Geriatric Trauma Considerations

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Introduction   

Physical trauma in later life can have long-lasting and debilitating effects. As part of the aging process, the human body undergoes a progression of frailty as functional capacity diminishes. Trauma can result in injuries, critical and non-life threatening, for any patient population. With the geriatric population’s vulnerabilities, less force is required to result in traumatic injury.  

An individualized, focused assessment and treatment plan is required to identify the problems that are specific to the geriatric population. Recognition and activation of a trauma code may have a lower threshold than with individuals from other age groups. 

Definition 

Physiological trauma is a physical injury that has the potential to be life-altering and result in serious harm, disability, and/or death. Trauma is most often associated with a catastrophic event such as a motor vehicle accident, gunshot wound, stabbing, or fall from a high elevation.  

In the geriatric population, trauma may occur at lower thresholds due to the frailty that is inherent in age-associated multisystem vulnerabilities (1). When providing healthcare, it is important to keep in mind with the geriatric population that excessive force may not be required to elicit a traumatic injury. Physical events that are not likely to cause major injury in populations under 65 years of age may have devastating effects on older individuals.  

Geriatric trauma may be caused by a fall from standing height or a minor car accident. A fall is the most common cause of unintentional injury death among adults over 65 years of age. The second most common unintentional injury death occurring in this population is car accidents due to traumatic brain injury (2).  

Geriatric trauma requires specialized training, knowledge, and critical thinking to accurately identify and guide prompt treatment of physical injuries. This must start with a thorough and focused assessment that considers the patient’s baseline, risk factors, comorbidities, chronic disabilities, and frailty status. 

Epidemiology 

The population of older adults increases each day evidenced by the fact that over 10,000 individuals in the United States turn 65 each day (2). Of all patients who are admitted to an emergency department due to trauma, approximately one-third of these are individuals over 65. This is expected to increase to 40% by the year 2050 (3). 

The three main types of traumas include blunt, penetrating, and deceleration. With the elderly population, the most common causes of injuries with older patients involve falls, motor vehicle crashes, burns, and penetrating injuries (7). Drastically disproportional is the rate of falls amongst this patient population. 75% of the injuries suffered by those over 65 are due to a fall (3).  

Outcomes are considerably poorer for patients as age increases. This is due to the effects of senescence, the phenomenon of aging causing deterioration of the body at individualized and varied rates (3). Progressive senescence leads to frailty, which is a better indicator of predicting vulnerabilities and complexities that result in poorer outcomes.  

Assessment 

As shown, the types of injuries most sustained amongst this vulnerable population differ from other age groups. The assessment must focus first on reducing further harm from injury and identifying potential injuries. Fractures are common with trauma and may not initially be evident when soft tissue damage has occurred. Imaging is necessary for diagnosis and treatment (4,7).  

Radiological imaging is a powerful tool that can quickly identify the type and severity of injury. This may include x-ray and fluoroscopy, computed tomography, magnetic resonance imaging, and ultrasonography (5).  

Nursing assessment should initially focus on the injured part or area most affected by the trauma. If possible, it is also very important to promptly establish functional independence prior to the accident to screen for damage that may otherwise be assumed as previously there.  

The gold standard for assessing trauma is the Advanced Trauma Life Support (ATLS) algorithm developed by the American College of Surgeons Committee on Trauma. Algorithms are provided based on the type of trauma and injuries sustained and guidance for clinical care (9). 

The ABCDE methodology is advised to thoroughly assess the body systems that are most concerning in stabilizing a patient with critical injuries. First, the airway must be established. Challenges with providing ventilation and performing intubation may occur due to poor-fitting dentures, lack of teeth, and arthritic changes, making it more difficult to open the mouth fully. Next, breathing is focused on. The decision to mechanically ventilate may be necessary. Circulation changes are reviewed with the prevention of hypovolemia as a significant goal. Tissue hypoperfusion, as evidenced by lactate levels, is more accurate than blood pressure thresholds, as chronic hypertension may mask true hypovolemia. Balanced fluid resuscitation and replacement of blood products, as needed, is advised to prevent progression to shock. The d stands for disability of the brain or spine. With a high rate of anticoagulant and antiplatelet medication use for preexisting medical conditions, individuals of advanced age are far more likely to suffer from intracranial hemorrhage in the presence of a traumatic brain injury.  

Spinal changes due to degenerative disease result in fractures and spinal cord injury with falls at ground level. For any suspicion of bleed or spinal injury, early CT imagining is advised for prompt diagnosis. With the identification of bleeding, anticoagulant or antiplatelet therapy should be reversed judiciously. Finally, exposure and environment look at concerns with musculoskeletal changes, hypothermia risk, and immobility concerns. Pressure injuries may occur quickly; patients should be removed from spine boards and cervical collars when safe to do so (9). 

Once that has been completed and the patient has been stabilized, a more thorough head-to-toe assessment that considers the individual’s medical history must occur. The geriatric population is more likely to suffer from multiple ailments and diagnoses where internal damage may not be evident (6).  

Co-morbidities that may be affected by trauma include heart conditions, bleeding disorders, and underlying dementia. A comprehensive assessment will elicit the data needed for a multidisciplinary team to better approach the patient’s treatment plan, retention of functional status, and maintain goals that prevent the progression of geriatric syndromes. 

Pathophysiology 

With changes related to change, the effects of trauma can have devastating and widespread decline. Geriatric populations are more likely to have chronic medical conditions that impair the ability to respond to the system’s demands to maintain a homeostatic state. Cardiovascular events may be more pronounced due to a decrease in cardiac output and myocardial chamber stiffness. Sinoatrial node cells lessen with age which can contribute to the likelihood of dysrhythmias. Vagal tone is increased which causes a lower basal heart rate. All of these factors contribute to a higher risk of hypoperfusion (9). 

Functional changes in the pulmonary system led to decreased elastic recoil, reduced functional residual capacity, decreased gas exchange, and a lessened cough reflex. These factors lead to an increased risk of pneumonia, respiratory failure, and more pain and guarding related to rib fractures (8, 9).  

The renal system loses mass, resulting in a lower glomerular filtration rate (GFR), and a lower sensitivity to hormones related to concentrating urine. This results in an inability to conserve fluid balance when hypovolemia is present. It is important to monitor labs and dose medications for renal insufficiency (9). 

As we age, lean body mass lessens and there are degenerative changes to joints, cartilage, and the spine. Osteoporosis increases the risk for fractures and arthritic changes result in decreased mobility. Skin and soft tissue lose elastin and the subcutaneous fat layer withers. These changes increase the risk of skin injury due to fragile, paper-thin skin and also make hypothermia more likely to occur (9). 

Age-related changes to the endocrine system increase cortisol levels and decrease the production of thyroxin. The thyroid does not respond to the thyroxin that is produced, leading to hypothyroidism. This has a cascading effect on temperature control, heart rate, and metabolic processes. These elements in addition to poor glycemic control make infections more likely to occur (6, 9). 

Clinical Signs and Symptoms 

Research has shown that trauma triage often misses identifying injuries in older patients who may need higher levels of care (7). This suggests a standardized protocol is of benefit to provide a comprehensive assessment that will aid in screening and identifying trauma in patients over 65 (7). 

Pain 

Pain is expected with any severe trauma. Signs of pain may include guarding, holding, cringing, and moaning or whimpering. The patient may not be able to verbalize or show where pain is, healthcare professionals should take care not to assume that the patient is not having pain. A stoic or flat affect may also be another way of expressing pain to watch for (3). Management of pain improves compliance with early ambulation, respiratory therapy, and participation in care (3) 

Head Injury (all from 8) 

• GCS < 13 
• Delayed bleeding, repeat of CT in 24 hours if initially normal 
• Headache 
• Loss of consciousness 
• Confusion 

Blunt & Penetrating Trauma (all from 8, 9) 

• Early and late bruising 
• Pain with palpation 
• Hemorrhage and hypoperfusion are signs of developing shock (systolic blood pressure of less than 110mmHg) 
• Altered ventilation (flail chest, tracheal deviation, wheezing) 
•  Impaired respiration (dyspnea, O2 sat < 90%) 
• Fracture displacement 

Spinal Injury (all from 9) 

• Numbness or tingling of extremities 
• Loss of mobility 
• Central cord syndrome 
• Multiple fractures of vertebral bodies 

Burns (all from 11) 

• Redness, blistering, and peeling of skin 
• Shock 
• Hypovolemia 
• Hyperkalemia 

Lab Values (all from 11) 

• Blood gases 
• Lactate 
• Complete Blood Count 
• Complete Metabolic Panel 
• Bleeding factors 
• Prothrombin Time/International Normalized Ration 

Treatment 

Initially, treatment is guided by the severity of the injury and the patient’s hemodynamic stability. Early stabilization is key to improved outcomes. Depending upon the type of injury, surgical intervention may be required. Empirical antibiotic use is appropriate for penetrating injuries or pre-surgical interventions.  

Once the initial injury is identified and managed based on clinical guidelines, treatment aims to provide supportive and rehabilitative care. This can include physical therapy, nutrition services, and psychosocial support.  

The healthcare team must remain vigilant to assess the patient’s progress once stabilization has occurred. The geriatric population is prone to unique complications after an injury that may require further medical treatment. These are detailed further below, and treatment should be tailored to the patient’s clinical presentation. 

Post-trauma recovery is often slow, and it is difficult for patients to return to their baseline. As aggressive treatment for life-threatening or severe injuries may be necessary to initially stabilize the patient, this can have long-term effects. This concept is referred to as iatrogenesis, a poor outcome due to a treatment that was intended to treat a patient’s disease process (6).  

Complications 

Complications that are associated with geriatric trauma include pneumonia, deep vein thrombosis and/or thrombophlebitis, urinary tract infections, acute kidney injuries, decubitus ulcers, and respiratory failure (3).  

Delerium, the sudden onset of an altered mental status of severe confusion and incohesive thought, is a high risk for all hospitalized individuals over 65. Delerium is linked to increased length of hospital bed days, higher mortality rates, and a decrease in patients returning home after hospitalization (3). 

Syndromes that are linked to the older population can include dysphagia, delirium, poor skin healing, incontinence, sleep disorders, and balance issues. Combining these factors that provide challenges to the healing process with higher rates of deep vein thrombosis and/or phlebitis, kidney failure, decubitus ulcer formation, and respiratory failure results in poor prognosis and outcomes. The risk for sepsis, cardiovascular events, and pneumonia is significantly higher (3). 

Nursing Care Considerations 

Interventions post-trauma can result in decreased mobility for the patient when traction or positioning devices must be used to assist with healing. It is imperative that bony prominences are padded, and the patient is turned regularly and frequently to prevent soft tissue injury and pressure ulcers (11). 

With any trauma of a vulnerable population, elderly maltreatment must be considered and screened for. Maltreatment may fall into any of the following categories: physical, sexual, neglect, and psychological. Physical findings that may be suggestive of elder maltreatment include contusions that are not consistent with the story, abrasions of the axillary, wrist, or ankle from restraints, and untreated fractures or injuries in various stages of healing. Injuries to the eyes, nose, and scalp or patterns of hair loss that are not typical are red flags that require further inquiry and reporting to the appropriate authorities per state laws and facility policies (9). 

A multi-modal approach to pain control is required. Opioids and benzodiazepines may reduce the amount of pain and anxiety that the patient is experiencing; however, side effects may include depression of respirations, lowered heart rate, dizziness, and excessive fatigue (10).  

Elderly patients are at a higher risk for delirium if dementia is present. Other risk factors include substance abuse, mechanical ventilation, and the severity of illness. The Confusion Assessment Method (CAM) is widely used to recognize delirium. Interventions that are aimed at preventing the onset of delirium include using target sedation with spontaneous breathing trials for mechanically ventilated patients, early mobilization, promotion of sleep through non-pharmacological methods, and frequent reorientation.  

Encouraging visitors can assist with re-orienting and stimulating the patient to be awake during the day. Activities that promote natural sleep patterns are also helpful, such as creating a quiet environment, lowering lights at bedtime, and following a schedule (8, 9).  

For trauma that involves a head injury, the patient’s neurological status must be frequently assessed. This may be completed with the use of the Glasgow Coma Scale (GCS) to monitor a patient’s level of consciousness. Any changes should be communicated to the attending healthcare provider immediately. 

Conclusion

Trauma in geriatric patients is a specialized field of medicine due to the complexities of aging, multi-factorial disease processes, and co-morbidities. Comprehensive assessments aimed at assessing for atypical trauma injuries are key to providing early treatment and intervention. The prognosis for recovery from traumatic injury is poor, even with earlier recognition, with morbidity and mortality rates higher than with other patient populations.  

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