The growing challenge of major trauma in older people: a role for Comprehensive geriatric Assessment?

Abstract

In this commentary article, we describe the impact that an ageing population is having on the nature of major trauma seen in emergency departments. The proportion of major trauma victims who are older people is rapidly increasing and a fall from standing is now the most common mechanism of injury in major trauma. Potential barriers to effective care of this patient group are highlighted, including: a lack of consensus regarding triage criteria; potentially misleading physiological parameters within triage criteria; non-linear patient presentations and diagnostic nihilism. We argue that the complex ongoing care and rehabilitation needs of older patients with major trauma may be best met through Comprehensive Geriatric Assessment (CGA). Furthermore, the use of frailty screening tools may facilitate more informed early decision-making in relation to treatment interventions in older trauma victims. We call for geriatric medicine and emergency medicine departments to collaborate—equipping urgent care staff with the basic competencies necessary to initiate CGA should be a priority, and geriatricians have a key role to play in delivery of such educational interventions.

The evolving nature of major trauma

The population is rapidly ageing and as a consequence, the demographic of patients presenting to emergency departments (EDs) is also changing rapidly. This is especially true of major trauma, defined as an injury severity score >15 [1]. Data from the UK Trauma Audit Research Network (TARN) reveals that the mean age of patient suffering major trauma rose from 36.1 years in 1990, to 53.8 years in 2013 [2]. Over the same period, the proportion of major trauma patients aged over 75 years rose sharply from 8.1 to 26.9% [2]. These projections suggest that those aged over 75 years will soon represent the single largest group of patients suffering major trauma [2]. The mechanisms of injury are also changing. In 1990, a fall from standing (i.e. <2 m) was the mechanism of injury in 4.7% of major trauma; by 2013, the same mechanism of injury accounted for 39.1% of major trauma cases. Major trauma in older people is associated with higher rates of mortality than in their younger counterparts [3] and thus presents healthcare systems with a rapidly increasing challenge. In this article, we highlight the factors that make major trauma in older people particularly challenging and reflect on the potential role of Comprehensive Geriatric Assessment (CGA) in this area.

The challenge of trauma in older people

A critical early step in the management of major trauma is recognition that a patient has potentially sustained major trauma—effective triage by paramedics ‘in the field’ is therefore crucial. In England, regional trauma networks have existed since 2012—these constitute major (Level 3) trauma centres (MTCs), where all tertiary referral trauma specialties are represented, and local (Level 2) trauma units (TU), with some major trauma capabilities. Each regional trauma network operates a trauma bypass system, with the aim of allowing the ambulance service to direct most of the major trauma to a MTC. There are, however, no nationally accepted triage criteria for major trauma – each UK regional trauma network adopts its own [4]. Many such criteria are derived from American field triage guidelines, which do include age (>55 years) as a ‘fourth level’ criterion for transfer to MTC; [5] in practice, the age criterion alone is rarely applied.

Some physiological parameters within triage criteria may be misleading in older patients with major trauma. For example, for an equivalent severity of intracranial injury, presenting Glasgow Coma Score is higher in older patients than in the young [4]. Furthermore, haemodynamic status is less predictive of mortality in older people who have sustained blunt trauma, when compared to younger patients [6]. The combination of pre-existing co-morbidities and medications the patient may be taking, can also result in alteration of the expected physiological responses to hypoxia, shock or pain. The net effect of this is under-triage of older people. Standard adult triage criteria have poor sensitivity in identification of older adults with severe injury that warrants transfer to an MTC [7].

In response to the challenges of effective triage in this patient group, some American organisations have developed geriatric-specific criteria; [7] these have been shown to be more sensitive for the need for MTC care, albeit less specific [7]. The risk of implementing criteria with lower specificity, is a huge resulting increase in the number of patients transferred to MTCs, a proportion of whom will not require this level of trauma expertise. Some centres have trialled the use of a ‘two-tier’ trauma team where both smaller, ED-based trauma teams and larger, multi-specialty trauma teams are available depending on the clinical need of the patient; [8] at present, there is insufficient evidence to determine the efficacy of this approach.

It is also important to compare and contrast how younger and older patients with major trauma present to medical services. Younger patients suffering such injuries would invariably attend an ED, typically brought there by ambulance. Older patients often present via more circuitous routes—they may attend their general practitioner or a minor injuries unit; they may be referred to an ambulatory care or medical admissions unit; they may present after a delay, sometimes of days; they may even sustain the injury whilst a hospital in-patient. Such non-linear presentations are potentially hazardous for the patient and thus pose those tasked with configuring trauma services with further challenges.

Adding insult to injury

Of major concern is evidence from research with paramedics in the USA—here, even when major trauma was recognised and acknowledged, there was still under-triage of older patients [9]. Older patients were found to be half as likely as similarly injured younger patients to be transported to a trauma centre. Further survey work, that sought to understand these differences, revealed that paramedics felt they had insufficient training in older peoples’ trauma, possessed a degree of diagnostic nihilism regarding older people and, worryingly, had received negative responses from trauma centre staff when they had taken older trauma patients to their departments [9]. Such responses may in part be explained by societal ageism, but they may also represent a disconnect between the construct of ‘major trauma’ held by emergency medicine staff and the current reality. Historically, ‘major trauma’ brings to mind younger patients, who have sustained life-threatening injuries, due to road traffic accidents or violence. Whilst this is clearly still the case (major trauma is the leading cause of death in people under the age of 45) the TARN data reported above highlights the changing face of major trauma in the 21st century, both in terms of the demographic of the sufferer and the mechanism of injury.

A role for CGA?

Once older major trauma victims have received initial care and stabilisation, a key question to consider is where are their ongoing needs best met? This patient group has complex ongoing healthcare needs—prevalence of cognitive impairment and polypharmacy are high, delirium and acute kidney injury are commonly encountered in-patient complications [10], as is increased end of episode requirement for care. Complex care needs demand complex care interventions, and input from a variety of different health professionals working as a multi-disciplinary team is essential. Such patients may require a protracted rehabilitation phase—healthcare professionals caring for them therefore need expertise in defining realistic treatment and rehabilitation goals. Simply parachuting a geriatrician into such scenarios does not appear to be the solution—centres where consultation with a geriatrician was made mandatory for older trauma patients within the first 24 h of admission, failed to demonstrate any definitive evidence of meaningful clinical benefit for patients [10–12].

Given the nature of this patient group and their healthcare needs, an approach analogous to CGA may be the solution to achieving better outcomes. There is compelling evidence that CGA is the most effective way to improve outcomes for older people with frailty [13]. Geriatricians are trained in delivering CGA in collaboration with a multi-disciplinary team, but ultimately there are insufficient geriatricians to provide care for every frail older person. The solution may instead lie in seeking to embed the basic competencies necessary to initiate CGA amongst urgent care staff [14], such that irrespective of the role or availability of a geriatrician, principles of CGA can be incorporated in the initial assessment and management of frail older trauma victims.

To change practice, a multifactorial approach is required. First, organisations need to acknowledge and reflect on the changing needs of the population they serve—the structures and processes that underpin care delivery must then be redesigned to facilitate delivery of improved outcomes. Trauma triage criteria, response from pre-hospital personnel and the skillset of MTC and TU teams all need to evolve to better meet the needs of older trauma victims. Given the ubiquity of frailty within 21st century healthcare systems, there is great need to facilitate deeper understanding of the concept within the acute care workforce. Frailty is an independent predictor of mortality, morbidity and hospitalisation in all older people, including in trauma [15]. The Frailty Index has been shown to be an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients [16]. A logical starting point would be training urgent care staff, and trauma team members, in the basic principles of assessing frailty. Screening for frailty ought not to be limited to the hospital environment—we call for this to be pushed ‘forwards’ in the patient journey, and incorporated into pre-hospital assessment. The use of frailty screening tools, such as the Clinical Frailty Scale, within pre-hospital triage criteria may facilitate more informed, judicious early decision-making in relation to treatment interventions, and may address the variable nature of current trauma triage in older people.

Second, education of health professionals is also crucial. Urgent care staff need to be able to deliver the basic competencies necessary to initiate CGA, such as: communicating with people with sensory and/or cognitive impairment, obtaining collateral histories, assessment of cognition, management of confusion and addressing polypharmacy [14]. Collaboration between geriatric medicine and emergency medicine departments is key—geriatricians ought to take a central role in educating about the core principles underlying CGA. It is important to acknowledge that simply increasing medical professionals’ knowledge and skills in relation to trauma in older adults; however, may not be sufficient alone to drive up quality of care. Attitudinal change amongst healthcare professionals is also required: clinical teachers should consider harnessing the potential of simulation-based learning, which has been shown to have a positive impact on attitudes towards older people [17]. Facilitating longitudinal follow-up of older patients who have sustained major trauma may also be transformative, since patient and public involvement in learning is recognised as a potent stimulus for attitudinal change [18]. In addition, positive long-term outcomes for older trauma patients are seen [19]—highlighting positive examples of these may go some way to challenging therapeutic nihilism amongst health professionals.

Conflict of interest

None declared.

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