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Home , Geriatric trauma

Evidence-Based Care of Geriatric Trauma Patients

a,b, c Steven E. Brooks, MD *, Allan B. Peetz, MD

KEYWORDS  Geriatric trauma  Geriatric  Frailty  Acute care surgery  Surgical critical care

KEY POINTS

 The doubling of the geriatric population over the next 20 years will challenge the existing health care system.  Care of geriatric trauma patients will be of paramount importance to the health care dis- cussion in America.  Geriatric trauma patients warrant special consideration because of altered physiology and decreased ability to tolerate the stresses imposed by trauma.  In spite of increased risk for worsened outcomes, geriatric trauma patients are less likely to be triaged to a designated .  There must be, with either patients or surrogate decision makers, an exploration regarding patient goals of care and a discussion about what patients would consider meaningful outcomes.

INTRODUCTION: WHY GERIATRIC TRAUMA? The United States is experiencing an exponential increase in its older adults unlike any that has ever occurred. With the aging of the baby boomer generation, the geriatric, commonly defined as those aged 65 and older, are the most rapidly growing segment of the US population.1 According to the Census Bureau this age group will nearly dou- ble in 2 decades, from 39.6 million in 2009 to 72.1 million in the year 2030.2,3 Although trauma is the number one cause of death in those aged 44 years and younger, it is also

The authors have no commercial relationships or financial interests to disclose. a Geriatric Trauma Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Depart- ment of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA; b Pediatric Intensive Care Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA; c Emergency General Surgery, Division of Trauma, Surgical Critical Care, Vander- bilt University Medical Center, Medical Arts Building Suite 404, 1211 21st Avenue South, Nash- ville, TN 37212, USA * Corresponding author. Department of Surgery, Texas Tech University Health Science Center, 3601 4th Street MS 8312, Lubbock, TX 79430. E-mail address: [email protected]

Surg Clin N Am 97 (2017) 1157–1174 http://dx.doi.org/10.1016/j.suc.2017.06.006 surgical.theclinics.com 0039-6109/17/ª 2017 Elsevier Inc. All rights reserved. 1158 Brooks & Peetz

the fifth leading cause of death when all age groups are considered.4 The doubling of the geriatric population will challenge the existing health care system, both numerically and monetarily. Why do we assign the term geriatric to trauma patients aged 65 years and older? Geriatric trauma patients have significantly higher mortality and poorer functional out- comes after major .3,5–7 Although they are injured less frequently than their younger counterparts, trauma is the fourth leading cause of death in those aged 55 to 64 years.4 Trauma is still the ninth leading cause of mortality in patients aged 65 years and older.4 Rather than having a derogatory connotation, the term geriatric represents the statistically significant inflection point in patients’ morbidity and mortal- ity for a given injury compared with a younger patient. Thirty-day mortality, a traditional outcome measure, is a poor metric in geriatric pop- ulations. Quality care may be associated with survival to discharge, but in the older population there exists high mortality within 2 months of discharge in geriatric trauma survivors.8–10 Those who do survive are often debilitated and institutionalized, an outcome that many would deem unsuccessful or even unacceptable. In the year 2000, the number of persons aged 65 years and older represented just more than 12% of the US population. By the year 2050, this group will increase to more than 20%.11 In addition to growing numerically, these older patients are living longer and more active lives. Those aged 80 years and older, the oldest old category, will increase to nearly 20 million persons by the year 2030.4 The changing composition of trauma patients reflects this growth. In a 2008 study, geriatric trauma patients accounted for 14% of all trauma-related emergency department (ED) visits. These data are consistent with both published and unpublished data at level 1 university trauma centers, such as Vanderbilt University (Nashville, Tennessee) and Texas Tech University (Lubbock, Texas), which showed an increasing percentage of geriatric trauma patients from 10% to 20% over a 10-year period.3 The fiscal impact of geriatric trauma care is undeniable and significant. The present political climate has ushered in an era of unprecedented attention to the economics of health care. Geriatric trauma accounts for 33% of all trauma health care expenditures in the United States, or $9 billion per year.12 The future cost of geriatric trauma will be integral to the health care discussion in America. The increasing number of geriatric and oldest old geriatric trauma patients will have serious financial implications for not only future trauma care but also for the entire US health care system.

PHYSIOLOGY IN GERIATRIC TRAUMA PATIENTS The evolution of clinical care in geriatric trauma originated with a dramatic shift in thought process about the physiology of the geriatric. In 1984 Harborview Medical Center published a review of 100 trauma patients older than 70 years that reported an 85% survival rate but noted that 88% did not return to their previous level of inde- pendence. The article stated that, “.what impact preexisting disease has on survival following injury has not been adequately studied.”13 In a 1986 study, Horst described 39 consecutive trauma patients more than 70 years of age and concluded, “[Mortality in the geriatric patient] should not differ substantially from other age groups.”14 These studies, in addition to others published in the 1980s, failed to detect outcome differ- ences between geriatric trauma patients and younger cohorts. The paradigm shift in recognizing these differences would not occur until the end of that decade. In 1990, Scalea and colleagues15 published an article that stated, “To our knowl- edge, no one has described managing geriatric trauma patients any differently than younger patients.diffuse is a very different disease process in the Geriatric Trauma Patients 1159 geriatric trauma patient. Older patients sustaining this type of injury are at consider- ably higher risk than younger patients.”15 The first step toward improving geriatric trauma care was acknowledging the outcome differences in geriatric injured patients and connecting those outcomes to differences to physiology.

PREEXISTING CONDITIONS: COMORBIDITIES AND CHRONIC ILLNESS Geriatric trauma patients may have many or all of the comorbidities that portend poorer outcomes in trauma:  Decreased vision and  Slower reflexes  Poorer balance  Impaired motor and/or cognitive function  Decreased muscle mass and/or strength  Decreased bone density  Decreased joint flexibility Additionally, 80% of geriatric trauma patients have at least 1 or more chronic dis- eases, such as hypertension, arthritis, heart disease, pulmonary disease, cancer, dia- betes, or history of stroke.4 These preexisting illnesses, when combined with the altered physiology of increased age described later, make geriatric trauma patients less able to tolerate the stress of trauma.

CENTRAL NERVOUS SYSTEM CHANGES IN THE GERIATRIC The central nervous system in geriatric patients may be impaired because of cortical and plaque buildup in the cerebrovascular vessels. Clinical implications include decrements in all 5 sensations in addition to cognitive decline. Decreased cerebellar function and associated worsening of balance add to risk of falls.4 The com- bination of polypharmacy and acute injury may exacerbate agitation and delirium in geriatric trauma patients.16

CARDIOVASCULAR CHANGES WITH AGING Geriatric patients have altered cardiovascular physiology, with cardiac function declining by 50% between 20 and 80 years of age.17 Patients in this age group will expe- rience 30% of all myocardial infarctions and 60% of all associated deaths.18 The cardiac muscle and conductive pathways are replaced with fat and fibrous tissue, predisposing the heart to arrhythmias. This stiffer heart is also more likely to have diastolic dysfunction, or inadequate ability to relax, decreasing its effectiveness as a pump. The heart’s first compensatory behavior for improving cardiac output in class II hemorrhagic shock, tachycardia, might be stultified by beta-blocker medications.19 The stiffer, fibrous heart limits increasing cardiac output via stroke volume. With the two mechanisms for improving cardiac output diminished, geriatric patients compensate by increasing sys- temic vascular resistance, resulting in a deceptively acceptable blood pressure. Understanding the cardiac changes and resultant difference in compensation pro- motes better pattern recognition for patients in danger with respect to vital signs. A 2010 review of more than 4000 trauma patients found a significant mortality increase in geriatric patients whose heart rates were greater than 90 beats per minute, an as- sociation not seen until a heart rate of 130 in younger patients.20 They also found that mortality markedly increased with a systolic blood pressure less than 110 in geriatric patients but not until a systolic blood pressure of less than 95 in young patients. 1160 Brooks & Peetz

Importantly, vital signs are less predictive of mortality in geriatric trauma patients.21 Additionally, the cardiovascular physiology and vital signs concerning in the younger population are not the same as those in geriatric trauma patients. Heart rate greater than 90 beats per minute or blood pressure less than 110 mm Hg should promote concern in the trauma surgeon.

PULMONARY AND THORACIC CHANGES WITH AGING Geriatric patients are particularly vulnerable to pulmonary disease. Lower respiratory tract pathology is the third leading cause of death and significant disability in persons aged 65 and older.22 Anatomic changes of the geriatric include kyphosis, or narrowing of the intervertebral disc spaces, leading to narrowing of the intercostal spaces and altering the angle and insertion of intercostal muscles.23 Decreasing skeletal muscle mass and strength, loss of type II fast twitch muscle fibers, weaker diaphragmatic inspiratory effort, gradual reduction in lung elastic recoil, reduction in alveolar surface area, decreased ATP reserve, and reduced response to hypoxia and hypercapnia contribute to an increasingly ineffective pulmonary system in the geriatric.22 Physiologic considerations include the decreasing minimal alveolar concentration of inhalational agents by 6% per decade after 40 years of age.22 Neuromuscular blocking agents may have an increased duration of action due to preexisting hepatic or renal disease. These patients have a more rigid chest wall, more compliant lungs that generate less elastic recoil, and parenchymal changes that lead to air trapping and hy- perinflation. These physiologic differences lead to increased residual volume by 5% to 10% per decade and decline of both forced expiratory volume in the first second of expiration and forced vital capacity by up to 30 mL per year.24 Geriatric patients are at increased risk for postoperative pulmonary complications, including aspiration, pneumonia, atelectasis, bronchospasm, pleural effusion, and pulmonary .22 These risks are related to age-acquired decrease in cough re- flex, decreased mucociliary epithelium function, decreased response to foreign anti- gen, and increased oropharyngeal colonization with microorganisms.25 The anatomic and physiologic changes of age all contribute to a pulmonary system that is less able to tolerate acute traumatic injury.

RENAL CHANGES IN THE GERIATRIC Anatomic changes of the renal parenchyma include glomerulosclerosis, a gradual replacement of glomerular tissue with fibrous tissue, causing a loss of 30% to 50% of cortical glomeruli by 70 years of age.26 Additionally, intimal thickening of both the afferent and efferent renal arterioles occurs secondary to atherosclerosis and atrophy of smooth muscle media.27 Perhaps the most profound renal anatomic change with ag- ing is the decreased ability to preserve the renovascular reflex, termed renovascular dysautonomy.28 This diminished ability to maintain hemostasis lessens the renal ca- pacity for preserving its own function in both hypotensive and hypertensive states. The sum of these anatomic and physiologic alterations in geriatric renal function results in higher risk or acute kidney injury (AKI) and also failure to recover function after AKI.29

GASTROINTESTINAL SYSTEM IN THE GERIATRIC Nutritional status of geriatric trauma patients is integral in predicting surgical risk. Malnutrition has been associated with increased postoperative morbidity, periopera- tive mortality, hospital length of stay (LOS), and decreased quality of life.30–32 Unfor- tunately, malnutrition is reportedly as high as 40% to 50% in hospital and nursing Geriatric Trauma Patients 1161 home settings.33 Fortunately, these are modifiable risk factors when nutritional inter- ventions are applied smartly. Recommended interventions include a brief nutritional assessment on admission using one of several available screening tools, ensuring that the prescribed diet is actually the one delivered to patients, and regular reassess- ment in the hospital for nutritional intolerance (nausea, emesis, pain, difficulty chewing or swallowing, or impaired bowel function).34

MECHANISMS OF INJURY IN THE GERIATRIC Ground-level falls (GLFs), accounted for 2.1 million ED visits among those aged 65 years and older in 2008.11 This staggering figure is almost 10 times more common than motor vehicle crashes, the second leading cause of trauma in older adults.35 Nearly 1 in 3 geriatric persons will have a GLF each year, and emergency medical ser- vices will respond to between 5 and 10 times more calls than for motor vehicle crashes.36 Six percent of GLF patients will sustain a fracture, and 10% to 30% of these patients will have .36 Most importantly, mortality in GLF patients is reported as high as 7%, underscoring that GLFs are not benign.36 Although the third most common mechanism is (geriatric) pedestrian versus auto, geriatric patients are especially vulnerable to violent assault (the fourth most common mechanism), resulting in 10% of geriatric trauma admissions. Significantly, these geri- atric victims of violence are 5 times more likely to die as a result of their attack when compared with younger victims.37

TREATMENT OF SPECIFIC Traumatic brain injury (TBI) is an epidemic problem in the geriatric trauma population, prompting more than 80,000 ED visits each year.17,38 Geriatric TBI patients have greater morbidity and mortality compared with younger TBI patients.39 The aging baby boomer generation has increased the prevalence of atrial fibrillation and other conditions requiring anticoagulation. In 2004, there were 31 million outpatient pre- scriptions for in the United States, a 45% increase from the prior 6 years.40 Use of this therapy increases the risk of intracerebral hemorrhage (ICH) 7- to 10- fold.41 The past decade has also given rise to irreversible anticoagulants, adding an additional degree of difficulty to the management of anticoagulation-associated ICH. Unfortunately, 1-month mortality following ICH approaches 40%, and only 12% to 39% of patients after an ICH regain independent function, underscoring the need for additional improvement in geriatric TBI treatment.42 The initial key to improved care in geriatric TBI is a high index of suspicion for injury and a low threshold for performing a computerized tomography (CT) scan to confirm the diagnosis. One study of geriatric, mild TBI patients reported a 14.3% incidence of acute pathologic changes on CT.17 There were no reliable clinical predictors of pathol- ogy identified; therefore, liberal use of head CT was recommended. Inability to rapidly diagnose ICH results in profound increases in morbidity and mortality, as coagulop- athy reversal and neurosurgical interventions are delayed.43 Patients on anticoagulation (AC) or antiplatelet (AP) therapy have presented with delayed ICH, thereby prompting some trauma services to perform repeat CT scans after an initial negative scan. Docimo and colleagues44 attempted to answer the question of whether head trauma patients on AC or AP, who presented with an initial CT negative for ICH, needed a second scan for delayed ICH. In this retrospective study, 2 of 168 patients (1.9%) presented with delayed hemorrhage, and both were on warfarin and had an in- ternational normalized ratio (INR) greater than 2.44 Based on review of prior literature 1162 Brooks & Peetz

and the conclusions of their study, the investigators noted the risk of delayed ICH was associated with the use of warfarin and, therefore, recommended the following44: 1. Patients on warfarin or warfarin/aspirin combo receive repeat head CT. 2. Patients on preinjury aspirin or clopidogrel should have a period of observation and clinical evaluation, followed by repeat head CT only for neurologic changes. Ivascu and colleagues43,45,46 published results of an aggressive protocol for TBI pa- tients on AC, describing one of the most significant mortality improvements in the trauma literature. The protocol, which ensured rapid CT of the head, initiation of INR correction for patients with coagulopathy on warfarin (Coumadin) within 2 hours, and correction of INR to less than 1.6 within 4 hours of admission, resulted in a 75% decrease in mortality for posttraumatic in geriatric patients.

Blunt Thoracic Injury and Rib Fractures Acute chest trauma, cardiopulmonary injury or thoracic skeletal insult, accounts for 25% of blunt trauma mortality.47 Pulmonary contusions are the most common blunt thoracic trauma injury and may occur in up to 75% of patients.47 Contusions may be an isolated injury, but trauma patients with severe thoracic skeletal trauma (such as ) nearly always have concomitant pulmonary contusions.47 This informa- tion prompts the trauma surgeon to consider the combination of rib fractures and pul- monary contusions as an injury constellation with inseparable pathophysiology, a thought process that has implications for optimal treatment. Bulger and colleagues48 published a seminal article describing geriatric trauma pa- tients as having twice the mortality and thoracic morbidity of younger patients with a similar injury. The study described 3 to 4 rib fractures as the break point for pneumonia when compared with younger trauma patients, conferring a 31% risk of pneumonia in geriatric patients compared with 17% in younger patients.48 When geriatric trauma patients sustain 6 rib fractures, risk of pneumonia skyrockets to worse than 50%. Mor- tality was also significantly worse at 3 rib fractures; nearly 1 in 5 geriatric patients died, with mortality increasing in geriatric trauma patients to 33%.48 In addition to the correlation between rib fractures and pneumonia/mortality, there is also a correlation between rib fractures and solid organ injury. is increased 1.7 times and 1.4 times, and 50% of patients with blunt cardiac injury have rib fractures.48 The key is recognition that rib fractures in the geriatric are a marker for increased mortality, morbidity, and concomitant polytraumatic injury. Rib fracture morbidity is predominantly explained by chest wall pain that limits pul- monary function. Pain first leads to chest wall splinting, decreased recruitment of alveoli, and development of atelectasis. This series of events, coupled with inadequate cough for clearing of secretions, increases the risk of pulmonary infection. The objec- tive measures of a forceful cough and the ability to inhale 15 mL/kg with incentive spirometry are useful in denoting adequate pain control in these patients.49 Bulger and colleagues48,50 demonstrated a significant drop in overall mortality across all age groups when patients received an epidural catheter for analgesia. These conclusions were supported by a National Trauma Data Bank study of nearly 65,000 rib fracture patients.51 Evidence-based guidelines for minimizing thoracic morbidity and mortality in geri- atric trauma patients with rib fractures include 1. Use of an optimal, multimodal analgesia regimen and aggressive chest physio- therapy should be applied to minimize the likelihood of respiratory failure and ensuing ventilator support.47 Geriatric Trauma Patients 1163

2. Consider epidural analgesia as a key part of that multimodal analgesia regimen.51 3. There should be early consideration of open reduction and internal fixation of rib fractures in selected patients.52–60 Evidence-based indications for surgical stabili- zation of rib fractures have been recently summarized in the literature.60–64

ORTHOPEDIC INJURIES Orthopedic fractures confer significant risk to the geriatric population. In a 2015 study of more than 25,000 US geriatric trauma patients in 127 hospitals, Maxwell and col- leagues65 found that 56% had a major operative procedure. Thirty-six percent of pa- tients had femoral neck fractures, the most common injury. Eighteen percent of the patients fractured either the neck or trunk. Twenty-one percent had either lower ex- tremity fractures or upper extremity fractures. Fractures of the hip, spine, proximal hu- merus, and wrist are disproportionally represented in geriatric trauma patients.66 Considerations for optimal care include preoperative risk evaluation, acute operative management, timing of operation, and functional outcomes. Fractures from low-energy mechanisms (ie, GLFs) are termed fragility fractures.66 Patients with such fractures should be evaluated for osteopenia, the treatment for which has been shown to lower secondary fracture risk.66 In higher-energy fractures, the skin, muscle, and tendon integrity alterations with age predispose soft tissue dam- age. Surrounding blood supply to the healing bone may be compromised. Importantly, only one long places geriatric trauma patients in the high-risk category, implicating fractures as a significant cardiovascular stressor and underscoring the need for potential preoperative risk modification whenever possible. Aggressive effort at early definitive repair has been shown in numerous studies to decrease risk of major medical complications.67–69 Early operative intervention has also been proven to reduce mortality. Earlier mobility after repair also lowers risk of pneumonia, bed sores, and pressure ulcers.67–69 One study of geriatric trauma hip fracture patients showed that those who received definitive repair after 48 hours had more than double the risk of death in the ensuing year.70 The principal tenants for fracture management are restoration of patients’ expected function expeditiously, preventing progressive decline, and avoiding decreased quality of life.

ABDOMINAL INJURIES Although blunt trauma management has become increasingly nonoperative in hemo- dynamically stable patients, geriatric trauma patients warrant careful consideration. For example, in case of a splenic injury, older patients are more likely to fail nonoper- ative management.71 Additionally, geriatric trauma patients compensate differently during acute hemorrhage (see physiology section earlier). University of Southern Cal- ifornia studied in the geriatric trauma population and found that 50% of the geriatric patients who died had normal vital signs.72 Those vital signs that would alarm the trauma surgeon in younger patients do not apply to geriatric trauma patients.20 The decision for nonoperative management weighs heavily on the trauma surgeon, as mortality increases when this management fails, more so than in younger patients.17

CRITICAL CARE AND INTENSIVE CARE UNIT DELIRIUM MANAGEMENT Because preventable complications in the geriatric dramatically worsen outcomes, improving triage by placing appropriate geriatric patients in the intensive care unit (ICU) may be the first step in morbidity and mortality improvement. A study of 1164 Brooks & Peetz

more than 22,500 trauma patients (including more than 7100 geriatric trauma pa- tients) revealed that geriatric patients had significantly lower ICU admission rates compared with younger patients with similar injury severity.73 Studies at both Balti- more Shock Trauma in Maryland and the University of Southern California at Los Angeles have shown improved outcomes with earlier activation and intensive monitoring in the geriatric.15,74 Nathens and colleagues75 demonstrated an improved mortality after trauma, which was most pronounced in geriatric trauma patients, in critical care units led by surgeon intensivists. Although comprehensive critical care of geriatric trauma patients is outside the scope of this article, tremen- dous advances in ICU delirium management have been described in the recent literature.16,76 Delirium is an acute brain dysfunction leading to prolonged cognitive dysfunction af- ter critical illness.77 The cardinal features of delirium are inattention and confusion that represent the brain temporarily failing.78 The association between delirium duration and adverse outcomes, such as prolonged mechanical ventilation, prolonged hospi- talization, persistent cognitive impairment, and increased 1 year post–critical illness mortality, has been well documented.79 Delirium is not only a significant risk factor for morbidity and mortality in the ICU but its management also affects the trajectory of trauma patients’ recovery as far out as 1 year after hospital discharge.79 Only one episode of delirium puts ICU patiens at 3 times the risk for death in the ensuing 6 months.80 Unfortunately, up to 80% of ICU patients will be diagnosed with delirium; in 2 out of 3 of these patients, the diagnosis will go unrecognized.77–80 Additionally, increased delirium duration is independently associated with greater disability in activities of daily living (ADLs) and worsening motor-sensory function at 1 year after ICU discharge.79 One year after critical illness, 25% of patients will have cognitive dysfunc- tion similar in severity to that seen in mild Alzheimer disease and 33% will have impair- ment commensurate with moderate TBI.77 One in 3 patients will also have physical disabilities in ADLs a year after critical illness.79 Delirium increases hospital costs by $2500 per patient leading to $6.9 billion of Medicare expenditures annually.81 The full extent of clinical and financial consequences has only been recognized in the past decade. A road map for integrated, evidence-based, patient-centered protocols for pre- venting and treating pain, agitation, and delirium in critically ill patients exists in the 2013 clinical practice guidelines published in Critical Care Medicine.16 These guidelines detail evidence-based recommendations for assessment and treatment of pain, depth of sedation, monitoring of sedation and brain function, detecting and monitoring delirium, risk factors for delirium, and delirium prevention and treatment.

CREATION OF A DEDICATED GERIATRIC TRAUMA UNIT Mangram and colleagues82,83 published 1 year of data following creation of a geriatric trauma unit for patients aged 60 years and older. The G-60 unit, as it was named, showed improvement in multiple morbidities, such as pneumonia, respiratory failure, and urinary tract infection. The G-60 also demonstrated mortality improvement.82,83 Decreases were seen in ED LOS, average ED to operative management time, surgical critical care unit LOS, and average hospital LOS.82,83 In spite of dramatic improve- ments in morbidity, mortality, and time-based secondary outcomes, hospitals throughout the country have not readily created similar specialized units to care for geriatric trauma patients. Geriatric Trauma Patients 1165

Dr Mangram previously hypothesized that such a unit might promote significant cost savings. Texas Tech University, a level 1 regional trauma and center in West Texas that admits more than 850 geriatric trauma patients annually, created a similar Geriatric Trauma Unit (GTU) and has affirmed this financial benefit (largely due to decreased ICU admissions and shorter hospital LOS).84 Suggested goals for a geri- atric trauma service include 1. Patients should be seen by the surgical service in less than 2 hours. 2. Patients should be admitted to the GTU in less than 4 hours. 3. Definitive surgical repairs occur within 48 hours. 4. Consultation of primary care physician or geriatrician should occur within 24 hours of admission for multidisciplinary management. 5. There should be evidence-based practice and optimal care for all traumatically injured patients (eg, prompt correction of coagulopathy TBI patients with therapeu- tic anticoagulation). 6. Discharge within 5 days with safe disposition planning.

OTHER CONSIDERATIONS IN GERIATRIC TRAUMA Triage Although geriatric trauma patients are at greater risk for adverse outcomes when compared with younger counterparts, they are actually less likely to receive care at trauma centers.75,85,86 A retrospective 10-year study in Maryland of more than 26,000 patients showed that undertriage was significantly more likely in patients older than 65 years.37 This finding is in spite of evidence that when surgical intensivists lead critical care in trauma centers, in-hospital mortality is greatly reduced.75 The mortality reduction is most pronounced in geriatric patients with comorbidities and decreased physiologic reserve.75 Geriatric patients in designated trauma centers are also less likely to experience preventable adverse events.85 Yet nearly half of injured older adults, especially those in older age groups and also female sex, are admitted to non- designated trauma centers.65 Literature supports a lower threshold for trauma activa- tion for injured patients aged 65 years and older; geriatric patients with at least one score of 3 or greater or those with a base deficit of À6or less should be treated at trauma centers staffed by surgical intensivists.1

Frailty Physical frailty is a syndrome describing diminished strength and endurance and decreased physiologic function and is a marker for physiologic age versus chrono- logic age.87 Physical frailty prevalence among geriatric trauma patients ranges from 44% to 78%.5,88 Rogers noted that undertriaged geriatric GLF patients had higher mortality than higher acuity patients who were evaluated as activated traumas.89 Studies such as these emphasize the need for assessment tools that identify phys- ical frailty. More than 30 instruments have been created to assess for frailty. Maxwell assessed 188 patients using the Vulnerable Elders Survey, Barthel Index, and the Life Space Assessment and concluded that screening injured older adults for frailty is both feasible and desirable for providing efficient and effective care interventions.88

ETHICAL DECISIONS IN GERIATRIC TRAUMA Complex ethical dilemmas are often the rule rather than the exception in caring for geriatric trauma patients. Futility provides some of these dilemmas, such as in the 1166 Brooks & Peetz

case of an 89-year-old, frail woman after a GLF, devastating , and 72-hour history of GCS less than 8 whose family members want everything done. Other dilemmas are created when treatments for acute trauma exacerbate preexisting conditions and create myriad of unwanted side effects, such as in the case of a 72- year-old gentleman with a history of advanced chronic obstructive pulmonary disease, who after sustaining multiple rib fractures in a motor vehicle crash, requires pain med- ications that exacerbate his underlying dementia and lung disease. Unfortunately, such patients and their ethical dilemmas are commonplace in the American trauma system. Geriatric patients account for at least 15% of our trauma pa- tients and a disproportionate number of our trauma-related deaths.90 Traumatically injured geriatric patients, even when highly functional and independent before trauma, are less likely to discharge home when compared with a younger patient with the same injuries.91 The ethical problems of geriatric trauma patients center around 4 main principles: autonomy, beneficence, nonmaleficence, and justice.8 Debating these principles may promote insight into the philosophic underpinnings of humanity, but it rarely pro- duces solutions for patient care in the acute setting. Asking yourself whether you are respecting a patient’s autonomy is about as impractical a question as it is stilted language. Trauma surgeons are often less interested in theoretic principle as they are with deciding the right thing to do for the patient immediately under their care. Ideally, they treat patients in accordance with best practice, evidence-based care. Although the evolution and advancement of this evidence-based care may result in keeping more patients alive, this lower mortality does not necessarily lead to restoring quality of life. Prolonged hospital LOS, protracted post–acute care recovery, and significant permanent disability in these geriatric patients suggest that geriatric trauma manage- ment has tremendous room for improvement. Although the disparate outcomes seen in geriatric trauma patients are not the result of an inattention to ethical standards, proper application of these standards may go a long way toward improving care for geriatric traumatically injured patients. The first step in navigating the moral dilemmas posed in geriatric trauma care is through improved communication when interacting with geriatric patients and their surrogates.92–96 Communication that determines patients’ goals of care and clarifies their definition of quality of life is a key ingredient for treatment and care. If communication is poor and these definitions are poorly defined, physicians may presume inaccurately and direct care toward an outcome that patients and/or family members deem unwanted or unacceptable.

THE 4 MAIN PRINCIPLES OF MEDICAL ETHICS Autonomy Autonomy is the ability of a person to make a decision freely. Accomplishing this re- quires informing, rather than coercing, patients. Patients must have the capacity to reasonably comprehend their options and also rationally use the information. Such ca- pacity may be compromised in the geriatric population. Dementia is the most common cognitive disorder of the geriatric and can affect pa- tients’ ability to make autonomous decisions. Evaluating capacity is not always straightforward. Determining capacity must include an understanding of patients’ def- icits and ability to comprehend the consequences of the decision being made. Mildly demented patients may have capacity to consent to an arterial line placement but may Geriatric Trauma Patients 1167 not have the capacity to determine code status. The assessment of capacity is a crucial component of any trauma surgeon’s duty when treating geriatric patients. Although detailing an examination of capacity is outside the scope of this article, the trauma surgeon should identify a surrogate decision maker when capacity is diminished. Surrogates are individuals who speak for patients. Strictly speaking, surrogates are individuals who perform the duties of substituted judgment. Surrogates provide substituted judgment through consistently communicating patients’ values. In doing so, surrogates effectively restore the patients’ voice. The trauma surgeon should facilitate, whenever possible, the surrogates’ ability to communicate patient values. This facilitation is often difficult in the trauma milieu as patients’ devastating injury or in extremis condition may necessitate communication under temporal duress. Although the ability to do this might be included in what some refer to as the art of medicine, there are guidelines to effectively improve communication of patients’ values.

Beneficence The principle of beneficence describes the duty of a trauma surgeon to make deci- sions that improve patients’ well-being. This responsibility is particularly difficult in the geriatric population, whereby survival can be subordinate to quality of life after discharge.8–10,90,97,98 That which is beneficent toward geriatric trauma patients de- pends on patients’ value system and what patients would consider a meaningful outcome. The beneficent trauma surgeon understands the importance of this as the foundation for goals of care, enabling the surgeon to determine the intended benefit of potential treatment options.

Goals of Care Defining patients’ or surrogates’ goals of care may promote understanding and agree- ment between patient (or surrogate) and physician regarding the plan of care. Schwarze and colleagues96 assert that a question posed to surrogates regarding what patients would want is flawed in that it emphasizes treatments (life support or comfort care) rather than promoting a discussion of the value of different outcomes.96 Instead, Schwarze and colleagues promote the use of words, such as say or think, to prompt families to deliberate, weigh options, and evaluate trade-offs from the pa- tients’ perspective.96 For example, asking a family member to tell you what his or her mother would say about living with a TBI and multiple broken bones in her pelvis and legs causes the family member to consider a loved one’s values, what the patient has said in the past, and the kinds of experiences the patient has previously enjoyed.96 The physician poses these questions with an equipoise and empathy, thereby enabling rational medical decision-making and prompting morally relevant and clini- cally useful answers.96,99 The defined goals of care may be used as a foundation for subsequent decision-making regarding appropriate interventions and treatment of geriatric trauma patients.

Nonmaleficence The most famous directive, first, do no harm, from The History of Epidemics in the Hippocratic corpus, is often easier said than done. This principle is especially difficult for surgeons whose care often involves the administration of a planned and deliberate trauma inherent in surgery. For injured geriatric patients, nonmaleficence describes a mindful and realistic approach to proposed treatments. Geriatric patients die more frequently after trauma.90 Geriatric trauma patients also have permanent, life- 1168 Brooks & Peetz

changing deficits more often than younger patients.90 One may assert that harm has been done when a treatment results in survival but leaves patients in an unacceptably debilitated state. Realistic expectations of that which might be achieved from various treatment options enable an informed decision-making process for patients or surrogates.

Justice Justice, the principle that defines the distribution of resources, addresses how the medical needs of the many in society must be balanced against the needs of the few or the individual. In an excellent review of ethical issues in geriatric trauma care, Cocanour8 simplifies the idea of justice for the trauma surgeon by highlighting what the health care team should consider when evaluating its clinical application: “The healthcare team must consider four main areas when evaluating justice: fair distribu- tion of scarce resources, competing needs for those resources, rights and obligations, and potential conflicts with established legislation.”8 Consideration of resources and balancing the needs of the many with those of the few or the individual serves to pro- tect vulnerable populations, such as geriatric trauma patients.

COMMUNICATION WHEN CARING FOR GERIATRIC TRAUMA PATIENTS Communication is paramount in uncovering patients’ definition of a meaningful outcome. Communication inadequacies in health care commonly generate ethical con- sults in clinical care.100 Surgeons are susceptible to having inadequate or poor end-of- life conversations because of time constraints, inadequate communication training, the complexity of clinical prognostication, and a tendency to overestimate prognosis.92 Cooper defines 9 elements for structured communication with patients in an emergency setting in order to maximize best possible outcomes and minimize harms: 1. Formulating prognosis 2. Creating a personal connection 3. Disclosing information regarding the acute problem in the context of the underlying illness 4. Establishing a shared understanding of patients’ condition 5. Allowing silence and dealing with emotion 6. Describing surgical and palliative treatment options 7. Eliciting patients’ goals and priorities 8. Making a treatment recommendation 9. Affirming ongoing support for patients and families Overall, effective communication is predicated on the clinician’s ability to effectively and sincerely affirm a commitment to patients’ well-being.

MULTIDISCIPLINARY APPROACHES TO GERIATRIC TRAUMA: CONSULTATION, SUPPORTIVE (PALLIATIVE) CARE, AND ETHICS CONSULT SERVICES Geriatrics Service Consultation Geriatric consultation services provide a specialized approach to care of geriatric pa- tients. The consultants may help navigate the unique problems posed to geriatric pa- tients and provide a more complete approach to their care. The addition of a geriatric consult service may lead to more effective in-hospital care and better outcomes.91,97 Lenartowicz and colleagues91 studied a compulsory geriatric consult service for trauma patients older than 60 years and found that, consistent with prior literature, the trauma team followed most of the recommendations from the geriatric Geriatric Trauma Patients 1169 consultants. These recommendations resulted in treatment changes and improved outcomes, including decreased incidence of delirium and discharge to long-term care facilities for patients admitted from home.91

Palliative/Supportive Care Consultation Similar to those for geriatricians, consulting a palliative care or supportive care service may also benefit geriatric trauma patients. These experts not only mange pain and symptoms but are also trained to communicate proficiently regarding goals of care and end-of-life concerns. Use of this specialized training profoundly effects delivery and type of care, especially when communication is poor or confrontational between surgeon and surrogate or when goals of care are unclear.

Ethics Consultation Ethics consultation services (ECS) are nearly ubiquitous in hospitals across the United States.100 Nearly 55% of US physicians order an ethical consultation, and up to 95% agree that the presence of this service is both useful and important.100 A consulting ethicist with specialized training evaluates ethical aspects of patient care and provides practical guidance regarding that care and are supported by a hospital ethics commit- tee that oversees the recommendations of the service. Ethics consults are most help- ful after a specific question is defined. Examples of questions for which an ethics consult service might be helpful include  Questions regarding who should serve as a health care proxy agent when the sit- uation (or the law) is unclear  Questions regarding who makes decisions in unbefriended, obtunded patients  Questions regarding code status disagreements between patients/surrogates and the care team  Questions regarding futility of care  Questions regarding withdrawal or continuation of life-sustaining treatment.  Questions regarding shared decision-making Ethics consultations may be called when a surgeon ascertains that there is some ethical conflict or ambiguity. ECS may also assist in cases when hospital policies are unclear. The ethics consult service may be requested by patients, families, nurses, physicians, or anyone participating in patients’ care. This accessibility enables the identifier of an ethical issue to ask the expertise of the ethics consult service without fear of reprisal or retribution.

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