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!
Our elderly population is growing rapidly, and the average age of the patients on the trauma service is escalating. These patients offer a number of challenges throughout their presentation to the hospital and the rest of their stay. Some trauma centers are now organizing special teams or response types to deal with the unique needs of this population. A few have adopted a separate response type when injured elderly patients present to the ED.
The group at Reading Hospital implemented a separate trauma activation tier, “Tier 3”, driven by emergency physicians, to manage these patients. Tier 3 was designed to identify patients > 65 years of age with the potential for occult blunt injury to the head and torso. The normal activation criteria at this center would not have necessarily identified these patients. This study retrospectively looked at demographics and outcomes for two separate three year periods, one before and one after implementation of Tier 3.
Here are the factoids:
- Geriatric volume increased significantly from 1715 to 3688 patients (!!), and more received expedited workup as either a trauma activation or Tier 3
- There were statistically significant decreases in time to CT (102 vs 128 minutes) and ED length of stay (361 vs 432 minutes) (see my comments)
- Mortality decreased from 8% to 5% overall, and from 19% to 11% in patients with head AIS > 3, both of which were significant
- Regression analysis showed that implementation of the Tier 3 response was an independent predictor of improved survival
Bottom line: This poster shows results that suggest having a specific response for select elderly patients who don’t meet trauma activation criteria can be beneficial. However, the devil is in the details. Each center must develop criteria for the Tier 3 response that mesh with their own activation criteria. And the details of that response need to be clinically significantly better than the usual consult response.
Questions and comments for the authors/presenters:
- Be careful not to confuse statistical significance with clinical significance. Decreasing mean time to CT from 2:08 to 1:42 is not that big of a deal. The same applies to 7 hours in the ED vs 6.
- Please share the Tier 3 criteria and details of the ED response.
- Have you modified your Tier 3 criteria and/or response since inception, and if so, how and why?
Click here to go the the EAST 2017 page to see comments on other abstracts.
Reference: “Tier 3”: Long term experience with a novel addition to a two-tiered triage system to expedite care of geriatric trauma patients.. Poster #34, EAST 2017.