More Than a Number: Age does matter in your assessment


 
 

A.J. Heightman, MPA, EMT-P | From the April 2009 Issue | Monday, March 30, 2009


We_re delivering emergency care at an interesting time in history, a time when the elderly are living longer and the baby boomers have aged collectively, placing unprecedented call-volume demands on EMS systems.

The elderly are also more mobile than ever before. That can be a blessing or curse depending on how you look at it. I watched a videotaped chase the other night involving four California Highway Patrol vehicles in pursuit of a 100-year-old woman for 30 miles on a freeway. They knew she was elderly, so they didn_t want to do a pit maneuver or spikestrip her tires and cause her to crash and get injured. They kept other vehicles away from her until they could get her to stop.

What did this little grandmother say when she approached the cameras? "I didn_t know they wanted me to stop. I thought they were escorting me home!" Whether she had Alzheimer_s or was just a little confused isn_t relevant, because she was driving a two-ton missile that could kill her and many other innocent people.

During my commute downtown to work each day, I see dozens of elderly folks, zipping along at 10Ï15 mph in battery-powered trauma scooters, just about the right speed to fracture their aging craniums. One lady (I have witnesses!) comes down a hill by our office on her scooter at full speed and either blasts a boat horn or yells at pedestrians to get out of her way.

The fact is that we_re going to see an increasing number of sick and traumatized "older folks," not just the stereotypical 65-plus folks we used to call "the elderly." We_re going to have to pay closer attention to all patients over the age of 55, particularly those who have pre-existing medical conditions and become traumatized.

Recently published "Guidelines for Field Triage of Injured Patients" (www.cdc.gov/fieldtriage) from the Centers for Disease Control and Prevention (CDC) makes it clear that adult trauma victims over the age of 55 are at increased risk for injury and death and should be considered for trauma center transfer when traumatized.

Seasoned EMS providers know that the 55-plus group tends to have a lot going on medically. These patients are often on multiple medications, have co-morbid factors, are stressed out, and more than 30% of them are obese.

To illustrate the predictability of mortality with age, the CDC guidelines cited that one-year mortality rates went from 6.9% for traumatized patients 18Ï54 years old to 10.8% for patients 55Ï64 years old, 17.3% for patients 65Ï74 years old, and a startling 32.2% for those 75Ï84 years old.

Another study of the effect of pre-existing conditions on the mortality ofgeriatric patients showed that every one-year increase in age over 65 corresponded to a 6.8% increase in mortality.

Medical literature points out that aging is a linear process that begins around age 30 and results in 1% of organ function loss per year. So it shouldn_t be surprising to you that the 55-plus age group fits in with what we thought was an elite group often referred to as "reaching retirement age," or elderly. Since the time they hit 30, 55-year-olds have lost 25% of organ function.

Changes may be subtle to the individual because, until they experience a 30% or higher functional loss, degeneration of their body systems may not be readily apparent to them (or you). But aging can have some nasty effects on multiple body systems simultaneously.

The body systems most affected by age include respiratory, cardiovascular, renal, hepatic, gastrointestinal, nervous and musculoskeletal. Therefore, it_s logical that an imbalance of one system often puts a few others out of whack.

The Institute of Medicine_s 2007 report on EMS pointed out that individuals aged 65-plus are almost four-and-a-half times more likely to use EMS services than younger individuals and that 27.5% of 65Ï74 year olds, and more than 40% of those 75-plus, were brought into the emergency department by ambulance.

These numbers are going to continue to climb over the next decade. And with the recent nosedive of the economy, people we used to think would reach 65 and retire can_t afford to do so now because the financial support to maintain the lifestyle they had planned has vanished.

Look at the big picture, and be careful how you use age in your assessment. Be aware that you may begin finding more and more of your "retirement age" patients collapsing in their new place of work instead of at their kitchen table. Read Ray Barishansky and Katherine O_Connor_s article, "Geriatric Trauma" (p. 58), and study the new CDC trauma triage guidelines. Most of all, remember that agedoes matter, and be prepared to manage the increasing demands of this

growing patient population.JEMS

References

  1. MacKenzie EJ, Rivara FP, Jurkovick GJ, et al: "A national evaluation of the effect of trauma-center care on mortality." New England Journal of Medicine. 354(4):366Ï378, 2006.
  2. Grossman MD, Miller D, Scaff DW, et al: "When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma." Journal of Trauma. 52(2):242Ï246, 2002.
  3. "Future of Emergency Care: Emergency Medical Services at the Crossroads." Institute of Medicine of the National Academies: Washington, D.C., 2007.



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Related Topics: Patient Care, Special Patients, Jems From the Editor

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A.J. Heightman, MPA, EMT-P

JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.

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