severity and risk of complications. Age more than 85 years; initial systolic blood pressure of less than 90 mm Hg; 3 or more unilateral rib fractures; or the presence of pneumothorax, hemothorax, or pulmonary contusion may be helpful in predicting adverse outcomes. However, these factors have not yet been validated. Elderly patients with 1 or more rib fractures are at high risk of mortality and therefore their dispositions should be carefully considered.
Musculoskeletal injuries
Musculoskeletal injuries are very common in elderly patients with trauma. The risk of osteoporosis and subsequent fractures increases with age. There are an estimated 9 million osteoporotic fractures worldwide every year, which significantly contribute to the disease burden in North America. Women are more affected than men. Overall, fractures in the geriatric patient population carry a high morbidity and mortality and negatively affect both the patients’ quality of life and society at large.
Forearm fractures are the most common, with hip fractures a close second. It is estimated that hip fractures will cost approximately $35 billion per year by 2040. Geriatric patients have a high mortality following a hip fracture and it is crucial that these patients receive expedient and coordinated care. Early surgical repair, balanced with medical optimization, has been shown to significantly reduce mortality and improve the chance of patients returning to their previous functional states. Evidence suggests that a dedicated orthogeriatric team approach to these patients may improve outcomes, including mortality and quality of life.
Pelvic fractures are less common but carry an equally high mortality of 5% to 20%. Elderly patients who sustain pelvic fractures are at increased risk of hemorrhage, are more likely to require angiography and blood transfusion, and are 4 times more likely to die as a result of their injuries. Lateral compression fractures are more common and more likely to require blood transfusion in geriatric patients compared with younger patients. A recent large study of stable pelvic fractures found that age more than 70 years, higher ISS, altered mental status, and need for blood transfusion predicted mortality. Older patients with pelvic fractures should be aggressively resuscitated because evidence suggests that, even with appropriate treatment and disposition, mortality remains high.
Disposition
Whether discharging or admitting patients, a multidisciplinary approach should be taken, including involvement of social work, case management, family members, and the patient’s primary care physician, because the risk of recurrent falls is very high in the elderly population. Certain factors increase the risk of a recurrent fall, including a history of multiple falls, impaired mobility, poor strength, and depression. Questions to consider before discharge include whether the patient has an acute underlying condition that requires further evaluation.
Can the patient walk?
Can the patient perform activities of daily living?
What resources does the patient have at home?
Is a home safety visit available?
Given the increased risk of complications and mortality, most elderly patients with trauma need admission to the hospital. As previously discussed, a significant percentage of elderly patients with trauma are under-triaged. Evidence supports direct triage or transfer to a dedicated trauma center if there is concern for any significant injury and certainly if there is a need for surgical, neurosurgical, orthopedic, or burn care. Transfer should not be delayed to obtain diagnostic tests that will not change management or disposition. Studies have shown that delays in care may affect morbidity and mortality in elderly patients with trauma, but the data are limited and more research is needed to definitively conclude that transfer improves outcomes.
Patients with a minor isolated injuries may be considered for discharge. Careful consideration should be given to patients with isolated rib fractures. If there is suspicion for potential respiratory compromise, then the patient should be admitted. If there is concern for concomitant injury, such as head injury, or if the patient’s history is limited by underlying medical conditions such as dementia or altered mental status, strong consideration should be given to admission.
Several factors must be considered before discharge, including the cause of the injury, what the patient’s home environment is like, who will be able assist the patient at home if needed, and who will follow-up with the patient. If a definitive discharge plan is not available, admission should be considered to facilitate coordination of an appropriate care plan.
Summary
As the population ages, geriatric patients with trauma will become increasingly common. The elderly are a unique population with respect to mechanism of injury, injury types, morbidity, and mortality. They are vulnerable to minor traumatic events and are likely to have poor outcomes if not treated aggressively. Physicians, particularly emergency medicine physicians and trauma surgeons, should be familiar with the physiologic changes of aging, understand the potential underlying comorbidities that affect elderly patients with trauma, and maintain a high index of suspicion for serious injury for all geriatric patients with trauma. Use of laboratory and diagnostic imaging studies should be liberal and physicians should have a low threshold to admit elderly patients with trauma.
Special Situations
Elder abuse
Elder mistreatment or abuse can be defined as intentional actions that cause harm or create a serious risk of harm, whether or not this is intended, to a vulnerable elder by that person’s caregiver or a person who holds a trusted position in relation to that elder. It can also include the failure of the caregiver to satisfy the elder’s basic needs or to protect that person from harm. Looking at the magnitude of the problem epidemiologically, nearly 25% of elders have reported psychological abuse. Six percent of older people in one study reported abuse within 1 month of the survey, and 5.6% of couples reported violence in their relationship. Five percent of family members surveyed in this study reported physical abuse toward care recipients with dementia in a 1-year period. When studying the literature on recorded rates of elder abuse using objective data, the incidence is significantly lower. There is a disconnect between what is being reported objectively and what elders are saying when asked directly. It is thought that a reasonably safe estimate is that 1 in 4 elders have experienced some form of abuse. ED clinicians should recognize the importance of asking about potential abuse of elderly patients, because they often report it if asked.
Risk factors and types of elder abuse
Elder abuse is an international problem. Studies from Asia to Europe and North America all report similar data. The greatest risk factor seems to be dementia. Close to half of individuals in America more than 85 years of age have some degree of dementia, and up to one-half of these people are abused. Institutionalized individuals with disabilities, especially women older than 65 years, are at significant risk for interpersonal violence (>50%) compared with only 21% of women without disabilities. Other types of elder abuse, in order of prevalence include, financial (5.2%), emotional and both physical neglect and to a lesser extent sexual abuse (0.6%).
Health impact of elder abuse
Elders who experience even modest abuse have a 300% increase in risk of death compared with nonabused cohorts. They have a higher incidence of bone and joint disorders, digestive problems, depression, anxiety, chronic pain, increased blood pressure, and heart problems. There is an estimated cost of $5.3 billion in extra health care costs related to elders who are abused.
Management principles
Assessment
Assessing elderly patients should include screening questions about how they are managing their daily lives and whether they are experiencing any psychosocial stress, because this is a risk factor for abuse. Ideally the patient should be interviewed alone. Caregivers should also be interviewed and assessed for caregiver fatigue because this can increase the risk of elder abuse. The patient’s cognitive and functional status must be assessed, and, if there is any concern by the clinician, this should be addressed before discharging the patient.
Capacity
In the end, it is up to the ED clinician to make a judgment on the elder’s capacity for decision making if there is suspicion or evidence for abuse. Taking into account the risk factors mentioned earlier, there should be a low threshold for admitting these patients to get them out of their potentially abusive environments, at least until a preliminary investigation into the patient’s safety is conducted.
Disposition
If it is determined that the patient is experiencing abuse, then discharge must be coordinated with home health services. If available, a social worker should be involved, the case should be reported, and a safe environment should be established. If there is family, they must be appropriately involved in this process. Also, clinicians must try to facilitate treatment of the underlying disease. For example, a physical limitation by a treatable illness may be causing anxiety and depression, causing the patient to act out, and putting the patient at risk for abuse by caregivers.
Reporting
All states mandate reporting for probable suspicion of elder abuse. Adult Protective Services should be notified. They will take a report and start an investigation. If the patient is in a licensed long-term care facility, there are long-term care ambassadors who are charged with investigating alleged incidents.
Hypothermia in the elderly
There are almost no studies on hypothermia in the elderly. By definition, hypothermia is the unintentional decline of body temperature less than 35°C. The coordinated systems of thermoregulation fail because the compensatory responses to minimize heat loss through radiation, conduction, convection, respiration, and evaporation are limited. A longitudinal study of patients noted an age-related decline in thermoregulatory capacity in aging individuals. Those people at risk for hypothermia seem to have a low resting peripheral blood flow, and a nonconstrictive pattern of vasomotor response to cold. They also have a higher incidence of orthostatic hypotension.
Survival of elderly with hypothermia
Case reports of elderly patients surviving after presenting with core temperatures of less than 28°C (82°Fahrenheit) have been published. Slow active external rewarming was used in those cases. The prognosis worsens as the patient’s age increases. Passive and active rewarming techniques are equally effective in elderly patients and have similar associated risks.
Rewarming techniques
Passive rewarming techniques include warm blankets, heating lamps, and warm humidified air. Patients may also be actively warmed using intravenous warm saline or cavitary lavage. Thoracic lavage has been studied in populations including patients as old as 72 years with a mean core temperature of 24°C (75° Fahrenheit). Most patients had no blood pressure or pulse on presentation. Patients either had tube thoracostomies done with lavage with warm fluids, or thoracotomies with lavage of warm fluids. They achieved a rewarming rate of 2.95°C per hour. Median time to sinus rhythm was 120 minutes, and median hospital stay was 2 weeks. Twenty-eight percent died, 85% had pulmonary complications, and 80% of survivors had full neurologic recovery. More recently cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) have been used for active rewarming of severely hypothermic patients. CPB confers significantly lower mortality (15.5% vs 53.3% standard rewarming in one study), with up to 60% surviving and 80% returning to previous level of activity. Patients receiving ECMO faired even better than the CPB patients. No data exist for survival and neurologic outcome in the elderly. At this time, patients who present with accidental hypothermia and in cardiac arrest should be strongly considered for CPB or ECMO, and it seems that thoracotomy or tube thoracostomy with warm irrigation before this confers a superior survival rate.
Suicide in the elderly
In North America, approximately 12 per 100,000 individuals 65 years of age and older die by suicide. Older white men have the highest prevalence. Risk factors include suicidal ideation (SI), suicidal behavior, mental illness, medical illness, losses and poor social supports, functional impairment, and low resiliency. In a Danish study, in addition to these risk factors, the investigators found homelessness, alcohol and drug dependence, institutionalized elders, prisoners, and other socially excluded people to be at highest risk for suicide. In the Netherlands, one-third of all suicides are attempted by elderly individuals.
Observations in suicidal elders
Certain patterns can be seen in elders with SI that lead to peers, loved ones, and caregivers missing the signs. Because many elderly patients survive major life events, loved ones assume that they are capable of coping with another major life event, loss, or threatening condition. Depression may not be apparent to relatives or may be assumed to be a natural reaction to aging. If relatives suspect depression, they may not know that it is a treatable condition or where they can seek treatment. The elderly depressed may not share their depressed thoughts about death and dying. They may not admit SI. Their symptoms of depression may be confused with the normal aging process.
Detecting suicidal ideation in the elderly
Few older adults who die by suicide have seen a mental health specialist in the days or weeks leading up their deaths. However, many have seen some type of caregiver, typically a primary care doctor. As a result, ED clinicians have an obligation to screen for depression and SI in elders, because its detection could save the patient’s life. Any of the patient’s social supports, friends, family, spouses, and institutional caregivers should be asked about the patient’s mood and any concern for depression and SI. Studies have shown a strong correlation between the social support/proxy having a strong impression of the patient’s risk for depression and active SI and actual depression and SI in the patient. It is therefore incumbent on ED clinicians to ask the supports whether they think the patient is depressed or suicidal, and, if so, to act aggressively on that information.
Treatment
Treatment is multifactorial. If acute severe clinical depression is detected in an elderly ED patient, then it is appropriate for the clinician to request an emergent psychiatric consult in the ED. Improving the severity of a patient’s active illness may improve the patient’s mood and depression, so clearly finding and treating all ongoing medical issues is important. Ensuring strong social supports and close psychiatric follow-up if necessary is also indicated. In addition, a Danish study found that limiting access for violent means of death reduced the rate of suicide. Be certain that the family removes any firearms in the household and takes away heavily sedating medications such as barbiturates, benzodiazepines, and narcotics. They should also limit contact with carbon monoxide gas produced by domestic gas furnaces or automobiles. The job of ED clinicians is primarily one of detection, prevention, and referral. Detection only occurs when the questions are asked, and the questions are only asked if the clinician is aware of the magnitude of the problem and keeps this in mind when evaluating the elderly patient.
Disclosures: None.
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