Elderly patients

 

Due to a decline in birth rates and increased life expectancy, New Zealand’s population is aging. In 2018, 15% of New Zealanders were aged 65 years or older and by 2051, this is projected to steadily increase.

 

From https://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/older-peoples-health-data-and-stats

 

This is significant as the elderly have increased morbidity and mortality from trauma as compared to their younger counterparts. They are more likely to suffer serious sequelae from more minor mechanisms and due to comorbidities and medications, and are less able to compensate physiologically after trauma.

Falls are the most common cause of injury in the elderly, followed by motor vehicle accidents.

Note, it is difficult to define when a person becomes “elderly”. The traditional cut off over 65 years seems quite “young” these days, however most of the research into geriatric trauma starts at here, so nominally trauma patients of >65 years can be considered in this group (noting that many patients >65 are extremely fit and well, and some patients <65 are physiologically much older). The degree of frailty is likely a better indicator of outcomes  following trauma rather than a cut off age.

Issues

Airway and cervical spine

  • Poor mouth opening
    • Difficult intubation
  • If edentulous – potentially difficult BVM

 

  • C spine stiffness/degenerative changes
    • Implications for intubation
    • Increased risk of C spine injury with minor mechanism

eg: odontoid peg #s relatively common from simple falls from standing

Have a lower index of suspicion for significant cervical spine injuries in the elderly even with minor trauma.
Plain films of the cervical spine can be of very limited utility in the elderly due to degenerative change. Perform a CT if concerned. 

 

Breathing

  • Decreased vital capacity, functional residual capacity
    • Decreased respiratory reserve
  • Chronic airways disease
  • Decreased elasticity of chest wall

 

  • Elderly who sustain a rib # have 2x mortality/morbidity of younger patients
    • For each extra rib # – mortality increases by 19%, risk of pneumonia increases by 27%2
Have a low threshold for admitting elderly patients with chest wall injuries for analgesia and monitoring

 

Circulation

  • Decreased cardiovascular reserve
    • Increased sensitivity to hypo/hypervolaemia
    • Decreased response to circulating catecholamines
      • May not mount usual physiological responses to blood loss
    • Baseline hypertension
      • May not appreciate signs of shock
    • Underlying cardiovascular disease
    • Meds: eg betablockers
      • May be falsely reassured by a “normal” heart rate
      • Unable to mount tachycardia to deal with decreased intravascular volume, can’t increase CO adequately
    • More likely to have aortic injury (even with “minor” mechanisms)
A HR of >90 or SBP <110 should be considered abnormal in the elderly and trigger concern for serious underlying injury

 

Disability

  • Brain atrophy – brain mass decreases by 10% by age 70
    • Increased risk of subdural and other intracranial haemorrhages
  • Underlying cognitive impairment can impede evaluation
  • Anticoagulation increases the risk of intracranial injury
  • Significant increase mortality in elderly with TBI
    • GCS <9 = 80% chance of death/serious disability 3
Have a lower threshold for CT brain imaging – see the Canadian CT head rules

 

Musculoskeletal injuries

  • Decreased bone density
    • More prone to #
  • More friable skin and soft tissues
    • Poor wound healing
  • Increased risk of complications from pelvis injuries

 

Abdominal injuries

  • More difficult assessment
    • Alterations in pain sensation with increased age/stoicism
      • More unreliable examination
    • Declining GFR with age
      • Issues with obtaining contrast studies

 

Other issues

  • Under-triaging, underestimation of severity of trauma, downplaying of more minor mechanisms
  • Less analgesia often provided
  • Consider that an acute medical event may have caused the trauma
    • Take a careful history, especially around falls
  • Consider NAI/elder abuse

 

 

References

 

  1. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery. 2014 Mar 1;76(3):894-901.
  2. Labib N, Nouh T, Winocour S, Deckelbaum D, Banici L, Fata P, Razek T, Khwaja K. Severely injured geriatric population: morbidity, mortality, and risk factors. Journal of Trauma and Acute Care Surgery. 2011 Dec 1;71(6):1908-14.
  3. Bulger EM et al. Rib fractures in the elderly. J Trauma. 2000:48(6):1040-6)
  4. LeBlanc J, Guise ED, Gosselin N, Feyz M. Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury. Brain Injury. 2006 Jan 1;20(8):779-90.

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About this guideline

Published: January 2018
Author: Emma Batistich
Updated: Emma Batistich (April 2021)
Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB, NRHL, St. John 
Review due: 2 years