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2019-3 Geriatric Trauma Prevention

Background

 

Geriatric trauma represents the relative influence of injury as an external stressor on the aging body culminating in falls and other injuries that present at trauma systems across the United States (US) (1). As the population ages, and increasing numbers of older adults are living longer, health care providers and hospitals are challenged to address geriatric trauma and associated issues (1). In 2015, costs of fatal and non-fatal falls exceeded $600 million and $30 billion respectively (2). Stakeholders for geriatric trauma include: pre-hospital providers, hospitals, post-acute care facilities, professional organizations, family and in-home caregivers, and the public-at-large. Geriatric trauma imposes a significant financial cost to patients and healthcare systems, and social/emotional implications for patients and families.

 

High Incidence of Trauma Among Older Persons

 

Within U.S. hospitals, falls have overtaken all other mechanisms as the leading cause of injury (3). Over 800,000 adults age 65 and older are admitted to hospitals annually for a fall, almost 3 million are treated in emergency departments and released, while another 29 million fall but never seek medical attention (8). As humans age, the body experiences a slow and gradual loss of the ability to generate energy to sustain itself, characterized by functional decline and other age-related chronic conditions (4). Geriatric trauma encompasses the confluence of aging-related decline, including risk of injury, and the physiologic response to maintain homeostasis during and after injury (1). Frailty is a state of vulnerability to internal and external stressors, caused by biological changes at cellular and subcellular levels that often leads to falls and increasing complexity recovering from illness or injury (5,6). Among geriatric trauma patients, frailty is a primary predictor of poor outcomes, including admission to skilled nursing facilities, functional decline, and mortality up to 1-year post-injury (7,8). Progressive loss of strength and energy contributes to incompetence of the axial skeleton, osteoporosis, stress fractures, and a declining ability to recover from injury (1). In 2016 29,668 adults died as a result of a fall (9). Family caregivers are often the mainstay of support for older adults with chronic, disabling conditions, yet their needs for recognition, information and support frequently go unnoticed and unacknowledged.

 

Injury prevention for older adults must be aimed at all levels of prevention, including primary, secondary and tertiary. Primary prevention averts injury before it occurs and is paramount to avoid the trajectory of rapid decline that often accompanies geriatric trauma. Secondary prevention reduces the impact of injury after it has occurred; few studies address specific interventions aimed at secondary prevention. Tertiary prevention acknowledges the impact of injury and aims to improve health span, quality of life, and readiness for end-of-life.

 

ATS believes that injury prevention for older adults is crucial and Trauma Centers should adopt some or all of the following measures in each of the following categories: 

 

Primary Prevention

  • Use trauma registry, emergency department, public health and other local injury surveillance data sources to collect fall demography data to enhance injury prevention efforts by identifying high-risk geographic areas and geriatric population cohorts (10).
  • Conduct annual frailty screening and fall risk assessments using evidence-based tools as initial steps toward effective fall prevention (11). Screening should include the predominant risk factors: maternal history of a hip fracture gait and balance instability, self-reported falls, previous fracture, low body weight, and self-report of fair or poor health (12, 13).
  • Encourage the use of evidence-based programs and multi-factorial interventions focused on strength, balance, flexibility, and endurance. (e.g., A Matter of Balance, Stepping On, Silver Sneakers, Stay Active and Independent for Life (SAIL), Tai Ji Quan: Moving for Better Balance, and Healthy Steps for Older Adults) for older adults to reduce the incidence of falls (14).
  • Driving Safety programs to optimize older drivers’ safety and to promote continuous safe driving (15).
  • Recommend the National Council of Aging (NCOA) as an important resource for identifying effective community-based programs (14).
  • Provide proven fall prevention strategies including:
    • Routine risk assessment
    • Review and modification of medications
    • Home hazard screening and modification
    • Vitamin D supplementation

Secondary Prevention

  • Teach and use effective communication and decision aids (e.g., https://www.ncoa.org/center-for-healthy-aging/falls-resource-center/falls-prevention-tools-and-resources/falls-prevention-older-adults-caregivers/) for older adults to improve knowledge, increase risk perception, decrease decisional conflict, and enhance participation in health care decision-making (16,17).
  • Ongoing frailty screening and fall risk assessment (11,12,13) with referral to specialists (vision, hearing) as appropriate.
  • Medication review during in-patient phase.
  • Individualized discharge planning, inclusive of recommendations to prevent repeat falls through utilization of community resources (i.e., physical therapy, strength and balance training, nutrition, social services, home safety inspection).
  • Include the care of frail, complex, and severely ill older adults (18) in efforts to train providers in geriatric-focused content.
  • Increase public awareness and remind patients and family caregivers that frailty and dying are normal final stages of life (19-21).

Tertiary Prevention

  • Encourage trauma-specific programs such as GEMS (22) and G-60 (23) which are aimed at optimizing recovery of older adults after injury using aggressive team-based approaches.
  • Provide support for family caregivers of older adults directly or by making referrals from the local community. Support should include assessing needs and providing services that will minimize health, economic and social challenges of the family caregivers (24).
  • Strive to reach the goal of reducing falls in older adults by 25% nationally.
  • Support future research targeted towards developing, testing, and implementing innovative caregiver support strategies (25).

Download a PDF of this position statement.

 

References

  1. Cooper Z, Maxwell CA, Fakhry SM, et al. A position paper: The convergence of aging and injury and the need for a Geriatric Trauma Coalition (GeriTraC). Journal of Trauma and Acute Care Surgery. 2017;82(2):419-422.
  2. Burns, ER, Stevens, JA, Lee, R. The direct cost of fatal and non-fatal falls among older adults – United States. Journal of Safety Research. 2016; 58:99-103.
  3. American College of Surgeons. National Trauma Data Bank 2016 Annual Report. 2016. Retrieved 18 February 2019 at https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20annual%20report%202016.ashx.
  4. Maxwell CA, Wang J. Understanding Frailty: A Nurse’s Guide. Nursing Clinics of North America. 2017;52(3):349-361.
  5. Clegg A, Young J. The frailty syndrome. Clinical medicine: Journal of the Royal College of Physicians of London. 2011;11(1):72-75.
  6. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. Journal of the American Medical Directors Association. 2013;14(6):392-397.
  7. Joseph B, Pandit V, Zangbar B, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis. JAMA Surgery. 2014;149(8):766-772.
  8. Maxwell CA, Mion LC, Mukherjee K, et al. Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival. Journal of Trauma and Acute Care Surgery. 2016;80(2):195-203.
  9. Centers for Disease Control and Prevention. Deaths from Falls Among Persons Aged ≥65 Years   — United States, 2007–2016.  Retrieved 8 April 2020 at https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a1.htm?s_cid=mm6718a1_w.
  10. Yiannakoulias N, Rowe BH, Svenson LW, Schopflocher DP, Kelly K, Voaklander DC. Zones of prevention: the geography of fall injuries in the elderly. Social Science & Medicine. 2003;57(11):2065-2073.
  11. Panel on Prevention of Falls in Older Persons. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society. 2011;59(1):148-157.
  12. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US preventive services task force. JAMA. 2018;319(16):1705-1716.
  13. Kruschke C. Fall Prevention for Older Adults. Journal of Gerontological Nursing. 2017;43(11):15-21.
  14. Aging NCOA. Find an Evidence-based Fall Prevention Program in Your Area. 2019. Retrieved 24 March 2019 at https://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-awareness-day/how-to-get-involved/find-evidence-based-falls-program-area/.
  15. Gagnon, S, Stinchcombe, A, Curtis, M, et al. Driving safety improves after individualized training: An RCT involving older drivers in an urban area.Traffic Injury Prevention. 2019; 20(6), 595-600.
  16. Van Weert JC, Van Munster BC, Sanders R, Spijker R, Hooft L, Jansen J. Decision aids to help older people make health decisions: A systematic review and meta-analysis. BMC Medical Informatics and Decision Making. 2016;16(1):45.
  17. Oczkowski SJ, Chung H-O, Hanvey L, Mbuagbaw L, You JJ. Communication tools for end-of-life decision-making in ambulatory care settings: A systematic review and meta-analysis. PloS one. 2016;11(4):e0150671.
  18. Callahan KE, Tumosa N, Leipzig RM. Big ‘G’and little ‘g’ Geriatrics education for physicians. Journal of the American Geriatric Society. 2017;65(10):2313-2317.
  19. Oliver D. “Progressive dwindling,” frailty, and realistic expectations. British Medical Journal. 2017;358:j3954.
  20. Gawande A. Being Mortal: Medicine and What Matters in the End. 1st ed. New York, NY: Metropolitan Books; 2014.
  21. Meier DE. The way we die now. Democracy Journal 2015(36). Retrieved 3 October 2019 at http://www.democracyjournal.org/36/the-way-we-die-now.php.
  22. Shah MN, Rajasekaran K, Sheahan III WD, Wimbush T, Karuza J. The effect of the geriatrics education for emergency medical services training program in a rural community. Journal of the American Geriatrics Society. 2008;56(6):1134-1139.
  23. Bukur M, Simon J, Catino J, Crawford M, Puente I, Habib F. The  American Surgeon. The G60 Trauma Center: A Future Consideration? 2017;83(6):547-553.
  24. Houry D, Florence C, Baldwin G, Stevens J, McClure RJ. The CDC injury center’s response to the growing public health problem of falls among older adults. American Journal of Lifestyle Medicine. 2016;10(1):74-77.
  25. Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine; Schulz R, Eden J, editors. Washington (DC): National Academies Press (US); 2016 Nov 8. Retrieved 3 October 2019 at  http://www.nationalacademies.org/hmd/Reports/2016/families-caring-for-an-aging-america.aspx.
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