As clinicians we are all aware of the healthcare challenges an aging population poses to primary, secondary and social care. Inevitably, as the population continues to age, the number of older trauma patients will rise. Compounding this, with advancements in the treatment of many chronic diseases, more older adults are now enjoying active lifestyles which can predispose to injury. In 2019-2020, 42.4% of Victorian adult major trauma presentations were in patients aged 65 years or older. This reflects an incremental increase over the preceding 5 years; this coming at a time when the number of major trauma patients under the age of 65 years has decreased.(5)
Older trauma patients bring an added layer of complexity to every stage of their management. The vital sign ranges provided in pre-hospital guidelines may be falsely reassuring due to ageing, co-morbidities and polypharmacy, with certain medications potentially blunting the physiological effects of trauma. Additionally, older patients are more susceptible to sustain significant injury following ‘low impact’ mechanisms or mechanisms with minor impact in younger adults, therefore adding further challenges to the pre-hospital and initial hospital assessment of injury. Older patients also have less physiological reserve to compensate for injuries and are more likely to suffer subsequent complications of hospitalisation such as hospital acquired pneumonia, delirium and venous thromboembolism.(6)
Older patients are more likely to die from trauma compared to their younger counterparts.(7) Clear guidelines for management are essential. Clinicians are duty-bound to ensure evidence-based practices are adapted when managing older person trauma.
A decreased brain mass leads to stretching of the bridging veins, making them more susceptible to tearing and bleeding.
Higher risk of significant intracranial hemorrhage, particularly subdural haemorrhage due to minor head trauma, with a higher frequency of bleeding and severity if prescribed oral anticoagulants. A lower threshold for CT scanning is appropriate in this cohort of patients.
A higher number of significant neck fractures occur in older people, even after events with minimal mechanism.
Injuries to the high cervical spine are more common, with more than two thirds involving C1 to C3.
Hyperextension of the cervical spine presents more often as central cord syndrome.
Swallowing reflexes may be deficient, leading to possible airway challenges and aspiration events.
Pre-existing heart disease will lead to a diminished cardiac reserve and a diminished response to catecholamines blunts the expected physiological tachycardia response to hemorrhage or pain.
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.
Increased systemic vascular resistance manifests as baseline hypertension. This can lead to clinicians being falsely reassured by blood pressure measurements seemingly ‘within range’.
Thrombosis may occur as a result of the trauma, reduced mobility, the possibility of an underlying undiagnosed malignancy should also be considered.
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 and more significant hypoxia with physiological stress.
Less sensitive to metabolic drivers of respiration including hypercapnia, hypoxia and acidosis.
Pre-existing renal impairment in combination with volume depletion will lead to further renal function compromise. It also makes the older population more prone to contrast induced nephropathy.
Older people might have chronic kidney disease, even though their creatinine levels are within the normal range. This is due to low muscle mass
Cirrhosis increases the risk of ischemia, reperfusion injuries, haemorrhage, post trauma complications and mortality.
Urinary and bowel injury can evolve insidiously.
Weaker bones and degeneration of joints make the older patients more susceptible to fractures, even in minor trauma.
Muscle atrophy – decreasing muscle mass can lead to impaired mobility and balance
Kyphosis and an increased anteroposterior diameter of the thoracic cage can lead to a loss of intra-thoracic volume and thoracic cage compliance.
Frailty is defined as a clinically recognisable state of vulnerability due to ageing associated decline in reserve and function in multiple physiologic systems.(8)
Frailty leads to decreased mobility and deconditioning, increasing the risk of falls and injury.
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.
Consider the use of a use of a validated frailty assessment tool, e.g. the clinical frailty score or frailty index when assessing and managing these patients. (9, 10)
Falls are the leading cause of trauma related mortality in older people (11), with older patients more likely to require hospitalisation, suffer complications, have longer stays and require discharge to a rehabilitation facility. Falls with an associated low mechansim will often represent a major traumatic mechanism in the older person population and can lead to significant morbidity and mortality. Frequency of falls from a low height (<1m) are steadily increasing with a burgeoning number of older patients falling from a standing position.
Increased risk of falls is also related to cognitive impairment, musculoskeletal disease burden, pain, polypharmacy (not just prescribed), muscle atrophy (sarcopenia preferred term), comorbid disease (such as Parkinson’s disease and similar conditions, strokes, peripheral neuropathic changes), malnutrition, cardiac disease (particularly arrhythmias and structural heart diseases), sensory declines (vision and hearing), as well as age -related changes in reflex reaction times and vision. (12, 13)
Syncope may be a triggering event of the fall. Acute causes include infection, acute renal failure, acute coronary syndrome, cerebrovascular events. Orthostasis or medication related syncope are common but serious causes as cardiac, haemorrhage, SAH or PE must be considered. A fall in the older patient should initiate a multi-factorial, comprehensive assessment. Syncope may be caused by cardiac arrhythmias, neurological deficits, glucose derangements, poor blood pressure control as well as volume depletion.
Sub-optimal pain management also leads to an increase in falls as apprehension or fear of mobilising due to pain causes deconditioning, loss of muscle mass and gait disturbances. Environmental factors also contribute to falls, for example stairs, rugs, uneven ground, pets and ill-fitting footwear.
As the population continues to age, there may be more older 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 older at a higher risk than any other group. Additionally, in Victoria, 41% of pedestrians who lost their lives in 2019 were aged over 70 years. (14) 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.
In the assessment of an older trauma patient, the possibility of an intentionally caused injury must be considered. Some cases of trauma are as a result of physical abuse.
As part of the secondary survey a detailed history and examination should be performed. A variance in history, physical signs or delay in seeking treatment could be indicators of elder abuse. This should prompt further investigation and reporting.