Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group.

Abstract

Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life. Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows: Is age itself a marker of increased morbidity/mortality? If so, what age should be used? Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes? Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used? Do trauma centers have better outcomes with geriatric trauma than nontrauma centers? Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified? What resuscitation end-points should be used for the geriatric trauma patient? Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring? Unfortunately, after examining the available literature, it is clear that evidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it difficult to compare outcomes across different patient populations. Finally, much of the literature concerning geriatric trauma is relatively “old,” that is, published more than 10 years ago. Given the significant improvements in patient care that have occurred over the past 10 to 20 years, recommendations made on the basis of outcomes achieved more than 10 years ago may not be applicable to today’s geriatric trauma patient. Despite the above-mentioned shortcomings, our committee still felt that it was important to summarize the available literature and make evidence-based recommendations where satisfactory evidence did exist. In light of the seven questions raised above, two broad areas of focus emerged within this guideline: issues of geriatric trauma triage, and issues of geriatric trauma resuscitation. Although there was considerable overlap between these two areas, each issue has been addressed separately within this guideline and, accordingly, two separate “subguidelines,” each with its own recommendations, evidentiary table, and areas for future research, constitute this practice management guideline for geriatric trauma. It is hoped that the information provided within this guideline will provide evidence-based support for the difficult decisions that are required to achieve optimal outcomes in this difficult but ever-increasing patient group. TRIAGE ISSUES IN GERIATRIC TRAUMA I. Statement of the Problem The process of triage, as it relates to the geriatric trauma patient, is an attempt to provide the patient with the appropriate intensity of medical resources, taking into account the severity of illness, the cost and availability of medical resources, the prognosis for functional survival and, if known, the expressed desires of the patient. For the geriatric trauma patient, this process begins in the prehospital phase of care, where decisions must be made regarding the appropriate patient destination, trauma center versus nontrauma center. In the resuscitative phase of trauma care, triage decisions regarding patient destination must again be made, specifically, whether patient circumstances dictate provision of intensive care resources or whether standard trauma inpatient care will suffice. Throughout the hospital phase of care, the patients must be “triaged” toward or away from operative procedures, invasive and expensive critical care therapies, and powerful yet potentially dangerous pharmacologic treatment options, decisions which, again, must be made on the basis of the likelihood of achieving a good, long-term outcome for the patient. An increasingly common circumstance, particularly in the geriatric trauma patient, involves the decision to withdraw, or perhaps not even institute, an aggressive course of treatment, when the clinical circumstances are incompatible with a quality of life that all parties concerned would deem acceptable. Fundamental to all of these triage decisions is the ability to predict with reasonable accuracy what a particular patient’s outcome might be depending on which triage decision is made. To be of any value to the trauma practitioner, and ultimately to the patient and his or her family, the clinical variables on which these predictions are to be based must be easy to obtain, reliable, and available to the trauma practitioner within a relatively short period of time after injury. The task, therefore, of this particular subcommittee was to determine whether there existed adequate support in the scientific literature to develop recommendations regarding (1) appropriate criteria for triage of the geriatric trauma patient to trauma centers, (2) the clinical variables that would be useful in predicting the need for intensive care resources for the geriatric trauma patient, and (3) those clinical circumstances where a nonaggressive approach from the outset could be justified. II. Process An initial computerized search was undertaken using MEDLINE with citations published between the years 1966 and 1999. Using the search words “geriatric,” “trauma,” “elderly,” and “injury,” and by limiting the search to citations dealing with human subjects and published in the English language, well over 2,300 citations were identified. From this number were then excluded letters to the editor, case reports, reviews, and a large number of articles dealing with minor injury mechanisms, particularly hip fractures from slip-and-falls. An additional cause for exclusion of references was publication before 1975, as it was felt that the trauma care provided at this time was so different compared with current trauma care that recommendations made on the basis of data from this earlier time period would not be valid. The abstracts of the remaining citations were each reviewed, and those articles that did not address prognostic variables or other issues pertinent to the triage of the geriatric trauma patient were further excluded. This yielded a total of 32 articles that constituted the initial evidentiary table (Table 1). The bibliographies of these 32 articles were then further reviewed and an additional 13 articles meeting the above-mentioned criteria were added, for a total of 45 references within the evidentiary table. Each reference was then reviewed by three trauma surgeons, and consensus was reached regarding appropriate classification of each reference according to the Canadian and United States Preventive Task Force. Criteria for achieving a specific classification and the number of articles for each class (the total number of classified references exceeds the total number of references by one because one two-part study was classified as both a Class II and Class III reference) are shown below:Table 1: Evidentiary Table: Triage Issues in Geriatric TraumaTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: Continued Class I: Prospective randomized controlled trials—the “gold standard” of clinical trials. Some may be poorly designed, have inadequate numbers, or suffer from other methodologic inadequacies (0 references). Class II: Clinical studies in which data were collected prospectively, and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies, and case control studies (two references). Class III: Studies based on retrospectively collected data. Evidence used in this class indicates clinical series, database or registry review, large series of case reviews, and expert opinion (44 references). III. Recommendations A. Level I: There are insufficient Class I and Class II data to support any standards regarding triage of geriatric trauma patients. B. Level II: 1. Advanced patient age should lower the threshold for field triage directly to a trauma center. C. Level III: 1. All other factors being equal, advanced patient age, in and of itself, is not predictive of poor outcomes after trauma, and therefore should NOT be used as the sole criterion for denying or limiting care in this patient population. 2. The presence of PECs in elderly trauma patients adversely affects outcome. However, this effect becomes progressively less pronounced with advancing age. 3. In patients 65 years of age and older, a GCS score ≤ 8 is associated with a dismal prognosis. If substantial improvement in GCS score is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients. 4. Postinjury complications in the elderly trauma patient negatively impact survival and contribute to longer lengths of stay in survivors and nonsurvivors compared with younger trauma patients. Specific therapies designed to prevent and/or reduce the occurrence of complications (particularly iatrogenic complications) should lead to optimal outcomes in this patient population. 5. With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly trauma patient, as the majority will return home, and up to 85% will return to independent function. 6. In patients 55 years of age and older, an admission base deficit ≤ −6 is associated with a 66% mortality. Patients in this category may benefit from inpatient triage to a high-acuity nursing unit. 7. In patients 65 years of age and older, a Trauma Score < 7 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients. 8. In patients 65 years of age and older, an admission respiratory rate < 10 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients. 9. Compared with younger trauma patients, patients 55 years of age and older are at considerably increased risk for undertriage to trauma centers, even when these older patients satisfy appropriate triage criteria. The factors responsible for this phenomenon must be identified and strategies developed to counteract it. IV. Scientific Foundation Triage is the process whereby the patient’s medical needs are matched with the available medical resources. For the geriatric trauma patient, the process begins in the prehospital arena, where prehospital providers must decide on the basis of relatively scant clinical information whether a patient should bypass the local hospital in favor of a trauma center. The American College of Surgeons Committee on Trauma (ACS-COT), among other medical organizations, in its manual Resources for Optimal Care of the Injured Patient, has published a set of triage criteria to aid prehospital providers in identifying appropriate patients for direct transport to trauma centers. 1 Within this document, it is suggested that patients older than age 55 should be “considered” for direct transport to a trauma center, apparently without regard to the severity of injury. This recommendation is based on a substantial medical literature that demonstrates significantly worse outcomes for geriatric trauma patients compared with their nongeriatric counterparts. One of the earliest studies to look at the influence of age on outcome from major trauma was the Major Trauma Outcome Study, sponsored by the ACS-COT. Data from 3,833 patients aged 65 years and older were compared with those of 42,944 patients less than 65 years of age. Mortality rose sharply between age 45 and 55 and doubled at age 75 years. This age-dependent survival decrement occurred at all ISS values, for all mechanisms of injury, and for all body regions. 2 Numerous other studies have supported the findings that the effect of trauma on the elderly is more serious than that on younger patients. 3–9 Given these findings, some authors have suggested triaging elderly trauma victims to trauma centers at a much lower threshold than similarly injured younger patients, to minimize mortality and morbidity. 10 Support for this recommendation can be found in a study by Smith et al., documenting fewer complications for elderly femur fracture patients treated at trauma centers versus nontrauma centers. 11 Despite these poorer outcomes, trauma patients 55 years of age and older are frequently triaged to nontrauma hospitals even when they satisfy well-defined anatomic or physiologic criteria. Compliance with physiologic criteria appears to be especially troublesome. 12 In two unrelated studies, undertriage in patients over the age of 55 was twice that of younger patients, 12,13 and a similar study demonstrated even worse results for patients over the age of 65. 14 The factors responsible for the increased morbidity and mortality seen in geriatric trauma are not entirely clear. It has been suggested that it is not patient age per se but the high incidence of preexisting medical conditions in the geriatric patient that accounts for the difference. Others have suggested that the elderly, simply by virtue of being more frail, sustain a greater degree of injury in response to a given impact, compared with their younger counterparts. The existing medical literature was therefore reviewed in an attempt to identify clinical factors that might be used to triage geriatric trauma patients to either aggressive versus nonaggressive treatment strategies. Age and Outcome It is difficult to find consensus in the existing literature regarding the relationship between patient age and outcome. Many of the reasons for this failure have been mentioned above, and include differences in the age definition of geriatric trauma and differences in inclusion criteria for the various studies. In addition to these two factors, there is a lack of uniformity regarding the length of follow-up required to define a poor outcome. This has been variably defined as death within 24 or 48 hours of injury, death before intensive care unit (ICU) or hospital discharge, and even death/vegetative outcome at 3 or 4 years postinjury. Furthermore, there are wide variances in the statistical methods used to explore the relationship between age and outcome. Many authors have documented a statistically significant difference between the mean age of geriatric survivors compared with the mean age of geriatric non survivors, and thus have concluded that age is significantly associated with poor outcome. Other authors have applied logistic regression analysis to their data set to determine which particular factors are predictive of adverse outcomes. Given the wide variation in inclusion criteria, outcome variables, and statistical methods present within the existing literature, the conflicting results regarding age and outcome are not surprising. Certainly, the largest data set examined to date is that published by Morris et al. in 1990. These authors examined 199,737 trauma admissions, aged 15 and older, to acute care hospitals in the state of California during 1986. Using logistic regression techniques, the ISS was found to be the best predictor of mortality in trauma patients, but age, gender, and PECs were also found to be independent predictive factors of mortality. Mortality was defined as in-hospital death. The authors also found that although the mortality from minor injury (ISS < 9) begins to increase beyond the age of 65, the mortality for moderate injuries (ISS of 9–24) begins to increase at 45 years of age. 4 This increase in trauma mortality beginning at age 45 had been confirmed by other investigators as well. 2,10,15 Several authors have examined the relationship between in-hospital mortality and age, with differing conclusions. Pellicane et al. demonstrated a statistically significant difference in age between elderly nonsurvivors and elderly survivors in a series of 374 geriatric trauma patients, defined as age greater than or equal to 65 years. Five of the deaths in this series occurred in the emergency department, a subset of patients that has been excluded from the analyses in other series. Burn patients, however, were excluded from this series. 16 In a similar study performed by Osler et al., of 100 geriatric trauma patients 65 years or older, no significant difference in age was found between elderly survivors and nonsurvivors. 9 Despite the fact that patients who died before transfer to the operating room or to the ICU were excluded in the series by Osler et al., mortality in this series was more than twice that in the series by Pellicane et al. Perhaps this is explained by the lower mean TS in the series by Osler et al. relative to that of Pellicane et al. (13 vs. 15.4). The series by Pellicane et al. contains nearly four times as many patients, which raises the possibility of a type II statistical error regarding the inability of Osler et al. to demonstrate a statistical difference between the ages of geriatric trauma survivors and nonsurvivors. A large and more recent study of 448 patients, 65 years and older, used a logistic regression analysis and demonstrated age to be significantly predictive of both early (< 24 hours) and late (> 24 hours) mortality. 17 In this analysis, survival was used as the outcome variable, with “geriatric status” (age ≥ 65 years) entered into the logistic regression equation. In so doing, geriatric status was associated with a 2.46-fold increased likelihood of early mortality and a 4.64-fold increased risk of late mortality. However, an even larger study yet, consisting of 852 patients, reported by Knudson et al., using stepwise discriminant analysis, did not find age to be predictive of in-hospital death. The authors reported a 1.33-fold increased risk of death associated with age status greater than 75 years, just barely missing statistical significance with a p value of 0.06. Interestingly enough, however, the age of 75 years was entered into the discriminant analysis, not the age of 65 or greater, which was the authors’ original age definition for entrance into the study. Perhaps statistical significance would have been demonstrated had age 65 or greater been used in the discriminant analysis. 18 Two studies specifically examined the relationship between age and in-hospital mortality for geriatric trauma patients admitted to the ICU. Neither found any association between age and outcome. In a small series of 39 patients requiring intensive care unit admission and placement of pulmonary and radial artery catheters, Horst et al. reported no significant difference in age between elderly survivors and nonsurvivors. As would be expected, overall mortality (31%) was high in this intensive care population of patients older than 60 years of age. Logistic regression analysis was not performed in this study, probably because of the overall low number of patients. 19 A more recent study by Shabot and Johnson examined two subsets of geriatric trauma patients, those between the ages of 65 and 74 and those 75 years and older. Outcomes in these 99 geriatric trauma patients were then compared with 940 “younger” patients between the ages of 13 and 64, all of whom were admitted to a surgical intensive care unit (SICU). SICU mortality was then examined by comparing survivors with nonsurvivors, regardless of age. As would be expected, there was no significant difference in age between nonsurvivors and survivors (39.0 years vs. 34.8 years), likely because of the 10-fold larger number of patients seen in the younger patient group. 20 Finally, several studies have examined the relationship of age to more long-term outcomes, although no clear consensus is evident. DeMaria et al. studied a group of 82 trauma patients over the age of 65 years. Patients with penetrating injury and isolated orthopedic injury were excluded, as were patients sustaining thermal injury. Survival was defined as 6 months postinjury. Not only were nonsurvivors older, but they also demonstrated higher ISSs and more complications. On the basis of these findings, the authors developed the Geriatric Trauma Survival Score (GTSS) and then prospectively tested it on 61 patients, with 92% accuracy. Unfortunately, the GTSS, although perhaps accurate, has little triage value at the time of patient admission, as it requires information not available to the practitioner at that time. 6 Van der Sluis et al. compared early and late mortality between elderly trauma patients and elderly hip fracture patients. Early mortality was higher for the trauma patients, but survival 7 to 8 years after injury was similar between the two groups. Logistic regression analysis was used to identify predictors of late mortality, and demonstrated age to be a significant predictor. 21 Van Aalst et al., in a study of blunt geriatric injury with a mean follow-up of almost 3 years, used logistic regression analysis to demonstrate an association between poor outcome and age > 75. 5 Oreskovich et al., however, failed to demonstrate any relationship between age and outcome at 1 year after injury in a group of 100 patients age 70 and older. 22 Broos et al., in two separate publications examining 6-month outcome in trauma patients aged 65 and older, did not find age to be predictive of mortality. 23,24 Inclusion criteria for each of these three latter studies were vaguely defined, and the 18% mortality in the study by Broos et al. is inexplicably low compared with other series of similarly injured patients. 9,17,25,26 A larger study, with a more plausible mortality, was published by Battistella et al. in 1998. This study involved 279 geriatric trauma patients, which the authors defined as age greater than 75. Mean ISS in this patient group was 9.4 and associated mortality was 23%. Using logistic regression analysis, the authors found that poor outcome, defined in this study as survival less than 6 months after hospital discharge, was not predicted by patient age. 27 The issue of long-term survival and quality of life in the geriatric trauma patient is discussed more fully below. Can the age of a geriatric patient, then, be used to predict outcome after trauma? Although age appears to have some value in mortality projections for a population of geriatric trauma patients, there is certainly no literature support for a specific age above which geriatric trauma in-hospital mortality can be predicted with any degree of confidence. It has been suggested, however, that early mortality may not be the best outcome measure in geriatric trauma, because of a high percentage of poor long-term functional survival in elderly trauma patients surviving hospital discharge. 22 The preponderance of available literature, however, suggests more favorable long-term outcomes, with up to 85% of survivors functioning independently at home at follow-up intervals as long as 6 years postinjury. 5,27–31 Thus, given reasonable long-term functional outcomes for geriatric trauma patients surviving hospitalization, and the inability of patient age, by itself, to predict in-hospital mortality, advanced patient age should not be used as the sole criterion for denying or limiting care in the geriatric trauma population. Preexisting Conditions and Outcome If chronologic age, then, is not useful in predicting geriatric trauma survival, perhaps it is the patient’s physiologic age, or the nature and extent of PECs, that determines outcome. Because the frequency of PECs does increase with age, it may be difficult to separate these two factors and their relationships to adverse outcomes in geriatric trauma. Unfortunately, once again because of a wide variety of age definitions for geriatric trauma, statistical methodologies, and outcome measures, the literature addressing the prognostic value of PECs in geriatric trauma outcome is inconclusive. The largest studies, and those with the best statistical methodology, do seem to demonstrate a significant predictive capacity of PECs for adverse outcomes in geriatric trauma. Morris et al., in two separate publications in 1990, examined hospital discharge data for trauma patients in California for the year 1986. Using logistic regression analysis in both studies, Morris et al. were able to demonstrate that PECs were important predictive factors of mortality, independent of age. The effect of PECs on mortality, however, became less important in patients over the age of 65, perhaps because at this age chronologic age becomes the predominant predictor of mortality, and the added presence of PECs does little to increase trauma mortality further. 4,32 Similarly, Milzman et al., in a study of nearly 8,000 trauma patients, noted a threefold increase in trauma mortality in patients with PECs compared with those without. Once again, the effect of PECs on mortality was noted to be independent of age although, like Morris et al., these authors noted a decreasing influence of PECs on trauma mortality with advanced age. 33 A more recent study published in 1997 by Gubler et al. examined risk factors for mortality among a group of 9,424 trauma patients, aged 67 and greater, who were discharged from acute care hospitals within the state of Washington in 1987. For each trauma patient in the series, four uninjured patients, matched for age and gender, were identified from the same Health Care Financing Administration (HCFA) database. Comorbid diagnoses (PECs) were identified for each patient, and a Comorbid Diagnosis Index Score was calculated. This score is a weighted index that takes into account not only the number but also the severity of PECs. 34 Using Cox proportional hazards regression, Gubler et al. found that patients with PECs were between 2.0 and 8.4 times as likely to die within 5 years of injury compared with those without PECs, depending on the number and severity of PECs. 8 Several smaller studies, each reporting the experience of a single trauma center and using logistic regression analysis, confirmed the value of PECs as predictive factors of poor outcome in geriatric trauma, although inclusion criteria and age and outcome definitions were not uniform among these studies. 17,27,35 Other studies have refuted these findings but suffer from methodologic and statistical shortcomings that weaken their conclusions. 19,22–24,36,37 Severity-of-Injury Scoring and Outcome A number of physiologic and anatomic “scores” have been shown to correlate with geriatric outcome. These include TS, Revised Trauma Score (RTS), GCS score, Acute Physiology and Chronic Health Evaluation Score (APACHE), Acute Physiology Score (APS), Simplified Acute Physiology Score (SAPS), ISS, Maximal Abbreviated Injury Score (MAIS), and the GTSS. In addition, although not “scores” in the typica