Outcome From Serious Injury in Older Adults

Delta Shock Index and higher incidence of emergency surgery in older adults with blunt trauma

PURPOSE

Vital signs are important for predicting clinical outcomes in patients with trauma. However, their accuracy can be affected in older adults because hemodynamic changes are less obvious. This study aimed to examine the usefulness of changes in vital signs during transportation in predicting the need for hemostatic treatments in older patients with trauma.

METHODS

This retrospective cohort study was conducted using data from the Japan Trauma Data Bank (2004-2019). Patients aged ≥ 65 years who were hemodynamically stable at the scene were included in this study. The incidence of emergency surgery within 12 h after hospital arrival was compared between patients with delta Shock Index (dSI) > 0.1 and those with dSI ≤ 0.1. Predicting ability was examined after adjusting for patient demographics, comorbidities, vital signs at the scene and on hospital arrival, Injury Severity Score, and abbreviated injury scale in each region.

RESULTS

Among the 139,242 patients eligible for the study, 3,701 underwent urgent hemostatic surgery within 12 h. Patients with dSI > 0.1 showed a significantly higher incidence of emergency surgery than those with dSI ≤ 0.1 (871/16,549 [5.3%] vs. 2,830/84,250 [3.4%]; odds ratio (OR), 1.60 [1.48-1.73]; adjusted OR, 1.22 [1.08-1.38]; p = 0.001). The relationship between high dSI and a higher incidence of intervention was observed in patients with hypertension and those with decreased consciousness on arrival.

CONCLUSION

High dSI > 0.1 was significantly associated with a higher incidence of urgent hemostatic surgery in older patients.

Health Conditions in Older Adults Suspected of Being Maltreated: A 20-Year Real-World Study

Older adult maltreatment (OAM) is a global problem that has attracted increasing attention due to the ageing population and its severe impact on victim health. Thus, this study aims to analyse the prevalence of certain health conditions in people ≥ 60 years old whom physicians from a local healthcare unit suspected to be victims of maltreatment. The specific objectives are to determine the prevalence rates of health-related risk factors, traumatic injuries and intoxications, mental disorders, and physical disorders. We conducted a real-world, retrospective, observational, and cross-sectional study based on secondary data analyses of electronic health records and healthcare registers of patients at the Local Healthcare Unit of Matosinhos (2001-2021). Information was obtained based on codes from the International Classification of Diseases, codes from the International Classification of Primary Care, and clinical notes (according to previously defined keywords). We identified 3092 suspected victims of OAM, representing 4.5% of the total population analysed. This prevalence is lower than the known rates. We also found that some health risk factors, traumatic injuries and intoxications, mental health disorders, and physical disorders presented higher rates in the suspected victims than among the total population. In this age group, we cannot assume that these health problems are only related to a possible current victimisation process; they could also be associated with adverse childhood experiences or intimate partner violence, among other forms of violence, all of which can lead to cumulative effects on the victim's health. This evidence increases healthcare providers' responsibility in detecting and reporting all cases of suspected maltreatment.

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.

Improving Post-Injury Care: Key Family Caregiver Perspectives of Critical Illness After Injury

There is little research about how caregiver experiences evolve from ICU admission to patient recovery, especially among caregivers for patients who have traumatic injuries. In this study, we characterize diverse caregiver experiences during and after ICU admission for injury.

Impact of aging on the immune response to traumatic brain injury (AIm:TBI) study protocol

BACKGROUND

Traumatic brain injury (TBI) in older adults leads to considerable morbidity and mortality. Outcomes among older adults with TBI are disparately worse than in younger adults. Differences in immunological response to injury may account for at least some of this disparity. Understanding how ageing differentially affects the immune response to TBI and how older age and these immunological changes affect the natural history of recovery following TBI are the goals of this study.

DESIGN/METHODS

A prospective multiple cohort design is being used to assess the effects of ageing and TBI on immune makers and to test predictors of impairment and disability in older adults following mild TBI. Older adults (>55 years) with mild TBI are enrolled with three comparison groups: younger adults (21-54 years) with mild TBI, non-injured older adults (>55 years) and non-injured young adults (21-54 years). For the primary analysis, we will assess the association between immune markers and Glasgow Outcome Scale-Extended at 6 months, using logistic regression. Predictors of interest will be inflammatory biomarkers. Multivariate linear regression will be used to evaluate associations between biomarkers and other outcomes (symptoms, function and quality of life) at 3 and 6 months. Exploratory analyses will investigate the utility of biomarkers to predict outcome using receiver-operating characteristic curves.

DISCUSSION

A better understanding of the recovery trajectory and biological rationale for disparate outcomes following TBI in older adults could allow for development of specific interventions aimed at reducing or eliminating symptoms. Such interventions could reduce impairment and healthcare costs.

Mental health history-a contributing factor for poorer outcomes in burn survivors

Background

A pre-morbid mental health history is common in patients with severe burn injuries. This creates challenges in providing rehabilitation. The aim of this study is to cross examine the possible impact of psychological co-morbidities on outcomes.

Methods

A notes audit was carried out examining patients that were admitted to Concord Hospital Burns Unit in a 3-year period (2010-2012). Patients with total body surface area (TBSA) of 20% or greater and aged between 16 and 50 years were included. Subjects were divided into a mental health group and a control group. SPSS version 21 statistic program was used for analysis the data.

Results

Data collected included length of stay, time to achieve independence, %TBSA, types of burns and surgery required. Results of 69 files showed that the average length of stay per %TBSA was nearly double in the patients with a mental health problem (1.47 vs 0.88). They also had a higher rate of re-graft (52% vs 22%) due to infection and poor nutrition. The average time for patients to achieve independence in daily living activity was significantly higher (p = 0.046) in the mental health group (36.2 days) versus the control group (24.1 days).

Conclusion

Patients with a mental health history may have poorer general health. This may result in a higher failure rate of grafting, leading to a requirement of re-graft. Hence, it took a longer time to achieve independence, as well as a longer hospital stay. A mental health history in burn survivors can be a contributing factor for poorer outcomes in the adult population.

Contributory Factors to critically wrong road-crossing judgements among older people: an integrated research study

Introduction

Older people are having higher risk of vehicle-pedestrian collisions. This study examines the relative importance of different environmental, physical and cognitive factors in contributing to critically wrong road-crossing judgements.

Methods

An integrated research design is adopted. Older pedestrians were recruited through Elderly Community Centres in Hong Kong. Data about their physical and cognitive ability were collected through setting up outreach laboratories within the participants' neighbourhood communities. In addition to obtaining two walking speeds, three clinical tests (the visual acuity test, Timed Up and Go test and Mini Mental State Examination [MMSE] test) were conducted. A questionnaire survey collected personal information and activity data. Eighteen different road-crossing scenarios showing the same dual-lane one-way local road with different traffic conditions (a vehicle approaching at different distances, at different speeds, and on different lanes) were captured in videos and presented to the participants. Their decision time and judgement for each scenario were recorded in a computer. Apart from descriptive statistics, a binary logistic generalised estimating equation model was estimated. The dependent variable is whether a road-crossing judgement was critically wrong or not.

Results and Conclusions

A total of 7,182 road-crossing judgements of 399 older people were collected. The most statistically significant factors contributing to critically wrong road-crossing judgements are the road environment variables of the speed and distance of the oncoming vehicle. On physical variables, walking speed is the most important factor. Lastly, the cognitive variable of MMSE score is significant. For the mild and moderate impairment groups, the chances of making a critically wrong judgement are 1.83 and 2.01 times that of the normal group respectively.

Elderly trauma

Across the world, the population is aging. Adults 65 years and older make up one of the fastest growing segments of the US population. Trauma is a disease process that affects all age groups. The mortality and morbidity that result from an injury can be influenced by many factors including age, physical condition, and comorbidities. The management of the elderly trauma patient can present some unique challenges. This paper addresses the differences that occur in the management of elderly patient who has been injured. This paper also includes a discussion of how to prevent injury in the elderly.

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

BACKGROUND

Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.

OBJECTIVE

Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.

DATA SOURCES

We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.

RESULTS

From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.

CONCLUSIONS/IMPLICATIONS

This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

Foot burns and diabetes: a retrospective study

BACKGROUND

Diabetes in conjunction with a foot burn can compound the challenges in wound healing; however, the impact of diabetes on outcomes of patients with foot burns has not been examined.

METHODS

A retrospective notes audit was conducted at the Concord Hospital Burns Unit for patients with foot burns who were admitted from 1(st) January 2012 to 31(st) December 2013. Data were collected for 15 subjects with foot burns and diabetes and 18 subjects with foot burns and no diabetes as a control group. Subjects were matched for percentage total body surface area of burns.

RESULTS

The mean inpatient and total lengths of stay for the diabetic group were 21.27 days and 64.80 days, which were significantly longer (P = 0.090 and P = 0.054) than the 9.61 days and 30.56 days in the control, based on a significance level of 0.10. The diabetic group was significantly older (P = 0.001), at 56.60 years versus 39.44 years in the control. Significantly (P = 0.033) more patients with diabetes were not working (n = 12/15 or 80.00 % versus n = 7/18 or 38.89 %) compared to the control. The diabetic group had higher rates of regrafting (n = 3/15 or 20.00 % versus n = 1/18 or 5.55 %) than the control and significantly (P = 0.013) more amputations (n = 5/15 or 33.33 % versus n = 0 or 0.00 %) compared to the control. Fewer patients with diabetes were prescribed pressure garments (n = 2/15 or 13.33 % versus n = 9/18 or 50.00 %), which was significant (P = 0.034). The increased age of patients in the diabetic group correlates with results from other studies. Healing time may be reflected by total length of stay, which was more than double for patients with diabetes, increasing demand and cost of inpatient and outpatient services.

CONCLUSION

This study highlights the importance of recognizing the potential for poorer outcomes for patients with diabetes and indicates the need for more burn prevention education and promotion in this 'at risk' patient group.

Physical Resilience in Older Adults: Systematic Review and Development of an Emerging Construct

BACKGROUND

Resilience has been described in the psychosocial literature as the capacity to maintain or regain well-being during or after adversity. Physical resilience is a newer concept that is highly relevant to successful aging. Our objective was to characterize the emerging construct of resilience as it pertains to physical health in older adults, and to identify gaps and opportunities to advance research in this area.

METHODS

We conducted a systematic review to identify English language papers published through January 2015 that apply the term "resilience" in relation to physical health in older adults. We applied a modified framework analysis to characterize themes in implicit or explicit definitions of physical resilience.

RESULTS

Of 1,078 abstracts identified, 49 articles met criteria for inclusion. Sixteen were letters or concept papers, and only one was an intervention study. Definitions of physical resilience spanned cellular to whole-person levels, incorporated many outcome measures, and represented three conceptual themes: resilience as a trait, trajectory, or characteristic/capacity.

CONCLUSIONS

Current biomedical literature lacks consensus on how to define and measure physical resilience. We propose a working definition of physical resilience at the whole person level: a characteristic which determines one's ability to resist or recover from functional decline following health stressor(s). We present a conceptual framework that encompasses the related construct of physiologic reserve. We discuss gaps and opportunities in measurement, interactions across contributors to physical resilience, and points of intervention.

High-energy skeletal trauma in the elderly

Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.

Mild Traumatic Brain Injury among the Geriatric Population

Mild traumatic brain injury (TBI) is an unfortunately common occurrence in the elderly. With the growing population of older adults in the United States and globally, strategies that reduce the risk of becoming injured need to be developed, and diagnostic tools and treatments that may benefit this group need to be explored. Particular attention needs to be given to polypharmacy, drug interactions, the use of anticoagulants, safety issues in the living environment, elder abuse, and alcohol consumption. Low-mechanism falls should prompt health care providers to consider the possibility of head injury in elderly patients. Early and tailored management of our seniors following a mild TBI can provide them with the best possible quality of life. This review will discuss the current literature on mild TBI in the older adult, address gaps in research, and discuss the implications for future care of the older TBI patient.

Descriptive epidemiology of serious work-related injuries in British Columbia, Canada

Objective

This study examined the rates and distribution of serious work-related injuries by demographic, work and injury characteristics in British Columbia, Canada from 2002–2008, using population-based data.

Methods

Claims for workers with a serious injury were extracted from workers’ compensation data. Serious injuries were defined by long duration, high cost, serious medical diagnosis, or fatality. Workforce estimates were used to calculate stratum-specific rates. Rate-ratios (RR) and 95% CIs were calculated using negative binomial regression for the comparison of rates, adjusting for gender, age and occupation.

Results

Women had a lower overall serious injury rate compared to men (RR: 0.93, 95% CI: 0.87–0.99). The 35–44 age group had the highest overall rate compared to the youngest age group. The rate for severe strains/sprains was similarly high for men and women in the 35–44 age group, although there was a differential pattern by gender for other injury types: the rate of fracture was similar across age groups for men, but increased with age for women (RR: 2.7, 95% CI: 2.2–3.3); and the rate of severe falls increased with age for men and women, with a larger three-fold increase for older women (men: RR: 1.8, 95% CI: 1.7–2.1; women: RR: 3.2, 95% CI: 2.7–3.7).

Conclusions

The risk of serious injuries is higher among specific age groups with different patterns emerging for men and women. Variations persisted within similar injury types and occupation groups in our adjusted models. These results provide evidence for the burden of serious injuries and a basis for future analytic research. Given projected demographic shifts and increasing workforce participation of older workers, intervention programs should be carefully implemented with consideration to demographic groups at risk for serious injuries in the workplace.

Utilization and costs of health care after geriatric traumatic brain injury

Despite the growing number of older adults experiencing traumatic brain injury (TBI), little information exists regarding their utilization and cost of health care services. Identifying patterns in the type of care received and determining their costs is an important first step toward understanding the return on investment and potential areas for improvement. We performed a health care utilization and cost analysis using the National Study on the Costs and Outcomes of Trauma (NSCOT) dataset. Subjects were persons 55-84 years of age with TBI treated in 69 U.S. hospitals located in 14 states (n=414, weighted n=1038). Health outcomes, health care utilization, and 1-year costs of care following TBI in 2005 U.S. dollars were estimated from hospital bills, patient surveys, medical records, and Medicare claims data. The subjects were further analyzed in three subgroups (55-64, 65-74, and 75-84 years of age). Unadjusted cost models were built, followed by a second set of models adjusting for demographic and pre-injury health status. Those in the oldest category (75-84 years) had significantly higher numbers of re-hospitalizations, home health care visits, and hours per week of unpaid care, and significantly lower numbers of physician and mental health professional visits than younger age groups (age 55-64 and 65-74 years). Significant age-related differences were seen in all health outcomes tested at 12 months post-injury except for incidence of depressive symptoms. One-year total treatment costs did not differ significantly across age categories for brain-injured older adults in either the unadjusted or adjusted models. The unadjusted total mean 1-year cost of care was $77,872 in persons aged 55-64 years, $76,903 in persons aged 65-74 years, and $72,733 in persons aged 75-84 years. There were significant differences in cost drivers among the age groups. In the unadjusted model index hospitalization costs and inpatient rehabilitation costs were significantly lower in the oldest age category, while outpatient care costs and nursing home stays were lower in the younger age categories. In the adjusted model, in addition to these cost drivers, re-hospitalization costs were significantly higher among those 75-84 years of age, and receipt of informal care from friends and family was significantly different, being lowest among those aged 65-74 years, and highest among those aged 75-84 years. Identifying variations in care that these patients are receiving and determining the costs versus benefits is an important next step in understanding potential areas for improvement.

Age-related mitochondrial changes after traumatic brain injury

Mitochondrial dysfunction is known to occur following traumatic brain injury (TBI) and has been well characterized. This study assessed possible age-related changes in the cortical mitochondrial bioenergetics following TBI. Three hours following a moderate TBI, tissue from the ipsilateral hemisphere (site of impact and penumbra) and the corresponding contralateral region were harvested from young (3- to 5-month-old) and aged (22- to 24-month-old) Fischer 344 rats. Synaptic and extrasynaptic mitochondria were isolated using a Ficoll gradient, and several bioenergetic parameters were examined using a Clark-type electrode. Injury-related respiration deficits were observed in both young and aged rats. Synaptic mitochondria showed an age-related decline in the rate of ATP production, and a decline in respiratory control ratios (RCR), which were not apparent in the extrasynaptic fraction. Following respiration analysis, mitochondrial samples were probed for oxidative damage (3-nitrotyrosine [3-NT], 4-hydroxynonenal [4-HNE], and protein carbonyls [PC]). All markers of oxidative damage were elevated with injury and age in the synaptic fraction, but only with injury in the extrasynaptic fraction. Synaptic mitochondria displayed the highest levels of oxidative damage and may contribute to the synaptic bioenergetic deficits seen following injury. Data indicate that cortical synaptic mitochondria appear to have an increased susceptibility to perturbation with age, suggesting that the increased mitochondrial dysfunction observed following injury may impede recovery in aged animals.

Older people and major trauma

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients.

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.

Human fatalities resulting from dog attacks in the United States, 1979-2005

INTRODUCTION

Dog attacks are a major public health concern worldwide. Dogs bite over 4 million people resulting in the hospitalization of 6000 to 13,000 people each year in the United States. Rarely deaths may occur after an attack.

METHODS

This study utilized the compressed mortality files from CDC WONDER to evaluate deaths from dog attacks over the 27-year period 1979-2005.

RESULTS

An average of approximately 19 deaths was reported annually from dog attacks during this time period. Males and children less than 10 years of age had the highest rate of death from dog attacks. Deaths have been reported in 49 states with Alaska reporting the highest death rate from dog attacks. The number of deaths and death rate from dog attacks appear to be increasing.

CONCLUSIONS

Deaths from dog attacks appear to be increasing as the population of both humans and dogs has increased during this time period. Children have the greatest risk of death. There is a need for a national reporting system on dog bites to fully capture the extent of fatalities and look at risk factors surrounding the attack. The development of effective prevention practices is dependent upon examination of these risk factors.

Pedestrian injuries in an ageing society: insights from hospital trauma registry

BACKGROUND

Traffic safety of the elderly is a growing public health issue.

METHODS

This study makes use of a linked hospital and police database. A total of 4,290 traffic casualty records were analyzed. The proportions of serious injury and mortality for different age groups are compared between pedestrian and nonpedestrian injuries. Logistic regression analysis is used to examine the relative significance of age, injury pattern, gender, crash time, and vehicle type on each dependent variable of hospital stay > or = 7 days, injury severity score (ISS) > 15, ISS > 30, and mortality.

RESULTS

The shares of pedestrian casualties with serious injury increased with higher age groups. Among pedestrian casualties, aged > or = 65 years was the only statistically significant variable in accounting for ISS > 30 and mortality. Aged > or = 65 years, lower extremity injury and heavy vehicles were important in accounting for long hospital stay. For ISS > 15, aged > or = 65 years, head or face injury, and thorax or abdomen injury were significant risk factors. After adjusting for confounding factors, the risk of hospital stay > or = 7 days, ISS > 15, ISS > 30, and mortality for an elderly pedestrian injury was 4.24 times (95% CI, 2.46-7.29), 2.77 times (95% CI, 1.17-6.55), 5.16 times (95% CI, 1.38-19.34), and 3.61 times (95% CI, 1.16-11.25) higher than a younger adult (aged 15-64 years). In contrast, age was not a significant independent risk factor for serious injury and mortality among nonpedestrian injuries.

CONCLUSIONS

Most developed economies are facing the problem of ageing. To develop an effective strategy to deal with elderly pedestrian trauma, a good quality linked database is a prerequisite.

Evaluation of the effect of intensity of care on mortality after traumatic brain injury

OBJECTIVES

To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity.

DESIGN

Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients.

SETTING AND PATIENTS

A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25-84 yrs with a diagnosis of traumatic brain injury.

MEASUREMENTS

Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy.

MAIN RESULTS

Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75-84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0).

CONCLUSIONS

There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.