Introduction


Management of elderly trauma patients presents a unique set of challenges. The incidence of elderly major trauma in Victoria is increasing, with now 36.4% of adult major trauma presentations related to patients aged 65 years or over at 2014-2015. As clinicians we are all aware of the increasing population of elderly individuals.  Those elderly individuals with sustained good health and greater autonomy are pursuing exciting and perhaps novel experiences which at times culminate in injury whilst other elderly patients are succumbing to trauma and injury during mundane everyday events. There is gender equality within the Elderly Trauma Population (ETP) as compared with the younger male-dominated Trauma population.
With the aging population comes more complex management issues unfamiliar to the younger trauma patient. Importantly it is a patient's physiologic reserve which can determine their recovery from traumatic injury rather than merely their chronological age.  Co-morbid clinical conditions can fundamentally dictate an elderly patient's recovery and even survival following Major and even Minor Trauma.  Be aware that even in situations where there are no overt life-threatening injuries the patient may succumb due to a limited physiologic reserve.
We are gradually understanding that we need to be pro-active in the pre-hospital setting and triage older trauma patients directly to MTS. There is the potential to under-estimate the burden of their injuries leading to protracted complex Hospital admissions increased morbidity and ultimate mortality.
Prehospital triage guidelines relating to vital signs may be unreliable in the older population, with certain medications masking the physiologic effects of trauma. Older patients are less likely to partake in risk taking behaviour and therefore less likely to be injured than younger individuals however older people are more likely to have a fatal outcome from their injuries. After admission for a fall ≤1 metre, the 1 year mortality rate for age 65 and older is approximately 47%.2 Elderly patients are less likely to die from the initial injury, rather due to secondary complications. The older patient will present with comorbid health conditions, prescribed medication and a frailty, making them more vulnerable to trauma and subsequent complications of hospitalisation such as pneumonia, infections and venous thromboembolism to name a few.4  Delirium can have a significant impact on Morbidity and Mortality for the Elderly Trauma patient - in both the short and long term. The in-hospital death rate for major trauma patients aged 85 years and over is as high as 35.2%.2
The elderly may be more susceptible to injury due to co-morbidities and physical changes associated with aging and it is essential to be aware of these differences when managing the older person trauma patient.
 

Older person Anatomy and Physiology

Head and Neck

  • A decreased brain mass leads to stretching of the bridging veins, making them more susceptible to tearing and bleeding.
  • There is a higher risk of significant ICH due to minor head injury, with a higher frequency of bleeding and severity if taking oral anticoagulants. A lower threshold to CT scan these patients should be considered.
  • A higher number of significant neck fractures occur in the elderly, even after low risk incidents.
  • Swallowing reflexes may be deficient, leading to possible airway challenges.

Cardiac

  • Pre-existing heart disease will lead to a diminished cardiac reserve.
  • Patients with a history of CHF and those on anticoagulant and antiplatelet medication or negative inotropes and/or chronotropes are at higher risk of poor outcomes after trauma.
  • The myocardium loses contractility resulting in a decreased cardiac output.
  • Maximum heart rates and ability to compensate for hypotension may decrease as a result of age and medications.
  • Vasculature thins and stiffens with ageing.
  • Increased risk of dysrhythmias.
  • Thrombosis may occur as a result of the trauma but also due to underlying undiagnosed malignancy.

Pulmonary

  • Underlying chronic obstructive pulmonary disease will impair lung function.
  • Increased chest wall rigidity and worsening kyphosis may lead to decreased respiratory vital capacity and poor respiratory reserve.
  • Lower lung capacity with significant hypoxia with physiological stress, making them more susceptible to the stressors of acute blood loss and fluid resuscitation.

Abdomen

  • Cirrhosis increases the risk of ischemia and reperfusion injuries as well as haemorrhage, post trauma complications and mortality.
  • Pre-existing renal impairment in combination with volume depletion will lead to further renal function compromise with at times critical questions to be considered regarding Renal Replacement Therapy. It also makes the elderly population more prone to contrast induced nephropathy.
  • Chronic kidney disease may be reflected in a high normal creatinine level due to a lower muscle mass.
  • Urinary and Bowel aberrations can evolve insidiously.

Musculoskeletal

  • Kyphosis and an increased anteroposterior diameter of the thoracic cage can lead to a loss of intra-thoracic volume and thoracic cage compliance.
  • Weaker bones and degeneration of joints make the ETP more susceptible to fractures, even in minor trauma.
  • Frailty leads to decreased mobility and deconditioning, increasing the risk of falls and injury.1

Frailty

  • Frailty is defined as a clinically recognisable state of vulnerability due to ageing associated decline in reserve and function in multiple physiologic systems.5
  • Frail patients with poor functional status and multiple comorbidities have worse outcomes after trauma. Pre-existing nutritional deficits may also play a role.
  • Prolonged immobilisation will impact more significantly on the older patient.Active strategies to prevent deconditioning and pressure injuries will be required.

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Mechanism of Injury

Falls

Falls are the leading cause of trauma related mortality in the elderly, with elderly patients more likely to require hospitalisation, suffer complications, have longer stays and require discharge to a rehab facility. Even relatively minor impact falls will often represent a major traumatic mechanism in the older person population and can lead to significant morbidity and mortality. Low falls (<1m) are steadily rising with a burgeoning number of our elderly patients falling from a standing position.
Direct contribution to the risk of falling can be due to decreased reaction times from arthritis, poor vision, as well as prescribed or over the counter medication. Syncope is also a common culprit, due to cardiac arrthymias, neurological deficits, glucose derangements, poor blood pressure control as well as volume depletion. Poor pain management can also lead to an increase in falls as there can be a fear of moving which in turn weakens muscles and leads to gait disturbances.
Environmental factors also contribute to falls in the elderly due to stairs, rugs, uneven ground, pets as well as ill-fitting footwear.

Road safety

As the population continues to age, there will be more elderly drivers on the roads who are at risk of being killed or seriously injured. Older patients are more likely to have severe injuries at lower speeds, with drivers aged 75 years or over at a higher risk than any other group. Additionally, almost a quarter (24%) of pedestrians who lost their lives in 2015 were aged 75+.6 Slower reaction times, loss of clarity in vision and hearing, loss of muscle strength and flexibility as well as the use of prescription medication which may cause drowsiness all contribute to how well older people drive. Ambulance and emergency services will need to maintain a high index of suspicion to the potential of major trauma in this group so as not to under-triage.

Elder abuse

In the assessment of an elderly trauma patient intentional injury to the patient must be considered. It is known that some cases of trauma are as a result of physical abuse. In the older patient injuries sustained may result in higher mortality than in younger patients.
As part of secondary survey as detailed history and examination should be performed. A variance in story, physical signs or delay in treatment could be indicators of elder abuse having occurred. This should prompt further investigation and reporting.7

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