Archives of Gerontology and Geriatrics 54 (2012) e426–e430

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

Stephen O’Neill a,*, Richard R. Brady a, Jan J. Kerssens b, Rowan W. Parks c

a Department of Surgery, Queen Margaret Hospital, Dunfermline, NHS Fife, United Kingdomb ISD, NHS Scotland, United Kingdomc Department of Clinical Surgery, Royal Infirmary of Edinburgh, Little France, Edinburgh, United Kingdom

A R T I C L E I N F O

Article history:

Received 29 October 2011

Received in revised form 30 December 2011

Accepted 17 January 2012

Available online 7 February 2012

Keywords:

Elderly

Surgery

Outcomes

Trauma

A B S T R A C T

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.

� 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

In Scotland, the population of over 75 year olds has increased by14% 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 menand 85.2 for women (Macninven, 2009). The incidence of reportedtraumatic injury in the elderly population is rising, commensuratewith the proportional increase in an ageing population, establish-ing elderly trauma as an issue of growing importance to currentand future health care provision and service design (Labib et al.,2011).

The annual cost to the National Health Service (NHS) of treatingtraumatic injuries is currently estimated at £1.6 billion, whichconsumes approximately 7% of the total annual NHS budget(Christensen et al., 2008). It is projected that as a component, theelderly trauma population will place increasing demands on

* Corresponding author.

E-mail address: stephenoneill@doctors.org.uk (S. O’Neill).

0167-4943/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2012.01.007

healthcare resources compared to other age groups, principally asthe elderly population are living longer and experiencing moreactive lifestyles, thus exposing themselves to a much greater risk oftrauma than previously (Labib et al., 2011).

There is compelling evidence that the elderly population haveworse clinical outcomes following traumatic injury compared toyounger trauma patient populations (Demaria et al., 1987; Osleret al., 1988; Champion et al., 1989; Mccoy et al., 1989) and withadvancing age, trauma outcomes in the elderly have been reportedto cumulatively deteriorate with each 1-year increase in ageresulting in a 6% increase in the probability of death (Grossmanet al., 2002). The explanation for poor outcomes in the elderlypopulation following trauma are multi-factorial and include co-morbid conditions, loss of functional reserve, blunted physiologicalresponses to trauma, impaired healing, reduced immunity, higherincidence of post-injury complications and reliance on medica-tions that complicate injury and resuscitation (Aschkenasy andRothenhaus, 2006). It is clear therefore that a greater emphasisneeds to be placed on prevention of injury in this age group ofpatients if outcomes are to be improved (Jacobs, 2003).

S. O’Neill et al. / Archives of Gerontology and Geriatrics 54 (2012) e426–e430 e427

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

This is the first study to fully address the issue of elderly traumain Scotland and utilizes one of the largest dedicated prospectivelycollected trauma databases in Europe to fully characterize thecontemporary incidence, demographics and outcomes of traumat-ic injury in elderly patients. The authors aimed to evaluateoutcomes in the very elderly, previously defined as >80 years ofage, as this population have been recognized as a particularlyvulnerable 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 factorsassociated with survival or mortality in the elderly followingtrauma. The secondary objective was to compare the epidemiologyof trauma in the elderly with younger patients.

2. Materials and methods

2.1. Population

STAG was established in 1991 to evaluate the management ofmajor trauma in Scottish hospitals. STAG maintains an indepen-dent, prospectively gathered, population database of over 50,000trauma patients admitted over an 11-year period to participatingNHS hospitals in Scotland. A maximum of 25 hospitals contributedto the national database throughout the duration of data collectionfrom February 1992 until December 2002.

Trauma patients older than 13 years of age, who were in-patients for three days or more, patients who died as a result oftrauma, or patients who were transferred to a regional ornational specialist service were included in the database, whichhas been estimated to capture 98% of seriously injured patientsin Scotland (Beard et al., 2000). Comprehensive proformas werecompleted at the time of admission and throughout theinpatient stay. This recorded key data regarding patientdemographics, details of the trauma incident, key physiologicalparameters on admission and trauma scores, number and typeof injuries, initial investigation and treatment, hospital stay andoutcomes.

Table 1Trauma by age group as a proportion of the total number of trauma patients on an an

Age 13–80 Age 81–106

Trauma cases/year % of total cases Trauma cases/year

1992 2055 91.2 198

1993 2182 91.9 192

1994 2388 92.5 195

1995 2780 91.4 263

1996 4346 90.8 440

1997 5877 90.3 632

1998 5719 90.8 582

1999 6324 90.8 638

2000 5700 90.7 585

2001 5311 90.6 554

2002 5184 91.0 512

Total 47,866 90.9 4791

2.2. Analysis

The study design was a retrospective analysis of a prospectivelycollected database. Discussions undertaken with the local ethicalcommittee confirmed that the study did not require NHS ethicalreview. Injuries were classified according to the AIS (1990revision–update 1998) (Gennarelli, 2001). The elderly populationwas defined as those over 80 years of age and was separatelyanalyzed and compared to the remaining patients aged 13–80years. Demographics and outcomes for a range of variables wereassessed and a comparative analysis of the characteristics in eachage group performed.

Categorical data was analyzed using Pearson Chi square as a teststatistic (or Fisher’s exact test for a 2 � 2 table), whilst continuousdata was analyzed using the non-parametric Mann Whitney U Teststatistic. Alpha was set at 0.05 for all tests.

A series of bivariate logistic regression analyses were used tomodel the probability of death in the 4791 elderly patients withvarious prognostic variables such as; age, mechanism of injury,gender, hemodynamic compromise [systolic blood pressure (SBP)<90 mmHg], GCS at presentation, severity of injury by AIS and ISSthat resulted in unadjusted odd ratios. This was followed by amultiple logistic regressions in the elderly group to assess whethera statistical association between one (or more) of the prognosticfactors and the outcome measure still held when the effect of otherprognostic factors were taken into account. This analysis resultedin adjusted odd ratios.

Finally, further analysis established whether the associationbetween the significant prognostic factors was the same (ordifferent) in younger patients aged 13–80 years compared to thoseover 80 years. For this purpose every significant prognostic factorwas fed into a logistic regression analysis with the probability ofdeath again as the dependent variable and the age group as amoderator variable (interaction effect). This amounts to acomparison of unadjusted odd ratios for the two age groups. Forthis purpose it was necessary to analyze older and youngerpatients simultaneously (n = 52,887).

3. Results

3.1. Overall demographics

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

nual basis.

Total

% of total cases Total trauma cases/year Total trauma cases/year %

8.8 2253 100.0

8.1 2374 100.0

7.5 2583 100.0

8.6 3043 100.0

9.2 4786 100.0

9.7 6509 100.0

9.2 6301 100.0

9.2 6962 100.0

9.3 6285 100.0

9.4 5865 100.0

9.0 5696 100.0

9.1 52,657 100.0

Table 2Mechanisms of injury by age group.

Age 13–80 Age 81–106 Total p value

% % % Chi-square test

Mechanism of injury

RTA 24.0 10.2 11,962 22.7 <0.001

Assault 10.5 0.4 5064 9.6 <0.001

Fall>2 m 10.5 2.4 5135 9.8 <0.001

Fall<2 m 42.5 84.1 24,374 46.3 <0.001

Sport 5.5 0.1 2622 5.0 <0.001

Other 7.0 2.8 3498 6.6 <0.001

Total 100.0 100.0 52,655 100.0

S. O’Neill et al. / Archives of Gerontology and Geriatrics 54 (2012) e426–e430e428

3.2. Comparison by age group

The elderly trauma patient population had a median age of 85years (range 81–106) and was predominantly of female gender(79.6% females versus 20.4% males, p < 0.001). In comparison therewere significantly more males (62.5% males versus 37.5% females,p < 0.001) in the younger patient cohort (<80 years old) (medianage = 46 years; range 13–80 years).

The majority of elderly trauma patients presented followingblunt (99.6%) as opposed to penetrating trauma (0.4%), whilstyounger patients had a significantly higher incidence of penetrat-ing trauma (6.4% versus 0.4%, p < 0.001) and less blunt trauma(93.6% versus 99.6%, p < 0.001). The most common mechanism ofinjury in the elderly population was a fall from a height <2 m(84.1%) (Table 2).

Elderly patients presented later to the accident and emergencydepartment (A&E) than younger patients (median 83 min versus62 min, p < 0.001). Elderly patients also had less hemodynamiccompromise than younger patients (1.8% versus 3.3%, p < 0.001).

The mean number of injuries (3 versus 2.3, p < 0.001) and meanISS (10.2 versus 8.7, p < 0.001) was significantly higher in theyounger trauma population. Younger patients sustained signifi-cantly more thoracic (8.8% versus 5.9%) and abdominal injuries(4.3% versus 1.1%) than elderly patients (p < 0.01). A higherproportion of elderly patients presented with upper limb traumacompared to the non-elderly (26.2 versus 15.3%) (p < 0.01). Themajority of other presenting injuries in the elderly followed a

Table 3Unadjusted odds ratios and associated 95% confidence intervals (CI) for separate logist

Odds ratio

Male versus female 2.776

Penetrating versus blunt 1.212

Lowfall versus Assault/RTA 1.170

Highfall versus Assault/RTA 0.290

Other versus Assault/RTA 0.780

GCS (1 point increase) 0.582

AIS score of most severe injury 4.425

ISS (1 point increase) 1.184

Head injury AIS 1,2,3 versus other 3.412

Head injury AIS 4,5,6 versus other 23.508

Chest injury AIS 1,2,3 versus other 2.646

Chest injury AIS 4,5,6 versus other 22.114

Abdo injury AIS 1,2,3 versus other 15.087

Abdo injury AIS 4,5,6 versus other 16.543

Leg/arm injury AIS 1,2,3 versus other 0.356

Leg/arm injury AIS 4,5,6 versus other 37.994

Spinal injury AIS 1,2,3 versus other 2.141

Spinal injury AIS 4,5,6 versus other 43.355

SBP<90 mmHg (yes versus no) 8.536

Time to presentation (1 h increase) 0.312

Time to theatre (1 h increase) 1.005

Note: ns = non-significant, abdo = abdominal.

similar distribution as that experienced in younger patients; leg(36.4% versus 37.9%), head (14% versus 16.9%), face (7.4% versus8.3%), spine (3.9% versus 4.8%), neck (0.3% versus 0.4%) and burninjuries (3.4% versus 4.9%).

Elderly patients were more often managed non-operatively(53.9% versus 38.1%, p < 0.001). If an operation was required in theelderly population, it was most commonly an orthopedic proce-dure (43.6% of all operations in the elderly) and less commonly aneurosurgical intervention (0.4%) or laparotomy (0.4%). Youngerpatients were still more likely to undergo an orthopedic procedure(51.5% versus 43.6%) but were significantly more likely to proceedto laparotomy (3.1%) or neurosurgical intervention (3.1%)(p < 0.001).

Younger patients were more likely to spend time in an intensivecare unit (ICU) (7.8% versus 2.6%) or high dependency unit (HDU)(9.5% versus 5.3%) (p < 0.001) than the elderly. However, themedian total length of hospitalization was greater in the elderlythan in the young (10 days versus 6 days, p < 0.001).

Finally, the absolute mortality in elderly trauma patients wasfound to be significantly higher than younger patients (9.9% versus4%, p < 0.001). In a sub-analysis of 10 patients (all female) from theSTAG database who were aged over the age of 100 years (0.002% oftotal elderly cohort) at the time of the traumatic injury, themortality rate was markedly higher at 30% compared to 9.9% in the>80 years population as a whole.

The majority of elderly patients with traumatic injuries diedwhilst an in-patient on a ward (75.2%) with younger patients

ic regression analyses on the probability of death in the elderly group (n = 4791).

95% CI for odds ratio

Lower Upper

2.272 3.391

0.276 5.318 ns

0.732 1.869 ns

0.229 0.369

0.478 1.271 ns

0.548 0.619

3.824 5.119

1.164 1.203

2.599 4.479

17.426 31.712

1.988 3.520

14.042 34.826

9.021 25.234

3.940 69.460

0.289 0.439

4.779 302.073

1.584 2.895

12.303 152.774

5.525 13.188

0.101 0.961

0.907 1.112 ns

Table 4Adjusted odds ratios and associated 95% CI for multiple logistic regression analyses

on the probability of death in the elderly group (n = 4791).

Odds ratio 95% CI for odds

ratio

Lower Upper

GCS (1 point increase) 0.713 0.669 0.759

Male versus female 1.800 1.397 2.321

SBP<90 mmHg (yes versus no) 3.950 2.127 7.335

ISS (1 point increase) 1.115 1.096 1.134

Spinal injury AIS 4,5,6 versus other 4.400 1.011 19.143

Leg/arm injury AIS 1,2,3 versus other 0.631 0.479 0.833

Note: odds ratios are adjusted for prognostic factors in this table.

S. O’Neill et al. / Archives of Gerontology and Geriatrics 54 (2012) e426–e430 e429

significantly less likely to die on a ward (23.1%) but more likely tobe dead at the time of presentation (26% versus 6.7%), die in theatre(15.5% versus 4.8%) or in the ICU (15.7% versus 6.7%) (p < 0.001). Asfor the other locations of recorded mortality, a smaller number ofelderly patients died in a neurosurgery ward (3.8%), in anotherhospital (2.5%) or in spinal injuries unit (0.2%).

3.3. Logistic regression

A series of separate logistic regression analyses of patients inthe elderly group demonstrated that men compared to women,patients who suffered a high fall (>2 m), those with lower GCSscores, higher AIS scores (of most severe injury) and higher ISSscores had a higher probability of mortality.

Also, patients with concomitant injuries (whether it were head,chest, abdominal, leg/arm, or spinal injuries), hemodynamicallycompromised patients and patients who took longer to arrive atA&E had a higher probability of mortality than other elderlypatients. The results are all summarized in Table 3 with unadjustedodds ratios.

In a multiple logistic regression analysis of patients in theelderly group only 6 out of the initial 21 prognostic factorsdisplayed an independent effect on mortality. These were GCS,male sex, hemodynamic compromise, ISS, concomitant majorspinal injury(ies) and concomitant minor leg/arm injury(ies). Theresults are summarized in Table 4 with adjusted odds ratios(adjusted for the prognostic factors present in Table 4).

The final multiple logistic regression was aimed at investigatingwhether age-group changed the effect of the 6 remainingprognostic factors with mortality. This was only so with GCS,male sex and concomitant major spinal injury(ies). For example, aGCS of 6 was associated with a mortality rate of>85% in the elderlybut in the younger population this was associated with a mortalityrate of <40% (Fig. 1). Conversely the effect of major injuries wasstronger in the age group 13–81 compared to the over 80s.

[(Fig._1)TD$FIG]

Glasgow Coma Scale

0.0

0.2

0.4

0.6

0.8

1.0

3 4 5 6 7 8 9 10 11 12 13 14 15

GCS

Mo

rtality

Age 13 - 80 Age 81 - 106

Fig. 1. Relationship between GCS and mortality by age group.

4. Discussion

This study aimed to assess the contemporary epidemiology oftraumatic injury in the elderly population of Scotland. The mainobstacle to an epidemiological approach for resource allocation hasbeen seen as its very demanding data requirements but given thata robust, prospectively gathered and highly compliant data sourcesuch as STAG has been provided and is available, it is an excellentbasis for the ‘‘epidemiological approach’’ to trauma resourcefunding (Vallejo-Torres et al., 2009). Without such epidemiologicaldata adequate allocation of healthcare resource allocation andplanning is problematic.

The elderly population were a consistent proportion of theoverall trauma population during the study period, but had ahigher absolute mortality rate following trauma at 9.9% comparedto the younger population who had a mortality rate of 4.4%.

The demographics of elderly trauma patients in this studyshowed a significant predominance of female patients and thismirrors the demographics of the overall elderly population inScotland. This is mainly due to longer life expectancy in females inScotland but is also partly due to male mortality rates related tosocio-political events such as the Second World War (Macninven,2009).

The vast majority of elderly patients presented with blunttrauma (99.6%), especially following a fall from <2 m (84.1%),which is an observation that has been shared by previous studies inthis age group (Gates et al., 2008; Labib et al., 2011; Peel, 2011). Theoverwhelming incidence of falls in this population suggests that itis this area that should be the primary focus of preventivestrategies for the reduction of traumatic injuries in this population.

Fall related injuries among older adults, especially females,whose medical expenditures are 2–3 times higher, are associatedwith substantial economic costs (Mcmahon et al., 1996). Withmanagement of fractures attributing to 61% of the expense of non-fatal elderly trauma, the implementation of a falls preventionpolicy could also be a cost effective strategy in a population ofpatients in whom the cost of management is extremely high,primarily due to the length of hospital stay (Mcmahon et al., 1996;Stevens et al., 2006).

Recent guidance on falls prevention suggests that elderlypatients with unsteady gait or history of fall should undergomulti-factorial fall risk assessment, including evaluation for muscleweakness, balance problems and postural changes in blood pressure.Any identified problems should be addressed with specificinterventions including podiatry, functional evaluation, use ofadaptive equipment or mobility aids, rationalization of medications,cataract treatment, vitamin D supplementation and environmentalevaluation of home circumstances (AGS/BGS, 2011).

This large contemporary population based study confirms thefindings of previous studies of trauma within an elderly populationwhich have identified increasing age, male sex, admission to ICU,greater ISS, injury severity, total injuries or injury caused by a fall(Tornetta et al., 1999; Richmond et al., 2002; Aitken et al., 2010).However, this is the first study to definitively identify specificvariables that are even stronger predictors of mortality in patientsaged over 80 years, in whom it appears that the relationshipbetween GCS, AIS of spinal injury and male sex is even more highlyrelevant than in younger patients.

Unfortunately a weakness of this study is the lack ofinformation regarding the impact of respiratory rate, heart rate,co-morbidities and medications on outcome. An additionalweakness of the study was the absence of descriptive observationof the presence or level of trauma team involvement at the time ofadmission.

A number of anatomical changes occur to the brain with aging,namely a decrease in weight and size, which could explain the

S. O’Neill et al. / Archives of Gerontology and Geriatrics 54 (2012) e426–e430e430

observed relationship between age, GCS and mortality. Thesechanges stretch bridging vessels over the surface of the brain,which combined with significant age related decline in cerebro-vascular autoregulation results in a much worse prognosis in theelderly following head injury (Czosnyka et al., 2005; Aschkenasyand Rothenhaus, 2006). This study showed GCS compromise in theelderly was associated at all levels with a much increased higherrisk of mortality compared to compromise of a similar level in theyounger population.

The higher risk of mortality following spinal injury in theelderly could be explained by a predisposition to cervical spineinjuries secondary to pre-existing cervical spondylosis but couldalso be due to the high incidence of spinal injuries occurring atmultiple levels in these patients (Lomoschitz et al., 2002).

Although it has previously been hypothesized that hormonallyactive women have better physiologic responses to shock andtrauma than their male counterparts, the reasons behind this effectand why it should remain so pronounced in post menopausalfemales remains uncertain. However, although not analyzed here, anincreased predisposition to infections including post-injury pneu-monia in the male sex could potentially be a contributory factor(Offner et al., 1999; Taylor et al., 2002; Gannon et al., 2004; Angeleand Chaudry, 2005; Choudhry et al., 2005; Deitch et al., 2007).

In conclusion, this is the largest European study focused onassessing the demographics, etiology, management and outcomesfrom traumatic injuries in the elderly. Key demographic andprognostic risk factors with relevance to both initial clinicalmanagement and decision making have been identified. Theimplication for the broader efforts in healthcare resource andplanning suggest that emphasis should be on prevention.

Conflicts of interest

None declared.

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