ACS TQIP

GERIATRIC TRAUMA
MANAGEMENT
GUIDELINES

Released October 2013

 Table of Contents
Background and Introduction.............................................................................................. 3
Trauma Team Activation......................................................................................................... 3
Initial Evaluation........................................................................................................................ 3
Specialized Geriatric Inpatient Care................................................................................... 5
Patient Decision-Making Capacity and Care Preferences........................................... 6
Discharge..................................................................................................................................... 7
Appendix I................................................................................................................................... 9
Beers Criteria for Potentially Inappropriate
Medication Use in Older Adults
Appendix II................................................................................................................................ 17
Legally Relevant Criteria for Decision-Making Capacity
and Approaches for Assessment of the Patient
Screening for Depression
Screening for Alcohol and Substance Abuse
Assessing Baseline and Current Functional Status in Ambulatory Patients
Assessing Gait and Mobility Impairment and
Fall Risk in Ambulatory Patients
Frailty Score: Operational Definition
Frailty Score
Screening for Nutritional Risk
Bibliography............................................................................................................................. 21
References................................................................................................................................. 27
Expert Panel............................................................................................................................. 28

2
Background and Initial Evaluation
Introduction The primary survey for the elderly is the same
as for any injured patient, but the secondary
Traumatic injury in the geriatric population is survey should emphasize the following:
increasing in prevalence and is associated with
higher mortality and complication rates compared zz Determine medications that affect
with younger patients. An appreciation for the initial evaluation and care.
decreased physical reserve, presence of various
comorbid diseases, and increased risk of elderly-  Coumadin
specific complications such as delirium that are  Clopidogrel
more common in elderly patients has prompted
 Other anticoagulants
development of elderly-specific care protocols within
the multidisciplinary trauma service model. The aim  ASA
is to employ better risk assessment, adherence to  Beta blockers
key preventive strategies, active surveillance, and
prompt recognition and treatment of complications  ACE inhibitors
when they occur to reduce mortality and morbidity
zz Consider common, acute, nontraumatic
in this patient population. This document serves
events that could complicate the
to consolidate recommendations from existing
patient’s presentation, including:
guidelines to provide concise, evidence-based,
expert panel rated lists of protocols and practices  Acute coronary syndrome (EKG)
to improve trauma care among elderly patients.
 Hypovolemia/dehydration
 Urinary tract infection
 Pneumonia
Trauma Team Activation  Acute renal failure
 Cerebrovascular event
Elderly patients can experience significant injury
in spite of a relatively trivial mechanism. Because  Syncope
of altered baseline vital signs due to changes
associated with aging, preexisting disease (for zz Lab assessment:
example, hypertension), or medications (for example,
Hypoperfusion is often underappreciated in
beta-blockers), the physiologic response to injury
the elderly. Base deficit should be assessed
might differ from that seen in younger patients.
expediently to identify those patients in occult
Alterations in mentation may be attributed to
shock who need resuscitation, abbreviated
dementia or delirium, leading to the potential for
evaluation, and admission to an intensive care
late recognition of shock or traumatic brain injury.
unit. The following panel of laboratory studies
These factors increase the risk for undertriage
is suggested for all elderly patients with injury:
by both emergency medical services (EMS) and
emergency department (ED) personnel. Undertriage  Lactic acid or blood gas (arterial or
of the elderly is associated with a two-fold increase venous) for baseline base deficit
in the risk of death. To mitigate late recognition of
significant injuries, a lower threshold for trauma team  PT/PTT/INR
activation should be used for elderly trauma patients.  Renal function (BUN, Cr, estimated GFR)
In many cases, this approach would require elevating
 Blood alcohol level
the level of activation by one tier based on age.
 Urine toxicology screen
zz Ensure trauma team activation for
 Serum electrolytes
all elderly injured patients meeting
trauma criteria (first or second tier).

3
zz Imaging: zz Anticoagulation reversal:

Occult injuries are common in the elderly. This field and the availability of products for
Initial imaging should include liberal use of reversal are also changing rapidly. A protocol
computed tomography (CT) scanning for to rapid anticoagulation reversal is associated
blunt injury. While the liberal use of CT scan with improved outcomes in injured patients.
imaging has become controversial because
of concerns of radiation exposure and cost,  It is suggested that a rapid anticoagulation
occult injuries are common in the elderly reversal protocol be developed in each
and radiation exposure is of minimal risk. center based on the availability of products,
local costs, and preferences. In general, the
 Imaging should include all CT scans needed following principles should be applied:
to rule out injury in appropriate areas at risk.  Warfarin reversal: While reversal of
zz Anticoagulation assessment and reversal: warfarin was typically managed using a
combination of vitamin K and plasma in
The frequent use of warfarin, antiplatelet the past, the availability and assessment of
agents (for example, clopidogrel, aspirin), direct newer prothrombin complex concentrates
thrombin inhibitors (for example, dabigatran), (PCC) have provided other options. PCCs
and direct factor Xa inhibitors (for example, available as four-factor concentrates (II,
rivaroxaban) in the elderly puts them at higher VII, IX, and X) can reverse the effects of
risk for significant bleeding events, even in the warfarin rapidly and are considered the
context of minor injury. Additionally, with the standard in most countries other than
exception of warfarin, where anticoagulant effect the U.S. At this time, only three-factor
parallels the international normalized ratio (INR), concentrates are available in the U.S.
an assessment of the level of anticoagulation is These PCCs lack factor VII and must
not possible with laboratory investigations that either be given with plasma or rVIIa.
are routinely part of the initial evaluation of the
injured patient. This field is changing rapidly,  Dabigatran: There is no means of reversing
but the following general principles apply: dabigatran. While dialysis can be used,
it is often not practical in the context of
 A normal INR should exclude the presence acute resuscitation. As dabigatran is an
of significant levels of dabigatran or inhibitor of direct thrombin inhibitor,
other novel anticoagulants in most, but administration of plasma is not effective.
not all, patients; however, note that the  Rivaroxaban: Like dabigatran there is no
INR might be only minimally increased agent that directly reverses the effects
in the presence of therapeutic doses of of this factor Xa inhibitor. However,
dabigatran. Rivaroxaban increases the INR early studies suggest that the effect
at therapeutic levels, but the effects are might in part be reversed by PCCs.
not equivalent to target levels of warfarin.
 Clopidrogel, aspirin: There are no
 Partial thromboplastin time (PTT) might agents that directly reverse the effects
be slightly prolonged with dabigatran, of these platelet antagonists. DDAVP or
depending on the instruments/reagents platelet transfusion can be considered
used for laboratory assessment. Rivaroxaban in the face of significant bleeding.
might cause mild PTT prolongations in
most patients with therapeutic levels.
 Other tests:
 Thrombin time: Dabigatran increases
the thrombin time (TT). A normal TT
excludes Dabigatran; however, note that
Rivaroxaban does not prolong the TT.
 Thromboelastography (TEG): TEG is
useful in identifying the presence of
dabigatran or ribaroxaban effect. TEG
will also identify the presence of effects
of platelet inhibitors like clopidrogel.

4
 zz If the response to two or more of the
following questions is “yes,” geriatric
Specialized Geriatric consultation should be obtained:
Inpatient Care  Before you were injured, did you need
someone to help you on a regular basis?
A proactive geriatric consultation is one in which an
individual with expertise in the management of the  Since the injury, have you needed more
geriatric patient (most often a geriatrician) evaluates help than usual to take care of yourself?
a patient early following hospitalization and prior to  Have you been hospitalized for one or
complications developing. This evaluation includes more nights during the past six months?
a comprehensive geriatric assessment (CGA), which
is a multidimensional, multidisciplinary diagnostic  In general, do you have
instrument designed to collect data on the medical, problems seeing well?
psychosocial, and functional capabilities and  In general, do you have serious
limitations of elderly patients. The information problems with your memory?
derived from this assessment assists in developing  Do you take more than three
treatment and follow-up plans. In 22 randomized different medications every day?
trials including more than 10,000 patients, a CGA
followed by appropriate treatment and follow- Geriatric trauma patients are at particular risk
up increases a patient’s likelihood of being alive for medication-related adverse events.
and in his or her own home at one year following
discharge by 25 percent. In trauma, proactive zz Establish past medication history.
geriatric consultation has been associated with  Attempt to communicate with the patient’s
fewer episodes of delirium, fewer in-hospital falls, immediate family and physician.
lesser likelihood of discharge to a long-term care
facility, and a shorter length of stay. An alternate  Document the patient’s complete
approach is to concentrate care of the geriatric medication list, including over-the-counter
patient so that care pathways are developed and and complementary/alternative medication.
expertise accrues to benefit the patient. For example,
zz Use the following geriatric medication
Mangram et al developed a geriatric trauma service
prescribing recommendations:
(“G-60 service”) in which all patients age > 60 were
admitted. This service worked in collaboration  Follow Beers Criteria. Use Beers
with a medical hospitalist, physiatrist, physical/ Criteria in decision making about
occupational therapist, respiratory therapist, pharmacotherapy. See Appendix 1.
nursing supervisor with geriatric expertise, social
worker, nutritionist, pharmacist, and a palliative  Discontinue nonessential medications.
care specialist. Implementation of this service  Continue medications with withdrawal
was associated with a reduction in time to the potential, including selective serotonin
operating room (OR), hospital and ICU length reuptake inhibitors (SSRIs), tricyclic
of stay, and rates of several complications. antidepressants, benzodiazepines,
antipsychotics, monoamine oxidase
zz Develop criteria for early geriatric inhibitors (MAOIs), beta blockers,
consultation and geriatric expertise on the clonidine, statins, and corticosteroids.
multidisciplinary trauma care team.
 Continue β-blocker or start if indicated.
Where limitations with geriatrician resources  Continue statins when appropriate.
impede routine geriatric consultation, the following
screening criteria may identify patients most  Adjust doses of medications for renal
likely to benefit from geriatric consultation. These function based on glomerular filtration rate.
criteria were adapted from the Identification of
Seniors at Risk (ISAR) screening tool. A positive
ISAR (>=2) has been associated with a greater
likelihood of functional decline, nursing home
admission, long-term hospitalization, or death.

5
Effective pain management can be a central
determinant of success in the drive to
improve pulmonary and toilet functions, Patient Decision-
optimize mobility, and mitigate delirium.
Making Capacity and
zz The following pain medication
strategies are recommended:
Care Preferences
More than 40 percent of patients require decision
 Use elderly-appropriate
making near the end of life, with 70 percent of those
medications and dose.
patients lacking decision-making capacity. Injured
 Avoid benzodiazepines. patients and their families are suddenly thrust into
 Monitor use of narcotics; consider a situation where health and subsequent quality of
early implementation of patient- life are placed in jeopardy. Unfortunately, decision
controlled analgesia. making and treatment preferences may not have
been established. The patient’s current condition
 Consider early use of nonnarcotics, and prognosis should be clearly communicated to
including NSAIDs, adjuncts, and tramadol. the patient and their family. Important decisions
 Epidural algesia may be preferable to that will need to be made regarding treatment
other means for patients with multiple must be emphasized so that patient treatment
rib fractures to avoid respiratory failure. preferences can be considered. Treatment burden
and potential functional outcome play a large role
It is important to obtain preinjury chronic in the decision-making process. In cases of impaired
medical conditions and functional status soon cognition, identification of the proxy decision maker
after admission. While it may not be possible is of importance, while realizing that surrogates
to obtain this information immediately, it is may not always be fully aware of the patient’s
imperative to do so as part of the tertiary survey treatment preferences. Liberal use of palliative care
to facilitate hospital care and discharge planning. services can help with complex decision making.
The compilation of this information and the
development of a subsequent care plan may be zz Discuss with family, surrogates, and
performed by a formal geriatrician consult or by the health care team and document in
adding personnel with geriatric expertise to the the medical record the following:
multidisciplinary trauma team. See Appendix 2.
 Patient’s priorities and preferences
zz Establish past history of elderly- regarding treatment options (including
specific comorbidities, including: operative and nonoperative alternatives)

 Pulmonary disease  Postinjury risks of complications,

mortality, and temporary/
 Chronic renal failure permanent functional decline
 Chronic anemia  Advance directives or living will and
 Depression how these will affect initial care and life-
sustaining preferences, including mechanical
 Baseline cognitive impairment ventilation, cardiopulmonary resuscitation
 Baseline functional impairment (CPR), hemodialysis, blood transfusion,
 Baseline frailty scores permanent enteral feeding, and transition
to comfort care should complications occur
 Baseline nutritional status
 Identify surrogate decision maker
 Alcohol, tobacco, drug abuse or dependence
(benzodiazepines, oxycodone)  Make liberal use of palliative care options

 Thyroid dysfunction  In appropriate setting, present hospice

as a positive active treatment
 Glucose intolerance
 Decubitus ulcer

6
zz Hold a family meeting within 72 hours The elderly may have limited reserve to
of admission to discuss goals of care. tolerate changes in intravascular volume.
It is important to prevent or correct occult
Delirium is common in elderly patients after hypovolemia as well as volume overload.
injury and is associated with increased morbidity
and mortality. It is important to assess the zz Monitor the patient’s fluid status
patient’s baseline cognitive function, assess with the following:
risk factors for delirium, and monitor for signs
and symptoms of delirium on a daily basis.  Daily fluid inputs and outputs
The Mini-Cog is a short assessment tool that  Daily weights
can be used for this purpose. Knowledgeable
informants, such as family, may need to assist  Consider central venous pressure monitoring
in providing preinjury baseline status.  Consider noninvasive cardiac
output in the ICU
zz Regularly evaluate and address
delirium risk factors: Postoperative and in-hospital complications
contribute to extended length of stay, functional
 Cognitive impairment and dementia outcome, and cost for the trauma patient. In
 Depression traumatically injured patients, functional ability,
including gait and fall risk, should be assessed as
 Alcohol use early as possible and compared with established
 Polypharmacy and psychotropic medications baseline function. Early mobilization and the use
 Poor nutrition of standardized care bundles can help prevent
development of many iatrogenic complications.
 Hearing and vision impairment
zz Protect patients from iatrogenic
zz Regularly monitor for reversible complications and functional decline:
causes of delirium:
 Develop a plan for early mobilization. Ensure
 Wake-sleep cycle disturbances ambulation within 48 hours of admission.
and sleep deprivation
 Assess for fall risk and address.
 Immobilization
 Institute aspiration precautions:
 Hypoxia
 Infection  Head of bed elevation at all
times with repositioning.
 Uncontrolled pain
 Sitting upright while eating and two
 Renal insufficiency, dehydration, hours after completion of eating.
and electrolyte abnormalities
 Evaluate for swallowing deficits.
 Urinary retention or presence
of urinary catheter  Perform chest physical therapy by incentive
 Fecal impaction or constipation spirometer or deep breathing exercises.

 Use of restraints  Place on bowel regimen if given opiates.

 Perform screening for:

 Presence for pressure ulcers with

Braden or Norton scale within
24 hours of diagnosis.
 Daily documentation of skin integrity.

7
 zz Communicate the results of the hospitalization
to the patient’s primary care physician (PCP).
Discharge Provide PCP with the discharge summary. Verbal
communication with the PCP can be very helpful.
Traumatic injury is a sentinel event that can
precipitate a trajectory of functional decline in zz Provide the receiving facility with a discharge
older patients. Studies show that the majority (up summary prior to the patient’s departure
to 88 percent) of seriously injured older patients fail from the hospital. Verbal communication with
to return to their previous level of independence the receiving facility can be very helpful.
and function, with many requiring long-term
nursing home placement. In addition to medical zz Arrange for a home health visit or
comorbidities that accompany aging, psychosocial follow-up phone call within one to
issues (for example, availability of a caregiver, home three days of discharge to assess:
safety) complicate the hospital and postdischarge
care of these patients. Despite the magnitude  Pain control
of the problem, little is known about how to  Tolerance of food, liquids
improve functional outcomes of injured elderly.
 Ability to ambulate
zz Begin developing a plan for transition  Mental status
to posthospital care or special unit care
in the immediate postinjury period.  Understanding of postdischarge
instructions/medications
zz Assess the following discharge planning
issues early during hospitalization:

 Home environment, social support, and

possible needs for medical equipment
and/or home health services
 Patient acceptance/denial of nursing home
or skilled nursing facility placement

zz Provide the patient or caregiver with a

written discharge document, including:

 Discharge diagnosis
 Medications and clear dosing
instructions and possible reactions
 Documentation of reconciliation between
outpatient and inpatient medications
 Directions for wound care
 Instructions for diet (nutrition
plan) and mobility
 Needs for physical and occupational therapy
 Contact information for the patient’s
continuity physician or clinic
 Establish an appointment with continuity
physician, specialty physicians, or clinic
 Clear documentation of incidental
findings that mandate follow-up
 Documentation of follow-up
appointment/telephone contact with
the surgeon six weeks after surgery
 Documentation of pending laboratory
tests or diagnostic studies, if applicable

8
Appendix 1
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
A n t i c h o l i n e r g i c s (e x c l u d e s T C A s)
First-generation Highly anticholinergic; clearance Avoid Hydroxyzine Strong
antihistamines (as single reduced with advanced age, and
agent or as part of and tolerance develops when promethazine:
combination products) used as hypnotic; increased High
zz Brompheniramine risk of confusion, dry mouth,
zz Carbinoxamine constipation, and other All others:
zz Chlorpheniramine anticholinergic effects/toxicity Moderate
zz Clemastine Use of diphenhydramine in
zz Cyproheptadine special situations such as acute
zz Dexbrompheniramine treatment of severe allergic
zz Dexchlorpheniramine reaction may be appropriate
zz Diphenhydramine (oral)
zz Doxylamine
zz Hydroxyzine
zz Promethazine
zz Triprolidine
Anti-Parkinson agents Not recommended for Avoid Moderate Strong
zz Benztropine (oral) prevention of extrapyramidal
zz Trihexyphenidyl symptoms with antipsychotics;
more effective agents
available for treatment
of Parkinson disease
Antispasmodics Highly anticholinergic, Avoid except Moderate Strong
zz Belladonna alkaloids uncertain effectiveness in short-term
zz Clidinium- palliative care
chlordiazepoxide to decrease oral
zz Dicyclomine secretions
zz Hyoscyamine
zz Propantheline
zz Scopolamine
Antithrombotics
Dipyridamole, oral short- May cause orthostatic Avoid Moderate Strong
acting* (does not apply hypotension; more effective
to the extended-release alternatives available; IV
combination with aspirin) form acceptable for use in
cardiac stress testing
Ticlopidine* Safer, effective Avoid Moderate Strong
alternatives available
Antiinfective
Nitrofurantoin Potential for pulmonary toxicity; Avoid for long- Moderate Strong
safer alternatives available; lack term suppression;
of efficacy in patients with CrCl avoid in patients
<60 mL/min due to inadequate with CrCl <60
drug concentration in the urine mL/min

9
 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
Cardiovascular
Alpha1 blockers High risk of orthostatic Avoid use as an Moderate Strong
zz Doxazosin hypotension; not recommended antihypertensive
zz Prazosin as routine treatment for
zz Terazosin hypertension; alternative
agents have superior
risk/benefit profile
Alpha blockers, central High risk of adverse CNS effects; Avoid clonidine Low Strong
zz Clonidine may cause bradycardia and as a first-line
zz Guanabenz* orthostatic hypotension; not antihypertensive
zz Guanfacine* recommended as routine
zz Methyldopa* treatment for hypertension Avoid others
zz Reserpine as listed
(>0.1 mg/day)*
Antiarrhythmic drugs Data suggest that rate control Avoid High Strong
(Class Ia, Ic, III) yields better balance of benefits antiarrhythmic
zz Amiodarone and harms than rhythm drugs as first-
zz Dofetilide control for most older adults line treatment of
zz Dronedarone atrial fibrillation
zz Flecainide Amiodarone is associated
zz Ibutilide with multiple toxicities,
zz Procainamide including thyroid disease,
zz Propafenone pulmonary disorders, and
zz Quinidine QT interval prolongation
zz Sotalol
Disopyramide* Disopyramide is a potent Avoid Low Strong
negative inotrope and
therefore may induce heart
failure in older adults;
strongly anticholinergic; other
antiarrhythmic drugs preferred
Dronedarone Worse outcomes have Avoid in patients Moderate Strong
been reported in patients with permanent
taking dronedarone who atrial fibrillation
have permanent atrial or heart failure
fibrillation or heart failure

In general, rate control

is preferred over rhythm
control for atrial fibrillation
Digoxin >0.125 mg/day In heart failure, higher dosages Avoid Moderate Strong
associated with no additional
benefit and may increase
risk of toxicity; decreased
renal clearance may lead to
increased risk of toxic effects
Nifedipine, immediate Potential for hypotension; Avoid High Strong
release* risk of precipitating
myocardial ischemia

10
 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
Spironolactone >25 mg/day In heart failure, the risk of Avoid in patients Moderate Strong
hyperkalemia is higher in older with heart failure
adults if taking >25 mg/day or with a CrCl
<30 mL/min
C e n t r a l N e r v o u s Sy s t e m
Tertiary TCAs, alone Highly anticholinergic, Avoid High Strong
or in combination: sedating, and causes orthostatic
zz Amitriptyline hypotension; the safety
zz Chlordiazepoxide- profile of low-dose doxepin
amitriptyline (≤6 mg/day) is comparable
zz Clomipramine to that of placebo
zz Doxepin >6 mg/day
zz Imipramine
zz Perphenazine-
amitriptyline
zz Trimipramine
Antipsychotics, first- Increased risk of cerebrovascular Avoid use for Moderate Strong
(conventional) and second- accident (stroke) and mortality behavioral
(atypical) generation (see in persons with dementia problems of
Table First- and Second- dementia unless
Generation Antipsychotics nonpharmacologic
on page 15 for full list) options have
failed and patient
is threat to self
or others
Thioridazine Highly anticholinergic Avoid Moderate Strong
and greater risk of QT-
Mesoridazine
interval prolongation
Barbiturates High rate of physical Avoid High Strong
zz Amobarbital* dependence; tolerance to
zz Butabarbital* sleep benefits; greater risk of
zz Butalbital overdose at low dosages
zz Mephobarbital*
zz Pentobarbital*
zz Phenobarbital
zz Secobarbital*

11
 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
Benzodiazepines Older adults have increased Avoid High Strong
SHORT- AND INTERMEDIATE- sensitivity to benzodiazepines benzodiazepines
ACTING: and decreased metabolism (any type) for
of long-acting agents; in treatment
zz Alprazolam general, all benzodiazepines of insomnia,
zz Estazolam increase risk of cognitive agitation, or
zz Lorazepam
impairment, delirium, falls, delirium
zz Oxazepam
fractures, and motor vehicle
zz Temazepam
accidents in older adults
zz Triazolam
May be appropriate for seizure
LONG-ACTING: disorders, rapid eye movement
zz Chlorazepate sleep disorders, benzodiazepine
zz Chlordiazepoxide withdrawal, ethanol withdrawal,
zz Chlordiazepoxide- severe generalized anxiety
amitriptyline disorder, periprocedural
zz Clidinium- anesthesia, end-of-life care
chlordiazepoxide
zz Clonazepam
zz Diazepam
zz Flurazepam
zz Quazepam
Chloral hydrate* Tolerance occurs within 10 Avoid Low Strong
days and risk outweighs the
benefits in light of overdose
with doses only 3 times
the recommended dose
Meprobamate High rate of physical Avoid Moderate Strong
dependence; very sedating
Nonbenzodiazepine Benzodiazepine-receptor Avoid chronic Moderate Strong
hypnotics agonists that have adverse use (>90 days)
events similar to those of
zz Eszopiclone benzodiazepines in older
zz Zolpidem adults (for example, delirium,
zz Zaleplon falls, fractures); minimal
improvement in sleep
latency and duration
Ergot mesylates* Lack of efficacy Avoid High Strong
Isoxsuprine*
Endocrine
Androgens Potential for cardiac problems Avoid unless Moderate Weak
zz Methyltestosterone* and contraindicated in men indicated for
zz Testosterone with prostate cancer moderate to severe
hypogonadism
Desiccated thyroid Concerns about cardiac effects; Avoid Low Strong
safer alternatives available

12
 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
Estrogens with or Evidence of carcinogenic Avoid oral and Oral and Oral and
without progestins potential (breast and topical patch patch: High patch: Strong
endometrium); lack of Topical vaginal Topical: Topical:
cardioprotective effect cream: Acceptable Moderate Weak
and cognitive protection to use low-dose
in older women intravaginal
Evidence that vaginal estrogens estrogen for the
for treatment of vaginal management
dryness is safe and effective of dyspareunia,
in women with breast cancer, lower urinary
especially at dosages of tract infections,
estradiol <25 mcg twice weekly and other vaginal
symptoms
Growth hormone Impact on body composition Avoid, except High Strong
is small and associated with as hormone
edema, arthralgia, carpal tunnel replacement
syndrome, gynecomastia, following pituitary
impaired fasting glucose gland removal
Insulin, sliding scale Higher risk of hypoglycemia Avoid Moderate Strong
without improvement in
hyperglycemia management
regardless of care setting
Megestrol Minimal effect on weight; Avoid Moderate Strong
increases risk of thrombotic
events and possibly
death in older adults
Sulfonylureas, long-duration Chlorpropamide: Prolonged Avoid High Strong
half-life in older adults;
zz Chlorpropamide can cause prolonged
zz Glyburide hypoglycemia; causes SIADH
Glyburide: higher risk
of severe prolonged
hypoglycemia in older adults
Gastrointestinal
Metoclopramide Can cause extrapyramidal Avoid, unless for Moderate Strong
effects including tardive gastroparesis
dyskinesia; risk may be further
increased in frail older adult.
Mineral oil, given orally Potential for aspiration Avoid Moderate Strong
and adverse effects; safer
alternatives available
Trimethobenzamide One of the least effective Avoid Moderate Strong
antiemetic drugs; can cause
extrapyramidal adverse effects
Pain Medications
Meperidine Not an effective oral analgesic Avoid High Strong
in dosages commonly used;
may cause neurotoxicity;
safer alternatives available

13
 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1
Organ System/ Strength
Therapeutic Quality of of Recom-
Category/Drug(s) Rationale Recommendation Evidence mendation
Non–COX-selective Increases risk of GI bleeding/ Avoid chronic All others: Strong
NSAIDs, oral peptic ulcer disease in high- use unless other Moderate
zz Aspirin >325 mg/day risk groups, including those alternatives are
zz Diclofenac >75 years old or taking oral not effective and
zz Diflunisal or parenteral corticosteroids, patient can take
zz Etodolac anticoagulants, or antiplatelet gastroprotective
zz Fenoprofen agents; use of proton pump agent (proton-
zz Ibuprofen inhibitor or misoprostol reduces pump inhibitor
zz Ketoprofen but does not eliminate risk; or misoprostol)
zz Meclofenamate upper GI ulcers, gross bleeding,
zz Mefenamic acid or perforation caused by
zz Meloxicam NSAIDs occur in approximately
zz Nabumetone 1% of patients treated for
zz Naproxen 3–6 months, and in about
zz Oxaprozin 2%–4% of patients treated for
zz Piroxicam 1 year; these trends continue
zz Sulindac with longer duration of use
zz Tolmetin

Indomethacin Increases risk of GI bleeding/ Avoid Indomethacin: Strong

peptic ulcer disease in Moderate
Ketorolac, includes parenteral
high-risk groups (see above Ketorolac: High
non–COX-selective NSAIDs)
Of all the NSAIDs, indomethacin
has most adverse effects
Pentazocine* Opioid analgesic that causes Avoid Low Strong
CNS adverse effects, including
confusion and hallucinations,
more commonly than other
narcotic drugs; is also a mixed
agonist and antagonist;
safer alternatives available
zz Skeletal muscle relaxants Most muscle relaxants poorly Avoid Moderate Strong
zz Carisoprodol tolerated by older adults
zz Chlorzoxazone because of anticholinergic
zz Cyclobenzaprine adverse effects, sedation,
zz Metaxalone increased risk of fractures;
zz Methocarbamol effectiveness at dosages
zz Orphenadrine tolerated by older adults
is questionable.
*Infrequently used drugs
ABBREVIATIONS: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin receptor blockers; CNS,
central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastrointestinal; NSAIDs, nonsteroidal
antiinflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; TCAs, tricyclic antidepressants.

14
 2012 AGS Beers Criteria for Potentially Inappropriate Medications
to Be Used with Caution in Older Adults1
Strength
Quality of of Recom-
Drug(s) Rationale Recommendation Evidence mendation
Aspirin for primary Lack of evidence of benefit Use with caution Low Weak
prevention of cardiac events versus risk in individuals in adults ≥80
≥80 years old years old
Dabigatran Increased risk of bleeding Use with caution Moderate Weak
compared with warfarin in in adults ≥75
adults ≥75 years old; lack years old or if CrCl
of evidence for efficacy <30 mL/min
and safety in patients
with CrCl <30 mL/min
Prasugrel Increased risk of bleeding in Use with caution Moderate Weak
older adults; risk may be offset in adults ≥75
by benefit in highest-risk years old
older patients (for example,
those with prior myocardial
infarction or diabetes)
Antipsychotics May exacerbate or cause Use with caution Moderate Strong
SIADH or hyponatremia;
Carbamazepine
need to monitor sodium
Carboplatin level closely when starting
Cisplatin or changing dosages in older
adults due to increased risk
Mirtazapine
SNRIs
SSRIs
TCAs
Vincristine
Vasodilators May exacerbate episodes Use with caution Moderate Weak
of syncope in individuals
with history of syncope
ABBREVIATIONS: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs,
selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants.

First- and Second-Generation Antipsychotics1

F i r s t- G e n e r a t i o n ( C o n v e n t i o n a l ) A g e n t s Second- Generation (At ypical) Agents
zz Chlorpromazine zz Aripiprazole
zz Fluphenazine zz Asenapine
zz Haloperidol zz Clozapine
zz Loxapine zz Iloperidone
zz Molindone zz Lurasidone
zz Perphenazine zz Olanzapine
zz Pimozide zz Paliperidone
zz Promazine zz Quetiapine
zz Thioridazine zz Risperidone
zz Thiothixene zz Ziprasidone
zz Trifluoperazine
zz Triflupromazine

15
 Drugs with Strong Anticholinergic Properties1
Antihistamines Anti-Parkinson Agents
zz Brompheniramine zz Benztropine
zz Carbinoxamine zz Trihexyphenidyl
zz Chlorpheniramine
zz Clemastine
zz Cyproheptadine
zz Dimenhydrinate
zz Diphenhydramine
zz Hydroxyzine
zz Loratadine
zz Meclizine
Antidepressants Antipsychotics
zz Amitriptyline zz Chlorpromazine
zz Amoxapine zz Clozapine
zz Clomipramine zz Fluphenazine
zz Desipramine zz Loxapine
zz Doxepin zz Olanzapine
zz Imipramine zz Perphenazine
zz Nortriptyline zz Pimozide
zz Paroxetine zz Prochlorperazine
zz Protriptyline zz Promethazine
zz Trimipramine zz Thioridazine
zz Thiothixene
zz Trifluoperazine
A n t i m u s c a r i n i c s ( U r i n a r y I n c o n t i n e n c e) Antispasmodics
zz Darifenacin zz Atropine products
zz Fesoterodine zz Belladonna alkaloids
zz Flavoxate zz Dicyclomine
zz Oxybutynin zz Homatropine
zz Solifenacin zz Hyoscyamine products
zz Tolterodine zz Loperamide
zz Trospium zz Propantheline
zz Scopolamine

16
Appendix 2
Legally Relevant Criteria for Decision-Making Capacity and
Approaches to Assessment of the Patient 2
Physician’s
Assessment Questions for
Criterion Patient’s Task Approach Clinical Assessment* Comments
Communicate Clearly indicate Ask patient Have you decided whether to Frequent reversals of choice
a choice preferred to indicate follow your doctor’s [or my] because of psychiatric or
treatment a treatment recommendation for treatment? neurologic conditions may
option choice indicate lack of capacity
Can you tell me what
that decision is?
[If no decision] What is making
it hard for you to decide?
Understand Grasp the Encourage Please tell me in your own Information to be
the relevant fundamental patient to words what your doctor understood includes nature
information meaning of paraphrase [or I] told you about: of patient’s condition, nature
information disclosed zz The problem with and purpose of proposed
communicated information your health now treatment, possible benefits
by physician regarding zz The recommended treatment and risks of that treatment,
medical zz The possible benefits and alternative approaches
condition and and risks (or discomforts) (including no treatment)
treatment of the treatment and their benefits and risks
zz Any alternative treatments
and their risks and benefits
zz The risks and benefits
of no treatment
Appreciate Acknowledge Ask patient to What do you believe is wrong Courts have recognized
the situation medical describe views with your health now? that patients who do not
and its condition of medical Do you believe that you need
acknowledge their illnesses
consequences and likely condition, some kind of treatment?
(often referred to as “lack of
consequences proposed insight”) cannot make valid
of treatment treatment, and What is treatment likely decisions about treatment
options likely outcomes to do for you?
Delusions or pathologic
What makes you believe levels of distortion or denial
it will have that effect? are the most common
What do you believe will causes of impairment
happen if you are not treated?
Why do you think your doctor
has [or I have] recommended
this treatment?
Reason about Engage in Ask patient How did you decide This criterion focuses on
treatment a rational to compare to accept or reject the the process by which a
options process of treatment recommended treatment? decision is reached, not the
manipulating options and What makes [chosen option]
outcome of the patient’s
the relevant consequences better than [alternative option]?
choice, since patients
information and to offer have the right to make
reasons for “unreasonable” choices
selection
of option
* Patients’ responses to these questions need not be verbal.

17
 Screening for Depression
P a t i e n t H e a l t h Q u e s t i o n n a i r e -2 ( P H Q -2 ) 3
1. In the past 12 months, have you ever had a time when you felt sad, blue,
depressed, or down for most of the time for at least two weeks?
2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn’t care about
the things that you usually care about or when you didn’t enjoy the things that you usually enjoy?
I n t e r p r e t a t i o n o f P H Q -2
If the patient answers YES to either question, then further evaluation by a primary
care physician, geriatrician, or mental health specialist is recommended.
NOTE: This screening test has not been validated in extremely frail elderly patients, those with severe concurrent
medical illnesses, those who are suffering from medication side effects, or those with impaired communication skills.

Screening for Alcohol and Substance Abuse

M o d i f i e d Ve r s i o n o f C AG E 4 -7
Ask the patient the following four questions:
1. Have you ever felt you should Cut down on your drinking or drug use?
2. Have people Annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or Guilty about your drinking or drug use?
4. Have you ever had a drink or drug first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
I n t e r p r e t a t i o n o f M o d i f i e d C AG E
If YES to any of these questions, consider perioperative prophylaxis for withdrawal syndromes.
If operation can be delayed, consider referring motivated patients to substance
abuse specialist for preoperative abstinence or medical detoxification.
Patients with alcohol use disorder should receive perioperative daily multivitamins
(with folic acid) and high-dose oral or parental thiamine (100 mg).

Assessing Baseline and Current Functional Status in Ambulatory Patients

S h o r t S i m p l e S c r e e n i n g Te s t f o r F u n c t i o n a l A s s e s s m e n t 8 , 9
Ask the patient the following four questions:
1. Can you get out of bed or chair yourself?
2. Can you dress and bathe yourself?
3. Can you make your own meals?
4. Can you do your own shopping?
I n t e r p r e t a t i o n o f Fu n c t i o n a l S c r e e n i n g Te s t
If NO to any of these questions, more in-depth evaluation should be
performed, including full screening of ADLs and IADLs.
Deficits should be documented and may prompt perioperative interventions (for example,
referral to occupational therapy and/or physical therapy) and proactive discharge planning.

18
 Assessing Gait and Mobility Impairment and Fall Risk in Ambulatory Patients10-12
T i m e d U p a n d G o Te s t ( T U G T )
Patients should sit in a standard armchair with a line 10 feet in length in front of the chair. They
should use standard footwear and walking aids and should not receive any assistance.
Have the patient perform the following commands:
1. Rise from the chair (if possible, without using the armrests)
2. Walk to the line on the floor (10 feet)
3. Turn
4. Return to the chair
5. Sit down again
Interpretation of TUGT
Any person demonstrating difficulty rising from the chair or requiring more than 15 seconds to complete the test
is at high risk for falls. Consider preoperative referral to physical therapy for more detailed gait assessment.

Frailty Score: Operational Definition13

Criteria Definition
Shrinkage Unintentional weight loss ≥10 pounds in past year
Weakness Decreased grip strength
Exhaustion Self-reported poor energy and endurance
Low physical activity Low weekly energy expenditure
Slowness Slow walking
I n t e r p r e t a t i o n o f t h e Fr a i l t y S c o r e
The patient receives 1 point for each criterion met.

0–1 = Not Frail

2–3 = Intermediate Frail (Pre-frail)
4–5 = Frail

Frail patients are at much higher risk of adverse health outcomes.

Intermediate frail patients are at elevated risk (less than frail ones) but are also
at more than double the risk of becoming frail over 3 years.

19
 Frailty Score14-15
Patient receives one point for each criterion (0–5)
Fr a i l t y C r i t e r i a Definition
Weight loss Unintentional weight loss ≥10 pounds in the past year.
Decreased grip strength Grip strength in the lowest 20th percentile by gender and BMI. Three trials are
performed with a hand-held dynamometer and the average value is used.
(weakness)
Men Women

BMI Kg Force BMI Kg Force

≤24 ≤29 ≤23 ≤17
24.1–26 ≤30 23.1–26 ≤17.3
26.1–28 ≤30 26.1–29 ≤18
>28 ≤32 >29 ≤21

Exhaustion For the following two statements:

1. “I felt that everything I did was an effort.”
2. “I could not get going.”
The patient is asked: “How often in the last week did you feel this way?”
0 = rarely or none of the time (<1 day)
1 = some or a little of the time (1–2 days)
2 = a moderate amount of the time (3–4 days)
3 = most of the time
The criterion is met if patient answers 2 or 3 to either statement.
Low physical activity Weekly energy expenditure, determined with the short version of the Minnesota
Leisure Time Activities Questionnaire in the lowest 20th percentile by gender:
Men: <383 kcal/week. Women: <270 kcal/week.
Slowed walking speed Walking speed in the lowest 20th percentile by gender and height. Time is measured
for a distance of 15 feet at normal pace. The average of three trials is used.
Men Women

Height Time Height Time

≤173 cm ≥7 sec ≤159 cm ≥7 sec
>173 cm ≥6 sec >159 cm ≥6 sec

Screening for Severe Nutritional Risk16

R i s k Fa c t o r s f o r S e v e r e N u t r i t i o n a l R i s k
zz BMI <18.5 kg/m2
zz Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction)
zz Unintentional weight loss >10%–15% within 6 months
Interpretation of Nutritional Screening
If YES to any above criterion, then the patient is at severe nutritional risk and should, if feasible, undergo a
full nutritional assessment by a dietician to design a perioperative nutritional plan to address deficits.

20
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Specialized Geriatric Inpatient Care

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26
References
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Geriatr Soc. February 29, 2012.

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depression in older people. J Am Geriatr Soc. April 2007;55(4):596-602.

4. Hinkin CH, Castellon SA, Dickson-Fuhrman E, Daum G, Jaffe J, Jarvik L. Screening for drug and alcohol abuse among
older adults using a modified version of the CAGE. Am J Addict. Fall 2001;10(4):319-326.

5. Beullens J, Aertgeerts B. Screening for alcohol abuse and dependence in older people using DSM criteria: A review.
Aging Ment Health. January 2004;8(1):76-82.

6. Berks J, McCormick R. Screening for alcohol misuse in elderly primary care patients: A systematic literature review. Int
Psychogeriatr. December 2008;20(6):1090-1103.

7. McGrath A, Crome P, Crome IB. Substance misuse in the older population. Postgrad Med J. April 2005;81(954):228-231.

8. Woolger JM. Preoperative testing and medication management. Clin Geriatr Med. November 2008;24(4):573-583, vii.

9. Lachs MS, Feinstein AR, Cooney LM Jr., Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A simple procedure for
general screening for functional disability in elderly patients. Ann Intern Med. May 1, 1990;112(9):699-706.

10. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for
prevention of falls in older persons. J Am Geriatr Soc. January 2011;59(1):148-157.

11. Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility discriminates nonfallers from one-time and frequent
fallers. J Gerontol A Biol Sci Med Sci. November 2000;55(11):M672-676.

12. Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr
Soc. February 1991;39(2):142-148.

13. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci.
March 2001;56(3):M146-156.

14. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci.
March 2001;56(3):M146-156.

15. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J,
Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. June 2010;210(6):901-908.

16. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P; DGEM (German Society for Nutritional Medicine),
Jauch KW, Kemen M, Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH; ESPEN (European Society for Parenteral and
Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr. April
2006;25(2):224-244.

27
Expert Panel
H. Gil Cryer, MD, FACS (Chair)
Professor of Surgery, Trauma/Emergency Surgery and Critical Care Program, UCLA, Los Angeles, CA

J. Forrest Calland, MD, FACS

Assistant Professor of Surgery, University of Virginia Health System, Richmond, VA

Warren Chow, MD
James C. Thompson Geriatrics Surgical Fellow, American College of Surgeons, Chicago, IL

Matthew Davis, MD, FACS

Trauma Program Director, Scott and White Memorial Hospital, Temple, TX

Mark Hemmila, MD, FACS

Associate Professor of Surgery, University of Michigan Health Systems, Ann Arbor, MI

Rosemary Kozar, MD, FACS

Professor of Surgery and Chief of Trauma, Memorial Hermann Hospital, Houston, TX

Sheila Lopez
Director of Trauma Service, Memorial Hermann Hospital, Houston, TX

Alicia Mangram, MD, FACS

Medical Director of Trauma Services, John C. Lincoln Hospital, Phoenix, AZ

Gary Marshall, MD
Professor of Surgery, University of Pittsburg Medical Center, Pittsburg, PA

Avery B. Nathens, MD, FACS

Professor of Surgery, University of Toronto, Surgeon in Chief of Department of Surgery, Sunnybrook Hospital, Toronto, ON

Ronnie Rosenthal, MD
Professor of Surgery, Yale University, Chief of Surgery of VA Connecticut Healthcare System, West Haven, CT

Areti Tillou, MD, MSEd

Assistant Professor of Surgery David Geffen School of Medicine, UCLA, Los Angeles, CA

Camillia Wong, MD
Assistant Professor, University of Toronto, Geriatrician and Associate Scientist, St. Michael’s Hospital, Toronto, ON

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) Best Practices Guidelines
have been developed for quality improvement purposes. The documents may be downloaded and printed for
personal use by health care professionals, and may also be used in quality improvement initiatives or programs.
The documents may not be distributed for profit without the written consent of the American College of Surgeons.

The intent of the ACS TQIP Best Practices Guidelines is to provide health care professionals with evidence-based
recommendations regarding care of the geriatric trauma patient. The Best Practices Guidelines do not include
all potential options for prevention, diagnosis, and treatment and are not intended as a substitute for the
provider’s clinical judgment and experience. The responsible provider must make all treatment decisions based
upon his or her independent judgment and the patient’s individual clinical presentation. The ACS shall not be
liable for any direct, indirect, special, incidental, or consequential damages related to the use of the information
contained herein. The ACS may modify the TQIP Best Practices Guidelines at any time without notice.

28
Notes

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Notes

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