Mortality associated with traumatic injuries in the elderly: A population based study

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Abstract

Elderly trauma is increasing in incidence and is associated with significant morbidity and mortality. The primary objective of the study was to identify factors associated with survival or mortality in the elderly following trauma. The secondary objective was to compare the epidemiology of trauma in the elderly with younger patients. A retrospective analysis was performed of data that was obtained from a prospectively collected multi-centre trauma database maintained by The Scottish Trauma Audit Group (STAG) containing details of 52,887 trauma patients admitted to 25 participating Scottish Hospitals over an 11-year period. Elderly trauma patients (aged >80 years) were separately analyzed and compared to younger trauma patients (aged 13–80). Of 52,887 trauma patients identified, 4791 were elderly (9.1%). Elderly patients had a higher absolute mortality rate following traumatic injury (9.9% versus 4%, p < 0.001). Mortality in the elderly was higher in males, following a high fall, with lower Glasgow Coma Scale (GCS), in those with higher Abbreviated Injury Scale (AIS)/Injury Severity Score (ISS), in those with concomitant injuries, hemodynamic compromise and following delayed presentation. Multiple logistic regression analysis confirmed an independent relationship between mortality and low GCS, male gender, higher ISS, higher AIS of spinal injury, hemodynamic compromise and concomitant minor leg/arm injury(ies) in the elderly. In conclusion, trauma in elderly patients is associated with significantly higher mortality. Low GCS, male gender, higher ISS, higher AIS of spinal injury, hemodynamic compromise and concomitant minor leg/arm injury(ies) have the strongest independent relationships with mortality after trauma in the elderly population.

Introduction

In Scotland, the population of over 75 year olds has increased by 14% in the last decade and is expected to rise a further 70% by 2033, when the life expectancy is anticipated to be 80.7 years for men and 85.2 for women (Macninven, 2009). The incidence of reported traumatic injury in the elderly population is rising, commensurate with the proportional increase in an ageing population, establishing elderly trauma as an issue of growing importance to current and future health care provision and service design (Labib et al., 2011).

The annual cost to the National Health Service (NHS) of treating traumatic injuries is currently estimated at £1.6 billion, which consumes approximately 7% of the total annual NHS budget (Christensen et al., 2008). It is projected that as a component, the elderly trauma population will place increasing demands on healthcare resources compared to other age groups, principally as the elderly population are living longer and experiencing more active lifestyles, thus exposing themselves to a much greater risk of trauma than previously (Labib et al., 2011).

There is compelling evidence that the elderly population have worse clinical outcomes following traumatic injury compared to younger trauma patient populations (Demaria et al., 1987, Osler et al., 1988, Champion et al., 1989, Mccoy et al., 1989) and with advancing age, trauma outcomes in the elderly have been reported to cumulatively deteriorate with each 1-year increase in age resulting in a 6% increase in the probability of death (Grossman et al., 2002). The explanation for poor outcomes in the elderly population following trauma are multi-factorial and include co-morbid conditions, loss of functional reserve, blunted physiological responses to trauma, impaired healing, reduced immunity, higher incidence of post-injury complications and reliance on medications that complicate injury and resuscitation (Aschkenasy and Rothenhaus, 2006). It is clear therefore that a greater emphasis needs to be placed on prevention of injury in this age group of patients if outcomes are to be improved (Jacobs, 2003).

However, adequate targeting of the necessary preventative measures needed to alleviate this significant and increasing health care burden continues to be problematic as the epidemiology, etiology and prognostic factors associated with traumatic injury in the elderly remain poorly understood (Labib et al., 2011). Enhanced recognition of the pattern of presentation in elderly patients with trauma will not only augment the possibility of prevention from a public health and services perspective but would also assist better decision making in future management of this patient population as a whole.

This is the first study to fully address the issue of elderly trauma in Scotland and utilizes one of the largest dedicated prospectively collected trauma databases in Europe to fully characterize the contemporary incidence, demographics and outcomes of traumatic injury in elderly patients. The authors aimed to evaluate outcomes in the very elderly, previously defined as >80 years of age, as this population have been recognized as a particularly vulnerable and understudied trauma population (Cagetti et al., 1992, Meldon et al., 2002, Bulpitt et al., 2006, Peters et al., 2010).

The primary objective of the study was to identify factors associated with survival or mortality in the elderly following trauma. The secondary objective was to compare the epidemiology of trauma in the elderly with younger patients.

Section snippets

Population

STAG was established in 1991 to evaluate the management of major trauma in Scottish hospitals. STAG maintains an independent, prospectively gathered, population database of over 50,000 trauma patients admitted over an 11-year period to participating NHS hospitals in Scotland. A maximum of 25 hospitals contributed to the national database throughout the duration of data collection from February 1992 until December 2002.

Trauma patients older than 13 years of age, who were in-patients for three

Overall demographics

From the STAG database, 4791 (9.1%) elderly trauma patients were identified with the remaining 47,866 patients (90.9%) aged between 13 and 80 years. The incidence of trauma in the elderly as a proportion of all trauma patients over the 10 full years of data collection, was consistently between 7.5% and 9.7% (Table 1).

Comparison by age group

The elderly trauma patient population had a median age of 85 years (range 81–106) and was predominantly of female gender (79.6% females versus 20.4% males, p < 0.001). In comparison

Discussion

This study aimed to assess the contemporary epidemiology of traumatic injury in the elderly population of Scotland. The main obstacle to an epidemiological approach for resource allocation has been seen as its very demanding data requirements but given that a robust, prospectively gathered and highly compliant data source such as STAG has been provided and is available, it is an excellent basis for the “epidemiological approach” to trauma resource funding (Vallejo-Torres et al., 2009). Without

Conflicts of interest

None declared.

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