Perioperative Management of the Geriatric Trauma Patient

Abstract

Purpose of Review

An increasing number of trauma patients are elderly. These patients present unique challenges due to their distinct physiological changes and injury patterns. This article aims to summarize recent literature on perioperative management of geriatric trauma patients for anesthesia providers.

Recent Findings

Ageing is a multisystem process which may impair the ability of the older person to physiologically respond to trauma. The addition of frailty may further increase their vulnerability to complications.

With regards to operative planning, regional anesthesia has not been shown to reduce the risk of delirium compared to general anesthesia. This has been mostly shown with regards to hip fractures, an injury with a high incidence amongst the elderly. There was no reduction in mortality with accelerated hip fracture repair within 6 h of presentation.

Summary

Geriatric patients sustain different injuries and mount more limited physiological responses to trauma than their younger counterparts. Pre-existing frailty amongst the elderly may also contribute to complications in the perioperative period.

Introduction

The 2020 US Census found that 1 in 6 people were over the age of 65 years, a total of 55.8 million people; the fastest growing demographic [1]. This number is projected to increase to 80 million by 2040 and by this time, there will be more people over the age of 65 than children under 18 years [2]. Similar changes are observed in countries around the world [3]. A third of all ambulatory surgical procedures are performed in adults older than 65 years [4] and over 30% of older adults undergo surgery during their last year of life [5].Thus, this demographic will comprise an increasing proportion of the practice of most anesthesiologists. There is a need for specialized geriatric perioperative care. Preoperative evaluation of older adults needs to consider multiple morbidities, polypharmacy and goals of care. Anesthetic requirements are often reduced due to ageing related physiological changes. Anesthetic care of older adults is different, for example, intraoperative hypotension is associated with one year mortality in older adults but not in young adults [6].

As a result of primary disease prevention, public health measures, improved management of chronic illness, declining tobacco consumption, improved occupational protections and better nutrition, more older adults are leading full and active lives. This results in an increase in exposure to potential trauma. Unintentional injury is the 8th cause of death for adults over 65 [7]. Injury accounts for 29% of geriatric presentations to the emergency department (ED) [8].

Older adults are at increased risk for almost all perioperative complications including cardiovascular, pulmonary, renal, central nervous system, wound infection, and death [9]. Healthcare costs for older adults requiring emergency surgery are substantially higher when compared to younger adults, primarily due to increased postoperative costs [10]. Identification of geriatric-specific risk factors is therefore important for patient-centered care [11].

Epidemiology

We must firstly define who an older patient is. Most commonly, this is described as an adult above 65 years of age, which is the definition we have adopted for this article, unless otherwise stated. This is further subclassified to the young-old (ages 65–74), middle-old (75–84) and the oldest-old (≥ 85 years). For a given Injury Severity Score (ISS), older people have a higher mortality than their younger counterparts [12]; the physiological effects of ageing are likely contributors to their poorer prognosis.

Blunt trauma mechanisms predominate amongst the geriatric population, but there is heterogeneity within this group. A recent review showed that the young-old predominantly sustained blunt injuries from motor vehicle collisions (MVC), while amongst the old-old the most common mechanism was ground level falls (GLF) [13]. The elderly are not excluded from the crisis of firearm violence and may also present with firearm injuries, especially self-inflicted [14].

Physiology of Ageing

The term geroscience refers to an interdisciplinary field which aims to understand the relationship between ageing and age-related diseases. A fundamental concept of geroscience is that numerous human diseases arise, at least in part, from ageing itself. This article is not intended to be a review of the physiology of ageing or geroscience in itself, other works explore this topic in more detail [15–17]. Ageing is a multisystem process occurring at the cellular level, with deterioration in cellular structure and function over time. Added to this primary decline, secondary ageing related to disease and environmental factors can accelerate this process. A summary of these system-wide effects and their implications for clinical assessment is shown in Table 1. Table 2 highlights the differences in physiological and laboratory parameters between younger and older patients in the setting of trauma.

Table 1.

Physiological effects of ageing

Organ systems	Physiological changes	Implications
Body composition & Musculoskeletal	Decreased muscle mass and bone density, increased adipose tissue	- Decreased basal metabolism - Increased risk of fall and fractures - Increased lipid soluble drug Vd
Central nervous	Decreased brain mass and neurotransmitter functions	- Increased cognitive impairment - Increased risk of postoperative delirium and cognitive decline - Increased sensitivity to most anaesthetics
Hepato-renal	Decreased liver and kidney mass and blood flow	- Decreased phase I drug metabolism - Decreased drug clearance & increased elimination half-life - Decreased GFR - Reduced fluid & electrolytes homeostatic functions
Cardiovascular	Stiffening of arteries, veins, and myocardium Conduction system change Increased sympathetic activity	- Systolic hypertension, widened pulse pressure, reduced venous reserve capacity - Increased ventricular hypertrophy and diastolic dysfunction - Less cardiac reserve to hyper & hypovolemia - Decreased maximum heart rate - More prone to dysrhythmias - Reduced response to β-receptor stimulation
Respiratory	Loss of muscle tone Increased chest wall stiffness and flattened diaphragm Decreased elastin & lung parenchymal stiffness	- Increased risk of upper airway obstruction and aspiration - Increased work of breathing - Increased residual volume & FRC - More prone to respiratory fatigue - Increased compliance and closing capacity at greater rate than FRC - Increased V/Q mismatch - Decreased resting PaO2
Endocrine	Decreased insulin secretion and increased resistance Decreased growth and sex hormones	- Increased perioperative hyperglycaemia and insulin requirement - Increased sarcopenia
Thermoregulation	Impaired hypothermic vasoconstriction and shivering	- More prone to hypothermia

FRC functional residual capacity, GFR Glomerular filtration rate, Vd Volume of distribution, V/Q Ventilation-Perfusion

Table 2.

Differences in physiological and laboratory parameters between younger and older patients

		Baseline		Trauma
		<65	≥65	<65	≥65
Coagulation	Fibrinogen (mg/dL)	314.1	416	216.2	268.5
	Platelets (×10−9/L)	277	230	248.2	212.4
	PTT (sec)	33.2	27	26.4	28.0
	INR	0.8–1.1		1.1	1.1
Arterial Blood Gases	SPO2(%)	95–100	95.5	97.2	93.9
	Base Excess (mmol/L)	−2 to + 2		−5.48	−2.48
Lab Values	Creatinine (mg/dL)	0.978	1.079	1.005	1.165
	Lactate (mmol/L)	>2.2		3.4	3.2
	Hemoglobin (g/dL)	14.65	14.20	12.89	11.63
Hemodynamic—Cardiac	SBP (mmHg)	118	136	126	140
	HR (beats/min)	86	68	105	91
Hemodynamic—Respiratory	RR (breathes/min)	12–20		18.6	18.7

Preoperative Considerations in Older Adults

Important geriatric-specific preoperative considerations that impact anesthesia planning and patient-readiness for the operating room include:

Undertriage in Geriatric Trauma

When older patients are injured, the extent of their injuries is more likely to be unrecognized compared to their younger peers. Undertriage of older adults is a systemic issue, with evidence that it occurs at all points of contact. Prehospital providers have longer on scene times when tending to geriatric trauma patients [18], older adults are more likely to be triaged to a lower level- or non-trauma center, especially after ground level falls, despite being seriously injured [19]. In the ED, they are less likely to receive a full trauma team activation, even with high ISS [20]. Efforts to improve recognition of severely injured older adults are ongoing. The implications for the anesthesia provider are patients may arrive to the operating room with unrecognized shock and significantly under-resuscitated or may have constellations of injuries that exceed the capacity of the center they have been admitted to.

Identifying Shock in Older Adults

A reason for the undertriage of geriatric trauma patients is the attenuated response older adults may display in response to an acute trauma. Normal hemodynamic thresholds for the identification of shock in adults are of lesser utility in the older adult. Baseline hypertension in the older adults and inability to mount a physiological tachycardia in response to hypovolemia can all contribute to falsely reassuring vital signs and delay the recognition of a profoundly shocked state. National triage guidelines and trauma centers have adjusted their triage parameters for older patients to consider a systolic blood pressure < 110 mmHg [21] and heart rate > 90 bpm [22] reflective of significant hemodynamic disturbance. An age adjusted shock index (HR/SBP x age) has been proposed [23] and validated [24]to improve the predictive value of detecting older adults with severe trauma.

Frailty

Frailty is a state of vulnerability to internal and external stressors due to a decline in reserve and function [25]. Frailty is not synonymous with old age, though older patients are more likely to be frail. Clinically, frailty presents as diminished strength and tolerance of exertion [26]. Frailty may have a greater bearing on outcomes after geriatric trauma than age alone [27].

Frailty is associated with increased perioperative complications, including unscheduled Intensive Care Unit (ICU) admissions, cardiorespiratory complications, prolonged hospital stay, death or discharge to a skilled nursing facility [28]. In this way, frail patients consume more resources during admission, making it imperative to identify these patients early. Though prehabilitation is well described for elective surgery, trauma does not lend itself to such opportunities. Anesthesiologists should consider higher levels of monitoring in the postoperative period, a critical time for postoperative complications which may go unrecognized. Consultation with a geriatric medicine specialist has been shown to improve adherence to geriatric care guidelines [29] and may reduce dependence on others for activities of daily living up to 1 year post discharge [30].

Many scoring systems and performance scales have been developed to identify frail patients. The Trauma-Specific Frailty Index is a validated 15-point tool designed to identify frailty and predict those with an unfavourable discharge disposition; death or skilled nursing facility [31].

Falls with Prolonged Down Time

Patients who have sustained injury in a fall and require surgical intervention may present with significant metabolic derangements from long down times. In one prospective review of older patients who had fallen and called an ambulance, 53% of patients were unable to get up themselves and 13% were on the ground for greater than one hour [32]. Prolonged down times are associated with dehydration, pressure injury and necrosis, rhabdomyolysis, hypothermia and urinary tract infections. The presence of these complications should inform the anesthesia plan.

Alcohol and Recreational Drug Use

An important consideration is the influence of illicit, nonprescription drugs and alcohol. ED visits for alcohol-associated falls amongst older adults is rising [33]. Methamphetamine use amongst elderly trauma patients (> 55 y) quadrupled over a 10-year study period at one Level 1 trauma center [34]. This has implications for anesthesia practice due to acute intoxication or management of withdrawals in the perioperative period. These findings underscore the importance of universal toxicology screening in trauma.

Elder Abuse

Anesthesiologists should consider elder abuse as a cause or contribution to trauma. It is estimated that 1 in 10 older adults are victims of abuse [35]. The American College of Surgeons issued guidance on recognition and intervention in elder abuse [36]; anesthesiologists have an obligation to act on any such concerns.

Prognosis in Geriatric Trauma

There are a number of outcome prediction models specifically for geriatric trauma patients. The Trauma-Specific Frailty Index has been mentioned previously [31]. The Geriatric Trauma Outcome Score (GTOS) is a validated scoring system for predicting death amongst this cohort [37]. The score is given as age + (ISS × 2.5) + 22 (if red blood cell (RBC) transfused within 24 h). The authors developed a nomogram to show the predicted mortality for a given GTOS. As examples, a GTOS of 177 and 233 corresponded to a predicted mortality of 50% and 90%, respectively. The utility of this score is to inform prognostication, goals-of-care discussions and resource utilization.

The GERtality score was developed to provide a simplified way of accurately predicting in-hospital mortality amongst geriatric trauma patients. The score ranges from 0 to 5, with 1 point assigned for each of 5 parameters; age > 80 years, Abbreviated Injury Severity Score ≥ 4, American Society of Anesthesiologists physical status classification ≥ 3, RBC transfusion prior to ICU admission and Glasgow Coma Scale < 14. A score of 0 was associated with 1.6% mortality while a score of 5 correlated with a mortality of 72.4%, when tested on the authors’ local trauma registry [38]. This score awaits validation.

Intraoperative Considerations

Anesthesia Technique: Regional vs General

There has been much debate regarding optimal anesthesia technique for older patients, mostly focused on delirium prevention. Delirium is an acute neuropsychiatric syndrome with a high prevalence among older trauma patients [39]. Delirium is associated with increased rates of complications, longer length of hospital stays, increased mortality and costs [40]. Regional anesthesia was investigated as a possible means to reduce the incidence of postoperative delirium. More trial data is emerging which appears to show an equivalence in outcomes between general and regional anesthesia for older patients. This has been most assessed in femoral neck fractures, an injury associated with high morbidity and economic burden.

The RAGA Randomized Trial (Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery) published its results in January 2022 [41]. The investigators sought to determine if regional anesthesia (RA) for hip fracture surgery reduced the incidence of postoperative delirium as compared to general anesthesia (GA). 950 patients aged 65 years and above with a hip fragility fracture were randomized to either RA without sedation or GA. Patients were assessed with the Confusion Assessment Model daily for 7 days post operatively. The investigators found no difference in the incidence of delirium between the groups; RA 6.2%, GA 5.1%, (unadjusted relative risk [RR] 1.2, [95% CI 0.7 to 2.0]; P = 0.57).

Similar results regarding the incidence of delirium between patients is also an important secondary outcome reported by the REGAIN investigators [42]. This group randomized 1600 patients > 50 years of age who were undergoing hip fracture surgery to receive either spinal anesthesia (sedation allowed for patient comfort) or GA. The primary outcome was a composite of death or a new inability to walk 10 feet without assistance from another person 60 days after surgery, metrics that are important to patients and their families. This occurred in 18.5% of patients following spinal anesthesia and 18% of patients following GA (RR 1.03, [95% CI 0.83 to 1.28]). The authors conclude that spinal anesthesia is not superior to GA in terms of incidence of death, independent walking, delirium or hospital length of stay. The same group subsequently examined similar longer-term outcomes up to 365 days following surgery and, again, found no significant differences between these groups [43]. Also, no difference in patient satisfaction between anesthesia modalities has been found on analysis of the REGAIN study cohort.

The results of the iHOPE study (Improve Hip Fracture Outcomes in the Elderly Patient), a trial designed to examine the incidence of serious cardiac and pulmonary complications following spinal v GA for hip fracture surgery, are awaited [44].

Best available evidence shows no clinically meaningful difference between anesthesia techniques for hip fracture surgery. However, the results quoted above are from pragmatic trials; individual patient and provider factors may make one modality more preferred for that individual. It seems plausible that a one-to-two-hour anaesthetic, either spinal or general, does not influence longer term outcomes. The difference will likely lie in the total perioperative management of that patient, from the emergency room to rehabilitation. The institution of multidisciplinary care bundles has been shown to lower the incidence of postoperative delirium [45, 46]. The American Society of Regional Anesthesia has described an Enhanced Recovery After Surgery (ERAS) protocol to optimize perioperative care and aggressively prevent postoperative complications [47].

The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial questioned whether accelerated time to operative fixation (within 6 h of diagnosis) vs standard care was associated with reduced mortality and morbidity at 90 days post-randomization [48]. No difference in the primary outcomes of mortality or major complications was found between groups. However, those in the accelerated group experienced less postoperative delirium, lower rates of urinary tract infections, earlier mobilization (median 25 h vs 46 h) and shorter length of hospital stay (mean 10 days vs 11 days).

The HIP ATTACK findings demonstrate that myocardial injury associated with hip fracture is relatively common (1 in 5 patients). This trial described a mortality benefit with accelerated surgical fixation specifically in those presenting with an elevated troponin (17 deaths [10%] of 163 accelerated-surgery patients with elevated troponin on admission vs 36 deaths [23%] of 159 standard-care patients with elevated troponin, [95% CI 0.24–0.77]). This finding was explored in greater detail in a subsequent post-hoc analysis [49]. Myocardial injury amongst these patients is often medically managed and surgery may be delayed while awaiting further cardiac testing and stabilization. The authors suggest that myocardial injury may be a direct consequence of the physiological stress of hip fracture in itself, and expedited correction may reduce the duration of this stress. HIP ATTACK 2 is currently recruiting patients > 45 years with low energy hip fractures and an elevated troponin on hospital arrival to provide more evidence on optimal timing of surgery. Society guidelines currently advise operative fixation within 36 h of presentation [50], though some centers aim to operate within 24 h [51]. Preoptimization needs to be carefully balanced with minimizing unnecessary surgical delays.

Airway Management in Spine Fractures and Spinal Cord Injury

Injury Patterns

Both spinal fractures and spinal cord injuries (SCI) are unfortunate consequences of trauma in the elderly. The pattern of acquired injuries differs from younger patients. Younger adults have greater cervical spine flexibility and are more likely to sustain injury at the more mobile C4 to C7 cervical vertebrae. The ageing process can increase rigidity of the cervical spine, making Cl to C2 the most mobile segment and increasing their propensity to injury [52], especially in GLFs.

Odontoid fractures are the most common acute cervical spine fracture amongst geriatric patients [53]. They are uncommonly associated with neurological injuries, presumably due to the size of the spinal canal at this level [54]. When type II fractures (those involving the neck of the odontoid process) are managed conservatively with immobilization, elderly patients have higher rates of non-union [55]. Immobilization in a halo brace is associated with increased risks of venous thromboembolism, deconditioning, aspiration, delirium and skin breakdown in the elderly [56].

The most severe traumatic spinal cord injuries (SCI), those with American Spinal Injury Association (ASIA) impairment scale A or B scores, occur from higher velocity mechanisms. These are more common amongst adults aged 65–75 years of age, who may engage in higher risk activites such as climbing ladders, horse riding etc. Less severe SCI (ASIA C and D) appears to occur more frequently in older adults who sustain GLFs [57]. A common pattern of spinal cord injury (SCI) in the elderly is central cord syndrome. These injuries can occur in isolation, in the absence of bony or ligamentous injury. The most common mechanism is a hyperextension injury of the cervical spine, especially in the setting of preexisting abnormalities such as spondylotic changes. Early surgical decompression is associated with improved recovery of upper limb function [58].

Airway Management

Improper airway management can compound disability in patients suffering from SCI. Researchers have examined the degree of cervical spine motion with different airway manoeuvres and intubating devices. Jaw thrust is associated with cervical spine movement between occiput and C3 when no cervical immobilization is used [59]. Fibreoptic intubation appears to result in less movement of the cervical spine than videolaryngoscopy [59], which in turn causes less movement than direct laryngoscopy [60]. Manual in-line stabilization should be performed when any airway manoeuvres are being carried out in patients with known or suspected cervical spine injury. Even when no concern for spine or cord injury exists, care should be taken during airway management of all elderly patients due to the prevalence of spondylotic changes. Cases of central cord syndrome following intubation for elective surgery have been reported [61, 62].

Traumatic Brain Injury in the Elderly and Reversal of Anticoagulation

Traumatic Brain Injury (TBI) in the elderly is increasing [63]. This is likely due to the rising proportion of the elderly population, increased frequency of falls, increasing use of anticoagulation and atrophic changes that occur in the ageing brain. Comparatively, older adults experience higher TBI-related morbidity and mortality than younger patients, with mortality being highest in those over 75 years of age [64]. The pattern of TBI in older adults differs compared to younger adults. Dural adhesion to the calvarium, cerebral atrophy and stretch of bridging veins make older adults more vulnerable to subdural hematomas (SDH) [65]. Presentation after head trauma may be delayed, as there is increased volume to accommodate hematoma expansion prior to the onset of symptoms. Coexistent cognitive impairment may further delay recognition.

Management of the acutely injured older patient in the perioperative period with an actual or suspected traumatic brain injury should follow the Brain Trauma Foundation Guidelines [66]. Emphasis should be on reducing the degree of secondary brain injury by maintaining appropriate cerebral perfusion. Systolic blood pressure should be maintained at a minimum of 110 mmHg for patients > 70 years.

Given the high prevalence of older adults who are prescribed antiplatelet and anticoagulant drugs, knowledge of how to reverse these medications is critical. The role anticoagulants play in outcomes following TBI is uncertain [67]. Anticoagulation in older patients is associated with worse initial severity of TBI, though outcomes may not be worse when coagulopathy is managed early and aggressively [68]. Reversal is indicated for any patient who has uncontrolled hemorrhage or has signs of bleeding into a critical space, such as the head. While full medication lists may not be available initially, any patient is a candidate for reversal if there is reason to believe an antiplatelet/anticoagulant agent is having a biological effect (usually 4 half-lives after last ingestion).

Common antiplatelet and anticoagulant drugs, and their associated reversal, are shown in Table 3. A more detailed narrative on reversal of anticoagulants in major hemorrhage is worth review [69].

Table 3.

Anticoagulant agents/biological effect/half-life/assays/measurement/reversal

Agents	Mechanism of Action	Half life (hours)	Laboratory test	Reversal or Treatment
Aspirin Clopidogrel Prasugrel Ticagrelor	Irreversible COX-1 inhibitor P2Y12 inhibitors, inhibit ADP receptor platelet aggregation	0.5 (effect lasts 7–10 days) 6–9 (effect lasts 4–7 days)	Aggregometry or TEG platelet mapping	No reversal, Platelet transfusion
Warfarin	Vitamin K antagonist, inhibit synthesis of factors II, VII, IX, X	20–60	PT, INR	Vitamin K (5–10 mg IV) 4-factor PCC (25–50 IU/Kg) FFP
Dabigatran	Direct thrombin inhibitor	12–17	Diluted or standard TT, ECT	Idarucizumab (5 g)
Rivaroxaban Apixaban	Direct antifactor Xa	5–13 8–15	aFXa*	Andexanet alfa ** Low: 400 mg in 15 min then 480 mg over 2 h High: 800 mg in 30 min then 960 mg over 2 h Alternatively, 4-factor PCC
Edoxaban Betrixaban	Direct antifactor Xa	10–14 19–27	aFXa*	4-factor PCC (25–50 IU/Kg) High dose andexanet alfa (off-label)

aFxa antifactor Xa activity.

^*drug specific calibrated or low molecular weight heparin calibrated

^**dose protocol per timing and dose of last anticoagulation medication and aFXa

PCC prothrombin complex concentrate, TT thrombin time, ECT Ecarin clotting time, TEG Thromboelastography

Transfusion in the Elderly

Blood transfusion of older injured adults at risk for major bleeding will need to occur in tandem with reversal of anticoagulation, as indicated. Even though blood transfusion is a tenant of damage control resuscitation, there remains debate about optimal ratios of blood products, optimal coagulation testing to guide transfusion and the optimal blood product to use. The paucity of robust evidence in this area is even more stark for older adults.

In the absence of more geriatric-specific data, these patients are managed like other adult patients, with balanced hemostatic resuscitation, in empiric ratios initially, until hemorrhage control has been achieved, intravascular volume has been restored, oxygen delivery has been optimized and coagulopathy has been corrected.

A retrospective cohort examined 3134 patients over the age of 65 years with traumatic injuries who received a massive transfusion (≥ 10 units Red Blood Cell (RBC) in 24 h or ≥ 5units in 4 h) with the aim of establishing an optimal RBC:plasma ratio for this group [70]. The primary endpoint was 24-h and 30-day mortality. Adjusting for confounders, this group found that patients resuscitated with a 1:1 ratio had lower mortality than those resuscitated at 2:1 ratios or higher.

Other investigators have sought to establish a futility threshold for massive transfusion in the elderly, both based on age and frailty. This was examined by retrospective analysis of the Trauma Quality Improvement Program (TQIP) database which demonstrated that mortality in injured patients increases incrementally by decade and increases with increasing RBC transfusion [71]. Though age should not be a contraindication to high volume transfusion, older patients have a higher mortality for a given RBC transfusion threshold than their younger peers. Older adults who received a massive transfusion also had a higher mortality rate at a given transfusion threshold than younger patients and the odds ratio of an older person dying from their injuries occurred at lower levels of RBC transfusion. However, frailty did not seem to correlate with futility thresholds in this cohort [72].

A second group to consider is the hemodynamically stable, anemic geriatric patient coming for surgery related to their injury. The American Association of Blood Bankers recently published updated guidelines on Red Blood Cell Transfusion [73]. While not specific to geriatric patients or trauma, these guidelines recommend a restrictive transfusion strategy where RBC transfusion is considered when hemoglobin concentration falls below 7 g/dl (strong recommendation, moderate certainty evidence). Transfusion can be considered for those having orthopedic surgery or those with a history of cardiovascular disease for hemoglobin concentrations below 8 g/dl. Restrictive transfusion thresholds reduce patient exposure while not increasing mortality. It is worth underscoring that these thresholds apply to hemodynamically stable individuals. The rapidity and physiological adaptation to anemia, underlying medical comorbidities and the anticipated surgical blood loss will all influence this threshold.

Postoperative Considerations

Failure to Rescue

Failure to rescue (FTR), defined as a death from a major complication [74], is a healthcare quality metric. It predominantly reflects the processes in place for recognizing and reacting to the development of clinical deterioration. Frail patients had a significantly higher FTR rate than non-frail or pre-frail individuals (non-frail: 4.6%, pre-frail: 3.5%, frail: 14.5%, p < 0.001) in a prospective group of 368 geriatric trauma patients [28]. This finding has been borne out in a more recent retrospective analysis of TQIP data [75]. Increasing age and ISS are also related to FTR events [76]. Identification of these patients early in their hospital course can prompt increased vigilance for complications.

Conclusions

Geriatric populations are increasing worldwide. Geriatric patients sustain different injuries and mount more limited physiological responses to trauma than their younger counterparts. Failure to recognize the severity of injury in a geriatric patient makes them vulnerable to poorer outcomes. Pre-existing frailty amongst the elderly may also contribute to complications in the perioperative period. These patients should be identified early and considered for higher levels of care.

Recent studies have not shown that regional anesthesia reduces the risk of postoperative delirium versus general anesthesia, specifically in hip fracture surgery. The optimal timing of hip fracture fixation is still to be elicited with a suggestion that correction within 6 h of presentation reduces delirium and hospital length of stay. An increasing proportion of elderly patients are on anticoagulant medications; anesthesia providers must be familiar with the reversal of these agents.

Data Availability

No datasets were generated or analysed during the current study.