2.6 HOURS Continuing Education By Christine L. Cutugno, PhD, RN THE ‘GRAYING’ OF TRAUMA CARE: ADDRESSING TRAUMATIC INJURY IN OLDER ADULTS Evidence-based strategies for managing trauma and its complications in this population. OVERVIEW: Trauma is the seventh leading cause of death in older adults. Factors that contribute to the higher rates of morbidity and mortality in geri- atric trauma victims include age-related physio- logic changes, a high prevalence of comorbidities, and poor physiologic reserves. Existing assessment and management standards for the care of older adults haven’t been evaluated for efficacy in geriat- ric trauma patients, and standardized protocols for trauma management haven’t been tested in older adults. Until such specific standards are developed, nurses must be guided by the relevant literature in various areas. The author reviews the mechanisms of traumatic injury in older adults, discusses the effects of aging and comorbidities, reviews assess- ment guidelines and prevention strategies for trauma-related complications, and outlines some evidence-based approaches for improving out- comes. An illustrative case is also provided. KEYWORDS: geriatric trauma, hospitalized older adults, older adults, trauma, traumatic injury Photo by Keith Brofsky. 40 AJN ▼ November 2011 ▼ Vol. 111, No. 11 ajnonline.com he “graying” of America is no secret; most of for hospitalized older adults. They are so common in us have heard some version of the statisti- this population that they’re becoming known as “geri- cal projections. In 2010 the U.S. population atric syndromes.”13 T of older adults—people ages 65 and older— What guides current care? The American Geriat- stood at about 40 million; by 2030, their numbers are rics Society (AGS) has proposed wider, standardized use expected to nearly double to more than 72 million.1, 2 of comprehensive geriatric assessment for older adults Most nurses are aware that working with older patients at each entry into the health care system.14 The Amer- poses some challenges not encountered as often with ican College of Surgeons (ACS) and the ACEP have ad- younger patients. Older adults have a higher rate of co- vocated the development of evidence-based clinical morbidity and routinely take more medications than protocols and pathways for both acute care and ongo- do younger ones, and they’re more likely to have unpre- ing management of geriatric patients.9, 15 These proto- dictable responses to treatment and to suffer adverse cols and pathways will undoubtedly draw upon many events during hospitalization.3 of the assessment and treatment standards implemented Trauma is the seventh leading cause of death in through the well-established Nurses Improving Care for older adults.4 Although older adults now constitute Healthsystem Elders initiative (http://nicheprogram. about 13% of the total U.S. population,5 they account org). But although such standards for geriatric patients for more than 25% of all hospital trauma admissions,6 have been developed, they’ve yet to be evaluated for and it’s likely that as the proportion of older adults rises, efficacy with those suffering from traumatic injury. And that percentage will also rise. Indeed, it’s been estimated although several standardized protocols for trauma that by 2050, about 40% of all trauma patients will be management exist, they were developed primarily for over age 65.6, 7 Falls are known to be the leading cause younger patients and haven’t been tested in older adults. of injury in older adults. Other common causes of in- Thus, until assessment and management standards spe- jury in this age group include motor vehicle collisions, cific to geriatric trauma patients are developed and widely pedestrian–motor vehicle collisions, assault, and ther- implemented, nurses will need to be guided by measures mal injuries. For any injury of a given severity level, older known to prevent iatrogenic complications in other pa- adults are more likely to suffer complications and die tient populations. than are younger ones. These statistics and projections are alarming, not only because of the personal costs to patients and fam- by 2050, about 40% of all ilies, but also because of the financial impact on our health care system. For example, in 2000 McMahon trauma patients will be and colleagues reported that the geriatric population consumed 33% of U.S. health care spending and 25% over age 65. of all trauma dollars.8 A 2008 report by the American College of Emergency Physicians (ACEP) noted that al- though older adults represent 15% of all patients seen This article reviews the mechanisms of traumatic in EDs, they account for 48% of ICU admissions and injury in older adults, discusses the effects of aging and use 50% more diagnostic resources.9 Such dispropor- comorbidities, reviews assessment guidelines and pre- tionate usage of resources is also likely to become greater vention strategies for trauma-related complications, as the population ages. It behooves us to examine what and outlines some evidence-based approaches for im- is being done—and to ask what more can be done— proving outcomes in geriatric trauma patients. A pa- to address these trends. tient case is also provided (see An Illustrative Case). While advanced age is associated with increased risks Terms defined. Although various lay definitions ex- of morbidity and death,4, 10 it’s not an independent pre- ist, this article uses the definition of serious injury or dictor of trauma outcome and “should not be used as trauma as stated by Richmond and colleagues: “the the sole criterion for denying or limiting care.”4 One anatomical and physiological derangements induced early study of geriatric trauma patients found that pre- by the application of external physical forces to the ventable complications contributed to over 30% of all body, resulting in injuries that threaten limb loss or deaths11; but more recent studies attribute many post- death.”10 Older adults here refers to people ages 65 trauma complications to preexisting conditions and or older; geriatric patients refers to patients in that age age-related physiologic changes.10, 12 Regardless, hospi- group. talizations for trauma are often prolonged, and recovery delayed, by many of the same iatrogenic complica- AGE AND COMPENSATORY RESPONSES TO TRAUMA tions addressed by the Institute of Medicine (IOM) in Why is trauma so much more “traumatic” for older peo- its 1999 report, To Err Is Human: Building a Safer Health ple? Factors that contribute to the higher rates of mor- System. These include adverse drug events, falls, pres- bidity and mortality in geriatric trauma victims include sure ulcers, inadequate nutrition, incontinence, and de- age-related physiologic changes, a greater prevalence lirium, and they contribute to unfavorable outcomes of comorbidities, and poorer physiologic reserves. [email protected] AJN ▼ November 2011 ▼ Vol. 111, No. 11 41 Physiologic changes associated with normal ag- maintain fluid and electrolyte balance.3, 18 Once they’re ing can predispose some older adults to serious injury injured, compensatory responses may be inadequate and make recovery of function less likely.8, 16 For exam- to stabilize older adults physiologically. Changes in vi- ple, advancing age is associated with diminished vision tal signs are less reliable indicators of instability. For and hearing, slower reflexes, and poorer balance. Older example, in a person with chronic hypertension, a seem- adults also tend to have more mobility limitations, re- ingly normal blood pressure reading may actually be in- duced muscle mass and strength, and less joint flexibil- dicative of hypotension. The “fight or flight” responses ity. Age-related changes in bone density and decreasing associated with injury are less robust in older people. lean muscle mass can make bone fractures more likely, Compensatory increases in heart rate may be impos- with hip fracture being the most prevalent. sible if the patient has an implanted pacemaker. The Comorbidities are very common in older adults. normal tachycardic response to injury may be blunted Approximately 80% of people ages 65 and older have or diminished in patients with chronic cardiac arrhyth- one or more chronic diseases17; the most common mias, such as atrial fibrillation. Although an older adult include hypertension, arthritis, heart disease, cancer, with atrial fibrillation might be able to achieve ade- diabetes, stroke, asthma, and chronic bronchitis or em- quate tissue perfusion under ordinary circumstances, physema.2 And comorbid illness is more often the ini- a traumatic injury can overwhelm the person’s com- tiating event for trauma in older adults than it is in pensatory abilities. Tissue hypoxia can in turn cause younger ones.8 other arrhythmias, such as premature ventricular con- Older adults generally have poorer physiologic re- tractions, that can further alter cardiac output. This cy- serves and are less able to maintain homeostasis, re- cle of tissue and organ hypoxia can have predictably sulting in poor temperature control and less ability to negative effects. AN ILLUSTRATIVE CASE rank Jones, age 83, was brought by paramedics to a local it was noted that his hematocrit hadn’t been reassessed since Ftrauma center after falling down a short flight of stairs in admission, so routine blood tests, including a complete blood his home. (This case is a composite based upon the author’s count and a metabolic panel, were also ordered at 4 PM. At experience). He was accompanied by his 82-year-old wife. 4:15 PM he became bradycardic and developed ventricular On arrival in the ED, Mr. Jones was awake and alert and fibrillation. He was resuscitated, but subsequently demonstrated complaining of pain in the right side of his chest, right wrist, signs of severe cerebral anoxia, later confirmed by neurology and right ankle. His vital signs on admission were as follows: consultation. The blood tests ordered just before the code pulse, 72 beats per minute; respiration, 30 breaths per minute was called revealed a hematocrit level of 18%.