Geriatric Trauma Management

Publication Date: November 21, 2023
Last Updated: November 22, 2023

Introduction and Acute Care


  • Trauma in older adults is increasing, both in number of cases and as a proportion of the total trauma center volume.
  • Unintentional injury is the seventh leading cause of death for older adults.
  • The outcomes for older adult trauma patients are worse than for younger trauma patients; older age is an independent risk factor for mortality.
  • Falls are the most common cause of injury in older adults and the leading cause of fatal injury.
  • Suicide rates are highest among older adults when compared with other age groups.

Trauma Team Activation & ED Evaluation

  • Injury mechanisms and vital signs do not reliably triage older adult patients.
  • Implement solutions for undertriage and lack of best practices.
  • A best practice for trauma centers is to have defined geriatric trauma activation criteria that are monitored for
  • compliance.
  • Recognize atypical and occult presentations in the geriatric patient.
  • Provide prompt, aggressive resuscitation in the unstable older adult trauma patient, and provide expedient, directed evaluation of the apparently stable older adult patient.
  • Interdisciplinary trauma care beginning in the ED is a best practice for geriatric patients.
  • Use a slow, gentle approach to care when possible. Removal of visual and auditory aids adds confusion and difficulty for older adult patients when responding to questions.

Frailty and Comorbidities


  • Optimal trauma care of the older adult patient must factor in any comorbidities, geriatric-specific syndromes, and reduced physiologic reserve.
  • Frailty syndrome involves decreased physiologic reserves across multiple organ systems, and it is associated with worse outcomes and increased mortality.
  • In trauma patients, frailty is often more predictive of adverse outcomes than age.
  • The Trauma-Specific Frailty Index (TSFI) is an effective, validated tool that can aid clinicians in identifying high risk patients and planning their care.
  • Early assessment and identification of patients with frailty is essential to optimize their care by involving interprofessional teams and implementing focused management plans.


  • Age is a known independent risk factor for delirium.
  • Patient development of delirium is dependent on a complex interaction between predisposing patientrelated factors and precipitating factors during the patient’s in-hospital stay.
  • The Confusion Assessment Method (CAM) and the CAM-ICU are recommended for identification of delirium.
  • Prevention of delirium focuses on minimizing the modifiable risk factors and treatment of underlying conditions that put the patient at risk for delirium.

Cardiac Comorbidities

  • An intravenous beta blocker (e.g., labetalol) or direct vasodilation using hydralazine is a reasonable first-line treatment for initial hypertension management.
  • Judicious fluid administration is good clinical practice for all older adults when they are not actively hemorrhaging.
  • Consider noninvasive cardiac output monitoring or ultrasound to help assess volume status in the acute resuscitation of the patient with heart failure.
  • For trauma patients with atrial fibrillation, maintain cardiac output and ensure perfusion with rate control and thoughtful fluid management.

Anticoagulation Assessment and Reversal

  • Obtain a history of anticoagulant use from all older adult trauma patients, followed by a coagulation profile to identify individuals needing close monitoring or aggressive reversal of anticoagulation.
  • Trauma protocols for rapid anticoagulation reversal are associated with improved outcomes in injured patients.
  • In patients with high thrombosis risk, consider prophylactic doses of easily reversible anticoagulants before reintroducing the full therapeutic dose of a DOAC.


  • The etiology of syncope in older adults can include reflex-mediated causes, orthostatic hypotension, arrythmia, structural disease of the heart, or cardiopulmonary abnormalities.
  • A best practice for older adults presenting with syncope and a serious traumatic injury is hospital-based evaluation and treatment.

Neurologic Comorbidities

  • Preexisting neurological disorders may complicate the initial evaluation of the trauma patient, especially if the patient’s medical history is unknown.

Pulmonary Comorbidities

  • Judiciously administer resuscitation fluids to trauma patients with chronic obstructive pulmonary disease (COPD).
  • When patients with pulmonary artery hypertension (PAH) require surgery, perform it at a center proficient in the treatment of patients with PAH.

Renal Comorbidities

  • Promptly evaluate the patient with acute kidney failure to identify reversible causes, change medication doses, and initiate discussions about renal replacement therapy (RRT).

Infection Comorbidities

  • Determine if an older adult has an infection during the initial admission evaluation.
  • The geriatric patient is at high risk for nosocomial infections.

Substance Use

  • Obtain a substance use history as soon as possible after trauma center arrival to guide the assessment and treatment plan.
  • Use evidence-based tools to closely monitor a geriatric trauma patient with identified substance use for complications from acute intoxication and/or withdrawal (e.g., delirium).
  • Focus screening to identify substance use disorders, including high-risk use, binge alcohol use, and prescription drug misuse.
  • Provide brief interventions based in motivational interviewing and other person-centered approaches that are nonjudgmental and nonconfrontational.

Psychiatric Comorbidities

  • Use well-established screening tools, including instruments designed for older adults, to identify psychosocial comorbidities.
  • Screen older adults for psychiatric comorbidities using sensitive communication skills, keeping in mind that they may be less likely to endorse psychiatric or substance use problems due to stigma or other reporting barriers.
  • A lack of social support and/or social isolation is one of the greatest risk factors for psychiatric comorbidities.

Other Psychosocial Issues

  • Assess geriatric patients for elder abuse and neglect.
  • Promote resilience in older adults with resources and referrals to maintain activity and social connectedness.

Medication Management

Pain Control

  • When planning injury pain management, consider an older adult’s potential for pain related to coexisting illness and other causes of underlying pain.
  • Consider the age-related physiologic changes that affect an older adult’s ability to self-report pain, as well as to respond to pain and pain management medications.
  • Use an opioid-sparing multimodal strategy to manage pain in older adults, including medications, regional analgesia, complementary physical therapies, and cognitive strategies.

Medications and Medication Reconciliation

  • Compile a complete list of all medications taken by an older adult from the individual, a family member, the primary care provider, or the living facility.
  • Use the Beers Criteria to review all medications an older adult usually takes to identify those with higher risk for adverse effects and to reduce polypharmacy.
  • Perform this review on admission, and reevaluate medications prescribed during hospitalization.

Guidelines for General Medication Reconciliation

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General Medication Reconciliation Recommendations
  • Establish an accurate preadmission medication list, including overthe-counter and complementary/alternative medications.
  • Use the Beers Criteria to guide decision-making about pharmacotherapy
  • Clarify home medications with instructions for use as “prn.”
  • Continue or taper medications with withdrawal potential, including SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), chronic benzodiazepines, chronic narcotics, anticonvulsants, antipsychotics, monoamine oxidase inhibitors (MAOIs), clonidine, and corticosteroids.
  • Avoid starting a new benzodiazepine during hospitalization.
  • Use nonopioids early for pain control.
  • Continue a beta blocker or start one, if indicated.
  • Continue statins where appropriate.
  • Adjust doses of medications for renal function based on GFR.
  • Include the diagnosis for antibiotic therapy and identify start/stop dates.
  • Clarify anticoagulation status in all patients.

Additional Guidance
  • Consider contacting the patient’s immediate family, living facility/group home, outpatient pharmacy, or primary care physician to aid in obtaining a current medication list when the patient is unable to provide it.
  • Ask what “prn” means to the patient; some patients may be using prn medications daily and scheduled.
  • Make sure to restart these medications as soon as possible if any are held for surgery.
  • Prescribe a new benzodiazepine, as appropriate, when certain medical situations exist or arise (e.g., seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, and periprocedural anesthesia).

Patient Centered Care

Care of the Older Adult Patient

  • Abuse of the older adult is common and infrequently detected, and the Geriatric Injury Documentation Tool can help with its documentation.
  • Patient-centered interdisciplinary interventions benefit geriatric patients requiring emergency surgery.

Hospital Care

  • Implement a geriatric-friendly hospital environmental design to minimize the hazards of hospitalization.
  • Implement geriatric-friendly care that focuses on delirium prevention, reduced indwelling urinary catheter use, early and safe mobilization practices, nutritional interventions, and promotion of sleep.

Geriatric Interdisciplinary Team

  • Consider a hospitalist consult for all geriatric trauma patients admitted to the trauma service.

Patient Decision-Making Capacity

  • Assessment of an older adult’s capacity is essential in situations that require life-or-death decisions.

Goals of Care

  • Excellent communication is needed to promote patientcentered care.
  • Goals-of-care conversations are an opportunity to engage patients and families in shared decision-making.
  • Quality communication ensures that surgical interventions offered align with a patient’s values and preferences.
  • Time-limited trials can be used in situations where the patient or family is ambivalent or when disagreement exists among the care team and family.
  • Improving communication skills requires training, practice, and feedback.

Family Meetings

  • After learning important clinical information, patients and families value shared decision-making during discussion-oriented meetings.
  • Planning for a family meeting involves having the patient care team reach consensus on a unified message that helps the family gain clarity in a stressful environment.
  • A best practice is having trauma team members prepare caregivers and patients for the postdischarge demands on them, especially if patients are to be released to their homes.

Postacute Care Rehabilitation

Postacute Care Rehabilitation

  • Postacute care (PAC) rehabilitation is an essential service for improving health outcomes of older adults associated with injury and hospitalization.
  • Rehabilitation involves evaluating the patient’s functional needs and establishing goals for improved function to improve the patient’s ADLs and level of independence.

Fall Evaluation and Prevention

  • Falls can result from poor physical condition, multiple medications, and environmental factors.
  • Geriatric patients need a focused fall risk assessment and fall-prevention plan.

Summary of Fall-Prevention Screening and Assessment Recommendations

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Focused Fall istory
  • History of falls: Detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences
  • Medication review: All prescribed and over-the-counter medications, with dosages
  • History of relevant risk factors: Acute or chronic medical problems (e.g., osteoporosis, urinary incontinence, cardiovascular disease)

Physical Examination
  • Detailed assessment of gait, balance, mobility function, and lower extremity joint function
  • Neurological function: Cognitive evaluation; tests of lower extremity peripheral nerves, proprioception, and reflexes; and tests of cortical, extrapyramidal, and cerebellar function
  • Muscle strength (lower extremities)
  • Cardiovascular status: Heart rate and rhythm, postural pulse, blood pressure, and, if appropriate, heart rate and
  • blood pressure responses to carotid sinus stimulation
  • Assessment of visual acuity
  • Examination of the feet and footwear

Functional Assessment
  • Assessment of ADL skills, including use of adaptive equipment and mobility aids, as appropriate
  • Assessment of the individual’s perceived functional ability and fear related to falling
  • Assessment of current activity levels, with attention to the extent to which concerns about falling are protective (i.e., appropriate to given abilities) or are contributing to deconditioning and/or compromised quality of life (i.e.,
  • due to fear of falling, individual is curtailing involvement in activities he or she is safely able to perform)

Environmental Assessment
  • Evaluate and monitor progress toward improving home safety (e.g., lighting, stairs, floors, rugs, showers)
  • Assure patient knows how to properly use assistive devices for mobility and balance (walking aids)
  • Make recommendations about safe living conditions, such as neighborhood sidewalks, uneven ground, and extreme weather (e.g., ice,

Common Medications Associated with Falls Based on the 2023 Beers Criteria

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  • NSAIDs
  • Non-TCA/non-SSRI (SNRIBC)
  • TCA (avoidBC)/SSRI
  • BenzodiazepinesBC
  • Polypharmacy (4 or more medications)
  • Other sedatives (avoidBC), hypnotics
  • Opioids
  • Anticonvulsants (avoidBC)
  • Antipsychotics (avoidBC)
  • Antiarrhythmics (Class 1A)
  • Antihypertensives
  • Loop diuretics

Implementation and Integration

Implementing the Guidelines

  • Trauma medical directors (TMDs), trauma program managers, trauma liaisons, registrars, and staff have a leadership role in implementing and supporting geriatric trauma management BPGs and monitoring facility compliance.
  • Implementation of the geriatric trauma management BPGs starts with a committed stakeholder work group (with representatives from internal medicine [internal/family/geriatric], a hospitalist, orthopaedics, neurosurgery, pharmacy, laboratory, rehabilitation, social work, transfer center, and EMS) that receives its directives from the TMD and trauma operations committee.
  • This work group is charged with completing a gap analysis to identify priorities for developing or revising the trauma center’s geriatric trauma management guidelines, identifying priorities, developing an educational plan to introduce the guidelines, and identifying a matrix with which to measure compliance.

Education Plan

  • Educational tools designed for each phase of care focus on staff member roles and responsibilities.
  • Education is provided to all staff members who have a role in caring for the geriatric trauma patient.
  • The geriatric trauma management BPGs are implemented after the education is completed.

Integrating the Guidelines

  • The trauma program will integrate elements from its defined geriatric trauma management BPGs into the trauma performance improvement (PI) process and trauma registry for review.
  • The trauma registry will integrate geriatric trauma management guideline performance data elements to facilitate reports and outcome reviews.
  • Trauma will integrate geriatric trauma management documentation standards into the EMR.
  • The TQIP geriatric cohort outcomes are specifically included, reviewed, and addressed through the trauma review processes.

Recommendation Grading


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Geriatric Trauma Management

Authoring Organizations

Publication Month/Year

November 21, 2023

Last Updated Month/Year

December 19, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Target Patient Population

Adults aged 65 and above presenting with trauma

Target Provider Population

Surgeons, internists, emergency medicine, critical care, geriatricians and other clinicians caring for adults 65 years and older

Inclusion Criteria

Male, Female, Older adult

Health Care Settings

Emergency care, Hospital, Long term care, Medical transportation, Operating and recovery room

Intended Users

Healthcare business administration, nurse, nurse practitioner, paramedic emt, physician, physician assistant


Management, Rehabilitation

Diseases/Conditions (MeSH)

D000058 - Accidental Falls, D005853 - Geriatrics, D014193 - Trauma Centers


frailty, geriatric falls, trauma, geriatrics, falls