June 1, 2026

For the next four weeks, this newsletter will focus on geriatric trauma. Caring for older trauma patients is becoming significantly more common as the population ages.

 Understanding the unique physiologic response to injury, injury patterns, and complications of recovery for older patients is now a mainstay of trauma care both in the field and in the hospital. The topics for the next four weeks will be:

1) geriatric trauma triage

2) geriatric orthopedic injuries

3) delirium, and

4) geriatric traumatic brain injury.  

Trauma triage focuses on getting the right patient to the right location at the right time. While seemingly straightforward, many variables come into play to ensure appropriate triage, and as a result, over- and under-triage are common. Over-triage (upgrading response to minor injuries) ensures that every patient sees the quickest and highest level of care, but overloads the trauma system and wastes resources needed for the most injured patients. Under-triage (downgrading major injuries) delays the most appropriate care. To ensure the most accurate triage, the American College of Surgeons Committee on Trauma (ACS-COT) has established triage criteria that focus on mechanisms of injury, mental status, and physiologic parameters. Advanced age and comorbidities can lead to baseline alterations in mental status unrelated to injury and blunted physiologic responses to trauma and blood loss. As a result, standard triage criteria may not match the degree of injury suffered by older trauma patients and lead to mistriage. The ACS-COT Guidelines (below) recognize these age-related physiologic differences with higher systolic blood pressure and lower heart rate thresholds for trauma patients over 65 years old.  

Knowing when to immediately transfer a patient from a lower level or non-trauma hospital to a Level 1 trauma center is difficult. This process is called re-triage. Delays in re-triage can lead to significantly higher rates of patient morbidity and mortality as need for re-triage is often related to need for hemorrhage control. While associated with significant patient health outcomes and trauma system costs, re-triage has not been well-studied. University Hospitals and Case Western Reserve University School of Medicine have partnered with three other trauma systems (Northwestern, University of Texas Houston and Duke) in a multi-site, NIH funded five-year research study addressed at improving re-triage entitled, Criteria for Re-Triage to Improve Trauma Induced Coagulopathy and hemorrhage associated Lethality (CRITICAL). An essential component of building evidence-based re-triage guidelines is to ensure that they are practical and feasible for the entire healthcare team including paramedics, EMS, transport teams, transfer center nurses, emergency medicine nurses, APPs, physicians, and trauma surgeons. As a result, the research team will be reaching out to EMS providers throughout Northeast Ohio to participate in surveys and focus groups aimed at collecting your thoughts, experiences, and opinions on re-triage.

Triage not only occurs in the field but also in the trauma bay and when the patient is hospitalized. Individual hospitals must determine the emergency medicine/trauma team response level when a patient arrives. For hospitals in low trauma, high geriatric areas, full trauma team activation may be necessary for many geriatric trauma activations. For high trauma volume centers, this may be overwhelming and unnecessary. Once hospitalized, trauma centers triage to identify those patients with higher rates of complications, longer lengths of stay, and higher chances of loss of independence. Typically, trauma centers will screen patients for frailty via a series of questions about medical history, activities of daily living, health and mental attitudes, social and family support and nutrition. Frail patients are then given additional resources to help avoid negative outcomes. Additionally, older trauma patients can be screened for sarcopenia which is a weakening of whole-body muscle mass that is closely associated with poorer outcomes. Sarcopenia can be quickly measured by determining the psoas muscle thickness on a CT scan.  

In the end, triage is all about trying to get the right patient to the right place at the right time, and geriatric patients have a unique set of challenges in this process.  

Next week, the topic will be geriatric orthopedic trauma. 

Thank you, 

Joseph Posluszny, MD

June 8, 2026

For the next three weeks, this newsletter will focus on geriatric trauma. Last week, our coverage of geriatric trauma triage included how the unique physiology and recovery of older patients make their triage and subsequent care challenging. This week, we'll focus on the all too common geriatric orthopedic injuries.   

Next week, the topic will be delirium, a common complication in geriatric care.   

Thank you, 

Joseph Posluszny, MD

June 15, 2026

For the next two weeks, this newsletter will focus on geriatric trauma. Last week, geriatric orthopedic injuries were discussed, including the impact of falls and classic fracture patterns. This week, the focus will be on delirium.

Delirium commonly develops in hospitalized patients, especially in older patients and trauma patients. Up to 30% of hospitalized patients will develop delirium, and in the ICU, delirium may be present in up to 80% of patients. Delirium can also develop in the outpatient setting from similar inciting factors and may be encountered when responding to older trauma patients in the field, which can be difficult to distinguish from a traumatic brain injury. 

Delirium is an acute disorder of cognitive thinking and attention. Delirious patients may be disoriented, have trouble maintaining their attention, have disorganized thinking, suffer from hallucinations and sleep disturbances, and have rapid behavior changes. The onset of delirium is within hours or days of changes to predictable patterns, medication changes, traumatic events, or a new medical illness. While some symptoms may overlap, delirium is different from dementia, which is a slow, chronic, and progressive decline in memory and cognitive function associated with permanent brain damage. Delirium has acute and reversible cognitive changes, while dementia is progressive and permanent. Recognizing this difference is key to prevention, treatment, and discussions on prognosis with family.  

The triggering factors for delirium overlap with the most frequent treatments, so appreciating predisposing factors and triggers is key to delirium treatment. Predisposing factors for delirium include advanced age, frailty, anemia, malnutrition, substance abuse, depression, and social isolation. Triggers include being post-operative, anticholinergic medications, psychoactive drugs, being in the ICU, infection, electrolyte imbalance, sleep alterations, immobilization, and being in a foreign environment. Identifying and preventing triggers that manifest into delirium is a mainstay of many age-friendly hospital programs that focus on reducing delirium prevalence.

Treatment for delirium is either non-pharmacologic or pharmacologic, with non-pharmacologic measures always preferred. First step non-pharmacologic treatments for delirium include simple, low-cost, low-intensity actions like restoring the sleep-wake cycle by keeping lights and sound on during the day and a quiet and dark environment at night, frequent reorientation of the person, date, time, and situation, ensuring patients have their glasses and hearing aids, ensuring family participation in care, and early mobility.  

One of the most important non-pharmacologic treatments for delirium is to stop medications that trigger delirium. When a patient is delirious, FTD (First Think Drugs).  

This requires a review of the medication administration record and stopping deliriogenic medications, which are often newly prescribed in the hospital. These medications include anticholinergics (diphenhydramine, scopolamine, etc.), benzodiazepines (lorazepam, diazepam, etc.), narcotics, and muscle relaxants (cyclobenzaprine, baclofen). In addition, home medication dosing for some commonly used medications (anticonvulsants, antidepressants) for older patients, especially those with impaired renal function, may be inappropriate, and consultation with a geriatric medicine specialist or pharmacist may be helpful. In addition, accidental discontinuation of essential home medications that an elderly patient has taken for years can lead to delirium, making reviews of home medications essential for older trauma patients.  

Pharmacologic treatments for delirium mirror the triggers for delirium. Antibiotics should be prescribed for infection, electrolyte abnormalities corrected when altered, and non-narcotic pain medication prescribed to treat pain, with low doses of narcotics used only when indicated. Antipsychotic medications, such as haldol, should only be administered when the patient is a danger to themselves or health care providers.  

Next week, the topic will be geriatric traumatic brain injury.   

Thank you, 

Joseph Posluszny, MD