Tag Archives: elderly

General

Falls In The Elderly: The Consequences

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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.

General

Dysphagia and Cervical Spine Injury

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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.

General

EAST Practice Guideline – Geriatric Trauma (2010 Update)

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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.