Geriatric Trauma

Alison P. Southern; Richard A. Lopez; Sharhabeel Jwayyed.

Author Information and Affiliations

Authors
Alison P. Southern; Richard A. Lopez1; Sharhabeel Jwayyed2.

Affiliations
1
Geisinger Medical Center
2
Western Reserve Health

Last Update: July 20, 2023.

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Continuing Education Activity

Assessment of the geriatric trauma patient is unique, and this population requires special
attention. As the elderly population increases, the number of geriatric trauma patients also
rises. Geriatric patients often suffer from mild to severe cognitive impairment,
cardiovascular, and pulmonary insufficiency, which can complicate trauma. This activity
describes the evaluation, diagnosis, and management of geriatric trauma and stresses the
role of team-based interprofessional care for affected patients.
Objectives:
 Explain why the geriatric population is at risk for trauma.
 Describe why geriatric trauma patients are at higher risk of complications or death.
 Identify management considerations for geriatric trauma patients.
 Explain why careful planning and discussion amongst interprofessional team
members involved in the management of geriatric trauma patients will improve
outcomes.
Access free multiple choice questions on this topic.
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Introduction
Assessment of the geriatric trauma patient is unique, and this population requires special
attention. As the elderly population increases, the number of geriatric trauma patients also
rises. Age-related changes can make caring for geriatric patients challenging and places
them at greater risk of morbidity and mortality. Geriatric patients often suffer from mild
to severe cognitive impairment, cardiovascular, as well as pulmonary and other organ
system insufficiency that can result in general frailty. These age-related physiologic
changes often limit the geriatric patient’s response to traumatic injury and place them at
high risk of complications and death compared to younger counterparts.[1][2][3]
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Etiology
Falls are the most common mechanism of injury followed by motor vehicle collisions and
burns. According to the Centers for Disease Control and Prevention (CDC), in 2014
alone, older Americans experienced 29 million falls causing seven million injuries and
costing an estimated $31 billion in annual Medicare costs. Determination of the cause of
the fall is an important element of the care plan for each patient. It is important to
determine if the fall was the result of an isolated mechanical process or a result of a
systemic condition that could put the patient at risk for additional falls. Factors that must
be considered include the patient’s functional status prior to the fall, location and
circumstances of the fall. [1][2]
Even if a reliable mechanical cause of the fall can be established, a complete medical
evaluation should be considered to evaluate for a pathological condition that caused the
fall. Occult anemia, electrolyte abnormalities, disorders of glucose metabolism should be
considered.[3]
Attention should be paid to the possibility of cardiovascular causes of the fall that include
orthostatic hypotension, dysrhythmia and myocardial infarction. Other pathological states
that can lead to falls include infection from urinary, pulmonary or soft tissue sources.
Neurologic disorders such as primary or secondary seizures should be on the differential
diagnosis. The role of polypharmacy and potential disruptions to normal physiologic
function cannot be understated.
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Epidemiology
Trauma is the fifth leading cause of death in the elderly population and accounts for up
to 25% of all trauma admissions nationally. Special considerations include multiple
comorbidities, polypharmacy, decreased functional reserve, and increased morbidity and
mortality, compared to younger adults. [4][5]
As the world population continues to age, geriatric traumas will continue to
increase. Mortality increases after age 70 when adjusting for injury severity score. Pre-
hospital geriatric trauma triage criteria improve identification of those needing trauma
center care.
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Pathophysiology
There are many anatomic and physiologic changes associated with normal aging which
need to be understood to best diagnose and treat geriatric trauma patients. As we age, all
our organ systems deteriorate with time and lose their underlying ability to function as
they once optimally had at a younger age. This leads to significant considerations that
must be undertaken when taking care of the geriatric trauma patient.
Nutrition
Elderly patients may present with various degrees of malnutrition due to either or both
protein or total caloric intake as well as various mineral and supplement deficiencies. This
can be secondary to a variety of reasons such as living on a fixed income, inability to
obtain appropriate food from stores, reduced desire to eat, poor taste, inability to prepare
meals and feed oneself. Nutritional deficiencies have significant effects on the host
including decreased ability to heal and immune suppression with an inability to fight off
infection. The host then becomes more susceptible to an insult and is at risk for further
morbidity and mortality.
Integument/Musculoskeletal
Elderly patients have a decrease in lean body mass, loss of tissue elastance, thinning of
the skin and an overall increase in total body fat. The thinning of skin makes it much
harder for thermoregulation making geriatric patients much more susceptible to
hypothermia even when in warm weather conditions. Skin becomes much less resistant
to shearing forces as the overall elastic content decreases making it much more
susceptible to skin tears and avulsions even with minor energy transfer. An increase in
total body fat results in a larger volume of distribution which needs to be considered with
medication administration. Loss of lean muscle mass and overall bone density via
demineralization processes such as osteopenia and osteoporosis lead to less strength, loss
of locomotion, balance, and ability to produce heat through shivering. Furthermore, loss
of bone density leads to a higher risk of fracture with a lower energy transfer associated
with more minor injury mechanisms.
Neurologic
Neurohumoral responses in the elderly patient are often blunted leading to a slower and
often less vigorous response to stimuli. Elderly patients often have some level of
neurocognitive decline and often present with reduced sensation to nervous stimuli. Co-
morbidities such as diabetes can lead to peripheral neuropathy which can lead to occult
wounds with insidious infections developing, loss of proprioception and a greater risk of
injuries from falls.
The central nervous system is also affected with aging, directly from normal parenchymal
atrophy as well as through systemic changes such as a decreased ability to auto-regulate
blood flow and underlying atherosclerotic cerebrovascular disease. Elderly patients are
also usually on a myriad of medications which often have an effect on the neurologic
system as well which could lead to drowsiness, loss of energy, oversedation, loss of
balance and memory which can place them at an increased risk for falls, motor vehicle
accidents or other injury mechanisms.
The brain parenchyma itself also atrophies and loses volume as we age which leads to
stretching of the bridging dural veins. When an elderly patient falls and strikes their head
or has a sudden inertial change, these veins are at high risk for rupture leading to subdural
hemorrhage development. Compounded with the fact the brain itself shrinks in size but
the calvarium maintains a fixed volume, clinical changes associated with intracranial
hypertension often present in a delayed fashion as it takes more blood volume to lead to
brain compression and shift. This is also somewhat protective in that elderly patients may
not have the acute cerebral herniation as their younger counterparts and may not need
surgical intervention to evacuate the hemorrhage.
Cardiovascular
The heart with aging becomes stiffer and therefore is less compliant and loses the ability
to contract harder to obtain a greater output when seeing a larger preload. (Frank-Starling
Law of the Heart) Furthermore, as we age the cardiac conduction system becomes more
fibrotic and the myocardium becomes less responsive to neurohumoral effects. This all
leads to a decreased ability for the geriatric trauma patient to preserve their cardiac output
which is defined as the product of heart rate and stroke volume. (cardiac output = heart
rate * stroke volume) This has clinical consequences for the elderly patient such that even
for relatively mild hypovolemia, whether due to poor intake with associated dehydration
or volume contraction or related to injury with hemorrhage, the resultant drop in pre-load
significantly affects the overall cardiac output. Coupled with a desensitized vascular
system to neurohumoral effects, there is less ability for the systemic vascular resistance
to increase the peripheral blood pressure or for the venous system to contract, decreasing
venous capacity and increasing preload to make up for this loss.
Polypharmacy also has a multitude of effects on the cardiovascular system in this patient
population in which beta-blockade, calcium-channel blockers, and cardiac glycosides are
common which leads to negative inotropic, dromotropic and chronotropic effects. Under
normal circumstances this is the desired effect of the medication, however, with an acute
insult, these medications prevent the host from amounting a normal physiologic response
to compensate and maintain homeostasis.
Shock, defined as global tissue hypoperfusion is often clinically defined as a systolic
blood pressure less than 90 mmHg. This definition is often incomplete for many patients
especially those who are geriatric trauma patients over the age of 65. Current literature
supports a systolic blood pressure of 110 mmHg to be a better benchmark which should
be used for this purpose to identify occult shock. Furthermore, certain indices have been
utilized to better detect occult shock as opposed to using one discrete variable such as
heart rate, blood pressure or urine output as all are insensitive. The utilization of the
shock index has been found to be a more sensitive indicator. It is calculated as the
quotient of the systolic blood pressure by the heart rate (shock index = heart rate/systolic
blood pressure). A shock index of 0.5-0.7 is considered normal, but when it exceeds 0.7,
the patient is in shock. [6] Further iterations of this index have also been proposed which
are felt to be more sensitive such as the respiratory adjusted shock index or RASI. RASI
is calculated by multiplying the shock index by (respiratory rate/10). When the RASI is
greater than 1.3, it suggests that the patient is in occult shock. [7]
Pulmonary
Overall pulmonary function is found to deteriorate in older adults. Commonly, the elderly
have less functional residual, vital and total lung capacities and on formal pulmonary
function testing, they often are found to have lower forced expiratory volumes over one
second as well as forced vital capacity. The respiratory reserve is therefore limited and
the ability to adapt compensatory physiologic processes to hypoxia, hypercarbia and
correct metabolic disturbances such as acidosis is blunted. Clinically this is important to
consider as even small perturbations to the elderly patient may manifest in respiratory
failure and often the clinical signs or symptoms may be subtle, and the astute clinician
should be aware of their insidious nature.
Additionally, as elderly patients lose their lean muscle mass, their ability to recruit
secondary respiratory muscles is decreased. Compounded with loss of tissue elastance
and greater total body fat deposition there is a decrease in chest wall compliance.
Suboptimal nutritional intake also factors into this as the patients often suffer from
inanition and cannot provide adequate metabolic supply for the additional need which
leads to respiratory failure. Atelectasis is very common in this patient population which
leads to underlying ventilation to perfusion mismatch with a resultant increase in
pulmonary shunting.
A pulmonary toilet is also decreased as we age and there is often chronic airway
colonization with microbes. The normal pseudostratified ciliated epithelium and goblet
cells which are responsible for the mucociliary escalator fail to remove microbes and
particulate matter from the lower airways and the elderly patient’s cough is often weak
due to loss of muscle mass which prevents effective pulmonary hygiene. Chronic
aspiration due to dysphagia is often seen in this patient population as well which
significantly affects the underlying pulmonary function and should be considered in all
geriatric patients who have a history of obesity, sedating medications, gastroparesis
associated with diabetes or reflux to prevent worsening aspiration and respiratory failure
if laid in the supine position. Strict aspiration precautions and gastric tube decompression
should be considered to prevent this possibly catastrophic event from occurring.
Gastrointestinal
Poor dentition leading patients to become edentulous necessitating prosthetic dentures is
common. Loss of the ability to chew foods can lead to poor nutritional intake. As we age,
our salivary glands also atrophy leading to less saliva production which impairs
lubrication of the food bolus and makes the process of deglutition more
challenging. Transfer of the food bolus from the oropharynx to the esophagus is also
impaired and can lead to aspiration as prior protective aerodigestive reflexes are often
blunted or absent.
Multiple medications affect the gastric lining and acidic milieu. This can lead to
worsening of the protective mechanisms for the gastric wall and lead to gastritis and other
forms of peptic ulcer disease. Often, the pharmaceutical alkalization of gastric acid can
lead to microbial overgrowth and if aspiration does occur, it can lead to a higher rate of
pulmonary infection.
Gastric and intestinal wall integrity is affected as we age leading to poor absorption of
both micro and macronutrients which may worsen underlying malnutrition. Overall
motility is slowed as well as the tissues become less responsive to neurohumoral and
endocrine stimuli. This can lead to a higher risk of reflux and constipation in this age
group.
The liver loses its overall parenchymal mass and its total blood flow also diminishes as
well. This in effect leads to a worsening ability to act as a filter to help with detoxification
of the host. The liver’s intrinsic ability to make proteins such as albumin is also
diminished which can lead to a decrease in oncotic pressure and worsening of third-
spacing of fluids. Also, free drug concentrations can increase in the face of
hypoalbuminemia leading to unwanted toxicities.
A decrease in the hepatic production of thrombopoietin can lead to thrombocytopenia as
there is less stimulation of the megakaryocytes in the bone marrow. Vitamin K dependent
clotting factors are also diminished due to loss of hepatic synthetic function as well as
less oral intake of vitamin K. Both factors can lead to a higher risk of coagulopathy in the
geriatric trauma population.
Genitourinary
A higher rate of urinary incontinence is seen in both women and men of older age. This
is partially due to neurohumoral desensitization of the bladder detrusor muscle. When the
detrusor fails to squeeze, post-void residual volumes can increase leading to higher rates
of bacterial overgrowth with infection and even lead to post-obstructive renal
failure. Prostatism in men is another common cause of the inability to completely
micturate and leads to mechanical urethral obstruction. Some medications that elderly
patients take may lead to acute urinary retention as well. Urinary tract infection is also
another very common occult cause of altered mental status in the elderly patient and
should be sought early and appropriately treated if found.
Like the other organs, the kidneys also are subjected to parenchymal tissue loss as we
age. The nephron load in the renal cortex is most affected. The glomerular filtration rate
is decreased leading to problems with clearance of solute and reabsorption of water which
in turn leads to disturbances in fluid and electrolyte homeostasis. It is not uncommon to
see a decrease in an elderly patient’s creatinine as their lean muscle mass decreases as
well with age and there is an associated increase in the tubular secretion of creatinine.
Serum creatinine levels can be within the normal range but may be misleading as the renal
function may still be grossly impaired.
Creatinine clearance, Ccr (mL/minute) = (140-age) * mass (kg)/serum creatinine * 72, is
often a better way to measure and determine renal function, especially in the geriatric
population with respect to the above physiologic changes of senescence. Creatinine
clearance is known to decrease with age, but in a variable way with up to one-third of
elderly patients with a marked decline. This is important to consider as many medications
may need to be renally adjusted to prevent nephrotoxicity.
Neurohumoral stimulation of the kidneys is also seen to decline as we age. The renin-
angiotensin-aldosterone system is downregulated such that the host becomes less
responsive to hypovolemia and salt retainment. As the renal function declines, the kidney
becomes less responsive to hypoxia which leads to less production of erythropoietin and
production of increased red-cell mass leading to anemia. The ability of vitamin D to
undergo hydroxylation decreases such that elderly patients will be at higher risk for
osteomalacia and osteoporotic fractures.
Hematologic
As we age, bone marrow mass decreases over time. Marrow is replaced by fat and
hematopoietic reserves decline. Another reason for the reduction in hematopoiesis is that
the marrow itself becomes less sensitive to stimulatory hormones. The functionality of
the red cells, platelets, and leukocytes all are found to develop qualitative defects even
though quantitatively they may be normal upon testing. Anemia is very common as well
in the elderly and a differential should be obtained which can give insight to the mean
corpuscular volume which can help to further delineate its cause. Macrocytic anemia is
usually from folate or B12 deficiencies most commonly from poor nutritional intake or
absorption issues which are both seen in the elderly. Microcytic anemia is often due to
iron-deficiency and can also be secondary to nutritional inadequacies but also can be
secondary to other causes in the elderly patient such as occult blood loss. Both should be
evaluated and corrected to help preserve or increase the geriatric trauma patient’s oxygen-
carrying capacity.
Immune
Decrements in immune function are commonly seen in the elderly patient. Loss of
immune function has been found to contribute to an increase in infections, autoimmune
disorders, and malignancies. Generalized malnutrition with vitamin and mineral
deficiencies are often found in the elderly and are a significant cause of immune
dysfunction.
Endocrine
Many elderly patients are on systemic steroids which lead to hyperglycemia,
immunosuppression and worsening wound healing. Furthermore, chronic glucocorticoid
therapy is associated with hypothalamic-pituitary-adrenal axis suppression and puts them
at risk for adrenal suppression requiring stress dosing at times of surgery, traumatic injury
or during critical illness. Also, many elderly patients are on thyroid hormone replacement
therapy and if critically ill, may become hypothyroid or euthyroid-sick. The astute
clinician should keep these common endocrinopathies in mind when involved in the care
of the geriatric trauma patient.
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History and Physical

Using all resources available for information gathering is important. Knowledge of the
patient’s baseline mental status can be crucial to identifying a serious injury. Often vital
signs appear normal until the patient deteriorates rapidly. Blood pressure and pulse may
mislead and be altered by polypharmacy. Comorbid conditions must be taken into
consideration. Following the assessment of airway, breathing, and circulation, the
physician should perform a complete head to toe physical examination of the patient.
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Evaluation
Advanced Trauma Life Support protocols should be followed during the initial evaluation
of the geriatric trauma patient. A complete geriatric assessment should be pursued,
including medical, cognitive, functional, and social assessments. Due to the possibility
of subtle pathological disease states or occult injury, a thorough evaluation should be
considered even if a reliable history of a mechanical fall can be established.[8][9]
Another aspect that is very important in managing the geriatric trauma patient is
performing an evaluation for frailty upon admission. Frailty is considered a syndrome of
physiologic deterioration that occurs with aging. It is often characterized as an inability
to adapt to acute illness or stress placed on the host which leads to a greater number of
complications, discharge to a care facility, disability and even death.
One important concept about frailty is that it is not solely defined by age. In fact, there
are many patients who have chronically poor health who are younger than 65 years of age
who would meet the definition of frailty. Frailty has traditionally been thought of as a
physical deterioration in which patients exhibit weight loss, loss of lean muscle mass with
associated weakness and decrease in walking speed all secondary to biologic
deterioration. However, newer views of frailty incorporate this concept with the idea that
there is also a concurrent deficit accumulation such as social impairment and cognitive
decline.
There currently is not a gold standard test available to detect frailty in the elderly,
however, there have been many tools developed which have helped determine who is
most at risk for an adverse outcome or prognosis. One of these easily applied screening
tools is the FRAIL scale. Where fatigue, resistance, ambulation, illnesses and loss of
weight make up the questions that are asked and each is assigned either a 0 or 1. A score
of 0 is best and 5 is worst where scores of 3-5 are considered frail, 1-2 pre-frail and 0
good health. One geriatric trauma-specific frailty index has been developed which utilizes
15 variables which can be abstracted from a patient’s chart to help aid clinicians in
planning discharge disposition. [10]
Other tools have been developed to aid in the prognostication for in-hospital mortality in
elderly trauma patients. One of these is: The Geriatric Trauma Outcome Score (GTOS;
[age] + [2.5 × Injury Severity Score] + 22 [if packed RBC transfused within ≤24 hours of
admission]. This has been validated as a prognostic indicator for in-hospital
mortality. [11] Newer predictors of elderly mortality after trauma have recently been
published. One of which is the quick elderly mortality after trauma (qEMAT) on
admission and the full elderly mortality after trauma (fEMAT) which is done after
radiologic evaluation. These both were found to accurately estimate in-hospital
mortality. [12]
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Treatment / Management
Based on the history and physical exam coupled with risk factor assessment, general
screening labs such as complete blood count, comprehensive metabolic panel, EKG,
urinalysis (UA), and radiographic studies should be considered. Central nervous system
imaging should be considered in patients who are taking antiplatelet or anticoagulant
medications and have an appropriate history and mechanism. [13][14][15]
Patients on anticoagulants found to have a significant intracranial hemorrhage require
aggressive management. Reversal of the anticoagulant must be achieved rapidly.
The new oral anticoagulants such as dabigatran (Pradaxa), apixaban (Eliquis), and
rivaroxaban (Xarelto) are indicated for a variety of clinical conditions that affect the
elderly. These include treatment of venous thromboembolism, stroke prophylaxis in non-
valvular atrial fibrillation, and acute coronary syndrome. The new oral
anticoagulants have a different mechanism of action than warfarin (Coumadin) acting to
inhibit Xa and Thrombin IIa in the coagulation cascade. Reversal of the anticoagulation
caused by new oral anticoagulants is different then anticoagulation caused by warfarin.
Only dabigatran has a direct reversal agent idarucizumab (Praxbind). Several other
targeted antidote reversal agents are in development.
Reversal of anticoagulation caused by warfarin historically relied on the use of vitamin
K and fresh frozen plasma (FFP). Recent literature suggests relying on vitamin K and
FFP might be less effective than the use of vitamin K and prothrombin complex
concentrates. Vitamin K and fresh frozen plasma (FFP) therapy often require 30 min to
60 min to thaw the FFP. Further, large volumes of FFP in the range of 30 cc/kg (4 to 12
units) are often required for adequate reversal. The time to infuse the necessary volume
of FFP can complicate care. Treatment with vitamin K and prothrombin complex
concentrates avoids these limitations. Prothrombin complex concentrates do not require
blood group system (ABO) compatibility testing and infusion volumes are less than 100
cc.
Reversal of the anticoagulation caused by warfarin or new oral anticoagulants should be
based on current institution-specific guidelines that are under constant revision.
Understanding the need for a thorough evaluation and aggressive resuscitation of the
injured geriatric patient is instrumental in improving outcomes.
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Differential Diagnosis
 Altered mental status
 Focal neurological deficits
 Headache
 Ischemic stroke
 Intraparenchymal haemorrhages
 Non-traumatic intracranial bleed
 Subdural hematomas
 Subarachnoid injuries
 Traumatic brain injury
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Pearls and Other Issues

Undertriage of geriatric trauma patients at risk for moderate to severe injury is a major
problem and often begins during the pre-hospital assessment. Studies have shown that
patients treated at a trauma center have improved outcomes. Other studies found that
compared with younger patients with similar injury severity scores (ISS) patients over 70
had a three-fold increase in mortality. Based on these and other studies, the American
College of Surgeons’ triage criteria suggests patients age 55 years and above be
considered for transport to a trauma center to receive their care. Also, geriatric trauma
criteria have been implemented at the state level to address undertriage.
These criteria help identify patients who would be more appropriately transported to a
trauma center. Data on the use of geriatric trauma criteria suggest overall outcomes have
improved. Pre-hospital providers must maintain a high clinical suspicion for serious
injury, regardless of the mechanism of injury.
Elder abuse is under-reported, and the incidence is rising. The prevalence of elder abuse
in the United States is estimated to be about 10%. It can present in many ways, for
example, physical, emotional, financial, sexual, and neglect. Physicians should maintain
a high level of suspicion to identify those at risk. Those in immediate danger should be
hospitalized.
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Enhancing Healthcare Team Outcomes

Geriatric trauma is on the rise and often presents in sinister ways. Because of advanced
age, a decline in organ function and limited reserve, geriatric patients are more likely to
die compared to younger people when sustaining the same type of trauma. Thus,
assessment and treatment of the geriatric trauma patient must be conducted by taking into
consideration of their unique physiology and associated co-morbidity. Because geriatric
trauma can have diverse presentations, an interprofessional approach is necessary. Often
geriatric abuse can present with somatic and neuropsychiatric features, and the key is to
be aware of this pathology. The majority of geriatric patients can heal after trauma, but
the healing period is long. Many often remain in the hospital for prolonged periods and
even when discharged tend to have a residual loss in function. As the care of the geriatric
trauma patient improves, it is hoped that the morbidity and mortality will also decrease.
Meanwhile, the onus is on healthcare workers to recognize earl