Pulmonary

The aging process also brings significant baseline anatomic and physiologic changes to the pulmonary system.⁶ The chest wall of the elderly individual changes over time with increasing kyphosis as well as decreasing height of intervertebral spaces. There is a decrease in strength of the intercostal muscles and diaphragm. After trauma, these anatomic changes place elderly patients at risk for earlier or more rapid respiratory failure as well as difficulty in liberation from the ventilator.^6–8 In addition to alterations in the chest wall, there are several changes in the pulmonary parenchyma of elderly individuals. These changes lead to increased compliance due to loss of elasticity and elastic recoil, emphysematous changes, and dysfunction of the mucociliary system. While anatomic changes are important, the altered pulmonary physiology of aging may lead to significant clinical implications when caring for the injured elderly patient. The elderly individual will have changes to pulmonary physiology including alterations in lung volumes, gas exchange, and respiratory drive.⁶ Lung volumes in elderly patients will have increased residual volume and functional residual capacity but decreased vital capacity and FEV1.^9,10 Alterations of pulmonary gas exchange in elderly patients include increased ventilation–perfusion mismatch as well as decreased diffusion across the alveolar–arterial membrane, both associated with a decrease in baseline PaO₂.^11,12 Due to deranged respiratory drive seen with aging, elderly patients will have a diminished physiologic response to both hypoxemia and hypercapnia.¹³ Some of the most common pulmonary comorbidities in the elderly trauma patients include COPD, asthma, and obstructive sleep apnea. Table 30-1 displays changes in cardiovascular and pulmonary physiology as well as common comorbidities encountered in the elderly trauma patient.

Renal and Gastrointestinal

Aging causes deterioration in renal function over time due to alterations in renal vasculature, microanatomy, as well as changes in renal physiology.¹⁴ Elderly patients commonly have low-grade and/or undiagnosed chronic renal insufficiency putting them at risk for development of acute kidney injury after trauma. Avoiding nephrotoxic agents, intravenous contrast, hyperglycemia, and hypovolemia can help prevent acute kidney injury in elderly trauma patients. Gastrointestinal derangements in the elderly patient may include dysphagia, gastroesophageal reflux, gastroparesis, and diarrhea or constipation.¹⁵ In addition, many elderly trauma patients will present in a state of malnutrition established long before the time of injury. It is important to screen elderly trauma patients for nutritional status and begin enteral nutrition early in the postinjury course.

Elderly trauma patients present with a wide array of altered physiology and comorbid conditions. These pre-existing medical conditions are usually treated in the outpatient setting by primary care providers, and the mainstay of treatment is often a long list of medications. These preinjury medications can have a profound effect on the management and outcomes of elderly trauma patients. In addition, elderly individuals have an altered ability to metabolize the medications they encounter prior to injury as well as during their hospitalization.

Medications

Elderly trauma patients may be taking a variety of medications that may affect initial presentation, evaluation and treatment, and eventually outcomes. As hypertension is the most common comorbidity, elderly trauma patients will often be taking preinjury antihypertensive medications. Diuretics will cause patients to present in a hypovolemic state prior to injury or hemorrhage. Preinjury beta-blockers will blunt the tachycardic response and may confound the initial presentation.¹⁶ The most significant preinjury medications in elderly trauma patients are anticoagulants and antiplatelet agents. Elderly patients may be on anticoagulants or antiplatelet agents for a variety of conditions including atrial fibrillation, ischemic cardiac disease, valvular heart disease, cerebrovascular accidents, or thromboembolic disease. The most common outpatient anticoagulant is coumadin (vitamin K antagonist), but there have been several newer anticoagulants brought to market recently. These include the direct thrombin inhibitor dabigatran as well as the Xa inhibitors, rivaroxaban and apixaban. The most common antiplatelet agents include aspirin (cyclo-oxygenase inhibitor) and clopidogrel (ADP inhibitor). Newer antiplatelet agents include newer ADP inhibitors, prasugrel and ticagrelor.

Reversal of anticoagulants and antiplatelet agents in elderly trauma patients can be a challenging and complex clinical scenario. The clinician must balance reversal to eliminate hemorrhage and thromboembolic complications associated with reversing anticoagulation or antiplatelet agents. Coumadin may be reversed with either fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC).^17,18 There is limited evidence regarding reversal of direct thrombin inhibitors or Xa inhibitors.^19–22 Dabigatran may be reversed with Idarucizumab (Praxnind). Intragastric activated charcoal may be administered if drug has been taken within 2 hours of presentation or hemodialysis may be considered. PCC may be considered for reversal of dabigatran but FFP is unlikely to have any therapeutic effect. Reversal agents for Xa inhibitors (Adnexanet alfa) are currently under investigation. Activated charcoal may be used or PCC may also be considered. Antiplatelet agents may be reversed with either DDAVP or platelet transfusion, but the indications for either therapy have not been elucidated.^21,23,24 Table 30-2 displays common preinjury anticoagulants and antiplatelet agents in the elderly trauma patient.

2 Once hospitalized, particular attention must be paid to medications ordered for the elderly trauma patient. Elderly patients have changes in pharmacokinetics and pharmacodynamics including alterations in absorption, bioavailability, distribution, metabolism, and elimination.²⁵ The American Geriatrics Society has published the Beers Criteria for potentially inappropriate medication use in older adults that can be used to refine inpatient medication management for elderly trauma patients.²⁶ Of particular importance to the management of the elderly trauma patients is the plan for pain control. Pain medications may have significant side effects in elderly patients including delirium, nausea, vomiting, constipation, renal dysfunction, and gastrointestinal bleeding. A multimodal approach with the lowest effective dose for pain control should be used for elderly trauma patients.²⁵

MECHANISM AND INJURIES

3 Mechanisms of injury for elderly trauma patients are most often a result of blunt trauma with falls, motor vehicle crashes, and pedestrian struck by auto being the most frequent. Falls are far and away the most common mechanism in elderly trauma patients, causing almost 75% of injuries.¹⁶ Fully, 90% of elderly falls are ground level falls. After hospitalization, older patients are at further risk for inpatient falls.²⁷ There are a variety of reasons that elderly individuals are at risk for falls including weakness, deconditioning from chronic illness, vision loss, gate and balance disturbances, slowed reaction time, and cognitive impairments.¹⁶ The American Geriatrics Society has developed clinical practice guidelines (Table 30-3) for the prevention of falls in older adults.²⁸

Elderly Abuse

4 An underreported but extremely important mechanism of injury in elderly trauma patients is abuse. Elderly abuse is committed by an individual who has a relationship with and is responsible for the well being of an elderly individual. Perpetrators of elderly abuse may include family members or care givers either in the home or at an assisted living facility. Abuse of the elderly is associated with depression, cognitive impairment, loss of functional capacity, and increased morbidity and mortality.²⁹ Several risk factors and warning signs for elderly abuse have been identified and are listed in Table 30-4.³⁰ If elderly trauma patients appear to be at risk for or display warning signs of possible abuse they may be assessed using a variety of available screening tools³⁰ including the American Medical Association (AMA) screening tool, the Conflict Tactics Scale (CTS), the Brief Abuse Screen for the Elderly (BASE), the Elder Assessment Instrument (EAI), or the Comprehensive Geriatric Assessment (CGA).

Traumatic Brain Injury

5 Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in elderly trauma patients.^31,32 TBI in elderly patients leads to almost 100,000 emergency department visits each year with the large majority requiring hospitalization. The most common mechanism causing TBI in elderly patients is falls (51%) followed by motor vehicle–related injuries (9%). All other causes combined make up 18% of TBI and about 20% are from an unknown cause. Imaging with head CT in elderly trauma patients should be used liberally for several reasons: (1) elderly patients have progressive brain atrophy leading to stretching of bridging veins and increased risk of subdural hemorrhage after trauma,³³ (2) clinical tools such as the New Orleans Criteria and Canadian CT Head Rule exclude elderly patients,^34,35 and (3) neurologic examination may be unreliable in elderly trauma patients.^36,37 The catastrophic combination of TBI and preinjury anticoagulation should prompt to rapid reversal of anticoagulation.^38,39

Fractures

Elderly patients have decreased cortical bone mass increasing their risk for fractures at lower levels of kinetic energy. As a consequence, older patients have increased risk of rib, spinal, pelvic, and extremity fractures after falls and other low impact mechanisms than younger patients.

Rib fractures are a significant cause of morbidity and mortality among older patients.⁴⁰ Retrospective studies show that in-hospital mortality for patients >65 years is double that of younger patients.^41,42 The risk of mortality and pneumonia increases with increasing number of ribs fractured, and patients with more than three fractures have worse outcomes.^41,43 Up to a third of older patients with rib fractures develop pneumonia and rib fractures are associated with mechanical ventilation and ICU length of stay.⁴¹

Osteoporosis, prior fracture, and functional impairment are all risk factors for pelvic fracture.⁴⁴ Over 80% of pelvic fractures are caused by falls, and morbidity and mortality after pelvic fractures is significant. In-hospital mortality approaches 8% and is up to five times higher than for younger patients.⁴⁵ Many patients after pelvic fracture require a cane or a walker, up to one-third are institutionalized, and 27% will die within a year of injury.⁴⁴

Spinal trauma is increasingly common in elderly patients.⁴⁶ The risk of cervical fracture after falls increases with age due to higher rates of cervical stenosis and degenerative disk disease.⁴⁷ An estimated 5% to 10% will sustain spinal injury and permanent neurologic deficit after cervical fracture, and 1-year mortality is estimated to be 20% to 30%.⁴⁸

Fourteen percent of elderly patients who sustain hip fracture after falls die within 6 months and almost one-fourth dies within a year.^49,50 Most do not regain prior functional abilities, and patients after hip fracture are five times more likely to live in an institution a year after injury. Hip fracture in older patients often leads to depression,⁵¹ social isolation, and worse overall health. Up to half of patients with hip fracture experience pain for many months after injury.⁵² Shorter time to surgery is associated with decreased mortality and fewer complications.⁵³

TRIAGE CRITERIA FOR OLDER PATIENTS

6 Trauma center care reduces in-hospital mortality for older trauma patients,^54,55 and the benefit of treatment at trauma centers for older patients increases with age.⁵⁶ However, triage of older patients can be quite challenging. Even severely injured older patients may not display standard signs of hemodynamic instability. Furthermore, because older patients cannot tolerate large blood loss and shock, some have advocated that systolic blood pressure ≤120 mm Hg should trigger trauma activation to prompt earlier intervention.⁵⁷ The Centers for Disease control suggest that injured patients >55 years should be transferred to a trauma center, regardless of injury severity.⁵⁸ The Eastern Association for Trauma (EAST) guidelines recommend that trauma centers should lower threshold for trauma team activation for elderly patients. Further, the guidelines suggest that older patients should be transferred to a level I center if they have a base deficit of –6 or greater, or one body system AIS is >3.⁵⁹ In a retrospective study using the National Trauma Data Bank, Pandit et al.⁶⁰ showed that shock index (HR/SBP) >1 was associated with higher rates of blood transfusions, exploratory laparotomy, in-hospital complications, and in-hospital mortality. Based on these findings, the authors recommend that patients with a shock index >1 should be transferred to level I trauma centers.

Despite evidence supporting higher triage, multiple studies show that older patients are routinely undertriaged. Data from the Washington State database showed that the likelihood of being transferred to a trauma center decreased above age 45.⁶¹ Compared to younger patients in the cohort, patients 81 years and older were only 11% as likely to be transported to a level I trauma center from the scene, and only 24% as likely to be transferred from a lower level center to a level I center. The relationship between trauma center admission and longer-term outcome is controversial. One study of severely injured older patients (ISS >15) in three counties in California showed that older patients were less likely to receive care at trauma centers, yet mortality at 60 days after injury was no different.⁶²

EVALUATION AND MANAGEMENT

Comprehensive Geriatric Assessment

Older patients are much more likely to have medical comorbidities, extensive lists of medications and social needs that require special attention. A retrospective study of older trauma patients showed that 69% of patients age 75 to 79 years and 90% of those >80 years have comorbidities.⁶³ The most common are cardiopulmonary (coronary disease, hypertension, congestive heart failure, and COPD). Geriatric syndromes such as dementia and frailty also play important roles and are frequently the primary contributors in falls and motor vehicle crashes. Malnutrition, hearing loss, vision loss, incontinence, polypharmacy, and osteoporosis all increase the risk of falls; weakness from sarcopenia and sensory deficits also place elders at high risk for being either struck by motor vehicles, or driving in motor vehicle crashes. Alcohol and substance abuse are under-recognized contributors to injury in geriatric trauma patients.⁶⁴

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