20

The
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Older
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Patient
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RITICAL /A
with
1999
ARE
a Spinal
URSING UARTERLY UGUST

Cord Injury

The most common cause of spinal cord injury (SCI) in older persons is falls, followed by motor vehicle crashes
and pedestrian/motor vehicle crashes. Upper cervical injuries, particularly central cord syndrome, are prominent
in the geriatric patient population. In addition, the mortality is higher, the complications are life threatening, the
hospital stay is longer, and the cost of care is significantly increased for the older trauma victim. Key words:
elderly, geriatric, spinal cord injury, trauma

Darlene Lovasik, RN, MN, CCRN, CNRN

Trauma Education Coordinator
University of Pittsburgh Health System
I N THE United States, the aging popula-
tion is living longer and is in better health
in its later years. In 1990, there were 30.9
Pittsburgh, Pennsylvania million people, 12.5 percent of the total pop-
ulation in the United States, who were 65 or
older. This portion of the population is pro-
jected to increase to 52 million by the year
2020.1 Because these older adults continue to
be active and mobile and to participate in
numerous activities, they also are likely to be
injured. Although older persons comprise
12.5 percent of the population, almost one
third of the deaths from injury occur in the
age group 65 and older. Falls are the most
frequent cause of unintentional injury and
are the leading cause of injury-related deaths
in people 75 years of age or older.1,2 In 1996,
the National Center for Injury Prevention
and Control reported 8,423 deaths as a result
of falls in persons 75 or older.2 It is the second
most common cause of injury and injury-
related death in the age group 65–74 years,
with 1,559 deaths following falls in 1996.2
One out of every three persons 65 or older in
the United States falls each year, making this

Crit Care Nurs Q 1999;22(2):20–30

©1999 Aspen Publishers, Inc.
20
 The Older Patient with a Spinal Cord Injury
a significant public health problem.3 In older
persons, 60 percent of fatal falls occur in the
home, 30 percent occur in public places, and
10 percent occur in a health care facility.4
While many falls result in an isolated ortho-
pedic injury, the consequence of a fall down
a flight of steps or off a ladder can be a
devastating injury. Dementia, decreased vi-
sual acuity, neurological and musculoskele-
tal impairments, difficulties in gait and
balance, and medication all are factors that
contribute to falls. In addition, environmen-
tal hazards such as poor lighting, loose rugs,
slippery or uneven floors, or objects on the
floor also may be involved. In 1995, first-
year health care charges for a spinal cord
injury (SCI) from a fall were $185,019 and
recurring annual charges were $26,238.5
Although falls are the most common mech-
anism of injury, more older patients are
brought to the hospital following a motor
vehicle crash. Older patients have a very high
motor vehicle crash rate, second only to the
16- to 25-year-old segment for the total num-
ber of crashes. The geriatric population also
suffers from a higher rate of fatal crashes than
any other age group, particularly in those
victims 75 or older.1 In 1996, 5,664 people
who were 65 or older died when they were
occupants of a motor vehicle in a crash.6 In
1995, first-year health care charges for an
SCI from a motor vehicle crash were $233,947
and recurring annual charges were $33,439.5
In the geriatric population, most motor
vehicle crashes occur during the daylight
hours, in good weather, and close to home.1
They are more likely to involve intersections,
traffic sign violations, right-of-way decisions,
and two-car accidents.7,8 Compared with a
younger age group, the older adult is less
likely to have ingested alcohol.8 Age-related
changes, particularly in the special senses,
21
may have contributed to the cause of the
crash. These include difficulties in cognitive
function, decreases in auditory acuity, loss or
changes in direct and peripheral vision, and
impairment of coordination and reaction time.
The person’s medical background and phar-
macological interactions/side effects also
must be considered.
Pedestrian-automobile crashes are the third
largest cause of traumatic mortality in older
persons, with 1,414 deaths reported in 1996.6
Some of the normal consequences of aging
contribute to this mechanism of injury. Os-
teoarthritis and kyphosis leads to a stooped
posture and makes it more difficult to raise
the head and see oncoming traffic. The aver-
age traffic signal in the United States as-
sumes that a pedestrian walks at 4 feet per
second; however, a slower pace and changes
in the gait make it difficult to cross a street in
the time allowed.7,8 Decreased reaction time,
poor judgment, and decreases in hearing and
vision also contribute.
PHYSIOLOGY OF AGING
Cardiovascular system: The patient age 65
and older has decreased cardiac pump func-
tion and lower cardiac output due to progres-
sive fibrosis of the myocardium. The
myocardium is also less sensitive to endoge-
nous and exogenous catecholamines and is
unable to respond to hypovolemia with a
compensating tachycardia. Atherosclerotic
disease results in decreased blood flow to
vital organs and a decreased physiologic re-
serve. Peripheral pulses may be diminished
or absent. Prescribed medication, particular-
ly digoxin and beta blockers, will limit the
normal physiologic response to injury by
impeding tachycardia in the presence of
shock.1,7–10
22 CRITICAL CARE NURSING QUARTERLY/AUGUST 1999
Respiratory system: The older patient has
decreased pulmonary compliance due to re-
duced lung elasticity and stiffening of the
chest wall. There is a decrease in alveoli
surface area for gas exchange. It is increas-
ingly difficult to clear bacteria from the bron-
chi due to atrophy of epithelial lining, and
chronic gram-negative colonization of the
upper airway predisposes the patient to pneu-
monia.1,7,8
Nervous system: A 10 percent reduction in
brain size occurs between the ages of 40 and
70 due to progressive atrophy. As a result, the
area between the skull and brain surface
increases and the bridging veins of the dura
mater are at risk for tearing and bleeding.
Additional changes in neurological function
include impaired judgment, poor memory,
and an inability to process new data. There
are changes in coordination, an altered “right-
ing” reflex, and difficulties with balance.
Clearly, these alterations will predispose the
older patient to a fall.1,7,8
Special senses: Older persons have de-
creased auditory acuity, particularly to high-
frequency tones, and may not have adequate
hearing aids as a result of denial or financial
concerns. Changes in vision include decreased
visual acuity, decreased peripheral vision,
and decreased tolerance to glare. In addition,
macular degeneration, cataracts, and glauco-
ma also contribute to reduced vision.1,7,8
Renal: There is an overall decline of 30–40
percent in renal mass by the age of 65. The
remaining nephrons have deterioration in the
tubules and glomeruli, therefore renal func-
tion can be impaired, although the patient
may have a normal serum creatinine. A nor-
mal serum creatinine does not mean normal
renal function. This is important when using
nephrotoxic substances such as iodinated
contrast, diuretics, and aminoglycosides.1,7,8
Musculoskeletal system: Osteoporosis will
predispose the older adult to bony fractures
with minor trauma. Additional changes in the
spine occur as a result of osteoarthritis and a
decrease in vertebral body height. Osteoar-
thritis causes spinal stenosis, predisposing
the spinal cord to injury, particularly central
cord syndrome. Kyphoscoliosis limits head
turning and looking upward and decreases
overall mobility, thereby increasing the like-
lihood of accidental injury from missed ob-
stacles. There is an overall decrease in muscle
mass, strength, and agility.1,7,8
Comorbid condition: Additional disease
states or illness will affect profoundly the
geriatric person’s response to injury. Some
premorbid conditions to consider include
cardiac disease, previous cardiac surgery,
hypertension, diabetes, chronic pulmonary
disease, liver disease, renal disease, malig-
nancy, and obesity.1
THE OLDER PATIENT WITH AN SCI
The full range of injuries to the spinal cord
and spinal column can be reviewed in other
literature. Specific conditions that particu-
larly affect older persons will be discussed
here.
One half of SCIs involves the cervical
spine and approximately 40 percent of these
will result in quadriplegia.11 SCIs are classi-
fied further as a complete injury with loss of
all sensory and motor function below the
level of the lesion or an incomplete injury
with preservation of some sensory or motor
functions. Neurogenic shock is a sign of
complete SCI. The descending autonomic
circuits are impaired. This results in brady-
cardia due to a lack of sympathetic stimula-
tion of the cardiac nerves and hypotension
caused by massive vasodilatation due to a
 The Older Patient with a Spinal Cord Injury
loss of sympathetic innervation to the periph-
eral vascular system.11–13 The patient also
loses somatic temperature control and will
not sweat below the level of the lesion.
Ischemia of the spinal cord occurs as a
consequence of local contusion and swelling
compromising the microcirculation or due to
occlusion of the anterior spinal artery or the
posterior spinal arteries. The cascade of sec-
ondary injury includes the accumulation of
oxygen free radicals that further damages the
cell membranes and increases the swelling of
the spinal cord. Current pharmacological
treatment, including steroids, aims at limit-
ing the release of oxygen free radicals and
blocking the harmful effects of biochemical
events.11
While the older patient may sustain an in-
jury at any level and with varying severity,
one type of incomplete SCI is more common
in the geriatric population than in other age
groups. Central cord syndrome generally is
seen in older patients with pre-existing cervi-
cal spinal stenosis and/or cervical spondylo-
sis with canal stenosis. 11–14 The typical
description is of a hyperextension injury as-
sociated with a fall. As the patient falls for-
ward, there may be facial impact. This
mechanism results in a unique pattern of neu-
rological dysfunction due to ischemia to the
central portion of the spinal cord, particularly
in the distribution of the anterior spinal artery.
As the nerve fibers ascend toward the brain,
the cervical, thoracic, and lumbar pathways
align in a specific sequence. The fibers for the
upper extremities, bowel, and bladder arise
centrally in the spinal cord while the fibers
for the lower extremities are located laterally
in the spinal cord. With central cord syndrome,
the motor and sensory functions of the upper
extremities are affected more than the func-
tions of the lower extremities.11–14
23
Neurological function returns in a charac-
teristic pattern with the lower extremities
regaining strength first, then bladder func-
tion returns, followed by the proximal upper
extremities, and finally the hands. Approxi-
mately 50 percent of these patients will not
recover full function of their upper extremi-
ties, principally fine motor movements of the
hands.11
While the most important radiologic test
for vertebral column injury is the plain x-ray,
routine films may not be abnormal on a
patient with central cord syndrome.11,12,14 To
evaluate the patient for a cervical injury,
anterior-posterior (AP), lateral, and open-
mouth odontoid views are obtained. In the
older patient, there may be degenerative
changes in the cervical spine and narrowing
of the cervical canal due to osteophytes (bony
spurs). If there is a question of a fracture or
dislocation, axial computed tomography (CT)
scan will be performed to further define the
bony injury. Magnetic resonance imaging
(MRI) scans also may be required to detect
injury to the stabilizing ligaments or evaluate
soft-tissue compression of the spinal cord
that may occur with an epidural hematoma or
traumatic herniated disk.11
CARE OF THE OLDER PATIENT
WITH AN SCI
Prehospital
Assume the patient has an SCI. After the
critical issues of airway, breathing, and cir-
culation have been addressed, the spine should
be stabilized with a rigid cervical spinal col-
lar applied as soon as possible and the patient
should be placed on a rigid backboard with
cervical immobilization devices. Due to ar-
eas of a lordosis or kyphosis, the geriatric
24 CRITICAL CARE NURSING QUARTERLY/AUGUST 1999
patient may have some discomfort following
immobilization. Padding in these areas as
well as behind the occiput will decrease this
secondary pain.11 If the patient requires intu-
bation to maintain an airway, movement of
the neck must be avoided. Orotracheal intu-
bation with in-line stabilization using the
three-person technique (one experienced pro-
vider to perform intubation, another to im-
mobilize the cervical spine, and the third to
apply cricoid pressure) may be utilized.11
Airway assessment in the geriatric patient
should include checking for and removal of
dental appliances.8
In some areas, prehospital staff may use
specific trauma criteria for classifying pa-
tients. It must be noted that field criteria that
ignore age may underestimate the serious-
ness of injury in older persons because those
with trauma experience poorer outcomes than
predicted by severity scores or physiologic
norms.15
EMERGENCY DEPARTMENT
Resuscitation
When the older patient has sustained an
SCI, aggressive initial resuscitation proceeds.
As with every trauma patient, the priorities
are Airway, Breathing, Circulation, Disabil-
ity, and Exposure (A, B, C, D, E).14 The
resuscitation team also must be aware of the
physiologic changes related to aging, the
patient’s past medical history, and medica-
tions the patient may have taken. In almost
every body system, the physiologic reserves
are limited and the older patient may deteri-
orate quickly, even with expert medical and
nursing attention.
Obtaining and maintaining a definitive air-
way is essential in the older patient with a
lack of pulmonary reserve and probable car-
diovascular disease. Even a mild hypoxia
may precipitate a downward spiral in these
fragile patients. In the patient with an SCI
above C-4, loss of both phrenic and intercos-
tal respiratory function will mandate intuba-
tion and mechanical ventilation.12 Patients
with injuries C-5 through C-8 have an intact
phrenic nerve; however, the intercostal mus-
cles are impaired.12 In addition, ascending
edema can rapidly cause respiratory difficul-
ty that requires immediate intervention.12 It is
best to err on the side of early intubation.
The initial assessment also will evaluate
breathing and include an examination for
life-threatening thoracic injuries such as ten-
sion pneumothorax, massive hemothorax,
cardiac tamponade, flail chest, or pulmonary
contusion. Treatment for these specific inju-
ries begins immediately after identification
of the problem, (for example, tube thoracos-
tomy, pericardiocentesis, pericardial window,
and so forth).14 Never underestimate a chest
injury.1 Due to progressive osteoporosis, the
older trauma patient also is more likely to
have a flail segment or rib fractures. If the
patient has lost sensation in this area follow-
ing a complete or incomplete SCI, he or she
will not feel discomfort at the site. However,
if the patient is neurologically intact, early
and adequate pain relief is essential to pro-
moting pulmonary health. Rib fractures and
chest wall contusions are intensely painful
and will lead to splinting and hypoventila-
tion. Inadequate pain management will in-
crease the work of breathing, increase the
oxygen demand, and will result in respiratory
failure in the older patient with poor respira-
tory reserve and chest wall compliance. Epi-
dural anesthesia generally will provide
adequate pain relief and should be initiated
early. Effective pain management for thorac-
 The Older Patient with a Spinal Cord Injury
ic injuries can be lifesaving. An additional
option is intubation and ventilatory support.1
Evaluating circulation in the older person
also is complicated. The patient’s blood pres-
sure may appear normal; however, if this
individual has a history of hypertension, a
blood pressure reading of 130 mm Hg systol-
ic may actually be 40 below his or her usual
systolic blood pressure of 170 mm Hg. This
early sign of shock may go unrecognized. In
addition, if the patient is taking medication
such as a beta blocker, he or she will not
compensate for a decreased blood pressure
with tachycardia. In light of potential pulmo-
nary and cardiac considerations, judicious
fluid management is recommended.1 Older
patients usually cannot increase cardiac out-
put to meet oxygen demands so they may be
candidates for early transfusion with packed
red blood cells to increase the oxygen-carry-
ing capacity rather than large volumes of
crystalloids and colloids.1 Warmed products
should be administered whenever possible.
Use vasopressors as needed. It may be neces-
sary to monitor the cardiopulmonary status
with a pulmonary artery catheter to ade-
quately evaluate the patient’s fluid volume
status and cardiac function.
Following the primary assessment of air-
way, breathing, and circulation, the second-
ary survey should include a complete
neurological assessment, particularly in those
patients with a significant mechanism for a
head injury or SCI. Head injury is the prima-
ry concern as the potential for disability is
evaluated in the geriatric trauma patient. CT
scans should be used early to assess the pa-
tient for a potential head injury. In the older
person, significant cerebral atrophy may mask
an expanding subdural hematoma until the
patient suddenly has a sudden and significant
deterioration in neurological status.1
25
Motor or muscle examination must include
grading of strength. Careful sensory scrutiny
should include light touch and pinprick sen-
sation in the major dermatomes. Testing for
deep tendon reflexes, a Babinski response,
rectal sphincter tone, and bulbocavernous
reflex is standard. Finding a sensory level on
the trunk or upper extremity essentially is
pathognomonic for the diagnosis of an SCI.
This patient requires an urgent MRI of the
affected area; however, this may not be pru-
dent in an unstable patient.11
The rigid backboard is used only as a
transport device and the patient should be
removed from the spine board as quickly as
possible. Decubitus ulcers are a result of
prolonged immobilization in spinal cord-in-
jured patients.14 If the patient is neurological-
ly intact, cervical spinal precautions, including
a cervical collar, are maintained until the
patient has been cleared radiographically and
clinically.
Full exposure of the patient also will pro-
vide information into the patient’s medical
history, particularly the presence of surgical
scars. The peripheral vascular status also can
be assessed fully.
If family members or other witnesses to the
event are present, they can contribute valu-
able information regarding the event:
1. Has the patient had more than one fall/
motor vehicle crash during the past
year? Is there a pattern of recurrent
injuries?
2. Did the patient complain of chest pain
or headache prior to the fall/motor ve-
hicle crash? Could a cardiac or neuro-
logical episode have contributed to the
situation?
3. Did the patient begin a new medication
or change doses of his or her current
medications? Is he or she compliant
26 CRITICAL CARE NURSING QUARTERLY/AUGUST 1999
with taking this medication as pre-
scribed?1
Medical and nursing management of
older patient with an SCI
Hypoxia, hypotension, and hypovolemia
contribute to ischemic spinal cord damage;
therefore, prevention and/or early treatment
of these deleterious signs are urgent. The
oxygen-carrying capacity of the blood, par-
ticularly to the microcirculation of the spinal
cord, is best accomplished with a hemocrit of
30–35 percent.11 If the older patient is hy-
potensive, continue to search for other causes
of shock before assuming the hypotension is
due to neurogenic shock.11,14
There is evidence that high-dose methyl-
prednisolone improves neurological out-
comes in patients with SCI. The
recommended dosage is:
• Initial dose: 30mg/kg IV drip given over
45 minutes
• Second dose: 5.4 mg/kg/hour IV con-
tinuous infusion for 23 hours.
Methylprednisolone has not been proven
to be effective if given 8 hours or more after
injury.11,12,14
If surgical management of the spinal injury
is indicated, surgery performed within the
first 12–14 hours can preserve, improve, or
restore spinal cord function. Surgery is post-
poned if the patient shows significant im-
provement in neurological function or if the
patient has a life-threatening injury as a result
of severe trauma.12 If the patient requires
surgery for repair of the spinal injury or other
traumatic injuries, the anesthesia team should
avoid adrenergic agonists or antagonists due
to the autonomic instability present in neuro-
genic shock. The denervated muscles are
responsive to acetylcholine and using succi-
nylcholine may precipitate a hyperkalemic
crisis during the first six months after a com-
plete SCI.11
Patients with an SCI also may lack abdom-
inal sensation and cannot describe early symp-
toms of bowel perforation or peritoneal
hemorrhage. An acute paralytic ileus requir-
ing stomach decompression through a naso-
gastric (NG) tube occurs with SCIs. It is
recommended that all patients be prescribed
stress ulcer prophylaxis. Following removal
of the NG tube, a bowel program is initiated
and the patient is monitored for constipa-
tion.11–13
Pulmonary complications are the major
cause of death in the quadriplegic spinal
cord-injured patient, particularly with the
high cervical spinal cord injury patients who
are ventilator dependent.11,16 Nursing care
includes aggressive pulmonary toilet with
chest physical therapy, frequent position
changes, and suctioning as needed. For the
non-ventilated patient, incentive spirometer,
and “quad-coughing” will decrease pulmo-
nary consequences.
Fevers increase system metabolism and
oxygen demand and may extend secondary
SCI; therefore, they must be treated aggres-
sively.11
The patient with an SCI will have an atonic
bladder and initially will require an indwell-
ing urinary catheter to manage overdisten-
tion. This predisposes the patient to urinary
tract infections (UTIs). If the patient can be
managed with intermittent catheterization
every 6–8 hours, it will reduce the incidence
of UTIs.12,13
Skin breakdown occurs from a combina-
tion of factors including paralysis, bed rest,
loss of vasomotor tone, and changes in the
skin composition. In the geriatric patient, the
skin is atrophic and delicate. The loss of skin
 The Older Patient with a Spinal Cord Injury
thickness, skin tensile strength, and subcuta-
neous fat reduces the external barrier to bac-
terial invasion and impairs wound healing.7,8
Decubitus ulcers may develop, especially
over the bony prominences of the sacrum,
heels, and ischium. The patient requires ex-
ceptional skin care and must be turned every
2 hours.
POST-ACUTE PHASE
As the patient becomes physiologically
stable and spinal shock is resolved, the extent
of the patient’s deficits becomes clearer. The
focus of care shifts from the injury itself to
the changes the injury has made in the pa-
tient’s life. Early rehabilitation services are
essential and discharge planning begins. Fam-
ily dynamics, social isolation, loneliness, fear,
and depression affect the individual’s re-
sponse to illness.
CASE STUDY
The patient was a 77-year-old white male
who fell down 14 steps and was found in the
fetal position at the base of the stairs. He had
called out “Oh, no” before he fell. The para-
medics found him unresponsive, hypoten-
sive at 70/palpation, bradycardic, and with
agonal respirations. Blood was found in the
mouth and he was intubated orally at the
scene. His wife stated he had a past medical
history for removal of a benign brain tumor
and adrenal insufficiency. His medications
were phenytoin and levothyroxine.
Upon arrival in the emergency department,
physical examination showed that the patient
was intubated, not sedated, with ecchymosis
and lacerations to his face. Blood pressure
was 70/palpation and pulse rate was 70. His
Glasgow Coma Score (GCS) was 3. He had
27
no movement of his extremities in response
to painful stimuli and fasciculations were
present. A right femoral 8.5 catheter was
placed and the patient was given a total of
four units of blood through warmer for a
hemocrit of 23. The post-transfusion hemat-
ocrit was 27. He also received 4 liters of
lactated Ringers solution and 2 liters of nor-
mal saline. A diagnostic peritoneal lavage
(DPL) was performed and was negative for
abdominal bleeding. Chest x-ray and pelvic
films also were negative. The spine films
were positive for disruption of the odontoid
but were difficult to evaluate and a CT scan
was recommended. His blood pressure im-
proved with volume. A CT scan of the head
was negative for head injury or hemorrhage;
however, there was evidence of the previous-
ly known craniotomy for meningioma.
In the intensive care unit (ICU), the patient
continued to be intermittently hypotensive.
Treatment with additional volume led to mild
pulmonary edema that was treated with furo-
semide. The ventilator was set for assist
control with a rate of 12, tidal volume of 700,
FiO2 of 80 percent, and PEEP 5 cm. His
temperature in the ICU was 33.4°C and he
was covered with a Bair Hugger.™
After his blood pressure stabilized, the pa-
tient had a CT scan of the cervical spine that
revealed a type III odontoid fracture with
anterior displacement of the C-2 body and an
epidural hematoma. There was a second epi-
dural hematoma from C-7 through T-3. The
patient had severe spinal stenosis C-3 through
C-7. Later that day, an MRI confirmed the
odontoid fracture with C-2 cord contusion and
anterior and posterior epidural hematoma and
C-5, C-6, C-7 fractures (probable hyperexten-
sion) with contusion at C-5, C-6, C-7 and an
epidural hematoma. He had severe pre-exist-
ing stenosis from C-4 through C-7.
28 CRITICAL CARE NURSING QUARTERLY/AUGUST 1999
The health care team consisting of the
neurosurgeon, intensivist, nurse, social work-
er, and chaplain met with the family to dis-
cuss the plan of care given this patient’s very
poor prognosis. The patient had stated very
strongly his prior wishes that he would not
like to be on long-term life support. The
family chose to honor his wishes and asked
that life support be withdrawn the next day.
Three days post-injury, ventilatory support
was withdrawn and the patient rapidly be-
came asystolic. His family remained with
him during this time.
PROGNOSIS
The prognosis for the patient with an SCI is
dependent on the severity and location of the
injury, the presence of pre-existing spinal
stenosis, the age of the patient at the time of
the injury, the ability to survive the first three
months after injury, and access to spinal cord
rehabilitation facilities.11,13 For the patients
with a complete SCI, if the injury remains
complete for more than 5 to 10 days, there is
less than a 5 percent likelihood of regaining
useful function of the arms and legs.11 How-
ever, patients with incomplete injuries usual-
ly have some improvement in function. One
study reported higher mortality risk was as-
sociated with higher neurological level, com-
plete SCI, older age at injury, and earlier year
of injury.16 The leading cause of death in-
volved the respiratory system, followed by
urinary complications and then heart dis-
ease.16 The group with the highest risk of
dying from respiratory disease was the pa-
tients aged 61 and older at the time of injury.16
Alander, Parker, and Stauffer17 studied in-
termediate-term outcomes of cervical spinal
cord-injured patients older than 50 years of
age at the time of injury. Forty-one consecu-
tive patients were followed for a minimum of
2 years (mean of 5.5 years). There were 13
complete and 28 incomplete cervical cord
lesions. None of the patients with complete
cord injury improved, all required extensive
care, and 77 percent (10) died within the first
year following the injury. Seventy-three per-
cent (19) of the incomplete cord injury group
had independent or near-independent abili-
ties with activities of daily living and 77
percent (20) were able to return home. Fifty
percent (14) of the incomplete cord injury
group had died by the time of a follow-up
visit.17
The prognosis also is age related. In the
patient aged 65–74 years, severe injury to the
head or spinal cord or critical deterioration
from other traumatic injury is associated with
a poor outcome.1 In the patient aged 75 years
and older, moderately severe injury results in
a poor outcome.1 After proceeding with ag-
gressive initial resuscitation, it is appropriate
to discuss the magnitude of the patient’s
injuries with the patient (if competent) and
family members. It is important to know if
the patient has prepared a “living will” or
other advance directives. There are multiple
legal and ethical issues involved and it is
essential to consult social services, pastoral
care, and other support services to help the
family and health care team with difficult
decisions. The primary issues are the pa-
tient’s right to self determination, medical
intervention only if it is in the patient’s best
interest, and medical therapy when its likely
benefits outweigh its likely adverse conse-
quences.7
PREVENTION
Preventing falls in the geriatric population
begins with identifying the potential hazards:
 The Older Patient with a Spinal Cord Injury
tripping over furniture, stairs, scatter rugs,
and other obstacles; stairs without railing;
and inadequate lighting. The older person
also is more likely to fall when placed in a
new environment. As the number of older
Americans increases, nurses can help de-
scribe and reduce the number of environ-
mental risks: floor surfaces can be covered
with nonslip materials, handrails can be placed
on both sides of a walkway, handgrips can be
placed in bathrooms, and improved lighting
can be placed in all areas, especially on steps
and landings. Other strategies are to increase
physical activity to improve strength, mobil-
ity, and flexibility.
The automobile probably will remain the
primary source of transportation for the aged,
given the sense of independence that driving
brings Americans. The controversial, ethical
debate over driving privileges for aging citi-
zens continues to be unresolved at the nation-
al level. Some states can restrict driving to a
certain time of day or geographic location.
Several states have reduced the length of the
license term to 2 to 3 years from the usual 4
years.18
REFERENCES
1. Kauder DR. Geriatric trauma. In: Peitzman AB, Rhodes
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delphia: Lippincott-Raven; 1998.
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29
Measures to reduce the incidence of motor
vehicle crashes include encouraging increased
use of public transportation, changing road
design to incorporate wider lanes and shoul-
ders, more one-way streets, better lighting,
bigger and brighter signs, and lower speed
limits in some locations. Programs also have
been developed to include training in defen-
sive driving skills. As a group, adults aged 70
years or older wear safety belts more often
than does any other age group except infants
and preschool children.19
SUMMARY
Geriatric trauma victims cannot tolerate
error. SCI in the older patient occurs follow-
ing falls, motor vehicle crashes, and pedestri-
an/motor vehicle crashes. Central cord
syndrome occurs more in the older patient
and is related to pre-existing spinal stenosis.
The diminished physiologic reserve associ-
ated with the aging process makes caring for
this patient a challenge.
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survival in spinal cord injury: A fifty year investigation.
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