Silver
Trauma

A ‘silver tsunami’ is breaking on the NHS

For those working in NHS emergency departments, they will be witnessing a “silver tsunami breaking on the NHS” says Professor Fiona Lecky, clinical professor in emergency medicine at CURE (the Centre for Urgent and Emergency Care Research).
Numbers of older people going to hospital with major trauma have increased significantly, as shown from the Changing Face of Major Trauma in the UK report, published in 2015 - when data was first collected in 1990, the average age of the major trauma patient was 36. By 2006, this had gone up to 40, then by 2014, the median age went to 54. 
The numbers of patients admitted to hospital in the 0-24 and 25-49 age groups was stable during 2004 to 2010 - but massive growth was seen among those aged 50 and over, and particularly in those aged 75 to 100 with major injury. 
The signature injury is traumatic brain injury, says Prof Lecky, with 75 per cent of older major trauma patients presenting usually with subdural injury; polytrauma is much more rare in that older bracket. 
Falls from standing or low height has been a driver of this - “the proportion injured in low energy falls has gone up to over 50 per cent, from standing height or less than two metres - this means the number of patients has increased from, for example, 40 to 50 patients to over 150 major injury patients each year,” says Prof Lecky. “There are actually very few patients injured by high-energy trauma, most of the patients aged 75 and over were injured in low-energy falls.”
Older people are more likely to be injured indoors, in their own homes - and as many older people - aged 70 to 90 - live alone, it can sometimes be hours or even days until they are taken to hospital. 
Using data from the Trauma Audit and Research Network (TARN) - which, since 2012, has made it compulsory that all trauma-receiving hospitals send their admissions statistics - it has become increasingly clear the extent to which major trauma services are being dominated by older people. 
“It is a real phenomenon,” says Prof Lecky, also research director of TARN.
“In 2017, after a lot of in-depth study, we published the Major Trauma in Older People report, and the first thing we looked at denominator factors - was this silver trauma phenomenon purely due to ageing of the population?
“We don’t think it is, actually. In terms of the population, older people accounted for close to 20 per cent in 2005, and that had probably only gone up by two per cent in prevalence by 2014. But the proportion had gone up to 40 per cent in terms of major trauma patients by 2014.
“By and large these patients have always been there, but they weren’t being diagnosed or recognised.”
One of the biggest changes in this situation is the access to CT scanning, says Prof Lecky. 
“Back in early noughties, it was very difficult to get a CT scan in major injury patients. Access to CT scanning is improving massively, we are now scanning more than 90 per cent major of trauma patients,” she says. 
The NICE head injury guidelines in 2004 made it compulsory to CT scan older people after head trauma, which has massively changed NHS practice, she adds. 
However, the reorganisation of trauma by NHS England in 2012, which sees an injured patient triaged for trauma - and taken to a
Major Trauma Centre if deemed necessary - can make things more problematic for the older generation. 
“As we found on TARN, older people have a higher Glasgow Coma score, as we get older brains tend to shrink - so a far more occult injury can be much more difficult to detect at scene of injury, and therefore can more difficult to detect in triage at scene of injury,” says Prof Lecky, pointing to the fact that only 38 per cent of silver trauma patients go directly to a Major Trauma Centre, whereas that is 57 per cent in the 16 to 64 age group. 
“They are also far less likely to see a consultant, because they are less likely to trigger triage tool, which pre-alerts the team
at the hospital,” she adds. 
This can incur a wait for a CT scan and being seen by a more junior medic, rather than the consultant who would be available had the scale of the trauma been communicated.
Once admitted to hospital, a secondary trauma to a Major Trauma Unit is also much less likely for an older person, says Prof Lecky. 
Surgery delays can also be seen, with only 15 per cent of older people having an operation after admission, whereas that is 37 per cent in those aged 16-59 - neurosurgeons can often be less keen to intervene quickly due to issues often seen in older people like existing conditions and anticoagulation issues. 
After admission, 16-59, 37 per cent get some kind of surgery - only 15 per cent of silver trauma will do. Lot of older people have conditions and anticoagulation issues to address before, but neuro surgeons far less likely to intervene. 
While frailty can play a central role in the reasons that older people sustain brain injuries as a factor in their falls, the NHS is helping to address this through its comprehensive geriatric assessment, which can help to identify and tackle some of the issues faced by each older person. 
“If we can get these patients seen by a geriatrician, this can reduce mortality by about 50 per cent,” adds Prof Lecky. 

Holistic rehab and getting the building blocks right

The individual frames of a traditionally animated film are photographs of drawings that are first drawn on paper.

To create the illusion of movement, each drawing differs slightly from the one before it. The animators' drawings are traced or photocopied onto transparent acetate sheets called cels, which are filled in with paints in assigned colors or tones on the side opposite the line drawings. The completed character cels are photographed one-by-one against a painted background by a rostrum camera onto motion picture film . The traditional cel animation process became obsolete by the beginning of the 21st century. Today, animators' drawings and the backgrounds are either scanned into or drawn directly into a computer system.

Various software programs are used to color the drawings and simulate camera movement and effects.

The final animated piece is output to one of several delivery media, including traditional 35 mm film and newer media such as digital video. The "look" of traditional cel animation is still preserved, and the character animators' work has remained essentially the same over the past 70 years. Some animation producers have used the term "tradigital" to describe cel animation which makes extensive use of computer technology. Examples of traditionally animated feature films include Pinocchio (United States, 1940), Animal Farm (United Kingdom, 1954), and Akira (Japan, 1988). Traditional animated films which were produced with the aid of computer technology include The Lion King (US, 1994) Sen to Chihiro no Kamikakushi (Spirited Away) (Japan, 2001), and Les Triplettes de Belleville (France, 2003).

In computer displays, filmmaking, television production, and other kinetic displays, scrolling is sliding text, images or video across a monitor or display, vertically or horizontally. "Scrolling", as such, does not change the layout of the text or pictures, but moves (pans or tilts) the user's view across what is apparently a larger image that is not wholly seen. A common television and movie special effect is to scroll credits, while leaving the background stationary. Scrolling may take place completely without user intervention (as in film credits) or, on an interactive device, be triggered by touchscreen or computer mouse motion or a keypress and continue without further intervention until a further user action, or be entirely controlled by input devices. Scrolling may take place in discrete increments (perhaps one or a few lines of text at a time), or continuously (smooth scrolling). Frame rate is the speed at which an entire image is redisplayed. It is related to scrolling in that changes to text and image position can only happen as often as the image can be redisplayed. When frame rate is a limiting factor, one smooth scrolling technique is to blur images during movement that would otherwise appear to "jump". The term scrolling is also used for a type of misbehavior in an online chat room whereby one person forces the screens of others in a chat to scroll by inserting much noise or special control characters.

Words from http://en.wikipedia.org/wiki/Animation and http://en.wikipedia.org/wiki/Scrolling.

'Time is brain'

The quicker medical teams can act, the more of the brain that can be saved post traumatic injury - but for older people, that can cause issues, says Dr Matt Wiles, consultant anaesthetist at Sheffield Teaching Hospitals NHS Foundation Trust.
The “fantastic but vulnerable” brain carries over 100 billion nerve cells and makes over a million new connections every second - but when it sustains trauma, it loses two million neurons, 14 billion synapses and 12km of nerve tissue every minute. 
Crucially, each hour, it sustains the equivalent of ageing 3.6 years - which is clearly a problem in already aged brains. 
“Time is brain, particularly when it comes to silver trauma,” says Dr Wiles. 
Falls from low height continue to persist as a key cause of such brain injury in older people. 
“My practical top tip is that when you hit 70, you need to make a decision whether to have stairs or alcohol in your life, you cannot have both,” jokes Dr Wiles. 
“Stairs are the motorbikes of the elderly.”
Hospital admissions for TBI in over 65s have risen by more than 50 per cent since the turn of the century, but the pressure on resources can mean problems in older people accessing urgent care. 
“The UK has a paucity of critical care hospital beds in comparison to across Europe and worldwide, and this inevitably leads to triage in terms of who we admit,” says Dr Wiles.
“We have a particular problem when we come to the older population. Comorbidities are far more common - diabetes, chronic heart disease, renal failure, chronic lung disease, all increase the risk of systemic complications and secondary issues.”
In addition, Dr Wiles points to the fact that silver trauma patients have largely been ignored by research studies, meaning management principles are being applied based on much younger populations. 
“In the last 20 years, we have seen no improvement in TBI outcomes in critical care, mainly because of our ageing population,” he says. 

‘You’ve got to nourish to flourish’

Why does nutrition even matter when it comes to rehabilitation? Sheri Taylor, director and specialist rehab dietician at Specialist Nutrition Rehab, uses an analogy to illustrate the crucial links. 
“Pretend your body is like a house, inside this house is a 24 hour live-in renovation team.
Every time there is damage or something breaks down, the renovation team is there as quickly as possible,” she says. 
“The quality of the repair job is going to be highly contingent on the building materials and supplies you make available to them. Ae you providing your team with brick, marble and high quality paint?
Or are you giving them duck tape and cardboard?”
After major trauma, this is even more crucial, says Sheri. 
“Your client’s body or house has been through the equivalent of a hurricane. There is structural damage, there is cosmetic damage and there is damage inside the house,” she says. 
“The question is, what supplies are your clients making available to their renovation teams to repair that damage?
“Are they eating lots of vegetables and fruits, high quality proteins and fats, the equivalent of bricks and marble - or are they living on takeaway, fast foods, crisps, chocolate? Either
the repairs will not happen at all or will not be to highest standard possible. 
“With older clients, there was already wear and tear on the house before the trauma even happened. For that reason, it is even more important for these clients to be eating nutritious foods.”
Sheri points to a number of key priorities to consider when supporting the recovery of older people post-trauma. Muscle mass is particularly crucial, she says. 
“After all the life-saving strategies have been put in place, our next priority needs to be preserving muscle mass, which can be the difference between independence and not,” says Sheri. 
“We all start losing muscle mass after the age of 30 - by the time you’re 80, that is down by around 40 per cent.
“Our silver trauma clients are already at a disadvantage before they end up in hospital. Frailty is a major problem, and the reason they’re frail is because they have less muscle mass.” 
Other factors including bone density, skin and the gut also need consideration, she says. 
“We lose three to five per cent of our bone density per decade, and up to four per cent when bed-bound. Physiotherapy should be introduced as soon as possible and nutrition is an important consideration, with a focus on adequate levels of vitamin D and calcium.
Treat any osteoporosis in the process,” says Sheri. 
“Skin becomes less elastic with age, and as a result pressure sores are more likely. This becomes hugely problematic if that person ends up in hospital. 
“Skin is one of the best examples of your renovation team in action. If you’ve ever had a client with a pressure sore, you will know how much that delays their rehab. I’ve met clients who have been bed bound for years through a pressure sore. They cannot get out into the community, their muscle mass and bone
density are decreasing by the month.”
With regard to the gut, constipation can affect appetite, which can therefore impact ability to take in nutrition, says Sheri. It is important to get adequate levels of fibre and enough levels
of fluid to get the gut moving
“Malnutrition may already be a factor when an older person is admitted to hospital, but after a stay in hospital, up to 75 per cent can experience this,” she adds. 
In this instance, the need for premium supplies is all-important, says Sheri, with vitamins including vitamin D, B12 and iron
being important.
While nutrition is mainly associated with food, the need to drink and maintain fluid levels is just as vital. Kidneys in older age are not as effective and the additional problems caused here can impact on everything else, says Sheri.