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 trauma center. 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 injury.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 blunt trauma 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 hearing 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 atrophy 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