Geriatric Population. Injury in Aging (Geriatrics) : How to Handle Older (Geriatric) Trauma Victims with Care
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Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher During your journey through this slide deck of Injury in Geriatric populations, you will experience: the measurement of injury; how old age (geriatrics) modifies clinical features & management (i.e. fractures, infection, confusion, host response); and how geriatric trauma victims differ from their younger counterparts. The links in this slide deck lead you to expert geriatric teaching resources that you will value and love. You will learn why trauma is so much more “traumatic” for geriatric populations. Existing assessment and management standards have not been evaluated for efficacy in geriatric trauma patients, only one third of Baccalaureate nursing programs require a course in geriatrics, and less than 1% of registered nurses are certified in geriatrics. Cutungo, C. (2011). With aging the body undergoes a progressive loss of function and vital organs lose their ability to compensate in times of physical and metabolic stress. Bartley, M. K. (2010). The “fight or flight” response in geriatric people is less robust. Cutungo, C. (2011). As a health care consumer it is important to recognize and be aware of how being geriatric modifies clinical features and increases the risk for complications and mortality. Learn it-Live it-Love it-Your path for a more informed life! Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
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Geriatric Population. Injury in Aging (Geriatrics) : How to Handle Older (Geriatric) Trauma Victims with Care
- 2. Why should injury Injury especially to the elderly In be worthy of discussion? Aging Trauma is the 7th leading cause of death in older adults. Why is trauma so much more “traumatic” for older people?
- 3. LET’S DISCUSS Measurement of injury How old age modifies clinical features & management (i.e. fractures, infection, confusion, host response) How older trauma victims differ from younger counterparts
- 4. Healthcare and Technology Advances Enable elderly to be more active Live in an environment that exposes them to many dangers
- 5. Older people who sustain injuries are more likely to die as a result of them, regardless of the severity of injury.
- 6. Despite the considerable proportion of trauma care resources consumed by the oldest people, research is directed towards needs of younger ones.
- 7. Injury Measurement Scoring systems grade severity Most scales based on: extent of anatomical injury physiological disturbance Abbreviated Injury Scale (1956) Injury by body region, 1 to 5
- 8. Injury Measurement Injury Severity Score (ISS) High validity Prevalence of significant pre-existing conditions increases elderly Importance of intercurrent diseases in determining outcome after injury Acute Physiology of Chronic Health Evaluation scale (APACHE) Severity of illness & age related to survival
- 9. Injury Measurement Simplified Acute Physiological Score (SAPS II) Good predictor of short and long- term mortality in the elderly Factors influencing mortality: Intrinsic: Age, severity of acute illness, previous health status Extrinsic: Medical environment, quality healthcare factors
- 10. Measuring Recovery Most outcome studies focus on survival Little attention is given to quality of survival Consider rates of change for function, disability & handicap
- 11. aggressive medical and rehabilitation of elderly trauma victims is justified adequate intensive treatment may improve outcome for elderly Recovery
- 13. FALLS IN OLDER ADULTS Leading cause of injury Leading cause injury- related mortality Account for > 60% of the total causes of injury in the US
- 14. CAUSES OF FALLS IN OLDER ADULTS Accidents Due to common changes of aging Environmental hazards Cardiac Dysrhythmias Orthostatic Hypotension Dizziness, Vertigo Syncope Vertebral-basilar insuf. Drugs Other
- 16. MOTOR VEHICLE COLLISION OLDER ADULTS More than 18% trauma-related deaths Two-vehicle collisions at intersections Risk is increased: changes in vision, hearing, reaction times, acute and chronic medical conditions, alteration in judgment
- 17. HOW AGE RAISES RISK HEART Stiffening decreased cardiac contractility, stroke volume, cardiac output Decreased sensitivity to catecholamines inability to mount tachycardia in stress
- 18. HOW AGE RAISES RISK LUNGS Rib fracture may lead to splinting hypoventilation promoting atelectasis, pneumonia, need for ventilatory support
- 19. THORACIC TRAUMA IN OLDER PEOPLE Aortic rupture Mediastinal widening Poorly defined aortic knob 80% die at the scene 20% may be stable on presentation
- 20. THORACIC TRAUMA IN OLDER PEOPLE Isolated chest injuries 2-3 times death risk Rib fractures Falls or blows to chest Occult pneumothorax Hemothorax Pulmonary contusions Prompt mechanical ventilation
- 21. HOW AGE RAISES RISK BRAIN Loses volume and the resultant space around the brain increased dural vein fragility reduced dural vein elasticity more susceptible to subdural hematomas
- 22. HOW AGE RAISES RISK SKIN Atrophic, extremely delicate, easily injured High risk complications from skin injury wound infection burns
- 23. HEAD INJURIES IN OLDER PEOPLE Modest increase incidence rates after 60 More common in men than in women Can be devastating in older people GCS less than 8 fatality rate of about 90% Survivors long hospital stays More severe neurological deficits Reduced capacity of aging brain to recover
- 24. HEAD INJURIES IN OLDER PEOPLE AS THE BRAIN AGES… Dura tightly adherent to skull epidural hematomas uncommon Progressive loss volume Increased space around brain Subdural hematomas or intraparenchymal hemorrhage more common emergent management of acute subdural hematoma is critical
- 25. HOW AGE RAISES RISK BONE Most frequently injured Osteoporosis humerus, radius, hip or pelvic fractures longer periods of immobility
- 26. HOW AGE RAISES RISK SPINE Degenerative spine spinal fractures with minor force upper cervical injuries odontoid fractures central cord syndrome more common
- 27. FALL-RELATED FRACTURES Nature of the fall dictates the nature of the fracture Wrist, proximal humerus outstretched arm imply person was moving reasonably fast at time of fall Stationary position or during slow locomotion most likely result proximal femoral fractures
- 28. FALL-RELATED FRACTURES Account for majority of cervical spine Fx Frail may sustain long bone Fx without a clear history of injury or falls “minimal trauma fractures” only precipitating factor is impaired mobility
- 29. ABDOMINAL TRAUMA IN OLDER PEOPLE Death rate visceral injuries around 80% Intolerant of shock Intolerant of unnecessary laparotomy Management demands urgency High degree of clinical expertise
- 30. MULTIPLE INJURIES IN OLDER PEOPLE Visceral injuries without fracture rare Long bone Must be stabilized early Control blood loss Reduce risk of fat embolism Enable early mobilization Bony injuries immediate life threats Skull fractures with brain injury Pelvic fractures Massive bleeding from lacerations to pelvic venous plexus Open pelvic fractures death rate 80%
- 32. OLDER TRAUMA VICTIMS Older accidental injury mostly women Younger accidental injury mostly men Old women out number old men Thinner bones more likely to fracture Occurrence of late deaths Peak death rate femur 1 mo. after injury Increased level for considerable time Higher total of mortality late after injury
- 33. MAJOR TRAUMA OUTCOME STUDY, 1990 Retrospective study over 120,000 patients US trauma centers, 10% were elderly Purpose: set national norms in trauma care and survival probability Older increased likelihood of death Older overrepresented unexpected deaths
- 34. APACHE III Chronological age alone accounted for 3% of variation in outcome Acute physiological abnormalities accounted for 86% Presence of shock has emerged as an enormously potent predictive factor for negative outcome Early invasive monitoring improves survival
- 35. It is not age that accounts for the poor outcome of older trauma victims, but factors that are strongly age related. Intrinsic Factors: co-existing disease, under nutrition and age-related changes in organs and physiological systems… …may contribute to outcome directly by limiting protective responses or indirectly by confronting diagnostic efforts.
- 36. Extrinsic Factors: medication and the attitudes of medical personnel may have similar important adverse effects.
- 38. Pharmacological Aspects Aging Many drugs cause: hypotension & confusion, predisposing falls, possible injury Changes in the host: predispose drug toxicity, potential for interactions More drugs higher reaction risk
- 39. Many drugs bind to proteins Sick old people often low albumin Drugs that bind to albumin (warfarin) Higher concentrations of free drug Pharmacological Aspects Aging Many water-soluble drugs excreted by kidneys declines glomerular filtration, prolong elimination Water-soluble therapeutic concentration lower dose (digoxin)
- 40. Pharmacodynamic Changes Altered responsiveness to a drug Increased sensitivity Pharmacological Aspects Aging Many drugs metabolized in liver Considerable variations from: drug to drug & person to person 2012 AGS Expert Panel Beers Criteria
- 41. DISEASE PRESENTATION OLD AGE Doctor may share patients’ views on aging Wrongly attribute treatable conditions to aging Prevalence of disability increases with age
- 42. DISEASE PRESENTATION OLD AGE Traditional model for medical practice Mainly from presentation younger people Account abnormality to single diagnosis Deviation from traditional model Multiple diseases often co-exist Atypical presentation of disease Disease in one organ may precipitate decompensation in another
- 43. DISEASE PRESENTATION OLD AGE Late or silent presentations Disease one site limits symptoms at another Disease often presents in advanced state Misinterpret symptoms as aging Mobility problems limit activity – Dyspnea not occur until heart failure advanced
- 44. IMMUNOSUPPRESSIVE EFFECTS OF INJURY Body’s response to surgery & trauma afferent nerve signals from site of injury Release cytokines & circulating stress hormones Infective complications account for most of the delayed deaths after injury Infection should always be considered when evaluating a patient whose condition has deteriorated
- 46. Hippocrates “old men have little innate heat…for this reason too, the fevers of old men are less acute than others, for the body is cold.” An apparent afebrile state may mask infection. Changes in vital signs are less reliable indicators of instability in older adults.
- 49. CONFUSION AND INJURY IN OLD AGE Whatever the relation confusion has a major impact on management Delirium, ICD 10 some disturbance in: Consciousness Cognition Psychomotor function Sleep-wake cycle Emotion
- 50. DELIRIUM Children, old people very susceptible Children – immaturity of CNS and of the cognitive and memory contents Older – changes in Neuro…pathological, chemical, physiological, psychological
- 51. DELIRIUM IN OLD AGE Pharmacologic agents that interfere with cholinergic function or sedation Alcohol withdrawal Sensory deprivation, the environment “talking across” increases confusion Depression may masquerade as confusion
- 52. TRAUMA IN OLD AGE “so healthy until now…” “why all of a sudden, he was walking and independent, still driving to church every Sunday…” “she was walking before she got here and isn’t leaving without walking out of here…” Homeostenosis
- 53. ORTHOGERIATRIC UNITS Identification, treatment of confusion Effectiveness depends on enthusiasm, resources, competence Minimal disturbances Minimal sedative medications Nursing organization key to success Nursing rehabilitation oriented
- 54. REFERENCES Horan, M. A., & Little, R. A. (Eds.). (1998). Injury in the aging (First ed.). New York, NY: Cambridge University Press. Bartley, M. K. (2010). Handle older trauma patients with care. Nursing 2010, August, 24-29. Cutugno, C. L. (2011). The ‘Graying’ of Trauma Care: Addressing Traumatic Injury in Older Adults. American Journal of Nursing, Vol. 111, No. 11, 40-48. http://www.modernmedicine.com http://consultgerirn.org/ http://www.environmentalgeriatrics.org/# http://www.cdc.gov/injury/wisqars/leading_causes_death.html
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