Trauma and the Old Patient

8/14/2019 Trauma and the Old Patient

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Western countries are continuing to age rapidly. By 2030, more than 25% of Western populations will be

over 65 years of age (Mandavia 1998). This phenomenon will alter the face of health care. The developing

world is also ageing rapidly. Patterns of health need are therefore changing dramatically across the whole

world. In older people, injury generates a disproportionately greater amount of health care costs (Mandavia

1998). It is therefore imperative that trauma services and other health care services understand the

principles of effective care of older people.

Interactions of multiple comorbidities, disabilities, medications, undernutrition, psychosocial issues,

environmental factors and ageing per se, whilst being unpredictable in the individual patient, are

increasingly common with advancing age. The resultant effects on physiology and physiological reserves

of many older people may render them more vulnerable to the effects of physical trauma and ensuing

complications (Horan et al. 1992). Trauma or post trauma care of older people therefore presents special

challenges to clinicians involved at the various stages of care, from site of injury to rehabilitation.

Causes and patterns of injury in older people are quite different to those of younger people (Martin andTeberian 1990). Health and physiological changes of older people are heterogeneous and therefore

unpredictable. Numerous studies of outcomes in older people indicate that comorbidities and physiological

changes are more important than age per se in predicting outcome from various medical and surgical

conditions (Grisso and Kaplan 1994). Individualized assessment is always required. Management

principles which guide the clinician are covered in later in this chapter.

Epidemiology

Overview (Baker et al. 1992, Fildes 1994, Schiller et al. 1995)

Trauma facts: older versus younger people:

Overall falls are the most common cause of injury. Motor vehicle accidents (MVA) predominate in

younger people

Incidence of trauma is relatively less common

Recurrence of trauma is more likely

Trauma is relatively less severe

Consequences of trauma are more serious

More injury occurs per unit force as age increases

Length of hospital stay longer

Increased cost per capita

Outcomes tend to be poorer in older people.

Currently the over 70s comprise over 15% of the US population. It has been predicted that those aged

over 85 years will comprise about 14% of the US population by the year 2000 (Baker et al). In Australia the


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over 65 years population is expected to increase to about 20% of the population in 2031, equating to a

three hundred percent increase from 1986 figures (Kallman and Kallman 1989). As a group, older people

are less likely to suffer trauma than younger people (van Aalst 1991, Fildes 1994) and when they do suffer

trauma it tends to be less severe (De Keyser et al. 1995).

In the USA, trauma is the fifth most common cause of death for persons over the age of 65 (Martin and

Teberian 1990). In Australia, 102 females and 141 males incur injuries per 100,000 over 65 years (Fildes

1994). The death rate rises exponentially with age, increasing dramatically over the age of 75 years

(Mandavia D 1998). In the USA, although older people represent only 14% of the population, they account

for 28% of fatalities and over 30% of trauma health costs (Oreskovich 1984). Weingarten (1982) reported

that trauma was usually less serious in older people but more costly. More over 85 year olds die from falls

than 18 to 19 year olds from motor vehicle crashes (Baker et al. 1992). Younger elderly are much less

likely to be injured by falls.

Overall, older people are less likely to be injured than younger people. In 1989 there were 16.5 episodes of

injury per 100 persons over the age of 65 compared to 23.8 per 100 persons for all ages (Levy et al.1993). However injuries in this age group are more likely to have a fatal outcome. In the USA 30,000 older

people die from trauma every year. A 12 month survey (Spaite 1990) of all trauma admissions of a 370,000

population found that 30% of 1,154 patients reviewed by trauma paramedics were over the age 75 years.

Females accounted for 65%. Of the 1,154, 53% were 70 79 years, 39% were 80 89 years and 7.6 % were

over 89 years. Trauma calls were 30% for over 70's and 52.3% for younger people. Trauma cases over 65

years old were more likely to be transported to hospital (75% vas 49%) than cases under 65 years. Gerson

and Skvarch (1982) reported that the elderly required advanced life support transport twice as often.

Although the outcome following trauma is worse with increasing age, aggressive treatment in older people

usually has a favourable outcome.

Under reporting of injury related death in the elderly appears to result from a bias to attribute death to

medical conditions either contributing to or resulting from trauma related death (Fife 1987).

Elder abuse, which is notoriously difficult to detect, is an under-reported cause of injury. Its prevalence is

estimated at between 3 and 5% of the elderly population (Kurrle et al. 1991).

Trauma recurrence is high in the elderly (Gubler 1996) and probably represents the recurrent nature of

falls and falls injuries of those who have already fallen.

Key points

Falls as compared to MVAs are the most common cause of trauma in the elderly

Trauma in the elderly is less severe but the consequences are more serious including longerhospital stays


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Injury mechanisms (van Aalst et al. 1991, Baker et al. 1992, Fildes 1994, Osler et al. 1994, Preston Smith

et al. 1990, Zietlow et al. 1994).

Causes of injury in usual order of prevalence are listed below. These are based upon surveys in Western

countries, which have used different methods, biased populations selection and different definitions and

parameters. Many trauma surveys followed patients through trauma retrieval systems and are therefore

biased against detecting injurious falls in older people.

1. Falls 40 to >80% (increasing percentage with increasing age).

2. Motor Vehicle Accidents over 20%

3. Suicide - 10%

4. Burns


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sometimes contradictory (De Maria 1993). Some facts appear to be reasonably clear and are outlined

below.

Morbidity in the elderly patient increases with injury severity (Knudsen at al 1994). In general, head injuries

are related to a worse outcome than other types of injury in the elderly (Zietlow 1994, van Aalst et al.

1991). Falls and pedestrian injuries and the presence of injury to the brain chest or abdomen are

significantly associated with mortality (Knudsen at al 1994).

Mortality from a defined level of trauma increases as age does from about 10% at age 45, to 15% at age

55, and 20% at age 75 (Finelli et al. 1989). Studies defining elderly as either >65 or >75 report mortality

rates ranging from 20% to 40% (Broos at al 1993, Zietlow et al. 1993, Knudson et al. 1994, van Aalst et al).

However, hospital mortality for fractured femur is only 5%. Trauma outcome is significantly poorer for older

people over the age of 85 (Shabot and Johnson 1993). This undoubtedly relates to comorbidities, which

predispose to complications. Severely brain injured (Glasgow Coma Scale (GCS) of five or less) elderly

patients experience a higher mortality (up to 80%), die more frequently from secondary organ failure, havepoorer functional recovery and consume more resources per favourable outcome than younger injury

matched patients (Pennings et al. 1993). Although trauma mortality and recovery is significantly worse

than that for younger people, several studies indicate that aggressive treatment of older trauma patients is

warranted. Based on a number of studies, between 55 to 80% of older people survive serious trauma

(Shapiro et al. 1998, and De Maria 1987). The majority of severely injured geriatric patients who survive

their injury return to some degree of independent living (van Aalst et al. 1991 and De Maria 1987).

Pedestrian death rates rise with age. After controlling for injury severity, injury severity score and

mechanism of injury, death rate rises from 10% after the age of 45, increasing to 20% at age 75.

Interestingly, trauma outcome could not be correlated with pre-existing disease in a survey by Preston

Smith (1990). In their review of critical care outcome in the oldest old trauma patient, Shabot and Johnson

(1995) state, decisions regarding outcome should be based on severity of illness rather than age, trauma

type or injury severity.

Physiological status in the emergency department appears to influence outcome. Mortality risk increases

with decreasing admission trauma score using either Trauma Score or Revised Trauma Score (Knudsen

et al. 1994). (Trauma Score comprises systolic blood pressure, capillary refill, respiratory rate, respiratory

expansion and Glasgow Coma Scale (GCS); whereas Revised Trauma score comprises systolic blood

pressure, GCS and respiratory rate). Hypotensive shock on arrival is a poor prognostic indicator (Horst et

al. 1986 and van Aalst 1991) and enhances mortality with increasing age (Osler et al. 1988). One study

found a statistically significant relationship between hypotension in the emergency department and

subsequent infection. Hypoventilation (respiratory rate of 30 have a poor prognosis. Requiring intubation upon admission is associated with poor outcome

(Pellicane et al. 1992). Complications including infection and multi-organ failure are common in the elderly

(occurring in up to one third) and influence morbidity and mortality (De Maria 1993).


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During admission, the following factors are associated with poor outcome: pulmonary infection, need for

prolonged mechanical ventilation, central nervous system injury, burns and hypovolaemic shock (De Maria

1987).

One complication will increase mortality from 5.4% to 8.6%. Two or more complications are associated

with a mortality of 30% (Preston Smith), indicating that elderly patients do not tolerate complications well.

Preventable complications in older patients with moderate degrees of injury warrant more aggressive care

than that required by younger patients (De Maria et al. 1987, Pellicane et al. 1992, Broos et al, Scalea et

al. 1991).

In one study, preventable complications which contribute to death occurred in 32% of all deaths and 62%

of organ failure deaths (Pellicane et al. 1992). The most common preventable complication was pulmonary

aspiration of naso-gastric or naso-duodenal feeds, despite chest X-ray confirmation of correct feeding tube

position. The authors suggest admitting all patients with Trauma Score < 15 to intensive care units.However, this accounts for 50% of all older trauma patients in his series.

Poor in hospital functional status at discharge has been associated with diabetes and dementia. Inpatient

factors such as premorbid functional status, cognition, nutritional status have not been included in most

trauma outcome studies.

Marriage has positively associated with in hospital post trauma functional outcome (Radke et al. 1992).

Rehabilitation requirements are high. Many of the studies examining outcome have not included long term

rehabilitation outcome in detail, including quality of life issues.

Key points

Head injuries have a poorer outcome than any other type of injury

Mortality from a defined level of trauma increases with age, trauma outcome is significantly

poorer for those over age 85

Lower trauma scores on admission are correlated with increased risk of mortality

Physiology (Horan et al. 1992, Schneider and Rowe 1990 and 1996, )

General

Summary of key features of physiology of ageing:

1. Causes of physiological decline:

genetically determined component

disuse (especially musculoskeletal and cardiovascular)

disease (obvious and occult)


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2. Heterogeneous- great variance of physiology of older populations

3. Unpredictable in an individual

4. Ageing per se does not cause disability

5. Drugs commonly exacerbate impaired physiology

Average ageing- an epidemiological concept (Rowe 1987)

Many physiological changes have been described in aged populations. As a population ages, there is

increasing scatter around the mean of any particular physiological function. The elderly are a

heterogeneous group in whom chronological age may be a poor indicator of a patient's physiological

status. Average population data do not always translate to clinical practice. Contributing multiple sub

clinical diseases impair the clinicians ability to predict physiological alterations in an individual.

Cardiovascular impairment may not be apparent on initial assessment. The onset of sepsis or relatively

minor blood loss may cause rapid decline in haemodynamic homeostasis manifesting as precipitous and

unexpected shock.

Ageing per se (Rowe 1987)

Ageing itself does not cause physiological decline to the extent that an older person's ability to function

and live independently is impaired. Disability is always due to disease. Some older people have

physiological performance that exceeds that of some healthy younger individuals. The true contribution of

the ageing process to physiological decline is less than previously thought (Bortz 1989). Many non

Western cultures have demonstrated remarkable absence of degenerative diseases that were once

thought to be part of the ageing process. Sensorineural hearing loss, systolic hypertension and

subsequent left ventricular hypertrophy, arthritis and coronary artery disease to name a few, seem to be

degenerative consequences of Western lifestyle superimposed upon the ageing process (Svanberg and

Selker 1994, Schneider and Rowe 1990). Pre-conceived notions about ageing seem to have caused

nihilistic approaches to care in some quarters and not the least affected the attitude of older people to

themselves (Ogle 1998).

Trauma places demands on physiological systems, which extends them to the maximum.

Relevance

In older trauma patient, physiological changes may have the following adverse effects (Horan et al. 1992),

including:

increased propensity to sustain trauma

increased severity of injury per unit force

disturbed maintenance of homeostatic mechanisms

increased risk of complications e.g. infections

prolonged healing rate

prolonged rehabilitation


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There is an increased probability of comorbid disease processes and drug effects contributing to impaired

physiological reserves in the elderly patient.

Possibly the two most important factors which influence physiological processes in older people are

nutritional status and physical activity. Both influence body composition (and therefore

pharmocodynamics), cardiovascular function, immune function, thoracic muscle function, sarcopaeniadevelopment, osteoporosis and thermoregulation. Nutritional status and physical activity are important in

preventing trauma and rehabilitation after trauma.

Nutrition

Nutritional status is implicated in the aetiology of many chronic diseases. Undernutrition is a major

predictor of poor outcome for older people in general (Lehmann 1989, Sullivan et al. 1991 and Sullivan et

al. 1994). Most surveys agree that about 50% (between 20 80%) of community dwelling older people are

undernourished depending on the definition used (Lipski 1995). Undernutrition in residential care

populations occurs in up to 80% of residents.

Assessment of nutritional status in the trauma patient is based on multiple measures, including i. estimates

of usual dietary intake premorbidly (dietary history), ii. evidence of recent weight loss, iii. anthropometric

measures of fat and muscle, iv. laboratory measures of blood count, simple biochemistry ,Vitamin B12,

folate, iron studies and serum proteins (albumin, retinol binding protein, and thyroxine binding protein),

which can be used as nutritional indices in the elderly patient. A medical history and examination may

reveal causes of malabsorption or diseases causing increased nutritional requirements.

Undernutrition in the older trauma patient relates to its adverse affect upon:

fat and collagen integrity reducing soft tissue protection to the skeleton and internal organs

capillary and small vessel integrity and therefore propensity to bleeding

immune function, especially cell mediated immunity increasing susceptibility to infection

thermoregulation (mild degrees of hypothermia in older people cause reduced balance

coordination and impaired cognition which probably contribute to Winter-time falls)

possible increased risk of osteoporosis and therefore fractured femur

muscle function pre and post trauma

delayed wound healing (Zinc and vitamin C are associated with improved wound healing rate)

mortality, morbidity, domicile after hospital care and functional status (nutritional supplementation

improves these outcomes) (Delmi et al. 1989)

In an individual patient with undernutrition, the cause is usually multi factorial.

Contributing factors include:


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1. Increased nutritional requirements

infection

some drugs, e.g. corticosteroids, anticonvulsants, antibiotics

injury

2. Reduced intake

sub-optimal dietary choices

anorexia due to GUT problems, sepsis, depression, narcotics, antibiotics

oral and chewing problems

impaired taste

swallowing problems

abdominal pain

diarrhoea (fear of)

3. Poor digestion / assimilation

undernutrition

achlorhydria

antispasmodics, anticholinergic, anticonvulsants and other drugs

malabsorption

Nutritional supplementation is associated with improved nutritional status, immune function, fewer

infections, improved respiratory muscle function in chronic lung disease patients and overall fractured

femur outcome.

Optimizing nutritional status is best achieved by provision of small frequent meals rather than larger meals

three times daily.

Key points

Undernutrition in the elderly is common and is an important aetiological factor in many chronic

diseases in the elderly

Body composition and sarcopaenia (Bennett and Gwinn 1998)

Total body weight plateaus between age 40 to 60 then undergoes a gradual decline. The fat free (lean)

mass tends to decline and body fat increases in a centripetal pattern. Much of the observed changes are

reversible. Muscle is an important source of metabolic protein because the majority of hospitalized older

trauma patients are unable to ingest adequate protein and other nutrients in the acute phase (Older et al.

1980, Delmi et al. 1990). Researchers have suggested that increased body fat is protective for hip


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fractures.

Sarcopaenia is a syndrome of ageing with a major contribution from disuse (Bloomfield 1997, LeBlanc et

al. 1992), undernutrition and age (Fiatarone et al. 1993).

The average 80 year old will demonstrate a 30 to 40% decline in voluntary strength of arm, leg and back

muscles compared to people aged 30 years. A significant proportion of older people will experience greater

declines from the average and can be said to define the frail elderly. This marked decline in muscle mass

and strength not only impedes the older persons ability to participate in basic activities of daily living, it also

predisposes the older person to falls and possibly other injuries due to reduced ability to protect

themselves during falls. Muscle may also act to protect internal organs from injurious impact. Muscle

weakness is also a significant predictor of mortality, self reported disability, nursing home entry and

relevant to functional recovery following trauma (Bassey et al. 1992, Guralnik et al. 1994).

Bone mass is closely correlated with muscle mass. Risk of fractured femur is increased by both low bonemass and muscle mass. Increasing muscle mass seems to increase bone mass in older people (Nelson et

al. 1994, Ryan et al. 1994).

Bed rest is associated with up to 5% loss of lower limb muscle strength per day. For those who already

have compromised strength, the consequences of bed rest may lead to inability to walk.

Immune function (Alder and Nagel 1994, Schneider and Rowe 1996)

The immune system comprises 8% of lean tissue mass. Involution of the thymus, beginning at puberty and

complete by middle age, may represent the first age related decrements in the immune system. Although

healthy older people have defects in both B and T cell activation, decline in cell mediated function is the

primary deficit in the older persons immune system.

Protein calorie undernutrition, and micronutrient deficiencies (zinc, selenium and vitamin B6) result in

decreased lymphocyte proliferation and decreased cytokine release (Lesourd 1997) closely resembling the

defects associated with ageing per se. These act cumulatively to seriously compromise immune function.

Older trauma patients, especially those who have suffered falls commonly have borderline nutritional

status. Following trauma, nutritional requirements increase while nutritional intake and / or assimilation are

commonly impaired.

Supplementation with micronutrients including Vitamin B6, Zinc, Vitamin E and B carotene is associated

with improved immune function measures including immune cell cytokine production and response

(Chandra 1992). Supplementation of elderly patients post fractured femur is associated with much

improved clinical outcome, including a trend to fewer infections, improved functional status, and reduced

morbidity and mortality at 6 months (Bastow 1983b, Delmi 1990). In community dwelling elderly people,

improved immune function is observed when intake of micronutrient exceeds the accepted RDI.


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Nutritional status is also relevant to susceptibility to the development of decubitus ulcer and secondary

infection of decubitus ulcers, which are common signs of malnutrition in institutionalized elderly patients.

Decreased particle clearance by the lung and poorer skin integrity with slower healing contribute to

increased susceptibility to infection

Key points

Cell mediated function is the primary deficit in the older persons immune system

Immune function is compromised by nndernutrition but improves with supplementation

Clinical relevance

Immune deficits are very common. Nutritional supplementation may reduce infection risk and skin

breakdown.

Cardiovascular (Lakatta 1990)

In older populations who have been screened to exclude cardiac disease, resting heart rate and cardiac

output do not appear to change significantly. However, at maximal exercise significant reductions of heart

rate, cardiac output and aerobic capacity occur with increasing age. In healthy older people, increases in

left ventricular filling lead to an increase in stroke volume, thereby partly compensating for the effect lower

maximum heart rate has on maximal cardiac output. With age, arterial compliance usually decreases,

resulting in increased arterial peak systolic pressure. Mild left ventricular hypertrophy develops as a

consequence and is associated with diastolic dysfunction. The heart becomes more reliant upon atrial

contraction to maintain ventricular filling and stroke volume. Diastolic blood pressure tends to fall in healthy

older people attenuating the increase in mean blood pressure.

There decreased chronotropic and inotropic response to catecholamine stimulation, due to decreased B

adrenergic modulation. According to cross sectional studies, maximal oxygen uptake falls at about 1% per

year (Fries 1980). Longitudinal studies demonstrate a non linear decline, which is especially rapid in

sedentary individuals. With regular endurance exercise the decline may by attenuated by about 50%

(Buskirk and Hodgson 1987).

Clinical relevance

Coronary artery disease and cardiac dysfunction are common, occurring in up to 15 % of over 70 year olds

and in 20% of 80 year olds (Duncan et al. 1996). Cardiovascular and oxygen delivery responses to

physiological stress are likely to be variable. Hypovolaemia and iatrogenic hypervolaemia may not be well

tolerated. The increased dependence upon left ventricular filling is accentuated in hypertensives and those

with ischaemic heart disease due to diastolic dysfunction, the latter often being subclinical in many cases.


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Antihypertensive, antianginal and diuretic drugs increase the propensity for hypotension. Clinical diagnosis

of aortic stenosis and its severity is notoriously difficult in the elderly. Its presence will greatly impede the

hearts ability to increase cardiac output and cope with reduced end diastolic filling pressure in

hypovolaemia or hypotension due to drugs. After load reductions may lead to reduced coronary artery flow

and increase the risk of ischaemia. Septic endotoxaemia may precipitate injurious falls, may also impede

cardiac and peripheral circulatory function. Cardiac trauma causing contusion or pericardial effusion will be

less well tolerated. Cardiac and haemodynamic monitoring should be considered for less severe degrees

of trauma, especially where evidence of cardiovascular disease is present.

Respiratory (Tockman 1994, Ogle 1998):

Ageing is associated with i. increased fibrous tissue in the lung parenchyma and bronchial tree, ii. reduced

pulmonary elasticity, iii. decreased chest wall compliance and iv. reduced alveolar surface area, resulting in

increased airflow resistance and reduced vital capacity and diffusing capacity. The work of breathing is

increased. Function of respiratory muscles is reduced, especially in sedentary and undernourished

patients (Efthimiou et al. 1988). Compensation occurs through increased contribution from the diaphragm

and abdominal muscles. An increased closing volume (increased volume at which small airways begin to

close) results in increased residual volume (by 40 to 50% by age 70) and mild reduction of PO2 (due to

V/Q mismatch in closed airways). Other changes include slowed clearance of particles from airways,

decreased pulmonary afferent neural sensory function and ventilatory response to hypoxia and

hypercapnia. Gag and coughing reflexes may suffer some slowing. Diseases such as stroke, Parkinsonism

and severe undernutrition exacerbate these problems.

Clinical relevance

Oxygen saturation should be monitored routinely in patients suffering relatively minor trauma (such as falls

causing lower limb fractures), because narcotic analgesics, bed posture, cardiovascular deficits and

anaemia will impair oxygen transport. Tranquilizing drugs should be avoided in nearly all cases of delirium

because they will exacerbate confusion and promote hypoventilation. Phenothiazines and butyrophenones

cause drug induced Parkinsonism which can reduce ventilatory capacity. Pain management needs very

close monitoring for efficacy and hypoventilatory effects.

Renal, fluid electrolytes (Beck 1994, Goldberg et al. 1987)

The primary importance of progressive loss of glomerular filtration rate in older persons relates to drug

excretion and adverse drug reactions which are common in older people. Gradual glomerular sclerosis

occurs with a 10% reduction in renal blood flow, and an 8ml/min decrease in glomerular filtration rate for

every decade after 40. How much of this renal decline is due to renovascular disease is unclear. Serum

creatinine remains fairly constant due to declining muscle mass. Fluid and electrolytes remain relatively

constant, however there is a decreased ability to maintain homeostasis in response to stress. There is

evidence that ADH may be excreted more readily in response to hypovolaemia and other stimuli causing

SIADH more frequently. Due to defects in thirst, urinary concentrating ability and free water excretion,


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elderly patients are prone to either hypernatraemia or hyponatraemia. Urine output is a less reliable sign of

hypovolaemia due to the decrease in urine concentrating ability. In patients with low muscle mass, serum

creatinine may falsely underestimate renal function. Serum creatinine becomes unreliable as an accurate

measure of renal function. Creatinine clearance equations based on serum creatinine and weight are

better although these may be unreliable measures in very old people.

Clinical relevance

In the context of serious trauma, older people are more prone to renal toxicity due to aminoglycoside

antibiotics and acute renal failure due to drugs and diseases which affect:

renovascular homeostasis (e.g. ACE Inhibitors, NSAIDs, diabetes nephropathy, microvascular

and macrovascular disease),

plasma volume: (e.g. diuretics, reduced thirst sensation) and blood pressure(e.g. diuretics,

antihypertensives and antianginals).

Measurement of blood levels of aminoglycosides is essential. Reduced thirst sensation places older

people at greater risk of dehydration and pre-renal renal failure.

Gastrointestinal

Changes in the gut with ageing per se have relatively little effect upon the ability to digest and absorb food

and nutrients. In normal healthy older people, age does not appear to effect small bowel mucosal

morphology or absorption (Lipski et al. 1992). Pancreatic digestive activity is reduced. However under

normal conditions this decline still allows plenty of digestive reserve. Maximal fat absorption is mildly

reduced in normal elderly and significantly reduced in sick older people. This may present a problem when

older people are unwell and have increased fat and energy requirements. Hypochlorhydria is a problem

and may inhibit absorption of certain vitamins such as Fe, B12 and folate. Folate deficiency is relatively

common in older people. It induces small bowel morphological changes and inhibition of folate absorption.

Clinical relevance

Chronic disease and disability are associated with poor digestion and undernutrition (Lehmann 1989). Frail

and disabled older people are generally undernourished. Patients over the age of 75 years who have

suffered a fall are at greater risk of being undernourished at the time of trauma. As a result of trauma and

other factors associated with hospitalization such as drug induced anorexia, and sedation, their nutritional

status may rapidly decline.

With increasing age, constipation is increasingly prevalent. Although ageing per seems to have minimal

effect upon colonic function (Melkersson et al. 1983), frail older people have a higher prevalence of chronic

colonic hypomotility and are at risk of drug induced hypomotility (usually anticholinergics) and the effects of

immobility. Faecal impaction causes anorexia and is a precursor to ileus and colonic perforation. The latter

may be relatively asymptomatic in the sick older patient, particularly if pain relief and sedatives are


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prescribed. Prevention is usually successful with adequate hydration, dietary fibre and appropriate use of

aperients, suppositories and enemata.

Skin. (Kaminer and Gilchrist 1994)

The skin offers a barrier against trauma, infection, heat and cold. Changes seen with age which

compromise these functions represent the effects of sun damage as much as ageing itself. Flattening of

epithelial layers, loss of collagen fibre strength and elasticity and a decrease in subcutaneous fat

contribute to thinner and more fragile skin and therefore to an increased likelihood of injury to aging skin.

Slower proliferation of keratinocytes and a decrease in blood supply result in slower healing after trauma to

the skin. The dermis being less vascular and supported by less subcutaneous tissue offers inferior

insulation especially in older females. Sweat gland numbers and function are decreased thereby reducing

evaporative heat loss.

Clinical relevance

Skin care requirements increase in frail older people. Decubitus ulcer prevention requires more frequent

turning and increased use of specialized mattresses. Upper limb skin tears incurred during lifting are

common and usually preventable. Preventable hypothermia may occur in hospitalized older people

because of central temperature control impairment and reduced subcutaneous fat and impaired cold

sensation.

Vision. (Schneider and Rowe 1996, Grisso and Kaplan 1994)

The prevalence of visual problems is very high amongst older people. Visual acuity, impaired adaptation to

darkness, peripheral vision, depth perception, glare tolerance, contrast sensitivity and accommodation

may all be affected by age related changes, cataracts, macular degeneration, glaucoma and diabetic

retinopathy.

Clinical relevance

Visual impairment has been associated with falls and fractured femur (Grisso 1994). Monocular vision and

poor depth perception have been associated with increased risk of MVA. Regular driving assessments

should be performed in older people.

Balance. (Maki and McIlroy 1996)

Increased body sway and a loss in righting reflex begin to occur in the sixth decade. (see

Pharmacodynamics below). Maintenance of posture depends upon coordination, central processing of

inputs from vision, vestibular organs, proprioceptive pathways, muscle tone and strength. With increasing

age, the frequency and amplitude of corrective movements involved in postural control have been shown

to increase. Although the underlying mechanisms are complex and incompletely understood, the

dopaminergic pathway may play a role, explaining why age related reductions in dopamine 2 receptors in


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the striatum may contribute. Neuropathological studies indicate numerous additional age related brain

changes including a significant reduction in cerebellar purkinje cells. Muscle weakness due to disuse and

undernutrition is common and reversible with physical therapy and exercise.

Clinical relevance

Drugs and other factors affecting any of the major components of postural control may increase falls risk.

Examples are as follows:

central neural pathways- hypothermia, benzodiazepines, major tranquilizers: butyrophenones and

phenothiazines (which have specific anti dopaminergic activity and therefore may cause drug

induced Parkinsonism, appendicular tardive dyskinesia, risk of hypothermia and reduced

alertness)

muscle function- disuse, undernutrition and benzodiazepines

peripheral neural function- diabetes, drugs

vision and vestibular function- drugs and degenerative diseases of the inner ear and eyes

Thermal regulation (Bastow 1983a, Harchelroad 1993)

In normal ageing there is no clinically significant impairment of thermal control. However thermal control is

commonly abnormal in frail and unwell older people. Impairment of normal shivering responses, metabolic

rate response to cold, vasoconstriction and subjective appreciation of cold are common. Surveys of older

people in Winter-time have indicated a significant number of older people living in the community were

hypothermic chronically (Fox et al. 1973).

Clinical relevance

Reduction of temperature by as little as 0.5 to 1 degree Celsius is associated with impaired alertness and

postural control (Bastow et al. 1983a). Centrally acting drugs which have been implicated in impaired

temperature control include alcohol, phenothiazines and butyrophenones. These have also been

implicated in reduction of sensory awareness, muscular activity and vasoconstriction. Other drugs such as

benzodiazepines, tricyclics and narcotics may impair temperature homeostasis. Undernutrition, liver failure

and chronic renal failure are associated with impaired central control of temperature.

Clinical pharmacology and principles of drug treatment (Denham 1990, Ruiz and Lowenthal 1995,

Montamat et al. 1989, Fox and Auestad 1990, Meyer and Reidenberg 1992)

Adverse drug reactions (ADRs) are common in hospitalized older people. Contributing factors include-

polypharmacy, the presence of age related alterations to pharmacokinetics and pharmacodynamics,

disease alterations to physiology and changes to body composition. The effects of trauma, operative

procedures and advancing undernutrition further compound these factors.


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Relevance

1. Psychotropic drugs are the greatest single risk factor for falls in older people (Tinetti et al. 1988,

Weiner et al. 1998). Falls have also been associated with polypharmacy, antihypertensives and diuretics.

Drugs most commonly affecting balance, righting reflexes, alertness, cognition or precipitating delirium

include:

Narcotics e.g. pethidine and morphine

Antipsychotics

Antidepressants especially tricyclics

Anticonvulsants

Antiparkinsonians

some NSAIDs e.g. indomethacin

some Ca ++ channel blockers and B blockers e.g. diltiazem

Newer generation antidepressants are not as sedating as many tricyclics, however they may all cause

confusion and some cause postural hypotension (Venlafaxine).

2. Psychotropic drugs are a risk factor for motor vehicle crashes in older people, especially those with

dementia.

3. Sick older people are at greater risk of ADRs in hospital than any other group of patients. Great care in

diagnosis and prescribing, followed by regular review of drug requirement and dose is warranted to avoid

serious iatrogenesis.

Adverse drug reactions in inpatients (Duncan 1990)

There are no specific studies of ADRs in older trauma patients. Several studies of hospitalized older

people have revealed high rates of ADRs, which increase with age.

Approximate incidences are listed:

Over 60 years 5 to 15%



ADRs directly account for about 3% of hospital admission. Geriatric Medical Unit admissions primarily due

to ADRs have ranged from 15 to 30%. Elderly trauma patients are therefore at great risk of ADRs,

especially in the presence multiple organ problems and multiple medications.

Common drug adverse effects may present differently in older people. These include

Confusion / delirium

Incontinence of urine

Faecal impaction


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Falls and gait disturbance

Anorexia (and poor nutrient intake)

For example, overdosing with narcotics may produce all these effects as well as ADRs typically described

in younger patients such as dry mouth.

Factors contributing to ADRs include.

1. General factors: These include being white and female, consuming multiple medications, medication

dose and a past history of ADR.

2. Multiple diseases: Ageing is associated with an increased incidence of treatable chronic disease.

Diseases accompanied by organ impairment may alter drug disposal and tissue sensitivity to drugs. In this

setting, multiple diseases and drugs increase the risk of drug interactions.

3. Inappropriate prescribing.

(a) Inaccurate diagnosis: Accurate diagnosis of symptoms is achieved by taking a relevant history and

proper physical examination. Symptoms need to be regarded has having at least one underlying aetiology

until proven otherwise. Two common examples of inappropriate diagnosis and prescribing are:

oedema treated with diuretics when the oedema is largely caused by immobility, a calcium

channel blocker prescribed for hypertension. This treatment may precipitate postural hypotension,

falls and urinary incontinence,

dizziness due to postural hypotension treated with prochlorperazine (which is not a good

treatment for any cause of dizziness in old people). This may result in drug induced

Parkinsonism, tardive dyskinesia and falls. Accurate history taking and proper examination is

essential in order to make reasonable diagnoses.

(b) Excessive dose prescribed.

In general, older people should be prescribed lower doses of drugs, which can be increased carefully and

titrated according to desired versus undesired effects. Emergency situations may demand aggressive drug

doses as per younger people.

The treatment of hypertension is a typical example, especially in the hospital setting. Antihypertensives are

often used excessively with the aim of acutely reducing chronically elevated blood pressure to normallevels. This may lead to hypotensive symptoms even at normal or elevated blood pressure levels, shock

and cerebral ischaemia with brain damage if the duration is sufficiently long. Commonly the only symptom

is postural hypotension with inability to walk. When treating the asymptomatic older person, gentle blood

pressure reduction is required over a period of days to weeks.

Key points


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ADRs are common in the elderly patient

Altered pharmacokinetics (Adler and Nagel 1994, Schwartz 1994, Tregaskis and Stevenson 1990).

Absorption

Absorption of drugs is mostly unchanged with age. Ageing per se alters many gut functions minimally. A

recent study has demonstrated that gut surface area is unchanged in healthy older people (Lipski et al.

1992). However, may older people have: alterations to gastric acidity, delayed gastric emptying, increased

intestinal transit time, decreased absorptive surface area, reduced gut blood flow, probable decreased gut

active transport, reduced liver size and liver blood flow. Despite these changes it appears that nearly all

drugs are absorbed normally. L Dopa is more rapidly and easily absorbed through the stomach than in

younger patients presumably due to reduced dopa decarboxylase activity in the mucosa. Delayed gastric

emptying, which occurs with anticholinergic drug use and in some diabetics, may reduce absorption rate

and peak drug level. The rate of absorption of antibiotics (and possibly other drugs) from an IM injection

may be slowed in older people(Ruiz and Lowenthal 1995).

First pass elimination (Woodhouse and James 1990)

It is unclear whether ageing is solely responsible for the reported age related reduction in first pass

metabolism of highly extracted drugs such as propranolol, verapamil, tricyclics and prazosin. These drugs,

and others are affected by hepatic blood flow. Increased blood levels may occur in patients who have

diseases or are taking drugs that affect hepatic blood flow e.g. cardiac failure and B-Blockers. Hepatic

function may vary greatly because of genetic and environmental factors such as nutrition, caffeine,

nicotine, alcohol, disease and ageing.

Drug distribution and body composition

Body composition determines volume of drug distribution. With age fat volume increases and water

volume (muscle mass) decreases. Increased fat volume will increase elimination half-life of fat-soluble

drugs (e.g. diazepam, lignocaine, tricyclics). Reduced body water volume increases the potential for higher

peak plasma level of water-soluble drugs (e.g. digoxin, ethanol, and paracetamol).

Protein binding

Protein binding may become clinically important if albumin levels are reduced during acute illness. In this

circumstance, the free level of protein bound drug increases. Tightly bound drugs are at most risk of being

subject to or causing drug displacement, which increases the active free portion of the displaced drug.

Examples of common drugs in which either avoidance or great care should be taken are aspirin, warfarin,

phenytoin and diazepam.


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Renal function and drug excretion

For every decade of life after the age of 40, renal blood flow reduces by about 10%. Tubular urinary

concentration function decreases by about 7% per decade. Serum creatinine is unreliable as an estimation

of renal function in older people. It is better to estimate creatinine-clearance using the formula

Creatinine clearance = (140 age) x weight (kg) x 0.85 for women

814 plasma Creatinine (mmol/l)

Dosage reduction is required for renally excreted drugs with narrow therapeutic windows and which are

mainly renally excreted e.g. digoxin and aminoglycosides. Because creatinine clearance estimation is still

potentially unreliable using this formula, monitoring blood levels of these drugs is recommended (Beck

1994, Goldberg 1987).

Altered pharmacodynamics (Schwartz 1994)

Older people have increased target organ sensitivity to psychotherapeutic drugs, digoxin, warfarin and

probably phenytoin also. There is evidence of age related decrease in cholinergic activity (Albert 1994). In

addition, people with Alzheimer's disease (which may otherwise be clinically occult) have even greater

cholinergic loss. Anticholinergic drugs therefore commonly precipitate delirium in older people. People with

Alzheimers disease and other dementias are far more likely to suffer a drug-induced delirium.

It is quite likely that therapeutic levels of phenytoin and digoxin are lower than those quoted for younger

people. Toxicity due to these two drugs seems to occur more frequently at so called therapeutic blood

levels.

Based on animal and human studies it is likely that older people generally have fewer and less responsive

alpha and beta-adrenergic receptors. Responsiveness to catecholamine administration is attenuated in

older people (Lakatta EG 1990).

Altered homeostatic mechanisms of blood pressure control place older people at greater risk of postural

hypotension. Drugs which reduce plasma volume, reduce sympathetic outflow, have secondary effects on

the vascular tree or blunt heart rate responsiveness may precipitate postural hypotension. Prolonged bed

rest also seems to reduce responsiveness of homeostatic mechanisms to orthostasis.

General clinical assessment and management

Providing optimal care requires an interdisciplinary approach involving ambulance and paramedical

officers, emergency physicians, surgeons, geriatricians, other physicians, allied health personnel and

nursing staff.


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Following are general considerations based on physiological, epidemiological and pharmacological

aspects discussed above.

General principles

Diagnostic principles in Geriatric Medicine

The traditional approach to diagnosis in medicine is based on finding a single unifying diagnosis, which

explains all the patients undiagnosed symptoms. In Geriatric Medicine, the paradigm is inverted. Multiple

pathologies impinging upon a single symptom or physical manifestation becomes the dominating

approach. Nonetheless, the wise clinician will attempt to use both approaches.

Altered disease presentation

Diseases in older people present in typical ways in many cases. However in many others, especially the

frail aged, diseases present atypically. For example hyperthyroidism often presents as the 'apathetic

thyroid' in older people. Pneumonia may present with few specific symptoms or signs other than weakness

and confusion. Myocardial infarctions are commonly painless. The most common sign of digoxin toxicity in

older people is a feeling of weakness whereas nausea is most common in younger people. Many

presentations are in the form of functional syndromes. Modern epidemiology has labeled these as Geriatric

Syndromes.

Trauma and the geriatric syndromes

Several multifactorial syndromes have been well described in older people. Various contributing factorsinteract and / or summate and impinge upon a single body function. These syndromes may result in

trauma or they may develop as a result of trauma and hospitalization. Syndromes include:

Falls

Gait disorders

Confusional states

Incontinence

Weight loss / undernutrition

Iatrogenesis- usually polypharmacy with adverse drug effects

Accurate diagnosis

Accurate diagnoses are essential in order to effectively reverse the reversible and prevent the preventable.

For example, in the elderly trauma patient with confusion, narcotic dosage needs to be carefully

determined. The pathologies contributing to delirium commonly include a combination of mild hypoxaemia

due to hypoventilation and mild aspiration pneumonia, faecal impaction (due to narcotics and bed rest) and

other drug side effects. Narcotics will cause hypoventilation, exacerbate colonic dysfunction and directly


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contusion or concussion.

Subacute phase - manage and prevent secondary comorbidities

Prevent common problems found in hospitalized older people that have significant sequelae:

Undernutrition give either nutritional supplements between meals or enteral feeding. Obtain

dentures when the level of consciousness is adequate.

Venous thromboembolism prophylaxis.

Decubitus Ulcers frequent turning, avoidance of soiled bed linen, management of incontinence.

Contractures early nursing and physiotherapy interventions.

Muscle wasting prevention i early mobilization and aggressive nutritional supplementation are

nearly always required in elderly trauma patients, ii early commencement of bed exercises.

Faecal impaction aperients, suppositories and close bowel chart monitoring

Iatrogenesis medication and procedure related e.g. drug induced Parkinsonism.

Delirium(see below)- avoid frequently moving patients from bed to bed or locating patient in a

ward environment that is excessively stimulating. Both may precipitate delirium. Always obtain a

premorbid cognitive history from a relative if necessary. Obtain eye glasses and hearing aides as

these may reduce delirium and delirium induced paranoia.

Remove indwelling catheters as soon as reasonably possible to avoid urinary sepsis and

development of urethral stricture.

Recovery phase

Early mobilization and rehabilitation

Determine risk factors for trauma (falls, driving risk etc) and the possibility of elder abuse.

Continue nutritional supplementation

Commence investigation of related conditions such as falls, osteoporosis and undernutrition

Be aware of late complications presenting as failure to rehabilitate

Decubitus ulcer prevention

Pressure area care is of great importance in older people who have a very high risk of acquiring decubitus

ulcers. Significant morbidity and mortality is associated with their acquisition that may delay discharge by

weeks or sometimes months. Management essentials include:

Recognize that this is a medical responsibility.

Titrate frequency of turning in bed according to skin thickness, vascular supply to heels, presence


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of diabetes or peripheral vascular disease, nutritional status.

Commence nutritional supplementation early.

Provide ripple or other mattresses for all at risk patients.

Increase skin and pressure prevention care for patients with hemiparesis or Parkinson's disease.

Delirium (Lipowski 1994)

Delirium or acute confusional state should not be confused with dementia, although delirium is more

common in dementia sufferers. Dementia is a chronic multifocal disorder of brain function that usually

progresses slowly. Delirium carries a very significant mortality risk that varies according to underlying

disease processes.

Delirium:

primarily a disorder of attention or consciousness

fluctuates in most cases (lucid periods)

may be 'quiet' or 'noisy' in manifestation

is usually acute in onset

occurs in older people with normal premorbid cognitive function

is very common in dementia sufferers

Delirium is very common in hospitalized older inpatients. Over one third of elderly inpatients can be

expected to suffer delirium in hospital. The aetiology is nearly always multi factorial and investigation for

multiple causes is essential.

The causes of delirium are too long to list. Essentially any medication and organ dysfunction including

faecal loading can cause or contribute to delirium. Benzodiazepine or alcohol withdrawal should be

considered. Stopping as little as one benzodiazepine sleeping tablet can trigger withdrawal. Early

management with diazepam is very effective, however doses required in older people are much less than

younger patients (diazepam having a half-life of up to 80 hours in older people). Reversing all these factors

is essential. Underlying dementia or previously occult dementia may be associated with prolonged

delirium. In older persons who were previously well cognitively the outcome is excellent if the underlying

problem is reversible. Delirium is common after head injury.

Clinical surveys have repeatedly shown that physicians do not recognize many cases of delirium. Its

manifestation may be subtle. Some patients present as passive, quiet and incommunicative people, others

present as uncooperative or with urinary incontinence.

Management of delirium in the context of trauma consists of:

Head CAT scan (even if trauma is a minor fall)

Reversing / treating maximally, all underlying medical problems


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Consider drug or alcohol withdrawal

Moving the patient to a quieter ward area

Avoidance of challenging the patient whom appears uncooperative. Avoidance of sedation except

when the patient is a danger to him/her self or others

Sedation with drugs such as haloperidol carries risk of causing drug induced Parkinsonism and

therefore should be avoided unless the patient is a risk to themselves or others.

A Geriatrician should be consulted.

The trauma patient with Parkinsons disease

Parkinson's disease is present in about 1% of older people. Immobility and muscle rigidity increase the risk

of venous thrombosis and decubitus ulcers. Difficulty eating, postural hypotension and faecal impaction

are more common. Early mobilization is and maintenance of L Dopa is essential. Subcutaneous

apomorphine is useful for patients who are NBM. Relatively safe antiemetics such as domperidone that do

not cause drug induced Parkinsonism are often needed. Drugs such as metoclopramide (Maxolon),

prochlorperazine (Stemetil) must be avoided absolutely. Sedation with phenothiazines or butyrophenones

is potentially disastrous. Nutritional supplementation and early recommencement of antiparkinsonian

treatment probably hasten recovery and reduce complications.

Blood Pressure Management

Rapid blood pressure reduction should be avoided in hypertensive patients especially if it is asymptomatic.

Rapid reduction is associated with brain ischaemia, falls, confusion and probably stroke. Brain

autoregulation requires time to accommodate to the reduced perfusion pressure. In the context of cerebral

haemorrhage induced by blunt trauma, it is wise to reduce blood pressure. However, the risk of cerebral

ischaemia to areas surrounding the haemorrhage is present with overzealous blood pressure reduction.

Admission to high dependency or intensive care units is mandatory.

In older people, blood pressure below 100 mmHg systolic peri anaesthetic in older people is associated

with post-operative delirium, implying brain ischaemia.

Carefully controlling pain or urinary retention may suffice to adequately reduce blood pressure.

Faecal impaction:

Faecal impaction is a multifactorial disorder associated with the development of bowel obstruction and

bowel perforation if left unattended. This condition is nearly always preventable.

Management Principles:

Monitor bowel chart. No bowel movement, faecal incontinence (impaction with overflow) or faecal

smearing indicate a problem for further investigation.


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Examine abdomen and rectum if there has been no bowel movement for more than 2 days in

hospital.

If the rectum is empty a high impaction may be present and is assessed with an abdominal X-ray.

Exclude electrolyte abnormalities (including serum magnesium and phosphate levels), narcotic

and other anticholinergic or antispasmodic medications.

If treated with narcotics analgesics adequate use of prophylactic aperients should be considered.

Intra-abdominal pathology should be considered including retroperitoneal haemorrhage and

pancreatitis.

If no intra-abdominal pathology is suspected, ensure adequate oral hydration, fibre in diet, stool

softener e.g. coloxyl and osmotic agent such as lactulose should be considered. Senna should

only be used periodically as a rule.

Falls (Baker et al. 1992, Fildes 1994, Nelson 1990, Tinetti 1994, Tinetti et al. 1997).

Falls are the most common cause of trauma and trauma deaths in older people. About 75% of fall related

deaths occur in the elderly. Fall related deaths are probably under-reported because complications are

usually denoted as the cause of death. The majority of falls in older people, especially the old old, occur

on the flat. About thirty percent of community dwelling persons over the age of 65 fall each year. Twenty

four percent of these resulted in serious soft tissue injury and 6 % resulted in fracture. About one in forty of

fallers are hospitalized. Risk of falling increases dramatically after age 75. Falls are more common in

mobile nursing home residents. One study found that 61% of subjects fell during their first year in the

nursing home. Each year at least 10 percent of older patients suffer a serious injury from a fall such as

fracture, dislocation or severe head injury. Evidence from Tinetti suggest that fear of falling is a risk factor

for further falls by causing further physiological decline. Falls and injuries are associated with fear of

falling, restricted activity, social withdrawal, pain and increased risk of further falls. Cummings (1985)

retrospective review found that nearly 60% suffered non syncopal falls. Forty three percent of older people

have their accidents at home (Fildes 1994)

Falls in older people are significant because of their propensity to cause injury.

Risk factors for falls:

Falls, like most Geriatric problems are multifactorial in nature. Risk factors for falls may be categorized into

extrinsic and intrinsic factors.1. Intrinsic (patient related factors)

Drugs affecting balance, alertness, movement

Episodic problems seizures, postural hypotension, cardiac syncope, vertigo

Gait disorder frailty, Parkinsonism, neuropathy

Painful arthritis or musculoskeletal pain


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Visual impairment

2. Extrinsic (environment related factors)

slippery surface

rugs, cords, foot wear, clothes

poor lighting

pets, toys etc

steps

need for aides e.g. toilet surrounds, rails

Tinetti (1988) calculated odds ratios (OR) for different risk factors in a study of 332 fallers. Psychotropic

drugs carried the largest risk, (OR- 28.3) followed by cognitive impairment (OR- 5.0), lower extremity

disability (OR- 3.8), palmomental reflex (OR- 3.0), foot problems (OR- 1.8) and number of balance and gait

problems; 0 2, (OR- 1.0); 3 5 (OR- 1.4); 6 7; (OR-1.9). The percentage increased risk due to falls

increased as the number of risk factors increased. No risk factors carried 8% risk. Risk then linearly rose, 4

risk factors being associated with a falling risk of almost 80%.

Repeat fallers may be at lower risk because anticipation of falling and learned mechanisms of minimizing

trauma may develop. Repeat fallers tend to avoid risks by restricting their activities.

Factors influencing fall injuries include:

height of the fall

velocity of impact and body weight

hardness of surface

soft tissue padding

female gender

presence of osteoporosis

age over 75

slowed reflexes and protective responses

Clinical assessment

Historical considerations

History is probably the most important diagnostic tool. Asking eyewitnesses to give descriptive accounts of

falls is very useful. The possibility of elder abuse warrants vigilance. Falls are commonly under-reported by

patients living in the community. Assessment is often triggered by a concerned relative or an injury

acquired from a fall.

Asking how, where, when and what the patient was doing when they fell gives useful information, however


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non specific symptoms usually mean multifactorial aetiology. Were there premonitory symptoms? How

long did it take for the patient to get back to their feet? How did they feel immediately after the fall? Did

they experience clamminess or nausea or were they incontinent? Did the fall occur whilst turning around or

turning the head? Was there loss of consciousness? Did the patients have difficulty walking or suffer pain

prior to the fall?

Patients will commonly say they felt either giddy, light headed or dizzy. These statements must be followed

by more specific questions to ascertain if possible, exactly what the patient experienced. These

descriptions may mean they just felt unsteady. Did the patient experience any vertigo (suggesting an inner

ear or brain problem), lightheadedness (suggesting a haemodynamic problem), darkening of vision

(suggesting either haemodynamic or vascular problems) or a sense of unsteadiness on their feet

(suggesting a balance problem)?

Falls at night may indicate poor lighting or rushing to the toilet because of urge incontinence.

Dizziness may relate to postural hypotension. Enquire about the relationship of falls to meals or micturition,

both of which are associated with increased postural hypotension. Symptoms relating to arrhythmias,

ischaemic heart disease, stroke or seizure should be asked specifically although they are relatively

uncommon causes of falls.

Occasionally a fractured femur may precede a fall. Pain in the hip may be noted first.

Undernutrition should be assessed through a diet history or nutritional screening tool such as NSI

(Nutritional screening Index) or Australian NSI, which if positive should lead to a full diet history and

nutritional assessment.

Physical examination

Firstly, exclude serious injury, then determine underlying medical problems precipitating and contributing to

falls. If there has been serious injury, parts of the examination may have to be deferred to a later stage.

Examination includes:

1. Assess haemodynamics and orthostatic blood pressure responses (if no serious injury). Measure pulse

rate and blood pressure at 0 minute after lying for at least 20 minutes and then at 1, 3, 5 minute intervals

after standing and note any symptoms.

2. Measure core body temperature regarding fever or hypothermia

3. Assess skin pallor, tissue turgor (chest) and integrity, especially if patient suffered a long lie

4. Neurological examination including alertness, mental state, cognitive function, extrapyramidal features

vision, hearing, gaze abnormalities, nystagmus and strabismus.

5. Examine the neck for reduced range of motion (if no acute neck trauma or acute pain without negative

radiology), indicating degenerative spine disease and possible central cord syndrome vulnerability.

6. Cardiovascular assessment- specifically looking for aortic stenosis, cardiac failure, rhythm disturbance

and carotid sinus sensitivity which requires monitoring and firm pressure over the carotid sinus high in the

neck deep to the angle of the jaw.

7. Gait and balance analysis


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Initial investigations

Initial laboratory analysis should include a standard Emergency Department trauma 'screen'. Thyroid

function and additional parameters of nutritional status are warranted e.g. transferrin, lymphocyte count

and total protein. Thyroid dysfunction is common in older people and subclinical disease may affect

management.

Chest X-ray and ECG should always be performed. Serial ECGs and cardiac enzymes may detect

painless myocardial infarction and should be ordered if there is suspicion.

The decision to order radiology is not significantly different in older people. Because pain perception may

not be quite as reliable, X-rays should be ordered more readily.

Management

Diagnose and treat specific injuries, assess the aetiologies possibly causing the falls, assess potentialenvironmental hazards, implement physical and nutritional rehabilitation programs.

1. Management is clearly determined by the contributing causes of the falls. Older people with balance

impairment, muscle weakness and sarcopaenia should be offered a trial of rehabilitation and strength

training. Strength training is highly effective in improving most parameters of mobility, muscle strength and

general well-being. It is safe for frail older people and well tolerated.

2. A high percentage of fallers and most frail fallers are undernourished. A nutritional

supplementation program is therefore appropriate. Several clinical trial studies in fractured femur sufferers

have shown lasting benefits after one course of nutritional supplementation. Other studies have shown

improved body composition and immune function indices.

3. Associated problems such as social isolation and depression should be diagnosed in hospital.

Management is commenced in hospital and is then addressed by the local aged care service and the

patient's family practitioner in follow-up.

4. Review of all medications is required in order to minimize falls risk. Sedatives should

particularly be reviewed.

5. Environmental hazards should be diagnosed through a home visit either by a geriatrician or

specialist occupational therapist.

6. For patients with osteoporosis, hip protectors should be considered in order to prevent

fractured femur.

Fractured femur(Grisso and Kaplan et al. 1994, Mossey et al. 1989, Parker and Palmer 1995)

Fractured femur is the most common serious injury in older people and is a major cause of personal and

health economic costs. In the USA 320,000 fractured femurs are predicted in the year 2,000. Most occur in

women who outnumber men and who have higher falling and osteoporosis rates. An 80 year old female

has approximately 15% chance of incurring a hip fracture before dying. Men have about half the risk. All

patients with fractured femur following a low velocity fall have osteoporosis.


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Outcome

Mortality from hip fracture is about 5% in hospital (Jette et al. 1987). One year mortality is about 25 to

30%, which is 14 to 18% higher than their peers (Mossey et al. 1989, Parker and Palmer 1995). Disability

following fractured hip is common, about 50% not reaching premorbid level of ability to climb stairs andwalk outdoors. About 65% do not regain all their prefracture activities of daily living (Mossey et al. 1989,

Parker and Palmer 1995, Grisso and Kaplan 1994).

In the USA following DRG linked payment systems, more patients are being discharged to long stay

facilities without rehabilitation programs.

Predictors of outcome

Predictors of outcome include: age, prefracture functional status, number of prefracture medical

conditions, mental status, depression, social factors, muscle strength and serum albumin at admission.

Fracture site, repair type, post surgical complications, number of days in hospital and discharge location

have not been related to outcome. Interestingly, in most studies, age has not been positive as an

independent predictor of outcome.

Specific management issues.

It is our recommendation that hip fractures be operated on within 24 hours of arrival to hospital.

Immobilization of patients causes increased mortality and morbidity. Prior to internal fixation, mortality

rates were as high as 40%. Some studies have suggested that longer that 48 hours operation time is

associated with poorer outcome.

Special care is required to prevent decubitus ulcers, which most commonly occur on the heel of the

affected limb (especially if the patient has a hemiparesis on the fracture side). The unaffected limb may

also be affected if sedation is used.

Secondary prevention of hip fractures.

Little research has been undertaken in this field. Evidence to date and consensus point to the following:

1. Reduce the risk of falls

Exercise has many benefits, including improved gait and ADL function. Some exercise trials have

demonstrated significant reductions in falls risk. Optimal exercise prescription has not been demonstrated

in this group. A trial assessing resistance exercise training is currently underway.

2. Treat osteoporosis (Kanis 1997, Kaw 1998, Sambrook 1995)

Whilst hormonal replacement therapy (Michaelsson et al. 1998), bisphosphonates (Liberman et al. 1995)

and other treatments are able to prevent non vertebral fractures, it is unlikely that a trial of secondary

prevention will be undertaken or completed specifically in a group of frail older people following hip fracture

for some time. Treatment of osteoporosis in this group seems appropriate and likely to be of benefit to

those who do not have severe underlying organ failure medically.


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Combination treatment may be more efficacious including combining progestagins with oestrogen and

bisphosphonates. Pre treatment dual energy X-ray absorptiometry (DEXA) is advised.

Several studies have demonstrated the ability of strength training to increase bone mineral density in frail

older people (Nelson et al. 1994, Ryan et al. 1994). Whilst awaiting the results of current research trials

into this treatment, it is our view that specific graduated strength training should be offered to all patients

following hip fracture.

Hip protectors (Lauritzen et al. 1997)

Hip protectors have demonstrated great efficacy in preventing hip fractures in nursing home residents.

Results from a community based trial of elderly fallers are awaited. Hip protectors may increase the risk of

other less serious injuries, nonetheless their outstanding results in the institutional setting allow us to

strongly recommend their use. Failure to wear hip protectors is the commonest cause of failure.

Nutritional supplementation

The vast majority of fractured femur sufferers ingest inadequate calories during hospitalization (Older et al.

1980). Nutritional supplementation has shown very good results in three studies (Bastow et al. 1983a).

Supplements should be given between meals. Unwell older people are unable to digest large meals fully.

Smaller meals given more frequently are more likely to optimize nutritional status. Only one study so far

has tested oral supplements (Delmi et al. 1990). Major benefits in mortality, complication rate, length of

stay and discharge destination were documented. The benefits were extended to the time of follow up at

least 6 months later. It is advisable to continue nutritional supplementation after discharge of older patients

post fractured femur. Supplements may need to be tailored to individual requirements and comorbidities

such as diabetes or renal failure.

Subdural haematomas and head injuries

Head trauma and dementia

Three case control studies have found an independent association between head trauma and Alzheimer's

disease. Trauma probably causes brain impairment that hastens the presentation of the disease

(Borenstein 1990).

Subdural haematomas (Cagetti et al. 1992, Ellis 1990, Howard et al. 1989, Rozelle et al. 1995, Spallone et

al. 1989)

Subdural haematomas occur in older people with relatively trivial trauma or no history of trauma at all. The

onset may therefore be insidious and its manifestations various. Subdural haematomas are known as

neurological mimickers in older people, presenting as dementia, delirium, stroke, seizures, mood

disturbances, transient ischaemic attacks. Bilateral haematomas, metabolic derangement and post-

operative complications are more common in older people. Older men are more likely to acquire subdural

haematomas than women. Mortality occurs in about 15% of sufferers. Neurological recovery is usually


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good in survivors who do not have suffer recurrence.

Pathophysiology of subdural haematomas: (Ellis 1990)

Subdural haematomas arise from bleeding bridging veins that are relatively intolerant of movement. Aged

veins are generally more fragile and older brains are more likely to move within the cranium because of

reduced brain size. The dura, which contains the bridging veins, is more adherent to the aged brain,

thereby explaining why brain movement is more likely to sever them, and why epidural haematomas are

more uncommon in older people. Hence acceleration injuries may be sufficient to cause vein rupture. A

direct blow to the head is not required. Haematomas tend to be larger in older people because of greater

low pressure space availability.

Diagnosis

Because trauma may be trivial it is not always evident on history (30 50% of cases) (Spallone et al. 1989,

Ellis 1990). Even acute haematomas may present relatively insidiously because of the increased size of

the subdural space. A high index of suspicion should be held for any older person who may suffer from

occasional falls and has some unexplained decline in function, cognition, language or gait, especially if it

fluctuates. Chronic subdurals may present with depression, confusion, dementia, stroke, headache,

urinary incontinence and behaviour change.

Acute subdural haematoma presentation symptoms include hemiparesis (50%), paraesthesias are

common, dysarthria (25%), incontinence or vomiting (10 20%), seizures (


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Of all spinal injuries attending a spinal unit, about 60% will have neurological deficit. Of these odontoid

fractures occurred in 33%. Neurological deficit recovery occurs in 80% of compression injuries and 60% of

extension injuries.

Motor vehicle accidents (MVA)

Older people have increased risk of being pedestrian victims (Kong et al. 1996). Pedestrian fatalities

account for 28% of MVA fatalities in older people whereas 16% of MVA deaths are in pedestrians for all

ages (Sattin). Drivers over 75 have 25% more crashes per licensed driver and are more likely to have

accidents at intersections than other ages. Crash rates per kilometer in over 75 year olds are second only

to teenagers. Older people have greater injuries from similar crashes and take longer to recover (Sattin).

Vision, especially night vision, neuromuscular reflexes, cognition and adverse medication effects may

explain the increased incidence of driver and pedestrian accidents.

Prevention involves clinician recognition of dementia and medication adverse effects. Screening of older

driver performance because of age and / or illness may reduce injuries.

Elder abuse (Kurrle 1991, Lachs and Fulmer 1993, Jones et al. 1988)

The diagnosis of elder abuse should be considered, for example, in any patient with a delayed

presentation of an injury (for example fractures healing unset), when an implausible explanation for illness

or injury is given, or if a patient is described as being accident prone. Neglect is more common than abuse,

and this can contribute to injury in a number of ways. Neglect may be either passive, when a care provider

is unable to provide care, or active, when a carer is actively withholding care. A carer may neglect to

provide an elderly person with glasses, a walking aid or a safe environment, thereby increasing their

propensity to falls and possibly the severity of the injury sustained form a fall. Under or over medication

may increase the likelihood of trauma, for example over sedation due to inappropriate benzodiazepine use

could contribute to falls, and over medication with warfarin may mean that otherwise trivial trauma results

in a severe bleed. If elder abuse or neglect is suspected the patient should be interviewed alone, and the

history of abuse or neglect should be elicited sensitively. Determine the patient's functional status and the

level of care required, and the level of care being provided by outside services. Carer support using

existing aged care services probably averts further abuse in some cases.

In Australia there is no mandatory reporting of suspected elder abuse. Referral to the local Aged Care

Assessment Team is advised.

Trauma and the Old Patient

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Transcript of Trauma and the Old Patient