Caring for Geriatric Trauma Patients

The Gray Tsunami:
Caring for Geriatric Trauma Patients
Greater St. Louis Chapter
American Association of Critical-Care Nurses
32nd Annual Spring Symposium
March 27, 2014
Presented by Cindy Lefton, PhD, RN
Clinical Education Specialist, Trauma and Acute Care Surgery
Barnes-Jewish Hospital
Vice President, Organizational Consulting
Psychological Associates
Copyright © Psychological Associates® 2014
By 2050, estimates indicate that
89 million people will be 65 or older
Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services (2013).
The State of Aging and Health in America.
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From 2010-2030, 10K Americans/year turn 65
Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services (2013).
The State of Aging and Health in America.
3
 72 million
older adults
 315 million
people in the
United States
Centers for Disease Control
and Prevention, U.S. Dept. of
Health and Human
Services (2013).
The state of aging and health
in America.
 6 out of every
10 people
will live in
a city
World Health Organization,
U.S. Dept. of Health
and Human Services
Global Health Observatory
(GHO) – Urban population growth.
http://www.who.int/gho/
urban_health/situation_trends/
urban_population_growth_text/en/
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Pre-existing
Conditions
“Older patients average 6 or more
pre-existing conditions”
-TNCC, 7th edition, 2013











Comorbidities
CHF
Cancer
Arthritis
HTN
Dementia/Alzheimer’s
disease
Diabetes
COPD
A-fib
Alcohol/illicit drugs
Literacy
-TNCC,7th edition, 2013
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In 2009-2010,
accidental injury
was the 5th
most frequent
cause of
geriatric
mortality
Banks & Lewis (2013). Trauma in the elderly:
Considerations for anesthetic management.
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MVCs
Second
most common
MOI
in the
geriatric
population
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Key Aspects of Geriatric Trauma Care are:
Pathophysiologic changes due to aging
(which can lead to sensory impairment)
Comorbidities
Medications/Med Recon
Compensatory Mechanism – low
physiologic reserve
Mechanism of Injury
 Falls
 Recreational activities
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Harborview Study, continued
 1-year mortality rate 33.2%
 GLF geriatric patients d/c to SNF were 3 times more likely to die
in a year of injury compared to patients d/c home
 30-day readmission rate 13.8% was
Ayoung-Chee, P., et al. (2014).
Long-term outcomes of ground-level falls
in the elderly.
similar to the rate for all injured
Medicare patients requiring
hospitalization
Nearly half the patients who survived
hospitalization were readmitted during
the study period
1-year mortality rates for geriatric GLF
for d/c to SNF 4 times higher than
expected
Key is returning to independent living
directly or to a SNF and then
independent living
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Harborview Study, continued
Of the survivors:
 51% d/c to SNF
 33% d/c home
without assistance
 6% d/c home with
assistance (home
health, etc.)
5% d/c to inpt rehab
Ayoung-Chee, P., McIntyre, L., Ebel, B.E., Mack, C.D., McCormick, W., & Maier, R.V. (2014).
Long-term outcomes of ground-level falls in the elderly.
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Harborview Study
 1,352 patients older than 65 experiencing a GLF who were
admitted to Level One trauma center
 Mean IIS score 16.2 with 27% of having severe ISS >24
15% of these patients had dementia
26% had at least 1 extremity
fracture, 6% had isolated hip fx
 51% had TBI
 57% were admitted to an ICU
12% died in the hospital
Ayoung-Chee, P., McIntyre, L., Ebel, B.E., Mack, C.D., McCormick, W., & Maier, R.V. (2014).
Long-term outcomes of ground-level falls in the elderly.
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Potential Airway
and C-Spine Complications
Dentures
Arthritis
PMH CVA
PMH Parkinson’s
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Potential Breathing Complications
 Physiological
reserve
 Calcification of ribs
 Recoil of chest
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Circulatory Complications
 Limited cardiac
reserves
 Compensatory
mechanisms
sluggish

Baroreceptor
sensitivity
 LV thickening
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Neuro Complications
 Brain atrophy
 Parasagittal bridging
vein stretch
 Slower nerve
transmissions
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Miscellaneous Complications
Skin thins
Subq fat
Musculoskeletal
changes
Contractility
Thyroid function
can
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Assessment
Physical changes in the patient with knowledge about the
aging process
Management
 Pain
 Fall and pressure
ulcer prevention
 VAP prevention
 Nutrition
Mental Status
 Delirium
 Dementia
 Depression
Hankinson, M.. Assessing Geriatric Care in the ED Setting, ENA Leadership Conference, March 2013
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Sequela from
“I’ve fallen and I can’t get up”
Lacerations
TBI’s
Fractures
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Medication in the
Geriatric Trauma Patient
Class of Medication
Change of Dose in
the Elderly Patient
Sedatives
Reduce bolus 50%
Depolarizing neuromuscular blocking agents
(succinylcholine)
No reduction in bolus
Nondepolarizing neuromuscular blocking agents No reduction in bolus
Opioids
Reduce bolus 50%
Table from Banks & Lewis (2013).
Trauma in the elderly: Considerations for anesthetic management, page 132.
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Ethics
 DNR
 Advance directives
and EOL
 Abuse and neglect
Safety
 Communication
 Environmental
issues
Hankinson, M.. Assessing Geriatric Care in the ED Setting, ENA Leadership Conference, March 2013
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Key Areas of Improvement
for Geriatric Trauma Care
 Under triage in the field
 Lack of recognition of the potential impact
minor mechanisms of injury have on the
patient
 Hypoperfusion
 EAST guidelines
have also identified
a lack of evidence
regarding geriatric
trauma guidelines
Bourg, P., Richey, M., Salottolo, K., & Mains, C.W. (2012). Development of a
geriatric resuscitation protocol, utilization compliance, and outcomes.
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Challenges in Geriatric Care
 Poly pharmacy
 Geriatric trauma patients more
likely to sustain various injuries
like c-spine fx and TBI
 Older trauma victims are less
likely than younger patients
to be transferred to Level 1 or
Level II trauma centers (Switzer, J.A.,
& Gammon, S.R. (2012). High-energy skeletal
trauma in the elderly).
 Underestimating hypoperfusion
 Identifying clear markers that
are population specific
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https://medsnap.com
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Geriatric Assessment Tools
and Guidelines
 Beers Criteria
 Assess potentially inappropriate med use in elderly
 STN guidelines for the care of geriatric patients taking anti-coags who
sustain TBI
 Check for safety: A home fall
prevention checklist for older
adults.
CDC – www.cdc.gov/injury
 Alzheimer’s Association –
St. Louis Chapter, Family
caregiver report
 Hastings Center, End-of-life
care guidelines
www.hastingscenterguidelines.org
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Resources
 Baylor & Deerbrook
Charitable Trust
 NICHE $
 Hartford Institute for
Geriatric Nursing
 Synthes $
 Mosby’s Nursing
Consult
 CPM CarePoints
from Elsevier
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Cindy Lefton PhD, RN
[email protected]
(314) 725-7771
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References
Ayoung-Chee, P., McIntyre, L., Ebel, B.E., Mack, C.D., McCormick, W., & Maier, R.V.
(2014). Long-term outcomes of ground-level falls in the elderly. Journal of Trauma
and Acute Care Surgery, 76(2), 498-503. doi: 10.1097/TA.0000000000000102.
Banks, S.E., & Lewis, M.C. (2013). Trauma in the elderly: Considerations for
anesthetic management. Anesthesiology Clinics, 31(1), 127-139. doi: 10.1016/
j.anclin.2012.11.004.
Bourg, P., Richey, M., Salottolo, K., & Mains, C.W. (2012). Development of a
geriatric resuscitation protocol, utilization compliance, and outcomes. Journal of
Trauma Nursing, 19(1), 50-56. doi:10.1097/JTN.0b013e31822b80f5.
Centers for Disease Control and Prevention, U.S. Dept. of Health and Human
Services (2005). Check for Safety: A home fall prevention checklistfor older adults.
Accessed Feb. 1, 2014. http://www.cdc.gov/HomeandRecreationalSafety/pubs/
English/booklet_Eng_desktop-a.pdf
.
Copyright © Psychological Associates® 2013
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References, continued
Centers for Disease Control and Prevention, U.S. Dept. of Health and Human
Services (2013). The state of aging and health in America.
Emergency Nurses Association, Trauma Nursing Core Course (TNCC ), 7th Edition
(2013).
Hankinson, M. Assessing Geriatric Care in the ED Setting. Presentation for ENA
Leadership Conference, March 2013.
Hardin, S.R. (2012). Hearing loss in older critical care patients: Participation in
decision making. Critical Care Nurse, 32(6), 43-50. doi: 10.4037/ccn2012225.
Switzer, J.A., & Gammon, S.R. (2012). High-energy skeletal trauma in the elderly.
Journal of Bone & Joint Surgery, 94(23), 2195-2204. doi: 10.2106/JBJS.K.01166.
World Health Organization , U.S. Dept. of Health and Human Services Global
Health Observatory (GHO) – Urban population growth. Accessed Feb. 1, 2014.
http://www.who.int/gho/urban_health/situation_trends/urban_population_growth_text/en/
Copyright © Psychological Associates® 2013
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