The elderly account for the most rapidly growing segment of the U.S. population. Twelve percent of the population is over age 55 and that number could increase to more than 20% as the Baby Boomer population ages.1,2 As of 2000, the number of individuals age 65 or greater had reached 35 million, and it is anticipated that by 2030, individuals age 65 or greater will reach 70.3 million, or 20% of the total U.S. population.3 While the elderly represent 12% of the population, they account for more than 36% of all ambulance transports and 25% of hospitalizations (see Table I).
Considering the potential impact the elderly have on our prehospital systems and the potential impact of EMS providers on patient outcomes, it is important to understand the unique issues related to caring for elderly trauma patients to ensure they are managed appropriately.
This article focuses on trauma to the elderly in the prehospital setting, including a review of pathological differences, the possible impact of coexisting disease processes, the effect of multisystem trauma on the elderly and an overview of prehospital treatment options.
The anatomy and physiology of the elderly differ from that of younger adult patients. Although some of these differences may appear to be inconsequential, they can significantly affect the treatment that is provided in the field.5 Consider, for example, the elderly patient's airway. Gum disease, tooth decay and dental prostheses can complicate basic and advanced airway management, as can dental work like caps, bridges and fillings.1,7 If the provider does not consider these types of potential differences, managing the patient's airway can become extremely challenging. Overly aggressive airway management may lead to bleeding, iatrogenic trauma or hypoxia.
In addition to airway differences, the elderly patient's respiratory system may be inhibited by osteoporosis, decreased vertebral body structure, pain, decrease in muscle mass or a decrease in chest wall compliance. The presence of an underlying chronic respiratory condition, such as emphysema or pneumonia, will also impair the effectiveness of the elderly trauma patient's respiratory system. By age 65, vital capacity is significantly reduced.1,6 Ciliary activity in the elderly patient is also decreased, which can lead to the inability to cough and contribute to development of complications like pneumonia.1 The presence of chronic comorbid disease states, such as coronary artery disease, renal disease or diabetes, can decrease the physiologic reserve in some patients. This can be significant, as these patients might become hypoxic more quickly and be less able to tolerate the hypoxia than younger trauma victims.
The cardiovascular system can also be influenced by age. In many patients, tachycardia is considered to be an early indicator of shock, but the elderly may be less able to produce tachycardia. Underlying heart disease or certain medications, both of which are more likely to be factors in the elderly, can affect the patient's ability to respond to stress by increasing the heart rate. Subtle clinical findings commonly present in the younger trauma patient (e.g., tachycardia, delayed capillary refill time) may not be present. Hypotension is not a reliable indicator of the severity of the patient's condition. The patient with chronic hypertension may mask the symptoms of hypovolemia through vasoconstriction. In these situations, blood pressure changes, tachycardia and delayed capillary refill time may not be reliable indicators of shock.1,7 Patients' blood pressures may appear normal when they are actually hypotensive.
The myocardium also changes with age. The left ventricle becomes thicker, resulting in reduced systolic function. This can contribute to decreased cardiac output and reduced ability to respond to stressors, such as hypovolemia. The myocardial electrical conduction system also becomes less effective. Left ventricular and electrical conduction changes may lead to complications, including arrhythmias, congestive heart failure or pulmonary edema. Cardiac output may be impaired, resulting in poor perfusion.1,7