Challenges of Managing the Older Surgical

Patient Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training 2013

Boomers are booming Every day 10,000 people turn 65 Life expectancy is 76.5 years

By 2050 1 in 5 Americans > 65

U.S. 2010

Scope of the problem • Frequency of geriatric trauma is on the rise • Compared with younger patients, geriatric

patients have higher rates of morbidity and mortality 1

• Injury is the 7th leading cause of death in elderly 2

• 1/3 of trauma deaths are in the elderly 2 • All trauma patients have high residual

mortality for years after the initial injury 2

1. Champion HR, AJPH, 1989 1. Morris JA, JOT 1990 2. CDC 3. Davidson, JAMA 2010

Most have good outcomes

• Up to 85% of survivors will function independently after discharge

• No clear cutoff where age is predictive

• Initial aggressive treatment for most • Non-responders have poor outcomes

East Guidelines, 2001 DeMaria, EJ, JOT, 1987

Mechanism of Injury by Age

• Annual incidence of falls: 30% age> 65, 50% age> 80

Lieberman et al.Can J Surg, 2003

Falls and…

• MVC • > 75 = highest crash

fatality rate

• Pedestrian struck • Changes in gait and posture, impaired hearing and Vision

• Violence • Assault, elder abuse

• Burns • Larger, deeper • 8% of injury related deaths

The challenges

Patients aren’t always what they appear or who their families tell you they are

Injury is only part of the problem

Weigh achievable outcomes

vs. the burden of care

Underlying causes • 84 yo M restrained single driver, HSMVC • On Warfarin, in shock with negative FAST • Acute decrease in mental status in the trauma bay

requiring intubation

Day 1: Subdural hemorrhage

The real culprit

DAY 3: Large right MCA stroke

He’s vigorous and sharp as a tack… • History from wife and children is that he’s

able to perform ADLs But when you probe

• Has been having mild memory and hearing

loss • Doesn’t drive very far anymore • Messing up the bills • He just hasn’t been feeling well lately

It’s all downhill…

2/17/2013

Some physiologic changes with age Cardiac Compliance

Vascular resistance max HR adrenergic response

Pulmonary Compliance Elasticity Diaphragmatic breathing

Endocrine Response to thyroid hormone Cortisol axis

2/17/2013

Changes in renal function

⇓ Thirst drive ⇓ Ability to clear

free water ⇓ Ability to

concentrate urine

Men Women

Levey AS, AMKD, 2009

Volume overload

Living on the edge…

http://www.ouhsc.edu/geriatricmedicine/education/Homeostenosis/HomeostenosisNew_Interpretation_of_Homeosteno.htm, accessed Feb, 2012

Comorbidities

• Trauma patients > 65 = 30% 1 • Trauma patients > 75 = 69% 2 • Associated with increased mortality and LOS 3

• But decreasing effect with age

Schwab, CW In Early care of the Injured patient, 1990 Milzman, DP, jot 1992 Morris JA, JOT, 1989 MacKenzie, EJ, JOT 1989

COMMON COMORBIDITIES

Cardiovascular HTN CAD CHF

Pulmonary COPD

Metabolic Hypothyroid Diabetes Obesity

Renal Chronic renal insufficiency

Neurological CVA Dementia

Psychiatric Depression Substance abuse

Trajectory of frailty • 7% of patients over 65 and 30% of patients over

80 are frail.

Singh M, et al. Mayo Clinic Proceedings 2008

The cycle of frailty

Singh M, et al. Mayo Clinic Proceedings 2008

Measures of frailty

Criteria Definition Shrinkage Unintentional weight loss

Weakness Decreased grip strength Exhaustion Poor energy and endurance

Low physical activity Low weekly energy expenditure

Slowness Slow walking

Fried LP, et al, J Geront A Biol Sci, 2001

Delirium • Prevalence rate 14-24% in hospitalized patients • Complicated 2.3 MM hospital stays in older persons • Costs $4 Billion

Risk factors Precipitants

Severe illness Cognitive impairment Dementia Infection Electrolyte or metabolic abnormalities Fracture Neuroleptic or narcotic use Male gender Age > 80

Physical restrains Malnutrition Male ETOH abuse Cognitive impairment Hypoxia Depression Preop electrolyte abnormalities Cardiac or vascular surgery

Inouye, SK, JAMA, 1996

Inouye, SK, JAMA, 1996

From: Marcantonio, ER et al . A clinical predictive rule for delirium after elective non-cardiac surgery. JAMA 1994;217:134-139

Inci

denc

e (%

)

p<0.001 for all comparisons

Delirium Bad outcomes

Marcantonio, ER et al. JAMA 1994;217:134-139

Old patients don’t get hungry or thirsty

http://www.mna-elderly.com/causes_of_malnutrition.html

Malnutrition in the elderly across settings

86% 67%

38%

91%

Hospital Nursing Home

Community Rehabilitation

Aspiration

Kozlow JH, et al. Crit Care Med 31:1930, 2003

Postoperative aspiration increases with age

High intensity care at the end of life

http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18, access Feb, 2012

High use of surgery in least year of life

Kwok et al, Lancet, 2011

Surgery leads to more hospital days and more days in intensive care during the last year

Kwok et al. Lancet, 2011

Key concept: Burden of care Burden of care High

Intensity %

Low Intensity

%

P value

Want to spend last days in hospital 8.4 8.4 NS

Want potentially life saving drugs that make me feel worse all the

time

14.4 16.5 NS

Want palliative drugs even if they are life shortening

77.7 73.4 NS

Mechanical ventilation if it would extend life by 1 month

21.0 21.4 NS

Mechanical ventilation if it would extend life by 1 week

12.1 11.7 NS

Barnato et al.: Med Care. 2007 May;45(5):386-393

Take home points

• Injury is often caused by other geriatric syndromes and comorbidities

• These folks can’t take a joke

• Be aggressive at first but reassess early

Risk

Benefit