Outcome in the Injured Elderly: Where Do We Go From Here?

Global burden of road traffic accidents in older adults: A systematic review and meta-regression analysis

PURPOSE OF THE STUDY

This study aims to estimate the burden of road traffic accidents and death among older adults.

DESIGN AND METHODS

A systematic literature review was conducted on 10 electronic databases for articles describing Road Traffic Accident(RTA) mortality in older adults until September 2016. A random-effects meta-regression analyses was conducted to estimate the pooled rates of road traffic accidents and death.

RESULTS

A total 5018 studies were identified and 23 studies were included. Most of the reported older adults were aged between 60 and 74 years, with majority being male gender and sustained minor trauma due to Motor-Vehicle Collision (MVC). The overall pooled mortality rate was 14% (95% Confidence Interval, CI: 11%, 16%), with higher mortality rates in studies conducted in North America (15%, 95% CI: 12%, 18%) and older adults admitted to trauma centers (17%, 95% CI: 14%, 21%). Secondary analysis showed that the very elderly adults (aged >75years) and pedestrians had higher odds of mortality death (Odds Ratio, OR: 2.05, 95% CI: 1.25, 3.38; OR: 2.08, 95% CI: 1.63, 2.66, respectively).

IMPLICATION

A new comprehensive trauma management guidelines tailored to older adults should be established in low and middle-income countries where such guidelines are still lacking.

Prognosis and health-related quality of life in elderly patients after a mild to moderate trauma

The aims of this study were to compare outcome after a mild to moderate trauma in three subgroups of patients of increasing age (A1: <50, A2: 50-74, A3: >74 years) and to assess potential health-related quality of life (HRQOL) impairment. This is a follow-up study of a cohort of 418 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University Hospital of Florence from July 2008 to February 2012. Six months after the event, a telephone interview using the Physical component summary (PCS) and Mental component summary (MCS) Health Composite Score (SF12) was conducted. Patients reported their QOL both at present and before trauma. In-hospital mortality was 10 of 418 (2.3 %); overall mortality was 27 of 244 (11 %) patients found at follow-up. No death was observed among A1 patients; overall mortality was (6/76) 7 % in A2 and (21/71) 30 % in A3 patients (p < 0.05 A1 vs A2, A1 vs A3 and A2 vs A3). Before the event, respectively, 94 and 96 % patients reported a normal MCS and PCS score (>39); after the event, the proportion of patients with a normal score value was significantly lower (MCS 70 %, p = 0.002; PCS 58 %, p < 0.0001). All subgroups showed a highly significant reduction in the scores' value due to the trauma. After the event, the proportion of patients with normal scores was significantly lower (all p < 0.0001, except for MCS score in A1 subgroup, who showed p = 0.013) within all subgroups. Elderly patients' prognosis was significantly worse compared with the younger counterpart; despite young patients' optimal outcome, HRQOL was uniformly reduced across all age groups.

Missed opportunities: under-detection of trauma in elderly adults involved in motor vehicle crashes

INTRODUCTION

Geriatric trauma, mainly as a result of motor vehicle crashes (MVCs), has been a persistent and serious problem for those older than 65 years of age. Because of physiological changes and pre-existing disease, older adults present a unique clinical challenge to emergency nurses and staff. "Are older adults involved in MVCs appropriately assessed and treated?"

METHODS

A review of the research literature, including 17 articles from 2003 to 2009, on the topic of geriatric trauma, specifically trauma that resulted from MVCs will be explored.

RESULTS

Four different areas were discussed: (1) the under-detection of geriatric trauma, (2) prehospital triage guidelines, (3)the injury severity score, and (4) common resultant injuries encountered by older adults.

DISCUSSION

Understanding specific patterns of injury in older adults and the geriatric trauma outcomes data is essential to emergency nursing practice. Following this literature review, the emergency nurse will be more comfortable managing the next geriatric patient arriving in the emergency department.

Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level I trauma centers

OBJECTIVE

To compare mortality in elderly trauma patients sustaining fall or motor vehicle collision (MVC) related injuries and who are subsequently treated at regional Level I (tertiary) trauma centers.

SUMMARY BACKGROUND DATA

An increase in the mean age of the Canadian population is leading to a higher proportion of older patients injured in falls who are subsequently treated at Level 1 trauma centers in Quebec. The Level 1 centers were designed to treat younger patients injured in MVCs and violent acts. As a result, discordance may exist between the type of care supplied at these centers and the increased demand for care tailored to older trauma patients.

METHODS

A retrospective cohort study comprised of 4,717 patients over the age of 65; 606 (12.8%) injured in MVCs and 4,111 (87.2%) in falls. The mean (SD) age was 79.6 (8.0) years and 67.9% were female. The mean (SD) Injury Severity Score (ISS) was 10.8 (7.4). Data were obtained from the Quebec Trauma Registry (QTR) for patients treated at 3 Level I trauma centers in the province of Quebec, Canada. The primary outcome measure in this study was mortality.

RESULTS

Being injured in a fall was a strong predictor for mortality, with an odds ratio of 5.11 (95% C.I. = 1.84-14.17, P = 0.002). Additionally, the adjusted mortality rate was 25.3% among fall victims, versus 7.8% for MVC patients. Female gender, older age, higher ISS and an increasing number of injuries were all associated with heightened mortality. In contrast, the number of body regions injured, experiencing complications, sustaining a hip fracture, the Revised Trauma Score, the Prehospital Index and the Charlson (comorbidity) Index had no association with mortality in the Level I centers.

CONCLUSIONS

Elderly patients sustaining fall-related injuries and treated at Level I trauma centers are at risk for excess mortality when compared with those injured in MVCs. Effective and efficient methods for treating this population must be determined.

Increasing the profile of the care of the older person in the ED: a contemporary nursing challenge

The numbers of frail older persons using emergency departments are already considerable and will continue to increase over time. There are a number of issues related to the assessment and care of older patients that are significantly different to other patient groups. The traditional emergency department (ED) model focusing on rapid triage, treatment and throughput does not meet the needs of many older patients, who have complex presentations, and require comprehensive assessment and referral. In response to this, there are already a number of appropriate and innovative approaches to the care of the older patient demonstrated in the literature. Nurses have a crucial role in contributing to these approaches and in raising the profile of quality care of the older person. Some specific areas that ED nurses can focus on include a more comprehensive approach to assessment and discharge planning, improved communication with the patient and their personal carers, attention to basic nursing care, and making the physical environment safer and less stressful for the older patient. While developing collaborations with their aged care nursing colleagues is important, emergency nurses need to view care of the older person as a central part of their own core business.