Elderly patients have more health issues and, as a result, take more medications for age-related comorbid problems. Therefore, polypharmacy is a unique medical issue to the geriatric trauma patient population and it is important to obtain this information during the initial hospital admission. Medications may have a direct impact on falls, bleeding, and mental status changes (see Table 2).
For the geriatric trauma patient, it is especially helpful to identify medications that will complicate or hinder their emergent medical or surgical management. One of the most dreaded surgical complications is bleeding while on anticoagulation. Multiple injury patients are at risk for coagulopathy due to shock, resuscitation with isotonic fluids, and infusion of multiple blood products. When this is compounded with the effects of systemic anticoagulation, the results can be lethal.

Surprisingly, age has not been proved to be an independent determining factor for bleeding complications from anticoagulation.¹⁰ However, there is a clear association of increased use of anticoagulation with age and this results in a large increase in the number of patients at risk for increased bleeding when injury occurs in an anticoagulated patient. There is controversy regarding the utility of anticoagulation for nonrheumatic atrial fibrillation in older patients. While increases in quality-adjusted life years of survival have not been shown, the risk of bleeding due to warfarin therapy seems to be counterbalanced by a protective effect against stroke.¹¹,¹² Most authors agree that careful management of the intensity of anticoagulation, keeping the international normalized ratio (INR) at or below 3.5 is essential to maximizing effectiveness while reducing complications. Low-intensity warfarin therapy (INR 2.0) is not associated with a reduced risk of bleeding.¹³ Anticoagulation, especially when the INR exceeds 3.5, may place the elderly patient at a higher risk for bleeding as a result of trauma. The consequences of anticoagulation, especially in the patient with brain injury, seem to carry a higher percentage of mortality compared to patients not on anticoagulation.¹⁴ This effect can be especially seen with cerebral hemorrhage and in patients older than 85 years.¹⁵ Several studies suggest that mortality is greater from fall-related intracranial bleeding in patients on warfarin where the INR exceeds 2.5 by as much as 10-fold.

If an unstable geriatric patient is known to be taking warfarin or heparin products, immediate correction of their coagulopathy is required with fresh frozen plasma. Recent reports suggest the utility of activated factor VIIa to rapidly reverse the deleterious effects of warfarin and massive coagulopathy from over resuscitation.¹⁶,¹⁷ Vitamin K is not considered as an adequate means of immediately reversing the effects of warfarin because of its time of effect. However, it is not unreasonable to administer if available for foreseeable long-term bleeding complications.¹⁸

Medications associated with increased risk of falls include antiarrhythmics, antihistamines, antihypertensives, antipsychotics, benzodiazepines, digoxin, laxatives, monoamine oxidase inhibitors, muscle relaxants, narcotics, tricyclics, selective seratonin reuptake inhibitors, and vasodilators.³

Advanced age is associated with an increased number of medical conditions. Several authors have shown through retrospective studies that preexisting medical conditions increase the mortality of the trauma patient between 2 and 8 times, and depending on the severity number of medical problems.¹⁹,²⁰,²¹ Medical conditions that are likely to complicate the geriatric patient’s hospital course and affect mortality from significant trauma include previous history of myocardial infarction, significant chronic obstructive pulmonary disease (COPD), poorly controlled diabetes, bleeding disorders, previous history of deep vein thrombosis (DVT), Alzheimer dementia, adrenal insufficiency, and osteoporosis.

Some past medical problems have themselves been associated with organ-specific trauma. For example, cerebral atrophy has been associated with intracranial hemorrhages, osteoporosis with fractures, and COPD with pneumothoraces and ventilator-associated pneumonia. Appropriate precautions should be taken if these medical problems are already known, and attention to detail becomes especially important in recognizing these potential issues that may arise during the hospital admission.

Previous surgery can be a complicating factor during a trauma laparotomy. Intra-abdominal adhesions can play a role in hollow viscous and solid organ injury by means of shear force and tear injuries. Oftentimes, adhesiolysis may become necessary during a damage control laparotomy taking valuable time away from obtaining hemostasis and the identification of major injuries. In addition, anatomy may be distorted due to previous resections and intestinal reconstruction.

In the chest, previous median sternotomy and thoracotomy will increase the level of difficulty in tube thoracostomy insertion and if needed, trauma-related thoracotomy or sternotomy. Extensive experience in reoperative surgery is necessary for successful outcomes.

The prognosis and outcomes from traumatic brain injuries in the geriatric patient have been shown to be much worse than in younger patients. Some studies have reported that mortality rates are doubled for patients older than 55 years who have traumatic brain injuries compared to younger patients.²² The Eastern Association for the Surgery of Trauma (EAST) practice management guideline for geriatric trauma recommends an initial course of aggressive treatment, followed by a reevaluation of the patient’s neurologic status at 72 hours postadmission.⁷ These recommendations are based on the data supporting admission Glasgow Coma Score (GCS) versus delayed GCS scoring. While the consensus is that a low-admission GCS confers a poorer prognosis, the actual score ranges from 7 to 11 with no consensus on a score to reliably predict outcomes. The data for delayed GCS scoring clearly shows high mortality percentages ranging from 90% to 100% for GCS scores between 8 and 9.²³,²⁴

Traumatic brain injuries with GCS <8 and computed tomography (CT) findings consistent with increased intracranial pressure (ICP) require invasive ICP monitoring. Once elevated ICPs are established, aggressive therapy to decrease this with hyperventilation, propofol, and mannitol should be expeditiously pursued. All these treatments have been shown to decrease ICP by different mechanisms. Hyperoxia, by increasing the fraction of inspired oxygen, has been shown to reduce cerebral lactate levels and possibly improve brain oxygen tension. Decompressive craniectomy is the last resort and is especially controversial among the geriatric population.

Spinal cord injuries are a significant source of morbidity and mortality in the elderly. Comparative studies have suggested that patients older than 65 years have approximately a fivefold increase in mortality after spinal cord injury compared to younger patients.²⁵ Mortality has also been reported to be higher in patients older than 50 years especially when the cord injury is severe. Patients older than 65 years are more likely to fracture their cervical spines by low-energy mechanisms compared to younger patients, causing these fractures to be often overlooked.²⁶

The elderly are particularly susceptible to dens and second cervical vertebrae fractures on the basis of biomechanical changes from degenerative disease in the mid and lower cervical spine. Predictors of cervical spinal injuries include neurologic deficits, severe head injury, and high-energy mechanism of injury.²⁷ CT scan in this setting has been proved to be both effective and cost saving for initial diagnosis. Magnetic resonance imaging (MRI) has a role in planning later definitive management when prompt evaluation by a neurosurgical specialist has been done.

Acute management for geriatric spinal injuries include immobilization, adequate pain control, invasive monitoring with pulmonary artery (PA) catheter with correction of hypotension and bradycardia, and corticosteroids. Our institutional practice has been to administer methylprednisolone based on the National Acute Spinal Cord Injury Study ([NASCIS] I and II) trials in patients with known blunt injury to the spinal cord who present within 8 hours of injury despite the lack of convincing evidence that functional outcomes are improved.²⁸,²⁹ Patients are given a 30 mg per kg bolus followed by a 5.4 mg/kg/hour infusion of steroid for 48 hours. Patients with transient neurologic deficit with negative radiologic studies should have flexion and extension cervical films before removal of the cervical collar. This is especially important in geriatric patients with known osteoporosis, cervical surgery, and degenerative disease of the cervical spine. The incidence of central cord syndrome is higher in the elderly population because of the aforementioned degenerative disease almost always present.