Trauma in the Elderly: Causes and Prevention
This article is the first in a continuing series on trauma care and the older adult. This series will discuss the growing problem of trauma in the elderly, including its causes and possible ways to prevent it, care in the acute stages, and manifestations and treatment strategies when trauma involves the torso, spine, brain, and hip. Authors include skilled experts in the trauma field representing various specialties at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and the University of Maryland School of Medicine.
Introduction
The aging of our population continues to present new challenges, as individuals of the baby-boom generation (the over 75 million persons born between 1946 and 1964) will soon enter their “golden years” and by 2040 will represent over 20% of the U.S. population. Modern medicine and the increased focus on geriatric health issues have done an excellent job in helping to keep adults healthier and more functional for longer periods of time. The good news is that more elderly persons than ever before are able to continue to enjoy both lifelong and novel hobbies, sports, outdoor activities, and risky behaviors that were almost unheard of only a few decades ago. A greater percentage of older persons continue to drive their own automobiles despite advancing age, and older women drivers are now the norm. These demographic changes in and of themselves increase the likelihood of an older person suffering a traumatic injury. Furthermore, many age-related changes also increase the likelihood of suffering a traumatic injury. In 2007, 11% of all persons admitted for trauma care were over the age of 65, a number expected to climb to as high as 40% over the next few decades; the elderly currently account for one-third of all health expenditures for trauma care, with even more dramatic increases in costs expected.
Elderly persons account for 25% of all injury-related fatalities, and trauma is the seventh leading cause of death in Americans older than age 65 years.1,2 Older trauma patients have more severe injuries, are more likely to have comorbid conditions, suffer more complications, and die more frequently following trauma than younger individuals. Furthermore, trauma frequently results in major disability, especially in those over age 80. Older trauma patients more frequently are injured from low-energy and household accidents. Falls are the leading cause of traumatic brain injury for persons over age 65 and the leading cause of death from trauma for those over 80 years of age.3 In 2003, more than 1.8 million persons over the age of 65 were treated in an Emergency Room for a fall-related injury, and more than 421,000 persons over age 65 were hospitalized as a result of their traumatic injury.4 Of those who fall, 20-30% sustain moderate-to-severe injuries that reduce their mobility and increase their risk of premature death. More than 185,000 adults age 65 and older were treated in Emergency Departments for nonfatal injuries as occupants in motor vehicle crashes in 2004 alone; motor vehicle accidents are the most common cause of death from trauma through age 79. In 2003, 7541 people age 65 and older died in motor vehicle crashes.5
Other forms of traumatic injury, such as thermal injury, homicides, and elder abuse, are similarly important. For example, thermal injury accounts for 4% of all unintentional deaths in persons over age 65. Similar to the pattern seen for motor vehicle accidents, thermal injuries are less well tolerated among older individuals—although burns covering 80% of total body surface area result in death among half of younger individuals; for those age 60-70 years, burns covering only 35% of total body surface area result in this same 50% mortality rate, which drops yet further to 20% burn area for the same mortality among those over the age of 70.
In 2002, there were 852 homicides in persons over the age of 60 in the United States, and in 2001, over 33,000 persons age 60 years and older were treated in U.S. hospital Emergency Departments as a result of a nonfatal assault. Annually, there are over 470,000 reports of elder abuse, with those over age 80 affected most frequently.6 It has been estimated that between 1 and 2 million Americans over the age of 65 years have at some time been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection, due to active or passive abuse and/or neglect. In a study evaluating reports of abuse to elderly nursing home residents, it was found that more than 9% of nursing homes had at least one citation for causing actual harm or doing something to put residents at risk of “immediate jeopardy,” while over 30% of nursing homes were cited for an abuse violation that had the potential to cause harm.7
While a traumatic injury in an older person may affect only one body component or organ system, injuries are often compound and affect multiple systems. Furthermore, the older person’s ability to heal and recover from traumatic injury is impinged upon by numerous factors, including existing comorbidities, age-related changes in physiological reserve and function, frailty, and social and financial resources. The increasing demands of trauma care for an ever increasing number of elderly persons will affect all aspects of society and continue to present a challenge to our healthcare system for many decades to come. Teams of experts will be needed to provide the multidisciplinary care that is required, and the geriatrician has the unique ability to assist in this effort by offering a perspective not often appreciated in conventional trauma care. This article highlights the most common causes of traumatic injury to the elderly and offers suggestions as to how best to prevent these injuries from occurring in the first place. As with all aspects of medical care, prevention is key!
Age-Related Factors Predisposing to Traumatic Injury During Later Life
As stated previously, increasing age has been associated with a decline in physiological reserve and functional status.8 This predisposes the older person to increased susceptibility to injury and a higher rate of mortality when injured. With normal aging, all five senses decline in function. Altered perception and a delayed and/or altered ability to respond may both predispose one to injury. Diminished or impaired proprioception may reduce awareness of an impending fall and alterations in mobility, while changes in flexibility, posture, and gait are additional risk factors for injury. Elderly persons may also have alterations in depth perception and hearing impairments that make it more difficult to see and hear traffic hazards and avoid them. Use of medications and alterations in how medications and alcohol are handled in the body with age also predispose to injury. It has been shown that older adults reach higher blood alcohol concentrations earlier than younger individuals due to changes in the volume of distribution of alcohol. Elderly men who have lost their wives have the highest rate of new alcoholism, and thus are particularly predisposed to traumatic injury.
Motor Vehicle Accidents
In 2007, 15% of all licensed drivers in the United States were over the age of 65 years as compared to 14% in 1997. Although older persons drive shorter distances than younger persons, and in general drive fewer miles per year, the rate of accident per mile driven is more than nine times greater for persons over the age of 70 as it is for drivers age 26-69 years. Furthermore, although among younger individuals men are more likely than women to be involved in an accident, older men and women are equally prone to motor vehicle accidents. When a collision involves an older driver and a younger driver, the older driver reportedly is two times as likely as the younger driver to be the one who was struck. Moreover, 22% of crashes involving older drivers occur while they are turning left, four times more often than occurs with younger drivers making a left turn. Elderly motorists account for 15% of fatal crashes, with 80% happening during the daytime and 72% involving a second vehicle. These differences highlight the increased susceptibility of older drivers and the need for interventions that decrease the frequency of auto accidents.9 Older drivers involved in fatal crashes have the lowest proportion of intoxication and are much more likely to be using personal restraints (77% vs 63% among those age 18-64 yr).
Age-prevalent illness can affect any organ system and add to the underlying changes that occur as part of the so-called “normal aging process.” Impaired vision (as may result from cataracts, macular degeneration, or presbyopia) may make it more difficult to see objects either at an appropriate distance to react to or in the periphery (a problem further compounded by decreased neck flexibility); depth perception may also be impaired. Many elderly persons report “glare” when seeing approaching lights. This may make nighttime driving particularly risky. Neurological impairments as may result from a stroke may impair ocular muscle movement, making it harder to track safely. Decreased hearing may impair the older driver’s ability to recognize warning sounds, and altered reflex response time, problems involving ability to feel with the sole of one’s foot and apply adequate pressure to brakes, as well as difficulty processing continually changing information may also predispose the older person to more accidents. Nonetheless, there is a great deal of variability as to why an accident occurs. It is also important to remember that not all accidents involving older persons are the direct result of something the older person did or failed to do.
Time of day appears to be a particular concern. Everyone is sleepier after a big meal, particularly after lunch, and many elderly persons are accustomed to napping at this time of the day. Driving at night is universally problematic, perhaps more pronounced in those with underlying visual impairments. Driving during rush-hour traffic has its own challenges with the need to constantly stop and start, presenting a problem for some; sensory overload resulting from many cars changing lanes may be an overwhelming and stressful situation leading to poor decisions and outcomes. Bad weather and the need to adjust driving style, use outside mirrors for blocked vision from the windshield, and the potential need to respond to snow and ice with emergent maneuvers all increase the risk of an accident.
Elderly drivers themselves have expressed the following concerns regarding driving: hostile behavior from younger drivers; experiencing information overload while driving on a multilane superhighway; preoccupation with taking great precautions; refusing to concede that the left lane is not a cruising lane; experiencing greater difficulty in talking while driving; frustration with signs whose letters aren’t large enough or are too similar to each other; fatigue during extended driving times; anxiety about being tailgated; increased difficulty in certain vehicle maneuvers such as parallel parking; and lapsing into daydreaming episodes.10
New drivers who are elderly may have additional difficulty, as many techniques associated with driving have become ingrained in those with years of driving experience. Many older women never learned to drive earlier in life due to social customs and limitations placed on them by their husbands. Now faced with being a widow, many older women are driving for the first time and need to learn how to maneuver in an often threatening and overwhelming environment.
The common behavior of driving in the “passing lane,” even if driving at the posted speed limit, may result in other drivers passing on the right out of frustration and lack of patience. This increases the risk of an accident. Elderly drivers are more likely to receive citations for failing to yield, making improper turns, and not stopping at red lights and stop signs. Older drivers have also been described as taking longer to start their car after stopping at an intersection and/or traffic light, to make turns, and to park. This may be due to a change in reaction time or lack of concern over time. Regardless, this often distresses other drivers and creates a hostile and accident-prone environment.
The AARP has opposed placing restrictions on drivers based on age and has also opposed requiring elderly persons to be tested in any additional manner. That said, AARP, American Automobile Association (AAA), and National Safety Council offer driving refresher courses for older persons, and certain states have additional mandates for older drivers. Illinois and New Hampshire, for example, require all persons over the age of 75 to take a driving test for license renewal, and the District of Columbia requires anyone older than age 70 to have a vision test and to provide a statement from a practicing physician certifying that the “applicant is physically and mentally competent to drive”; those over the age of 75 must pass both a written and road test in order to renew their license. While some states require a driver’s test if a driver is “determined” to be “unsafe” or “mentally or physically not fit,” there are no consistent definitions or reliable tests to predict how safe a driver will be. Driving simulators are being used with increasing frequency and can provide a range of driving conditions and lighting to not only train drivers but also to assess their driving skills and safety.
An Internet survey reported that whereas 66% of drivers age 15-24 years admitted to frequently “swearing” while driving, this behavior was common to only 42% of those over age 55. Fifty-two percent of young drivers admitted to driving 15 or more miles over the speed limit as compared to 19% of older drivers, 36% of younger drivers admitted that they failed to use signaling as compared to 13% of older drivers, 16% of young drivers admitted to running red lights as compared to 2% of older drivers, and 19% of younger drivers reported tailgating dangerously close as compared to 6% of older drivers. One-third of younger drivers reported feeling “stressed” while driving as compared to 50% of older drivers.11
Although older drivers vary greatly in skill, underlying medical conditions, medications, and experience, there are steps that can be taken to help reduce the chances of having a motor vehicle accident during later life. Similar to younger drivers, in addition to keeping their automobiles in good repair, including attention to appropriate tire pressure, balancing, and brake maintenance, periodic eye examinations and use of necessary glasses will ensure proper vision. Given the difficulties with nighttime driving outlined above, it should be avoided as much as possible. When necessary, routes that have appropriate lighting, a minimal amount of roads with oncoming traffic, and the fewest number of necessary left turns should be chosen. Realizing that early afternoon and 30-60 minutes after meals are times associated with the most fatigue, carefully choosing the time when one drives may also be of benefit. Similarly, one should avoid driving if medications must be taken that can slow reflexes or alter the sensorium. It should be recognized that certain medications may linger for many hours, even overnight, and these increase one’s risk of having an accident. Anytime a new medication is being used, it is wise to avoid driving until one knows how it will affect one’s ability to function. Individuals who are having active problems with cardiac arrhythmias, seizure activity, swings in blood pressure or blood sugar, or impaired motor response due to musculoskeletal and/or neurological problems are advised to avoid driving. Finally, distractions while driving should be eliminated, including cell phone use, changing radio stations, or reading directions or maps while driving. If there is any concern over a patient’s ability to drive safely, he or she should be advised to avoid doing so and seek evaluation.
While driving is often a necessity for the older person’s ability to live independently, it brings with it a great deal of responsibility. Motor vehicle accidents are potentially life-altering and life-ending for both the driver and others. These, as well as the high cost of automobile upkeep and insurance, must be included in the calculus; taking taxis, riding with family and friends, or using public transportation are all options that may make sense.
Burn Injury
Burns are another all-too-frequent cause of injury to older persons. One particular risk comes from tap water maintained at temperatures greater than 130 degrees F. Reducing water heater temperature to 120 degrees F will reduce the frequency and severity of burns while still providing warm water to wash. When away from home, the elderly also need to “test” the warmth of the water before plunging full body into a bath or shower. When cooking, attention to hot liquids is essential, including taking necessary precautionary steps to avoid splatter and turning down the temperature after liquid reaches a boil to avoid an “overflow” and the potential for harm. Open flames are a particular concern, and loose garments and clothing that is flammable should be avoided while near them. With fire also comes smoke and carbon monoxide, and functional carbon monoxide and smoke detectors, as well as both having and knowing how to use an easily accessible fire extinguisher, are crucial. Flammable products should not be stored at home, and old newspapers should be discarded. Finally, while smoking is not advised for health reasons, it is also a common cause of home fires and burn injury (especially if one falls asleep with a lit cigarette). Here, as elsewhere, prevention is key!
Falls
Approximately 30% of individuals over the age of 65 living in the community (and > 50% of those living in residential care settings) fall every year. Furthermore, half of these do so repeatedly. Although these falls are diverse in their risk factors, precipitants, and mechanics, 20% of falls result in injury requiring medical attention (5% result in fractures or other serious injury). Among women over the age of 75, these percentages double. Despite the importance of the foregoing etiologies of trauma, more than 80% of all injury-related admissions for those over the age of 65 years are due to falls. Furthermore, these all too often are sentinel events. Perhaps the most feared consequence of a fall—a hip fracture—in addition to commonly being associated with long-term pain and functional impairment (< 50% fully recover), is associated with a 20% chance of death and a 25% chance of institutionalization as a direct result. Falls (especially with injury) are usually the result and cause of gait and balance difficulty. As one fall increases the risk of future falls, and fear of this leads to decreased mobility, gait and balance further deteriorate in a vicious, isolating cycle. Falls may be thought of as resulting from the interaction of intrinsic (specific to the individual) and extrinsic (environmental) risk factors triggered by a precipitating cause. Examples of the former include arthritis, visual impairment, vestibular dysfunction, neuropathy or muscle weakness, as well as gait and balance problems that may result from improper footwear, restraints, or other environmental hazards. These factors dramatically increase the chance of a fall when coupled with acute or exacerbations of chronic illness, slips/trips, dizziness, or syncope.
Although each case is unique and deserves individualized consideration, evaluation needs to include an assessment regarding previous falls, cognition, balance, gait, strength, chronic diseases (including particular focus on vision, postural blood pressure, and targeted neurological, musculoskeletal, and cardiovascular exams), medications, nutrition, and mobility. In the hospital or nursing home, these assessments are often based on risk factors, while in the community they may be more focused on function. A number of validated measures exist to assess the older person’s risk of falling, including the Tinetti Performance-Oriented Mobility Assessment,12 Berg Balance Test,13 and Studenski Functional Reach.14
As with the foregoing, prevention is key. Unfortunately, education alone has proven ineffective. Individuals at risk need to be taught about their own specific risk factors as well as what to do if they fall and can’t get up. Homes should be evaluated and corrections made to reduce factors that may predispose to a fall, thus anticipating problems and eliminating them. In particular, strength and balance training have both reduced falls in a variety of settings, particularly when targeted.15,16 Other modalities to reduce risk factors include medication management, home safety evaluation/modification, expedited cataract surgery, pacemakers (in highly selected patients), and measures to mitigate injury when falls do occur (eg, vitamin D, calcium, other supplements) and use of warning devices that facilitate assistance when necessary.17 Maintaining appropriate levels of vitamin D have also been shown to help prevent falls, though the specific reason for this benefit remains uncertain at this time. While there is limited evidence of effectiveness/cost savings with the use of hip protectors in the nursing home setting for those at highest risk of a fall, poor compliance significantly limits their broad use, and little is known about their effectiveness in community-based elderly persons.
The authors report no relevant financial relationships.
Dr. Blumenthal is from the University of Maryland School of Medicine and Baltimore VA Medical Center; and Ms. Plummer is from the University of Maryland School of Nursing, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore. Dr. Gambert is Professor of Medicine and Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director of Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Dr. Stein is Chief of Critical Care, R Adams Cowley Shock Trauma Center, and Associate Professor of Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore.