Are Trauma Surgeons Geriatricians Now?
There was a time when the prototypical trauma patient was relatively easy to imagine: A young adult was involved in a motor vehicle crash, suffered a high-energy injury, and arrived at the trauma center with obvious injuries that required rapid diagnosis and treatment.
That patient still exists. But increasingly, the trauma patient looks very different.
Trauma centers are caring for more patients in their 70s, 80s, and 90s. Many are injured in falls at home. Their injuries may include hip fractures, rib fractures, pelvic fractures, traumatic brain injuries, and cervical spine injuries.
These may not be the patients who initially drew many surgeons to trauma. It is also fair to acknowledge that caring for older, medically complex trauma patients can be challenging. Their hospitalizations may be longer and more complicated, often involving multiple consulting services, careful management of comorbidities and medications, and a greater risk of complications and functional decline. Historically, many of these patients were not the primary focus of trauma programs. But as the trauma population has changed and as expectations for identifying and caring for older injured patients have evolved, they have become an increasingly important part of contemporary trauma care.
This raises an interesting question for trauma programs: Are trauma surgeons becoming geriatricians?
In some respects, they have had to.
The Injury Is No Longer the Whole Story
Trauma surgeons have always treated the whole patient and not simply the injury, but in younger patients, the injury is often the primary focus. Surgeons operate, monitor, and discharge.
But the increasing number of older trauma patients changes the complexity of that responsibility. Consider an 85-year-old who falls while walking to the bathroom and sustains several rib fractures. At first glance, this might seem relatively straightforward. But the patient may also have heart failure, COPD, osteoporosis, and mild cognitive impairment. The patient may take 10-12 medications and may already use a wheelchair because of difficulties walking independently.
The rib fractures are still the primary injury, but they are only one part of the patient's clinical problem. Pain can lead to shallow breathing and pneumonia. Opioids can worsen confusion and precipitate delirium. Immobility can rapidly result in functional decline. The trauma surgeon has to consider all of these issues while simultaneously managing the injuries.
The older trauma patient often requires an assessment of the circumstances surrounding the injury, the patient's baseline function, cognitive status, medications, comorbidities, and ability to return to the level of independence that existed before the injury.
The ACS guidelines specifically emphasize an interdisciplinary approach to geriatric trauma beginning in the emergency department and continuing throughout the patient's hospitalization.
So What Does the Trauma Surgeon Need to Know?
Trauma surgeons already manage many of the medical issues that accompany geriatric trauma, such as anticoagulation, respiratory distress, infection, nutrition, pain management, and postoperative complications. They also understand the consequences of traumatic injury in ways that many other specialists do not.
While there may be hesitation among the trauma team to assume responsibility for the full care of these patients, it also doesn't make sense for the trauma team to only care for the injury and consult other medical services for everything else. Trauma surgeons need enough geriatric knowledge to recognize the unique risks facing older patients and to know when additional expertise is needed.
That distinction is important. The trauma surgeon does not need to become a geriatrician. But the trauma surgeon needs to understand the unique challenges of caring for injured older adults and recognize when the patient would benefit from one.
What Does a Geriatrician Bring to the Trauma Team?
A geriatrician is a physician or provider who specializes in the medical care of older adults. Most typically, a geriatrician has completed residency in internal medicine or family medicine and a fellowship in geriatric medicine. Their additional training focuses on the interaction between aging, illness, function, cognition, medications, and quality of life. They are trained to evaluate things such as frailty, delirium and dementia, falls, polypharmacy, functional decline, nutrition, mobility, rehabilitation, goals of care, and the interaction of multiple chronic diseases.
Not every hospital has access to a geriatrician, and not every older trauma patient requires one. An experienced internal medicine physician or hospitalist can provide substantial value to the trauma team, particularly for patients with multiple chronic conditions. Medical co-management can help address medication reconciliation, cardiac and pulmonary disease, renal dysfunction, diabetes, anticoagulation, perioperative risk, and other issues that may complicate recovery.
Where a geriatrician brings additional expertise is in the physiology and functional consequences of aging, namely the role of frailty, cognitive impairment, functional decline, polypharmacy, falls, and complex goals of care.
The point is not to create another layer of specialists around every trauma patient. It is to recognize that older trauma patients sometimes have needs that extend beyond the traditional expertise of a trauma surgeon or even an internal medicine provider. Because a geriatrician approaches the patient through a somewhat different lens, the focus is not only on the acute injury and the patient's chronic diseases, but also on cognition, function, frailty, medications, mobility, nutrition, goals of care, and the patient's ability to maintain independence. Without concerted effort, those issues can easily become secondary when a patient has an obvious traumatic injury. But for an older adult, they may determine the ultimate outcome.
A surgeon may successfully repair a hip fracture. The geriatrician may be thinking about whether the patient will be able to walk again.
The trauma team may appropriately treat the patient's intracranial hemorrhage. The geriatrician may be considering baseline cognitive function, delirium risk, medication management, and what recovery is likely to look like.
The trauma surgeon may determine that a patient can survive an operation. The geriatrician may help the team and family understand what that survival might mean in terms of function and quality of life.
These are not competing perspectives. They are complementary ones.
Does Geriatric Co-Management Actually Make a Difference?
The evidence is encouraging, although it is not a simple story.
A 2020 systematic review and meta-analysis evaluated the effect of geriatric consultation in older trauma patients. They found that geriatric consultation was associated with a mean reduction in hospital length of stay of 1.11 days. However, the analysis did not demonstrate a mortality benefit, and the authors noted that the overall quality of the available evidence was limited. That is an important finding because it illustrates what we should (and should not) expect from geriatric consultation.
A retrospective study of more than 1,300 older trauma patients found that geriatrician consultation improved discharge planning. When the geriatric consult was integrated into the trauma service, discharge to skilled nursing facilities decreased by 67%, accompanied by an increase in discharges home with outpatient services. The authors concluded that geriatrician involvement was associated with more favorable discharge disposition, although the study design cannot establish that the consultation itself caused the change.
A single-center study evaluated a proactive geriatric trauma consultation service involving older trauma patients and found fewer requests for internal medicine and psychiatry consultations and a reduction in delirium from 50.5% to 40.9%. Among patients admitted from home, discharge to long-term care decreased from 6.5% to 1.7% after implementation of the geriatric consultation service.
A study published in JAMA Surgery reported that older adults who received routine geriatric consultation after trauma had better recovery of function over the following year than the comparison group. After adjustment for age, sex, race/ethnicity, length of stay, comorbidities, injury severity, rehabilitation, complications, and surgery, the geriatric consultation group retained an average of 0.67 additional activities of daily living (ADL) abilities compared with controls.
These studies underscore that the value of adding a geriatrician or geriatric-specific care may not be in simply reducing mortality, but rather in improving other outcomes: preventing delirium, preserving mobility, reducing inappropriate medications, improving discharge planning, addressing goals of care, and helping patients return to their previous level of function. For an older adult, those outcomes can be enormously important.
Should Every Older Trauma Patient See a Geriatrician?
Probably not. Age alone is not a sufficient reason to require geriatric consultation.
A healthy 72-year-old with an isolated injury and no significant medical or functional limitations may not need a geriatrician. A frail 72-year-old with dementia, polypharmacy, recurrent falls, multiple chronic conditions, and significant functional limitations may benefit greatly from one.
Trauma programs should therefore consider developing criteria for identifying patients who are most likely to benefit from additional geriatric or medical expertise. Some trauma programs have moved toward targeted consultation based on frailty and geriatric syndromes rather than age alone. For example, Vanderbilt's geriatric trauma practice management guideline identifies severe frailty, polypharmacy, high-risk medications, recurrent falls, persistent delirium, cognitive concerns, multiple high-risk comorbidities, and fragility fractures as triggers for geriatric consultation. This approach recognizes an important distinction: being older does not automatically make someone a geriatric medicine patient, but being older and medically, cognitively, or functionally vulnerable may.
There is not one universal age/criteria threshold for geriatric consultation. The important point is that the decision should be intentional rather than left entirely to chance. Trauma programs should develop criteria for early geriatric consultation and involve providers familiar with geriatric care early in the clinical course.
What Does This Mean for Trauma Program Design?
The changing geriatric trauma population should cause trauma programs to look carefully at their existing processes and ask these questions:
Are older patients being appropriately identified during triage?
Are activation criteria accounting for the possibility that a relatively minor mechanism can produce a serious injury in an older adult?
Is frailty assessed?
Are baseline functional and cognitive status documented?
Are delirium prevention strategies incorporated into routine care?
Are medications reviewed early?
Are physical and occupational therapy involved early enough to prevent unnecessary functional decline?
Are goals-of-care conversations occurring when appropriate?
Does the trauma service have a defined pathway for involving geriatrics, internal medicine, pharmacy, rehabilitation, palliative care, and other disciplines?
The Bottom Line
So, are trauma surgeons geriatricians now? Not really. But they are increasingly caring for patients whose injuries cannot be separated from the realities of aging.
The trauma surgeon still needs to be the expert in trauma. The ability to rapidly diagnose injuries, resuscitate patients, determine the need for surgery, manage complications, and coordinate trauma care remains at the center of the specialty.
What may need to change is the composition of the team around that surgeon. The older trauma patient may need a trauma surgeon, but may also need a geriatrician or internist, pharmacist, physical therapist, occupational therapist, social worker, case manager, nutritionist, and sometimes palliative care. The goal is to build a system in which the trauma service can recognize and address the full range of problems that determine whether an older patient actually recovers.
So while trauma surgeons may not need to become geriatricians, trauma programs do need to become better at caring for geriatric patients.
