Senior Trauma Patients An Integrated Approach

Visit the link below to download the full version of this book:

https://medipdf.com/product/senior-trauma-patients-an-integrated-approach/

Click Download Now

Editors
Hans-Christoph Pape Stephen L. Kates
Department of Trauma Surgery Department of Orthopaedic Surgery
University Hospital Zurich Virginia Commonwealth University
Zürich, Switzerland Richmond, VA, USA

Christian Hierholzer Heike A. Bischoff-Ferrari

Department of Trauma Surgery Department of Aging Medicine
University Hospital Zurich and Aging Research
Zürich, Switzerland City Hospital Zurich-Waid
Zurich University
Zürich, Switzerland

ISBN 978-3-030-91482-0    ISBN 978-3-030-91483-7 (eBook)

https://doi.org/10.1007/978-3-030-91483-7

© Springer Nature Switzerland AG 2022

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
We would like to dedicate this book to Prof. Dr. Hans-Peter
Simmen, Prof. emeritus, Department of Trauma, University of
Zurich, Switzerland, for his accomplishments in regard to
orchestrating the first certified Geriatric Trauma Center in
Switzerland.
Foreword

It is well known that people are getting older in all industrialized countries
offering good quality of life as well as modern medical treatment. For instance,
statistical mean age is as high as 86 years for women and 82 years for men in
Switzerland, respectively. Similar figures are reported from other European
nations. To provide optimal treatment for aged persons, many hospitals estab-
lished specialized geriatric departments in the last years. Even congresses with
tailored programs are held to fit the scientific needs for treating elderly people.
A femur fracture in 80-year-old person may not only be a broken bone. In
the presence of comorbidities, it is an “attack on the entire organism.”
Identical surgical principles are applied. However, impaired bone quality and
comorbidities make the healing process much more complicated. The follow-
­up care requires the advice of many specialists; the rehabilitation procedures
have to be adapted.
The people 70+ suffer more severe injuries. According to publicly avail-
able data from the “German Trauma Registry,” 25% of the polytraumatized
patients are over 70 years old. These injuries include not only high velocity
trauma such as road traffic accidents but rather low impact trauma resulting
from a fall on stairs. It is not unusual that frail patients present with head
injury (intracerebral hematoma), serial rib fractures with lung contusions in
addition to a hip fracture. Many persons 70+ are on anticoagulant or anti-
platelet agents which aggravate their condition.
How to go on if you are called to an aged patient suffering from fractures
in addition to many comorbidities such as an insulin-dependent diabetes and
bleeding disorders due to antiplatelet agents following stent implantation ?
Please, consult this textbook.
This textbook Senior Trauma Patients: An Integrated Approach is designed
to improve diagnostics and treatments of patients 70+, who belong to the most
difficult ones, a doctor has to deal with. The editors are to be congratulated:
They realized a comprehensive overview on geriatric trauma. I am sure that this
reference work will help to better understand and treat the sickest patients.

Hans-Peter Simmen
Professor Emeritus of Surgery, Former Chairman
of the Department of Traumatology
University Hospital Zurich
Zurich, Switzerland

vii
Preface

The world’s aging population is rapidly growing, and many older adults will
suffer low energy trauma due to falls or accidents. Over the past decade,
many initiatives have been developed to improve the management of older
adults with such injuries.
The two most popular approaches include efforts to improve the aftercare
provided by orthopedic trauma surgeons and the interdisciplinary comanage-
ment approach that involves both geriatricians and surgeons. The latter
approach has been adopted widely and involves care in the hospital, including
medication management, peri-surgical care, and prevention of secondary
fractures by standardized protocols.
Among these initiatives are Orthogeriatric Management with the Fragility
Fracture Network (FFN) and the AO, the Geriatric Trauma Center certifica-
tion initiative by the German Trauma Association and the German Geriatric
Association, and the “Own the Bone” by the American Orthopaedic
Association (AOA).
This book covers the essential aspects of geriatric fracture management,
perioperative care, postoperative ICU management, and follow-up care.
Because the number of geriatric (poly-) trauma cases will rise significantly, it
includes a new standard operating procedure (SOP) for these and other
patients. Outcome differences (compared with younger patients) are explained
for major fracture types along with physiological compensation mechanisms,
frailty, and nutrition. We hope that this comprehensive text will add to the
general knowledge of this important topic.

Zürich, Switzerland Hans-Christoph Pape

Richmond, VA, USA  Stephen L. Kates
Zürich, Switzerland  Christian Hierholzer
Zürich, Switzerland  Heike A. Bischoff-Ferrari

ix
Contents

Part I Introduction: Physiology of Ageing

1 Epidemiology������������������������������������������������������������������������������������   3
Marianne Comeau-Gauthier, Daniel Axelrod,
and Mohit Bhandari
2 Cardiovascular Ageing�������������������������������������������������������������������� 13
Marco Luciani, Frank Ruschitzka, and Giovanni G. Camici
3 Bone Mineralization and Osteoporotic Changes�������������������������� 23
Enrique Guerado, Juan Ramón Cano, Vicente Crespo,
and Antonio Campos
4 The Concept of Sarcopenia and Frailty ���������������������������������������� 43
Heike A. Bischoff-Ferrari
5 Applied Fall and Fracture Epidemiology 70+ ������������������������������ 47
Heike A. Bischoff-Ferrari

Part II Prevention of Complications Related to Ageing

6 Protein Malnutrition, Falls, and Fractures in Older

Trauma Patients ������������������������������������������������������������������������������ 53
Patricia Lanz and Heike A. Bischoff-Ferrari
7 Supplementation: Vitamin D, Calcium������������������������������������������ 61
Heike A. Bischoff-Ferrari
8 Exercise Concepts for Fall Prevention ������������������������������������������ 67
M. Mattle and R. Theiler
9 Falls Risk Assessment���������������������������������������������������������������������� 79
Jesse Zanker, Steven Phu, and Gustavo Duque
10 FRAX������������������������������������������������������������������������������������������������ 89
John A. Kanis, Nicholas C. Harvey, Helena Johansson,
Mattias Lorentzon, Enwu Liu, William D. Leslie,
and Eugene V. McCloskey

xi
xii Contents

11 Falls’ Prevention by Self-Managed Scoring���������������������������������� 101

Sascha Halvachizadeh, Christian Hierholzer,
and Hans-Christoph Pape
12 Pharmacological Treatment of Patients with Osteoporosis���������� 107
René Rizzoli

Part III Geriatric Care Concepts in Acute Care

13 Prevention of Delirium in The Elderly������������������������������������������ 123

Egemen Savaskan
14 Frailty Assessment and Treatment ������������������������������������������������ 129
Michael Gagesch and Olga Theou
15 Pain Management���������������������������������������������������������������������������� 137
Markus Gosch
16 Polypharmacy: Less is More���������������������������������������������������������� 143
Thomas Münzer
17 Perioperative Care Program: Zurich-POPS
Zurich-PeriOperative-care-for-older-PatientS������������������������������ 149
Heike A. Bischoff-Ferrari
18 Palliative Care Concepts����������������������������������������������������������������� 153
Mathias Schlögl

Part IV Fracture Care Service Models

19 Fracture Liaison Service (FLS)—Intersectoral

Treatment of the Disease After Osteoporosis-­Associated
Fractures ������������������������������������������������������������������������������������������ 165
Wolfgang Böcker, Eric Hesse, and Christian Kammerlander
20 Building A Senior Trauma Centre�������������������������������������������������� 167
Carl Neuerburg, Alexander Martin Keppler, Evi Fleischhacker,
Johannes Gleich, and Christian Kammerlander

Part V Specific Treatments in Acute Care

21 Specifics of Fracture Stabilization in Geriatric Bone ������������������ 179

Richard Stange and Michael J. Raschke
22 Orthogeriatric Inpatient Management������������������������������������������ 191
Zachary A. Kons, Sarah E. Hobgood, and Stephen L. Kates
Contents xiii

23 Comanagement Admission and Timing of Surgery���������������������� 207

Valentin Neuhaus and Carina Pothmann
24 Diagnostic Procedures: Coagulation���������������������������������������������� 213
Jan-Dirk Studt, Alexander Kaserer, and Donat R. Spahn
25 Prevention and Management of Infections in Elderly������������������ 217
F. Ziegenhain, G. N. Jukema, and H. Sax

Part VI Surgical Management of Major Fractures

26 Preparation for Surgery: What to Consider���������������������������������� 227

Markus Gosch
27 Management of Anemia������������������������������������������������������������������ 233
Julian Rössler, Jan Breckwoldt, and Donat R. Spahn
28 Specifics of Surgical Management:
Proximal Femur Fractures�������������������������������������������������������������� 237
Abhishek Ganta and Kenneth A. Egol
29 Specifics of Surgical Management: Pelvis�������������������������������������� 261
Chima D. Nwankwo, Edward R. Westrick,
Gregory T. Altman, and Daniel T. Altman
30 Open Fractures in the Elderly�������������������������������������������������������� 275
Erin Pichiotino, Dylan Nugent, and Kyle J. Jeray
31 Obesity and the Senior Trauma Patient���������������������������������������� 297
Douglas Lundy, Sydney E. Burke, and Jennifer L. Bruggers
32 Spinal Fracture in the Elderly�������������������������������������������������������� 303
Paul A. Anderson

Part VII Intensive Care Management of the Geriatric Patient

33 Standard Operating Procedures in Geriatric Polytrauma���������� 319

F. Ziegenhain, H. Teuber, and K. O. Jensen
34 Specifics of Surgical Management:
Patient in Critical Condition���������������������������������������������������������� 325
Sascha Halvachizadeh and Hans-Christoph Pape
35 Plastic Surgery: Hand and Soft Tissue Trauma
in the Elderly Patient ���������������������������������������������������������������������� 331
Jan A. Plock, Flavien Mauler, Andreas Weber,
and Christian Tschumi
xiv Contents

Part VIII Rehabilitation and Outcomes

36 Geriatric Rehabilitation������������������������������������������������������������������ 343

Theiler Robert, Freystaetter Gregor, Simmen Hans-Peter,
Pothmann Carina Eva Maria, and Neuhaus Valentin
37 Functional Recovery After Hip Fracture�������������������������������������� 347
Mohammad Auais, Katie Sheehan, Jay Magaziner,
and Lauren Beaupre
 Part I
Introduction: Physiology of Ageing
 Epidemiology
1
Marianne Comeau-Gauthier, Daniel Axelrod,
and Mohit Bhandari

1.1 Introduction although trauma mortality increases significantly

from the age of 55 [13–19], independently from
Geriatric patients may pose unique and signifi- the degree of injury. Additionally, some authors
cant challenges in the trauma setting with regard have reported specific predictive factors that may
to injury severity assessment, resuscitation, and apply for patients aged 80 years and older only
treatment, when compared to patients under the [14, 20]. The National Trauma Data Bank
age of 65 years. Apart from the substantially (NTDB) reports the first peak in the number of
higher morbidity and mortality [8, 9], one must trauma-related injuries leading to admission to a
recognize the critical and unique psychosocial trauma center between ages of 14–29 years old,
components in the care of the elderly [10]. While primarily from motor vehicle-related accidents,
special considerations should be made for the and reports a second peak starting after the age of
geriatric polytraumatized patient, current 50 years, when falls begin to increase [1]. Males
evidence-­based recommendations are founded account for 70% of all incidents up to age 70,
primarily on retrospective studies including a sig- while after 71 years, most patients are female [1].
nificant portion of registry-based cohort studies
and a limited number of prospective studies [7,
11, 12]. To date, no randomized controlled trials 1.2 Clinical Significance
have been performed to guide best practice and of the Aging Process
improve outcomes. on the Polytraumatized
The geriatric trauma population is commonly Patient
defined as patients aged 65 and older [12],
1.2.1 Age-Related Physiologic
Decline
M. Comeau-Gauthier · D. Axelrod (*)
Division of Orthopedic Surgery, McMaster
University, Hamilton, ON, Canada Despite defining the elderly as aged above
e-mail: [email protected]; 65 years, the impact of aging on trauma has been
[email protected] found to be as early as 40 years [21]. The combi-
M. Bhandari nation of age-related immunosenescence and
Division of Orthopedic Surgery, McMaster trauma-related immune dysregulation likely con-
University, Hamilton, ON, Canada
tributes to a higher mortality and morbidity rate
Department of Health Research Methods, Evidence in older adults [22]. It was found that elderly vic-
and Impact (HEI), McMaster University,
Hamilton, ON, Canada
tims had increased tissue inhibitor of metallopro-
e-mail: [email protected] teinases-­2 (TIMP-2) levels [23], an indicator of

© Springer Nature Switzerland AG 2022 3

H.-C. Pape et al. (eds.), Senior Trauma Patients, https://doi.org/10.1007/978-3-030-91483-7_1
4 M. Comeau-Gauthier et al.

the severity of pathologic immune activation, and corroborated by two subsequent large registry-­
polytraumatized geriatric patients more often based cohort studies [41, 42]. These findings are
develop SIRS compared with younger patients highly significant as under-triage of an elderly
[24]. victim leads to fourfold the mortality and dis-
Decreased myocardial pumping efficacy [25– charge disability rate as compared to their
27], decline in myocardial conducting system younger counterparts [43].
responsiveness to demands on the cardiovascular Several factors have been reported to impair
system [28, 29], hypertension [30], and accumu- adequate triage of elderly patients, including
lation of atherosclerotic plaque [26] lead to a nar- healthcare provider bias, unrecognized comor-
rower range of end diastolic volumes required to bidities, communication impairment, inaccuracy
preserve and optimize cardiac function/output. of Glasgow Coma Scale (GCS) scoring in geriat-
These changes in the cardiovascular system ric patients, and lack of reliable parameters indi-
translate into a reduced ability to respond to cator of injury severity and sufficient resuscitation.
hypovolemia and shock and challenges during Elderly victims are found to be less likely to trig-
resuscitation, as both under-resuscitation and ger a trauma team activation, despite a similar
over-resuscitation are harmful [31], which is why percentage of ISS above 15 and the higher need
some authors advocate for a lower threshold in for urgent craniotomy and orthopedic procedures
implementing invasive monitoring in this popula- [43]. A noisy and chaotic trauma bay is certainly
tion [12, 32, 33]. The loss of functional respira- not favorable to doctor-patient communication
tory reserve, decreased lung compliance, loss of and history taking in a “hard of hearing” elderly,
alveolar surface, and increased ventilation/perfu- which is often assumed as intellectual impair-
sion mismatch [34] added with higher rates of ment [10]. Mental status examinations and GCS
multiple rib fractures with a seemingly lower scoring can be particularly difficult in geriatric
transfer of energy [35–37] could partially account patients with preexisting cognitive decline, hear-
for a higher number of days on ventilators [3] and ing impairment, or sequelae of previous strokes
a higher risk of pulmonary infection [37] associ- [44]. Furthermore, heart rate and blood pressure
ated with elderly victims. Increased prevalence were not found to be predictive of severe impend-
of osteoporosis in this population [38] leads to ing mortality and inadequate resuscitation in
higher severity fractures compared to younger patients aged above 65 years old [43]. Increased
patients with a similar mechanism of injury. mortality has been reported among the elderly
Increased intracranial space due to brain atrophy with heart rates greater than 90 beats per minute
and greater stretching of intracranial vessels and systolic blood pressure less than 110 mmHg,
directly increase the rate of intracranial bleedings while the same increase in mortality is not seen in
[18, 39]. younger patients [45].
Current guidelines from the America Trauma
Life Support (ATLS) recommend transporting
1.2.2 Effect on Triage any patient older than 55 years old to a trauma
center [46], while the Eastern Association from
In a 10-year retrospective review (1994–2004) of the Surgery of Trauma (EAST) guidelines rec-
the Maryland Ambulance Information System by ommend geriatric-specific care for any patient
Chang et al. [40], elderly victims were three older than 65 years old [12]. Recent evidence-­
times more likely to be under-triaged compared based review from EAST has shown decreased
with younger patients, which remained signifi- mortality in severely injured geriatric patients
cant on multivariate analysis (controlling for treated in trauma care centers as compared to
year, sex, injury, mechanism, transport reasons, non-trauma centers, and therefore, recommend
emergency medical service provider level train- initial assessment and care in a certified trauma
ing, jurisdictional region). These results were center [7].
1 Epidemiology 5

1.3 Mechanisms of Injury humerus shaft (7%), hand (7%), proximal

humerus (5%), and foot (4%) [55]. Of all the
While trauma is the fifth cause of death in the spine injuries, only 13% required surgery [55].
elderly, blunt trauma secondary to a fall from any Injuries to the odontoid and the C1–C2 level are
height is the leading cause of high-energy inju- the most frequent spinal injuries [5, 6] and can
ries in the geriatric patient [1, 3, 47–50], repre- result from a seemingly trivial mechanism of
senting nearly three-quarters of all traumas in injuries such as a fall from standing or seating
this population [3], followed by traffic-related height. Around 95% of the pelvis fractures did
accidents, either as the driver or as a pedestrian not require surgical management from which lat-
hit by a car [1, 49, 50]. Penetrating trauma, eral compression injury types are most frequently
­firearm injuries, assault, and burns are much less encountered [56], whereas 10% of the acetabu-
common. Adults aged over 65 are almost two to lum fracture were treated operatively [55]. Long
three times more likely to die of their injuries, bones, pelvic, rib, and sternal fractures are most
even after controlling for race, sex, injury mecha- commonly seen due to osteoporosis. These frac-
nism, and ISS [3, 50, 51] Geriatric status was tures are usually more complex secondary to
found to be one of the main independent factors bone osteoporosis, making it more fragile or the
for mortality across all mechanisms of injury presence of prosthesis/implants. Adults aged
[49]. 70 years old are less likely to have solid organ
A 10-year retrospective review found that injuries compared with younger patients [57].
nearly 60% of trauma admission in the geriatric Although abdominal traumas are rare, they, much
population are secondary to high-energy mecha- like other injuries, have four times higher mortal-
nism [3]. However, elderly presented following ity compared to the younger trauma patients [5,
low or high-energy injury mechanism are nearly 58] and are significantly more frequent in the
seven times more likely to have higher non-survivors [59].
Abbreviated Injury Score (AIS) to any body
region [2] and usually present with a higher ISS
[3] as compared with younger patients. 1.3.1 Falls
Traumatic brain injuries (TBI) are the leading
cause of trauma-related mortality and morbidity In the largest aggregation of U.S./Canadian
in the elderly, with falls as the leading causative trauma registry data, NTDB reports falls as the
mechanism (51%), followed by motor vehicle leading cause of admission in a trauma center,
traffic crashes (9%) [4]. Independently of the while the largest number of deaths are caused by
mechanism of injury, subdural hematomas are fall-related injuries [1]. Elderly patients pre-
three times more likely in the elderly population sented with an ISS ≥ 16 were more likely to have
[3, 5]. Extensive guidelines on primary assess- sustained a fall from any height [48, 60] and less
ment, imaging indications, and normalization of likely to have sustained a firearm injury [60].
the lowering of the International Normalized When comparing younger and older groups,
Radio (INR) have been published in an attempt to same-level falls resulted in serious injury 30% of
prevent the disastrous outcomes associated with the time in the elderly group compared with 4%
severe TBIs [52–54]. in the younger patients [48]. In the same study,
A 6-year retrospective chart review (2004– falls from standing height were also responsible
2010) from a level I trauma center reported the for an ISS above 15, approximately 30-fold more
frequency of fracture location in high-energy in the elderly group [48].
(ISS ≥ 16) geriatric traumas. Elderly most often Low energy falls are responsible for more than
sustained a fracture to the spine (74%), followed 50% of traumatic-related deaths in patients over
by the pelvis (35%), femur (31%), forearm 65 years old, while they account for only 9–11%
(24%), clavicle (23%), scapula (21%), tibia/fib- of injury-related deaths in younger individuals
ula (19%), ankle (17%), acetabulum (10%), [61, 62]. Additionally, the elderly are up to 4
6 M. Comeau-Gauthier et al.

times more likely to die from a fall compared As such, healthcare providers should maintain a
with patients under the age of 65 years old [3, high suspicion index for chest injuries in this
49]. Traumatic brain injury [4, 63, 64] and long population and scrutinize radiographs for chest
bone fractures [4] are the leading cause of mor- wall fractures that are easily missed on plain,
tality and morbidity following a fall. Other inju- low-quality, radiographs taken in the trauma bay
ries that commonly occur to the elderly following [35].
ground-level falls are cervical spine fractures, rib
fractures, and pelvis fractures, which are most
frequently lateral compression injuries, while 1.3.3 Pedestrian Injuries
abdominal injuries are rare [64]. Death-related
falls from a low height (≤3 m) are most com- In regard to pedestrian injuries, tibia and com-
monly associated with fractures of the skull, cer- bined tibia and femur fractures are more common
vical spine, and thoracic injuries and are more in adults and the elderly, whereas femur fractures
likely to occur as the height of the fall increases, are more common in children [15, 17]. This pro-
whereas fracturing of the lower extremities is pensity for femur fracture is likely related to the
more likely to occur as the height of the fall patient’s height and location of the first impact.
decreases [65]. In the same study, postmortem In general, patients older than 55 years will have
skeletal analysis reports only a rare incidence of more intracranial injuries [15, 17, 68], upper [68]
upper extremity fractures in cases of fatal low and lower extremity fractures [15, 17, 68], and
free falls [65]. Growing evidence supports the more pelvic fracture [15, 68], but similar rate of
promotion of ground-level falls as high-energy solid organ injury [17, 68], abdomen [17, 68],
mechanism of injury in geriatric trauma. and GI injuries [17, 68]. The seriousness of the
injuries also showed a significant linear increase
with increasing age [15, 17] along with mortality
1.3.2 Traffic-Related Injuries rate [3, 15, 17, 68]. While spinal injuries are
uncommon in children and young adults, the risk
Traffic-related injuries account for 10–25% of of spinal injuries increases significantly with age
trauma admission in the elderly population [3]. [15, 17], demonstrating the importance to have a
Although this particular population does not nec- high index of suspicion when evaluating the
essarily have a higher incidence of traffic-related spine in elderly patients.
accidents [35], they have twice the mortality rate
as compared to their younger counterpart [3, 35–
37, 66, 67], either as a driver, a passenger, or a 1.3.4 Other Mechanism of Injuries
pedestrian. Patients aged more than 55 years old
are more likely to sustain severe (ISS ≥ 16) or Other mechanisms of injuries include penetrating
critical injuries (ISS ≥25) with a higher rate of trauma, abuse and assaults, and burns. They are
severe head injuries (AIS head/neck score ≥ 3) less frequent in the elderly compared with their
[18, 36], spinal injuries [18], pelvis fractures younger counterparts; nevertheless, they are
[18], and chest injuries [18, 35–37], from which associated with higher mortality, longer ICU stay
the three most common include rib fractures [35– [69], higher morbidity [69], more complications
37], flail chest [35], and sternum fractures [35]. [69], and longer length of hospital stay [69] and
While younger patients have a higher rate of less likely to be discharged home [69]. Geriatric
abdominal, solid organ (spleen, liver, kidney), patients have the highest suicide risk among all
and facial injuries [18, 35], operative rates for age group [70] and constitute the third leading
chest, abdomen, and musculoskeletal injuries are cause of injury in this population [71]. Patients
similar for both group ages [35]. Moreover, the older than 75 years were significantly more likely
number of rib fractures has been correlated with than patients 55–74 years old to suffer self-­
increased mortality and risk of pneumonia [37]. inflicted injuries [72]. The most common meth-
1 Epidemiology 7

ods used are firearms and jumping from height decrease in hospital mortality or ICU length of
[73, 74], both of which are associated with the stay [87]. Others have reported a slight, but
highest case-fatality rate [1]. barely significant, improvement in mortality
rates over the past 10 years [83, 88].

1.4 Outcomes
1.4.2 Discharge Status
1.4.1 Comorbidities and Mortality
Elderly trauma patients are more likely to be dis-
The in-hospital death rate in geriatric trauma vic- charged into a care facility compared with
tims has been estimated from 15% to 30%, younger patients with similar injuries [36].
whereas mortality in younger patients has been Grossman et al. [78] examined long-term sur-
estimated at 4–8% [8, 75–78]. One explanation is vival and functional status in geriatric trauma
the higher comorbidity rate compared with patients 5 years after previous study completion;
younger patients [49, 50, 79], longer Intensive nearly half of the patients were still alive, with
Care Unit (ICU) stay [3, 35], and higher rate of 22% of geriatric patients still living at home. The
overall complications [3, 80, 81], which increase authors report that although it was not possible to
the likelihood of death or severe disability [50]. determine the true cost-effectiveness of this out-
In a meta-analysis by Hashmi et al. [8], combined come, it is likely considered as a desirable out-
odds of dying in those older than 74 years was come following trauma and appreciable long-term
1.67 (96% CI, 1.34–2.08) compared with patients survival with a reasonable functional status can
aged 65–74 years old, while no significant differ- be anticipated for some [78]. In another study,
ence was observed between those aged recorded discharge disposition demonstrated that
75–84 years old compared with those older than 45% of patients were ultimately discharged
84 years old. However, registry-based cohort home, and 76% returned to baseline indepen-
reported a linear relationship between age and dence with activities of daily living or returned to
mortality rate [47, 82, 83]. Among all injuries, the baseline level of activity [89].
head traumas, spinal cord, and extremity injuries The ISS and comorbidities appear to play a
have the highest risk of in-hospital mortality, role in predicting mortality, but not necessarily
with severe head injury correlating with mortality functional outcome and discharge status [11, 32,
the most [4]. 89]. Geriatric patients older than 80 years have
Geriatric status [80, 81, 84], ISS (≥9 and poorer functional outcomes than those aged
≥16) [47, 63, 76, 80–85], GCS (≤8) [20, 47, 63, 65–80 years [90]. Furthermore, geriatric patients
76, 81–83, 85], intubation [20, 47], coagulopa- who do not respond to aggressive resuscitation
thy and blood thinners [20, 63], anemia [63, 85], efforts within a timely fashion are more likely to
fluid requirements [76, 82, 84], dementia [86], have poorer outcomes [11]. The EAST guide-
and pre-existing pulmonary conditions [86], lines propose to consider less aggressive resusci-
cardiovascular [80, 81, 86] or liver disease [80, tation measures in “non-responders” or without
81, 86], and chronic renal failure [20, 81, 86] improvement within 72 h in patients with initial
have been shown to be predictors of mortality. GCS score less than 8 [11, 12]. Although elderly
Similarly, the development of cardiovascular victims are at higher risk of mortality and mor-
complications [76, 80], ARDS [76], renal fail- bidity than younger patients, we are not able to
ure [80] or infections [47, 76, 80], and geriatric accurately predict functional outcomes based on
status [80, 81, 84] also contribute to a higher initial presentation, with the exception of severe
mortality rate. A retrospective review compar- head injury [11]. This requires prompt and
ing mortality and outcomes in the early decade aggressive treatment program to allow geriatric
vs late decade could not report a significant patients to regain their preinjury functional level.
8 M. Comeau-Gauthier et al.

1.4.3  alliative Care and Withdrawal

P and productive members of society, even after a
of Care significant trauma [50].

A recent evidence-based review by EAST has

not shown a definitive and solid evidence to jus- References
tify the use of routine palliative care in the geri-
atric population, while no studies have 1. (COT) ACoSACoT. National Trauma Data Bank
effectively assessed the impact on discharge Annual Report 2016. 2016 [cited 2020 August
21]; Available from: https://www.facs.org/quality-­
disposition, quality of life, pain, and long-term
programs/trauma/tqp/center-­p rograms/ntdb/
functional status [7]. The argument for routine docpub.
palliative care in geriatric trauma patients is 2. Henary BY, Ivarsson J, Crandall JR. The influence of
driven by the decreased length of stay [91–93] age on the morbidity and mortality of pedestrian vic-
tims. Traffic Inj Prev. 2006;7(2):182–90.
and hospital costs [91] without negatively
3. Lowe JA, Pearson J, Leslie M, Griffin R. Ten-year
impacting mortality in the ICU [94, 95]. incidence of high-energy geriatric trauma at a level 1
However, Kupensky et al. [93] compared geri- trauma center. J Orthop Trauma. 2018;32(3):129–33.
atric trauma patients who had received a pallia- 4. Thompson HJ, McCormick WC, Kagan
SH. Traumatic brain injury in older adults: epidemiol-
tive medicine consultation compared with those
ogy, outcomes, and future implications. J Am Geriatr
who had not; patients receiving palliative care Soc. 2006;54(10):1590–5.
were significantly older, had higher mean ISS, 5. Mandavia D, Newton K. Geriatric trauma. Emerg
and higher mortality rate than patients who did Med Clin North Am. 1998;16(1):257–74.
6. Lomoschitz FM, Blackmore CC, Mirza SK, Mann
not receive palliative care.
FA. Cervical spine injuries in patients 65 years old
Withdrawal of support remains more common and older: epidemiologic analysis regarding the
in the very old patient. There remains a paucity of effects of age and injury mechanism on distribu-
documentation in regard to advance directives tion, type, and stability of injuries. Am J Roentgenol.
2002;178(3):573–7.
and code status [96, 97]. Patients receiving palli- 7. Aziz HA, Lunde J, Barraco R, Como JJ, Cooper
ative medicine care were significantly more Z, Hayward Iii T, et al. Evidence-based review of
likely to discuss advanced directives and resulted trauma center care and routine palliative care pro-
in consensus around goals of care [93]. cesses for geriatric trauma patients; A collaboration
from the American Association for the Surgery of
Trauma Patient Assessment Committee, the American
Association for the Surgery of Trauma Geriatric
1.5 Conclusion Trauma Committee, and the Eastern Association
for the Surgery of Trauma Guidelines Committee. J
Trauma Acute Care Surg. 2019;86(4):737–43.
The geriatric population is expected to live lon- 8. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ,
ger, with more comorbidities, while having more Friese RS, et al. Predictors of mortality in geriatric
active lives much more later in life, thereby trauma patients: a systematic review and meta-­analysis.
engaging in activities that increase the risk of J Trauma Acute Care Surg. 2014;76(3):894–901.
9. McCoy GF, Johnstone RA, Duthie RB. Injury to the
high-energy trauma [3]. One must recognize elderly in road traffic accidents. J Trauma Acute Care
one’s own bias regarding treatment of the geriat- Surg. 1989;29(4):494–7.
ric patient as well as the increased mortality rate 10. Marciani RD. Critical systemic and psychosocial
associated with this specific population even in considerations in management of trauma in the
elderly. Oral Surg Oral Med Oral Pathol Oral Radiol
instances of low energy traumas. Evidence sug- Endodontol. 1999;87(3):272–80.
gests very little, if any, improvement in incidence 11. Jacobs DG, Plaisier BR, Barie PS, Hammond JS,
rates of fall-related injuries and death and the Holevar MR, Sinclair KE, et al. Practice management
need for much-needed investment in preventive guidelines for geriatric trauma: the EAST Practice
Management Guidelines Work Group. J Trauma
measures. No specific factors have been found to Acute Care Surg. 2003;54(2):391–416.
be predictive of functional outcomes, and aggres- 12. Calland JF, Ingraham AM, Martin N, Marshall
sive management is warranted as there remains a GT, Schulman CI, Stapleton T, et al. Evaluation
substantial potential to retain the elderly as active and management of geriatric trauma: an Eastern