Injury, Int. J. Care Injured 46 (2015) 1701–1702
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Trauma in the elderly: Burden or opportunity?
Trauma clinicians worldwide are currently faced with growing numbers of elderly patients, often with multiple co-morbidities, who are suffering serious injuries. This is an evolving public health challenge for the United States and most other countries [1]. Trauma clinicians have both an ethical duty to our patients and a practical obligation to our respective medical systems with finite resources to determine the appropriateness of aggressive care after traumatic injury in an increasingly aging population [2]. The US Census Bureau predicts that, by 2030, 20% of the population will be 65 years and older and, according to the Centers for Disease Control, unintentional injury is a leading cause of death in this age group. More than 3.2 million US citizens over 65 years suffer an unintentional injury each year and about 45000 die from these injuries [3]. According to the recent Australian Government Intergenerational Report [4], in 2014–15 there are 3.1 million (13%) of the population aged 65–84 years and this will increase to 7 million (17.7%) by 2054–55. For those 85 years and older, the number is expected to increase from about 500,000 (2%) in 2014–15 to approximately 2 million (4.9%) in 2054–55. In the latest report from the Australian Institute of Health and Welfare [5], injury resulted in 10668 deaths in 2009–10 (7.6% of all deaths) with 1/3 of all male injury deaths and 2/3 of all female injury deaths occurring at age 65 years and older. The most common causes of deaths were falls (32%), intentional self harm (21%) and transport accidents (14%). While injury is the leading cause of death in the under-35 year age group, it occurs even more frequently in the older age group with the highest frequency occurring in those over 65 years. In 2013, patients 65 years and older contributed 27% of the major trauma patients admitted to NSW hospitals [6] and falls contributed 75% of the admissions in this cohort of patients. The rate of injury increases sharply from 75 years and older as does the case fatality rate to 26.7% compared to those less than 75 years with a case fatality rate of 8%. We know the numbers of older people are increasing compared to the rest of the population, and they are injuring themselves more frequently and more seriously compared to those less than 65 years. These patients often have multiple co-morbidities, which also contribute to long, and often complicated, stays in hospital. Injury prevention and education initiatives are relatively inexpensive to provide but do not always result in the desired outcomes of decreasing rates of injury. While it is possible to legislate for compulsory seat belt wearing and random breath tests, it is not possible to stop people falling while climbing a ladder or stairs, or crossing the road. http://dx.doi.org/10.1016/j.injury.2015.07.036 0020–1383/ß 2015 Published by Elsevier Ltd.
It is also difficult to measure decreased reaction time and concentration ability, or marginal visual problems involved in driving a car, yet these issues are often related to motor vehicle crashes in the elderly. Perhaps the process of testing fitness to drive a motor vehicle over the age of 65 years needs to be more rigorous and reflect the full range of driving conditions, but this would be costly and time consuming to apply. There is also the thorny issue of personal freedom versus public responsibility for the licensing authorities. The provision of the best available, efficient and safe care for the older age group is paramount but equally important are decisions about limiting care when it is likely to be counter productive or futile. Can the current trauma literature provide any guidance regarding those injured elderly trauma victims who will do well after aggressive resuscitation for traumatic injuries and those who will have a poor outcome of death or severe disability? Duvall et al. [2] found that patient age, injury severity score, and comorbidities are not useful to predict futility of care (95% chance of dying) for the elderly after injury. However, other authors [7] have found that early mortality in those >65 years correlated with Injury Severity Score (ISS) and late mortality with lower ISS and medical complications. In a recent meta-analysis of mortality after brain injury in those patients >60 years [7], the authors found an overall mortality rate of 38.3%. They also found there was an almost double (1.74) the rate of death in those >75 years when compared to those 65–74 years and the risk of dying from a severe (GCS 3-8) or moderate (GCS 9-12) head injury far outweighed that of a minor head injury (13-15) by odds ratios 12.69 and 5.31, respectively. They attributed the increased mortality rates above to complications of the head injury, presence of chronic disease, conservative management techniques or the consequences of biological aging. There has been recent interest in measuring the known decline in physiological reserve with aging and whether this may contribute to worse outcomes in elderly trauma patients [8]. However, there is considerable heterogeneity in the degree of physiological decline in older patients, which has led to the concept of ‘‘frailty’’. Frailty [1] is defined as ‘‘a syndrome of decreased physiological reserve and resistance to stressors, which results in increased vulnerability to poor health outcomes, worsening mobility and disability, hospitalisations and death.’’ As frailty has many facets, a number of assessment tools have been developed to aid in objective and reproducible measurement of frailty.
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Editorial / Injury, Int. J. Care Injured 46 (2015) 1701–1702
Joseph et al. [9] investigated the concept of the 50-variable Frailty Index (FI) in predicting outcomes in the elderly trauma population. The FI includes assessment of the following: patient demographics (age, comorbidities and medications taken), social activity, activities of daily living, nutrition and general mood; and a patient with a score above 0.25 was thought to be frail. They measured the FI in 250 elderly trauma patients over a 2-year period and found that 44% of the patients were frail. Patients with frailty were more likely to have in-hospital complications (infections, deep vein thrombosis) and adverse disposition outcomes (skilled nursing facility or death). They found that frailty was a better predictor of complications after injury than age or ISS. They also went on to develop a 15-variable Trauma-Specific Frailty Index (TSFI) [10] which they found to be an independent predictor of adverse discharge disposition, whereas age was not. It appears that age and injury severity are less predictive of outcome after elderly trauma than pre-existing physiological capacity or frailty. We know that patients with increasing levels of frailty are likely to have longer, more complicated and more expensive in-hospital stays. If we are able to better predict the outcomes in elderly trauma patients by measuring the effects of physiological aging on each individual early in their hospital admission, this would facilitate improved communication with family members about treatment options, including palliative care, and more efficient allocation of hospital resources. Early involvement of Geriatricians as part of the Trauma Team in the assessment and management of these patients would be a logical first step as this would assist the decisions around appropriate ongoing care and the management of co-morbidities.
References [1] Joyce MF, Gupta A, Azacar RJ. Acute trauma and multiple injuries in the elderly population. Curr Opin Anaesthesiol 2015;28:145–50. [2] Duvall DB, Xiujun Z, Elliot AC, et al. Injury severity and comorbidities alone do not predict futility of care after geriatric trauma. J Pall Med 2015;18: 246–50. [3] Centres for Disease Control and Prevention. Ten leading causes of death and injury charts http://www.cdc.gov/injury/wisqars/leadingcauses.html [accessed 26.05.15]. [4] Intergenerational Report Australia in 2055. March 2015. The Commonwealth of Australia. http://www.treasury.gov.au/PublicationsAndMedia/ Publications/20152015-Intergenerational-Report [accessed 26.05.15]. [5] Australian Institute of Health and Welfare 2014. Australia’s Health 2014. Australia’s health series no.14. Cat. no. AUS 178 Canberra: AIHW. [6] NSW Institute of Trauma and Injury Management. Major Trauma in NSW, 2013. A report from the NSW Trauma Registry. NSW Agency for Clinical Innovation. www.aci.health.nsw.gov.au [7] McIntyre A, Mehta S, Aubut J, et al. Mortality among older adults after a traumatic brain injury: a meta-analysis. Brain Inj 2013;27:31–40. [8] Scoles GLS, Tornetta P. Multiple trauma in the elderly: new management perspectives. Orthop Trauma 2011;25:S61–5. [9] Joseph B, Pandit V, Zangbar N, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients. JAMA Surg 2014;149(8). 766–722. [10] Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg 2014; 219:10–7.
Anthony Josepha,b,c,* Royal North Shore Hospital, Sydney, Australia b Sydney Medical School, University of Sydney, Australia c Australasian Trauma Society, Australia a
*Correspondence to: Royal North Shore Hospital, Sydney, Australia E-mail address: [email protected] (A. Joseph).
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Trauma in the elderly: Burden or opportunity?
Trauma clinicians worldwide are currently faced with growing numbers of elderly patients, often with multiple co-morbidities, who are suffering serious injuries. This is an evolving public health challenge for the United States and most other countries [1]. Trauma clinicians have both an ethical duty to our patients and a practical obligation to our respective medical systems with finite resources to determine the appropriateness of aggressive care after traumatic injury in an increasingly aging population [2]. The US Census Bureau predicts that, by 2030, 20% of the population will be 65 years and older and, according to the Centers for Disease Control, unintentional injury is a leading cause of death in this age group. More than 3.2 million US citizens over 65 years suffer an unintentional injury each year and about 45000 die from these injuries [3]. According to the recent Australian Government Intergenerational Report [4], in 2014–15 there are 3.1 million (13%) of the population aged 65–84 years and this will increase to 7 million (17.7%) by 2054–55. For those 85 years and older, the number is expected to increase from about 500,000 (2%) in 2014–15 to approximately 2 million (4.9%) in 2054–55. In the latest report from the Australian Institute of Health and Welfare [5], injury resulted in 10668 deaths in 2009–10 (7.6% of all deaths) with 1/3 of all male injury deaths and 2/3 of all female injury deaths occurring at age 65 years and older. The most common causes of deaths were falls (32%), intentional self harm (21%) and transport accidents (14%). While injury is the leading cause of death in the under-35 year age group, it occurs even more frequently in the older age group with the highest frequency occurring in those over 65 years. In 2013, patients 65 years and older contributed 27% of the major trauma patients admitted to NSW hospitals [6] and falls contributed 75% of the admissions in this cohort of patients. The rate of injury increases sharply from 75 years and older as does the case fatality rate to 26.7% compared to those less than 75 years with a case fatality rate of 8%. We know the numbers of older people are increasing compared to the rest of the population, and they are injuring themselves more frequently and more seriously compared to those less than 65 years. These patients often have multiple co-morbidities, which also contribute to long, and often complicated, stays in hospital. Injury prevention and education initiatives are relatively inexpensive to provide but do not always result in the desired outcomes of decreasing rates of injury. While it is possible to legislate for compulsory seat belt wearing and random breath tests, it is not possible to stop people falling while climbing a ladder or stairs, or crossing the road. http://dx.doi.org/10.1016/j.injury.2015.07.036 0020–1383/ß 2015 Published by Elsevier Ltd.
It is also difficult to measure decreased reaction time and concentration ability, or marginal visual problems involved in driving a car, yet these issues are often related to motor vehicle crashes in the elderly. Perhaps the process of testing fitness to drive a motor vehicle over the age of 65 years needs to be more rigorous and reflect the full range of driving conditions, but this would be costly and time consuming to apply. There is also the thorny issue of personal freedom versus public responsibility for the licensing authorities. The provision of the best available, efficient and safe care for the older age group is paramount but equally important are decisions about limiting care when it is likely to be counter productive or futile. Can the current trauma literature provide any guidance regarding those injured elderly trauma victims who will do well after aggressive resuscitation for traumatic injuries and those who will have a poor outcome of death or severe disability? Duvall et al. [2] found that patient age, injury severity score, and comorbidities are not useful to predict futility of care (95% chance of dying) for the elderly after injury. However, other authors [7] have found that early mortality in those >65 years correlated with Injury Severity Score (ISS) and late mortality with lower ISS and medical complications. In a recent meta-analysis of mortality after brain injury in those patients >60 years [7], the authors found an overall mortality rate of 38.3%. They also found there was an almost double (1.74) the rate of death in those >75 years when compared to those 65–74 years and the risk of dying from a severe (GCS 3-8) or moderate (GCS 9-12) head injury far outweighed that of a minor head injury (13-15) by odds ratios 12.69 and 5.31, respectively. They attributed the increased mortality rates above to complications of the head injury, presence of chronic disease, conservative management techniques or the consequences of biological aging. There has been recent interest in measuring the known decline in physiological reserve with aging and whether this may contribute to worse outcomes in elderly trauma patients [8]. However, there is considerable heterogeneity in the degree of physiological decline in older patients, which has led to the concept of ‘‘frailty’’. Frailty [1] is defined as ‘‘a syndrome of decreased physiological reserve and resistance to stressors, which results in increased vulnerability to poor health outcomes, worsening mobility and disability, hospitalisations and death.’’ As frailty has many facets, a number of assessment tools have been developed to aid in objective and reproducible measurement of frailty.
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Editorial / Injury, Int. J. Care Injured 46 (2015) 1701–1702
Joseph et al. [9] investigated the concept of the 50-variable Frailty Index (FI) in predicting outcomes in the elderly trauma population. The FI includes assessment of the following: patient demographics (age, comorbidities and medications taken), social activity, activities of daily living, nutrition and general mood; and a patient with a score above 0.25 was thought to be frail. They measured the FI in 250 elderly trauma patients over a 2-year period and found that 44% of the patients were frail. Patients with frailty were more likely to have in-hospital complications (infections, deep vein thrombosis) and adverse disposition outcomes (skilled nursing facility or death). They found that frailty was a better predictor of complications after injury than age or ISS. They also went on to develop a 15-variable Trauma-Specific Frailty Index (TSFI) [10] which they found to be an independent predictor of adverse discharge disposition, whereas age was not. It appears that age and injury severity are less predictive of outcome after elderly trauma than pre-existing physiological capacity or frailty. We know that patients with increasing levels of frailty are likely to have longer, more complicated and more expensive in-hospital stays. If we are able to better predict the outcomes in elderly trauma patients by measuring the effects of physiological aging on each individual early in their hospital admission, this would facilitate improved communication with family members about treatment options, including palliative care, and more efficient allocation of hospital resources. Early involvement of Geriatricians as part of the Trauma Team in the assessment and management of these patients would be a logical first step as this would assist the decisions around appropriate ongoing care and the management of co-morbidities.
References [1] Joyce MF, Gupta A, Azacar RJ. Acute trauma and multiple injuries in the elderly population. Curr Opin Anaesthesiol 2015;28:145–50. [2] Duvall DB, Xiujun Z, Elliot AC, et al. Injury severity and comorbidities alone do not predict futility of care after geriatric trauma. J Pall Med 2015;18: 246–50. [3] Centres for Disease Control and Prevention. Ten leading causes of death and injury charts http://www.cdc.gov/injury/wisqars/leadingcauses.html [accessed 26.05.15]. [4] Intergenerational Report Australia in 2055. March 2015. The Commonwealth of Australia. http://www.treasury.gov.au/PublicationsAndMedia/ Publications/20152015-Intergenerational-Report [accessed 26.05.15]. [5] Australian Institute of Health and Welfare 2014. Australia’s Health 2014. Australia’s health series no.14. Cat. no. AUS 178 Canberra: AIHW. [6] NSW Institute of Trauma and Injury Management. Major Trauma in NSW, 2013. A report from the NSW Trauma Registry. NSW Agency for Clinical Innovation. www.aci.health.nsw.gov.au [7] McIntyre A, Mehta S, Aubut J, et al. Mortality among older adults after a traumatic brain injury: a meta-analysis. Brain Inj 2013;27:31–40. [8] Scoles GLS, Tornetta P. Multiple trauma in the elderly: new management perspectives. Orthop Trauma 2011;25:S61–5. [9] Joseph B, Pandit V, Zangbar N, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients. JAMA Surg 2014;149(8). 766–722. [10] Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg 2014; 219:10–7.
Anthony Josepha,b,c,* Royal North Shore Hospital, Sydney, Australia b Sydney Medical School, University of Sydney, Australia c Australasian Trauma Society, Australia a
*Correspondence to: Royal North Shore Hospital, Sydney, Australia E-mail address: [email protected] (A. Joseph).
