A February 2014 study by the Insurance Institute for Highway Safety on trends in older driver crash rates and fragility contains some surprising statistics with important implications for emergency medicine (http://www.iihs.org/frontend/iihs/documents/masterfiledocs.ashx?id=2059). The new study, an update of previously published age-related crash data, reaffirms that, as licensed driver fatality rates have declined across all age groups—even though drivers 70 and older remain more likely to die in car crashes than those aged 35 to 54—the rate of decline has been much more pronounced for the elderly than for middle-aged drivers.
According to police-reported crash data from 20 states, between 1997 and 2012, fatal crash rates declined by 42% for older drivers and 30% for middle-aged drivers; data between 1995 and 2008 indicate that the crash fatality rate per miles driven fell 39% for older drivers compared with 26% for middle-aged drivers. Most recently, the declines in fatality rates per licensed drivers were 18% for both age groups during 2007 through 2012, though the number of miles driven by the elderly continued to steadily increase during the study period.
The substantial declines in car crash fatalities for elderly drivers probably result from a combination of drivers remaining healthier longer, better postaccident emergency care, and cars made safer by side air bags, stabilizer and rollover-reduction systems, and automatic braking to avoid collisions. Regardless of the reason or reasons, decreasing automobile-related mortality will increase the number of the elderly who may subsequently visit EDs for (unrelated) health issues.
But the dramatic improvement in elderly safe-driving statistics should also dispel the idea that in other areas, including illnesses, injuries, and treatments, older patients will always remain less able to function adequately or be able to adapt to new conditions than will younger people. For example, a powerful new antibiotic may reduce the fatality rate in all adults, but much more so in the elderly. With respect to the evaluation and treatment of closed-head injuries, aging may allow the elderly to tolerate some expanding lesions better than younger adults thereby avoiding sudden life-threatening conditions—though after falls that may not be significant in younger adults, uncontrollable hemorrhaging may result from blood vessels that are more vulnerable in the elderly.
The point is that in many instances, elderly patients who present to EDs are not just sicker versions of younger adults, but different—sometimes sicker, to be sure, but often not as sick or sick in a different way, with fewer or different signs and symptoms associated with a particular illness. Often-cited, an acutely confused elderly patient, with little or no temperature elevation, no abnormal breath sounds, and no chest X-ray indication of consolidation, may nevertheless have pneumonia causing hypoxia that results in confusion. Another example is the dough-like abdomen of an elderly patient with nondescript gastrointestinal distress, instead of the expected board-like rigidity in a younger adult that accompanies a perforated bowel.
In the years to come, technology will make it possible for older people to function at higher levels, as they live longer. Can’t remember an important person or event? “Google” anything you can think of associated with the person or event, and the information you are seeking becomes an easy multiple choice exercise on the screen. But newer and better medications that can enable people to live longer and better, will only work when emergency physicians know how to recognize the different patterns and choose the best medications and treatments for conditions in that age group.
This is what Geriatric Emergency Medicine is all about.