When your trauma patient is over

Nursing, Apr 2003 by Steffen, Karen A

BY 2020, MORE THAN 20% of Americans will be age 65 or older. As people lead longer, more active lives, trauma has become the seventh-leading cause of death for older adults. Age-related physiologic changes such as deteriorating sight and hearing, poor coordination, and weakness predispose older people to trauma. Elderly trauma patients present a special challenge to health care providers because age-related physiologic changes and preexisting medical conditions put them at higher risk for death than younger trauma patients. (See How Age-Related Changes Raise the Risk.) Compared with a younger trauma victim, an elderly patient isn't as likely to die as a direct consequence of her injury, but rather from preexisting medical conditions or trauma complications.

In this article, I'll discuss why elderly patients are especially vulnerable to trauma and how to tailor your nursing care to support healing and minimize future risks.

Facts about failing

Falls are the most common source of traumatic injury in older adults, followed by motor-vehicle accidents and auto/pedestrian accidents. Most falls involving the elderly occur during ordinary daily activities, such as walking, and don't involve dropping from a great height.

Age-related changes and health problems that predispose elderly patients to falls include impaired sensation and proprioception (position sense), visual and auditory disturbances, unsteady gait and balance, neuromuscular disorders, muscle weakness, degenerative joint disease, osteoporosis, dementia, and syncope.

When treating an elderly patient who's fallen, assess the reason behind the fall. For example, if she says she fainted, check her medications to see if any of them could cause such adverse reactions as orthostatic hypotension. She should also receive a syncopal workup, including an evaluation for cardiovascular and cerebrovascular disease, metabolic disorders such as hypoglycemia, disorders of vascular tone or blood volume, psychogenic disorders, and seizures.

You can help your elderly patient reduce her risk of falls by advising her to keep frequently used objects close to her bed or chair so she can reach them easily and to wear shoes with nonskid soles that fit well and provide good support.

Also advise the patient and her family to clear her environment of potential hazards. For example, they should keep walkways uncluttered and avoid using loose or scatter rugs. Other helpful interventions include balance and gait testing, balance and gait retraining, strengthening exercises, use of gait aids, and treatment for pain, medical conditions, and foot problems. If possible, the patients drug regimen should be revised to eliminate sedating drugs.

Driving into trouble

Motor-vehicle accidents are the second most common cause of injury in the elderly, who may be more prone to accidents because of age-related visual and auditory changes and longer reaction times. Many elderly people try to compensate by not driving at night or in bad weather, so most accidents involving elderly drivers occur during the day, in good weather, at intersections, and close to home. Alcohol, reckless driving, and excessive speed, which play a significant role in many accidents involving younger people, are less likely factors in this age-group.

To help prevent injuries related to motor-vehicle accidents, remind your patient to use seat belts and instruct her not to drive when using medications or substances that might impair alertness or coordination. Suggest she take driver improvement courses sponsored by the American Association of Retired Persons to help her learn how to adapt her driving practices to accommodate declining functional capabilities. Encourage periodic hearing and vision testing.

Walking hazards

Being hit by a motor vehicle while walking is the third most common way elderly patients are injured. Elderly pedestrians struck by motor vehicles are more likely to die than younger victims. Because of age-related physical changes, such as diminished peripheral vision and progressive kyphosis, many older adults have trouble seeing approaching vehicles. Poor hearing can prevent them from noticing warning horns. An unsteady gait, coupled with diminished strength and decreased reaction time, may keep them from moving out of harm's way.

To help your elderly patient stay safe while walking, suggest that she ask a relative or friend to help her with errands. If she must walk along busy roads, she should travel during daylight hours, in good weather, and wear light-colored clothing. Tell her to avoid rush hour and busy intersections. Having her hearing and vision tested periodically and using hearing aids and eyeglasses also will increase her safety.

Caring for an older patient after an injury

As with any patient who's suffered a traumatic injury, begin nursing care with a primary and secondary trauma survey. For an older adult, also consider how the following physiologic changes associated with aging may affect your interventions.

Screening can help you detect early or mild cognitive impairment or other age-related neurologic changes that may affect your patient's care. Consider the MiniMental State Exam, which can establish a cognitive baseline and also helps determine a patients cognitive decline over time.