Christopher R. Carpenter, MD, MSc, FACEP, FAAEM, AGSF
Washington University School of Medicine
Division of Emergency Medicine, Associate Professor
Past-Chair, ACEP Geriatric Section

Case Scenario
An 80-year-old female presents to your emergency department (ED) after a standing level fall. She reports multiple prior falls in the preceding 12-months and states that she is walking more because her children took away her driver’s license 2 years ago after she had a minor car accident. Today’s triage note listed a history of atrial fibrillation treated with warfarin and her INR is 2.9. In addition, her medications included treatment for hypertension and hyperlipidemia. Your primary and secondary exam reveals left hip tenderness and a coccyx contusion, but no other injury. After observing her for 4-hours in the ED and noting an unremarkable hip and pelvic x-ray, CT-head and C-spine imaging, and no free fluid on POC FAST exam, you ambulate her and note no difficulty with the Get-Up-and-Go test. She wants to be discharged home and her primary care physician agrees via telephone that she should be discharged with follow-up in his office the next day. Her family has reservations about her home safety, but also agree that her perspectives should be respected and she is discharged home with next day follow-up.

Unfortunately, overnight she returns to the same ED with another fall that occurred at 3AM while trying to get from her bed to the bathroom. She is unresponsive upon arrival and family note that she went to bed early because of her long day in the ED. CT reveals a large SDH, which continues to expand over the next 4-hours despite aggressive management with Vitamin K and Protein Complex C. Neurosurgery recommends conservative management based upon her presenting GCS. Later that day family withdraws care and she expires. Could anything have been done to prevent this death at the time of the first ED evaluation?

Epidemiology

Geriatric adults represent 23% of trauma admissions, and traumatic injury is the fifth leading cause of death in this age group.^1,2 In the 85 and older subset of geriatric adults, 1 in 5 is treated in an ED for injury every year in the United States (U.S).³ Injury-related hospitalizations for geriatric adults continue to increase.⁴ Standing level falls and motor vehicle accidents (MVA) are the most common mechanisms of trauma in this age-group.^5,6 The challenges of an aging population are not isolated to the U.S. either; geriatric trauma is the most common presenting complaint for older adults worldwide.^7,8

Prognostic Assessment – History and Physical Exam

When adjusted for Injury Severity Scores, geriatric trauma patients have twofold increased mortality and significantly longer hospital LOS compared with younger populations.⁹ Even the seemingly minor trauma of a ground level fall often (as in the case above) represents a sentinel event for older adults: up to 35% of older adults with minor blunt trauma who are discharged from the ED experience functional decline within 3-months.^10-12 Functional decline increases ED recidivism.¹³ Surprisingly, despite decades of research to develop risk-stratification tools like the Identification of Seniors at Risk and the Triage Risk Stratification Tool, no accurate instruments exist to identify the subset that is most at risk for post-ED functional decline while they are still in the ED.^14-16 In fact, emergency medicine cannot currently even predict short-term fall-risk amongst elderly non-fallers¹⁷ or fallers,^18,19 so layers of complexity must be unraveled to move from what we believe that we understand to what we can actually measure and understand to what we can do to improve the outcomes for these vulnerable patients.

Diagnostic and Prognostic Labs & Imaging Resources

Most laboratory tests are of low utility in the identification of specific injuries or their seriousness in geriatric trauma patients, but anticoagulation status should always be assessed.²⁰ Although warfarin use alone does not predict mortality, the duration and degree of anticoagulation do predict adverse outcomes in head injury patients.^21-25 A low threshold for CT scanning in all geriatric patients is encouraged, but particularly for those who are on anticoagulants.^26-28 Unfortunately, a normal brain CT scan at the time of the initial ED evaluation does not eliminate the risk of a delayed intracranial hemorrhage in subsequent days. Head injury patients, and more importantly their caregivers, must be advised to carefully monitor the patient’s mental status in the days following a traumatic head injury. While it has been thought prudent to arrange an observation admission and repeat CT scan for those on anticoagulation therapy, this strategy has not been adopted by most hospitals due to cost and crowding concerns.

Vital signs are inaccurate to predict injury severity in geriatric patients. The product of age multiplied by shock index is a slightly more accurate predictor of mortality.²⁹ A base deficit of ≤ -6 has been used as a laboratory marker of trauma-related mortality and anticipated prolonged ICU care.³⁰ While there is controversy over the value of central venous pressure monitoring, it is a particularly challenging modality of care in the elderly who can least afford an iatrogenic complication on top of their trauma.³¹ More recently venous lactate appears promising. As opposed to shock index and traditional vital signs, venous lactate is an independent predictor of geriatric trauma mortality when adjusted for age, Glasgow Coma Scale and Injury Severity Score.³² Using venous lactate-guided therapy to identify occult hypoperfusion with early trauma surgeon involvement is associated with improved survival.³³ Researchers are also developing nomograms to predict mortality-related complications such as wound infection, empyema, urinary tract infection, deep venous thrombosis, pressure ulcer, and pneumonia based on age, gender, and number of pre-existing co-morbidities.^34,35

Specific Injuries

Head Injuries

Hospitalization rates for older adults with head injuries are increasing.³⁶ Traumatic brain injury (TBI) in geriatric patients leads to over 80,000 ED visits in the U.S. every year and 75% result in hospitalization.37 Standing level falls and to a much smaller degree MVA are the leading causes of head injuries in the elderly^.36,38,39 The length of time that patients are anticoagulated and the extent of anticoagulation increase head injury related mortality.^24,25 Patients over the age of 75 are less likely to survive surgical intervention than younger populations following head injury^.38 In one review of geriatric TBI victims with initial Glasgow Coma Scale ≤ 8, the overall mortality was 71%, and no patients over the age of 85 survived with or without surgery.⁴⁰ Surprisingly, the recovery potential of geriatric TBI patients has remained static for decades.³⁹

Cervical Spine Injuries

Standing level falls are the most common injury mechanism preceding C-spine fractures and C1 or C2 fractures are more common in geriatric trauma patients than in younger patients.⁴¹ Even minor degrees of trauma can cause fracture in a neck already damaged by osteoarthritis or other kinds of joint disease. If the goal is to identify every possible C-spine injury than CT scan and MRI are ideal.⁴² However, many injuries identified on CT scan that are missed by x-ray alone are clinically inconsequential, and require neither operative intervention nor spine immobilization that would not otherwise have been recommended.

Special Situations

Elder Abuse and Neglect

Up to 1.2 million older adults (4% of all senior citizens) suffer mistreatment in the U.S. with 450,000 new cases every year.⁴³ Elder abuse and neglect is a complex issue with multiple potential risk factors within the geriatric patient, perpetrator, relationship, and environment.⁴⁴ Most abuse does not occur in nursing homes, but in the home of community-dwelling older adults. Abuse is more likely in developed countries⁴⁵ and in urban settings.⁴⁶ Types of abuse include abandonment, psychological, financial, neglect, physical, sexual, or resident-to-resident aggression.⁴³ Physical abuse is less common than psychological abuse and financial exploitation^.45 The elder abuse suspicion index is a 6-question screen for this problem.⁴⁷ and the American Medical Association has also developed a screening instrument.^43,48

Driver safety

Large and increasing numbers of older adults, including those over age 85, are current drivers.⁴⁹ Older adults are overall less likely to be the driver in MVAs on a per-accident basis because they drive less frequently than younger populations. Most (78%) geriatric MVA victims are discharged home from the ED.⁵⁰ After assessing and treating MVA-related injuries, emergency providers have an obligation to assess the role of age and age-related co-morbidities to prevent future MVA-related injuries to the patient and to society.⁵¹ Multiple resources exist to guide clinicians, patients, and families to assess driving safety.⁵² Office based testing for driver safety is increasingly available and cutoff norms are being established to increase the accuracy to predict future MVAs.^53,54 If time, space, and personnel are available, ED-based driver safety testing is also possible.⁵⁵

Fall risk

Fall-related injuries are common geriatric patient presenting complaint in EDs worldwide and one-third of home-dwelling older persons fall every year.⁵⁶ However, older adults in the ED usually do not have a fall-risk assessment obtained as part of their ED evaluation.^57,58 As previously noted, one significant barrier to routine fall-risk stratification in the ED is that instruments designed to do so lack validation in the emergency setting.¹⁹

Case Scenario

Although our 80-year-old fall victim could have been encouraged to remain in the hospital for serial exams, fall prevention nursing, physical therapy assessment of future fall risk, and a repeat head CT, research evidence does not support empiric decisions based on age-alone. There is also no certainty that an admission at the time of the first ED visit would have prevented the second fall or detected the SDH earlier than the outpatient approach, since the SDH could have been a result of the initial (or any of several prior) falls. Furthermore, being hospitalized is also a risk for adverse events like delirium and iatrogenic infections. Most importantly, admitting this patient at the time of the first ED visit would have clearly been in direct opposition to her preference to be discharged home and family reluctantly agreed. Nonetheless, 21st Century Medicine can and must become better equipped to deliver the appropriate disposition to those patients most likely to benefit in the short time that we have to evaluate them in the contemporary ED.

The Future

Effective geriatric trauma management and efficient injury prevention continue to evolve and solutions will require the mutual and sustained engagement of both the ACEP Trauma and Injury Prevention Section and the ACEP Geriatric Section. Several potentially high-yield questions exist which could substantially improve the outcomes for these vulnerable trauma patients.^59,60 Which 1-in-3 blunt trauma patients without injury sufficient to justify admission would benefit from short-term post-ED interventions to reduce adverse outcomes? How do providers accurately identify future fall-risk? If accurate screening instruments can be derived to identify these subsets, how will they be used in the busy ED environment? Do most EDs have access to resources upon which high-risk subsets will depend once identified? What is the role of Geriatricians, Trauma Surgeons, and other specialists to improve the outcomes of this subset that is discharged from the ED? Lacking a National Institute of Acute Trauma, who will fund such research? Unfortunately, most current evidence is retrospective and single center so TIPS has an immediate opportunity to join the Geriatric Section to render meaningful answers to these questions.

REFERENCES

1. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc. 2006;54(10):1590-1595.
2. Keller JM, Sciadini MF, Sinclair E, O'Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012;26(9):e161-e165.
3. Carter MW, Gupta S. Characteristics and outcomes of injury-related ED visits among older adults. Am J Emerg Med. 2008;26(3):296-303.
4. Pracht EE, Langland-Orban B, Tepas JJ, Celso BG, Flint LM. Analysis of trends in the Florida Trauma System (1991-2003): changes in mortality after establishment of new centers. Surgery. 2006;140(1):34-43.
5. Yildiz M, Bozdemir MN, Kilicaslan I, et al. Elderly trauma: the two years experience of a university-affiliated emergency department. Eur Rev Med Pharmacol Sci. 2012(16 Suppl 1):62-67.
6. Sharma OP, Oswanski MF, Sharma V, Stringfellow K, Raj SS. An appraisal of trauma in the elderly. Am Surg. 2007;73(4):354-358.
7. Downing A, Wilson R. Older People's Use of Accident and Emergency Services. Age Ageing. 2005;34(1):24-30.
8. Salvi F, Mattioli A, Giannini E, et al. Pattern of use and presenting complaints of older patients visiting an Emergency Department in Italy. Aging Clin Exp Res. 2013;25(5):583-590.
9. Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. J Trauma. 2002;53(3):407-414.
10. Shapiro MJ, Partridge RA, Jenouri I, Micalone M, Gifford D. Functional decline in independent elders after minor traumatic injury. Acad Emerg Med. 2001;8(1):78-81.
11. Wilber ST, Blanda M, Gerson LW, K.R. A. Short-term functional decline and service use in older emergency department patients with blunt injuries. Acad Emerg Med. 2010;17(7):679-686.
12. Sirois MJ, Emond M, Ouellet MC, et al. Cumulative incidence of functional decline following minor injuries in previously independent older Canadian emergency department patients. J Am Geriatr Soc. 2013 61(10):1661-1668.
13. Wilber ST, Blanda MP, Gerson LW. Does functional decline prompt emergency department visits and admission in older patients? Acad Emerg Med. 2006;13(6):680-682.
14. Bissett M, Cusick A, Lannin NA. Functional assessments utilised in emergency departments: a systematic review. Age Ageing. 2013;42(2):163-172.
15. Carpenter CR. Deteriorating functional status in older adults after emergency department evaluation of minor trauma-opportunities and pragmatic challenges. J Am Geriatr Soc. 2013;61(10):1806-1807.
16. Carpenter CR, Shelton E, Fowler S, et al. Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2015;22(1):1-21.
17. Carpenter CR, Scheatzle MD, D'Antonio JA, Ricci PT, Coben JH. Identification of fall risk factors in older adult emergency department patients. Acad Emerg Med. 2009;16(3):211-219.
18. Tiedemann A, Sherrington C, Orr T, et al. Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments. Emerg Med J. 2013;30(11):918-922.
19. Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler S, Lo AX. Predicting Community-Dwelling Older Adult Falls Following an Episode of Emergency Department Care: A Systematic Review. Acad Emerg Med. 2014 21(10):1069-1082.
20. Williams TM, Sadjadi J, Harken AH, Victorino GP. The necessity to assess anticoagulation status in elderly injured patients. J Trauma. 2008;65(4):772-777.
21. Kennedy DM, Cipolle MD, Pasquale MD, Wasser T. Impact of preinjury warfarin use in elderly trauma patients. J Trauma. 2000;48(3):451-453.
22. Kirsch MJ, Vrabec GA, Marley RA, Salvator AE, Muakkassa FF. Preinjury warfarin and geriatric orthopedic trauma patients: a case-matched study. J Trauma. 2004;57(6):1230-1233.
23. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma. 2006;60(3):553-557.
24. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma. 2007;63(3):525-530.
25. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database. J Trauma. 2007;63(3):519-524.
26. Calland JF, Ingraham AM, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S345-S350.
27. Mack LR, Chan SB, Silva JC, Hogan TM. The use of head computed tomography in elderly patients sustaining minor head trauma. J Emerg Med. 2003;24(2):157-162.
28. Riccardi A, Frumento F, Guiddo G, et al. Minor head injury in the elderly at very low risk: a retrospective study of 6 years in an Emergency Department (ED). Am J Emerg Med. 2013;31(1):37-41.
29. Zarzaur BL, Croce MA, Magnotti LJ, Fabian TC. Identifying life-threatening shock in the older injured patient: an analysis of the National Trauma Data Bank. J Trauma. 2010;68(5):1134-1138.
30. Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma. 1998;45(5):873-877.
31. Stewart RM, Park PK, Hunt JP, et al. Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring. J Am Coll Surg. 2009;208(5):725-737.
32. Salottolo KM, Mains CW, Offner PJ, Bourg PW, Bar-Or D. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scan J Trauma Resusc Emerg Med. 2013;21:7.
33. Bar-Or D, Salottolo KM, Orlando A, Mains CW, Bourg PW, Offner PJ. Association between a geriatric trauma resuscitation protocol using venous lactate measurements and early trauma surgeon involvement and mortality risk. J Am Geriatr Soc. 2013;61(8):1358-1364.
34. Min L, Burruss S, Morley E, et al. A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients. J Trauma Acute Care Surg. 2013;74(4):1125-1132.
35. Pines JM, Carpenter CR, Raja A, Schuur J. Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules. 2nd ed. Oxford: Wiley-Blackwell Publishing; 2013.
36. Jamieson LM, Robrets-Thomson KF. Hospitalized head injuries among older people in Australia, 1998/1999 to 2004/2005. Inj Prev. 2008;13(4):243-247.
37. Papa L, Mendes ME, Braga CF. Mild Traumatic Brain Injury among the Geriatric Population. Curr Transl Geriatr Exp Gerontol Rep. 2012;1(3):135-142.
38. Bouras T, Stranjalis G, Korfias S, Andrianakis I, Pitaridis M, Sakas DE. Head injury mortality in a geriatric population: differentiating an "edge" age group with better potential for benefit than older poor-prognosis patients. J Neurotrauma. 2007;24(8):1355-1361.
39. Mohindra S, Mukherjee KK, Gupta R, Chhabra R. Continuation of poor surgical outcome after elderly brain injury. Surg Neurol. 2008;69(5):474-479.
40. Mitra B, Cameron PA, Gabbe BJ, Rosenfeld JV, Kavar B. Management and hospital outcome of the severely head injured elderly patient. ANZ J Surg. 2008;78(7):588-592.
41. Wang H, Coppola M, Robinson RD, et al. Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center. J Clin Med Res. 2013;5(2):75-83.
42. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 2010;68(1):109-114.
43. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273.
44. Johannesen M, LoGiudice D. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing. 2013;42(3):292-298.
45. Sooryanarayana R, Choo WY, Hairi NN. A review on the prevalence and measurement of elder abuse in the community. Trauma Violence Abuse. 2013;14(4):316-325.
46. Eulitt PJ, Tomberg RJ, Cunningham TD, Counselman FL, Palmer RM. Screening elders in the emergency department at risk for mistreatment: a pilot study. J Elder Abuse Negl. 2014 (in press).
47. Yafee MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276-300.
48. Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin North Am. 2006;24(2):491-505.
49. Betz ME, Lowenstein SR. Driving patterns of older adults: results from the Second Injury Control and Risk Survey. J Am Geriatr Soc. 2010;58(10):1931-1935.
50.  Platts-Mills TF, Hunold KM, Esserman DA, Sloane PD, McLean SA. Motor vehicle collision-related emergency department visits by older adults in the United States. Acad Emerg Med. 2012;19(7):821-827.
51. Carr DB. Commentary: The role of the emergency physician in older driver safety. Ann Emerg Med. 2004;43(6):747-748.
52. Carr DB, Ott BR. The older adult driver with cognitive impairment: "It's a very frustrating life". JAMA. 2010;303(16):1632-1641.
53. Molnar FJ, Patel A, Marshall SC, Man-Son-Hing M, Wilson KG. Clinical utility of office-based cognitive predictors of fitness to drive in persons with dementia: A systematic review. J Am Geriatr Soc. 2006;54(12):1809-1824.
54. Ott BR, Davis JD, Papandonatos GD, et al. Assessment of driving-related skills prediction of unsafe driving in older adults in the office setting. J Am Geriatr Soc. 2013;61(7):1164-1169.
55. Molnar FJ, Marshall SC, Man-Son-Hing M, Wilson KG, Byszewski AM, Stiell I. Acceptability and concurrent validity of measures to predict older driver involvement in motor vehicle crashes: an Emergency Department pilot case-control study. Accid Anal Prev. 2007;39(5):1056-1063.
56. Schrijver EJM, toppinga Q, de Vries OJ, Kramer MHH, Nanayakkara PWB. An observational cohort study on geriatric patient profile in an emergency department in the Netherlands. Neth J Med. 2013;71(6):324-330.
57. Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and Nurse Acceptance of Geriatric Technicians to Screen for Geriatric Syndromes in the Emergency Department. West J Emerg Med. 2011;12(4):489-495.
58. Tirrell G, Sri-On J, Lipsitz LA, Camargo CA, Kabrhel C, Liu SW. Evaluation of older adult patients with falls in the emergency department: discordance with national guidelines. Acad Emerg Med. 2015;22(4):461-467.
59. Carpenter CR, Heard K, Wilber ST, et al. Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment. Acad Emerg Med. 2011;18(6):644-654.
60. Carpenter CR, Shah MN, Hustey FM, Heard K, Miller DK. High yield research opportunities in geriatric emergency medicine research: prehospital care, delirium, adverse drug events, and falls. J Gerontol Med Sci. 2011;66(7):775-783.

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