The Changing Landscape of Trauma Care, Part 1

Trauma in the Elderly Population

There has been and continues to be an increase in the elderly population in the United States. In 2014, 46 million Americans representing 15% of the total population were older than age 65 years.¹ Of all age groups in the United States, the elderly population is one of the fastest growing and, according to the 2010 Census, grew at a faster rate than in previous years.² This growth is expected to continue as many of the post-World War II baby boomer generation age. By the year 2030, an estimated 1 in 5 Americans will be older than 65 years of age—representing a 7% absolute increase from 2010 to 2030.¹

Furthermore, men and women in this population are maintaining an active lifestyle well into their seventh and eighth decade, which has led to an increased incidence of trauma in this age group, primarily from falls and low-velocity MVCs. According to data from the National Trauma Data Bank in 2016, nearly 43% of all traumatic incidents occurred in patients older than age 55 years, as compared to only 32% in 2010.^3,4 Today, injury is the seventh leading cause of death among the elderly population.⁵

Pre-existing Conditions and Comorbidities

The elderly population tends to have more complex medical histories, with pre-existing conditions and comorbidities—both of which result in intolerance to alterations from normal physiology after acute trauma and may place them at risk for complications and death. This point was highlighted in an invited commentary by one of us (TS) over 20 years ago, in which he stated, “Resting organ function often is preserved, but the ability to augment performance in response to stress is greatly compromised.”⁶

Studies in the early 1990s established a link between trauma outcomes and comorbidities.^7-9 Morris et al⁷ found that ischemic heart disease, diabetes, chronic obstructive pulmonary disease, congenital coagulopathy, and cirrhosis highly influence trauma outcomes. They also noted that 25% of trauma patients over age 65 years had at least one of these five comorbidities and were nearly two times more likely to die. These findings were confirmed in 2002 by Grossman et al,⁸ who demonstrated that each year over age 65 years held a mortality increase of 6.8%.⁸ Additionally, they found that congestive heart failure, cancer, renal disease, and hepatic disease were the comorbidities with the highest impact on mortality.⁸

The presence of pre-existing conditions or comorbidities has also been associated with increased risk for complications, and subsequent increased mortality. In 2010, Aitken et al⁹ found that 6.2% of elderly trauma patients developed pneumonia postinjury, which was associated with increased intensive care unit (ICU) and hospital length of stay.Pre-existing pulmonary disease and higher Injury Severity Scores (ISS) were also found to be risk factors, demonstrating a 5.9% incidence of acute kidney injury in this group, conferring a 10-fold increased risk of mortality.

In efforts to improve outcomes in elderly trauma patients, many centers have integrated geriatric consults in the ED for all patients over a certain age, following injury. Though Olufajo et al¹⁰ were unable to demonstrate an in-house or 30-day mortality benefit after implementing a mandatory geriatrics consult for patients over age 70 years, they did show a nonstatistically significant trend toward fewer ICU readmissions with the consults.

In 2001, Demetriades et al¹¹ reported a 50% mortality rate among patients aged 70 years and older who met criteria for full trauma team activation. Interestingly, the mortality rate for patients over age 70 years was 24%, compared to 7.6% for younger patients admitted during the same period. Those in the 70 years and older age group who did not meet criteria for full trauma team activation still had a 16% mortality rate, and 24% required ICU admission.

Demetriades et al¹¹ also demonstrated that prehospital/admission vital signs in patients 70 years and older were often normal but misleading. In this group, 63% of patients with an ISS greater than 15, and 25% with an ISS greater than 30 did not have tachycardia or hypotension criteria for full trauma activation.¹¹ These findings have led to recommendations for a lower threshold for trauma activations in geriatric patients.¹²

Recent studies have suggested that adding an age threshold to the trauma activation criteria may improve outcomes without leading to an unacceptable overtriage rate. In 2016, Hammer, et al¹³ reported improved outcomes, with only 2% of patients being overtriaged, when they added to their trauma activation criteria an age threshold of 70 years, regardless of physiology or mechanism of injury. They ultimately concluded that it was appropriate and cost-effective. In 2017, Cooper et al¹⁴ published a position paper on the Geriatric Trauma Coalition (GeriTraC) covering the convergence of aging and injury. The mission of GeriTraC is to improve geriatric trauma care from prevention to transition of care.¹⁴