TRAUMA IN THE ELDERLY

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CHAPTER 78 TRAUMA IN THE ELDERLY

Benjamin Braslow, Donald R. Kauder, C. William Schwab

The age at which a person becomes elderly has not been resolved by a clear consensus in the literature, but most agree that it falls in the span between ages 55 and 75. According to the 2000 census, 35 million (12.4%) Americans were over age 65, and by 2050, this age cohort is projected to reach 86 million (20.7%). The elderly constitute the most rapidly growing segment of the U.S. population. Today’s elderly enjoy a level of physical freedom unmatched by prior generations. Improved access to health care and assisted living communities allow many older Americans to function relatively independently well into their ninth decade. Traumatic injuries very often compromise this autonomy, creating dependence on relatives or caregivers for assistance with activities of daily living. Unfortunately, a number of physical factors predispose the elderly to injury, including diminished postural stability, motor strength, coordination, visual acuity, and hearing. These common changes often lead to an inability to recognize and avoid many environmental hazards, thus converting normal daily activities into treacherous and frequently lethal events. In direct correlation with this rapid expansion of this sector of the population, hospitals are treating increased numbers of geriatric trauma patients. In 2001, over 3.2 million elderly patients who sustained unintentional injuries were evaluated in U.S. emergency departments; 2.2 million (68.7%) were admitted. These patients have been shown to have more adverse outcomes, including case fatality rates and complications. In 2002, unintentional injury was the fifth leading cause of death in the United States overall and the ninth leading cause of death in those aged 65 and older, accounting for over 33,000 victims. Survivors exhibit a higher prevalence of functional impairment, often requiring longer hospital stays and complex discharge arrangements. Not surprisingly, the elderly, comprising just over one-tenth of the population, account for nearly one-third of health care resources expended on trauma.

PHYSIOLOGY

There are numerous physiologic changes that influence the treatment of injury in elderly patients. With advancing age there is a normal, unavoidable, progressive loss of functional reserve in each organ system. The degree of loss is subject to individual variations and is distinct from the pathologic loss of function associated with comorbid diseases prevalent in senescence. Such conditions include but are not limited to hypertension, pulmonary disease, cardiovascular disease, diabetes, and renal failure. This combination of diminished reserve and concomitant disease significantly limits the ability of the elderly trauma patient to absorb physical insult and subsequently recover. It also impacts the care rendered to such patients at every level of intervention, from prehospital provider to trauma surgeon to surgical intensivist to physical therapist.

Most significantly, the cardiovascular system demonstrates age-related changes that affect the elderly patient’s response to severe trauma. With age there is a progressive loss of myocytes and a compensatory increase in myocyte volume in both ventricles along with fat cell infiltration in the interstitial space of the ventricular walls and septum. The myocardium progressively stiffens, resulting in decreased diastolic relaxation and slowed ventricular filling. The heart becomes less efficient, with a progressive decrease in its ejection fraction. Stroke volume is diminished, leading to an increased reliance on the atrial contribution to increase end-diastolic volume in order to maintain cardiac output. The heart can be extremely sensitive to both hypovolemia and hypervolemia, resulting in a very narrow therapeutic window. Further, there is a decreased inotropic and chronotropic response to both endogenous and exogenous betaadrenergic stimulation and progressive deterioration of the conducting system by cell atrophy, fibrosis, and calcification. This ultimately leads to a lowering of the maximal achievable heart rate and of the ability to adequately increase cardiac output during stress. Structural changes in the arterial tree also affect cardiac function in the elderly. Arterial intimal hyperplasia with concomitant atherosclerosis produces stiffness of the arterial walls, resulting in a reduction of diastolic pressure despite systolic hypertension and limiting coronary blood flow. This becomes most clinically important during stress, when myocardial oxygen demand increases but coronary blood flow is restricted. Prescription antihypertensive medications such as beta-blockers, calcium channel blockers, and diuretics—all very commonly prescribed for the elderly population—can also play a major role in the impairment of the cardiovascular response to stress and injury. The multifaceted age-related decline in cardiovascular function makes it incumbent upon the treating trauma physician to carefully plan treatment regimens and closely monitor this patient population during resuscitation.

The aging process significantly affects pulmonary physiology as well. With age, costal cartilage becomes calcified and the chest wall becomes more rigid, decreasing lung compliance. Respiratory muscles atrophy, and an increased reliance on diaphragm function and abdominal musculature for breathing develops. Forced vital capacity is decreased, as is forced expiratory volume in one second (FEV₁). Lung parenchymal changes are noted with aging as well. Fusion of adjacent alveoli occurs, which decreases surface tension forces and reduces pulmonary elastic recoil. Thickening of the alveolar basement membrane decreases gas-diffusing capability, resulting in V/Q mismatch and higher alveolar-arterial oxygen gradients. There is also decreased airway sensitivity and efficiency of the mucociliary clearance mechanism. A history of smoking compounds the deleterious affects of aging on pulmonary anatomy and function. Clinically, these changes manifest as decreased cough effectiveness, predisposition to aspiration and pneumonia, and decreased compensatory responses to hypoxia and hypercarbia. Aggressive pulmonary toilet, adequate pain control, judicious use of mechanical ventilation, and careful monitoring of fluid status become imperative in preventing pulmonary complications in the elderly trauma population.

Anatomic changes evident in the elderly kidney include cortical mass loss secondary to glomerulosclerosis (acellular obliteration of glomerular capillary architecture) and tubular senescence. Hypertension, diabetes mellitus, and atherosclerosis accelerate these processes. Physiologically, these changes manifest as a reduced glomerular filtration rate (GFR). After the age of 40 years, the GFR decreases 1 ml/min/year. Tubular senescence blunts the reabsorption and secretion of solutes. Most significant is the decreased capacity to reabsorb sodium and to secrete potassium and hydrogen ions. The juxtaglomerular apparatus in elderly patients produces less renin and limits the response to aldosterone. The response to antidiuretic hormone is also attenuated. All of these changes mandate hypervigilant monitoring of fluid, electrolyte, and acid base balance in the injured elderly patient, especially those requiring surgery, during which massive fluid shifts are expected. Yet another factor leading to hypovolemia is a decreased thirst response, which often predisposes them to hypovolemia. Predicting decreased renal function in the acute setting can be difficult. A reduction in muscle mass with age often results in a normal serum creatinine despite a reduced creatinine clearance. Age-adjusted formulas for creatinine clearance are much better estimates of renal function in the elderly patient than serum creatinine levels. Potentially nephrotoxic agents, such as intravenous radiographic contrast, should be used with extreme caution even if serum creatinine levels appear within normal limits.

Significant age-related changes also occur in the central nervous system. Cortical atrophy progresses with age, resulting in an increased volume of the subdural space. This allows for greater movement of the brain during traumatic impact, which can result in serious parenchymal damage. Relatively minor mechanisms of injury may result in more frequent subdural and subarachnoid hemorrhage secondary to greater shearing forces on parasagittal bridging veins. Large volumes of blood may accumulate intracranially before symptoms of intracranial hypertension develop. This process is compounded by the frequent use of anticoagulant and/or antiplatelet medications in this population for a variety of prophylactic and therapeutic indications. Likewise, a greater degree of brain swelling may occur before symptoms appear. Vision, auditory function, vibrotactile sensation, reflex timing, and pain perception are all blunted with age. These changes, in combination with age-related deterioration in cognitive ability, memory, and information processing, not only contribute to an increased predisposition to injury in the elderly, but also may obscure their post-traumatic evaluation.

Changes in the musculoskeletal system have significant impact on the elderly patient’s predisposition to injury. There is a progressive loss of muscle mass and strength with age. Loss of motor neurons, collagen and adipocyte infiltration, and diminished myosin-ATP activity are also contributing factors. Progressive erosion of cartilage and ligamentous stiffening, especially in weight-bearing joints, affects mobility and can be a source of chronic pain. Attempts at postural compensation can alter weight-bearing mechanics and cause injury to other musculoskeletal structures. Age-related bone loss secondary to osteoporosis causes further loss of strength and greater susceptibility to fracture, most commonly seen in the hip, pelvis, wrist, and ribs. Vertebral collapse is associated with progressive kyphosis, which alters the center of gravity and contributes to balance disturbances. This process is more pronounced in women but is relevant to both sexes. Women lose up to 35% of cortical bone mass and 50% of trabecular bone mass over their lifetime; men lose about one-third less. These changes in strength and flexibility contribute to progressive limitation of movement, making the elderly patient more vulnerable to injury and complicating the recovery process.

Neurohumoral senescence is also quite common. There is a global decreased sympathetic response to stress in the elderly. This is multifactorial, related to neurologic, musculoskeletal, and endocrine alterations associated with age. Thermoregulation is impaired secondary to a decreased cutaneous vasoconstriction response to cold environments, which renders the elderly trauma patient more susceptible to hypothermia. Immune function also shows an age-related decline, specifically related toT-lymphocyte-mediated immunity. The response of T lymphocytes to interleukin 2 is impaired, as is the stress-related increase in natural killer-cell activity. These changes increase the elderly trauma patient’s susceptibility to infection. Furthermore, markers of the systemic response to surgical stress (tumor necrosis factor α, interleukin 6, and CD11b/CD18 expression) have been shown to be more elevated after surgical stress in older (compared with younger) patients. This increase in cytokine response to surgical stress has been postulated to increase the incidence of systemic inflammatory response syndrome in the elderly and may explain an increased incidence of postoperative morbidity.

MECHANISM OF INJURY

Blunt trauma accounts for the overwhelming majority of geriatric injuries, with falls being the most common mechanism. The Center for Disease Control reported over 3.6 million geriatric fall-related injuries in 2003. Although multilevel falls do occur in the elderly population, same-level falls predominate. Interestingly, the associated morbidity of these low-level falls in the elderly is significant, producing a spectrum of injuries similar to those seen in falls from a height. It is estimated that 28%–45% of elderly people residing in the community and 45%–61% of elderly nursing home residents will fall each year. Falls are the leading cause of injury-related death in people over 75 years of age and are second only to motor vehicle crashes in those between 65 and 74 years. Although elderly men and women seem to fall with the same frequency, serious injuries are twice as common among women. This is likely because of their more extensive osteoporosis and decreased muscle mass. When compared with a younger population, elderly fall victims sustain more severe injuries over multiple body regions for similar mechanisms of injury. Most concerning is the fact that half of all hospitalized elderly fall victims who fall at home are subsequently discharged to a nursing home. Common risk factors for falls include inappropriate use of assist devices, alterations in gait, declines in proprioceptive and vestibular function, peripheral neuropathies, and overall loss of strength and coordination. Many medications may be implicated as well, especially those that may induce hypotension (beta-blockers, calcium channel blockers, etc.) or sedation (sleeping pills, anxiolytics, etc.). Approximately 25% of falls in the elderly are caused by an underlying medical problem, mandating medical investigation beyond simply treating the injuries sustained in the fall. Implementation of fallintervention programs, modification of environmental hazards (repair of loose carpets, improved lighting, appropriate placement of grip bars), modification of medicine doses and schedules, use of mobility aids (walkers, wheelchairs, canes), and participation in physical strength and conditioning programs were shown to reduce fall incidence rates at participating elderly residence facilities from 2.9 to 1.7 per person year for active seniors.

Motor vehicle crashes are the second most common mechanism of injury leading to death following geriatric trauma, totaling over 7200 deaths in 2001. In 2003, there were 19.8 million older licensed drivers in the United States (10% of all licensed drivers compared with 9% in 1993), an increase of 27% since 1993. According to the National Highway Traffic Safety Administration, drivers aged 65–74 years old have the second highest rate of vehicular crash fatalities, falling just behind drivers aged 16–20. Despite driving less frequently and over shorter distances, drivers older than 75 years have the highest incidence of traffic fatalities per mile driven. The elderly are more likely to be involved in crashes in good weather and at a location close to home. Most traffic fatalities involving older drivers occur in daylight, on a weekday, and involve at least one other vehicle. Age-related impairment of driving skills, including diminished visual acuity and delayed reaction times, no doubt contributes to this increased crash rate. Luckily, this is countered by the relative absence of other significant causative factors such as speeding and intoxication. Older drivers involved in fatal crashes have the lowest proportion of intoxication of all adult drivers. Geriatric drivers involved in a motor vehicle crash should be evaluated as to their physical and cognitive abilities and counseled on driving restrictions and the need for frequent ongoing assessment.

Declines in peripheral vision, hearing, judgment, gait speed, and reaction time put older pedestrians at considerable risk for being struck by moving vehicles; they account for 18% of all pedestrian fatalities. The pedestrian struck death rate for this age group (3.17 per 100,000) is higher than for any other age group. Recent studies show that regarding injuries to a pedestrian struck, age plays a critical role in the anatomic distribution and severity of injuries. Older victims are significantly more likely to suffer severe injuries, especially to the head and chest. Severe abdominal trauma, spinal injuries, and fractures of the pelvis and tibia also increase significantly with age. One causative mediator of elderly pedestrian injury might be that the standard time allotted for most crosswalks in the United States assumes a walking speed of 4 feet per second, which is often unobtainable in this population. This correlates with the observation that one-third of all pedestrian fatalities in individuals over 65 years occurred within a crosswalk, double that of other pedestrians. Municipal identification of particularly dangerous intersections can result in crosswalk modification to provide better visibility, longer crossing times, and more appropriate danger notification to both drivers and pedestrians.

The elderly population is especially vulnerable to violent crime, both in and out of the home. Violent assaults account for approximately 10% of all geriatric trauma admissions. Although the elderly comprise only about 6% of all assault victims in this country, they are five times more likely to die as a result of their attack as compared with their younger counterparts. Decreased mobility and strength and impaired cognition and judgment are major factors that contribute to the inability of the elderly to adequately defend themselves. Attacks on the elderly primarily involve blunt instruments. Penetrating injuries via knife or firearm are increasing in frequency in the United States and were recently reported by the Center for Disease Control and Prevention to account for over 50% of assault related fatal injuries in the elderly.

Domestic abuse is unfortunately a growing source of nonaccidental trauma in the elderly. The true magnitude of this problem is clouded by variances in legal definitions and reporting accuracy. The National Aging Resource Center on Elder Abuse estimated in 1998 that only 1 in 15 cases of geriatric abuse is reported. Often this is a result of denial on the part of the victim as well as the abuser. Over 2 million cases of elder abuse and/or neglect are thought to occur annually in the United States, involving up to 6% of the elderly population. Longer life expectancy coupled with altered family dynamics and financial difficulties are frequent reasons for such mistreatment. Elderly females experience abuse more often than males, and persons older than 80 are abused two to three times more often than those between 65 and 80. Similar to child abuse, detection mandates a high degree of suspicion, especially when there are signs of physical injury or neglect that are inconsistent with the mechanism described.

Sadly, self-inflicted injury in the elderly is not a rare event. Depression secondary to the death of a loved one, chronic illness, and unmitigated pain are common reasons given for self-inflicted injury in the elderly population. Of the more than 11,000 geriatric selfinflicted injuries reported in this country in 2001, 48% resulted in mortality. In over half of these self-inflicted deaths, a firearm was used.

Burns account for approximately 8% of traumatic deaths in the elderly. Geriatric patients often have decreased cutaneous sensation and diminished reaction times. They are more likely to experience prolonged thermal exposure and to sustain more extensive and more severe burns than younger patients at the same scene. Scalding is the most common form of burn injury in the elderly, typically from bath water. Not surprisingly, elderly burn victims have a higher mortality rate for the same extent of burn than do younger patients. Burns exceeding 50% of total body surface area are almost uniformly fatal in elderly victims. Inhalation injury is poorly tolerated in the geriatric burn population secondary to limited pulmonary reserve and, if present, can increase the already prominent mortality rate. The same is true of the cardiovascular system with respect to the massive volume resuscitation that is required for optimal burn management. Cardiac intolerance is frequently implicated in early post-burn death in the elderly.

OUTCOMES

Both short- and long-term outcomes after trauma are worse in geriatric patients when compared with their younger counterparts. A higher prevalence of pre-existing medical conditions in the elderly patient as well as a reduced physiologic reserve are thought to account for these poor outcomes. Elderly trauma victims poorly tolerate hemodynamic instability or the increased physiologic demands that often accompany even minor trauma or its complications. Geriatric patients have been shown to have increased rates of cardiac, respiratory, renal, and infectious complications during hospitalization when compared with younger patients. As expected, the most severely injured patients and the patients with the most significant pre-existing conditions manifest the most nosocomial complications, which negatively impact survival. More than 33% of patients over 65 years of age have at least one chronic medical condition. Gubler et al. showed that the increased risk of death in elderly trauma patients persists for up to 5 years from the time of hospitalization for injury. In this study of over 9400 elderly patients, the presence of any pre-existing comorbidity was shown to increase the risk of mortality within those 5 years following hospitalization for an injury between 2 and 8.4 times, depending on the number of comorbid diagnoses. Pre-existing conditions such as liver disease, renal disease, malignancy, congestive heart failure, and a prior spinal cord injury have been shown in multiple studies to increase the risk of death in elderly trauma patients with minor injury severity scores (ISS). This relationship does not appear to hold for more severely injured patients. As a patient’s ISS rises above 15, chronic medical conditions cease to have a significant effect on outcomes; and above 25, survival becomes a primary function of the severity of injury. Grossman et al. identified an ISS of 30 as “LD₅₀” (50% of the geriatric population that sustained this magnitude of injury died) for blunt geriatric trauma independent of mechanism or comorbidities. Interestingly, Perdue et al. found that despite controlling for ISS, Revised Trauma Score (RTS), pre-existing disease, and the development of complications, elderly patients were almost five times more likely to die after trauma than younger patients.

The high morbidity and mortality rates seen in geriatric trauma have led some authors to advocate routine admission to the intensive care unit and invasive hemodynamic monitoring (pulmonary artery catheters, arterial lines, central venous pressure monitors) for elderly patients with predicted ISS of over 9, any evidence of hypoperfusion, or significant pre-existing disease. Scalea et al. compared elderly, multiply injured trauma patients who appeared clinically stable after initial evaluation and underwent early invasive monitoring and goal-directed resuscitation with historical controls. Forty-three percent of patients were found to be in cardiogenic shock and showed further evidence of a systemic low flow state despite initial “normal” vital signs. With early intervention, mortality was reduced by half. Schultz et al. showed this benefit in a randomized trial of elderly patients with isolated hip fractures. Patients who received perioperative invasive monitoring had a tenfold reduction in postoperative mortality when compared with controls.

Despite their initially higher mortality rate, and the increased likelihood of dying within the 5-year period following injury, a significant number of elderly patients who survive their acute injury are able to eventually return to levels of reasonable function and resume independent living. In an analysis of nearly 39,000 elderly trauma patients in Pennsylvania, Richmond et al. showed that overall, more than half (52%) of those discharged from the hospital went directly home. Twenty-five percent were discharged to a skilled nursing facility (SNF), and 20% went to a rehabilitation facility. Grossman et al. showed a predisposition for those patients aged more than 80 years to require SNF placement (37%), whereas patients aged 65–79 more frequently returned home (53%). It is estimated that 50% of geriatric trauma patients discharged to a SNF eventually return home, and on average about 63% of patients discharged home with assistance will eventually return to some reasonable level of independent living. Often, home care agencies, spouses, and family members play an integral role in allowing patients to remain living at home.

MANAGEMENT OF SPECIFIC ORGAN INJURIES

The nonoperative management of splenic injuries has become a well-established practice in hemodynamically stable patients. Splenectomy has been all but eliminated in the pediatric trauma population, and its incidence is quite low in young adults. However, this strategy remains controversial in patients older than 55 years. This reluctance dates back to early reports by Smith and Godley demonstrating high failure rates in this population. Anatomic explanations of this have indicated that older spleens have a weakened capsule and fragile vasculature secondary to a decrease in the amount of smooth muscle and elastin fibers. This prevents older spleens from adequately contracting and retracting damaged vessels within the injured parenchyma. More recent published results of nonoperative management of splenic injury in older patients have challenged age 55 and older as an exclusion criterion, with reported success rates up to 80%. Despite these published successes, a recent large, multicenter study sponsored by the Eastern Association for the Surgery of Trauma concluded that older patients fail this nonoperative approach more often than their younger counterparts, and those who do so suffer increased mortality and morbidity. Factors associated with an increased risk of failure of nonoperative management of splenic injury include higher grade injuries (grades IV and V), a contrast blush or pseudoaneurysm seen on computed tomography (CT) scans, combined liver and splenic injuries, and the need for multiple blood transfusions. Although the optimal management of geriatric blunt splenic injuries is still a matter of debate, the limited physical reserve of the elderly patient must be carefully considered when determining an individualized plan of care. Knowing that hypotension is poorly tolerated in this population has led many surgeons to consider splenectomy as the more conservative approach.

Blunt chest injury and rib fractures are commonly encountered in the geriatric trauma patient and can account for a significant amount of morbidity and even mortality. Aside from treating the inherent complications associated with pneumothorax, hemothorax, and pulmonary contusion, managing chest wall pain is imperative in this population, the goal being to minimize chest wall splinting and maximize pulmonary effort. Inadequate pain control in the setting of decreased pulmonary reserve or underlying intrinsic lung disease can have devastating clinical consequences. Older trauma patients with isolated thoracic trauma suffer increased rates of acute respiratory distress syndrome and symptomatic pleural effusions, and have three times the risk of developing pneumonia when compared with their younger counterparts. For the elderly, in-hospital mortality increases in a linear fashion, with the number of rib fractures present starting at about 10% for one to two ribs fractured and approaching 40% when seven or more ribs are involved. Providing adequate analgesia to support deep breathing and coughing so as to limit atelectasis and hypoxia and to clear secretions is the mainstay of care but can be very difficult to achieve. Use of parenteral narcotics, while usually effective, can be dangerous if not closely titrated and monitored. Oversedation can result in hypoventilation, leading to hypercarbia and hypoxia. In a population already predisposed to coronary ischemia, hypoxia, even for brief periods, can be lethal. Oversedation also interferes with pulmonary toilet efforts and can lead to aspiration complicated by chemical pneumonitis or pneumonia. Ileus is also a common untoward effect of systemic narcotic analgesia. Many recent reports show significant decreases in pulmonary complications and mortality with the use of epidural analgesia compared with parenteral analgesia. Bulger et al. found that when comparing elderly patients with rib fractures who did not receive epidural analgesia with those who did, the mortality rate decreased from 25% to 11%. A randomized study by Ullman et al. showed a statistically significant decrease in length of intensive care unit stay, duration of mechanical ventilatory assistance, and hospital length of stay with epidural analgesia use. These benefits were achieved with few complications and lower overall hospital costs.

Elderly patients receiving oral anticoagulant therapy, including warfarin, clopidogrel, and aspirin, present a particularly difficult clinical challenge to the trauma surgeon. These medications are most commonly prescribed for a variety of prophylactic and therapeutic indications, including atrial fibrillation, prosthetic mechanical heart valves, pulmonary thromboembolism, previous deep venous thrombosis, and atherosclerotic coronary and/or peripheral vascular disease. Common sense would dictate that patients taking the medications would suffer more severe bleeding and worse outcomes than patients with a normal coagulation profile, but this has not been consistently supported in the literature. However, the subset of anticoagulated older patients who have sustained traumatic intracranial bleeding clearly fare worse. A recent analysis by Mina et al. of patients on anticoagulation medications with intracranial injury found a near 40% mortality rate as compared with less than 10% for matched controls not receiving any anticoagulation. Anticoagulated patients presenting with suspected closed head injury should undergo expedient head CT scanning and reversal of their anticoagulation if bleeding pathology is identified. The ideal strategy for when and how to reverse anticoagulation after injury remains ill defined and is fraught with complex decisions regarding the risks and benefits of such therapy. Usually fresh frozen plasma and/or vitamin K is used in Coumadin reversal and for correction of the International Normalized Ratio (INR), whereas platelet transfusion and desmopressin serve to counter the antiplatelet effect of clopidogrel. Recently recombinant coagulation factors (i.e., Factor VIIa) and prothrombin complex concentrates have also demonstrated efficacy in the reversal of oral anticoagulant therapy, but their use in the elderly population is limited by the high risk of thrombotic complications.

The evaluation of spinal injury in the geriatric patient can also be clinically challenging. Pre-existing organic brain syndrome or pre-existing neurological deficits can further confound the diagnosis. Radiographic clearance can be equally difficult because of degenerative changes commonly present. Upper cervical injuries are predominant in the elderly population, with odontoid fractures being the most common. Age-related cervical spinal stenosis and increased osteophyte formation put older patients at especially high risk of central cord syndrome. This is seen most often following a forward fall with the chin striking an object or the floor, resulting in cervical hyperextension and acute pinching of the spinal cord. This results in bleeding in the more central regions of the spinal cord, producing preferential neurologic deficits in the upper extremities. Because there is often no concomitant bony injury, CT scanning can miss this diagnosis. In this clinical setting, magnetic resonance imaging becomes the imaging modality of choice to elucidate the injury. Prognosis for complete recovery following central cord syndrome is poor for older patients. In those over 70, bladder control and ambulatory function are restored only 20% and 40% of the time, respectively, and mortality can be in excess of 50%.

CONCLUSIONS

While geriatric patients have many physical and psychological factors predisposing them to injury and complicating their recovery, many have good outcomes and maintain a high quality of life after injury. Health care providers must pay careful attention to comorbidities and the potential impact of reduced physiologic reserve. Although the morbidity and mortality observed in the injured elderly population may be higher when viewed in the aggregate, each patient must be aggressively evaluated and managed with the goal of expedient return to the highest possible quality of life and level of functioning. When caring for the injured elderly, one must maintain a high index of suspicion for injury and a low threshold for aggressive invasive monitoring in an intensive care setting.

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TRAUMA IN THE ELDERLY

PHYSIOLOGY

MECHANISM OF INJURY

OUTCOMES

MANAGEMENT OF SPECIFIC ORGAN INJURIES

CONCLUSIONS

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TRAUMA IN THE ELDERLY

PHYSIOLOGY

MECHANISM OF INJURY

OUTCOMES

MANAGEMENT OF SPECIFIC ORGAN INJURIES

CONCLUSIONS

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