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
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