Assume mild decrease in physiologic reserve to hemodynamic or respiratory stressors.

Expect more frequent presence of chronic diseases (diabetes mellitus, cardiovascular disease, hypertension, previous surgery, blood transfusion).

Suspect the use of prescription or over-the-counter (OTC) medications.

Assume the patient is competent to provide an accurate medical history.

Look for subtle signs of organ dysfunction, especially cardiovascular and respiratory systems.

Proceed with standard diagnostic and management schemes.

Accept the presence of age-related and acquired disease-induced physiologic alteration of organ systems.

Expect frequent presence of chronic disease and medications to treat them. Assume a higher incidence of previous surgery and blood transfusion.

Evaluate the patient for competency to provide a reliable medical history. Early review of the history with the patient’s relatives or personal physician is often helpful.

Provide early, appropriate resuscitation to optimize cardiac performance and oxygen delivery.

Any history of loss of consciousness, alteration in mental status, cognitive or sensory function indicates the presence of brain injury and requires brain imaging with CT.

Standard diagnostic and management schemes should be pursued, including early aggressive operative management.

Poor outcomes, especially with severe injury to the central nervous system (CNS) or marked physiologic deterioration secondary to injury, are more frequent.

Check for advance directives guiding care.

Proceed as in 2.

Poor outcome should be assumed with moderate to severe injury, especially with the CNS injury or any injury causing physiologic dysfunction.

After aggressive initial resuscitation and diagnostic maneuvers, reassess the magnitude of the patient’s injuries and discuss appropriateness of care with the patient (if competent) and family members.

Check for advanced directives.

Consider early consultation with experts in ethics and social services to help the family and medical team with difficult decisions.

Decrease in brain tissue mass can result in loss of intracranial volume which results in more “space” needed to fill before intracranial pressure elevation and increased vascular shearing injury which can result in frequent intracranial hemorrhage.

Decreased cerebral blood flow can manifest as blunted sensation (visual, auditory, tactile). Cognitive function is often altered, and the perception of pain can be blunted. Alterations in cerebellar function, gait, and balance increase susceptibility to injury, such as falls.

Cognition and sensorium may be altered by CNS active medications or pre-existing neurologic disease (e.g., dementia) which can significantly impact neurologic evaluation after injury.

Cardiovascular disease is common. Myocardial dysfunction impairs the ability to improve cardiac contractility in response to stress and catecholamine surge. Conduction abnormalities develop and results in different forms of dysrhythmias; atrial fibrillation is the most common.

Arteriosclerotic vascular disease can impair blood flow to organs and tissues in the CNS and peripheral arterial system. Baseline peripheral pulse examination can be diminished or absent.

Cardiovascular medications are common, including beta-blockers. Undesirable side-effects include blunting of reflexive or catecholamine-induced tachycardia and increases in cardiac output. Elders are preload dependent, and hypovolemia (from dehydration, diuretic use, blood loss, etc.) is poorly tolerated. Blood pressure measurement may be misleading due to underlying chronic hypertension, anti-hypertensive medication use, diuretics, or dehydration.

Declining chest wall compliance, respiratory muscle strength, and lung elasticity results in alveolar collapse and decreased arterial oxygenation.

Injury-related torso pain can hasten the development of poor inspiratory effort, atelectasis, and pneumonia; this makes adequate treatment of pain important. Epidural anesthesia/analgesia and non-steroidal anti-inflammatory drugs (NSAIDs) are good options. Opioids in titrated doses and carefully monitored for respiratory effects are helpful; these can be given in continuous fashion or short interval boluses via patient-controlled analgesia (PCA) pumps.

Decrease in renal cortex mass results in as much as 25% functional cortical loss. Glomerular filtration rate (GFR) decreases, and renal tubule reabsorption is impaired resulting in problems with solute clearance and water balance.

Lean body mass decreases with age and creatinine production declines. Serum creatinine levels can remain within normal range even though renal function may be impaired. Therefore, calculate creatinine clearance (C_Cr) to assess function: C_Cr (mL/min) = (140 − age) × mass (kg)/serum creatinine × 72.

Use nephrotoxic agents such as intravenous contrast, aminoglycosides, diuretics, and vasopressor with care and after optimizing volume status.

Osteoarthritis is the second most common chronic medical condition in adults over 65 years in the United States. Pain often compromises mobility and impairs the ability to avoid injury. As a result of diminished muscle mass, strength, and
agility, they have an inability to avoid obstacles and serious injury, especially when falling (altered righting reflex).

Analgesics, often in the form of over the counter medications (aspirin, nonsteroidals, etc.) are commonly used and often not be perceived as “medications” when history is taken despite the impact on bleeding or renal function.