Nursing Center - Journal Issue

WITH THE GRAYING of America, older adults are increasingly victims of injury from falls and other traumatic events. Physical changes that occur with aging affect severity of injury and recovery and decrease physiologic reserves.

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Older adults' physiologic status may differ from that of younger adults and negatively impact their response to traumatic events. This article will help you tune into these differences and their consequences so you can provide the specialized care these patients need.

Fast-growing population

Currently, more than 12% of the U.S. population is age 65 years and older. Over the next several decades, this number is projected to grow to more than 20% of the total population.1 Healthcare and technology advances have paved the way for older adults to be more active, enjoy healthier lifestyles, and live longer. Hospitals are developing units designed specifically for older adults, and nursing programs are incorporating more gerontologic content.

As the population of older adults grows, however, traumatic injuries are also on the rise. Unintentional injury is the ninth leading cause of death in those age 65 and older, with falls topping the list.2 Older adults may have a lower risk of traumatic injury than their younger counterparts due to factors such as more cautious driving and less risky behavior, but they're more likely to suffer more severe injuries or die. This increase in morbidity and mortality stems from a decline in physiologic reserves with aging, which can be quickly exceeded after a traumatic injury.

With aging, the body undergoes a progressive loss of function. Vital organs lose their ability to compensate in times of physical and metabolic stress.3 For more information, see How age-related changes raise the risk and also see Resource at the end of this article.

Falls and other mechanisms of injury

The means by which a person is injured is called the mechanism of injury. Falls, the leading cause of injury and injury-related mortality in older adults in the United States, account for nearly 62% of the total causes of injury in those age 65 and older.2 Each year, an estimated 40% of older adults will fall at least once.4

Head trauma and fractures, the most common injuries following a fall, can be devastating to an older person, interfering with quality of life and the ability to remain independent. Preexisting medical conditions, decreased sensory input and muscle strength, altered motor coordination, and slower reaction times are just a few of the factors contributing to a higher fall risk. As this at-risk population grows, the nursing profession must use available resources and fall prevention programs in the community to reduce falls and help older adults remain healthy and active longer.

Motor vehicle collisions (MVCs) cause almost 6% of unintentional injuries and account for more than 18% of trauma-related deaths among older adults-second only to falls.2 Although older adults tend to use more caution while driving, multiple risk factors place them at a higher risk of being involved in an MVC. Changes in vision, hearing, and reaction times, along with acute and chronic medical conditions, increase the risk for older drivers.

Older pedestrians struck by a motor vehicle make up 19% of all pedestrian fatalities.5 Many age-related changes may contribute to these accidents. For example, kyphosis inhibits cervical range of motion, hindering a person's ability to see oncoming traffic or crossing signals. Inability to walk quickly, reduced reaction time, and decreased vision and hearing are also factors.

Figure. How age-rela... - Click to enlarge in new window

Figure. How age-related changes raise the risk

Other trauma-related events include violence, including violent crime, elder abuse, and self-inflicted injuries. Although younger people are more likely to be victims of violence secondary to more risky behavior, older adults are often vulnerable to violent crimes consisting of blunt and penetrating injury.

Although it's not always easy to detect, always assess for elder abuse and properly investigate all suspected cases. All states have laws against elder abuse and a system for reporting suspected abuse. Follow your institution's policies and procedures and your state's laws about reporting elder abuse.

First response

After any traumatic injury, the best outcomes are achieved through immediate and aggressive resuscitation, special vigilance against complications, and early mobilization of the patient.3 Level II recommendations by the Eastern Association for the Surgery of Trauma (EAST) are that older adults should lower the threshold for field triage directly to a trauma center.6 Clinical and physiologic signs, as well as mechanism of injury, should guide the provider in triage.

Because older patients have limited physiologic reserves, monitor them closely and promptly intervene with any sign of decreased ability to compensate. If an older patient shows signs of being unable to compensate, deterioration can progress rapidly.3 For example, older patients have decreased cardiovascular reserve due to the physiologic changes of aging. Patients experiencing hemorrhage have a reduced ability to increase their heart rate to maintain cardiac output. Low cardiac output then leads to poor perfusion and organ failure.

For an older patient, the basics of resuscitation and initial assessment are the same as for younger adults, with a few special considerations. As with any patient, remember the "ABCDE's" of resuscitation (airway with cervical spine immobilization, breathing, circulation, disability, and exposure).7

* Airway assessment with simultaneous cervical spine stabilization or immobilization is crucial. Assess airway patency and remove dentures if they're loose, ill fitting, or interfering with the airway. Early control of the airway is critical.8 Ensure that bag-valve mask devices, artificial airways, and equipment for endotracheal intubation are readily available.

* Older patients lack pulmonary reserve and are more likely to have underlying cardiovascular disease, making even seemingly minor episodes of hypoxemia significant.8 Always monitor oxygen saturation and administer supplemental oxygen if appropriate. When assessing breathing, be mindful that a seemingly minor rib fracture in an older patient can significantly impair oxygenation. Fractured ribs and chest wall contusions are very painful; in the presence of poor lung compliance and limited pulmonary reserve, they can lead to life-threatening complications.5

* When you assess circulation, remember that many older patients have preexisting diseases that may affect their cardiovascular status. They may also be taking medications that can affect heart rate or BP, such as beta-blockers, digoxin, and calcium channel blockers. If the patient is taking a medication that lowers heart rate, you may not find tachycardia, which is generally a compensatory mechanism in decreased cardiac output states, such as hypovolemic shock.

* Pay close attention to signs of stress and decompensation and act accordingly. Use fluid resuscitation judiciously as these patients are at high risk for fluid volume overload, and use early invasive monitoring such as central venous pressure monitoring when indicated.8

* To assess disability, conduct a brief neurologic exam. Assessing neurologic function in an older person with preexisting dementia can be a challenge, but never assume that confusion is a normal assessment finding in an older person. If possible, determine the patient's usual baseline mental status by asking family or caregivers. If confusion is new for the patient, it can be a sign of underlying medical problems, including hypoxemia, head injury, sepsis, or shock.

* During the exposure phase of your assessment, look for visible injuries. Keep the patient warm. Because older adults have less subcutaneous fat and their shivering response may be absent or diminished, they're more vulnerable to hypothermia.

Consider the history

Many times, preexisting medical conditions contribute to the traumatic event, such as when an older patient with cardiovascular disease has a syncopal event and falls down a flight of stairs. The patient's traumatic injuries need to be treated, but so does the underlying medical condition that caused the fall. For example, syncope caused by a dysrhythmia should be evaluated by a cardiologist and treated appropriately. Understanding the circumstances of the event will help rule out medical causes or physical abuse.

Obtain the patient's medical history and a more detailed history of the traumatic event at this time. Be sure to collect information such as:

* details about circumstances leading to the traumatic event

* preexisting medical conditions

* surgical history

* current medications, including herbal and dietary supplements and over-the-counter products

* baseline mental status

* social history, such as any current use of illicit drugs or alcohol.

Knowing which medications the patient is taking is crucial. For example, if a patient is taking a drug that impairs coagulation, such as warfarin, clopidogrel, or aspirin, the risk of bleeding is significant, especially within the brain. Mortality is high in older patients with head trauma resulting in intracranial hemorrhage.9 Obtain an international normalized ratio in all patients taking warfarin.

A thorough neurologic assessment plays a major role in the care of patients taking anticoagulants. All patients taking anticoagulants who have a change in mental status should have a computed tomography scan of their head.10

Nursing considerations

The EAST guidelines for geriatric trauma state that older patients who sustain postinjury complications have poor outcomes.6 Poor outcomes are commonly associated with cardiovascular, infectious, and pulmonary complications.9 These nursing interventions can reduce risks and improve outcomes.

Mobility. Initiate progressive mobility as soon as possible to prevent skin breakdown, improve pulmonary status to prevent pneumonia, and decrease the risk of deep vein thrombosis (DVT). Involve physical therapists to assist with any mobility limitations, weakness, or imbalance issues. Identify patients at risk for pressure ulcers and implement prevention strategies for all patients identified as being at risk. Pressure ulcers are a leading cause of morbidity and mortality in older adults. Pay careful attention to reducing pressure, friction, and shearing forces with frequent turning and repositioning, protective devices (pillows or other devices to keep bony prominences from direct contact with each other), and pressure-relieving surfaces (specialty mattresses and beds). Be aware of your facility's policies about pressure ulcer prevention and implement interventions appropriate for a patient at high risk.

Pain control. Optimal pain management improves and enhances mobility, optimizes pulmonary toileting, and contributes to emotional well-being. Aggressively manage pain from rib contusions and fractures to improve pulmonary toileting and ventilation and prevent pneumonia.11

The method of pain control must be chosen carefully to minimize pain and prevent complications. I.V. opioids and patient-controlled analgesia are often effective in the acute phase. Because opioids may also lead to sedation and depression of the respiratory and central nervous system, use caution when administering this class of medications to older patients. Older patients should be started on the lowest recommended dose and titrated up carefully if needed. Epidural analgesia, which also provides adequate analgesia and may be another option for pain management, is associated with lower mortality and pulmonary complications compared with I.V. opioids.11

Venous thromboembolism (VTE) prophylaxis. VTE, which includes DVT and pulmonary embolism (PE), is a leading cause of morbidity and mortality after trauma. According to the American College of Chest Physicians (ACCP) guidelines, DVT risk exceeds 50% in major or multisystem trauma patients who are without DVT prophylaxis, and PE is the third leading cause of death in those surviving beyond the first day.12 Increasing age alone is a risk factor; when combined with other risk factors such as trauma and immobility, older adults are at extremely high risk for VTE.

When possible, early mobility should be the first defense. Options for VTE prophylaxis include graduated compression stockings, intermittent pneumatic compression devices, the venous foot pump, and low-molecular-weight heparin (LMWH). The ACCP guidelines for VTE prophylaxis in trauma patients recommend routine prophylaxis in all trauma patients.13 LMWH should be used, in combination with mechanical modes of VTE prophylaxis. Emphasize adherence to the use of these devices with both the patient and the family, and direct careful attention to their proper use.

An ounce of prevention

Preventing injury in older adults involves a close review of the two major causes of injury in older adults: falls and MVC. Identifying fall risk is one of the first steps of prevention. Suggest physical therapy services to improve strength, endurance, balance, and mobility.14

Preventing falls. Initiating a fall precaution program while the patient is in the hospital is of utmost importance. Because older adults usually fall at home, modifying the home is an important part of fall prevention.14 When the patient is discharged from the hospital, initiate a home safety evaluation and a physical therapy evaluation, if appropriate. A professional will conduct a home safety assessment to identify safety issues and make recommendations, such as improving lighting, removing throw rugs, and installing grab bars in the bathtub.

Preventing MVC. The thought of losing driving privileges can be very disheartening to an older patient. Although many older people alter their driving habits to avoid dangerous situations, this group experiences a high incidence of motor vehicle-related events.

Healthcare providers should counsel their patients about medical conditions and adverse reactions to medication that may impair their ability to drive safely. Suggest driver refresher courses through the American Automobile Association or the AARP and offer referrals to driver rehab specialists through occupational therapists or state motor vehicle programs, when appropriate.15

Many healthcare providers are reluctant to report impaired drivers to the division of motor vehicles for fear of jeopardizing their relationship with the patient or breaching patient confidentiality. Healthcare providers need to be aware of their individual state laws pertaining to this issue and comply accordingly.

Better outcomes

Nurses are at the forefront of caring for older trauma victims. Your comprehensive understanding of how age-related changes can affect outcomes during and after trauma will help your patients recover to the fullest extent possible.