It is estimated that approximately 40% of the projected 25 million octogenarians comprising the U.S. population by the year 2025 will suffer cardiovascular symptoms, many of whom will require cardiovascular surgical treatment.18 With advances in cardiopulmonary bypass technique, myocardial protection, and improved perioperative care, coronary artery bypass grafting (CABG) and valve replacement operations can be safely performed in elderly patients. Senile calcific aortic stenosis is common within this population, and referral for aortic valve replacement is increasing, encompassing many patients who are >75 years old. Interestingly, despite some degree of age bias in the referral of patients for major cardiac surgery, advanced age alone is not a predictor of poorer outcomes or increased mortality compared to younger patients. It has been demonstrated that emergency operations, preoperative New York Heart Association (NYHA) functional class 3 or greater, and chronic renal failure were the main predictors of increased operative mortality, but not patient age, per se.18 In one study, preoperative renal dysfunction, cerebrovascular disease, valve surgery, and catastrophic state were independent predictors of increased mortality in elderly patients.19 Elderly patients with nondialysis-dependent renal dysfunction had a 60% chance of death during a 5-year follow-up period compared to 25% in elderly patients without a history of renal dysfunction. Similarly, the presence of cerebrovascular disease resulted in a two-fold increase in mortality among elderly patients.19 Even patients who were 80 years of age or more did not have any significant increase in surgical risk and within this population, the 4-year actuarial survival was 70.5% with an event-free survival of approximately 60.6%.19
There has been an increase in definitive operative intervention to elderly patients requiring CABG. Although older patients have higher morbidity and mortality rates after cardiac surgery than do younger patients, these rates are decreasing. The Society of Thoracic Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.20 This decline in morbidity and mortality rates likely reflects better preoperative assessment and patient selection. Furthermore, this decline has occurred despite the advancing age of cardiac patients at time of referral, advanced disease, and greater comorbid disease burden. Elderly patients are more likely to have significant triple-vessel disease accompanied by poor ejection fraction, left ventricular hypertrophy, significant valvular disease, and previous history of myocardial infarction than are younger patients.20 Elderly patients also are more likely to be classified as NYHA functional class 3 or higher and are more likely to present on an emergent basis, in part because of reluctance to provide elective surgical intervention because of presumptive poorer outcome. Despite the increased risk of morbidity and mortality compared to younger patients, elderly patients, including those >80 years old, can undergo CABG with acceptable mortality risk. The overall mortality rate is approximately 7% to 12% for elderly patients, including those in whom CABG is performed under emergency conditions. The mortality rate decreases to approximately 2.8% when CABG is performed electively with careful preoperative evaluation.21
There also is an increasing percentage of the geriatric population who present with symptomatic valvular disease requiring intervention. The most common valvular abnormality present in elderly patients is calcific aortic stenosis, which can lead to angina and syncope.22 The operative mortality from aortic valve replacement is estimated to be between 3% and 10%, with an average of approximately 7.7%.20 If aortic stenosis is allowed to progress without operative intervention, CHF will ensue. The average survival of these patients is approximately 1.5 to 2 years. If a patient is a candidate for operative intervention, age should not be a deterrent, especially considering the potential to increase life expectancy. It has been recommended that the carefully selected, minimally symptomatic octogenarian with aortic stenosis should be considered a low-risk patient and be expected to experience an uneventful operative course and expedient recovery. More importantly, if elective procedures are delayed until symptoms or left ventricular dysfunction develop, patients may suffer from unnecessary increased operative risk and mortality.18 Early intervention results in a demonstrable improvement in quality of life in these patients, with many improving their NYHA functional classification.
Elderly patients require surgery for mitral valve disease when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality rate as high as 20%.20 Left ventricular function usually is compromised in patients requiring intervention, leading to a poorer outcome in these patients. The surgical outcome for mitral valve procedures depends on the extent of the disease, age of the patient, presence of pulmonary hypertension, and extent of coronary artery disease. The presence of comorbid conditions combined with the emergent nature of surgery in a large percentage of elderly patients further worsens the outcome. Therefore, a decision regarding management of mitral valve disease should be individualized to each patient with the previously mentioned below factors considered. Another concern regarding elderly patients who require surgery for valve disease is the additional requirement for coronary revascularization. This increases the morbidity and mortality from surgical intervention. An elderly patient with many comorbid conditions in need of a combined procedure should only have critically stenosed vessels bypassed.22 Therefore, advanced age is not a contraindication to performing combined procedures; however, a higher mortality rate should be expected. Neurologic complications from valve surgery are particularly common in elderly patients. It has been estimated that approximately 30% of patients >70 years old who undergo valve procedures develop either transient or permanent neurologic dysfunction.22 This often is a result of embolism from debris dislodged from the valve during the procedure or from a formed thrombus in the right atrium.
An important consideration in valve replacement procedures in elderly patients is the type of prosthesis to be used. Elderly patients are at increased risk from bleeding-associated anticoagulation complications. This is especially significant in patients who have experienced falls and minor trauma that have resulted in intracranial hemorrhage. To avoid the lifelong requirement for anticoagulants, bioprosthetic valves should be used in place of mechanical valves whenever possible.22 Although the bioprosthetic valves are not as durable as mechanical valves, studies demonstrate excellent structural integrity 10 years postprocedure, making it an appropriate choice in an elderly patient.
The incidence of most cancers is age dependent, and the expanding aged population is rapidly increasing the number of elderly patients who require multimodal therapy for various oncologic diseases, including lung, breast, pancreas, esophagus, stomach, and colorectal malignancies. Approximately 50% of cancer diagnoses are currently made in patients aged 70 years or older.10 It is predicted that the increase in the elderly population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased life expectancy of the geriatric patient coupled with the increasing incidence of cancer with advancing age will lead to an increased prevalence of malignant disease requiring surgical intervention. This is an area of great interest given that randomized clinical trials to determine the outcomes of elderly patients undergoing curative resections, as well as neoadjuvant and adjuvant therapy, are lacking. In addition, elderly patients are rarely included in clinical trials; therefore, treatment decisions are often based on individual surgeon experience and non-geriatric data, and may be flawed by inherent biases regarding the outcome of complete oncologic resections in elderly patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy and radiation without proven efficacy in this geriatric population. This highlights the need for research targeting the specific needs of elderly patients with malignancy to aid in the development of specific treatment guidelines for various cancers within this age cohort.
Currently, the geriatric population is undertreated for malignant diseases and does not receive curative resections or adjuvant therapies afforded to same-stage younger patients.11 Potential reasons include poorer functional status compared to younger patients, patient and family preference, age bias, life expectancy, and concerns regarding quality of life after major operative interventions.23 Surgeons will be challenged to decide whether major surgery is justified in elderly patients, especially those with limited life expectancy. Effectiveness of oncologic surgery in elderly patients depends on whether a cure can be achieved safely without compromise to functional status or quality of life. Postoperative life expectancy should be improved by surgery, or, at the very least, not diminished. A useful treatment algorithm is provided in Fig. 47-3. A study undertaken using the Surveillance, Epidemiology and End Results database assessing cancer-directed surgery (CDS) for localized disease for solid malignancies found that the rates of CDS declined with increasing age for all cancers, especially noted for the aged elderly >70 years old. In addition, CDS was less likely to occur with patients found to have lung, esophagus, stomach, liver, or pancreatic cancer. A careful assessment of the general and cancer-related condition of the patient is crucial to planning the best surgical intervention and postoperative adjuvant therapy.
A useful treatment algorithm to illustrate the effectiveness of oncologic surgery depends on the balance between achieving cure and maintaining functional quality of life (QOL). (Reproduced with permission from Balducci L, Beghe C. Cancer Control. Journal of the Moffitt Cancer Center. 1999; 6:466.)
Formulating a comprehensive, multimodal treatment plan for an elderly patient with a malignancy amendable to surgical intervention is based on careful consideration of the patient’s expected life span, specifically if the life span is expected to exceed survival from the malignancy. Additionally, considerations include the patient’s ability to tolerate the surgery and any complications that may ensue, as well as the likelihood that the patient would suffer a complication from the cancer which would adversely impact quality of life.24 An ongoing international study that is titled “Preoperative Assessment of Cancer in the Elderly (PACE)” is designed to evaluate a scoring system that aids in assessing the oncogeriatric patient for surgical intervention. The PACE study incorporates several validated instruments that assess the functional and physiologic status of patients, including the Mini Mental State Examination, capacity to perform ADLs, Geriatric Depression Scale, and the ASA classification among other useful instruments. Interestingly, the PACE assessment also includes The Physiological and Operative Severity Score which has been shown to predict morbidity and postoperative mortality in general surgery and in patients with lung and colorectal malignancy. This score includes the age of the patient and gives consideration to operative factors, including the type of surgical procedure used, the presence and extent of malignancy, and the timing of the operation (i.e., planned elective procedure or an emergency intervention).10 Palliative interventions are a part of the therapeutic armamentarium; however, a surgeon must weigh these variables carefully to determine which surgical intervention (i.e., palliative vs. curative) is appropriate.
It is projected that there will be a 72% increase in the number of elderly women diagnosed with breast cancer in the United States by 2025. Furthermore, 50% of breast cancers occur after the age of 65 years old and 25% after the age of 75 years old.25 The estimated risk for development of new breast cancer is one in 14 women aged 60 to 79 years old compared to one in 24 in women aged 40 to 59 years old.25 Mortality rates following breast cancer surgery in elderly women is <1%, and therefore, surgical interventions remain the cornerstone of therapy for breast cancer in elderly women. However, as expected, the presence of comorbid conditions affects clinical outcomes in elderly patients with breast cancer. A recent study demonstrated the presence of comorbid conditions in patients with breast cancer rose to as high as 55% in patients >80 years of age, with cardiovascular disease, diabetes, and previous cancer being most common.26 As expected, the resulting 5-year survival rate was lower in patients with two or more comorbid conditions.
A recent study on risk factors for breast cancer in patients >75 years of age showed similarity to younger women and included obesity, nulliparity, family history, and advanced age at menopause.27 Interestingly, although breast cancer presentation in elderly patients may be diagnosed at more advanced stages, both clinical and pathologic data demonstrate less aggressive disease in elderly women with more favorable biologic characteristics. Elderly breast cancer patients are more likely to have estrogen-positive tumors and increasing endocrine responsiveness.27 Despite these relative advantages, a large number of elderly women are not offered conventional therapies for breast cancer. Moreover, elderly patients who are offered breast conservation surgery for breast cancer are less likely to have axillary dissection, postoperative radiation, and chemotherapy. This will undoubtedly influence surgical outcomes in elderly patients with breast cancer considering that local recurrence rates after conservative surgery without radiotherapy are reported as high as 47%. Advancing age has been demonstrated to be an independent predictor of nonconcordance with treatment guidelines for definitive surgical therapy and adjuvant chemotherapy, as well as hormonal therapy. One study demonstrated that the odds of receiving a recommendation for chemotherapy decreased by 22% for each year of advancing patient age.23 The nonsurgical management of breast cancer in elderly patients is falling out of favor because there is currently no rationale for denying surgical therapy for elderly breast cancer patients. Surgery and hormonal therapy were the best options for overall survival, breast cancer–specific survival, and disease-free survival. A Cochrane Review concluded that treatment with tamoxifen alone is not an acceptable option because of higher local progression of disease; 81% compared to 38% with surgical intervention. Furthermore, the response rate only lasts for approximately 18 to 24 months.23 The final conclusion is that surgery remains the standard of care for elderly patients with breast cancer. Alternative therapies should be reserved for patients who have multiple comorbid conditions leading to poor candidacy for operative intervention, those who are frail, or those who refuse surgery.
A timely study comparing the mortality after breast-conserving surgery (BCS) alone, BCS plus radiation therapy, mastectomy, and the receipt of adjuvant tamoxifen in elderly breast cancer patients confirmed that less than standard treatment for these patients resulted in increased mortality. Elderly women receiving BCS without radiotherapy have more than twice the rate of breast cancer mortality compared to women undergoing mastectomy. In addition, in older women with estrogen receptor and progesterone receptor positive tumors receiving tamoxifen, the rate of breast cancer death increased substantially with the decreasing duration of tamoxifen use.28 The standard of treatment for elderly patients with breast cancer should be the same as younger patients; BCS plus radiotherapy when indicated. If patients decline postoperative radiotherapy or are medically unfit for radiotherapy, mastectomy should be performed. Furthermore, elderly patients with tumor size <2 to 3 cm and no clinical evidence of axillary involvement should be offered sentinel node biopsy.29
One of the most interesting controversies surrounding breast cancer in elderly women is the appropriate age limits of screening. A retrospective study demonstrated a decline in cancer-related mortality among women who underwent regular screening mammography up to 75 years of age.27 Women who underwent at least two mammographic examinations between the ages of 70 and79 years experienced a two-and-one-half–fold reduction in breast cancer mortality compared to elderly women who did not undergo screening.23 The screening benefits depend on life expectancy. In women with multiple comorbidities, the decision to perform screening should be based on estimated life expectancy. People with <5 years of life expectancy are unlikely to benefit from screening. The American Geriatric Society recommends that screening should be individualized rather than set by age-specific guidelines. The current recommendation is that no upper age limit for screening be set as long as the estimated life expectancy is 4 or more years.
The incidence of colorectal cancer (CRC) increases with advancing age, similar to most other malignant conditions. Approximately 90% of cases of CRC are diagnosed in patients >55 years old.33 Of concern is the increased postoperative morbidity and mortality following extensive surgical resections in elderly patients, with a significant increase in patients >70 years old. In fact, inhospital mortality for patients >85 years old undergoing surgery for colorectal malignancy is estimated to be nine-fold greater than for younger patients.30 Furthermore, elderly patients often have decreased cancer-specific survival compared to younger patients. It has been proven that the 5-year cancer-specific survival for CRC is similar among the age cohorts. Therefore, age is not an independent factor accounting for the decreased survival among elderly patients. It is rather a consequence of comorbid conditions and impaired physical capacity necessary for recovery from perioperative physiological stress.30 This leads to bias regarding poorer outcomes in elderly patients. For this reason, many elderly patients are receiving suboptimal cancer therapy and limited resections resulting in decreased survival rates and poorer outcomes. With the ever aging population, this must be addressed and clinical modifications implemented to improve outcomes of elderly patients undergoing surgical interventions for colorectal malignancies. Elderly patients should have continued, aggressive screening for colorectal malignancy and strict adherence to accepted surgical and adjuvant treatment guidelines.
One of the most important aspects to delivering appropriate care to elderly patients with CRC is to consider the patient’s wishes as well as expectations from the surgical intervention. In this respect, functional outcomes and quality of life take precedence in treating elderly patients, especially the aged elderly. Of patients >75 years old who underwent elective surgery, few demonstrated protracted decline in ADLs and most experienced significant improvement in quality of life.31 Approximately 10% of elderly patients >80 years old have protracted postoperative disability. Estimation of physical ability and surgical stress is useful for predicting decline in ADLs and postoperative disability. It has been shown that, in patients <80 years of age, a complete resection for cure is most important, whereas in patients >80 years old, avoidance of a stoma becomes paramount. These are important considerations for the geriatric surgeon.30
A prospective study was recently undertaken to specifically evaluate the epidemiology and risk of surgical intervention for CRC in elderly patients. A large cohort of 47,455 patients was divided based on age <75 years old and >75 years old.30 It was determined that a significant portion of elderly CRC patients are female, with multiple comorbidities leading to advanced ASA levels of 3 and above. The study determined that elderly patients underwent surgical interventions less often than younger patients (81% vs. 88%, respectively, P <.001), more frequently required urgent or emergency operations, and were more likely to have operative procedures in which the primary cancer was not resected. Obstructive tumors are significantly more common in patients >70 years old, and elderly patients are still presenting far too commonly with surgical emergencies resulting from obstruction and perforation in up to 40% of the cases.11 In addition, elderly patients had higher postoperative mortality than younger patients (10.6% vs. 3.8%, respectively). Right colectomies, Hartmann’s procedures with colostomy, transanal endoscopic microsurgery, and transanal resection of tumors were more common in elderly patients, whereas formal resections, including low anterior and abdominoperineal resections, were more common in younger patients.30 Elderly patients are less likely to undergo CDS; with each half a decade increase in age >70 years old, the odds of receiving cancer-directed surgery were reduced by 44%. Interestingly, many of these patients presented with lesions of lower-stage Duke’s cancer classification. However, this was not secondary to earlier presentations as one might assume, but rather secondary to understaging from surgical treatment. Accurate staging may not be possible with local resections, limiting the number of lymph nodes available for proper staging.32 Elderly patients also are less likely to undergo preoperative irradiation and neoadjuvant chemotherapy, reducing the likelihood of curative resection.30
Liver resection for CRC liver metastases in properly selected elderly patients 70 years of age or greater is feasible with older patients having similar operative survival to younger patients. Palliative surgery remains a viable option for elderly patients with disseminated CRC and should be aimed at the reduction of symptoms such as pain, obstruction, or hemorrhage. Bowel obstruction can be relieved with intestinal bypass or a diverting colostomy. The most common site of disseminated disease is the liver, and uncontrolled liver metastases are responsible for pain, abdominal distention, jaundice, and inferior vena caval obstruction. Elderly patients with metastatic disease who are not candidates for curative resection may be considered for ablation of the lesions by local destruction, cryotherapy, or radiofrequency ablation. More traditional means such as chemotherapy, which can be administered via the hepatic artery or radiation, also may be used.33
Similar to breast cancer, an upper age limit for CRC has not been clearly established. Screening for CRC may not lead to an observed survival benefit until 5 years or longer after screening had occurred. This would limit the benefit of screening in aged populations with limited life expectancy. An interesting way of looking at this controversy is from a recent study that determined that the number of screening colonoscopies needed to prevent one CRC-related death (the number necessary for survival or NNS) increased as with increasing age and comorbidities. For example, in healthy men and women aged 75 to 79 years old, the NNS was 50. The corresponding NNS in patients 90 years and older was 279 in women and 482 in men.34 Consideration for continued screening in very elderly patients should take into account age and predicted life expectancy, comorbid burden, expected duration of the protective effect of screening, risk for cancer, results of previous screening colonoscopies, and patient preference.34
Lung cancer is the leading cause of cancer-related deaths in the United States for patients >70 years old. National Cancer Institute statistics show that the peak incidence of lung cancer is between 75 and 79 years of age. Elderly lung cancer patients also have a higher mortality rate, and therefore, the peak mortality rate is between ages 75 and 84 years.35 Non–small cell lung cancer accounts for roughly 80% of all lung cancer cases, and >50% of these patients are >65 years of age. Interestingly, approximately 30% of these patients are 70 years or older at diagnosis.36 Lung cancer is highly prevalent among elderly patients, so much so that a 2-cm, asymptomatic, solitary pulmonary nodule in a 70-year-old male smoker has a >70% chance of being an occult lung cancer. Squamous cell carcinomas are more common among elderly patients than among younger patients, and these tumors are associated with a higher incidence of local disease, tend to have lower recurrence rates, and have longer survival times than nonsquamous cancers.35 In cases of resectable primary lung cancer, surgery remains the treatment of choice independent of age.11
The estimated life expectancy of untreated lung cancer is approximately 9 months. This can increase to as high as 18 months with palliative chemotherapy and radiation. However, the life expectancy of an elderly patient who has undergone a successful operative resection is estimated to be as high as 31 months, making this the preferred option when feasible.13 However, despite this and the fact that more elderly patients present with stage 1 disease, elderly patients are offered curative surgery less frequently than younger counterparts. The same holds true for chemotherapy and radiation.
Advanced age is an independent risk factor for death after thoracotomy, with significantly increased mortality after age 65. These reasons are multifactorial partly due to the physiologic debilitation that occurs with division of the intrathoracic muscles that aid in respiratory function and the loss of lung volume after resections.13 One study demonstrated that patients 70 years of age or older who underwent thoracotomy for lung cancer had an operative mortality rate of 14%, which is directly related to the extent of the pulmonary resection. In one of the largest prospective, multi-institutional trials conducted, The Lung Cancer Study Group, increasing age led to a significant increase in 30-day mortality for patients undergoing thoracotomy and lung resection.13 They found overall mortality to be approximately 3.5% in patients <65 years old, which rose to 7.3% for patients 70 years or older and as high as 8.1% for octogenarians. However, with improved surgical options, including minimally invasive video-assisted thoracic surgery (VATS) in the past decade, the mortality rate has ranged from 3% to 5% in carefully selected patients.2 In a recent study conducted to determine if VATS resulted in lower morbidity in the elderly population in comparison to open, rib-spreading thoracotomy, the overall morbidity for minimally invasive surgery was 28%; this increased to 45% with traditional open procedures.36 Furthermore, elderly patients undergoing VATS tended to have less severe complications compared to patients undergoing thoractomy.36 Limited resections (segmentectomies) may be a consideration in elderly patients with limited life expectancy or poor cardiac and pulmonary reserve who may not tolerate a more extensive procedure. Some studies have shown that limited resections may provide a comparable survival rate to lobectomies in elderly patients as long as the resection includes all foci of tumors and provides a microscopically free margin. The most striking finding was that any survival difference between treatment modalities disappeared after 71 years of age. Interestingly, even smaller resections such as VATS and wedge resection may be a viable oncologic option in an elderly patient with resectable disease but limited life expectancy.13 This is limited to very small tumors <7 mm in diameter and not yet proven to be clinically efficacious. Of particular interest is that VATS procedures may result in lower rates of postoperative confusion in elderly patients and this may be secondary to the decreased physiologic stress of minimally invasive procedures, faster recovery rates, and decreased narcotic requirement for pain control.13 Careful preoperative selection and optimization combined with aggressive postoperative care and rehabilitation make surgical intervention for resectable disease feasible in aged populations.
Patients >65 years of age currently account for approximately 23% of total hospital trauma admissions—many of which are multisystem and life threatening.37 Geriatric trauma will continue to challenge surgeons in understanding the physical and physiologic impact of various mechanisms of injury, the need for careful assessment of comorbid conditions with particular attention to medication regimens, the rehabilitative capacity of an elderly trauma patient, and the knowledge of specific interventions that help to minimize morbidity and mortality in this population following traumatic injury.
The current geriatric population has fewer disabilities and is considerably more active than previous generations, which predisposes them to traumatic injuries. The most common type of trauma is blunt injury resulting from falls and motor vehicle collisions or pedestrian accidents. Falls currently account for 20% of severe injuries in elderly patients. Many underlying chronic and acute diseases common to elderly patients place them at increased risk for falls. These diseases include postural hypotension, leading to syncopal “drop attacks”; dysrhythmias from sick sinus syndrome; autonomic dysfunction; polypharmacy with improper dosage of antihypertensive and oral hypoglycemic agents resulting in hypotension; and hypoglycemia, respectively.38
Elderly patients also can fall victim to penetrating trauma, especially in elderly patients who may have underlying depression and suicidal ideations or are victims of elder abuse. It is estimated that approximately 40% of all trauma patients by 2050 will be >65 years old.39 With the expanding elderly population, this will be an increasing source of morbidity and mortality; the risk of death after major trauma with multi-system and life-threatening injuries rises steeply after age 45 years old and doubles by age 75 years old. In contrast to what is observed for abdominal and thoracic surgery, even after controlling for injury severity and pre-existing medical conditions, patients aged 65 years and older sustaining traumatic injury were 4.6 times more likely to die than younger patients.39 Of note, there are several interesting aspects of care of the acutely injured elderly patient that must be kept in mind. First, physiologic reserve can be challenged by trauma. For example, previously unknown disease such as cardiac impairment may be acutely unmasked. Secondly, medications common to elderly patients, such as beta blockers and anticoagulation, cannot only inhibit the physiologic response to stress but may even worsen injury. Finally, elderly patients with impaired functional status posttrauma are more likely to lose their ability to function independently without the support of a nursing home.
Elderly patients are particularly susceptible to trauma due to changes that occur with aging, specifically, gait instability, decreased hearing and visual acuity, presence of confusion or dementia, underlying comorbid conditions, and poor to tolerate the physiologic stress of traumatic injuries. Pre-existing medical conditions increase the risk of death after trauma significantly (up to three-fold).37 This is worsened when combined with an elderly patient’s decreased functional reserve for handling physiologic abnormalities accompanying major trauma, such as hypotension and hypoxia. It is important to consider a trauma patient’s age, as patients aged 65 to 80 years old have a 6.6% overall mortality rate after traumatic injury, which rises to 10% in patients 80 years or older.42
Despite the increased risk of morbidity and mortality after traumatic injury, it is interesting to note that there is currently an undertriaging of elderly patients to level 1 trauma centers despite high injury severity scores.39 In one study, elderly patients >65 years old were five times more likely to be undertriaged to nondesignated trauma hospitals than younger counterparts.39 However, a reduction in morbidity and mortality and posttraumatic complications as well as faster rehabilitation can result from better triaging practices. In one particular study involving acutely injured octogenarians with injury severity scores between 21 and 45, inhospital survival was as high as 56% in trauma centers, and this dramatically decreased to 8% in those treated at nontrauma hospitals.39
It is important to determine the medication regimen of elderly trauma patients. Medications such as beta blockers, calcium channel blockers, diuretics, and afterload reduction agents may impair critical augmentation of myocardial function in trauma patients, especially if they are hypovolemic. Approximately 20% of the elderly population with coronary artery disease and 10% of those with hypertension are currently on beta blocker therapy.39 Therefore, tachycardia, one of the most valued signs of continued hypovolemia from either ongoing blood volume loss or underresuscitation, is lost in the elderly patient on beta blocker therapy. This makes interpretation of hemodynamic parameters in elderly patients inaccurate and, at times, misleading, which could lead to delays in appropriate interventions and resuscitation. However, it is important to keep in mind that, to date, evidence supporting early hemodynamic monitoring in elderly patients is lacking.
The other medication class that can be detrimental to an elderly, acutely injured patient is anticoagulation, ranging from aspirin and clopidogrel (Plavix) to warfarin, which may, at times, be supratherapeutic. Massive intracranial hemorrhages resulting from minor falls from standing in elderly patients are demonstrated in Fig. 47-4. Warfarin therapy may be used in patients with atrial fibrillation, DVT, and prosthetic heart valves. The mortality rate of elderly patients on warfarin with a traumatic intracranial hemorrhage was 48% compared with 10% in an age-matched cohort not on anticoagulation therapy; it is unknown for the newer factor Xa inhibitors.39 One of the most important caveats to treating elderly patients on anticoagulation with blunt head injury is the potential for significant, life-threatening intracranial hemorrhage despite initial normal head (computed tomography) CT scans. In one study, >70% of patients with minor mechanisms and negative CT scan, admitted for observation subsequently, clinically deteriorated within 12 hours of admission with a Glasgow Coma Scale of <10 and were subsequently found to have significant intracranial hemorrhages.39 Therefore, prompt reversal of anticoagulation, particularly if supratherapeutic, is warranted to reduce morbidity and mortality following blunt head injury. In addition to increased risk of mortality in elderly patients sustaining blunt head trauma, a significant portion fail to resume functional independence after traumatic injury. It is estimated that approximately 20% to 25% of elderly trauma patients require discharge to a skilled nursing facility for long-term care and rehabilitation.37 Poor functional outcome has been attributed to several factors among which are age >75 years old, presence of shock on admission, severe head injury, and development of infectious complications.
Massive intracranial hemorrhage resulting from seemingly minor trauma. An 86-year-old patient fell from a standing position and presented to the emergency room with six hours of injury with a Glascow Coma Scale of 5 and a blood pressure of 167/55. She was on aspirin and clopidogrel therapy for ischemic heart disease, along with 14 other medications for congestive heart failure, diabetes, and hypertension. She expired from her intracranial wounds. (Photo used with permission of Dany Westerband, MD, Suburban Hospital, Bethesda, MD).