Trauma and falls in the elderly

Case-control analysis of hip fractures with concurrent benzodiazepine and opioid use and surgery class at a single teaching institution

In this study, we analyze the relationship between polypharmacy and surgical treatment in a population at a single teaching institution. The design of the study is a case-control analysis of hip fractures. The setting is at a single teaching institution located in Galveston, Texas, USA. Over a 5-year period, we conducted a retrospective review of patients within our medical record who underwent surgery for a hip fracture, identified by current procedural terminology codes 27235 and 27236. Our primary variable was a prescription of opioids, benzodiazepines, or both 30 days preoperatively and surgery performed. The main outcome measures were prescription of controlled medications and surgical class. We used descriptive analysis to summarize each variable as mean or frequency for continuous and categorical variables and subsequently assessed the association between demographic variables and drug prescription and surgical class. Of the 378 patients who met our inclusion criteria, 68.0% were females and 32.0% were males. The average age was 77.8 years. Most patients had a displaced hip fracture (61%). Most patients underwent a hip hemiarthroplasty (233, 61.6%) versus either a closed reduction with percutaneous pinning (125, 33.1%) or hip open reduction internal fixation (20, 5.3%). There was no significant difference between polypharmacy and hip fracture surgery; however, reported alcohol use was significant in both groups. In our patient population, opioid and/or benzodiazepine prescriptions were not significantly linked to hip fracture surgery, but documented alcohol use was found to be significant in both groups. We noted a higher prevalence of opioid and benzodiazepine prescriptions than was previously reported. As patients age, we should be cautious about the effects of polypharmacy and alcohol use and their impacts on the elderly.

Utility of Torso Imaging for Elderly Patients Sustaining Ground-Level Falls

INTRODUCTION

Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center.

METHODS

Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF.

RESULTS

A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging.

CONCLUSIONS

The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.

Outcomes of severe isolated blunt chest trauma in young and geriatric patients

PURPOSE

Our understanding of the growing geriatric population's risk factors for outcomes after traumatic injury remains incomplete. This study aims to compare outcomes of severe isolated blunt chest trauma between young and geriatric patients and assess predictors of mortality.

METHODS

The ACS-TQIP 2017-2020 database was used to identify patients with severe isolated blunt chest trauma. Patients having extra-thoracic injuries, no signs of life upon presentation to the emergency department (ED), prehospital cardiac arrest, or who were transferred to or from other hospitals were excluded. The primary outcome was in-hospital mortality. Univariate and multivariable regression analyses were performed to assess independent predictors of mortality.

RESULTS

A total of 189,660 patients were included in the study, with a median age of 58 years; 37.5% were aged 65 or older, and 1.9% died by discharge. Patients aged 65 and older had significantly higher mortality (3.4% vs. 1.0%, p < 0.001) and overall complications (7.0% vs. 4.7%, p < 0.001) compared to younger patients. Age ≥ 65 was independently associated with mortality (OR: 5.45, 95%CI: 4.96-5.98, p < 0.001), prolonged hospitalization, and complications. In the geriatric group, age > 75 was an independent predictor of mortality compared to ages 65-75 (OR: 2.62, 95%CI: 2.37-2.89, p < 0.001). Geriatric patients with an MVC, presenting with a GCS ≤ 8, and having an SBP < 90 had the highest mortality of 56.9%.

CONCLUSION

The geriatric trauma patient with isolated severe blunt chest injury has significantly higher mortality and morbidity compared to younger patients and warrants special consideration of multiple factors that affect outcomes. Individual predictors of mortality carry a greater impact on mortality in geriatric patients.

DOACs for Older adults with Atrial Fibrillation and Falls: Results from the prospective single-centre DOAFF study

INTRODUCTION

Falls are one of the most fearsome events in anticoagulated older adults. The evidence concerning safety of direct oral anticoagulants (DOACs) in falling elderly patients with atrial fibrillation (AF) is still limited.

METHODS

We prospectively enrolled consecutive anticoagulant-naïve patients aged 65 years and older, starting anticoagulation with DOACs for AF. The study cohort was stratified in fallers vs. non-fallers, according to the occurrence of at least one fall during the 2-year follow-up and bleeding outcomes were evaluated.

RESULTS

We enrolled 524 consecutive patients. Mean age was 80.8 years and they were mostly women (54.0%). Among the study cohort, 148 patients (28.2%) presented at least one fall episode during the study period. After the adjustment for potential confounders, no difference was found between fallers and non-fallers for all the study outcomes: major bleeding [HR: 1.04 (95%CI: 0.58-1.85)], intracranial haemorrhage [HR: 1.63 (95%CI: 0.69-3.80)], clinically relevant non-major bleeding [HR: 1.21 (95%CI: 0.83-1.76)], and all-cause death [HR: 1.51 (95%CI: 0.85-2.69)]. The presence of a prior cerebrovascular event [HR: 2.27 (95%CI: 1.12-4.62); p-value: 0.02] and polypharmacy [HR: 1.60 (95%CI: 1.08-2.39); p-value: 0.02] were the main drivers for major and clinically relevant non-major bleedings, respectively.

CONCLUSIONS

Falls in an anticoagulant-naïve population aged 65 years and over starting a DOAC for AF do not increase the bleeding risk. Thus, the presence of falls should not discourage clinicians from prescribing DOACs also in this subset of patients.

Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups

Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.

Stress-Induced (Not Diabetic) Hyperglycemia is Associated With Mortality in Geriatric Trauma Patients

INTRODUCTION

Stress-induced hyperglycemia (SIH) is associated with worse outcomes among trauma patients. It is also known that injured geriatric patients have higher mortality when compared to younger patients. We sought to investigate the association of all levels of SIH with mortality among geriatric trauma patients at a level 1 academic trauma center. We hypothesized that SIH in the geriatric trauma population would be associated with increased mortality.

METHODS

A retrospective review of all geriatric patients admitted to our level 1 trauma center over a 3-year period (January 2018-December 2020) was performed using the institutional trauma database. Data collected included demographics, injury severity score (ISS), emergency department (ED) blood glucose level, ED systolic blood pressure (SBP), and mortality. Patients were divided into 4 groups based on emergency room blood glucose level, as follows: normoglycemic (<120 mg/dL), mild hyperglycemia (120-150 mg/dL), moderate hyperglycemia (151-199 mg/dL), and severe hyperglycemia (≥200 mg/dL). Multivariable logistic regression analysis was performed to evaluate the association of SIH and in-hospital mortality adjusting for ISS, age, comorbidities, and ED SBP.

RESULTS

A total of 4432 geriatric trauma patients were admitted during the study period, of which 3358 patients (75.8%) were not diabetic. There were 2206 females (65.7%), 2993 were White (89.2%), with a mean age of 81.5 y. There were 114 deaths (3.4%). Univariate results showed that there was a statistically significant association between mortality and glucose groups (P < 0.01). The number of deaths in the four glucose groups were, as follows: 30 (2.0%), 32 (3.8%), 20 (6.2%), and 10 (12.2%), respectively. Multivariable logistic regression analysis results showed that compared to the normoglycemic group, the risk of death was higher in the mild, moderate, and severe glucose groups, as follows: mild group (OR 1.80, 95% confidence interval [CI] 1.04-3.13, P 0.04), moderate group (OR 2.53, 95% CI 1.34-4.80, P < 0.01), and severe group (OR 5.04, 95% CI 2.18-11.67, P < 0.01).

CONCLUSIONS

Mild, moderate, and severe SIH are statistically significant predictors of death among geriatric trauma patients independently of ISS, age, comorbidities, and SBP.

Are There Any Differences in Road Traffic Injury Outcomes between Older and Younger Adults? Setting the Grounds for Posttraumatic Senior Personal Injury Assessment Guidelines

Injury outcomes seem to be more severe in older than younger persons. This may make personal injury assessment (PIA) particularly difficult, mainly because of seniors’ previous health frailties. To set the grounds for seniors’ PIA guidelines, we compared an older with a younger adult population of trauma victims and, secondarily, identified differences between the groups regarding three-dimensional and medico-legal damage parameters assessment. Using a retrospective study of victims of road traffic accidents, we compared the groups (n = 239 each), assuring similar acute injury severity (ISS standardised difference = 0.01): G1 (older adults); G2 (younger adults). Logistic regression was used to estimate the odds ratio. G1 revealed higher negative consequences when considering the three-dimensional damage assessment, with more frequent and severe outcomes, being a cause of further difficulties in daily living activities, with a loss of independence and autonomy. Nevertheless, regarding the medico-legal damage parameters, permanent functional disability did not show significant differences. This study generates evidence that reveals the need to rethink the traditional methodology of PIA in older persons, giving more relevance to the real-life contexts of each person. It is essential to: obtain complete information about previous physiologic and health states, begin the medico-legal assessment as early as possible, make regular follow-ups, and perform a multidisciplinary evaluation.

Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care

INTRODUCTION

Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center.

PATIENTS AND METHODS

We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated.

RESULTS

Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%.

DISCUSSION

These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging.

CONCLUSION

Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.

Factors Predictive of Mortality among Geriatric Patients Sustaining Low-Energy Blunt Trauma

Background: In geriatric trauma patients, higher mortality rate is observed compared to younger patients. A significant portion of trauma sustained by this age group comes from low-energy mechanisms (fall from standing or sitting). We sought to investigate the outcome of these patients and identify factors associated with mortality. Methods: A retrospective review of 1285 geriatric trauma patients who came to our level 1 trauma center for trauma activation (hospital alert to mobilize surgical trauma service, emergency department trauma team, nursing, and ancillary staff for highest level of critical care) after sustaining low-energy blunt trauma over a 1-year period. IRB approval was obtained, data collected included demographics, vital signs, laboratory data, injuries sustained, length of stay and outcomes. Patients were divided into three age categories: 65−74, 75−84 and >85. Comorbidities collected included a history of chronic renal failure, COPD, Hypertension and Myocardial Infarction. Results: 1285 geriatric patients (age > 65 years) presented to our level 1 trauma center for trauma activation with a low-energy blunt trauma during the study period; 34.8% of the patients were men, 20.5% had at least one comorbidity, and 89.6% were white. Median LOS was 5 days; 37 (2.9%) patients died. Age of 85 and over (OR 3.44 with 95% CI 1.01−11.7 and 2.85 with 95% CI 1.0−6.76, when compared to 65−74 and 75−84, respectively), injury severity score (ISS) (OR 1.08, 95% CI 1.02 to 1.15) and the presence of more than one comorbidity (OR 2.68, 95% CI 1.26 to 5.68) were independently predictive of death on multi-variable logistic regression analysis. Conclusion: Age more than 85 years, higher injury severity score and the presence of more than one comorbidity are independent predictors of mortality among geriatric patients presenting with low-energy blunt trauma.

Falls, healthcare resources and costs in older adults with insomnia treated with zolpidem, trazodone, or benzodiazepines

Background

Falls are the leading cause of injury-related death among older Americans. While some research has found that insomnia heightens falls, health care resource utilization (HCRU) and costs, the impact of insomnia treatments on fall risk, mortality, HCRU and costs in the elderly population, which could be of substantial interest to payers, has not been fully elucidated. This study evaluated the risk of falls and related consequences among adults ≥ 65 years of age treated with common prescription medications for insomnia compared with non-sleep disordered controls.

Methods

This was a retrospective cohort analysis of deidentified Medicare claims from January 2011 through December 2017. Medicare beneficiaries treated for insomnia receiving zolpidem extended-release, zolpidem immediate-release, trazodone, or benzodiazepines were matched with non-sleep disordered controls. The main outcomes were falls, mortality, healthcare resource utilization (HCRU), and medical costs during the 12 months following the earliest fill date for the insomnia medication of interest. Generalized linear models controlled for several key covariates, including age, race, sex, geographic region and Charlson Comorbidity Index score.

Results

The study included 1,699,913 Medicare beneficiaries (59.9% female, mean age 75 years). Relative to controls, adjusted analyses showed that beneficiaries receiving insomnia medication experienced over twice as many falls (odds ratio [OR] = 2.34, 95% CI: 2.31–2.36). In adjusted analyses, patients receiving benzodiazepines or trazodone had the greatest risk. Crude all-cause mortality rates were 15-times as high for the insomnia-treated as controls. Compared with controls, beneficiaries receiving insomnia treatment demonstrated higher estimated adjusted mean number of inpatient, outpatient, and emergency department visits and longer length of inpatient stay. All-cause total adjusted mean costs were higher among insomnia treated patients ($967 vs $454).

Conclusions

Individuals receiving insomnia treatment had an increased risk of falls and mortality and higher HCRU and costs compared with matched beneficiaries without sleep disorders. Trazodone and benzodiazepines were associated with the greatest risk of falls. This analysis suggests that significant risks are associated with common, older generation insomnia medication treatments in the elderly. Nonetheless, these results should be interpreted with caution as the use of these medications may be indicative of underlying morbidity with potential for residual confounding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03165-6.

Severe or not so severe? The gravity of geriatric trauma

Background:

Due to associated comorbidities, the elderly population is more vulnerable to injuries with complications. This study was done to assess the severity of trauma and outcome of injuries among these patients presenting to the Emergency Department (ED).

Materials and Methods:

This was a retrospective cohort study. We included all patients aged more than 60 years, who presented to the ED with trauma in the year 2018. Details of the mode of trauma, severity of injuries and outcome were analysed.

Results:

During the study period a total of 7666 trauma patients presented to ED, among which 879 (879/7666: 11.4%) were in the geriatric age group. The mean age was 68.9 (SD: 7) years with 90.8% being young-old (60–79 years) and 9.2% being old-old (>80 years). Common modes of injuries were road traffic accidents (RTA) (64%) fall on level ground (FLG) (20%) and fall from height (FFH) (8%). Most of them had Injury Severity Score (ISS) and New Injury Severity Score (NISS) score of 0–7, i.e.: 62% and 51%, respectively. On multivariate logistic regression analysis RTA, FFH FLG and triage priority 1 patients were associated with trauma in the old-old as compared to the young–old age groups significantly. Independent risk factors associated with severe trauma were seen RTA, FLG and priority 1 patients. Forty-four per cent patients were managed by the ED team alone. Trauma speciality departments referred to included orthopaedics (47%), neurosurgery (22%), trauma surgery (14%), plastic surgery (8%) and hand reconstruction surgery (6%). About half of the population under study was discharged stable (44%), of which the majority belonged to the young-old category (44.1%). The in-hospital mortality rate was 0.5% (4/879).

Conclusion:

This study shows the gravity of multiple injuries sustained by the geriatric age group with RTA, FLG and FFH being the predominant causes of trauma. The NISS highlights the severity of injuries in the old and the frail.

Pattern of trauma in elderly patients seen at the trauma centre of national hospital Abuja, Nigeria

Introduction

The global population is aging, creating challenges for health systems. The mean age of patients with major trauma has increased over time, posing some challenges for trauma system designs. Elderly trauma patients are said to have higher mortality rates and longer hospital and intensive care unit stays. This study is aimed at assessing the pattern of injuries in elderly population in a dedicated trauma centre of a developing economy.

Methods

This is a retrospective study of all patients aged 60 years and above seen in the trauma centre of a West African tertiary hospital over a three year period from January 2017 to December 2019. Relevant parameters including Sociodemographic data, injury pattern and injury scores were derived from the trauma registry. Data analysis was done using statistical package for social sciences (SPSS) version 24. Results were presented using tables and a figure.

Results

A total of 183 patients aged 60 years and above were enrolled out of 4549 general trauma patients, representing 4% of the trauma patient population seen. Male to female ratio was 2.3 with the mean age of 65 ± 6.3. The most frequent mechanisms of injury were motor vehicular crash (MVC) (48.4%), followed by falls (16.5%). More proportion of females (21.8%) were significantly found to suffer falls compared to their males (14.2%) counterparts (p < 0.05). Traumatic brain injury was the commonest diagnosis accounting for 24.3% of cases. The predominant revised trauma scores (RTS) and injury severity scores (ISS) were 12 and 1–15 respectively, with overall mortality of 6.1%.

Conclusion

The proportion of elderly trauma patients studied in this centre is low. MVC is still the leading mechanism of injury in our elderly trauma population. The mortality rate is however low in this study, in line with the low trauma and severity scores. Preventive measures for MVC should be strongly encouraged to reduce the incidence of elderly trauma patients in this part of the world.

Elderly trauma mortality in a resource-limited setting: A benchmark for process improvement

INTRODUCTION

As life expectancy improves globally, the burden of elderly trauma continues to increase. Sub-Saharan Africa is projected to have the most rapid growth in its elderly demographic. Consequently, we sought to examine the trends in characteristics and outcomes of elderly trauma in a tertiary care hospital in Malawi.

METHODS

We performed a retrospective analysis of adult patients in the trauma registry at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2011-2017. Patients were categorized into elderly (≥ 65 years) and non-elderly (18-64 years). Bivariate analysis compared the characteristics and outcomes of elderly vs. non-elderly patients. The elderly population was then examined over the study period. Poisson regression modeling was used to determine the risk of mortality among elderly patients over time.

RESULTS

Of 63,699 adult trauma patients, 1,925 (3.0%) were aged ≥ 65 years. Among the elderly, the most common mechanism of injury was falls (n = 725 [37.7%]) whereas vehicle or bike collisions were more common in the non-elderly (n = 15,967 [25.9%]). Fractures and dislocations were more prevalent in the elderly (n = 808 [42.0%] vs. 9,133 [14.8%], p < 0.001). In-hospital crude mortality for the elderly was double the non-elderly group (4.8% vs. 2.4%, p < 0.001). Elderly transfers, surgeries, and length of stay significantly increased over the study period but mortality remained relatively unchanged. When adjusted for injury severity and transfer status, there was no significant difference in risk of in-hospital mortality over time.

CONCLUSION

At KCH, the proportion of elderly trauma patients is slowly increasing. Although healthcare resource utilization has increased over time, the overall trend in mortality has not improved. As the quality of care for the most vulnerable populations is a benchmark for the success of a trauma program, further work is needed to improve the trend in outcomes of the elderly trauma population in Malawi.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

The utility of head CT scans in geriatric patients with hip fractures following a low energy injury mechanism: A retrospective review

OBJECTIVES

Hip fractures are common low-energy orthopaedic injuries in the geriatric population. The purpose of this study is to determine the frequency of CT head exams and the incidence of clinically significant intracranial bleed in patients with low energy hip fractures.

DESIGN

A retrospective cross-sectional review was completed to identify hip fractures presenting to an academic health centre between 2006 and 2015. Our inclusion criteria were those patients with low energy hip fractures and medical records were reviewed to determine whether a CT head scan was utilized as part of their workup.

RESULTS

A total of 2114 patients were reviewed with an average age of 83.2 years. Hip fractures were treated with a hemiarthroplasty in 59.1% of the patients and with a dynamic hip screw in 40.9% of the patients. 26.9% (n = 502) of the patients received a CT head scan as part of their workup. Sixty-two patients (12.3% of patients who received a CT scan or 2.9% of the study population) were found to have had an acute intracranial bleed. None of these patients required neurosurgical intervention and only 9 (14.5% of patients with a positive CT head) had a modification to their thromboprophylaxis post-op. Of the 15 (26.4%) patient on home anticoagulation for a pre-existing medical condition, 10 (67%) had a delay in reinitiating their anticoagulation greater than 24 h post-operatively.

CONCLUSION

During the study period, 26.7% of patients received a CT scan, with only 2.9% of patients suffering from a concurrent intracranial bleed. None of the patients with a positive scan required neurosurgical intervention, and scan results did not routinely alter DVT prophylaxis. Resuming home anticoagulation was delayed greater than 24 h post-operatively in ten (67%) of cases. With the challenges of resource allocation, potential delays to surgery and costs associated with CT scans, these investigations should be reserved for patients who have a history or physical exam findings of head trauma or are on anticoagulation pre-injury in the low energy hip fracture population.

LEVEL OF EVIDENCE

Level III.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.

Evaluation of Cervical Spine Fracture in the Elderly: Can We Trust Our Physical Examination?

The purpose of this trial was to compare National Emergency X-Radiography Utilization Study (NEXUS) criteria (NC) with computed tomography (CT) as the gold standard to evaluate cervical spine (C-spine) fractures in elderly blunt trauma patients. We prospectively compared adult blunt trauma patients 65 years or older (E) with younger than 65 years (NE), evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NC compared with CT in these two cohorts. A total of 2785 blunt trauma patients were included of whom 320 were E (average age, 75 years) and 2465 were NE (average age, 36 years). Incidence of C-spine fracture was 12.8 per cent (E) versus 7.4 per cent (NE) ( P = 0.002). Age was an independent predictor of fracture ( P = 0.01). NC had a sensitivity of 65.9 per cent in E and PPV of 19.3 per cent in E ( P = 0.001) versus a sensitivity of 84.2 per cent in NE and PPV of 10.6 per cent ( P < 0.0001). The specificity was 59.5 per cent for E versus 42.6 per cent for NE (NPV, 92.2% E vs 97.1% NE). This study suggests that NEXUS criteria are not an appropriate assessment tool when applied to severe blunt trauma patients, particularly in the elderly population who had more missed injures than their younger counterparts. CTshould be used in all blunt trauma patients regardless of whether they meet NEXUS criteria.

Wearable Fall Detector Using Recurrent Neural Networks

Falls have become a relevant public health issue due to their high prevalence and negative effects in elderly people. Wearable fall detector devices allow the implementation of continuous and ubiquitous monitoring systems. The effectiveness for analyzing temporal signals with low energy consumption is one of the most relevant characteristics of these devices. Recurrent neural networks (RNNs) have demonstrated a great accuracy in some problems that require analyzing sequential inputs. However, getting appropriate response times in low power microcontrollers remains a difficult task due to their limited hardware resources. This work shows a feasibility study about using RNN-based deep learning models to detect both falls and falls’ risks in real time using accelerometer signals. The effectiveness of four different architectures was analyzed using the SisFall dataset at different frequencies. The resulting models were integrated into two different embedded systems to analyze the execution times and changes in the model effectiveness. Finally, a study of power consumption was carried out. A sensitivity of 88.2% and a specificity of 96.4% was obtained. The simplest models reached inference times lower than 34 ms, which implies the capability to detect fall events in real-time with high energy efficiency. This suggests that RNN models provide an effective method that can be implemented in low power microcontrollers for the creation of autonomous wearable fall detection systems in real-time.

Trauma in elderly patients: a study of prevalence, comorbidities and gender differences

AIM

Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population.

PATIENTS AND METHOD

We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT.

RESULTS

In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%.

DISCUSSION

The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity.

CONCLUSIONS

Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.

The evaluation of geriatric patients who presented with trauma to the emergency department

INTRODUCTION

Geriatric patients are subject to traumas more frequently due to age-related physiopathological changes. The objective of the study was to evaluate the demographic properties of geriatric patients who presented with trauma to the emergency department in addition to establishing the course of the diagnosis and treatment.

MATERIAL AND METHODS

Nine hundred and twelve geriatric patients who presented with trauma to the emergency department during one year were included in this retrospective study. Cause of the presentation, demographic properties, diseases, medications, sites of trauma, departments of consultations, departments that the patients were admitted to, discharge, mortality and morbidity rates were obtained from the folders of the subjects. The subjects were assigned to age groups 65-79 years old and over 80 years old.

RESULTS

60.4% (n = 551) of the 912 subjects were female, 39.6% (n = 361) were male and the mean age of the subjects was 77.16 (65-100). Falls were the most common cause (80.3%) of traumas, and the most frequently affected parts of the body were the extremities. The over 80 group was the most frequently consulted group (p = 0.01) and women were admitted more often to the hospital (p = 0.03). Of the patients who presented with trauma, 28.9% (n = 264) were hospitalized and 2% (n = 18) died. The most common causes of death of patients were femur fractures and intracranial hemorrhages.

CONCLUSIONS

Due to high mortality and morbidity, this geriatric patient group deserves a multidisciplinary approach beginning with the emergency departments.

[Reconstruction of lower limbs in old age-an interdisciplinary approach : Geriatric assessment, perioperative management, diagnostics and treatment targets]

Complex injuries of the lower extremities in geriatric patients with multiple pre-existing comorbidities represent an increasing challenge to an interdisciplinary team of surgeons. Functional reconstruction of the extremity through osteosynthesis, revascularization and defect coverage aims to preserve mobility and achieve an early return to activities of daily life at home, while avoiding major amputation and the associated risks regarding morbidity and mortality. An interdisciplinary assessment of geriatric patients regarding dystrophy of soft tissue and skín, cardiovascular and metabolic comorbidities as well as specific geriatric diagnostics are crucial steps in ensuring favorable outcomes. Perioperatively, all improvable risk factors should be actively optimized and a specialized interdisciplinary approach to treatment planning (extremity board) is absolutely necessary for success of treatment. It outlines the special features of the geriatric assessment, diagnostics, perioperative management and treatment targets.

Clinical Indications of Computed Tomography (CT) of the Head in Patients With Low-Energy Geriatric Hip Fractures: A Follow-Up Study at a Community Hospital

Introduction:

A seemingly large percentage of geriatric patients with isolated low-energy femur fractures undergo a head computed tomography (CT) scans during initial work up in the emergency department. This study aimed to evaluate the pertinent clinical variables that are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed.

Methods:

A retrospective review performed at a level II trauma center including 713 patients over the age of 65 sustaining a femur fracture following a low-energy fall. The main outcome measure was pertinent clinical variables that are associated with CT scans that yielded positive findings.

Results:

A total of 713 patients over the age of 65 were included, with a low-energy fall, of which 76.2% (543/713) underwent a head CT scan as part of their evaluation. The most common presenting symptom reported was the patient hitting their head, 13% (93/713), and 1.8% (13/713) were unsure if they had hit their head. Of those evaluated with a head CT scan, only 3 (0.4%) had acute findings and none required acute neurosurgical intervention. All three patients with acute changes on the head CT scan had an Injury Severity Score (ISS) greater than 9, Glasgow Coma Scale (GCS) less than 15, and evidence of trauma above the clavicles.

Discussion:

None of the patients with a traumatic injury required a neurosurgical intervention after sustaining a low-energy fall (0/713).

Conclusion:

Head CT scans should have a limited role in the workup of this patient population and should be reserved for patients with a history and physical exam findings that support head trauma, an ISS > 9 and GCS < 15.

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly

INTRODUCTION

Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.

METHODS

A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).

RESULTS

33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.

DISCUSSION

These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

Geriatric chest wall injury: is it time for a new sense of urgency?

Geriatric trauma has become an increasingly recognized management concern for trauma centers, and hospitals alike, on a national scale. The population of the United States is aging, as life expectancy rates have demonstrated a steady climb to an average of 78.8 years of expected life. With pervasive efforts of medical screening, prevention and chronic medical condition management, more elderly people will lead more active lifestyles and will be more predisposed to injury. As best practice guidelines specific for the geriatric trauma population have yet to be developed, many researchers have identified management strategies that have offset complications and mortality rates inherent to this patient population after injury. The impact of rib fractures in the 65-year and older patient population has been well documented, as have the mortality and pneumonia rates yet, historically, little attention has been directed to curtailing these adverse outcomes with more advanced treatment options. With the advent of rib plating for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists. In this review, we focus on the characteristics of the geriatric trauma patient, areas of management where improvement opportunities have been identified, chest wall injury in the elderly patient, rib plating as a treatment option and offer our data to facilitate a better understanding of rib plating's impact in the geriatric trauma patient.

It was not a hip fracture - you were lucky this time - or perhaps not! A prospective study of clinical outcomes in patients with low-energy pelvic fractures and hip contusions

INTRODUCTION

Prehospital and hospital emergency care guidelines have been developed for patients with suspected hip fracture. Initial radiography can identify a number of patients with other injuries, generally pelvic fractures and hip contusions. Little is known about the prognosis for these patients. The aim of this study is twofold: i) to investigate the injury pattern of patients assessed in prehospital emergency care as suffering from a suspected hip fracture and ii) to compare clinical outcomes between patients with verified hip fracture (HF) and those with other hip injuries (OHI).

METHOD

The study design was prospective. Older patients with suspected HF after low-energy trauma were identified in prehospital emergency care. Injury type was determined by radiological imaging. Comparisons of length of stay, adverse events, repeated prehospital emergency care and mortality were made between verified HF and OHI cases.

RESULTS

449 patients were included, 400 in the HF and 149 in the OHI group (86 hip contusions, 46 pelvic fractures and 17 other injuries/diseases). The HF group had a significantly longer hospital stay (9.5 days vs. 6.3 for the OHI group; p < 0.001) and more adverse events while in hospital (34% vs. 19%; p < 0.001). We found no evidence that the groups differed with regard to other outcomes: mortality during hospital stay (4% vs. 2%, p = 0.42), at 4 (16% vs. 13%; p = 0.35) and 12 months (21 vs. 23%; p = 0.64), the proportion that experienced an adverse event (24% vs. 22%; p = 0.65) and the proportion that required another ambulance transport within 6 months after discharge (40% vs. 34%; p = 0.16). The results were not strongly affected by adjustments for possible confounders.

CONCLUSION

Older patients who suffer a low-energy pelvic fracture or a hip contusion are common in prehospital and hospital emergency care. These patients need attention as they have poor outcomes in terms of adverse events, mortality and recurrent need for ambulance transport after discharge from hospital. While individualized multidisciplinary care is recommended for hip fracture patients, it might also be suitable for other geriatric hip injuries.

The Impact of Obesity on Outcomes in Geriatric Blunt Trauma

Blunt trauma is poorly tolerated in the elderly, and the degree to which obesity, a known risk factor for suboptimal outcomes in trauma affects this population remains to be determined. The incidence, prevalence, and mortality rates of blunt trauma by demographics, year, and geography were found using datasets from both the Global Burden of Disease database, and a Regional Level II trauma registry. Global Burden of Disease data were extracted from 284 country-year and 976 subnational-year combinations from 27 countries for the period 1990 to 2015. The regional trauma registry was interrogated for patients ≥70 years admitted with blunt trauma between 2014 and 2016. The incidence of elderly blunt trauma from falls increased at a global, national (United States), and state (WV) level from 1990 to 2015 by 78.3 per cent, 54.7 per cent, and 42.7 per cent, respectively with concomitant increases in mortality rates of 5.7 per cent, 102.6 per cent, and 89.3 per cent (P < 0.05). The regional cohort had a statistically similar mortality (obese, n = 320 vs nonobese, n = 926 of 4.8% vs 4.4%, respectively, P > 0.05). The hospital length-of-stay, Glasgow Coma Scale score, and systolic blood pressure on presentation were similar (P > 0.05) as was the Injury Severity Score. Major medical comorbidities were identified in 280 (87.5%) and 783 (84.6%) patients in the obese and nonobese groups, respectively. Blunt trauma, secondary to falls, has increased in elderly patients at a global, national, and state level with a concomitant increase in mortality rates. Although a similar increase in the incidence of blunt trauma in the elderly was noted at a regional center, its mortality has not been increased by obesity, possibly because of similar comorbidity rates.

Injury Patterns and Outcomes of Trauma in the Geriatric Population Presenting to the Emergency Department in a Tertiary Care Hospital of South India

Background:

The geriatric population is more prone for injuries with complications due to their associated comorbidities. This study was done to understand the mode, severity, and outcome of injuries among geriatric patients presenting to the emergency department (ED).

Materials and Methods:

This retrospective study included all patients >60 years who presented with trauma between October 2014 and March 2015. Details of the incident, injuries, and hospital outcome were noted.

Results:

Among 8563 geriatric patients, who presented to the ED during the study, 427 (4.9%) patients were trauma related. The mean age was 69 (standard deviation: 6.76) years with 87.6% being young-old (60–79 years) and 12.4% being old-old (>80 years). Majority (63.2%) were Priority 2 patients. The median time between the incident and ED arrival among Priority 1 patients was 3 h (interquartile range: 2–5). Common modes of injuries were slip and fall (37.4%), two-wheeler accidents (25.8%), fall from height (9.1%), and pedestrian (8.9%). The ED team alone managed 25.8% of patients. Specialty departments referred to included orthopedics (48%), neurosurgery (18.3%), plastic surgery (4.2%), HLRS (4%), and others. Injuries due to slip and fall were significantly more among the old-old (P = 0.001), and two-wheeler accidents were more among the young-old (P = 0.001), respectively. Superficial head injuries (28.8%), extremity (24.8%), facial (18.7%), and traumatic brain injuries (17.8%) were common presentations. Thoracic injuries were significantly more among the old-old (P < 0.001). Half (46.3%) of the young-old were discharged stable (P = 0.017). In-hospital mortality rate was 0.7% (3/427), while 12.9% (55/427) left against medical advice due to poor prognosis.

Conclusion:

Our study demonstrates the pattern of injury seen in the elderly in an urban setting in India. From this, we perceive the need for a prospective study evaluating the causes for geriatric trauma, which would help work on ways to prevent and minimize injuries in the elderly.

History and physical exam predictors of intracranial injury in the elderly fall patient: A prospective multicenter study

OBJECTIVES

A prior single-center study demonstrated historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population.

METHODS

This is a prospective observational study of patients ≥65 years presenting after a fall to three EDs. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anticoagulants/antiplatelet use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients.

RESULTS

723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulation/antiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed.

CONCLUSION

In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC.

Significance of Blood Transfusion Units in Determining the Probability of Mortality among Elderly Trauma Patients Based on the Geriatric Trauma Outcome Scoring System: A Cross-Sectional Analysis Based on Trauma Registered Data

Background: For elderly trauma patients, a prognostic tool called the Geriatric Trauma Outcome Score (GTOS), where GTOS = (age) + (ISS × 2.5) + (22 if any packed red blood cells (pRBCs) were transfused within 24 h after admission), was developed for predicting mortality. In such calculation, a score of 22 was added in the calculation of GTOS regardless of the transfused units of blood. This study aimed to assess the effect of transfused blood units on the mortality outcomes of the elderly trauma patients who received blood transfusion (BT). Methods: Detailed data of 687 elderly trauma patients aged ≥65 years who were transfused with pRBCs within 24 h after admission into a level I trauma center between 1 January 2009 and 31 December 2016 were retrieved from the Trauma Registry System database. Based on the units of pRBCs transfused, the study population was divided into two groups to compare the mortality outcomes between these groups. Adjusted odds ratios (AORs) with its 95% confidence intervals (CIs) for mortality were calculated by adjusting sex, pre-existing comorbidities, and GTOS. Results: When the cut-off value of BT was set as 3 U of pRBCs, patients who received BT ≥ 3 U had higher odds of mortality than those who received BT < 3 U (OR, 3.0; 95% CI, 1.94–4.56; p < 0.001). Patients who received more units of pRBCs still showed higher odds of mortality than their counterparts. After adjusting for sex, pre-existing comorbidities, and GTOS, comparison revealed that the patients who received BT of 3 U to 6 U had a 1.7-fold adjusted odds of mortality than their counterparts. The patients who received BT ≥ 8 U and 10 U had a 2.1-fold (AOR, 2.1; 95% CI, 1.09–3.96; p < 0.001) and 4.4-fold (AOR, 4.4; 95% CI, 2.04–9.48; p < 0.001) adjusted odds of mortality than those who received BT < 8 U and <10 U, respectively. Conclusions: This study revealed that the units of BT did matter in determining the probability of mortality. For those who received more units of blood, the mortality may be underestimated according to the GTOS.

The epidemiology of elderly falls attended by emergency medical services in Victoria, Australia

BACKGROUND

With an increase in the proportion of older people in the community comes an increase in the demand on emergency medical services (EMS) by elderly patients who have fallen.

OBJECTIVE

To describe the epidemiology of elderly falls patients attended by EMS in Victoria, Australia and identify predictors of transport and repeat falls.

METHODS

A retrospective review included all elderly (age ≥ 65 years) falls patients attended by EMS between 2010 and 2017. Patient characteristics are described using descriptive statistics. Predictors of transport to hospital and repeat falls were identified using multivariable logistic regression analyses.

RESULTS

Between 2010 and 2017 EMS attended 324,060 elderly falls patients, which represents 9.7% of EMS attended workload in Victoria. The median age of patients was 83 years (IQR: 76-88) and 60.2% were female. Comorbidities and medication use were common, while private residence (64.3%) and nursing home (20.0%) were common scene locations. Overall, 78.8% of falls events resulted in transport to hospital by EMS. Predictors of transport to hospital included female gender, one or more pre-existing medical conditions or current medications and meeting the pre-hospital trauma triage criteria or hospital major trauma criteria. To investigate predictors of repeat falls, the follow-up period was restricted to 12-months post initial fall, which resulted in 30,997 patients and 42,873 (13.2%) repeat fall incidents. The median number of days between the initial fall and a second fall was 98 (IQR: 27-206). Predictors of repeat falls included living at a nursing home, one or more pre-existing medical conditions and one or more current medications.

CONCLUSIONS

Older falls patients place significant demand on EMS resources in Victoria, Australia, accounting for 9.7% of EMS attendances. Despite high demand, just 3.8% of elderly falls patients received a 'lights and sirens' emergency transport response to hospital. Furthermore, a large number of falls incidents recorded during the study period were repeat falls. Access to alternative pathways of care like GP referral, allied and community health services may benefit this patient group. Development and enrolment into such programs may improve patient outcomes by minimising falls risk and decrease demand on EMS and hospital resources.

Blunt cerebrovascular injury in elderly fall patients: are we screening enough?

Background

Blunt cerebrovascular injuries (BCVI) are generally associated with high-energy injury mechanisms. Less is known regarding lower-energy injuries in elderly patients. We sought to determine the incidence of BCVI and characterize current BCVI screening practices and associated complications in elderly ground-level fall patients (EGLF, ≥ 65 years). We hypothesized that BCVI in EGLF patients would be clinically significant and screening would be less common.

Methods

A retrospective study was performed utilizing the National Trauma Data Bank (NTDB, 2007–2014) and single institutional data. BCVI risk factors and diagnosis were determined by ICD-9 codes. Presenting patient characteristics and clinical course were obtained by chart review. The NTDB dataset was used to determine the incidence of BCVI, risk factors for BCVI, and outcomes in the EGLF cohort. Local chart review focused on screening rates and complications.

Results

The incidence of BCVI in EGLF patients was 0.15% overall and 0.86% in those with at least one BCVI risk factor in the NTDB. Upper cervical spine fractures were the most common risk factor for BCVI in EGLF patients. In EGLF patients, the diagnosis of BCVI was an independent risk factor for mortality (OR1.8, 95% C.I. 1.5–2.1). The local institutional data (2007–2014) had a BCVI incidence of 0.37% (n = 6487) and 1.47% in those with at least one risk factor (n = 1429). EGLF patients with a risk factor for BCVI had a very low rate of screening (44%). Only 8% of EGLF patients not screened had documented contraindications. The incidence of renal injury was 9% irrespective of BCVI screening.

Conclusions

The incidence of BCVI is clinically significant in EGLF patients and an independent predictor of mortality. Screening is less common in EGLF patients despite few contraindications. This data suggests that using age and injury mechanism to omit BCVI screening in EGLF patients may exclude an at-risk population.

Trial registration

IRB approval number: PRO15020269. Retrospective trial not registered

Utility of Abdominal Computed Tomography in Geriatric Patients on Warfarin with a Fall from Standing

Context:

Geriatric head trauma resulting from falls has been extensively studied both in the presence and absence of blood thinners. In this population, however, the prevalence and extent of abdominal injury resulting from falls are much less defined.

Aim:

We aim to evaluate the utility of abdominal computed tomography (CT) imaging in geriatric patients on Warfarin with a recent history of fall.

Setting and Design:

A retrospective analysis was completed of consecutive geriatric patients who presented to a Level 1 Trauma Center emergency department after fall from standing while taking Warfarin.

Methods:

Inclusion criteria included age 65 years or older and fall while taking Warfarin. Incomplete medical records were excluded from the study. Data collection included the type of anticoagulant medications, demographics, physical examination, laboratories, CT/X-ray findings if ordered, and final diagnosis on admission. Categorical variables were examined using Pearson's Chi-square where appropriate (expected frequency >5), or Fisher's Exact test. Continuous variables were examined using nonparametric Wilcoxon rank tests.

Results:

Eight hundred and sixty-three charts were reviewed. One hundred and thirty-one subjects met inclusion criteria. Mean age was 83 years. Nearly 39.6% of patients were male. A total of 48 patients had abdominal CT imaging. Seven of the 131 patients (5.3%) had an abdominal injury. Abdominal tenderness was predictive of injury, with 4 of 7 cases with abdominal injury demonstrating abdominal tenderness versus only 10 of 124 cases without abdominal injury demonstrating tenderness (P = 0.003). Abdominal CTs were ordered in 11 of 19 cases of patients that exhibited head trauma yet none of these patients were shown to have sustained abdominal trauma (P = 0.08). There was no association between international normalized ratio level and presence of abdominal injury (P = 0.99).

Conclusions:

A small percentage of elderly fall patients on Warfarin have a significant abdominal injury. Anticoagulated geriatric patients are sometimes subjected to abdominal scans liberally without supporting physical examination findings such as abdominal tenderness or presence of a distracting injury. Specifically, the utility of abdominal CT is questionable in isolated head injury patients. Further, taking Warfarin or other anticoagulant medications do not seem to increase the risk of intraabdominal injury.

Age effect on the prediction of risk of prolonged length hospital stay in older patients visiting the emergency department: results from a large prospective geriatric cohort study

BACKGROUND

With the rapid growth of elderly patients visiting the Emergency Department (ED), it is expected that there will be even more hospitalisations following ED visits in the future. The aim of this study was to examine the age effect on the performance criteria of the 10-item brief geriatric assessment (BGA) for the prolonged length of hospital stay (LHS) using artificial neural networks (ANNs) analysis.

METHODS

Based on an observational prospective cohort study, 1117 older patients (i.e., aged ≥ 65 years) ED users were admitted to acute care wards in a University Hospital (France) were recruited. The 10-items of BGA were recorded during the ED visit and prior to discharge to acute care wards. The top third of LHS (i.e., ≥ 13 days) defined the prolonged LHS. Analysis was successively performed on participants categorized in 4 age groups: aged ≥ 70, ≥ 75, ≥ 80 and ≥ 85 years. Performance criteria of 10-item BGA for the prolonged LHS were sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR], area under receiver operating characteristic curve [AUROC]). The ANNs analysis method was conducted using the modified multilayer perceptron (MLP).

RESULTS

Values of criteria performance were high (sensitivity> 89%, specificity≥ 96%, PPV > 87%, NPV > 96%, LR+ > 22; LR- ≤ 0.1 and AUROC> 93), regardless of the age group.

CONCLUSIONS

Age effect on the performance criteria of the 10-item BGA for the prediction of prolonged LHS using MLP was minimal with a good balance between criteria, suggesting that this tool may be used as a screening as well as a predictive tool for prolonged LHS.

Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: what do we know about avoidable incidents? Results from a scoping review

OBJECTIVES

Older cognitively impaired adults present a higher risk of hospitalisation and mortality following a visit to the emergency department (ED). Better understanding of avoidable incidents is needed to prevent them and the associated ED presentations in community-dwelling adults. This study aimed to synthetise the actual knowledge concerning these incidents leading this population to ED presentation, as well as possible preventive measures to reduce them.

DESIGN

A scoping review was performed according to the Arksey and O'Malley framework.

METHODS

Scientific and grey literature published between 1996 and 2017 were examined in databases (Medline, Cumulative Index of Nursing and Allied Health, Ageline, Scopus, ProQuest Dissertations/theses, Evidence-based medecine (EBM) Reviews, Healthstar), online library catalogues, governmental websites and published statistics. Sources discussing avoidable incidents leading to ED presentations were included and then extended to those discussing hospitalisation and mortality due to a lack of sources. Data (type, frequency, severity and circumstances of incidents, preventive measures) was extracted using a thematic chart, then analysed with content analysis.

RESULTS

67 sources were included in this scoping review. Five types of avoidable incidents (falls, burns, transport accidents, harm due to self-negligence and due to wandering) emerged, and all but transport accidents were more frequent in cognitively impaired seniors. Differences regarding circumstances were only reported for burns, as scalding was the most prevalent mechanism of injury for this population compared with flames for the general senior population. Multifactorial interventions and implications of other professionals (eg, pharmacist, firefighters) were reported as potential interventions to reduce avoidable incidents. However, few preventive measures were specifically tested in this population.

CONCLUSIONS

Primary research that screens for cognitive impairment and involves actors (eg, paramedics) to improve our understanding of avoidable incidents leading to ED visits is greatly needed. This knowledge is essential to develop preventive measures tailored to the needs of older cognitively impaired adults.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01–2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05–1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04–1.40).

Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review

OBJECTIVES

The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma.

METHODS

EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes.

RESULTS

Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured.

CONCLUSIONS

While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

The influence of caregivers' burden on the quality of life for caregivers of older adults with chronic illness in Nigeria

BACKGROUND

This study investigated the impact of caregivers' burden on health-related quality of life (HRQoL) among the caregivers of older adults, and tested the predictive effect of burden and socio-demographic factors on HRQoL.

METHODS

The study employed a cross-sectional design. Three hundred and twenty-five caregivers of older adults with chronic illness were purposively selected. Data were collected using the Zarit Burden Interview and Short Form (SF-36) Health Survey. Data were analyzed descriptively and inferentially.

RESULTS

Findings revealed that 59.1% of caregivers experienced severe burden. In measuring the HQRoL, respondents performed poorly in seven domains: Role limitation due to emotional problems (19.69 ± 9.46), Energy/fatigue (43.47 ± 16.46), Emotional well-being, (45.83 ± 13.93), Social functioning (49.09 ± 18.46), Role limitation due to physical function (43.33 ± 10.15), Physical functioning (43.6 ± 18.73), and General health (37.31 ± 12.09). Respondents, however, showed a higher score in the pain domain (56.77 ± 35.79). Furthermore, findings revealed a positive correlation between caregivers' burden and General health (r = 0.342), Emotional well-being (r = 0.222), and Physical functioning (r = 0.083). Similarly, there is a negative correlation between caregivers' burden and Social functioning (r = -0.618), Role limitation due to physical activities (r = 0.459), Role limitation due to emotional well-being (r = -0.530), and Energy/fatigue domains (r = -0.509). In addition, burden of caregiving (β=-3.142119, p = 0.000) and age (β=0.612752, p = 0.011) are predictors of the quality of life of caregivers.

DISCUSSION

This study concluded that there is a high prevalence of caregivers' burden resulting in poor HQRoL. In addition, burden and age are predictors of the quality of life of caregivers.

Early predictors for massive transfusion in older adult severe trauma patients

BACKGROUND

Many scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.

METHODS

We prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.

RESULTS

The area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p<0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10-14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05-90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04-39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30-19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57-9.04), lactate levels (OR: 1.20, 95% CI: 1.04-1.39) and shock index (OR: 2.67, 95% CI: 1.05-6.84). Traditional vital signs were not early risk factors.

CONCLUSION

We suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

BACKGROUND AND OBJECTIVE

The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients.

METHODS

Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated.

RESULTS

Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%].

CONCLUSION

Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.

Geriatric Trauma

Within the next 15 years, 1 in 5 Americans will be over age 65. $34 billion will be spent yearly on trauma care of this age group. This section covers situations in trauma unique to the geriatric population, who are often under-triaged and have significant injuries underestimated. Topics covered include age-related pathophysiological changes, underlying existing medical conditions and certain daily medications that increase the risk of serious injury in elderly trauma patients. Diagnostic evaluation of this group requires liberal testing, imaging, and a multidisciplinary team approach. Topics germane to geriatric trauma including hypothermia, elder abuse, and depression and suicide are also covered.

Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients

Introduction:

Trauma in elderly population is frequent and is associated with significant mortality, not only due to age but also due to complicated factors such as the severity of injury, preexisting comorbidity, and incomplete general assessment. Our primary aim was to determine whether age, Injury Severity Score (ISS), and preexisting comorbidities had an adverse effect on the outcome in patients aged 65 years and above following blunt trauma.

Methods:

We included 1027 patients aged ≥65 years who were admitted to our Level I Trauma Center following blunt trauma. Patients’ charts were reviewed for demographics, ISS, mechanism of injury, preexisting comorbidities, Intensive Care Unit and hospital length of stay, complications, and in-hospital mortality.

Results:

The mean age of injured patients was 78.8 ± 8.3 years (range 65–109). The majority of patients had mild injury severity (ISS 9–14, 66.8%). Multiple comorbidities (≥3) were found in 233 patients (22.7%). Mortality during the hospitalization stay (n = 35, 3.4%) was associated with coronary artery disease, renal failure, dementia, and warfarin use (P < 0.05). Chronic anticoagulation treatment was recorded in 13% of patients. The addition of a single comorbidity increased the odds of wound infection to 1.29 and sepsis to 1.25. Both age and ISS increased the odds of death as −1.08 and −2.47, respectively.

Conclusions:

Our analysis shows that age alone in elderly trauma population is not a robust measure of outcome, and more valuable predictors such as injury severity, preexisting comorbidities, and medications are accounted for adverse outcome. Trauma care in this population with special considerations should be tailored to meet their specific needs.

Extremity injuries and dementia disproportionately increase the risk for long-term care at older age in an analysis of German Health Insurance routine data for the years 2006 to 2010

Background

Extremity injuries (EI) and dementia are important causes of long-term care (LTC), but they can also cause each other and are often present concurrently. Mobility-limiting EI can increase the risk of dementia, and dementia increases the risk for falls, which are often the cause of EI. When EI and dementia are present together, they can increase their negative effect on long-term care risk. This study aims to assess the strength of this interaction and the role of different body regions and severities of EI regarding LTC risk.

Methods

We use Cox proportional-hazard models on LTC as dependent variable. EI (primarily fractures) and dementia (all types) are the central independent variables. We control for age, sex, rehabilitation and 18 relevant comorbidities. Analyses are based on health claims records for 2004–2010 for a random sample of about 122.000 insurants of Germany's largest public health insurance "AOK" aged 65+, about 25.000 of whom entered LTC.

Results

Without concurrent dementia, non-severe EI (NSEI) of the lower and both extremities and all kinds of severe EI (SEI) increase LTC risk (HR: hazard ratio with 95% confidence interval. Lower NSEI: HR = 1.09 [1.05–1.14]; both NSEI: HR = 1.36 [1.29–1.44]. Lower SEI: HR = 1.67 [1.57–1.79]; upper SEI: HR = 1.27 [1.19–1.37]; both SEI: HR = 1.94 [1.81–2.07]). Dementia alone increases LTC risk more than fourfold (HR = 4.23 [4.11–4.35]).

Taking the interaction of EI and dementia into account, the concurrent presence of EI and dementia tends to increase the LTC risk more than expected for lower as well as upper NSEI and SEI. Summarily, when lower or upper EI and dementia are both present, the LTC risk tends to be higher than expected, suggesting synergistic effects.

Conclusions

EI and dementia are important independent risk factors for long-term care. When lower or upper EI and dementia are present together, the resulting long-term care risk is increased disproportionately. Since the concurrent presence of both conditions increases the risk for care need, and a working treatment for dementia is not in sight, preventing EI, lessening the impact of EI and improving the outlook after an EI could help to reduce LTC need in the coming decades.

[Elderly victims of trauma: preexisting conditions, medications taken at home and indexes of trauma]

The objective was to identify the sociodemographic profile of the elderly victims of trauma, to characterize preexisting conditions and medications taken at home, and to calculate indices of trauma and clinical outcomes. This is a retrospective and exploratory analysis from a database of a general hospital between 2008 and 2010. There were studied 131 elderly, mean age 69.9 years, 73.3% male, 55.1% married, 54.7% retired, 65.6% had preexisting conditions and 48.9% used drugs at home. There was a representative number of falls (31.3%), followed by running over (28.2%), with the head/neck region being the most affected (59.5%). Moderate trauma prevailed (44.3%), with conditions of survival after the event (80.2%). There was an association between mechanism of trauma and preexisting disease (p=0.01) and between mechanism of trauma and sex (p=0.03). The knowledge of the variables involved with the elderly victims of trauma enables healthcare professionals to plan preventive measures aimed at improving the assistance.

Describing visible acute injuries: development of a comprehensive taxonomy for research and practice

BACKGROUND

Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients.

METHODS

We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries.

RESULTS

We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility.

CONCLUSIONS

Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.

Hip fractures in the elderly-: A Clinical Anatomy Review

As elderly populations rise worldwide, the amount of hip fractures have continued to increase and result in substantial medical burdens in many countries. This increase goes hand-in-hand with an increase in surgical procedures to correct hip fractures. The medical burden imparted by hip fractures and their corrective surgeries necessitate a clinically relevant understanding of the hip joint including the vascular, neural, and musculoskeletal structures directly associated with and neighboring the joint. It is critical to appreciate how the normal hip anatomy is disrupted by a fracture and how this disruption is heavily influenced by the fracture's location. The effects of advancing age on the integrity of the hip joint and the risk of hip fractures further complicate hip anatomy. Consequentially, normal hip anatomy, aging and the pathology introduced by fractures play major roles in how hip fractures are approached surgically. This article aims to review the clinically relevant anatomy of the healthy hip joint, age-related changes that influence the joint, hip fractures, and corrective surgeries for hip fractures. Clin. Anat. 30:89-97, 2017. © 2016 Wiley Periodicals, Inc.

Early Predictors of Mortality in Geriatric Patients With Trauma

OBJECTIVE

To identify variables that predict mortality in geriatric patients with trauma.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 147 geriatric patients with trauma (age ≥65) with a predicted probability of survival of 10%-75% based on the Trauma Score-Injury Severity Score (TRISS).

MAIN OUTCOME MEASUREMENTS

Patients were divided into 2 cohorts: survivors and nonsurvivors. The following variables available at presentation were analyzed: age, mechanism of injury, temperature, systolic blood pressure, pulse rate, shock index, respiratory rate, Glasgow Coma Scale (GCS) score, base deficit, and hematocrit (HCT). The Injury Severity Score (ISS) and TRISS were calculated for both cohorts.

RESULTS

Of the 147 patients analyzed, 84 (57%) died during the index hospitalization and 63 (43%) survived. The mean age of nonsurvivors was significantly higher than that of survivors (78.6 vs. 76.1 years; P < 0.04). A greater number of nonsurvivors (72.6%) sustained injuries as a result of a low-energy mechanism compared with survivors (54%; P = 0.02). GCS, temperature, and respiratory rate were significantly lower for nonsurvivors, whereas base deficit was higher (P < 0.05). The TRISS was predictive of survival (TRISS 0.27 vs. 0.53, P < 0.001), but the distinguishing capacity of the TRISS to predict mortality was limited (area under the receiver operator curve; 0.67; 95% confidence interval 0.58-0.76; P < 0.0001).

CONCLUSIONS

Older age, lower GCS, and a low-energy mechanism of injury are associated with a higher mortality rate in this at-risk geriatric trauma population. Early identification of predictors of mortality may help care providers more accurately assess injury burden in geriatric patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.