Elderly patients who are admitted to the hospital for monitoring and surgical treatment of traumatic injuries could have better geriatric care if medical teams took one extra step -- offering geriatric consultation, according to new research findings from surgical and geriatric medicine teams at the Ronald Reagan University of California at Los Angeles (UCLA) Medical Center. The study is published online as an "article in press" in the Journal of the American College of Surgeons and will appear in a print edition this spring.
When a person over age 65 comes to the emergency room -- most commonly for severe injuries due to falls, according to the Centers for Disease Control and Prevention1 -- the most severely-injured receives care from the trauma surgery team during his or her stay at the hospital. He or she will be monitored for any subsequent injuries like internal bleeding, and then usually discharged.
"Trauma teams are generally good at making sure a range of specialists get involved like neurologists and orthopedists, but typically there is no geriatrician involved," explains the study's lead author Lillian Min, MD, MSHS, assistant professor of geriatric and palliative medicine at the University of Michigan Health System. Geriatricians are physicians who specialize in health issues related to aging, such as dementia and limited mobility.
Many hospitals, however, don't have a geriatric medicine team. "If they do have geriatricians, they are typically consulted very late in the hospital course, sometimes on the day of discharge," explained Dr. Min, who was on the geriatric medicine team at UCLA during the study.
"Generally, older patients don't do as well as younger patients after traumatic injuries," Dr. Min added. In fact, adults over age 65 are the only age group to see an increase in hospital admissions related to trauma, the study authors wrote. "Even for something as simple as several rib fractures, an older patient would require a longer stay due to complications such as pneumonia, needing more pain management or more attention to helping them to walk and return home again, than a younger patient with the same injury."
Dr. Min's research team wanted to examine whether involving geriatric specialists early on could improve outcomes for older adult trauma patients. They offered routine geriatric consultations to 76 patients over age 65 who were admitted to UCLA for trauma care for longer than 24 hours between December 2007 and November 2009. Geriatric medicine specialists collaborated with the trauma surgery team to assess the patients' previous level of functioning, family support, financial challenges, mobility and cognition.
At discharge, the geriatric consultants assessed whether there was a loss of function. "That assessment told us what kind of help they may need at home," Dr. Min said. The plan could include physical therapy, nursing home care or home health care.
The researchers compared those patients with a group of 71 similar patients who were admitted to the hospital the year before, from December 2006 to November 2007 who were not routinely offered geriatric consultation. By analyzing the medical records of both groups, they calculated detailed quality-of-care scores based on 33 quality indicators that scored how well the medical team provided care for the older patients in such areas as cognition, mobility and functional status.
"If someone's grandmother was admitted for trauma care after a fall, the quality indicators reflect whether the team asked about her functional status before the fall," explained Dr. Min. "Was she running up the stairs with a full load of laundry or was she already frail and struggling with mobility? Those are two different levels of functionality. We think that knowing this information is crucial to determining the patients' hospital course, recovery, and how well the team can make a safe discharge plan."
Results showed that the group routinely offered geriatric consultation passed 74 percent of the quality indicators concerning geriatric care, while the group without geriatric consultation only passed 68 percent of the time, a difference that was statistically significant even after adjusting for age and the severity of the injuries.
The consultations also significantly improved care for cognition and delirium by 8.4 percentage points.
"This study is just a start, but the take-home message is that by involving geriatric consultations early on, we could detect that overall care was better," Dr. Min said.
Ideally, more hospitals would have geriatric specialists available to assess frail older adults who are admitted for trauma care, as part of an overall strategy to avoid treatment complications and readmissions. Still, families of older adults can request a geriatric specialist, if one is available at the hospital, Dr. Min advises.
"If there is someone who specializes in aging -- a doctor, a nurse, or a social worker -- do tell them about your loved one's pre-existing medical conditions and disabilities," Dr. Min added. "Alert them early on."
Dr. Min said that families often realize the need for such care if their aging family members come home from the hospital too soon. Then, these patients have to go back to the hospital because their pain is not under control, medications aren't properly reconciled, or more therapy is needed to restore mobility and function.
"Geriatric care may not be available everywhere," Dr. Min said, "so we all have to become geriatricians, for the sake of our family members, especially as our population ages."
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