Geriatric trauma: Top 10 lessons from older patients

Erin Rader MSN, RN, PMHCNS-BC  Nursing2010

William F. Fallon MD, MBA, FACS  November 2010  
Volume 40 Number 11 
Pages 55 - 58

 
 

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OLDER ADULTS MAY become trauma patients because of falls, motor vehicle crashes (MVCs),
pedestrian injuries, burns, violence, or abuse. Even moderately severe injuries can be critically
significant in older patients, requiring long hospitalizations or rehabilitation. Delaying aggressive care
can negatively impact outcomes.1

Whether in the ICU, the medical-surgical unit, or rehabilitation, older trauma patients can present a
complex nursing care challenge. Trauma encompasses the physical, psychological, and spiritual
responses that can have an overwhelming impact on a vulnerable older person for months or years.
This article presents some lessons we've learned that can make a real difference in the healing of
vulnerable older adults after traumatic injury.

1. Age isn't just a measure of time.

Many older adults in the United States enjoy the benefits of better healthcare. They're living longer,
healthier, and more active lives. We all know fit 85-year-olds who are very active in hobbies, sports, or
even jobs. We also know 60-year-olds with many chronic diseases who function poorly. Chronic
illnesses such as heart failure, emphysema, diabetes, renal failure, and osteoarthritis decrease
physiologic reserves and can make recovery from trauma difficult.

An older person with a chronic illness is three times more likely to experience complications after a
traumatic injury.2 In patients with advanced age and chronic illness, even a moderate injury such as a
fracture can result in increased morbidity and mortality. In our research of those 65 and older, we call
this the grim triad: advanced age + comorbidity + moderate injury.3

Older trauma patients are at great risk for functional loss. For an older adult, hospitalization alone has
been shown to lessen independence after returning home, and traumatic injury threatens long-term
independent function. Improved outcomes require the combined efforts of various disciplines and
specialties.3 You need to assess more than just the patient's age and physical injuries.

2. Don't judge a book by its cover.

As a person ages, the body changes in many subtle ways, often resulting in poor balance, decreased
motor strength and coordination, and poor postural stability. Add in diminished visual acuity and
possibly a loose rug or some clutter in the home, and an older person will most likely fall. Half of older
adults who fall will fall repeatedly and on a level surface.2 A person who's acutely or chronically ill is at
increased risk for falling or being involved in a MVC. Diminished peripheral vision or auditory acuity can
make walking near a street dangerous.

Medications can cloud judgment, leading to injury. Many burn and scald injuries occur when the older
person isn't thinking clearly.

When older adults consume alcohol, major problems can occur. Alcohol can cause postural imbalance
and poor judgment in someone who's already at high risk for falls. Long-term alcohol intake contributes
to peripheral neuropathy, cerebellar damage, encephalopathy, and osteoporosis.2 And drinking and
driving don't mix at any age.

Older people may not complain about pain, especially if pain is chronic, but it can slow rehabilitation,
decrease appetite, and increase risk for depression. Confusion in older adults with a traumatic head
injury may be dismissed as dementia. Additionally, their impaired sight or hearing complicate the
situation even further.

If you're judging a book by its cover, you may not realize that these issues are contributing to the older
trauma patient's failure to thrive.

3. When technology walks through the door, basic patient care can fly out the window.

Many older trauma patients are admitted to the ICU, where we rely heavily on technology, and it can
be just as hard to keep up with new equipment and technology in a medical-surgical unit. But, even
with these technologic advances, older trauma patients still need fundamental nursing assessments and
interventions. For example, pressure-relieving surfaces alone can't substitute for daily skin
assessments and turning and repositioning patients at least every two hours.

Devastating problems can begin subtly. Beyond the ABCs, pay close attention to the integumentary
system and the other body systems, including the cardiovascular, pulmonary, and neurologic systems.
Use therapeutic positioning to minimize the risks of further physiologic injury, maintain homeostasis,
and promote optimum recovery.4

Involve the physical therapist and the occupational therapist very early, whether the patient is in an
ICU or a medical-surgical unit. Collaborate with interdisciplinary healthcare team members to enhance
patient goals. Your keen assessment skills can't be replaced by technology.

4. You can't manage what you don't know.

Make it your job to know special management considerations for older trauma patients. Even before a
traumatic event occurs, an older person may be using several medications. Then after the trauma,
more drugs may be added.

When older patients take corticosteroids, some adverse reactions can be more serious than in younger
people. This is especially true of thinning of the skin, osteoporosis, diabetes, hypertension, and
infections.

Anticoagulant drugs can increase the risk of GI bleeding with abdominal injury, or intracranial bleeding
after head injury, especially in those older than 80. Be aware of the many medications that interact
with anti-coagulants. Always ask patients whether they take over-the-counter medications, including
herbal and nutritional supplements, because some increase bleeding risk.

A course of antibiotics can cause major drug interaction issues for older adults, especially those taking
multiple daily medications.

A national expert panel has been charged with updating the widely used Beers criteria for potentially
harmful medications in older adults. This panel has identified dozens of medications, including some
whole classes of medications, that are inappropriate for adults age 65 or older.5Become familiar with
problematic medications on this list. Note that benzodiazepines increase fall risk and antihistamines can
contribute to a fall-related injury, delirium, or urinary retention.

Dementia can also pose special challenges after trauma in any setting. People with dementia no longer
have the cognitive reserve that protects the normal brain. Think of them as at-risk performers walking
a mental tightrope. Even an uncomplicated urinary tract infection can knock them off the rope.
Older patients are also at higher risk for the acute confusional state (delirium) that can occur after
injury or surgery.

Assess for the cardinal signs of delirium: acute change in mental status with symptoms that fluctuate
over minutes to hours, the inability to focus on conversation or tasks, disorganized behavior, and either
hyper-alertness or drowsiness.

Delirium can occur in older patients with no history of dementia. If a patient develops an acute change
in mental status, report it immediately. Nursing interventions include frequently reassuring and
reorienting patients (unless agitated); providing appropriate sensory stimulation, facilitating sleep, and
encouraging mobility.

5. The art of being present.

This gift of self is pivotal in the nurse-patient relationship, especially with patients who have
experienced traumatic injuries. Be there in the moment both physically and psychologically, focusing
your energy while providing care. Listening can be a transforming interaction. A presence that says,
"I'm here for you" can validate the older person's experience. Be open to discussing the traumatic
event and its consequences, including any losses. Loss is the hallmark of geriatric depression.

Was a loved one hurt or lost in the MVC? Was the injury a result of violence? While undergoing a
lengthy rehabilitation, is your patient worrying about beloved pets? Your open and giving behaviors can
facilitate the healing process.

6. Communicate, communicate, communicate.

Because caring for older patients with traumatic injury is complicated, teamwork across disciplines and
specialties enhances quality. Communication is the key.

The patient's plan of care should reflect multidisciplinary short- and long-term outcome goals. Always
remember that the patient and the family are part of the team.

Learn simple communication strategies. If the patient can't verbally communicate (for example, due to
sedation, confusion, or dementia), then talk with the family to gather information and encourage them
to take part in formulating goals on the patient's behalf. Communicate goals to the team and back to
the patient and family, and as you update the plan, communicate again.

7. History is a bridge to the past and a link to the future.

History is a story well told, and for an older person, it may be long. Obtain a thorough health history
from patients and loved ones. It's critical to know who these patients are. What were they like before
the trauma? How well did they function? What motivated them at home and will this motivate them
now? Who's important in their lives? How do they tell their story?

Most important, what's their perception of who they were and how do they see themselves now? Are
they generally hopeful? What coping skills did they use in the past? Can you support those now? Based
on their experience and knowledge, what does recovery mean to them? This is all part of the history
that we use to help them move forward.

8. Fear is the enemy within.

One of our favorite questions to older patients is, "What's your biggest fear?" This discussion opens
doors and breaks through many barriers. Some fears are particular to older trauma patients: fear of
not returning to previous level of functioning, fear of falling, fear of being placed in a long-term-care
facility, fear of burdening the family, fear of Alzheimer disease, fear of dying.

Discovering your patients' primary fears tells you what they're thinking about, what keeps them awake
at night, what keeps them from attempting to help themselves, or what makes them push themselves
too early. These fears can contribute to depression and anxiety and inhibit healing.

You'll discover that much can be done to allay particular fears. Call on the team of healthcare
providers, social workers, pastors, psychiatric staff, and therapists to help and integrate the
recommendations into the patient's plan of care. Actions conquer fear.

9. A goal without a plan is just a wish.

Help your patients set obtainable short-term goals and at least one measurable long-term goal. Do
they want to attend their granddaughter's wedding or their own 80th birthday party?

Help them formulate realistic, achievable, and measurable goals for their healthcare. Provide ongoing
support, reassurance, and positive reinforcement, especially when short-term goals are achieved.

10. Living isn't the same as quality of life.

You'll face many ethical dilemmas while caring for older trauma patients. In the last decade, the
process for discussing quality-of-life issues has become very transparent. Your responsibilities include
being an advocate for your patient, supporting decisions, and ensuring that the patient and loved ones
fully understand the issues and consequences of the patient's decisions. In some situations, you'll be
responsible for helping the family come to terms with the reality that recovery isn't achievable. In such
cases, your message should be consistent with that of the other members of the healthcare team.

You'll need your best interpersonal skills, so above all, know yourself and your biases. Patients and
families aren't expected to adopt our values and beliefs. While they're living, we support them in
finding the quality they seek.

Making a difference

Remember the differences in assessment and management of older persons after trauma, the
importance of communication, and your opportunities to make a difference in outcomes for this
vulnerable population.

REFERENCES

1. DeGolia PA, Rader EL, Peerless JR, Mion LC, Campbell JW, Fallon WF Jr. Geriatric trauma care:
integrating geriatric medicine consultation within a trauma service. Clin Geriatr. 2009;17(1):38-44.
[Context Link]

2. Fallon WF Jr, Rader E, Zyzanski S, et al. Geriatric outcomes are improved by a geriatric trauma
consultation service. J Trauma. 2006;61(5):1040-1046. [Context Link]

3. Campbell JW, DeGolia PA, Fallon WF, Rader EL. In harm's way: moving the older trauma patient
toward a better outcome. Geriatrics. 2009;64(1):8-13. [Context Link]

4. Christie RJ. Therapeutic positioning of the multiply-injured trauma patient in ICU. Br J Nurs.
2008;17(10):638-642. [Context Link]
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