Older adult trauma: outcome variables
Likelihood of hospital admission [38]
Patient Characteristics and Outcomes
Patient characteristics (i.e., clinical characteristics and demographics) represent the patient’s baseline status at the outset of treatment or usual status before injury. Patient characteristics are particularly important in older adults in light of increasing age, comorbidities, and declines in physiologic reserve, cognition, and functional ability. Failure to consider all potential risk factors in the data collection process can introduce bias that results in inaccurate conclusions [3]. Table 22.2 summarizes patient characteristic variables examined in a sample of older adult trauma studies.
Table 22.2
Summary of patient characteristic variables in selected older adult trauma studies
Older adult trauma: patient characteristic predictor variables |
|---|
Other (addressed in only one or two studies): |
Race [10] |
Number of injuries [26] |
Presence of dementia [17] |
Angle of impact [19] |
Nonuse of restraints [19] |
Injury to other occupants [19] |
Post-hospitalization institutionalization [14] |
Extremity injury [26] |
In-Hospital Mortality (IHM)
The association of advancing age and increased IHM is validated in many studies; however, IHM rates within individual studies reflect differing inclusion criteria for study samples. Inclusive, multi-institutional studies report lower IHM than exclusive studies. For example, IHM ranged from 3.2 to 4.3 % in two inclusive multi-institutional studies [7, 10] and 15.8–17 % in exclusive single-center studies [18, 61]. Of note, an increased size and an inclusive scope of patients dilute overall IHM rates.
An increasing injury severity score is consistently associated with higher IHM. In two inclusive multicenter studies, higher injury severity (ISS) resulted in odds ratios for IHM ranging from 1.07 to 2.77 [10, 11]. Other studies [6, 8] compared ISS among different age groups. For example, one study (N = 802,211) included patients with an ISS between 10 and 15 with a mortality rate in young patients (< age 60) of 1.4 % compared with 5.9 % for older patients (≥ age 60) (p < .001) [6]. In a second study (N = 7121), the mortality rate for patients 18–64 years old was 2.6 % compared with 7.4 % for the cohort 65 years and older (p < .05) [8].
Several studies demonstrated a relationship between gender and higher IHM rate for males compared with females. For example, in three studies the odds ratios for IHM in males were 1.0 [21], 1.4 [7], and 2.05 [43], as compared with 1.0 [7, 43] and 0.66 [21] for females.
The influence of comorbidities on IHM was examined in several studies with varied results that appear to be dependent on sample inclusion criteria. For example, Pracht et al. [62] found that in patients aged 65–74, the probability of mortality increased as the number of comorbidities increased, while Labib et al. [5] found that in patients 65 years and older with an ISS of greater than 15, preexisting comorbidities were not associated with higher IHM.
Falls are the predominant mechanism of injury (MOI) in older adult trauma but carry a relatively low incidence of IHM. Richmond et al. [26] found that blunt trauma in older adults carried a lower odds ratio of IHM (0.35) compared to penetrating trauma. In other studies, pedestrian injuries and burn injuries were associated with higher mortality rates when compared with other mechanisms of injury [44, 46, 47, 55].
Complications (adverse events) have also been associated with IHM in several studies. Perdue et al. [42] examined infectious complications, Smith et al. [53] examined the number of complications, and Horst et al. [52] examined septic complications. Richmond et al. [26] reported odds ratios of IHM for select complications: cardiovascular complications (2.85), pulmonary complications (2.01), and other complications (2.15). More recently, Labib et al. [5] found that respiratory complications, in contrast to cardiac, renal, and neurologic complications, carried an increased risk for IHM. Adams et al. [25] reported that infectious complications peaked between age 45 and 65 and then declined with increasing age.
Post-Hospitalization Mortality (PHM)
Post-hospitalization mortality refers to death occurring at any time after discharge from the index hospitalization for injury. Various studies in injured older adults examined PHM at 30, 60, 90, 180, and 365 days post-discharge. The outcome of PMH is particularly important in this population and is perhaps more reflective of the complex interaction between injury and aging. For example, PHM will likely differ in a 79-year-old with significant pre-injury functional limitations and multiple injuries, compared with a highly active 79-year-old with multiple injuries. The effect of injury on the first patient may trigger a rapid decline resulting in death within 2 years, while the second patient may recover to a pre-injury status and survive 10 or more years.
A number of studies have examined the association between increasing age and PHM. Gorra et al. [7] reported IHM ranging from 3.2 to 3.7 % in four geographic regions, while 30-day mortality ranged from 2.8 to 3.5 % in four geographic regions. Clark et al. [16] found a 7.5 % 30-day mortality rate as compared to 3.7 % for IHM. Zarzaur et al. [15] reported a 79.6 % survival rate (20.4 % mortality) at 2 years post-injury in patients 75 and older. Gallagher et al. [63] reported a 2-year mortality rate of 36 % in patients 60 years and older, compared with 7 % in younger patients. More recently, Davidson et al. [14] examined PHM by age and other patient characteristics and found a significant PHM (16 % by 3 years) in injured patients; age was a strong predictor of PHM. These findings indicate that risk of mortality continues beyond hospital discharge. In fact, from a recent study that used Medicare Provider Analysis and Review (MEDPAR) data for the states of Oregon and Washington (2001/2002), Fleischman et al. [64] reported a continued rise in PHM with stabilization occurring at 6 months post-injury and 89 % of change occurring by 60 days. These findings encourage researchers to evaluate both IHM and PHM with caution and call for clinicians to place a greater emphasis on post-discharge care planning [64].
Other Outcomes
Length of stay (hospital and ICU) has been examined in several studies, showing associations among increasing age [8, 18], higher injury severity [31, 59], increased complications [23, 41], and increased length of stay (LOS). Studies have also reported associations between increasing age and development of complications [9, 18, 23, 25, 32]. Other studies have reported significant association between higher injury severity and development of complications [7, 26, 41]. Tornetta et al. [41] reported that injury severity predicted the development of acute respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications. Bochicchio et al. [23] found that older patients who developed nosocomial infections had higher injury severity scores. Adams et al. [25] reported a significant breakpoint at age 45 for decubitus ulcers and acute renal failure with infectious complications peaking between age 45 and 65 and declining with increasing age. Finally, studies have examined advanced age and under–triage [35–37], suggesting that under-triage of injured older adults to non-trauma centers is significantly higher than in younger adults.
Functional Status
Functional status, as an outcome, has been examined in several studies [9, 27–29, 65, 66]. While methods of outcome measurement differed among studies, all studies found significant functional decline after injury in the elderly. Older persons, who are hospitalized for acute illnesses, including surgical interventions, are more prone to develop functional decline and are discharged to institutions for long-term care. While other age groups are recipients of long-term care services, the elderly constitute the largest consumers of long-term care, primarily through nursing home admissions [65]. More than 90 % of geriatric trauma patients required home or institutional nursing care 1 year after injury [47].
While it is important to understand the current and projected growth in numbers of the elderly, it is equally important to note that only a small percentage of this population are actually living in institutionalized care at any given point in time. Even previously independent elders become vulnerable as mobility, cognition, nutrition, and continence can be affected by traumatic injury and operative intervention, resulting in the need for long-term care. As noted previously in this chapter, patients with pre-trauma impairment and cognitive issues are at greatest risk.
Function can best be described as a continuum ranging from complete independence to prediction of death [66]. There is wide variability in the concept of what defines function in an older patient. Functional impairment can simply be defined as a decreased ability to meet one’s own needs. Looked at comprehensively, function in older people includes independent performance of basic activities of daily living (ADL), social activities, or instrumental activities of daily living (IADLs), and the assistance needed to accomplish these tasks, as well as sensory ability, cognition, and capacity to ambulate.
Older patients also differ in aging physiology and anatomy compared to the young. Function is different and can be complicated in the older patient. Disease often presents first as functional loss in older persons, and conversely, functional loss can be the result of disease. Epidemiological studies demonstrate that pain, whatever the source, is overlooked as a potential cause of disability. Fall risk is increased with pain [67]. Symptoms from disabling movement disorders such as Parkinson’s disease are varied and include tremor, rigidity, bradykinesia, akinesia, postural abnormalities, and dementia. In addition to fractures, osteoporosis can limit mobility by increasing the fear of falling in the elderly, leading to many of the complications associated with immobility [68]. Does identification of morbidity in older people add to understanding of function? Function in the elderly is more than motor ability and the capacity to perform. Do sensory deficits impair communication of needs? Does bladder incontinence contribute to a 70-year-old’s social withdrawal?
Cognitive impairment, often underdiagnosed, is a risk factor for medication nonadherence and poor compliance which can lead to further decline in function. The actual reaching distance of an 82-year-old man in a wheelchair with a shoulder injury may be more predictive of function than measuring movement of abduction itself. The combination of arthritis and fractures on movement in navigating a two-story home highlights the need for a holistic understanding of physical function in an older person. Preservation in all spheres of function is critical to restoring independence.
While there are few longitudinal studies evaluating function after injury for older trauma patients, recent research has demonstrated the loss of one ADL in the year following an injury is significant. Limitation in ADL is a stronger predictor of hospital outcomes (functional decline, length of stay, institutionalization, and death) than the admitting diagnosis [69]. Previously injured older persons are at higher risk for recurrent injury when compared to those not previously injured [70].
It is important to recognize all risk factors for functional decline, including injuries, acute illness, medication side effects, pain, depression, malnutrition, decreased mobility, prolonged bed rest (including the use of physical restraints), chronic indwelling Foley catheters, and changes in living environment or routines. Complications that result from functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, increased risk for long-term institutionalization, and depression [71]. Even during the recovery phase, common causes of general loss of function such as failure to thrive, weight loss, dehydration, and falls can be difficult to pinpoint. Decline can happen quickly, so prompt identification and treatment of the inciting problem is paramount to a good outcome.
Early identification and management of new or existing medical issues that complicate recovery after injury may improve outcomes for older patients. It is noted in the literature that higher morbidity in the geriatric trauma patient is associated with preexisting medical conditions, a decline in organ function, altered physiologic responses to minor injuries, and atypical symptoms and signs of injury [72]. A useful but grim triad offers some measure of predictability. Chronological age plus comorbid disease associated with even moderate injury overwhelms limited physiologic reserve and coping mechanisms for the geriatric trauma patient, which then impairs function [12].
Trauma encompasses the physical, psychological, and spiritual responses that can have an overwhelming impact on the vulnerable or frail older patient. Recent literature concludes that application of aggressive evaluation and resuscitation principles to the geriatric patient improves mortality and morbidity. Although geriatric surgery principles highlight the difference in care between the young and the old in the very early course of recovery, the risks and challenges that older trauma patients present require knowledge and application of principles of geriatric care beyond the acute treatment phase. Consistent utilization of three key principles can move the hospitalized elderly patient towards improved function: (1) treating the individual and not just the injury, (2) the alignment of team resources, and (3) improving function in the context of the care continuum.
Care must be taken to avoid agism. Stereotyping of older patients by health professionals may manifest through discriminatory communication and treatment [73]. Older people are not simply a cross section of a chronically diseased population. Geriatric psychological literature shows that the older a person becomes, the more diverse in personality she/he becomes from peers. To make sense of our world, we categorize; but health-care providers should not assume that older people are all alike. If we see patients as incompetent without assessing them, we will not give them choices or ask the serious questions that need to be answered concerning their care. If patients are seen as feeble and frail, we might assume that their premorbid ADL were minimal. Older patients need respect and a sense that they are viewed as individuals.
A complete history should focus on more than the traumatic event and should include a comprehensive geriatric history and assessment for not only care, but also better outcomes. Diminished pre-injury functional status is a leading predictor of poor outcomes. How well did the older patient function before the injury? How do the patient and family describe the patient’s “normal” day-to-day routine? Many older people live with disability, and limited function may be a unique and satisfactory adaptation for them.
The social history is vital information at the time of admission. Documented assessments often contain scant statements such as “lives with spouse” or a social history that is “noncontributory.” Knowledge that the elderly patient is a professor of literature at the local college and has been married for 49 years reflects a high functional level of independence. However, an injury which results in multiple rib fractures may significantly affect the patient’s ability to return to this pre-injury ADL. After a lifetime of independent decision-making, patients may find themselves completely dependent with uncertain futures. The patient should be approached with respect and dignity as an individual and informed of choices tailored to him.
Assessing fear is critical. Fears, of death, pain, procedures, and the unknown, are more obvious in the hospital setting. Other fears might not be as obvious. If overwhelmed, the patient may become avoidant, resulting in missed therapies and regress back into inactivity. Asking the question: “What is your biggest fear right now?” can be helpful in planning care and in assisting patients who fear falling, nursing home placement, becoming a burden to their loved ones, and the inability to return to a previous level of functioning. Naming the fear out loud lessens its ability to create anxiety and depression that can inhibit healing. Appropriate support can be given to allay these fears and move older patients towards their goals.
Patient motivation as a facilitator of recovery is pivotal. The key to motivation is sharing in one’s own goal setting. The older patient should participate in setting obtainable short-term goals and to pursue personal, realistic, and measurable long-term goals, such as attending family celebrations. The trauma team should emphasize function rather than dysfunction and demonstrate hope, optimism, and a sense of humor. The patient and family should be constantly educated regarding the value of independence and the consequences of decline. Recovery is a highly individualized process. By formulating what is desirable and achievable and understanding the older person’s unique capacities and limitations, providers can facilitate preservation of as much independence and the sense of dignity as possible.
Continuum of care is a concept describing an integrated system of care that guides and tracks the patient over time through a comprehensive array of health disciplines and services spanning all levels of care. When the older injured patient enters this continuum, the process becomes complex. Although there is great variability in all aspects of presenting needs and care, elderly patients need follow-up through rehabilitation and eventual transition to independent living. The continuum of geriatric care focuses on the individual’s functional abilities and resources in the context of the individual’s disease or post-trauma state.
Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of elderly patients to perform ADLs at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care [74]. The assessment and treatment plan should be individualized, and it should be assessed and modified frequently throughout hospitalization based on the patient’s response to treatment. Assessment tools and geriatric-focused clinical pathways can optimize systematic evaluation.
An argument opposing the use of functional assessment tools is that professionals should have the ability to accurately determine the needs of an older patient based on their years of clinical experience. Members of an interdisciplinary team may not agree on what to treat first and how to maintain the momentum of progress in the face of complications and setbacks that are common in older patients who are susceptible to functional decline.
Assessment Tools
The concept of functional assessment is to “measure change.” There are several validated and reliable functional assessment tools used across disciplines for spheres of functionality. Functional assessment should be ongoing throughout hospitalization to make necessary adaptations and to maintain safety and independence.
The Functional Independence Measure (FIM) has been tested for adults of all ages. An analysis of the construct validity and retest reliability of the FIM for persons over age 80 revealed that the motor subscale of the FIM (items A–M) was both valid and stable; the cognitive subscale (items N–R) had construct validity but was less stable; the FIM score could be used to determine a rehabilitation efficiency ratio or the FIM change over the length of stay; and medical comorbidities correlated with lower rehabilitation efficiencies [75].
In the timed “Get up and Go” test, a patient is asked to rise from an armchair, walk 3 m (10 ft), return to the chair, and sit down. The score is the time in seconds it takes to complete this task. This test has significant inter-rater reliability as well as content reliability and predicts whether a patient can walk safely alone outside [76].
The Berg Balance Measure is a 56-point scale that evaluates performance during 14 common activities, including standing, turning, and reaching for an object on the floor. This test has high inter-rater and intra-rater reliability, and while designed to be use as a clinical assessment tool, the Berg Balance test scores were shown to correlate with laboratory test of balance [77].
The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform ADL independently. Clinicians typically use the tool to detect problems in performing ADL and to plan care accordingly. The index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Patients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment [78].
The (Folstein) Mini-Mental State Exam (MMSE) contains questions on orientation, attention, and other cognitive functions. Contrary to popular opinion, it was not created as a diagnostic test for dementia, but is a brief screening tool that allows quantification of cognition over time. It may not detect dementia in people with premorbid high intellectual functioning, and it may inaccurately suggest dementia in cases of the dementia syndrome of depression, previously known as pseudodementia. Screening separately for both dementia and depression is important for determining the patient’s ability to return to independent living [79].
The Geriatric Depression Scale – Short Form is a brief (15-item) questionnaire with yes/no answers that the patient can self-administer, and it has been validated in persons over 55 years old [80].
The Confusion Assessment Method (CAM) assesses for delirium and is not specific to the geriatric population. The CAM was designed for use in various clinical settings. It is simple to administer and designed for clinicians who are not psychiatrically trained [81].
There are many assessment tools for other conditions and syndromes in older adults, including falls, pain, and alcohol use. Clinical pathways are intended to address foreseeable aspects of the condition, enhance care, prevent complications, and reduce length of stay and costs. The American College of Emergency Physicians and American College of Surgeons have advocated for the development of evidence-based clinical protocols and pathways for both acute care and ongoing management of geriatric patients to improve functional outcomes [82, 83]. The American Geriatric Society Task Force on the Future of Geriatric Medicine has recommended optimizing the health of older persons by incorporating the principles of geriatric medicine into existing clinical guidelines [84].
Assessing Care Of Vulnerable Elders (ACOVE)
The ACOVE project, developed through expert consensus, assessed the medical conditions prevalent among the elderly that contribute to morbidity, mortality, and functional decline for which effective methods of treatment or prevention exist. For each condition, quality-of-care process indicators were identified to evaluate the care provided to vulnerable elders. ACOVE-3, the third phase of this project, was completed in 2007 and includes 392 quality indicators covering 26 different conditions in four domains of care: screening and prevention, diagnosis, treatment, and follow-up and continuity. Three of these conditions involve the most basic functions of the human body – cognition, ambulation/mobility, and elimination – which are of importance when assessing the decline of a patient’s health due to aging. Available training modules focus on educating the providers about geriatric syndromes, including cognitive impairment, falls and mobility disorders, and urinary incontinence [85].
The Vulnerable Elderly Survey-13 (VES-13) is a function-based tool that relies on patient self-reporting living independently in the community to identify older persons at risk for health decline. The VES-13 considers age, self-rated health, limitations in physical function, and functional disabilities. The feasibility of using the VES-13 was tested as part of the ACOVE project, an initiative to develop tools for measuring quality of care for elders at increased risk for a decline in health. The investigators who developed and assessed the ACOVE used the VES-13 to screen 2,200 elders by telephone. The average time to complete the screening was less than 5 min [86]. The VES-13 has been validated on uninjured older populations and has been used to predict risk of death and functional decline in the next 12 months in vulnerable elderly patients [87].
In a recent prospective observational pilot study at a Level I TC, investigators examined whether the VES-13 pre-injury score (the higher the score, the higher the risk) would predict complications or mortality in combination with injury severity. The study controlled for ISS and comorbidity and found that each additional VES-13 point was associated with greater risk of complication or death. The authors suggested that the VES-13 might be a useful tool to predict complications and death in older adults with traumatic injury if utilized early in the hospitalization [88]. The VES-13 may help to identify patients at risk for a decline in health who would benefit from geriatric trauma clinical pathways and a geriatric team approach.
Just as aggressive care and resuscitation after trauma can contribute to better outcomes, optimization of comorbid conditions, prevention of complications, and preservation of function can help towards maintenance of ADL performance. Early recognition of functional, cognitive, and affective impairment through team assessment and utilization of available tools can enable prompt and appropriate management through the use of geriatric principles and care pathways aimed at improving functional outcomes. Utilizing the continuum of care concept, interdisciplinary assessment, and proactive management in providing a framework for delivery of optimal health care to the older patient population may influence a reduction in the incidence and prevalence of functional decline, as well as a decrease in morbidity associated with functional decline.
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