Published: Friday, January 7, 2005 at 1:29 p.m.
Last Modified: Friday, January 7, 2005 at 1:29 p.m.
Birth of the Gerontologist-Traumatologist
In 2004 in the state of Florida, there are 3.1 million people over the age of 65; 2.44 million of them have drivers' licenses. In just six years, the number of people over the age of 65 in the state is projected to increase by 15% to 3.6 million. In the counties that the new area trauma center services, currently there are 131,294 people over the age of 65. By 2010, this number is projected to increase by 18% to 158,535 people.
Nationally, in the year 2000, there were 35 million people over the age of 65. By the year 2030, it is project that there will be 71 million people over the age of 65, 9.6 million being over the age of 85.
Although some in health care think these numbers mean job security, the challenges these numbers represent will be immense and will strain our health care system incredibly. In particular, for trauma, the elderly account for 10-14% of all trauma injuries, but 25% of all trauma-related deaths. Also, 25 to 33% of all trauma-related health care dollars go to this population. In 1994, it was estimated that the cost of geriatric trauma was 20 billion dollars a year. The mortality rate among geriatric trauma patients is six times higher than that of younger patients.
The pattern of injury of the elderly is different from that of the younger patient. In the younger patient, injuries such as motor vehicle collisions and penetrating trauma are greater. In the elderly population, the pattern of injuries changes. Falls (40%) then motor vehicle collisions (28 %), then automobile versus pedestrian accidents (10 %), then assault and domestic abuse, and then burns represent, in decreasing order, the pattern of injury for the elderly.
In the elderly, falls cause more than seven million injuries a year and result in 10,000 deaths a year. As many as one-third of the elderly population will experience a fall requiring treatment at a hospital every year. The falls usually occur from a flat surface or from relatively low heights. The reason for the falls is multi-factorial, but hazards such as stairs are not the greatest cause. Co-morbid conditions (which can account for up to 25% of falls), medications (such as sedatives and anti-hypertensives), and deterioration of vision, strength, and coordination are higher predictors of falls than are physical hazards.
In elderly patients who are involved in car accidents, there is a higher rate of accident per mile driven than in younger drivers. The elderly are responsible for the majority of crashes in which they are involved; are much more likely to have an underlying medical problem, such as syncope, causing the accident; and are more likely to crash in seemingly favorable conditions, such as in daylight and good weather. The elderly can have decreased cerebral skills, motor skills, and auditory and visual acuities that all can add to difficulty in driving a motor vehicle. It has been estimated that at least 20 percent of those 85 or older driving are considered to have mild to moderate dementia. Up to age of 80 in Florida, depending upon a person's driving record, alternate renewal methods may allow a person to forgo a vision screening for up to 18 years. The injuries for the young and old are similar, but the elderly are much more likely to have a higher severity of injury. On the flip side, alcohol is much less common a cause of the elderly patients' accidents.
Automobile versus pedestrian accidents in the elderly have the highest rate of mortality per accident. It is estimated that the death rate per accident is as high as 32.6%. Most of these accidents occur at crosswalks, with up to 46% of fatalities occurring within a crosswalk. Contributors to this high rate of being injured in a crosswalk include declines in direct and peripheral vision, hearing, memory, and judgment. Also, the standard time allotted for crossing the crosswalk, four feet per second on average, may be unattainable in some elderly people.
Assault and domestic abuse represent a growing and under-recognized form of trauma in our society. It is estimated that up to two million causes of elder abuse and neglect occur each year. Just like with child abuse, elder abuse requires a high degree of suspicion. Abuse can take many forms including intentional physical or verbal assaults, neglect or abandonment, and financial exploitation. Abusers can commonly be in the immediate family. The patient becoming more and more dependent on the family can lead to more stress, which can in turn lead to the caregiver striking out against or neglecting the victim. Sometimes, the families will bring the patients to the emergency room simply because the stress of taking care of the family member is too great.
When the ER physician calls the patient's primary care physician to admit the patient, the under-represented phenomenon of ER-physician abuse can take place trying to get the patient admitted.
Due to the thinning of the skin and decreased ability to fight infection, burns in the elderly can be devastating. In the elderly, most burns occur at home. Up to 10% of patients who die of burns are in this population and they can constitute as much as 20% of admissions for burns. Elderly burn victims have a higher mortality than those younger victims with smaller-sized burns. The total body surface area of the burn carries the greatest predictor of mortality. It is estimated that a full thickness burn of 10 to 14% total body surface area can carry up to 50% mortality. Other contributors to the mortality of burns in the elderly are development of pneumonia, sepsis, co-morbid conditions, and excess fluid requirements.
Aging is characterized by a decreased functional reserve and poorer ability to cope with stressors, thus producing an increased risk of death. Also, co-morbidity has substantial influence on the mortality and morbidity of geriatric trauma. It is has been reported that 50 percent of geriatric trauma patients greater than age 65 will have a preexisting disease; this number rises to 65 percent over the age of 75. The pre-existing diseases that have the most influence on mortality rates in trauma are cardiac disease followed by malignancy, and then renal disease. To better understand this situation, one just needs to look at each major organ system and see how trauma affects each one.
Cardiovascular disease is the most prevalent medical problem in the elderly and alters the body's response to trauma. Age-related changes in the conduction system of the heart do not allow a maximal increase in heart rate to occur. Myocardial oxygen demand increases with the stress of trauma. But due to underlying atherosclerotic disease, maximal oxygen delivery can not take place due to limitation of blood flow through the coronary arteries. Also, prescription medicine and pacemakers play a significant role in the impairment of the cardiovascular system to respond to stress and injury. For all these reasons, an elderly patient in shock may actually have normal vital signs and yet be in serious distress. This phenomenon has caused many to advocate for using invasive monitoring early in the course of the patient. Deep venous thrombosis and pulmonary embolus can complicate the course of the elderly trauma patient's recovery due to bed rest involved in their recovery, as well as to direct injury to the blood vessels.
Age-related changes in the respiratory system also affect the elderly patient. As people age, the chest wall becomes more rigid due to loss of elasticity and becomes weaker due to osteoporosis. This situation leads to more rib fractures and sternal fractures. The pain associated with rib fractures, along with decreased physiologic reserve, may predispose patients to respiratory complications such as hypoxia and pneumonia, thus leading to the need of ventilatory support.
Central nervous system injury in the elderly is the most common form of mortality in elderly trauma patients. Severe head injury patients with a Glascow Coma Scale of eight or less have a mortality of up to 90 percent. Epidural hematomas are less common in the elderly due to the dura becoming tightly adherent to the skull. Age-related atrophy leads to increased space around the brain for the formation of subdural hematomas. This increased space around the brain allows for more bleeding to occur before symptoms arise. Thus, some significant subdural hematomas may only present with subtle neurologic changes. Also, subdural hematomas become more common because the bridging veins become more fragile. Thus the use of CT scan should be liberal in the elderly with suspected head trauma.
Age-related changes to the kidneys also affect the elderly patient's ability to respond to trauma. Decreases in renal blood flow, renal mass, number of functioning glomeruli, and prescription medicine - such as diuretics - all can have an adverse affect on the patient's ability to respond to trauma. Decreasing muscle mass may lead to a normal-appearing serum creatine when in reality the kidney function is impaired. Potentially nephrotoxic agents, such as intravenous contrast agents and some antibiotics, can also affect the kidneys of trauma patients.
Osteoporosis, along with progressive loss of muscle mass, can have a profound influence on the elderly patient and lead to more musculoskeletal injuries in general. Long bone fractures, including hip fractures, cervical spine fractures, vertebral compression fractures, and pelvic fractures are more common in the elderly and take less force to produce these fractures due to the osteoporosis.
Abdominal injuries in the elderly can also be difficult to manage. The abdominal exam can be unreliable in the elderly and significant intra-abdominal injury can take place with minor trauma. Elderly patients tolerate exploratory lapartomies less well than the young, and diagnostic peritoneal lavage can be difficult due to previous abdominal surgeries.
Unfortunately, significant trauma can affect multiple organ systems and can be devastating in the elderly with co-morbid illness. One cannot over look the need and importance of addressing end-of-life issues with patients and families. Almost equally important to the injury itself is the socioeconomic impact that the injury can have on the patient, as well as the psychological stress of potentially becoming less independent after the injury.
In conclusion, geriatric patients have a different range of injuries than the young, with falls much more common. Due to co-morbid illness and age-related changes in the body, trauma in the elderly can have significantly more morbidity and mortality. Rapidly changing demographics in the population will make trauma in the elderly much more prevalent in the decades to come and will cause a significant strain on health care resources.
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