Geriatric Trauma Care: Reflecting on the Past While Looking Forward

1. Geriatric trauma care:
Reflecting on the past while
looking forward
Avery B. Nathens MD PhD
Professor of Surgery, University of Toronto
Director, ACS Trauma Quality Improvement
Program

2. Trauma ~ 1998
• 22 yo male, previously well
• multiple GSW to abdomen, presents in shock
• Laparotomy, 14 units of blood
• Hepatorraphy, splenectomy, bowel resection
• ICU – 3 days
• Ward – 6 days, discharged home

3. Trauma - 2015
• 72 yo male, cleaning roof, falls
• Atrial fibrillation, MI, on plavix and dabigatran
• Subdural hematoma, T-spine fracture, multiple rib
fractures
• ICU -2 weeks, pneumonia, trach, acute renal failure,
• Family meetings to discuss goals of care
• Ward – 4 weeks, course complicated by delirium, UGI
bleed , decubitus ulcer
• Discharged to rehabilitation

5. US Birth Rates
6/10/2015
Postwar
baby boom
1946-1964

6. Was this predictable?
• In part
• First baby boomers reached 65 in 2011
• Age>65 projected to reach 20% of the population by 2050
• Longevity was underestimated
• Elderly make up 12% of population yet account for
• 26% of office visits, 47% of hospital outpatient visits
• 38% of EMS responses, 35% of hospital stays,

7. 0
10
20
30
40
50
60
70
80
90
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
Numberofcitations
Firearm-related injuries Elderly
What were we thinking?
Pubmed citations: 1980-2015

8. US Federal Research Funding
clinicaltrials.gov: 2002-15
0
10
20
30
40
50
60
70
80
02-04 04-06 06-08 08-10 10-12 12-15
Numberofstudies
Year
Pediatric trauma
Geriatric trauma

10. NSCOT –National Study of Cost and
Outcomes in Trauma Care
• Prospective cohort
study
• 18 level I trauma
centers and 51 large
non-designated centers
in 15 urban regions
• Extensive data
collection to allow for
risk adjustment
• Follow-up x 1 year

11. National Evaluation of the Effect of
Trauma Center Care on Mortality
N Engl J Med, 2006
20% lower
mortality in
trauma
centers
0
2
4
6
8
10
12
14
In hospital 30 d 90 d 365 d
Mortality(%)
Time from injury
NTC TC
N=15,000 patients

12. Trauma center care & the elderly
The unspoken NSCOT data
Trauma
center
Non-trauma
center
Mortality
reduction
Overall 7.6% 9.5% 20%
Age<55 5.9% 9.0% 34%
Age>55 12.3% 13.1% 6% (NS)
Mackenzie, New Engl J Med, 2006
We have a problem!

13. Trauma PI: Have We Forgotten Our
Elders?
Haas, Ann Surg, 2011
N Elderly
Young High Average Low
High 7 29% 71% 0%
Average 120 6% 88% 6%
Low 5 0 40% 60%
High quality care DOES NOT translate into benefit for
the elderly

14. American College of Surgeons
Trauma Quality Improvement
Program

15. TQIP Benchmarking report

16. Geriatric Best Practice Guidelines
• Consolidation of existing
recommendations and
guidelines to provide
concise, evidence-based,
expert panel rated lists of
protocols and practices to
improve care of the elderly
trauma patient.

17. The patients doctors don’t know
Rosanne Leipzig, NY Times, 2009
• Pediatrics and Obstetrics are MANDATORY rotations in
medical school
• Most MD’s will never take care of a child or deliver a baby
• Medical schools require NO training in geriatric
medicine!
• Average surgeon’s practice is made up of at least 1/3 elderly
patients & half of all hospital days
• Center for Medicare and Medicaid Services
• Payer for patients>65
• Contributes $8 billion/yr to support residency training
• NO mandate that training focus on unique needs of the elderly

18. AKA
The “Don’t kill Granny List”

19. Minimum Geriatric Competencies
• 26 competencies in eight domains
• Medication Management
• Self-Care Capacity
• Falls, Balance & Gait Disorders
• Hospital Care for Elders
• Cognitive & Behavioral Disorders
• Atypical Presentation of Disease
• Health Care Planning & Promotion
• Palliative Care

20. Knowledge
Skills Attitude

21. Old attitudes on the elderly
“Second childishness and mere oblivion”
Shakespeare’s As You Like It, 1599

22. Old attitudes on the elderly
“About the age of 50, the elasticity of the
mental processes on which treatment
depends is, as a rule, lacking. Old people are
no longer educable.”
Sigmund Freud, early 1900’s

23. Ageism
• Dr. Robert Butler
• Founding director of the National
Institute on Aging
• “Modern medicine has created a
huge group of people for whom
survival is possible but satisfaction in
living elusive”
• Defined “ageism”
• Prejudicial attitudes
• Discriminatory practices
• Institutional practices that perpetuate a
negative stereotype

25. Newer facts about getting old
• People report getting happier as they get older
• Less focus on negative emotional stimuli
• Most unhappy in middle age
• Gender roles merge
• Women become more assertive
• Men get more emotionally attuned
• Personalities become more vivid
• We become more of who we are

26. Old age is getting younger
Gerstorf, Pscyhology and Aging, 2015
• Berlin Aging Study, 1990-3, Berlin Aging Study II,
2013-4
• Matched “statistical twins” - age, gender, education
and health status
• Concluded
• Today’s 75-year-olds are cognitively much fitter than
the 75-year-olds of 20 years ago
• Higher levels of well being
• Greater life satisfaction

29. Meeting the Challenge to Care
for the Injured Elderly
6/10/2015

30. Provide great trauma
care…AND
6/10/2015

31. Avoid the Hazards of Hospitalization
• Deconditioning
• Aspiration
• In-hospital falls
• Delirium (and complications of)
• Pressure sores
• Functional incontinence (family
rejection)
Functional independence
Nursing home

34. “The routine involvement of appropriate medical specialists to
evaluate and manage the elderly patient’s comorbid conditions is
desirable. Moreover, a well coordinated, multidisciplinary
approach that acknowledges the unique challenges associated
with the elderly is encouraged”

35. Making a difference
• Improve access to care
• Lower threshold for trauma team activation
• Prompt evaluation and early intervention
• Early multidisciplinary care with engagement of
geriatric expertise where necessary
• Acknowledge patient preferences at the end of life

36. Transport destination by Toronto neighborhood

37. Trauma center
n = 477
Non-trauma center
n = 421
Male 76% 54%
Age > 65 18% 51%
Mechanism
Fall
MVC
Stab wound
Gunshot wound
Other
30%
26%
16%
14%
12%
66%
7%
3%
1%
17%
Field triage practices
p < 0.05

38. Biases in trauma center
transport in Toronto
Odds Ratio (95%CI)
• Female 0.65 (0.45 – 0.94)
• Fall (vs MVC) 0.14 (0.08 - 0.23)
• Age > 65 (vs16-24) 0.28 (0.16 – 0.50)
Doumouras AG, Haas B, Gomez D, de Mestral C, Boyes DM, Morrison LJ, Craig AM,
Nathens AB. Prehosp Emerg Care. 2012

39. Access to Trauma Center Care
Gomez& Nathens, Ann Surg, 2013
Female
Male
18-24
25-40
41-55
56-64
64-75
76-84
>85
Age
Trauma center
care
MoreLess

40. Potential barriers to trauma
center access
• Ageism - EMS, ED provider
• Lack of knowledge or misperceptions related to
benefit
• Patient preference
• “Connected” to local hospital
• Prefers to stay in community
• Insensitive triage criteria

41. When do you activate the trauma
team?
• Are thresholds for identifying the severely injured
geriatric patient too high?
• Trauma team activation
• Compliance with TTA criteria poor for elderly (Cherry, Surgery,
2010-Pennsylvania)
• Undertriage rates twice as high in elderly (Rainer,
Resuscitation, 2007)

42. Triage and the elderly
• Conventional criteria might miss the high risk
elderly
• “Normal vital signs”
• Poor recognition of neuro changes
• Lower energy mechanisms>greater injury
• Limited physiologic reserve – greater opportunity to
get into trouble with lesser injury

43. Age as a criterion for TTA
• Evaluated pre/post addition of age>70
• Subtle other changes
• More invasive monitoring, early resuscitation, ICU admission, early
intubation prior to CT
0
10
20
30
40
50
60
Pre Post
Mortality (%)
Mortality(%)
Demetriades, BJS, 2002

44. Right intervention at the right
time
• Resuscitate before non-
essential operative
procedures
• …but where
unnecessary, don’t wait
• Avoid prolonged
operations

45. Canadian Medical Association Journal, Jan 2014
6 HRS from
ED to OR

46. HIP ATTACK
Pilot study
Accelerated
care
Standard care
Major periop complication 30% 47%
Death 3% 13%
Preop MI 3% 10%
Postop MI 13% 23%
Major bleeding 7% 13%
Delirium 13% 30%
Hospital LOS 9d 12d
FIM score 62 53

47. Bring geriatric expertise to
your patients
• Comprehensive geriatric assessment
• Interdisciplinary
• Evaluation to determine medical, psychological, and
functional capability
• Management to provide a coordinated and integrated
plan for treatment and followup

48. Systematic review of CGA
Ellis, Cochrane Database Syst Rev, 2011
• 22 randomized controlled trials, >10000 patients
• “Comprehensive geriatric assessment increases a
patient's likelihood (by 25%) of being alive and in
their own home at up to 12 months”
• …and more likely to experience improved cognitive function

49. Identifying Seniors at Risk (ISAR)
• If “yes” to two or more of the following then obtain a
geriatric consult
• Before you were injured, did you need someone to help
you on a regular basis?
• Since the injury, have you needed more help than usual to
take care of yourself?
• Have you been hospitalized for one or more nights during
the past six months?
• In general, do you have problems seeing well?
• In general, do you have serious problems with your
memory?
• Do you take more than three different medications every
day?

50. Innovative Solutions
• Mangram, “G60 unit”, 2011
• Process changes, concentration of care
• Shorter ED LOS, time to OR, hospital LOS, mortality,
complications
• Lenartowicz, “Proactive geriatric consultation”,
2012
• APN, geriatrician
• Early involvement of expertise directed to prevention
of geriatric syndromes and discharge planning
• Shorter LOS, less delirium, falls, fewer discharges to
long term care

51. “After a focused review of our institution’s data
provided by the Trauma Quality Improvement
Project of the American College of Surgeons, we
developed a new multidisciplinary approach to
geriatric trauma care, termed the Geriatric Trauma
Institute”

53. Treatment in a “center for
geriatric traumatology”
• Grund et al, Dtsch Arztebl Int. Feb 2015
(Mannheim, Germany)
• Collaborative model - Trauma surgeons and
geriatricians
• Fewer admissions to the ICU
• Lower mortality

54. J Trauma, April 2015

55. Geriatric trauma centers??

56. Acknowledging patient
preferences at the end of life

57. Withdrawal of care
Penetrating
Blunt
Shock
TBI Elderly
0
10
20
30
40
50
60
Withdrawalofcare(%)
Withdrawal of care among deaths

58. Withdrawal of care by center
0
10
20
30
40
50
60
70
80
90
100
Withdrawal(%)

59. Does withdrawal of care affect
“hospital performance”
Early
(4 days)
N=108
Late
(7 days)
N=92
25
20
15
10
5
0
Timetodeath(days)

60. Association between early
withdrawal and TBI-related
mortality
Adjusted odds of
death
Overall 0.95 (0.83- 1.09)
Age>80, GCSm<3 1.46 (1.05 to 2.02)

68. “Perfection is not attainable, but if
we chase perfection we can catch
excellence” – Vince Lombardi

69. Excellence is a journey, not a
destination