The Geriatrician in the Trauma Service Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training 2013

Challenges of the Geriatric Trauma Patient

Challenges of the Geriatric Patient

Case fatality rates are highest in patients age 75+.

• more pre-existing conditions

• altered responses to apparently minor injuries

• atypical physiologic signs of injury

• more serious injuries for same mechanism of injury

Challenges of the Geriatric Patient

Falls is a geriatric syndrome and the leading cause of trauma in the elderly.

• the largest number of deaths is caused by fall-related

injuries

It is not just about the injury in geriatric patients.

• the Injury Severity Score (ISS) does not fully capture the potential for mortality in older adults

• the ISS does not predict discharge placement

Challenges of the Geriatric Patient

J Am Geriatr Soc 2002;50:215-222.

Specialized trauma centers may improve outcomes … but this is only a trend.

• The risk of death is lower among older patients treated

at trauma centers than among those treated at non-trauma centers.

• death in hospital RR 0.94 (0.56-1.61) • death at 365 days RR 0.92 (0.67–1.28)

Challenges of the Geriatric Patient

N Engl J Med 2006; 354:366-378.

Challenges of the Geriatric Patient

It’s complicated! COPD Aortic stenosis Hypertension Congestive heart failure Peripheral vascular disease Diabetes Depression Osteoporosis Osteoarthritis Gout Detrusor instability Glaucoma Macular degeneration

Aspirin Metoprolol Simvastatin Ramipril Spironolactone Metformin Tiotropium Citalopram Risedronate Vitamin D Calcium Allopurinol Acetaminophen

… and she lives with her husband who has dementia in a 3-level townhouse!

Challenges of the Geriatric Patient

Geriatric patients stay long enough to develop the hazards of hospitalization.

Ann Intern Med 1993;118:219-223.

Challenges of the Geriatric Patient

Geriatric patients stay long enough to lose function.

• one third of older adults develop a new disability in an ADL during hospitalization

• half of these are unable to recover function

J Am Ger Soc 1993;41:1353-60. Ann Intern Med 1993;118:219-223.

Quality Improvement Solutions:

Comprehensive Geriatric Assessment and Proactive Consultation Models

The Comprehensive Geriatric Assessment (CGA)

A comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a co-ordinated and integrated plan for management and longitudinal follow-up.

J Am Geriatr Soc 1991;39:8S-16S.

CGA is effective for inpatients.

• more likely to be “living at home” at 6 months (OR 1.25, 95% CI 1.11 to 1.42; P=0.000)

• more likely to be “living at home” at end of scheduled follow-up (OR 1.16, 95% CI 1.05 to 1.28; P=0.003)

• less likely to be institutionalized (OR 0.79, 95% CI 0.69 to 0.88, P<0.0001)

The Comprehensive Geriatric Assessment (CGA)

Cochrane Database of Systematic Reviews 2011

CGA is effective for inpatients. • less likely to suffer death or deterioration (OR 0.76,

95% CI 0.64 to 0.90; P=0.001)

• more likely to experience improved cognitive function (OR 1.11, 95% CI 0.20 to 2.01 (P=0.02)

Cochrane Database of Systematic Reviews 2011

The Comprehensive Geriatric Assessment (CGA)

Proactive Comprehensive Geriatric Assessment

Key features of proactive geriatric consultation • proactive, systematic case finding

• early involvement, within x hours of admission

• prevention of geriatric syndromes

• implementation of recommendations (writing orders)

• early attention to discharge planning

Proactive Comprehensive Geriatric Assessment

Proactive geriatric consultation improves clinical outcomes. • decreased delirium rates among hip fracture

patients1

• shorter lengths of stay in patients admitted to a hospitalist service2

• reduction in medical complications in elective

orthopedic patients3 1. J Am Geriatr Soc. 2001;49(5):516-22. 2. J Am Geriatr Soc. 2009;57(11):2139-45. 3. Age Ageing. 2007;36(2):190-6.

The Role of the Geriatrician

1. Provision of structured, medical, functional, cognitive and psychosocial evaluation to improve clinical outcomes;

2. Prevention of age-specific complications related to co-morbid disease, hazards of hospitalization, or potentially inappropriate medications; and

3. Development of recommendations to the trauma team regarding appropriate discharge planning.

The Role of the Geriatrician

Geriatric Issues Addressed

1. medication review 7. pain 2. cognition 8. nutrition 3. mood 9. decubitus ulcer 4. mobilization and falls risk 10. restraint use 5. continence 11. medical complications 6. sensory impairment 12. discharge planning

The Role of the Geriatrician

Embrace complexity. It's the kind of care older people want.

1. Patient/family preferences domain 2. Interpreting the evidence domain 3. Prognosis domain 4. Clinical feasibility domain 5. Optimizing therapies and care plans domain

J Am Geriatr Soc 2012

Geriatric Trauma Consultation Service Implementation and Evaluation

Geriatric Trauma Consultation Service Implementation

• all patients 65 years or older • CGA is completed within 72 hours of admission • standardized assessment form • recommendations are communicated in written form

(dictated transcription and written orders) and supplemented with verbal communication

• weekly attendance at interdisciplinary Trauma team rounds

• frequency and intensity of follow-up is individualized

Ann Surg 2012. 256:1098-101.

Geriatric Trauma Consultation Service Evaluation Complication Pre-GTCS (n = 238), % Post-GTCS (n = 248), % p-value

Geriatric Complications

Falls 2.0 0.8 0.72

Delirium 50.5 40.9 0.05

Physical restraint use 52.5 50.3 0.65

Other Trauma Quality Indicators

Decubitus ulcer 2.0 4.4 0.26

Deep vein thrombosis 0.0 0.5 1.00

Pulmonary embolus 3.5 3.5 0.96

Myocardial infarction 0.5 2.0 0.37

Pneumonia 14.1 18.2 0.27

Cardiac arrest 2.0 3.9 0.75

Missed injuries 7.1 8.4 0.63

Length of Stay

Overall 19.4 15.4 0.13

Discharge Destination

Nursing home 6.5 1.7 0.03

Ann Surg 2012. 256:1098-101.

Summary

The Geriatrician in the Trauma Service

• the disease burden in geriatric patients extends beyond the trauma

• geriatricians embrace complexity

• proactive geriatric consultation may decrease delirium, preserve function, and decrease institutionalization