Hospitalized Injured Older Adults: A 21st Century Challenge by: Cathy A. Maxwell, MSN, RN, and Lorraine C.

Mion, PhD, RN, FAAN Traumatic injury can no longer be regarded as a phenomenon of the young. Trauma affects more than 9% of the U.S. population annually, with the percentage of injured older adults increasing as the population ages. By 2030, the number of injured adults will exceed 7 million annually. Leading causes of injury in persons over age 65 include falls (63.7%) and motor-vehicle-related incidents (12.3%). More than 47% of patients discharged from hospitals with a primary diagnosis are aged 65 or older. Falls are the leading cause of injury in older adults, comprising more than 60% of hospital admissions for injured patients over age 64 and over 80% of hospital admissions after age 84. Falls are the leading cause of traumatic brain injury in older adults, and in turn, traumatic brain injury accounted for 46% of fatal falls. The types of injuries sustained by older adults are similar to those of younger patients, but the severity and consequences of injury can be greater because of physical and physiologic changes associated with aging including loss of muscle mass and fat stores, osteoporotic changes, and diminished physiologic reserve. Compared with younger trauma patients, hospitalized injured older adults (HIOAs) are predisposed to postinjury complications, delays in recovery, readmissions, and shortened post-hospitalization survival. The care and management of HIOAs is more complex given, comorbidities and physical and cognitive impairments. As frontline providers within hospitals, nurses are significant contributors to care of HIOAs in emergency departments, inpatient units, and critical care units. Unfortunately, trauma publications and education programs have not addressed necessary competencies for care of HIOAs. For example, the Emergency Nurses Association (ENA)-sponsored Trauma Nursing Course Provider Manual currently contains a brief (2- page) section on older adult trauma focusing on epidemiology, mechanism of injury, and physiologic differences. There is a need for improvements in the domain of geriatric nursing, in which integration of injury and geriatric-specific directives is sorely needed. In light of these challenges, what do we know regarding predictors f outcomes for HIOAs? Do specific processes of care improve the likelihood of a better outcome? How can nurses prepare to meet this acute care challenge? What Do We Know? Multisite studies on HIOAs show that advancing age and injury severity are leading predictors of worse outcomes such as in-hospital mortality, post-hospitalization mortality, increased hospital length of stay, and development of complications. The presence of underlying comorbidities increases the likelihood of a poor outcome. Although patient characteristics as predictors of are consistent and intuitive, organizational factors and processes of care associated with outcomes of HIOAs are much less studied and are primarily conducted at single sites. Best practices and quality indicators specific to agerelated needs have barely begun to be addressed in trauma-related publications and journals. Despite the dearth of studies for HIOAs, a significant body of literature does exist for the larger domain of hospitalized older adults and findings are applicable as interactions of aging and hospitalization are germane to all hospitalized older adults. Systematic reviews examining relationships

between admission factors and hospital outcomes reveal dominant factors affecting outcomes during hospitalization are functional status and cognitive status. Similarly, systematic reviews examining processes of care associated with outcomes for hospitalized older adults show that interventions addressing geriatric-specific conditions (i.e., functional and cognitive decline) improve outcomes such as functional status, incidence of delirium, and length of hospital stay. These findings draw attention to the need to address these issues in the subdomain of HIOAs. Existing studies and resources and established initiatives provide a foundation that can support the expansion of clinical practice guidelines and research within the field of geriatric trauma. Directives for the Future The Institute of Medicine (IOM) report Retooling for an Aging America: Building the Healthcare Workforce calls for fundamental reform in the way that care is delivered to older adults. The recently enacted Patient Protection and Affordable Care Act includes healthcare workforce enhancements drawn from legislation created from the IOM report. Prominent geriatric resources include programs such as Nurses Improving Care to Health System Elders (NICHE), Hospitalized Elder Life Program (HELP), Geriatric Education Centers (GEC), Association of Directors of Geriatric Academic Programs (ADGAP), the Donald W. Reynolds Foundation, and Care of the Hospitalized Aging Medical Patient (CHAMP). National Initiatives such as the Geriatric Nursing Education Consurtium (GNEC) and the American Nurses Association (ANA)-sponsored Nurse Competence in Aging are programs aimed at maximizing geriatric competence among nurses. Many nursing organizations advocate for delivery of high-quality care to hospitalized older adults, including the ANA, ENA, American Association of Critical Care Nurses (AACN), American Academy of Nurse Practitioners (AANP), and American Organization of Nurse Executives (AONE). The John A. Hartford Foundation Institute for Geriatric Nursing provides directives for nurses and identifies primary competency areas for care of hospitalized older adults. Another important initiative, Assessing Care of Vulnerable Elders (ACOVE), was developed in collaboration between RAND Health and Pfizer, Inc. Over a 10-year period, the ACOVE project has developed 392 quality indicators covering 26 conditions specific to vulnerable elders. The ACOVE quality indicators (QIs) include a subset of 30 QIs that address challenges of hospitalization. Nine of the 30 indicators are related to cognition or functional ability, the leading predictors of outcomes for hospitalized elders. For example, one QI states, IF a hospitalized elder has a suspected or definite diagnosis of delirium, THEN there should be a documented attempt to attribute the altered mental status to a potential etiology. This QI is based on rigorous research that revealed improved outcomes among patients who received this intervention. The ACOVE QIs provide evidence-based approaches in highlighting the processes of care that are most likely to improve outcomes for hospitalized elders. Considering the scarcity of evidence specific to HIOAs, where should we turn for sources to improve quality and direct clinical care and future research? Within individual trauma centers, we must acknowledge that the need for to address injury does not minimize the need to address geriatric specific conditions. Within state trauma systems, we must recognize strengths of all acute care facilities and base our triage decisions on injury and geriatric-specific needs. Within all hospitals (trauma or nontrauma centers), we must avail ourselves of the many resources outlines here to advance evidenced-

based practice for our patients. Clinical initiatives should include interventions aimed at the prevention and treatment of functional and cognitive decline during hospitalization. Discharge planning must be aimed at continuing recovery. Future research should aim to study the related importance of both injury-specific and geriatric-specific interventions in the face of varying injury severity and preadmission factors such as cognitive and functional status. In summary, aging, injury, and hospitalization is a challenging triad for health care providers. Hospitalized injured older adults are a vulnerable and understudied population. As geriatric clinicians I acute care settings, we an advocate for evidence-based care aimed at the whole patient using currently available resources such as ACOVE. Targeted agendas for both clinicians and researchers should include utilization of established resources for care of the broader domain of hospitalized elders. Safe passage through the health care system compels approaches and will require attention and vigilance from all providers. Reference: Geriatric Nsg Vol.32,No.2.Mar/Apr 2011.www.gnjournal.com