Worldwide, the population is aging. Currently in the US, about 1 in 8 people are considered elderly (age >= 65). In 15 years, this number is expected to double to 1 in 4.
But as every trauma professional knows, there are the elderly, and then there are the elderly. What do I mean by this? I’ve seen 50 year olds who look and act like they are 80, with a medication list 10 deep. And I’ve also seen 90 year olds who are still ballroom dancing with the ladies.
Can we tell these cohorts apart, and do we need to? Sure, you can apply the “eyeball” test, but it’s not always accurate. Well, there are a number of frailty indexes that have been developed that try to make this process a bit more objective. The trauma group in Tucson looked at frailty index as a predictor of hospital disposition to see if it could offer any assistance in discharge planning.
Here are the factoids:
- 100 consecutive patients aged 65 or more were studied over a one year period at a Level I trauma center
- Frailty was calculated using the Canadian Study of Health and Aging Frailty Index, using 50 of the demographic, comorbidity, medication, social history, activities of daily living, and general mood variables
- Overall, patients had moderate injury with average ISS 14, AIS-Head 2, and GCS 3
- 69% of patients had a favorable outcome (discharged to home or rehab) vs 31% unfavorable outcome (skilled nursing facility or death)
- Frailty index was highly and significantly correlated with unfavorable outcome
- Age 65 or more alone was not predictive of unfavorable outcome
Bottom line: Just the fact that a patient is older does not mean that they are more likely to do poorly. The frailty index (FI) used in this study includes 50 variables, which indicates how complex this concept is. This scale has been used in non-trauma patients, and is now validated for trauma. Although somewhat complicated due to the sheer number of variables, it appears that this tool may be valuable in predicting discharge disposition if applied soon after admission. And it also raises the interesting question of whether hospital interventions may be able to change a predicted unfavorable outcome into a favorable one.
Reference: Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? J Trauma 76(1):196-200, 2014.
I’ve had several requests for a piece on geriatric trauma. We know that elderly patients (officially age > 55) have worse outcomes for the same degree of injury. And as they get older, mortality rises rapidly. Here are some practical tips for trauma professionals.
- For EMS: As I mentioned yesterday, heed the CDC trauma triage guidelines. Older patients have better outcomes at trauma centers, so take advantage of it.
- In the ED: Ask immediately about anticoagulation. This can cause life threatening situations, especially in the face of intracranial hemorrhage. If your patient is taking anything that interferes with clotting, treat them like a STEMI or stroke patient. Time is of the essence. Draw coags and get rapid access to the CT scanner. Refer to the guidelines I previously published on reversing the usual culprits.
- Most elderly patients with any degree of head trauma need a head CT. They can hide bleeding well, until it’s too late to save them.
- Once admitted, treat them very carefully. Even minor errors (too much fluid, unneeded IV contrast) can cause significant complications.
- Use as little narcotic as possible. Acetaminophen and ibuprofen work great. Lidocaine patches may be helpful in may cases. Steer away from narcotics and muscle relaxants as much as possible to avoid altering mental status.
- Watch sleep patterns. Sleeping meds are bad, but reducing interruptions in the middle of the night is good (do they really need vital signs taken at 2AM?).
- Look at the patient’s baseline status. Are they a spry 90 year old, or a demented 70 year old who falls all the time? Have realistic expectations and communicate them with the family if major procedures or intubation are considered. Sure, we have the technology to fix many things, but at what cost to the patient? The family needs to understand the real likelihood of ICU, tracheostomy, and prolonged or permanent debilitation. Don’t make them as miserable as you can make the patient.
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.
Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, 78(13):950-956, 2012.
All of next week, I’ll be writing about a topic that is becoming more and more important: geriatric trauma. Our population is aging, and the number of older patients being admitted to trauma centers is exploding.
Here are the topics to be covered:
- How We Take Care Of Our Elders
- Thoughts On Geriatric Trauma
- Elderly Trauma And The Frailty Index
- The Medical Orthopaedic Trauma Service
- Falls In The Elderly: The Consequences
- Effect Of an In-Hospital Falls Prevention Program
And please feel free to leave comments and suggest future topics!
I previously wrote about the impact of adding a hospitalist to the trauma service to improve care of geriatric trauma patients. Method Dallas Medical Center created a specific geriatric trauma service, which they called the G-60 service, in 2009. They published their data after one year of experience in 2012.
All patients 60 years of age and older with injuries <48 hours old were admitted to a specific hospital unit. All admitted patients were seen immediately by the trauma surgeon and a hospitalist. Other involved services included rehab, palliative care, PT and OT, pharmacy, nutrition, respiratory therapy, and social work, as needed. The hospitalist was also tasked with expedited clearance for surgical procedures.
Time-to-care goals included G-60 service activation and ED evaluation within 30 minutes, admission to the G-60 unit within 4 hours, operative procedures (if needed) within 36 hours, and discharge within 5 days if appropriate. Multidisciplinary rounds with the full complement of personnel were held twice weekly.
A total of 393 patients were admitted to the G-60 service over a period of one year. A control group of 280 patients from the year before implementation were used for comparison.
Here are the factoids:
- Mechanism of injury was blunt 98% of the time, as expected. Most were falls, and the frequency increased from 68% to 75% after implementation of G-60.
- ICU admission rate remained steady at about 20%
- Significant time-to-care decreases were seen in all 4 categories. ED length of stay decreased by 2 hours, and time to OR decreased by more than half a day.
- Hospital length to stay decreased from 7 to 5 days, and ICU LOS decreased from 5 to 3 days. Both were statistically and financially significant.
- There were significant decreases in the incidence of complications, including UTI, renal failure, CHF, ventilator associated pneumonia, and respiratory failure.
- There was no change in DVT or PE rates.
Bottom line: Implementation of a multidisciplinary trauma service that addresses the special problems of injured elderly patients improves outcomes, and would appear to save a lot of money. I have observed a very obvious age shift in the trauma population at my own trauma center, and I know quite a few other trauma medical directors who are seeing the same thing. We are all going to need to develop the equivalent of a G-60 service to improve outcomes and reduce the financial challenges of taking care of these patients. However, using age 60 as the threshold will miss a number of elders who might benefit. Frailty measures and common sense will need to be taken into account to make sure all appropriate patients can benefit from this type of service.
Reference: Geriatric trauma service: A one-year experience. J Trauma 72(1):119-122, 2012.