**4.3. Risk of bleeding**

In the elderly population, both age-related structural changes and usage of some chronic medications may increase the risk of bleeding. Chronic anticoagulant therapy can increase the risk of hemorrhage, especially intracranial hemorrhage (ICH) [31]. The usage of warfarin at the time of injury also makes mortality significantly higher after the age 70 [32]. Recent data show that Apixaban, dabigatran and rivaroxaban have lower risk of intracranial bleeding compared to warfarin [54]. However, they may potentially carry more risk of major bleeding than warfarin [55]. The influence of preinjury aspirin therapy on bleeding and the mortality is still uncertain [56]. However, the increased risk of subdural hematoma following head trauma was shown in the patients who are under preinjury aspirin plus clopidogrel therapy [57]. Hemorrhage cannot be tolerated appropriately. Therefore, the management of elderly trauma patients who are under anticoagulant therapy requires special care. Early diagnosis, close monitoring and maintaining optimal hemoglobin level are crucial. The optimal hemoglobin level for injured elderly patients is still controversial. A general suggestion is that hemoglobin concentration should be maintained over 10 g/Dl in order to maximize oxygen carrying capacity and delivery. Also, correction of coagulation defects is very important. According to the Eastern Association for the Surgery Trauma, all elderly patients with evidence of posttraumatic ICH on CT with Warfarin should have their INR be corrected toward a normal range within 2 h of admission [58]. Moreover, tranexamic acid, an antifibrinolytic agent, may reduce blood loss after traumatic injury. According to the recent data, tranexamic acid may reduce mortality without significant adverse side effects when given within 1–3 h [59]. The dose is 1 g of tranexamic acid IV bolus over 10 min, followed by 1 g IV over 8 h.

**Pain management** altered physiology changes the way analgesic drugs are distributed and metabolized therefore the pain management of geriatric trauma patient requires extra caution. The main approach should provide optimal treatment of pain while minimizing the risk of medication-related adverse effects. The standardized tools to assess the pain may be beneficial [60] (**Table 2**).


The search of literature mostly suggests that paracetamol should be considered as a firstline treatment for both acute and chronic pain due to its efficacy and good safety profile. NSAIDs are one of the most widely used painkillers. Clinicians must be concerned about the

BNZ: benzodiazepines; CNS: central nervous system; EMLA®: Eutectic Mixture of Local Anesthetics (lidocaine and prilocaine); IV: intravenous; LAs: local anesthetics; NO: nitrous oxide; NPO: nothing per os (by mouth); NSAIDs: nonsteroidal anti-inflammatory drugs, including aspirin: PO: per os (oral); PCA: patient-controlled analgesia; PRN: as

Modified from American Pain Society, Section IV: Management of Acute Pain and Chronic Noncancer Pain. http://

**\***Titrate opioids carefully to maintain stable cardiovascular and respiratory status. Monitor neurological and

**\*\***Contraindications to opioid analgesia include altered sensorium, full-term pregnancy, lung disease or inability to

**Pain type or source**

Burns Acetaminophen,

Minor trauma Acetaminophen, NSAIDs

pain

preemptive analgesia and postprocedural

americanpainsociety.org/uploads/education/section\_4.pdf.

**Table 2.** Systemic medications for acute pain management.

monitor and manage certain side effects (e.g., respiratory depression). **\*\*\***Hypnotic general anesthetic that produces good sedation.

Procedural pain NSAIDs for

needed; TD: transdermal.

NSAIDs, during rehabilitative phase

**Nonopioids Opioids Adjuvant** 

taking PO

High dose of IV opioids ± PCA for NPO patients; oral opioids (e.g., morphine, hydromorphone) when

Opioids for mild-tomoderate pain

IV opioids (e.g., morphine, hydromorphone, fentanyl) unless contraindicated\*\*

neurovascular status continuously in patients with head injury or limb injury, respectively.

**analgesics**

Parenteral ketamine (very

rare) IV lidocaine (very rare)

Local anesthetics (e.g., EMLA®, lidocaine, bupivacaine, ropivacaine) IV ketamine

**Other Comments**

http://dx.doi.org/10.5772/intechopen.77151

Use of ketamine is restricted to pain refractory to other treatments due to severe CNS side effects. Inhaled NO is used for incident pain Infusion of low-dose lidocaine is restricted to burn pain refractory to opioids.

Geriatric Trauma

127

Local anesthetics may be applied topically (e.g., EMLA®), injected into tissue, or used for nerve blocks Use of ketamine limited by severe CNS side effects

BNZ Inhaled NO

BNZ (e.g., diazepam, lorazepam, midazolam) Inhaled NO Propofol\*\*\*


BNZ: benzodiazepines; CNS: central nervous system; EMLA®: Eutectic Mixture of Local Anesthetics (lidocaine and prilocaine); IV: intravenous; LAs: local anesthetics; NO: nitrous oxide; NPO: nothing per os (by mouth); NSAIDs: nonsteroidal anti-inflammatory drugs, including aspirin: PO: per os (oral); PCA: patient-controlled analgesia; PRN: as needed; TD: transdermal.

Modified from American Pain Society, Section IV: Management of Acute Pain and Chronic Noncancer Pain. http:// americanpainsociety.org/uploads/education/section\_4.pdf.

**\***Titrate opioids carefully to maintain stable cardiovascular and respiratory status. Monitor neurological and neurovascular status continuously in patients with head injury or limb injury, respectively.

**\*\***Contraindications to opioid analgesia include altered sensorium, full-term pregnancy, lung disease or inability to monitor and manage certain side effects (e.g., respiratory depression).

**\*\*\***Hypnotic general anesthetic that produces good sedation.

data show that Apixaban, dabigatran and rivaroxaban have lower risk of intracranial bleeding compared to warfarin [54]. However, they may potentially carry more risk of major bleeding than warfarin [55]. The influence of preinjury aspirin therapy on bleeding and the mortality is still uncertain [56]. However, the increased risk of subdural hematoma following head trauma was shown in the patients who are under preinjury aspirin plus clopidogrel therapy [57]. Hemorrhage cannot be tolerated appropriately. Therefore, the management of elderly trauma patients who are under anticoagulant therapy requires special care. Early diagnosis, close monitoring and maintaining optimal hemoglobin level are crucial. The optimal hemoglobin level for injured elderly patients is still controversial. A general suggestion is that hemoglobin concentration should be maintained over 10 g/Dl in order to maximize oxygen carrying capacity and delivery. Also, correction of coagulation defects is very important. According to the Eastern Association for the Surgery Trauma, all elderly patients with evidence of posttraumatic ICH on CT with Warfarin should have their INR be corrected toward a normal range within 2 h of admission [58]. Moreover, tranexamic acid, an antifibrinolytic agent, may reduce blood loss after traumatic injury. According to the recent data, tranexamic acid may reduce mortality without significant adverse side effects when given within 1–3 h [59]. The dose is 1 g

**Pain management** altered physiology changes the way analgesic drugs are distributed and metabolized therefore the pain management of geriatric trauma patient requires extra caution. The main approach should provide optimal treatment of pain while minimizing the risk of medication-related adverse effects. The standardized tools to assess the pain may be

**analgesics**

IV ketamine (very rare)

IV ketamine (very rare)

**Other Comments**

ketamine is restricted to pain refractory to other treatments due to severe CNS side effects Inhaled NO is used for incident pain

ketamine is restricted to pain refractory to other treatments due to severe CNS side effects. Inhaled NO is used for incident pain

Inhaled NO Use of

Inhaled NO Use of

of tranexamic acid IV bolus over 10 min, followed by 1 g IV over 8 h.

**Nonopioids Opioids Adjuvant** 

Bolus or continuous IV opioids\* during emergency phase; PO or IV opioids during healing phase

Bolus or continuous IV opioids during emergency phase plus regional anesthesia

beneficial [60] (**Table 2**).

Acetaminophen, NSAIDs during posttrauma healing

NSAIDs (parenteral, oral) during posttrauma healing

phase

phase

**Pain type or source**

126 Trauma Surgery

Major trauma generalized pain

Major trauma (regionalized pain)

**Table 2.** Systemic medications for acute pain management.

The search of literature mostly suggests that paracetamol should be considered as a firstline treatment for both acute and chronic pain due to its efficacy and good safety profile. NSAIDs are one of the most widely used painkillers. Clinicians must be concerned about the


Unfortunately, these statistics may represent an inaccurate underestimation because elder abuse often is not recognized and tends to be underreported. Elder abuse can be classified into five main categories and manifestations is shown in **Table 3**, but several types of abuse

Geriatric Trauma

129

http://dx.doi.org/10.5772/intechopen.77151

The risk factors can be stated as: shared living situation, social isolation, dementia, female gender, relationship of victim to perpetrator (spouse), personality characteristics of victim

Also it is crucial to screen for elder abuse in geriatric trauma patients, especially who have cognitive impairment or who are unwilling to report it due to fear. Health professionals are well positioned to identify elder abuse, detect vulnerabilities and evaluate interventions. If

abuse or neglect is suspected or confirmed, management strategies should be applied.

Department of Emergency Medicine, Marmara University Pendik Research and Training

[1] U.S. Census Bureau. P23-212, 65+ in the United States: 2010. Washington, DC: U.S. Government Printing Office; 2014. https://www.census.gov/content/dam/Census/

[2] National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-Term Trends in Health. Hyattsville, MD; 2017. https://www.cdc.gov/nchs/data/hus/

[3] López-Otín C, Blasco MA, Partridge L, Serrano M, Kroemer G. The halkmarks of aging. Cell. 2013 Jun 6;**153**(6):1194-1217. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836

[4] Johnson KN, Botros DB, Groban L, Bryan YF. Anatomic and physio pathologic changes affecting the airway of the elderly patient: Implications for geriatric-focused airway management. Clinical Interventions in Aging. 2015 Dec 4;**10**:1925-1934. DOI: 10.2147/

[5] D'Errico A, Scarani P, Colosimo E, Spina M, Grigioni WF, Mancini AM. Changes in the alveolar connective tissue of the ageing lung. An immunohistochemical study. Virchows

Archiv A Pathological Anatomy and Histopathology. 1989;**415**(2):137-144

Address all correspondence to: dr.banuarslan@hotmail.com

library/publications/2014/demo/p23-212.pdf

may occur simultaneously.

(hostility), race (black) [63].

**Author details**

Hospital, Istanbul

hus16.pdf#020

CIA.S93796 eCollection 2015

174/

**References**

Banu Arslan

**Table 3.** Clinical markers indicating abuse or neglect [66, 67].

potentially life-threatening side effects such as gastrointestinal hemorrhage. And, it must be given with proton-pump inhibitor (PPI) cover. In carefully selected and monitored patients, opioids usually provide fast and effective pain relief. The weak opioids including co-codamol, codeine and dihydrocodeine may elicit adverse effects such as cognitional decline and constipation. Although tramadol's GI effects lesser than other weak opioids, potential to precipitate delirium and reduced seizure threshold may limit the usage [61]. Strong opioids include morphine, oxycodone and fentanyl may also be used to treat moderate and severe pain, especially if the pain causes functional impairment. Dose titration based on patient's response is required, in order to avoid side effects such as sedation, nausea or vomiting.

### **4.4. Elder abuse/maltreatment**

Elder abuse is a global public health and human rights problem which is associated with morbidity and premature mortality. According to the latest data, the prevalence of elder abuse can vary widely. In USA, 10% of older adults have experienced some form of elder abuse [62]. Unfortunately, these statistics may represent an inaccurate underestimation because elder abuse often is not recognized and tends to be underreported. Elder abuse can be classified into five main categories and manifestations is shown in **Table 3**, but several types of abuse may occur simultaneously.

The risk factors can be stated as: shared living situation, social isolation, dementia, female gender, relationship of victim to perpetrator (spouse), personality characteristics of victim (hostility), race (black) [63].

Also it is crucial to screen for elder abuse in geriatric trauma patients, especially who have cognitive impairment or who are unwilling to report it due to fear. Health professionals are well positioned to identify elder abuse, detect vulnerabilities and evaluate interventions. If abuse or neglect is suspected or confirmed, management strategies should be applied.
