Tag Archives: elderly

How We Take Care Of Our Elders

Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.

The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria. 

The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.

There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.

Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.


Related post:

Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, epub ahead of print, March 21, 2012.

Urinary Tract Infection in the Elderly Trauma Patient

Yesterday I talked about using a medical orthopaedic trauma service to provide better care to elderly patients with fractures. Many of these patients have multiple pre-existing diseases and are quite fragile. A recent paper from the Rhode Island Hospital shows just how fragile these patients may be.

Urinary tract infection (UTI) is one of the most common nosocomial infections, accounting for about 40% of all such infections. The vast majority are related to indwelling bladder catheters. It is so much of a problem that, in order to decrease federal spending in the US, Medicare now denies payment for care related to these infections.

This study looked at the relationship between UTI and bladder catheters and how this infection relates to overall mortality in older trauma patients. It was a retrospective review of 6 years of data from a single institution. After excluding patients who entered the hospital with a UTI, they found that 12% of their patients developed this infection and 72% were indeed related to catheters. Males had a significantly increasing risk of UTI with increasing age. And the risk of death from UTI increased about 7% per year after age 55.

Bottom line: Urinary tract infections are especially bad for the elderly. As part of your daily rounds on any patient, look at every tube and line and ask yourself “is that really needed any more?” If not, get rid of it before it kills your patient!

Related post:

Reference: The development of a urinary tract infection is associated with increased mortality in trauma patients. J Trauma ePub ahead of print, doi: 10.1097/TA.0b013e31821e2b8f, July 2011.

Falls In The Elderly: The Consequences

Falls among the elderly are a huge problem. Our trauma service typically has 6-12 elders who have sustained significant injuries on it at any given time. About a third of people living at home over the age of 65 fall in a given year. At 80 years and up, half fall every year.

Because of this, falls are the leading cause of ED visits due to an injury for those over 65. What exactly are the societal consequences of all these falls? A yet to be published study from the Netherlands looked at injuries, costs and quality of life after falls in the elderly.

The top 5 most common injuries included simple wounds, wrist and hip fractures, and brain injuries. Although hip fracture typically was #5 in the 65-74 age groups, it was uniformly #1 in the 85+ group. Patterns were similar in both men and women. Interestingly, hip fractures were by far the most expensive, making up 43% of the cost of all injuries (total €200M). The next closest injuries by total cost, superficial injuries and femur fracture, made up only 7% of the total each!

As you can imagine, quality of life suffered after falls as well. A utility score based on the EQ-5D, a validated quality of life score, was lower in fall victims. Even after 9 months, this score did not return to baseline. About 70% of elders who were admitted after their falls described mobility problems and 64% had problems with their usual activities. Over a quarter expressed problems with anxiety or depression.

Bottom line: An array of falls prevention programs are available. They need to be more aggressively implemented to reduce costs and improve the quality of life of our elders.

Reference: Social consequences of falls in the older population: injuries, healthcare costs, adn long-term reduced quality of life. J Trauma (in press), 2011.

Dysphagia and Cervical Spine Injury

Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons:

  • Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx
  • Rigid cervical collars, such as the Miami J and Aspen, and halo vests all force the neck into a neutral position. Elderly patients may have a natural kyphosis, and this change in positioning may interfere with swallowing. Try extending your neck by about 30 degrees and see how much more difficult it is to swallow.
  • Patients with cervical fractures more commonly need a tracheostomy for ventilatory support and/or have a head injury, and these are well known culprits in dysphagia

A study in the Jan 2011 Journal of Trauma outlines the dysphagia problem seen with placement of a halo vest. They studied a series of 79 of their patients who were treated with a halo. A full 66% had problems with their swallowing evaluation. This problem was associated with a significantly longer ICU stay and a somewhat longer overall hospital stay.

Bottom line: Suspect dysphagia in all patients with cervical fractures, especially the elderly. Carry out a formal swallowing evaluation, and adjust the collar or halo if appropriate. 

Reference: Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 70(1):46-50, 2011.

EAST Practice Guideline – Geriatric Trauma (2010 Update)

The EAST Practice Management Guideline on management of geriatric trauma was updated early this year. This post gives the details of the proposed changes. Click here to open a copy of the existing PMG for comparison.

Prehospital Triage

  • Level II – Injured patients with advanced age (>=65) and pre-existing medical conditions (PECs) should lower the threshold for field triage directly to a designated/verified trauma center.

Triage Issues

  • Level II – With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly patient.
  • Level III – Patients 70 years of age or greater should receive care under the structure of the highest level of trauma activation and receive liberal application of invasive monitoring.
  • Level III – Elderly patients with at least one body system with an AIS >= 3 should be treated in designated trauma centers, preferably in ICUs staffed by surgeon-intensivists.

Low GCS

  • Level III – In patients 65 years of age or older with a GCS < 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions.

Head injury and anticoagulation

  • Level III – All patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission. Those with suspected head injury should be evaluated with head CT as soon as possible after admission. Patient receiving warfarin with post-traumatic intracranial hemorrhage should receive initiation of therapy to correct their INR to normal range within 2 hours of admission.

Base deficit for triage

  • Level III – Base deficit measurements may provide useful information in determining status of initial resuscitation and risk of mortality for geriatric patients. ICU admission should be considered for patients >=65 with an initial base deficit >= -6.

Deleted guidelines – the following have been recommended for deletion from the PMG.

  • Attempts should be made to optimize cardiac index > 4L/min/M2 and/or oxygen consumption index of 170 cc/min/M2.
  • Complications negatively impact survival. Specific therapies to reduce complications should lead to optimal outcomes.
  • Admission trauma score < 7 is associated with 100% mortality and aggressive therapeutic interventions should be limited. 
  • Admission respiratory rate < 10 is associated with 100% mortality and aggressive therapeutic interventions should be limited.