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394 J. Menaker and T.M. Scalea
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mucociliary function worsens, with fewer cilia per square
centimeter. Secretion clearance is also impaired. This, in
addition to poor dentition, increased oropharyngeal colonization, swallow dysfunction, and a decreased lower esophageal sphincter tone, predisposes the elderly to aspiration
pneumonia and pulmonary infection [44]. Gram-negative
organisms predominate in the oral flora, increasing the risk
of pulmonary infection from aspiration [47].
Osteopenia of the thoracic cage may increase the rate of
pulmonary contusions, rib fractures, and pneumo- and hemopneumothoraces as the bony thorax cannot absorb transmitted kinetic energy. Accordingly, flail chest in the elderly
correlates with prolonged mechanical ventilation [48]. In
those with a flail chest, age has been shown to be the strongest predictor of poor outcome and is directly proportional to
mortality [49]. Elderly patients who sustain rib fractures
have twice the mortality rate of younger patients with similar
injuries [50]. The number of rib fractures increases, so does
the incidence of pneumonia and death [50, 51]. Pain control
is critical to allow deep breathing and prevent pulmonary
complications.
Renal Disease
A number of structural changes occur in the kidney as one
ages. Decrease in renal tubular length and thickening of
basement membranes, as well as interstitial fibrosis and atherosclerosis of capillary beds, lead to ineffective secretion
and resorption abilities of the aging kidney [32]. Between the
age of 25 and 85, 40% of the nephrons become sclerotic. In
addition, between the age of 30 and 85, there is a 20–25%
decrease in renal mass, from renal cortical loss [52]. By age
80, the glomerular filtration rate (GFR) has decreased
approximately 45%, but serum creatinine remains the same
due to concomitant muscle mass loss [44]. Thus, serum creatinine for a given level of renal function is falsely low.
The lower GFR causes a diminished ability to concentrate
urine in the aging kidney. A concomitant decrease in response
to aldosterone and antidiuretic hormone further prevents the
kidney from producing concentrated urine. Furthermore,
diuretics prevent the aging kidney from concentrating the
urine and make urine output a less reliable marker for renal
perfusion in the elderly.
Once injured, the elderly who have renal insufficiency or
failure may have additional problems. The platelet dysfunction commonly seen with renal failure may lead to prolonged
bleeding even after minor trauma. Electrolyte disorders,
most notably hyponatremia, hypo- or hyperkalemia, hypomagnesemia, and hypocalcemia may cause dysfunctional
neural transmission, cardiac dysrhythmias, seizures, mental
confusion, muscular weakness, or syncope.
Drugs used to evaluate and treat the older trauma victim
may further impair renal function. Extensive imaging with
iodinated contrast may damage already impaired renal parenchymal and tubular system and lead to contrast-mediated
nephropathy. Nonsteroidal anti-inflammatory drugs
(NSAIDs) are frequently used to treat pain and avoid the
sedative effects of narcotics, but use of these agents is associated with a significant risk of interstitial nephritis. Lifethreatening infections with gram-negative organisms may
require aminoglycosides, but such therapy may induce renal
dysfunction despite seemingly acceptable drug levels.
Despite renal replacement therapies, acute renal failure in
trauma patients results in a mortality rate of approximately
50%, regardless of cause [53–55].
Musculoskeletal
Degenerative joint disease is common in the elderly and
results in limited range of motion around major axial joints
and puts the individual at high risk of injury. Lean body mass
decreases by 4% every 10 years after the age of 25 and 10%
every 10 years after the age of 50 [32]. Osteoporosis, with
loss of up to 60% of trabecular bone and 35% of cortical bone
[30], has been cited as a major factor contributing to the high
incidence of fractures seen in elderly trauma patients [56].
Aging also influences the site of cervical spine fractures.
In younger patients, the lower cervical spine region is more
mobile and is the location of many cervical spine injuries.
However, in the elderly, the lower cervical spine is less
mobile due to degenerative changes, and the more mobile
region of C1 and C2 is more often the site of injuries in the
elderly [57].
Gastrointestinal
There is decreased hepatic function in the elderly due to a
40% hepatic mass loss by the age of 80 [58, 59]. Preexisting
liver dysfunction increases mortality after trauma [8, 20, 21].
Hepatic disease has the strongest effect on trauma mortality
of all preexisting medical conditions and is associated with
an increased mortality in elderly trauma patients with less
severe injuries [8, 20]. Morris et al. demonstrated that cirrhosis, in trauma patients of any age, increased the risk of
dying, with an odds ratio of 4.5 [21].
The elderly trauma patients are at an increased risk of intestinal infarction. Acute hemorrhage, neurogenic shock, or cardiac dysfunction from acute injury can all result in low flow
states. In the elderly with underlying vascular calcification or
mural thrombus, any decrease in flow can cause significant
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compromise to the bowel and result in intestinal ischemia.
Additionally, geriatric patients often do not manifest peritoneal signs and tend not to localize pain, making the diagnosis
difficult [32]. This lack of peritoneal irritation can be a result
of decreased abdominal musculature. In addition, polypharmacy, dementia, or Alzheimer’s can obscure the physical
exam in the elderly, making the diagnosis of an intraabdominal injury more difficult.
Metabolic/Endocrine
By age 80, the elderly have lost almost 40% of their lean
muscle mass [44]. During muscle breakdown for gluconeogenesis, critically ill patients lose a significant amount of
muscle mass. As the elderly start with less muscle mass, the
proportion of loss is greater [60]. Thus after injury, the
elderly quickly become severely malnourished, and nutritional support should begin early. A 2005 Cochrane review
on nutritional supplementation in the elderly suggested that
early nutrition reduced unfavorable outcomes, long-term
complications, and days spent in rehabilitation [61].
The most notable endocrinopathy of aging is glucose
intolerance. This hyperglycemia is a result of both decreased
secretion of insulin and increased resistance to insulin [11,
60, 62–64]. Increasing age is associated with an increase in
serum glucose, but not an increase in insulin after mild or
moderate trauma [63]. There is also a decrease in thyroid
function and responsiveness to metabolic stress in the elderly.
Aging cause fibrosis of the thyroid gland with a decrease in
the amount of T3 released. This results in a lower basal metabolic rate [32]. The elderly also lose their natural responses
to cold and are at a higher risk of hypothermia [65, 66].
Warming, therefore, should be implemented as quickly as
possible after injury.
Epidemiology of Injury in the Elderly
Falls
Falls are the most common injury in the elderly. Most falls
occur in or about the home, with the greatest number during
winter [67]. Most tend to be ground-level falls, while falls
from great heights are uncommon [30]. Between 30 and 40%
of the population over 65 years of age who live in the community sustain a fall each year [68–73]. This is higher for
persons living in long-term care facilities [69, 70, 72]. About
30–55% of falls in those over the age of 65 years cause minor
injuries such as bruises and abrasions [73–75]. Fractures
occur in 4–6%, 25% being hip fractures, while other major
injuries requiring hospitalization occur in an additional
2–10% [72, 76]. Elderly women are no more likely to fall,
but sustain serious injury, usually fractures, more commonly
than men [13, 77]. Men incur more CNS injuries and have
higher mortality following falls [13]. This may be from
higher risk-taking and underreporting of less severe fall injuries in men [13].
Inability to get up after a fall is common. In one study,
50% of the elderly could not get up without assistance from
weakness or limited motion due to underlying musculoskeletal disabilities [77]. A large prospective study demonstrated
that 14% of patients who fell were unable to get up after
5 min or more, and 3% of patients were down for longer than
20 min [73]. Another study showed that 41% of patients
treated in an emergency room after a fall reported being
unable to get up within 5 min, and 3% of patients lay on the
floor for more than 3 h [78]. Prolonged down time can cause
decubiti, dehydration, and even rhabdomyolysis.
Numerous studies [13, 76, 79, 80] have outlined the risk
factors for falls among the elderly (Table 31.5). Debilitating
chronic diseases such as parkinsonism, stroke, arthritis,
Ta b l e 31.5 Risk factors for falls and fall-related injuries
Chronic debilitating diseases
Parkinson’s
Strokes
Arthritis
Anemia
Dementia
Neuromuscular disorders
Acute illnesses
Advanced age
Sensory impairments
Unsteady gait
Lower extremity weakness
Low body mass
Caucasian
a
Exercise
Previous falls
Dependence for ADLs
Postural hypotension
Syncope
Dysrhythmias
Seizure
Carotid stenosis
Aortic stenosis
Medications
Benzodiazepines
Phenothiazines
Antidepressants
Diuretics
Laxatives
Diltiazem
ADLs activities of daily living
a
Exercise has an inconsistent effect on the incidence of falls and fall-
related injuries (see text)
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dementia, and anemia are more prevalent in the population
of elderly who sustain falls [81]. Among the other factors are
older age, Caucasian race, history of previous falls, polypharmacy (especially psychotropic agents, diltiazem, laxatives, and diuretics), dependence for activities of daily living,
low body mass and impaired mobility, muscle strength, gait,
balance, vision, hearing, and cognition [73, 75, 76, 82].
These factors have all been correlated with an increased risk
of falls and fall-related injury. The role of exercise as a risk
factor is not clear. Exercise may lead to increased coordination and strength. While some studies have shown significant
decreases in the incidence of falls, exercise also increases the
exposure of the elderly to possible fall scenarios [81].
Falls amongst the elderly result from complex interactions
of structural and physiologic disabilities. The consequences
of a fall depend on such factors as the kinetic energy generated during the fall as well as the ability of the body structures to absorb and the fall surface to accept the energy. In
addition, the protective responses, the garments of the faller,
and the direction and body location of the impact will affect
the outcome of the fall [77]. Functional consequences of the
aging process along with an alteration in cognition may lead
to increased risk-taking. Lack of realization of their limitations also predisposes the elderly to falls. Duthie suggested
that approximately 25% of falls in the elderly were caused by
an underlying medical problem [83]. Loss of muscle mass
and changes in body composition result in decreased strength.
Combined with a limited range of motion due to degenerative
joint diseases, the elderly are less able to absorb the kinetic
energy during a fall. Thus, many falls that are categorized as
accidents are truly interactions between identifiable environmental hazards and increased individual susceptibility to
those hazards from accumulated effects of age and disease
[72]. Therefore, management of the elderly fall victim must
include an investigation into the cause of the fall, which can
frequently be determined from a thorough history.
Falls lead to life-altering consequences in the elderly.
Approximately 8% of the elderly population seeks emergency care after a fall; 30–40% of older persons treated in the
emergency department for a fall are hospitalized, with an
average length of stay of 8–15 days [79, 84, 85]. In contrast
to the younger patient seen in the ED after a fall, older patients
usually do not die as a direct result of the fall. Instead, preexisting medical conditions and secondarily acquired complications are often the cause of death [21, 30]. As a result,
complications from falls are the leading cause of death from
injury in men and women over the age of 65 years [85].
The economic impact of falls in the elderly is huge.
Numerous studies have attempted to estimate this financial
impact; however, the wide variation on methodology makes
it somewhat difficult to compare the results. Estimates range
from $6.2 billion to $20 billion per year [86–89].
Motor Vehicle Collision
Motor vehicle collisions (MVC) are the second most common
mechanism of injury in those 65 years of age and older. In
2005, over 177,000 elderly people suffered nonfatal injuries
as a result of a MVC [90]. Injury pattern, however, is independent of age except for sternal fractures (11% elderly vs. 1.5%
younger) [56]. Older drivers who are hospitalized after an
MVC have significantly higher mortality rates, longer hospital
stays, and are less likely to be discharged directly to their
homes [91]. There is a greater frequency of intracranial hemorrhage and chest injury in the elder population that contribute
to poor outcome as well. For similar injuries, older adults are
five to six times more likely to die than their younger counterparts [30]. For those over 85 years of age, the fatality rate
increases to seven to nine times that of younger drivers [92].
Elderly drivers appear to have lower crash rates compared
with younger drivers, but they drive less often. When normalized for the number of miles driven, the >65 years group
has the second highest crash rate after new drivers. The
>85 years group has the highest per-mile-driven crash rate of
all age groups. The elderly are more likely to be involved in
vehicle–vehicle crashes, usually during daylight hours, close
to home and frequently at intersections [93]. Cook et al.
found that the elderly were no more likely to have a crash
involving a right-hand turn but were more than twice likely
to crash during a left-hand turn than younger drivers [94].
The elderly are also more likely to be found at fault by investigation officers [95].
Reduced vision or hearing, impaired judgment, and
reduced reaction times are well recognized as factors leading
to MVC in the elderly. Koepsell and coworkers showed that
diabetes, especially when insulin-dependent, significantly
increased the risk of a MVC with injury [96]. Rehm and Ross
showed that elderly crash victims had a significantly higher
incidence (74 vs. 14%) of underlying disease(s) such as cardiac, hypertension, diabetes, or neurologic diseases than did
victims in the young cohort [
often involved in MVCs involving the elderly compared to
younger drivers [95, 97].
95]. In addition, alcohol is less
Pedestrian–Motor Vehicle Collision
McCoy et al. showed the elderly were more likely to be
involved in a pedestrian crash as a result of walking into
oncoming vehicles, often due to confusion or impairment of
visual or auditory acuity [56]. Reduced gait speed of the
elderly pedestrian may be inadequate to complete the crosswalk at time-controlled traffic intersections, leaving the elder
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in the street exposed to inattentive drivers. In 1961, Haddon
et al. demonstrated an increased risk of pedestrian crashes
and fatalities with increasing age [98]. Others have corroborated this association [99, 100].
Burns
Deaths from burns are the fifth most common cause of unintentional injury death in the USA [101]. In 2005, there were
approximately 3,200 fire/burn-related deaths in the USA. Of
these, approximately one-third occurred in those over the age
of 65 years [102], most of them sustained at home [103].
Diminished senses, impaired mentation, slower reaction
time, reduced mobility, and bedridden states may decrease
an elder’s ability to identify fire and also to escape harm.
This may result in a more severe injury and an increased likelihood of death [104].
Extensive burn in the elderly has a poor prognosis; however, the fatality rates from burns in this age group are variable. Lionelli et al. demonstrated an overall mortality of 47%
in patients 75 years of age and older [105], while Covington
et al. demonstrated a mortality of 60% in the same age group
[106]. Lionelli also demonstrated a nearly 50% reduction in
mortality when comparing rats in the 1970s to those in the
1980s and 1990s (77 vs. 41%). A study by McGill and colleagues demonstrated a 72% survival in the elderly burn victim when aggressive burn care was used [107].
The discharge of an elderly burn patient must be well
thought out. For those with minor burns, returning to their
home with some assistance will most likely be adequate. For
those who have suffered more severe injury, rehabilitation
will be required. Most importantly, for those who return
home, an in-depth evaluation of home safety modification
helps prevent recidivism.
Elder Abuse
Ta b l e 31.6 Risk factors for elder abuse
Increased frailty of the victim
Cognitive impairment of the victim
Mental illness of the abuser
Substance abuse by the abuser
Family history of violence or antisocial behavior
Victim and abuser live together
Isolation of the victim
Recent life stress
incidence of elder abuse ranges from 2 to 10% [110]. In a
random-sample, community-based epidemiologic study,
3.2% of those surveyed reported to having been victims of
either physical, or psychological abuse, or neglect since they
turned 65 [109]. This number may underestimate the magnitude of the problem owing to the victim’s reluctance to admit
abuse for fear of loss of care, retribution from the abuser, or
from being ashamed to be in an abusive relationship.
Risk factors should alert the healthcare provider to the
diagnosis of abuse (Table
31.6) [111, 112]. Once suspicion is
raised, the victim should be interviewed one-on-one to
increase the likelihood of disclosure of the extent and details
of the abuse. Victims may be embarrassed revealing such
details to a group of health-care personnel. The details of the
abuse should be documented completely in the medical
record for the possibility of subsequent legal action. The
physician who documents or suspects elder abuse is ethically
obligated, and in most states legally bound, to report the case
to an adult protective service agency.
The most important intervention is to protect the victim
from danger. The victim may be reluctant to leave the care of
their abuser because of ambivalence regardless of the perceived danger. Unless the victim lacks the cognitive skills to
make informed decisions, individual liberty must not be
compromised. The physician should interview the abuser in
a nonconfrontational fashion to better understand the situation. The physician should acknowledge and empathize with
the difficulty of shouldering the burden of elder care. Armed
with this additional information, the physician is better prepared to intervene to break the abuse cycle.
The US National Academy of Sciences defines elder abuse
as: “(a) intentional actions that cause harm or create a serious
risk of harm to a vulnerable elder by a caregiver or other
person who stands in a trust relationship to the elder or (b)
failure by a caregiver to satisfy the elder’s basic needs or to
protect the elder from harm” [108]. The abuse includes physical, psychological, sexual, and financial, as well as neglect.
Such injuries are considerably more subtle in their presentation than those from a physical assault.
Only 1 in 14 incidences of elder abuse come to the atten-
tion of the authorities [109]. Thomas estimated that the
Suicide
In 2004, suicide was the third leading cause of injury-related
death for those 65 years of age and older [1]. Those over the
age of 75 had the highest rate [113]. Only about 25% of the
elderly who attempt suicide are actually successful [114].
Risk factors for suicide in the elderly population include psychiatric disorders, especially depression; medical conditions,
especially cancer or chronic lung disease; moderate to heavy
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alcohol use; and social isolation. Changes in behavior such
as altering a will, new preoccupation with religion, or giving
away life possessions may be warning signs of impending
suicide.
Management
Triage
Triage for the geriatric patient should provide the appropriate intensity of medical care, taking into account factors
including severity of injury, cost, availability, prognosis for
functional recovery, and patient desire. This process begins
in the prehospital setting when decisions must be made
regarding the appropriate facility [115]. In 2006, The
American College of Surgery Committee on Trauma suggested that patients over the age of 55 years be triaged to a
trauma center [116]. However, in reality, the elderly are the
most undertriaged group and suffer increased morbidity and
mortality as a result of underresuscitation [117].
Many of the physiologic and anatomic scores used in
trauma correlate with outcomes in geriatric patients; however, these scores have little value in that they are not derivable at the time when triage decisions are made. The Trauma
Score (TS), comprised of blood pressure, respiratory rate,
respiratory effort, GCS, and capillary refill is readily obtainable and can be used to assist in triage. The minimal score is
0, and the maximal score is 16. The Revised Trauma Score
(RTS) eliminates respiratory effort and capillary refill, resulting in a score range of 0–8. Osler et al. demonstrated that no
patient with a TS < 7 survived to reach the hospital and that
no patient arriving at the hospital with a TS < 9 survived the
hospitalization [118]. Knudson and colleagues demonstrated
a 100% mortality in those 65 years of age and older having a
TS < 7 [119]. This suggests that when geriatric patients have
a TS < 7, one must question the utility of aggressive treatment and resource allocation. A study of 374 patients over
the age of 65 demonstrated an overall mortality of only 5%
in those with a TS of 15 or 16, 25% in those with a TS of
12–14, and 65% in patients with a TS < 12 [120]. These data
suggest that appropriate triage and aggressive care, including
admission to an ICU, for those with a TS of 7–14 may
improve survival.
Initial Management and Resuscitation
The first few minutes of resuscitation of the elderly trauma
victims differs very little from that of younger patients. Early
intubation in the multi-injured elderly trauma patient should
be considered as it reduces the work of breathing and
avoid progressive respiratory failure and cardiovascular
may
collapse. As the elderly have limited cardiovascular reserve,
they are vulnerable to hypotension from induction agents,
and reduced doses should be used. In addition, limited pulmonary reserve may make preoxygenation difficult, causing
rapid desaturation during intubation.
A normal blood pressure for a younger patient may be a
relative hypotension for an elderly patient with history of
hypertension. Geriatric patients are more likely to present in
shock than younger patients matched for trauma and ISS
[121]. In the Major Trauma Outcome Study (MTOS),
Champion et al. showed that geriatric patients had four times
the incidence of cardiovascular complications as the young
cohort, supporting the importance of improving cardiovascular response of the elderly trauma patient to maximize survival potential [3].
Scalea and colleagues demonstrated that significant
hemodynamic compromise occurs in elderly patients who
were clinically stable after their initial evaluation for blunt
trauma [
65 who were hemodynamically stable after their initial resuscitation had pulmonary artery catheters (PACs) inserted. The
authors defined patients to be in cardiogenic shock if they
had a cardiac output (CO) of less than 3.5 L/M and/or a
mixed venous saturation (MVO
demonstrated an increase in survival from 7 to 53% by early
optimization of all patients with volume, inotropes, and
afterload reduction. The authors concluded that emergent
invasive monitoring identifies occult shock early and
improves outcome. Schultz et al. performed a randomized
trial of resuscitation in 70 patients with fractures of the hip
[122]. The monitored group had a PAC placed, while the
control group only had a central venous line placed. Despite
numerous weaknesses in the study, the mortality for the
monitored group was 2.9% and was 29% in the control
group. In addition, DeMaria et al. concluded that aggressive
treatment, including invasive monitoring, decreased mortality in trauma patients over 75 years of age [123]. To avoid
potential complications associated with PACs, efforts have
been made to develop alternative, less invasive techniques of
cardiac output monitoring. Although initial studies have
shown comparable accuracy and precision between the PAC
and newer less invasive techniques, further studies are ongoing [124, 125].
levels correlate with mortality in the geriatric population
[126]. Although the authors used 55 years as their cutoff, a
BD £−10 had an 80% mortality, −6 to −9 a 60% mortality, −3
to −5 a 23% mortality, and ³−2 had an 18% mortality
(Fig. 31.2). Other studies correlated the rate of serum lactate
clearance after trauma with survival [127, 128]. Patients
had a mortality rate over 75% if it took more than 48 h to
normalize lactate.
43]. Over a 2-year period, all patients over the age of
) of less than 50%. They
2
Davis and Kaups showed that admission base deficit (BD)
Fi g u r e 31.2 Mortality rate by
100
AGE< 65
AGE> 64
90
80
70
60
50
Percent
40
30
20
10
0
GCS 13-15 GCS 10-12 GCS 6-9 GCS <6
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base deficit category and age
(reprinted with permission from
Davis and Kaups [
126]).
Management Considerations for Specific
Injuries in the Elderly
39931 Care of the Injured Elderly
Head Injuries
In persons 65 years of age and older, traumatic brain injury
(TBI) is responsible for over 80,000 ED visits annually [129].
In 2006, over 2.8 billion dollars were spent on treating TBI in
those older than 65 years [130]. Falls are the leading cause
(51%), while MVCs are a distant second (9%) [129]. As
many as 73% of elderly TBI patients may have at least one
comorbid condition as compared to only 29% of younger
patients [131]. Treatment of some of these chronic conditions
includes the use of aspirin and warfarin, which increases the
risk of TBI in the elderly. A study by Lavoie et al. found that
9% of the older patients with TBI were taking warfarin preinjury and that it was associated with more severe TBI and a
higher rate of mortality [132]. Older age has been well recognized as an independent predictor of worse outcome after
TBI, even with relatively minor head injuries [133, 134]
(Fig. 31.3). Older TBI patients also have been found to have
longer length of stays, resulting in greater cost of care [135].
Significant TBI in the elderly can be caused by minimal
trauma and may initially present with little or no neurologic
deficits. In elderly patients with mild TBI (GCS 13–15), 14%
of patients have a lesion on CT scan, four of which required
neurosurgical intervention [136]. These authors recommended CT scan for patients over 65 years of age presenting
with TBI. Due to the atrophy of the elderly brain, the distance traversed by the bridging veins is increased. This
increased distance allows intracranial hemorrhages to have
significant amount of room to expand prior to demonstrating
any clinical signs. Thus, subdural hematomas are three times
more common in the elderly [137].
Fi g u r e 31.3 Percentage of elderly survivors and nonelderly survivors
by GCS score (reprinted with permission from Susman et al. [134]).
Management of the head-injured elder is generally similar to that of the head-injured young patient: specifically
rapid diagnosis of the specific neurologic injury using head
CT scans and avoidance of secondary brain insult resulting
from hypotension and hypoxia. Intracranial pressure (ICP)
monitoring is paramount as is ensuring adequate cerebral
perfusion pressure (CPP). A study by Czosnyka et al. demonstrated that ICPs decrease in the elderly, with a resultant
increase in CPP [133]. The authors also demonstrated that
there is a decrease in autoregulation in the elderly. Current
guidelines for CPP management may not be appropriate for
the elderly. Comorbidities may affect the responsiveness and
perfusion needs of the cerebral vasculature in these patients.
Some studies have shown that preinjury warfarin use
in the elderly had no effect on mortality in trauma patients
[138, 139]. However, others have shown that it is, in fact,
associated with increased frequency and severity of TBI,
and a higher mortality [132, 140]. A study by Fortuna et al.
demonstrated that those with a hemorrhagic brain injury on
warfarin had a 34% mortality [141]. This was compared to
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those taking aspirin or clopidogrel, who had a mortality of 13
and 6%, respectively. All patients were similar in age and
had similar ISS and head abbreviated injury score (AIS).
Any patient who has a traumatic hemorrhagic brain injury
and an elevated INR should have the warfarin reversed. The
risk of immediate mortality, related to the TBI, far outweigh
risk for adverse thromboembolic events from the preexisting
condition. Traditionally, fresh frozen plasma (FFP) has been
used. Using a reversal protocol of 2 units of uncrossed FFP
followed by an additional 2 U of matched FFP, Ivascu et al.
demonstrated decreased reversal time from 4.3 to 1.9 h, with
a subsequent improvement in mortality from 50 to 10%
[142]. However, large volumes of FFP are often required to
fully reverse warfarin. This can cause pulmonary edema and
volume overload in the elderly patient with compromised
cardiac and/or renal function. Alternatives to FFP do exist.
Stein et al. demonstrated that a single dose on 1.2 mg of
recombinant activated factor VIIa (rfVIIa) rapidly and effectively treats mild to moderate coagulopathy following injury
[143]. In addition, they demonstrated that rfVIIa reduced the
time to neurosurgical intervention (144 vs. 446 min) and
decreased the use of blood products, without increasing the
rate of thromboembolic complications [144]. In addition,
despite having an increased pharmacy cost for those who
have received rfVIIa, overall, the use of rfVIIa may actually
decrease overall hospital charges [145]. Other alternatives
include prothrombin complex concentrates (PCCs) as well
as vitamin K and cryoprecipitate. Cartmill et al. demonstrated a more complete and quicker reversal time in patients
on warfarin needing an emergent neurosurgical intervention
using PCCs compared to FFP and vitamin K [146].
Elderly trauma patients on warfarin with TBI are particularly susceptible to clinical deterioration. In a recent
study by Cohen et al., 56 of 77 patients with a GCS of
13–15 who were either discharged or admitted for observation had a clinical deterioration with a mortality rate greater
that 80% [147]. As a result, any elderly patient on warfarin,
with head trauma and a therapeutic INR, should be admitted and observed for a minimum of 12–24 h even if the
initial head CT scan shows no injury [148]. A repeat CT
scan should be done for any change in the patient’s neurologic exam.
Spinal Injuries
Cervical fractures have a prevalence of 2.6–4.7% in patients
older than 65 years [149, 150]. Low-energy falls are the most
common mechanism among the elderly [151]. Injuries at the
upper cervical region are associated with the longest hospital
treatment. Golob et al. demonstrated a 22% in-hospital mortality
in elderly patients with isolated cervical spine fractures [152].
Patients who are awake, alert, nonintoxicated, have no
cervical tenderness, neurologic deficit, or distracting injury
do not need any radiographic evaluation, regardless of age
[153]. Although the three-view plain radiograph has been the
traditional initial modality for cervical spine evaluation,
many now use CT as the initial evaluation tool for cervical
spine injury due to the high rate of missed injuries on plain
films [154–159]. If a neurological deficit is present, then
magnetic resonance (MR) should be used to evaluate ligamentous and/or spinal cord injury [160, 161].
Cervical stabilization is the primary end point, be it with a
cervical collar, halo, or operation. A 1985 report by Pepin
et al. stated that patients with odontoid fractures who were
over the age of 75 years did not tolerate a halo and that surgical stabilization and an appropriate brace were superior [162].
Halo alone led to an increased rate of pneumonia and decubiti. In contrast, Malik et al. used a halo for ten patients over
the age of 75 years, and most tolerated the halo relatively well
[151]. Additionally, Weller et al. reported no complication
with halo usage in patients over the age of 70 years [163]. The
halo allows for mobilization in the early postinjury period,
which is paramount in reducing complications.
Central cord syndrome (CCS), usually resulting from
hyperextension, is more likely to occur in the elderly due to
underlying cervical stenosis [93]. Patients usually present
with upper extremity weakness that is greater than lower
extremity weakness. A 1990 study by Penrod et al. demonstrated that at follow-up, 97% of younger patients with CCS
were ambulatory, whereas only 41% of the elderly with
CCS were able to walk. In addition, the younger patients
with central cord syndrome achieved independence in selfcare of bladder and bowel function more frequently than did
the older group [164, 165]. DeVivo et al. demonstrated that
the elderly, defined as those aged 61 years and older, had a
59% 2-year survival as compared to 95% in a younger
cohort [166].
Thoracic Injuries
The elderly have a higher mortality from chest trauma as a
result of the initial injury as well as secondary pulmonary
insults [167, 168]. Routine use of cardiac enzymes, electrocardiogram (EKG), and echocardiography to identify cardiac
injuries may be beneficial. Early intubation and mechanical
ventilation should be considered for any elderly trauma
patient that shows signs of respiratory compromise. Although
intubation may increase pneumonia and the need for tracheostomy, the procedure may be lifesaving.
A number of studies have focused on rib fractures in the
elderly and subsequent outcome. Cameron et al. demonstrated
increased morbidity in the elderly with multiple fractures
40131 Care of the Injured Elderly
40%
30%
20%
Mortality (%)
10%
0%
1-2 3-4
Rib fx #
5-6
Yo ung
Elderly
> 6
#
*p<0.05
#p=0.11
Fi g u r e 31.4 Relationship between mortality and number of rib fractures
(reprinted with permission from Bulger et al. [50]).
Fi g u r e 31.5 Mortality by
number of rib fractures in all age
groups (reprinted with permission from Sharma et al. [170]).
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compared to younger patients [169]. In 2000, Bulger et al.
retrospectively evaluated patients over the age of 65 years
with rib fractures compared to those younger than 65 [50].
Despite similar ISS and chest abbreviated injury score (AIS),
the elderly had fared significantly worse in all outcome measures (Table 31.7). Sharma and colleagues also demonstrated
a twofold increase in mortality in the elderly with rib fractures
[170]. Mortality increased as the number of rib fractures
increased [50, 170] (Figs. 31.4 and 31.5).
Traumatic aortic injures (TAI) are often initially suspected
by a widening of the mediastinum on a plain chest X-ray.
Prior to the widespread use of CT scan, TAI was definitively
diagnosed with the use of angiography. Over the last 10 years,
there has been a significant change in the management of
TAI from the traditional, standard operative repair (OR).
A 1994 study by Camp et al. that compared OR in the young
and the elderly demonstrated a 163-fold increased likelihood
of mortality in the elderly [171]. In a 2006 study, Hirose et al.
showed promise with nonoperative management in some
high-risk elderly patients with small aortic tears [172].
Endovascular stent grafts (SG) were initially used for
high-risk, multiply injured patients or those with comorbid
disease, i.e., the elderly [173]. However, many centers now
use them as their initial treatment of choice for TAI [174].
A 2008 multicenter American Association for the Surgery of
Trauma (AAST) study compared 193 patients who had either
an OR or endovascular SG for a TAI [174]. The study did not
specifically breakdown outcome by age; however, using
multivariable analysis, those over the age of 55 who received
Ta b l e 31.7 Outcome measures
Age (years)
Parameter
Mean ventilator days
Mean ICU days
Mean hospital days 15.2
Mortality (%) 22 10 <0.001
Source: Reprinted from Bulger et
Kluwer Health
ICU intensive care unit
4.3 ± 9.2 3.1 ± 9.2 =0.16
6.1 ± 10.0 4.0 ± 9.4 <0.05
± 16.5 11.0 ± 13.1 <0.01
al. [50] with permission from Wolters
p Value³65 18–64
402 J. Menaker and T.M. Scalea
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an endovascular SG had a significantly lower mortality.
Unfortunately, the rates of long-term complications including
delayed leak, migration, and thrombosis are currently
unknown. It seems reasonable to assume an overall benefit
for the elderly to have an SG placed as opposed to a thoracotomy performed.
Abdomen/Pelvis Injuries
Significant intraabdominal injury occurs in approximately
one-third of elderly patients with multisystem trauma [175].
The clinical abdominal exam is less reliable in the elderly, and
as such, liberal use of diagnostic studies is recommended [14,
175]. Ultrasound appears to be a reliable initial radiographic
modality for evaluating an intraabdominal injury. Although
free fluid on an ultrasound suggests an injury, it cannot differ-
entiate between a solid organ injury and a hollow viscous
injury. A study by Rozycki and colleagues demonstrated that
ultrasound had an overall sensitivity of 83.3% and specificity
of 99.7% [176]. In blunt trauma patients who were hypoten-
sive (systolic blood pressure <90 mmHg), both sensitivity and
specificity were 100%. Although the study did not evaluate the
elderly per se, the oldest person in the study was 84 years old.
CT scan can be used to evaluate a hemodynamically stable
patient to identify the presence of intraabdominal injuries. An
IV contrast agent is typically used to better identify vascular
injuries. This can often be problematic in the elderly for a
number of reasons. Interactions with specific medication, such
as metformin, can cause a lactic acidosis. In addition, contrastinduced nephropathy can be as high as 25% in patients with
preexisting renal dysfunction, diabetes, advanced age, and
concurrent usage of nephrotoxic drugs [177]. A meta-analysis
suggested that pretreatment with N-acetylcysteine was most
effective in preventing contrast-induced nephropathy [178].
However, most of the studies used pretreatment for 24 h,
which is not feasible after injury. Merten et al. demonstrated
that a protocol using pre- and posttreatment with bicarbonate
was more effective than saline alone in preventing contrast
nephropathy [179]. A 2006 review by Pannu et al. supports
the use of hydration, bicarbonate, and low volumes of iso- or
low-osmolar contrast in at-risk patients [180].
Nonoperative management of blunt splenic injuries has
become standard of care. Early studies showed a high failure
rate for those over the age of 55 years [181–183]. Recently,
however, this has been challenged, and a number of studies
have shown that age is not associated with increased failure
rate [184–186]. Thus, age over 55 years is no longer considered a contraindication to nonoperative management of
splenic injuries. Clinicians must monitor those with highgrade injuries and free pelvic fluid closely, as they have a
higher failure rate.
Fractures
Hip fractures remain the most frequent cause of hospital
admission after trauma in the elderly. Liberal use of CT scan
or MR is wise in patients with high index of suspicion for
fracture with negative plain radiographs [187]. Myers et al.
showed that the mortality for men with hip fractures was
60% higher than for women [188]. In addition, factors associated with in-hospital death included sepsis, pneumonia,
and gastrointestinal disorders. The risk of dying after hip
fracture was doubled in patients with cardiac disease, cancer,
or cerebrovascular disease. These authors concluded that the
most important complication leading to in-hospital deaths
after a hip fracture was sepsis.
Almost 30 years ago, Laskin et al. proposed a management scheme for intertrochanteric fractures in the elderly.
This included early rigid fixation using compression hip
screws to allow early mobilization and immediate weight
bearing to assist with vigorous pulmonary toilet [189].
The longer the elderly remain bedridden, the more likely
they are to have complications, including atelectasis, pneumonia, need for mechanical ventilation, venous thrombosis,
muscle atrophy, and skin breakdown, all leading to longer
hospital stay and increase in mortality. Thus, early orthopedic consultation, fracture fixation, and physical therapy are
warranted.
Pelvic fractures are common in the elderly. A 2002 study
by Henry et al. demonstrated that most elderly patients
have lateral compression fractures, which are usually not
associated with significant bleeding [190]. However, the
authors found that the elderly are more likely to have fracture-associated hemorrhage and require angiography. In
addition, the outcome for older patients with pelvic fractures was significantly worse than for younger patients.
Recognizing these differences in fracture and bleeding patterns in the elderly identifies those at high risk and helps
guide resuscitation.
Few studies have investigated management of other specific fractures in the elderly. Roumen et
nal fixation for unstable Colles’ fractures was no more
effective than nonoperative management in the elderly [191].
Ritchie et al. noted good limb salvage for open tibial fractures in patients over 60 years of age. Thus, age alone should
not represent a contraindication to limb salvage in patients
with severe open fractures and concomitant vascular injuries
[192]. Helfet et al. reported that open reduction internal fixation (ORIF) of displaced acetabular fractures can yield good
results in the elderly and obviate the need for a total hip
replacement [193]. Bogner and colleagues demonstrated
that a percutaneous reduction and internal fixation of the
proximal humerus in patients over the age of 70 years provided a comfortable and mobile shoulder [194]. The authors
al. found that exter-
40331 Care of the Injured Elderly
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state that this less invasive method provides a satisfactory
alternative to replacement and traditional techniques of
internal fixation.
Burns
Advances in burn care over the past 50 years have improved
mortality rates across all age groups [195]. Although the
elderly have a reduced rate of survival with less severe burns
than their younger counterparts, the long-term outlook for
those who do survive is somewhat optimistic. Manktelow
et al. reported that 53% of those burned elders who survived
did not have a more dependent living status on discharge
[196]. Another 8% of patients achieved independent status
within 5 years of the burn. Discharged patients did not have an
accelerated death rate compared to that of the unburned population. In addition to the standard management of burn victims, the elderly present other challenges. The elderly burn
victim may suffer hypoperfusion in the face of normal vital
signs and adequate urine output. Bowser-Wallace et al. advocated hemodynamic monitoring for routine management of
severe burns in the elderly [197]. They noted excellent survival in the elderly who were resuscitated with hypertonic lactated saline. Early wound closure has been viewed as a major
advance in the management of young burn patients, resulting
in decreased length of hospitalization and decreased mortality.
Kara et al. demonstrated that early excision and grafting in the
elderly yielded fewer episodes of infection, resulting in a
reduction in hospital stay, but it did not improve survival
[198]. Others have shown improvement in survival of elderly
burn patients with early excision and grafting [199, 200].
Rehabilitation
The aim of rehabilitation is “to restore an individual to his/her
former functional environmental status or, alternatively, to
maintain or maximize remaining function” [201]. Unlike
younger patients in whom rehabilitative outcomes are more
apt to be dramatic, the geriatric patient is likely to make subtle
progress. The degree of independence the patient is able to
attain is dictated by these modest achievements and can mean
the difference between living at home and living in a long-term
care facility [201]. For many elders, independence is their
ongoing reason to live. The physician caring for the injured
elder must understand the importance of attaining or maintaining independence for their elderly patients and do whatever is
necessary to achieve this. The elderly with chronic debilitating
disease more frequently require rehabilitative services following trauma because of the limitations imposed by injury.
Long-Term Outcome
It is generally accepted that both short- and long-term
outcomes after injury are considerably worse in the elderly
than in younger patients. Despite this, The Eastern Association
for the Surgery of Trauma (EAST) practice guidelines
recommend that age should not be used as a criterion for
limiting care as with aggressive initial management because
as many as 85% return to independent living [117]. Others
have demonstrated somewhat less promising outcomes of the
injured elderly. A study of 38,000 patients over the age of 65
demonstrated that 50% went home and that 25% were discharged to a skilled nursing facility [202]. Taylor et al. demonstrated a nearly twofold increase in mortality risk in
geriatric trauma patients even after controlling for comorbid
diseases [5]. Inaba et al. reported in a study of injured elderly
that, at long-term follow-up, only 68% of patients were living
independently as compared to 98% before injury. Furthermore,
an additional 20% required skilled home care [203].
Prevention
The first step toward prevention of injury is to recognize the
individuals who are most likely to suffer injuries. Many of the
factors that predispose the elderly to injury should be discovered on routine history-taking in the elderly patient. There are
three injury-prevention approaches: (1) preevent strategies,
focusing on increasing public awareness through education
or influencing legislation, (2) event strategies, which involve
interventions to reduce energy transfer during the injury, and
(3) postevent strategies, which deal with efforts to improve
resuscitation and reduce complications. In the elderly trauma
population, the first two hold the most promise.
As an example, geriatric care groups have developed
interventions such as home safety inspections, modifying
medications known to affect balance adversely, gait training,
and improving any correctable sensory deficits in an effort to
reduce the incidence of falls. MVCs may potentially be
avoided by identifying and reporting individuals who are
unfit drivers. This includes persons with visual or hearing
deficits, dementia, or disabling musculoskeletal disorders,
and those using medications that decrease driving skills. In
an effort to refresh skills and update traffic knowledge, driver
education courses for adults over 55 years of age have been
established by the American Association of Retired Persons
(AARP) and the National Retired Teachers Association.
Retting et
program significantly reduced the fatal and serious injury
occurrence by 43 and 86%, respectively [204]. This program
implemented prolongation of traffic-light times to accommodate the decreased gait of the elderly, modifications of road
al. showed that a pedestrian accident-prevention
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