Managing Older Adults with Ground-Level Falls Admitted to a Trauma Service: The Effect of Frailty Bellal Joseph, MD,* Viraj Pandit, MD,* Mazhar Khalil, MD,* Narong Kulvatunyou, MD,* Bardiya Zangbar, MD,* Randall S. Friese, MD,* M. Jane Mohler, PhD,†‡ Mindy J. Fain, MD,†‡ and Peter Rhee, MD*
OBJECTIVES: To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail. DESIGN: Prospective observational study. SETTING: Level 1 trauma center. PARTICIPANTS: All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age SD 79.5 8.3, 54% male). MEASUREMENT: A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. RESULTS: Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9–17), and the mean FI was 0.20 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2–2.3, P = .01). Thirty-six (32.7%) participants were discharged to an institutional facility. Frail participants were more likely to be discharged to an institutional facility (OR = 1.42, 95% CI = 1.08–3.09, P = .03) after a GLF. CONCLUSION: Frail individuals have a higher likelihood of fractures and discharge to an institutional facility after a GLF than those who are not frail. The FI may be used as an adjunct for decision-making when developing a
From the *Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery; †Arizona Center on Aging; and ‡Division of Geriatrics, General Internal Medicine, and Palliative Medicine, Department of Medicine, University of Arizona, Tucson, Arizona. Address correspondence to Bellal Joseph, Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724. E-mail: [email protected] DOI: 10.1111/jgs.13338
JAGS 63:745–749, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
discharge plan for an elderly adult after a GLF. J Am Geriatr Soc 63:745–749, 2015.
Key words: frailty; ground-level discharge disposition; outcomes
falls;
fractures;
T
he population of the United States is rapidly aging, which has led to an increase in the number of traumarelated emergency department visits and hospital admissions in older adults.1,2 Falls are the most common cause of trauma-related injury and the leading cause of traumarelated mortality in elderly adults.3 Recent estimates suggest that more than 2.3 million elderly adults with fallrelated injuries are treated in emergency departments each year, at an estimated cost of more than $30.4 billion.3,4 Ground-level falls (GLFs) are overwhelmingly the most common mechanism of injury, but the extent of injury and the outcomes in older adults with GLF, are highly variable. Elderly adults who have experienced a trauma form a unique cohort of individuals because of their lack of physiological capacity and risk of adverse outcomes after injury.2,5 Assessment of the extent of injury in these individuals and clinical decision-making for older adults is often challenging. Frailty is defined as a state of low physiological reserve and vulnerability due to age-related loss of physical, social, and cognitive functioning.6,7 Frailty has been shown to be an independent predictor of in-hospital complications in elderly adults who have experienced a trauma and for unfavorable discharge disposition,2,5 but frailty has never been evaluated as a risk factor for the extent of injury in elderly adults with a GLF. The aim of the current study was to evaluate the extent of injury and assess the outcomes in elderly adults who have experienced a trauma as a result of a GLF. It was hypothesized that frail elderly adults who experienced a GLF would be at higher risk of fracture and institutionalization than those who are not frail.
0002-8614/15/$15.00
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METHODS After approval from the institutional review board at the University of Arizona, a 1-year prospective analysis was performed of all elderly adults (≥65) who had experienced a trauma and presented to a Level 1 trauma center. All elderly adults who met trauma team activation criteria and were admitted in the hospital after a GLF independent of the treatment team were included. In the Level 1 trauma center at the University of Arizona, all individuals who experience a trauma are evaluated and primarily admitted under the trauma and acute care surgery service, with other services such as neurosurgery and orthopedics surgery as consulting specialties. Individuals who were transferred to the trauma center from other institutions, rehabilitation centers, or skilled nursing facilities were excluded. Intubated, intoxicated, or unresponsive individuals without family representatives for whom a frailty index (FI) could not be calculated were also excluded because there were potential confounding factors for accurately assessing frailty in these individuals. It was also desired to select a homogenous participant population with a GLF to assess the true effect of frailty on outcomes in elderly adults who experience a trauma. Trauma team activation criteria are based primarily on the type and mechanism of injury and hemodynamic status of the individual. These criteria classify individuals who have experienced a trauma into green, white, and red levels. Individuals with insignificant blunt mechanism of injury who are hemodynamically stable are triaged as trauma green, the lowest level of trauma team activation. Trauma red is the highest level of activation. Demographic characteristics (age, sex, race and ethnicity), injury characteristics (type and mechanism of injury), vital parameters on presentation (Glasgow Coma Scale score, systolic blood pressure, heart rate, and temperature), X-ray and computed tomography (CT) findings, hospital and intensive care unit length of stay, and discharge disposition were prospectively recorded. The Injury Severity Score (ISS) and head Abbreviated Injury Scale (h-AIS) score were obtained from the trauma registry. The trauma registry is a mandatory database maintained at all trauma centers as required by the American Association for the Surgery of Trauma. The trauma registry was used only to record the ISS and AIS score, because these are calculated upon discharge and not prospectively collected. A single investigator approached elderly adults with a GLF and an inpatient admission on the first day of their hospital admission for enrollment in the study. After obtaining informed consent, the FI was administered, with an emphasis that the questions assessed the individual’s preinjury health condition. In the case of intubated or nonresponsive individuals, the information was obtained from the individual’s closest relative. Each individual was followed throughout the hospital course, and data were collected. No clinical decisions were made based on the individual’s FI score. Frailty was assessed using a modified FI with 50 variables.8 The majority of the variables were dichotomous (present or absent), whereas others had multiple options. The presence of each variable was scored as a point, and the FI was calculated as total number of deficits divided by
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total number of variables. A higher FI indicated greater likelihood of being frail. A FI score of 0.25 has been established as the standard cutpoint to define frail individuals and was chosen to categorize participants as frail or nonfrail.5,8 The primary outcome measure was incidence of fractures. Fractures were defined as rib, upper extremity, lower extremity, spine, or pelvic fractures. Extremity fractures were confirmed using X-ray findings. Cervical spine fractures were confirmed according to CT of the cervical spine. The on-call radiologist reviewed all X-ray and CT images, and a single investigator (trauma surgeon (BJ)) confirmed the findings. Secondary outcome measures were in-hospital complications, hospital length of stay, and discharge to an institutional facility. In-hospital complications were defined as infectious (pneumonia, sepsis, urinary tract infections) or hematological (deep venous thrombosis, disseminated intravascular coagulation). Discharge to an institutional facility was defined as discharge to a rehabilitation center or a skilled nursing facility. Data are reported as the means SD for continuous variables, medians and ranges for ordinal variables, and proportions for categorical variables. The Student t-test was used for parametric variables and the Mann–Whitney U test for nonparametric variables. While performing the statistical analysis to identify factors associated with outcomes, all factors that could potentially contribute to the outcomes were assessed using univariate analysis. Based on the results of the univariate analysis, all factors with P ≤ .20 were used in a multivariate regression model. This criterion was used based on the published literature commonly describing this statistical analysis. On multivariate logistic regression analysis, variables were considered significant at P ≤ .05. All statistical analyses were performed using SPSS version 20 (SPSS, Inc., Armonk, NY).
RESULTS Three thousand four hundred fifty-one individuals who had experienced a trauma presented to the trauma center during the study period, of whom 458 were aged 65 and older; 167 of these had a GLF, and 110 of these were included in the analysis. Of the 56 excluded individuals, 37 were transferred, 10 did not consent to enroll, and a FI could not be calculated in nine. The mean age of the 110 individuals included in the study was 79.5 8.3, 54% were male, the median ISS was 14 (range 9–17), the median h-AIS was 3 (range 2–3), and the mean FI was 0.20 0.12 (ranging 0.04–0.79). Forty-three (38.2%) participants were frail on admission. The most common injuries were extremity fractures (n = 45), followed by chest injury (n = 14), traumatic brain injury (n = 10), and abdominal injury (n = 2). Table 1 shows the types of fractures occurring in frail and nonfrail participants. Upper extremity fractures were found in 14.5% (n = 16) participants and lower extremity fractures in 18.2% (n = 20). Frail participants were more likely to have femur (P = .04) and tibial (P = .04) fractures than nonfrail participants. Of the 10 participants with femur fractures, four had a hip fracture (fracture of the proximal end of the femur). All four of these
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Table 1. Details of Fractures and Outcomes Frail, n = 43
Variable
Rib, n (%) Upper extremity Humerus Radius Ulna Lower extremity, n (%) Femur Tibia Fibula Spine, n (%) Cervical Thoracic Lumbar Pelvic, n (%) In-hospital complications, n (%) Length of stay, mean SD Hospital Intensive care unit Ventilator days, mean SD Discharge disposition, n (%) Home Rehabilitation Skilled nursing facility Mortality, n (%)
7 (16.3)
Nonfrail, n = 67
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Table 2. Univariate and Multivariate Analysis for Development of Fractures P-Value
5 (7.5)
Univariate Analysis
.12
Multivariate Analysis
Odds Ratio (95% Confidence Interval) P-Value
Variable
6 (13.9) 8 (18.6) 3 (7.0)
6 (8.9) 4 (6.0) 5 (7.5)
.31 .045 .85
7 (16.3) 9 (21.0) 7 (16.3)
3 (4.5) 5 (7.5) 9 (13.4)
.04 .04 .72
1 4 4 2 7
0 1 1 2 3
(0.0) (1.5) (1.5) (3.0) (4.5)
— .04 .04 .71 .03
Frailty index ≥0.25 Age Sex Insurance ED systolic blood pressure ED heart rate ED respiratory rate ED temperature ED Glasgow Coma Scale score Injury Severity Score
6.7 6.1 3.6 3.2 2.1 1.1
5.1 4.9 2.4 2.1 1.8 0.9
.03 .046 .09
ED = emergency department. For univariate analysis, P < .20 was considered significant, for multivariate analysis P < .05 was considered significant.
20 (46.5) 14 (32.6) 8 (18.6) 2 (2.3)
52 (77.6) 10 (14.9) 4 (6.0) 1 (1.5)
.02 .03 .04 .71
(2.3) (9.3) (9.3) (4.6) (16.2)
SD = standard deviation.
participants were frail. Twelve participants had rib fractures, and five had spinal fractures. There was no difference in the incidence of rib fractures between frail and nonfrail participants (P = .12). Ten (9%) participants developed in-hospital complications. In-hospital mortality was 2.7% (n = 3). There was no difference in in-hospital mortality (P = .71) between the two groups. Seventy-two (65.2%) participants were discharged home. Frail participants were less likely to be discharged home after a GLF than nonfrail participants (P = .02).
2.11 1.35 1.09 1.04 1.32
(1.31–4.20) (1.09–3.51) (0.86–2.82) (0.51–4.55) (1.11–1.94)
.001 .04 .15 .61 .04
1.81 1.15 1.02 — 1.13
(1.15–2.32) .01 (0.91–2.23) .14 (0.74–1.52) .32
1.18 1.06 1.15 1.13
(0.91–2.62) (0.89–2.81) (0.91–6.45) (0.72–1.59)
.11 .50 .93 .51
1.06 (0.85–2.12) .21 — — —
1.33 (1.15–3.92) .02
1.21 (1.11–3.23) .04
(0.96–1.31) .14
or greater (P = .01), age (P = .03), insurance status (P = .04), systolic blood pressure (P = .03), Glasgow Coma Scale score (P = .03), fracture (P = .04), and injury severity (P = .02) were associated with discharge to an institutional facility. After adjusting for age, sex, severity of injury, vital parameters, and development of fractures in a multivariate regression analysis, a FI of 0.25 or greater was independently associated with discharge to an institutional facility (P = .03) in participants with a GLF. Table 3 demonstrates the results of univariate and multivariate regression analyses for the factors associated with discharge to an institutional facility.
Table 3. Univariate and Multivariate Analysis for Discharge to an Institutional Facility Univariate Analysis
Multivariate Analysis
Factors Associated with Development of Fractures Forty-five (40.1%) participants developed fractures after a GLF. On univariate analysis for identifying factors associated with the development of fractures in individuals with a GLF, a FI of 0.25 or greater (P = .001), age (P = .04), systolic blood pressure (P = .04), heart rate (P = .12), and injury severity (P = .02) were associated with fractures. After adjusting for age, sex, severity of injury, and vital parameters in a multivariate regression analysis, a FI of 0.25 or greater was independently associated with fractures (P = .01) in elderly adults after a GLF. Table 2 demonstrates the results of univariate and multivariate regression analysis for the development of fractures.
Factors Associated with Discharge to an Institutional Facility Thirty-six (32.7%) participants were discharged to an institutional facility. On univariate analysis, a FI of 0.25
Variable
Frailty index ≥0.25 Age Sex Insurance ED systolic blood pressure ED heart rate ED respiratory rate ED temperature ED Glasgow Coma Scale score Fracture Injury Severity Score
Odds Ratio (95% Confidence Interval) P-Value
1.61 1.12 1.07 1.12 1.18
(1.12–3.44) (1.05–2.21) (0.78–3.12) (1.08–2.81) (1.12–2.32)
.01 .03 .20 .04 .03
1.42 1.09 1.01 1.07 1.11
(1.08–3.09) (0.82–1.92) (0.58–2.45) (0.95–1.52) (0.98–1.82)
.03 .22 .51 .23 .15
1.09 1.12 1.12 1.21
(0.97–3.24) (0.81–1.90) (0.76–2.75) (1.05–2.41)
.19 .50 .62 .03
1.01 (0.65–2.75) .39 — — 1.09 (0.89–2.12) .12
1.14 (1.07–2.21) .04 1.24 (1.12–3.79) .02
1.02 (0.92–1.95) .09 1.17 (0.85–3.12) .11
ED = emergency department. For univariate analysis, P < .20 was considered significant, for multivariate analysis P < .05 was considered significant.
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DISCUSSION GLFs are commonly considered an insignificant mechanism of injury, but a GLF can be devastating in an elderly person. Older adults experience a wide variety of injuries and outcomes from GLFs, and there is a need to identify the contributing factors to improve the management of these medically complex individuals. This study demonstrates that the FI is an effective tool to assess elderly adults with a GLF. Frail individuals who experienced a trauma were more likely than those who were not frail to develop fractures and be discharged to an institutional facility after a GLF. The FI may be used as a screening tool in the assessment of extent of injury and to assist providers in optimizing the outcomes of their elderly adults who have experienced a GLF. GLFs are associated with significant morbidity and mortality in elderly adults who have experienced a trauma.9–12 Frail participants were more likely to have a severe injury than nonfrail participants after a GLF. Several studies have highlighted the importance of a GLF as a significant mechanism in elderly adults, but none of these studies assessed the physiological differences in elderly adults.10–12 Using the concept of frailty to understand an older adult’s physiological capacity provides a valuable assessment tool for injury and outcomes in elderly adults with a GLF. Older age has been associated with worse outcomes in individuals with a GLF.9–12 Frailty was superior to age in predicting outcomes in elderly adults in the current study, and age was not associated with outcomes in elderly adults with falls. Previous studies found a significant association between age and poor outcomes in individuals who experienced a trauma,10,12 but these studies were retrospective and comprised a heterogeneous population of old and young individuals. The FI should be used as a substitute for age as a clinical assessment tool for elderly adults who have experienced a trauma with a fall-related injury. The concept of frailty has been used to predict elderly adults at risk of falls.13–15 Several studies have reported similar findings, with a higher incidence of hip, nonspinal, and spinal fractures in elderly adults,13–15 but all these studies focused primarily on community-dwelling women to assess the recurrence risk for falls. To the knowledge of the authors of the current study, frailty has never been used to assess injury patterns and outcomes after falls, and this is the first study to assess frailty in a subset of elderly adults who experienced a trauma with a GLF. The odds of sustaining a fracture after a GLF was 1.8 times as high in frail elderly adults as in those who were not frail. They were also more likely to have extremity and spinal fractures. Efforts to assess frailty early in the course of management will help identify elderly adults who are at risk of developing significant injuries after a GLF. Early understanding of the extent of injury in elderly adults will ultimately benefit overall care and facilitate appropriate resource allocation. Discharge disposition is an important outcome in the management of individuals after GLFs.2,16,17 A previous study demonstrated a significant association between frailty and discharge disposition.2 Similarly, several other studies have highlighted the relationship between frailty
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and adverse discharge disposition,16,17 but all these studies have focused on individuals who have not experienced a trauma or individuals who have experienced a trauma without stratifying the population based on mechanism of injury. The current study found that frail participants were more likely to be discharged to an institutional care after a GLF than nonfrail participants. By focusing on a subset of participants with a GLF, the current study highlights the importance of the physiological vulnerability of elderly adults who have experienced a trauma. Further understanding of the mechanism of this physiological vulnerability can help develop focused strategies to improve outcomes in elderly adults with fall-related injuries. The ISS and AIS score are well-established markers of poor outcomes in individuals who have experienced a trauma, but they are not available to clinicians during the acute management of patients. The 50-variable FI is a well-established, widely accepted scoring system routinely used for assessing outcomes in elderly adults.6,8 It is based on the individual’s physical, cognitive, psychological, and social functioning. In individuals who have experienced a trauma, the FI has been shown to be an independent predictor of discharge disposition and in-hospital complications. FI was superior to age and ISS for predicting outcomes in elderly adults who have experienced a trauma.2 The FI independently predicted development of fractures and discharge to an institutional facility. Therefore, the FI can help in understanding the extent of injury and may help to improve care, communication with the individual’s family, and hospital resource allocation. The results of this study should be interpreted within the context of its limitations. First, only short-term outcomes were evaluated and not the effect of frailty on longterm functional outcomes and quality of life. Second, although it was a prospective study, it was a single-institution study, and the results might not be generalizable beyond a similar population. Third, although the FI was calculated using 50 variables, not all of the factors known to increase the likelihood of fractures in elderly adults were controlled for. Fourth, the effect of activities of daily living on development of fractures and discharge disposition was not assessed. Nevertheless, this the first known analysis to assess frailty in the subset of elderly adults who have experienced a trauma with a GLF, and it demonstrates poorer outcomes in frail than in nonfrail individuals after falls.
CONCLUSION The FI is an effective assessment tool in elderly adults with GLFs. Individuals with a high FI who experience a GLF are more likely to have multiple fractures and to be discharged to an institutional facility. Early assessment for frailty in elderly adults with falls may aid in their overall management and facilitate the judicious use of hospital resources.
ACKNOWLEDGMENT Conflict of Interest: The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.
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Author Contributions: Joseph, Pandit, Khalil, Friese, Rhee: study design. Joseph, Pandit, Khalil, Kulvatunyou, Zangbar, Friese, Rhee: literature search. Joseph, Pandit, Khalil, Zangbar: data collection. Joseph, Pandit, Khalil, Kulvatunyou, Zangbar, Friese, Mohler, Fain, Rhee: data analysis. All other authors: data interpretation and manuscript preparation. Sponsor’s Role: There was no sponsor for this study.
REFERENCES 1. A Profile of Older Americans: 2010, Administration on Aging, United States, Department of Health and Human Services, 2010 [on-line]. Available at http://www.aoa.gov/aoaroot/aging_statistics/profile/2010/docs/ 2010profile.pdf Accessed September 15, 2014. 2. Joseph B, Pandit V, Rhee P et al. Predicting hospital discharge disposition in elderly trauma patients: Is frailty the answer? J Trauma Acute Care Surg 2014;76:196–200. 3. Falls among older adults: An overview [on-line]. Available at http:// www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html Accessed September 15, 2014. 4. Stevens JA, Corso PS, Finkelstein EA et al. The costs of fatal and non-fatal falls among older adults. Injury Prev 2006;12:290–295. 5. Joseph B, Pandit V, Zangbar B et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis. JAMA Surg 2014;149:766–772. 6. Joseph B, Pandit V, Sadoun M et al. Frailty in surgery. J Trauma Acute Care Surg 2014;76:1151–1156.
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7. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56A:M146–M156. 8. Searle SD, Mitnitski A, Gahbauer EA et al. A standard procedure for creating a frailty index. BMC Geriatr 2008;8:24. 9. Spaniolas K, Cheng JD, Gestring ML et al. Ground level falls are associated with significant mortality in elderly patients. J Trauma 2010;69:821– 824. 10. Helling TS, Watkins M, Evans LL et al. Low falls: An underappreciated mechanism of injury. J Trauma 1999;46:453–456. 11. Sampalis JS, Nathanson R, Vaillancourt J et al. Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level I trauma centers. Ann Surg 2009;249:488– 495. 12. Velmahos GC, Spaniolas K, Alam HB et al. Falls from height: Spine, spine, spine!. J Am Coll Surg 2006;203:605–611. 13. Ensrud KE, Ewing SK, Taylor BC et al. Frailty and risk of falls, fracture, and mortality in older women: The Study of Osteoporotic Fractures. J Gerontol A Biol Sci Med Sci 2007;62A:744–751. 14. Tom SE, Adachi JD, Anderson FA et al. Frailty and fracture, disability, and falls: A multiple country study from the Global Longitudinal Study of Osteoporosis in Women. J Am Geriatr Soc 2013;61:327–334. 15. Ensrud KE, Ewing SK, Taylor BC et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med 2008;168:382–389. 16. Makary MA, Segev DL, Pronovost PJ et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901–908. 17. Lee DH, Buth KJ, Martin BJ et al. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation 2010;121:973–978.
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OBJECTIVES: To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail. DESIGN: Prospective observational study. SETTING: Level 1 trauma center. PARTICIPANTS: All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age SD 79.5 8.3, 54% male). MEASUREMENT: A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. RESULTS: Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9–17), and the mean FI was 0.20 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2–2.3, P = .01). Thirty-six (32.7%) participants were discharged to an institutional facility. Frail participants were more likely to be discharged to an institutional facility (OR = 1.42, 95% CI = 1.08–3.09, P = .03) after a GLF. CONCLUSION: Frail individuals have a higher likelihood of fractures and discharge to an institutional facility after a GLF than those who are not frail. The FI may be used as an adjunct for decision-making when developing a
From the *Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery; †Arizona Center on Aging; and ‡Division of Geriatrics, General Internal Medicine, and Palliative Medicine, Department of Medicine, University of Arizona, Tucson, Arizona. Address correspondence to Bellal Joseph, Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724. E-mail: [email protected] DOI: 10.1111/jgs.13338
JAGS 63:745–749, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
discharge plan for an elderly adult after a GLF. J Am Geriatr Soc 63:745–749, 2015.
Key words: frailty; ground-level discharge disposition; outcomes
falls;
fractures;
T
he population of the United States is rapidly aging, which has led to an increase in the number of traumarelated emergency department visits and hospital admissions in older adults.1,2 Falls are the most common cause of trauma-related injury and the leading cause of traumarelated mortality in elderly adults.3 Recent estimates suggest that more than 2.3 million elderly adults with fallrelated injuries are treated in emergency departments each year, at an estimated cost of more than $30.4 billion.3,4 Ground-level falls (GLFs) are overwhelmingly the most common mechanism of injury, but the extent of injury and the outcomes in older adults with GLF, are highly variable. Elderly adults who have experienced a trauma form a unique cohort of individuals because of their lack of physiological capacity and risk of adverse outcomes after injury.2,5 Assessment of the extent of injury in these individuals and clinical decision-making for older adults is often challenging. Frailty is defined as a state of low physiological reserve and vulnerability due to age-related loss of physical, social, and cognitive functioning.6,7 Frailty has been shown to be an independent predictor of in-hospital complications in elderly adults who have experienced a trauma and for unfavorable discharge disposition,2,5 but frailty has never been evaluated as a risk factor for the extent of injury in elderly adults with a GLF. The aim of the current study was to evaluate the extent of injury and assess the outcomes in elderly adults who have experienced a trauma as a result of a GLF. It was hypothesized that frail elderly adults who experienced a GLF would be at higher risk of fracture and institutionalization than those who are not frail.
0002-8614/15/$15.00
746
JOSEPH ET AL.
METHODS After approval from the institutional review board at the University of Arizona, a 1-year prospective analysis was performed of all elderly adults (≥65) who had experienced a trauma and presented to a Level 1 trauma center. All elderly adults who met trauma team activation criteria and were admitted in the hospital after a GLF independent of the treatment team were included. In the Level 1 trauma center at the University of Arizona, all individuals who experience a trauma are evaluated and primarily admitted under the trauma and acute care surgery service, with other services such as neurosurgery and orthopedics surgery as consulting specialties. Individuals who were transferred to the trauma center from other institutions, rehabilitation centers, or skilled nursing facilities were excluded. Intubated, intoxicated, or unresponsive individuals without family representatives for whom a frailty index (FI) could not be calculated were also excluded because there were potential confounding factors for accurately assessing frailty in these individuals. It was also desired to select a homogenous participant population with a GLF to assess the true effect of frailty on outcomes in elderly adults who experience a trauma. Trauma team activation criteria are based primarily on the type and mechanism of injury and hemodynamic status of the individual. These criteria classify individuals who have experienced a trauma into green, white, and red levels. Individuals with insignificant blunt mechanism of injury who are hemodynamically stable are triaged as trauma green, the lowest level of trauma team activation. Trauma red is the highest level of activation. Demographic characteristics (age, sex, race and ethnicity), injury characteristics (type and mechanism of injury), vital parameters on presentation (Glasgow Coma Scale score, systolic blood pressure, heart rate, and temperature), X-ray and computed tomography (CT) findings, hospital and intensive care unit length of stay, and discharge disposition were prospectively recorded. The Injury Severity Score (ISS) and head Abbreviated Injury Scale (h-AIS) score were obtained from the trauma registry. The trauma registry is a mandatory database maintained at all trauma centers as required by the American Association for the Surgery of Trauma. The trauma registry was used only to record the ISS and AIS score, because these are calculated upon discharge and not prospectively collected. A single investigator approached elderly adults with a GLF and an inpatient admission on the first day of their hospital admission for enrollment in the study. After obtaining informed consent, the FI was administered, with an emphasis that the questions assessed the individual’s preinjury health condition. In the case of intubated or nonresponsive individuals, the information was obtained from the individual’s closest relative. Each individual was followed throughout the hospital course, and data were collected. No clinical decisions were made based on the individual’s FI score. Frailty was assessed using a modified FI with 50 variables.8 The majority of the variables were dichotomous (present or absent), whereas others had multiple options. The presence of each variable was scored as a point, and the FI was calculated as total number of deficits divided by
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total number of variables. A higher FI indicated greater likelihood of being frail. A FI score of 0.25 has been established as the standard cutpoint to define frail individuals and was chosen to categorize participants as frail or nonfrail.5,8 The primary outcome measure was incidence of fractures. Fractures were defined as rib, upper extremity, lower extremity, spine, or pelvic fractures. Extremity fractures were confirmed using X-ray findings. Cervical spine fractures were confirmed according to CT of the cervical spine. The on-call radiologist reviewed all X-ray and CT images, and a single investigator (trauma surgeon (BJ)) confirmed the findings. Secondary outcome measures were in-hospital complications, hospital length of stay, and discharge to an institutional facility. In-hospital complications were defined as infectious (pneumonia, sepsis, urinary tract infections) or hematological (deep venous thrombosis, disseminated intravascular coagulation). Discharge to an institutional facility was defined as discharge to a rehabilitation center or a skilled nursing facility. Data are reported as the means SD for continuous variables, medians and ranges for ordinal variables, and proportions for categorical variables. The Student t-test was used for parametric variables and the Mann–Whitney U test for nonparametric variables. While performing the statistical analysis to identify factors associated with outcomes, all factors that could potentially contribute to the outcomes were assessed using univariate analysis. Based on the results of the univariate analysis, all factors with P ≤ .20 were used in a multivariate regression model. This criterion was used based on the published literature commonly describing this statistical analysis. On multivariate logistic regression analysis, variables were considered significant at P ≤ .05. All statistical analyses were performed using SPSS version 20 (SPSS, Inc., Armonk, NY).
RESULTS Three thousand four hundred fifty-one individuals who had experienced a trauma presented to the trauma center during the study period, of whom 458 were aged 65 and older; 167 of these had a GLF, and 110 of these were included in the analysis. Of the 56 excluded individuals, 37 were transferred, 10 did not consent to enroll, and a FI could not be calculated in nine. The mean age of the 110 individuals included in the study was 79.5 8.3, 54% were male, the median ISS was 14 (range 9–17), the median h-AIS was 3 (range 2–3), and the mean FI was 0.20 0.12 (ranging 0.04–0.79). Forty-three (38.2%) participants were frail on admission. The most common injuries were extremity fractures (n = 45), followed by chest injury (n = 14), traumatic brain injury (n = 10), and abdominal injury (n = 2). Table 1 shows the types of fractures occurring in frail and nonfrail participants. Upper extremity fractures were found in 14.5% (n = 16) participants and lower extremity fractures in 18.2% (n = 20). Frail participants were more likely to have femur (P = .04) and tibial (P = .04) fractures than nonfrail participants. Of the 10 participants with femur fractures, four had a hip fracture (fracture of the proximal end of the femur). All four of these
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Table 1. Details of Fractures and Outcomes Frail, n = 43
Variable
Rib, n (%) Upper extremity Humerus Radius Ulna Lower extremity, n (%) Femur Tibia Fibula Spine, n (%) Cervical Thoracic Lumbar Pelvic, n (%) In-hospital complications, n (%) Length of stay, mean SD Hospital Intensive care unit Ventilator days, mean SD Discharge disposition, n (%) Home Rehabilitation Skilled nursing facility Mortality, n (%)
7 (16.3)
Nonfrail, n = 67
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Table 2. Univariate and Multivariate Analysis for Development of Fractures P-Value
5 (7.5)
Univariate Analysis
.12
Multivariate Analysis
Odds Ratio (95% Confidence Interval) P-Value
Variable
6 (13.9) 8 (18.6) 3 (7.0)
6 (8.9) 4 (6.0) 5 (7.5)
.31 .045 .85
7 (16.3) 9 (21.0) 7 (16.3)
3 (4.5) 5 (7.5) 9 (13.4)
.04 .04 .72
1 4 4 2 7
0 1 1 2 3
(0.0) (1.5) (1.5) (3.0) (4.5)
— .04 .04 .71 .03
Frailty index ≥0.25 Age Sex Insurance ED systolic blood pressure ED heart rate ED respiratory rate ED temperature ED Glasgow Coma Scale score Injury Severity Score
6.7 6.1 3.6 3.2 2.1 1.1
5.1 4.9 2.4 2.1 1.8 0.9
.03 .046 .09
ED = emergency department. For univariate analysis, P < .20 was considered significant, for multivariate analysis P < .05 was considered significant.
20 (46.5) 14 (32.6) 8 (18.6) 2 (2.3)
52 (77.6) 10 (14.9) 4 (6.0) 1 (1.5)
.02 .03 .04 .71
(2.3) (9.3) (9.3) (4.6) (16.2)
SD = standard deviation.
participants were frail. Twelve participants had rib fractures, and five had spinal fractures. There was no difference in the incidence of rib fractures between frail and nonfrail participants (P = .12). Ten (9%) participants developed in-hospital complications. In-hospital mortality was 2.7% (n = 3). There was no difference in in-hospital mortality (P = .71) between the two groups. Seventy-two (65.2%) participants were discharged home. Frail participants were less likely to be discharged home after a GLF than nonfrail participants (P = .02).
2.11 1.35 1.09 1.04 1.32
(1.31–4.20) (1.09–3.51) (0.86–2.82) (0.51–4.55) (1.11–1.94)
.001 .04 .15 .61 .04
1.81 1.15 1.02 — 1.13
(1.15–2.32) .01 (0.91–2.23) .14 (0.74–1.52) .32
1.18 1.06 1.15 1.13
(0.91–2.62) (0.89–2.81) (0.91–6.45) (0.72–1.59)
.11 .50 .93 .51
1.06 (0.85–2.12) .21 — — —
1.33 (1.15–3.92) .02
1.21 (1.11–3.23) .04
(0.96–1.31) .14
or greater (P = .01), age (P = .03), insurance status (P = .04), systolic blood pressure (P = .03), Glasgow Coma Scale score (P = .03), fracture (P = .04), and injury severity (P = .02) were associated with discharge to an institutional facility. After adjusting for age, sex, severity of injury, vital parameters, and development of fractures in a multivariate regression analysis, a FI of 0.25 or greater was independently associated with discharge to an institutional facility (P = .03) in participants with a GLF. Table 3 demonstrates the results of univariate and multivariate regression analyses for the factors associated with discharge to an institutional facility.
Table 3. Univariate and Multivariate Analysis for Discharge to an Institutional Facility Univariate Analysis
Multivariate Analysis
Factors Associated with Development of Fractures Forty-five (40.1%) participants developed fractures after a GLF. On univariate analysis for identifying factors associated with the development of fractures in individuals with a GLF, a FI of 0.25 or greater (P = .001), age (P = .04), systolic blood pressure (P = .04), heart rate (P = .12), and injury severity (P = .02) were associated with fractures. After adjusting for age, sex, severity of injury, and vital parameters in a multivariate regression analysis, a FI of 0.25 or greater was independently associated with fractures (P = .01) in elderly adults after a GLF. Table 2 demonstrates the results of univariate and multivariate regression analysis for the development of fractures.
Factors Associated with Discharge to an Institutional Facility Thirty-six (32.7%) participants were discharged to an institutional facility. On univariate analysis, a FI of 0.25
Variable
Frailty index ≥0.25 Age Sex Insurance ED systolic blood pressure ED heart rate ED respiratory rate ED temperature ED Glasgow Coma Scale score Fracture Injury Severity Score
Odds Ratio (95% Confidence Interval) P-Value
1.61 1.12 1.07 1.12 1.18
(1.12–3.44) (1.05–2.21) (0.78–3.12) (1.08–2.81) (1.12–2.32)
.01 .03 .20 .04 .03
1.42 1.09 1.01 1.07 1.11
(1.08–3.09) (0.82–1.92) (0.58–2.45) (0.95–1.52) (0.98–1.82)
.03 .22 .51 .23 .15
1.09 1.12 1.12 1.21
(0.97–3.24) (0.81–1.90) (0.76–2.75) (1.05–2.41)
.19 .50 .62 .03
1.01 (0.65–2.75) .39 — — 1.09 (0.89–2.12) .12
1.14 (1.07–2.21) .04 1.24 (1.12–3.79) .02
1.02 (0.92–1.95) .09 1.17 (0.85–3.12) .11
ED = emergency department. For univariate analysis, P < .20 was considered significant, for multivariate analysis P < .05 was considered significant.
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DISCUSSION GLFs are commonly considered an insignificant mechanism of injury, but a GLF can be devastating in an elderly person. Older adults experience a wide variety of injuries and outcomes from GLFs, and there is a need to identify the contributing factors to improve the management of these medically complex individuals. This study demonstrates that the FI is an effective tool to assess elderly adults with a GLF. Frail individuals who experienced a trauma were more likely than those who were not frail to develop fractures and be discharged to an institutional facility after a GLF. The FI may be used as a screening tool in the assessment of extent of injury and to assist providers in optimizing the outcomes of their elderly adults who have experienced a GLF. GLFs are associated with significant morbidity and mortality in elderly adults who have experienced a trauma.9–12 Frail participants were more likely to have a severe injury than nonfrail participants after a GLF. Several studies have highlighted the importance of a GLF as a significant mechanism in elderly adults, but none of these studies assessed the physiological differences in elderly adults.10–12 Using the concept of frailty to understand an older adult’s physiological capacity provides a valuable assessment tool for injury and outcomes in elderly adults with a GLF. Older age has been associated with worse outcomes in individuals with a GLF.9–12 Frailty was superior to age in predicting outcomes in elderly adults in the current study, and age was not associated with outcomes in elderly adults with falls. Previous studies found a significant association between age and poor outcomes in individuals who experienced a trauma,10,12 but these studies were retrospective and comprised a heterogeneous population of old and young individuals. The FI should be used as a substitute for age as a clinical assessment tool for elderly adults who have experienced a trauma with a fall-related injury. The concept of frailty has been used to predict elderly adults at risk of falls.13–15 Several studies have reported similar findings, with a higher incidence of hip, nonspinal, and spinal fractures in elderly adults,13–15 but all these studies focused primarily on community-dwelling women to assess the recurrence risk for falls. To the knowledge of the authors of the current study, frailty has never been used to assess injury patterns and outcomes after falls, and this is the first study to assess frailty in a subset of elderly adults who experienced a trauma with a GLF. The odds of sustaining a fracture after a GLF was 1.8 times as high in frail elderly adults as in those who were not frail. They were also more likely to have extremity and spinal fractures. Efforts to assess frailty early in the course of management will help identify elderly adults who are at risk of developing significant injuries after a GLF. Early understanding of the extent of injury in elderly adults will ultimately benefit overall care and facilitate appropriate resource allocation. Discharge disposition is an important outcome in the management of individuals after GLFs.2,16,17 A previous study demonstrated a significant association between frailty and discharge disposition.2 Similarly, several other studies have highlighted the relationship between frailty
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and adverse discharge disposition,16,17 but all these studies have focused on individuals who have not experienced a trauma or individuals who have experienced a trauma without stratifying the population based on mechanism of injury. The current study found that frail participants were more likely to be discharged to an institutional care after a GLF than nonfrail participants. By focusing on a subset of participants with a GLF, the current study highlights the importance of the physiological vulnerability of elderly adults who have experienced a trauma. Further understanding of the mechanism of this physiological vulnerability can help develop focused strategies to improve outcomes in elderly adults with fall-related injuries. The ISS and AIS score are well-established markers of poor outcomes in individuals who have experienced a trauma, but they are not available to clinicians during the acute management of patients. The 50-variable FI is a well-established, widely accepted scoring system routinely used for assessing outcomes in elderly adults.6,8 It is based on the individual’s physical, cognitive, psychological, and social functioning. In individuals who have experienced a trauma, the FI has been shown to be an independent predictor of discharge disposition and in-hospital complications. FI was superior to age and ISS for predicting outcomes in elderly adults who have experienced a trauma.2 The FI independently predicted development of fractures and discharge to an institutional facility. Therefore, the FI can help in understanding the extent of injury and may help to improve care, communication with the individual’s family, and hospital resource allocation. The results of this study should be interpreted within the context of its limitations. First, only short-term outcomes were evaluated and not the effect of frailty on longterm functional outcomes and quality of life. Second, although it was a prospective study, it was a single-institution study, and the results might not be generalizable beyond a similar population. Third, although the FI was calculated using 50 variables, not all of the factors known to increase the likelihood of fractures in elderly adults were controlled for. Fourth, the effect of activities of daily living on development of fractures and discharge disposition was not assessed. Nevertheless, this the first known analysis to assess frailty in the subset of elderly adults who have experienced a trauma with a GLF, and it demonstrates poorer outcomes in frail than in nonfrail individuals after falls.
CONCLUSION The FI is an effective assessment tool in elderly adults with GLFs. Individuals with a high FI who experience a GLF are more likely to have multiple fractures and to be discharged to an institutional facility. Early assessment for frailty in elderly adults with falls may aid in their overall management and facilitate the judicious use of hospital resources.
ACKNOWLEDGMENT Conflict of Interest: The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.
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Author Contributions: Joseph, Pandit, Khalil, Friese, Rhee: study design. Joseph, Pandit, Khalil, Kulvatunyou, Zangbar, Friese, Rhee: literature search. Joseph, Pandit, Khalil, Zangbar: data collection. Joseph, Pandit, Khalil, Kulvatunyou, Zangbar, Friese, Mohler, Fain, Rhee: data analysis. All other authors: data interpretation and manuscript preparation. Sponsor’s Role: There was no sponsor for this study.
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