Trauma And The Old Patient

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 and Teberian 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

 

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 longer hospital stays

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 <10% 5. Assault / elder abuse - 1 to 5 % 6. Choking about 2 % 7. Self induced poisoning <2% 9. Miscellaneous 1 to 9% The majority of trauma is caused by falls and motor vehicle crashes (driver, passenger and pedestrian). The incidence of falls is increasing. This is probably related to the increasing proportion of old old who are more prone to falls and fractures than young old. Elderly women have higher rates of fall injuries than elderly men. Older men have higher rates of injuries from burns and motor vehicle accidents, including pedestrian accidents. They also have higher rates of death from these three categories. Among those aged 65 to 74 years, nearly one quarter of deaths are due to falls and over one third are due to motor vehicle crashes. By age 75, 50% of deaths from injury are due to falls and less than 20% due to motor vehicle crashes. Falls increasingly dominate injuries and injury deaths with advancing age (Baker et al. 1992). A survey of trauma indicated that 10% of falls in older people were caused by a specific medical diagnosis. Outcomes (Baker et al. 1992, De Maria et al. 1987a, De Maria et al. 1988, De Maria 1993, Fildes et al. 1994, Mandavia 1998, Schiller et al. 1994, van Aalst et al. 1991) As the elderly population increases, we are faced with a greater number of injured elderly patients. Depending on the series, up to 40% of elderly trauma patients die. It is therefore desirable to be able to predict which patients will benefit from treatment in order to avoid subjecting patients and their families to treatment in futile situations and more importantly to ensure that older people are not denied access to potentially useful treatment. For further discussion of trauma outcomes, see specific trauma types. Outcome clearly depends upon the individual's general health, the nature and severity of trauma and the occurrence of complications. Little research has been undertaken in this field, and most studies have failed to include important risk factors for geriatric outcome such as pre trauma Comorbidities, dementia, undernutrition, anthropometry, medication use, functional status and combinations of risk factors. Study subject numbers have been too few to detect real and relevant associations. Trauma populations studied and definitions of trauma employed have varied significantly enough to produce results which are

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, have poorer 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 <10 per minute) also has a predictive value. Mortality increases as respiratory rate decreases. Patients over the age of 85 who have a 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).

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)

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 clinician’s 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

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, sarcopaenia development, 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:

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

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 bone mass 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 person’s 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.

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 person’s 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.

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 heart’s 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,

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

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

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 includepolypharmacy, 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.

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% Over 70 years 10 to 20% Over 80 years 15 to 20% 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

•

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 normal levels. 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

•

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.

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 Alzheimer’s 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.

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 patient’s 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 factors interact 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

act on the brain to induce delirium. Oxygen therapy, ventilation monitoring and measurement of oxygen saturation are especially important in the older patients whether or not the chest has been involved in trauma. Consideration of temporarily discontinuing the patient’s long term drugs such as antidepressants should be given. Accurate diagnosis of past diseases is required. After weighing risks and benefits in the individual, dosage may be reduced depending on the acute issues. Alternatively, analgesic drugs such as tramadol may be used with greater safety because they have minimal neurological and respiratory side effects.

Management principles: Acute phase initial assessment and management •

Determine mechanism of trauma. Also consider whether ‘elder abuse’ has occurred (see below)

•

Determine immediate effects of trauma and institute resuscitation. Close haemodynamic and pulse oximetry monitoring is associated with improved outcome in older patients with relatively mild injuries.

•

If in doubt, admit the elderly patient to a higher dependency unit for the first 48 hours for relatively moderate trauma because of higher risk of acquiring complications early.

•

Determine possible medical problems precipitating injuries e.g. arrhythmias, infections, hypothermia, pressure areas (long lie). Urinary tract infection, pneumonia, faecal impaction, drug toxicity, alcohol, hypothermia or a vascular event for example may have precipitated a fall.

•

Commence monitoring for delayed manifestations of trauma which may present either typically or 'atypically' e.g. subdural, underlying infection, shock, hip fracture, remediable complications such as circulatory shock and skin condition at vulnerable pressure points.

•

Identify, prevent and manage undernutrition early, aggressively and carefully. Nasogastric or nasoduodenal feeding carries significant morbidity, which can be minimized by careful tube positioning and posturing. Overnight feeding carries additional risk of aspiration. Percutaneous gastrostomy tube feeding has some advantages.

•

Review drugs that may be contributing to underlying presentation or complications associated with bed rest e.g. faecal impaction.

•

Look for and investigate Geriatric Syndromes. These give clues to multiple underlying pathologies that may be reversible.

•

Prevention of pressure areas begins at the scene of trauma. Decubitus ulcers commonly occur in busy Emergency Departments. Cutaneous and subcutaneous changes associated with age place frail older people at greater decubitus ulcer risk, especially if oxygen transport is impaired. Use of specialized mattresses with frequent turning or turning on an hourly basis is necessary.

•

Regular review for other complications of trauma is particularly warranted in patients who arrive confused and in whom pain localization is poor. Brain CT scan is warranted in these patients, however confusion is commonly due to causes other than acute intracranial bleeding, cerebral

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

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

•

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 Parkinson’s 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.

•

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

•

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

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

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 potential environmental 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.

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 and walk 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.

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 mimicker’s in older people, presenting as dementia, delirium, stroke, seizures, mood disturbances, transient ischaemic attacks. Bilateral haematomas, metabolic derangement and postoperative 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

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 (<10%). Acute subdurals carry a worse prognosis, especially in the very old (35 50%)(Ellis 1990, Cagetti et al. 1992 and Rozelle et al. 1995). Factors associated with poor outcome include: reduced level of consciousness, extreme old age, acuity and requiring craniotomy rather than simple drainage.

Treatment Acute progressive subdurals require drainage quickly. Chronic subdurals require drainage if they are not spontaneously resolving or if disability is relatively severe. In some cases chronic subdurals are found incidentally and no treatment is required apart from monitoring. Craniotomy is required to treat symptomatic haematoma recollection.

Cervical injury (Spivak et al. 1994, Lieberman and Webb 1994) Older people tend to suffer less neurological damage from spinal injuries than younger people. This undoubtedly reflects the different mechanism of injury usually a high-speed accident in the younger people and fall in the old. Older people who do suffer major neurological damage have a very poor outcome, having a 60 fold mortality rate. Cervical spondylosis is more common in older people, thus increasing the likelihood of central cord syndrome in people with relatively minor trauma such as a fall or whiplash injury. New neurological deficits following falls in older people may be due central cord syndrome. The prognosis for neurological recovery from this syndrome is reasonably good.

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.