Elderly injury: a profile of trauma experience in the Sunshine (Retirement) State

Decline in Explanatory Power of Trauma Mortality Models With Age: Varying Contribution of Glasgow Coma Scale, Injury Severity Score, Comorbidities, and Frailty

INTRODUCTION

Adjusting for confounding variables is critical for objective comparison of outcomes. The explanatory power of variables used in adjusted models for injury and their relative utility across age groups has not been well-defined. This study aimed to assess the explanatory power of covariates commonly adjusted in injury research and their relative performance across age groups.

METHODS

Inpatients 18-100 y (2017-2022) were selected from 90 hospital trauma registries. Patients were grouped into sequential 5-y age blocks. Mortality was defined as the proportion of patients "expired + hospice". Dominance analysis was used to determine the average contribution (McFadden's R2) for covariates commonly included in multivariable logistic regressions.

RESULTS

Three hundred seventeen-thousand one hundred thirty-six patients were included (51.1% male, mean age: 63, mean injury severity score [ISS]: 9.8, mean Glasgow Coma Scale: 14.3, 93.5% blunt). Total explanatory power (McFadden's R2) for mortality was highest in youngest age group (52.7% in 18-24 group) and decreased with age, with the lowest R2 (19.6%) in 95-100 group. Regardless of age, the Glasgow Coma Scale was the most important covariate (R2 ranging from 9.0% to 20.4%). At age 18-24 y, ISS was a more dominant contributor than Elixhauser Score, but beyond 55 y, Elixhauser Score became more dominant than ISS.

CONCLUSIONS

The explanatory power of adjustment models including common covariates is limited and varies significantly across age groups, decreasing linearly with age. Adjusting for outcomes using these covariates may limit objective comparisons especially for older adults. Additional research is needed to identify covariates that enhance the explanatory power of adjustment models to allow for more objective comparisons across all ages.

All elderly are fragile, but some are more fragile than others: an epidemiological study from one of the busiest trauma centers in Italy

As the older population increases, the number of elderly accessing the emergency department following a trauma increases accordingly. High-level trauma enters together with the identification of predictive parameters for poor outcome and mortality, may result in a death rate improvement of up to 30% in this group of patients. This study analyzes the epidemiology of major trauma admissions at Niguarda Trauma Center in Milan, Italy, focusing on the geriatric population and aiming to discriminate the trauma outcomes in the range of population between 65 and 75 years old (Senior Adult) and to compare it with the outcomes among people over 75 years old (Elderly). The variables analyzed included mortality, mechanism of injury, body district injured, Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), Geriatric Trauma Score (GTO), and outcome. Head trauma remains the main cause of mortality with falls and road accidents being the most common mechanism of injury. Frailty and associated use of anticoagulant and antiplatelet therapy increased the risk of death by 42%. The subdivision of the elder patients into two groups (65-75 and > 75) showed a difference in the probability of death and effective mortality rate.

Geriatric Trauma in a High-Volume Trauma Centre in Cape Town: How Do We Compare?

BACKGROUND

Little is known about the injury profile of older persons from low-and-middle-income countries, such as South Africa, where violence is prevalent. This study aimed to identify common mechanisms of injury (MOI), severity, complications, and outcomes in elderly patients admitted to a referral trauma centre in Cape Town.

METHODS

A retrospective review was performed of all patients ≥60 years presenting at Tygerberg hospital trauma centre over an eight-month period. Descriptive statistics were computed for all variables of interest, and the relationship between the MOI, injury severity score (ISS), complications, and outcomes were assessed.

RESULTS

Of the total 7,635 trauma cases admitted, patients ≥60 years accounted for 4% (n = 275). The most frequent MOI was low falls (58%). Of these 11% of injuries were intentionally inflicted. Among them 35% of the patients experienced complications. The ISS was positively associated with the number of complications (p < 0.01). The mortality rate was 6.5%. An ISS of ≥10 was associated with increased mortality (p < 0.01). The number of complications was positively associated with mortality (p < 0.01).

CONCLUSIONS

In contrast to high-income countries (HICs), the cohort of elderly patients admitted to the trauma centre made up a relatively small portion of the total admissions. Compared to HICs, intentionally inflicted injuries and preventable MOI were common in our sample, underscoring the importance of addressing causative factors. Notably, the ISS was strongly associated with the number of complications and an ISS ≥10 was associated with mortality, highlighting the utility of the ISS in identifying elderly trauma patients most at risk of negative outcomes.

Long term outcomes in older trauma patients admitted to the ICU: A prospective study

BACKGROUND

Prior studies have shown an increase in mortality in elderly patients when compared to their younger cohort.

METHODS

Level 1 trauma patients ≥50 years old were recruited upon admission to the ICU and prospectively followed. After an initial survey, inpatient data were collected and phone surveys were completed at 3 and 6 months.

RESULTS

100 patients were included. There was an 18% inpatient mortality. At 6 months, the mortality rate was 24%; 73% of surviving patients reported good health. 6-month nonsurvivors had a higher percentage requiring preinjury assistance with ambulation.

CONCLUSIONS

Severe trauma in patients ≥50 years of age carries a significant rate of mortality however survivors have good outcomes. Need for assistance with ambulation prior to injury is associated with 6 month mortality and could be used as a screening tool for interventions.

Redefining geriatric trauma: 55 is the new 65

INTRODUCTION

As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines.

METHODS

Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities.

RESULTS

A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001).

CONCLUSION

This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations.

LEVEL OF EVIDENCE

Epidemiological study, level III; Care management, level IV.

Postmortem Analysis of Fall Victims According to Age Groups: A Comparative Study

Fall represents an important cause of death and its relation with the population aging evidences the need of a broad analysis considering different aspects associated with its occurrence. The objective of this study was to compare fatal victims due to unintentional fall among adults, young olds, olds, and oldest olds, according to sociodemographic data, characteristics, and severity of the trauma. This study is a cross-sectional, comparative study analyzing autopsy reports of fatal victims due to fall, admitted to the Medical Legal Institute of Sao Paulo, Sao Paulo, Brazil, in 2015. The following age groups were: adults (≥18 and <60 years), young olds (≥60 and <70 years), olds (≥70 and <80 years), and oldest olds (≥80 years). The Pearson's χ, Fisher's exact, Kruskal-Wallis, and Dunn tests were applied to compare the groups, with a significance level of 5%. Regarding the 469 fatalities analyzed (57.8% males, mean age: 71.3 ± 18.2 years), there was a higher frequency of oldest olds (43.5%), ground-level falls (70.1%), femoral fractures (35.0%), and delayed deaths (79.6%) due to posttraumatic complications (57.2%). Adults, young olds, olds, and oldest olds differed significantly (p ≤ .005) in relation to the total of analyzed variables, with a special remark on the differences between the age extremes. High frequencies of femoral fractures and delayed deaths due to complications of treatment in low-severity fall victims, especially those older than 70 years, make it necessary to improve fall prevention programs in the older adults and to create a line of care for this population.

External fixation in the elderly

Orthopaedic trauma is an increasingly common problem in geriatric patients. As demands of daily life and recreational activities are increasing in these patients, surgeons need to be able to manage geriatric fractures to achieve good functional results. Reduced bone quality in the elderly presents a considerable challenge and may preclude the use of established surgical stabilisation techniques that are performed in younger trauma patients. Furthermore, pre-existing medical conditions and considerable comorbidities in the elderly could complicate standard surgical procedures that younger patients would be offered. In this respect, application of external fixators represents a validated, minimally-invasive treatment opportunity. This review article summarises the use of external fixation in geriatric trauma patients for wrist fractures, proximal femoral fractures, pelvic fractures, and ankle fractures. Modern modifications, like pin coating with hydroxyapatite, and aspects of pin care will be discussed.

Impact of age on the clinical outcomes of major trauma

PURPOSE

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.

METHODS

Review of the literature.

RESULTS

Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.

CONCLUSION

The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Undertriage of major trauma patients in the US emergency departments

BACKGROUND

There is evidence that regionalized trauma care and appropriate triage of major trauma patients improve patient outcomes. However, the national rate of undertriage and diagnoses of undertriaged patients are unknown.

METHODS

We used the 2010 Nationwide Emergency Department Sample to estimate the national rate of undertriage, identify the prevalent diagnoses, and conduct a simulation analysis of the capacity increase required for level I and II trauma centers (TCs) to accommodate undertriaged patients. Undertriaged patients were those with major trauma, injury severity score ≥ 16, who received definitive care at nontrauma centers (NTCs), or level III TCs. The rate of undertriage was calculated with those receiving definitive care at an NTC center or level III center as a fraction of all major trauma patients.

RESULTS

The estimated number of major trauma patient discharges in 2010 was 232448. Level of care was known for 197702 major trauma discharges, and 34.0% were undertriaged in emergency departments (EDs). Elderly patients were at a significantly higher risk of being undertriaged. Traumatic brain injury (TBI) was the most common diagnosis, 40.2% of the undertriaged patient diagnoses. To accommodate all undertriaged patients, level I and II TCs nationally would have to increase their capacity by 51.5%.

CONCLUSIONS

We found that more than one-third of US ED major trauma patients were undertriaged, and more than 40% of undertriaged diagnoses were TBIs. A significant capacity increase at level I and II TCs to accommodate these patients appears not feasible.

Survival advantage for elderly trauma patients treated in a designated trauma center

BACKGROUND

This article analyzes the effectiveness of designated trauma centers (DTCs) in Florida concerning reduction in the mortality risk of severely injured elderly trauma victims.

METHODS

Inpatient hospital data collected by the Agency for Health Care Administration were used to identify elderly trauma patients. An instrumental variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, comorbidities, and type of injury. The model was estimated using a bivariate probit full information maximum likelihood model to determine the impact of triage to a trauma center as opposed to a nontrauma hospital.

RESULTS

After adjusting for confounding influences, treatment at a DTC was associated with a statistically significant reduction of 0.072, 0.040, and 0.036 in the probability of mortality for patients in the age groups 65 years to 74 years, 75 years to 84 years, and ≥ 85 years, respectively.

CONCLUSIONS

Treatment of severely injured elderly trauma patients in DTCs is associated with statistically significant gains in the probability of survival.

Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008

OBJECTIVES

To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.

DESIGN

Retrospective analysis.

SETTING

Acute care hospitals in California.

PATIENTS

All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.

MAIN OUTCOME MEASURE

Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.

RESULTS

Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.

CONCLUSION

Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

INTRODUCTION

The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.

METHODS

This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level.

RESULTS

Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively).

CONCLUSION

This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals

PURPOSE

To examine the relationship of level of care (trauma center [TC], nontrauma center [NTC] hospitals) on three outcomes: survival, length of stay, and discharge disposition.

DESIGN

Retrospective secondary analysis of a subset of data (1,418 patients age 65 to 99 years) from a large statewide study in which the purpose was to compare admission patterns (TCs and NTCs) of motor vehicle (MV) trauma patients according to age and sex. The New Jersey UB-92 Patient Discharge Data for 2000 were used in this analysis.

METHODS

Demographic and clinical variables were compared using descriptive data, independent samples t tests, Pearson chi square, and Mann-Whitney U analyses. Logistic regression and multiple regression analyses were performed to examine relationships between level of care and three outcome variables, survival, length of stay, and discharge disposition, while controlling for age and severity of injury.

RESULTS

NTC admission was the only predictor of survival and discharge to home, but injury severity was the strongest predictor of length of stay, followed by NTC care. The odds of survival and discharge home decreased slightly as age and injury severity increased.

CONCLUSIONS

This analysis indicated preliminary evidence that level of care influences survival, length of stay, and discharge disposition. Studies are warranted for researchers to examine the influence of postinjury variables, including complications, stress reaction, and depression on outcomes.

Mortality in severely injured elderly trauma patients--when does age become a risk factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) > or = 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46-55 years of age) to 13.0% (patients ages 56-65 years) in patients with ISS 16-24; from 23.8% to 32.1% in those with ISS 25-50; and from 62.2% to 82.1% in those with ISS 51-75 (P < or = 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P < or = 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P < or = 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma-an increase that was independent of trauma severity.

A national evaluation of the effect of trauma-center care on mortality

BACKGROUND

Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers).

METHODS

Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers.

RESULTS

After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non-trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries.

CONCLUSIONS

Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.

Fractures in access to and assessment of trauma systems

BACKGROUND

Trauma is a major public health problem and organized systems of trauma care have been shown to substantially reduce trauma-related mortality. Currently California and many other states have incompletely developed systems of trauma care delivery. This study was undertaken to determine how frequently patients incurring serious trauma in California receive treatment at a trauma center.

STUDY DESIGN

Hospital discharge records for 360,743 acute trauma patients for 1995 to 1997 were analyzed. Abbreviated Injury Scale scores were calculated from discharge diagnosis codes. Severity of trauma and the need for trauma center treatment was defined by eight Abbreviated Injury Scale criteria combined with patient age and type of injury.

RESULTS

According to study criteria, 67,718 patients needed trauma center care and 56% were treated at a trauma center. Among patients less than 55 years of age, 62% were treated at a trauma center compared with 40% of those aged 55 years or more (p < 0.0001). For patients less than 55 years old with brain injuries, 66% were treated at a trauma center compared with 44% for patients aged 55 years or more (p < 0.0001). Of the 29,849 patients who met Abbreviated Injury Scale criteria but were not treated at trauma centers, 59% were in counties with designated trauma centers and 41% were in counties without trauma centers.

CONCLUSIONS

Only 56% of seriously injured patients in California were treated at trauma centers, despite most of the injuries occurring in the catchment areas of designated trauma care systems. Substantial undertriage of serious trauma patients to trauma centers appears to be occurring, especially in older persons and in persons with brain injuries. Efforts to understand why undertriage is occurring so frequently are hampered by fragmentation of the systems of care, inadequate data management systems, and lack of trauma care performance reporting by non-trauma center hospitals.

Trauma in the elderly: intensive care unit resource use and outcome

BACKGROUND

As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity.

METHODS

This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis.

RESULTS

Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30.

CONCLUSION

Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

Characteristics and outcomes of serious traumatic injury in older adults

OBJECTIVES

To describe the seriously injured older adult; characterize and compare the differences in injury characteristics and outcomes in three subgroups of seriously injured older adults: aged 65 to 74, 75 to 84, and 85 and older; and identify risk factors for death, complications, and discharge placement at hospital discharge.

DESIGN

A retrospective secondary analysis of a statewide trauma data set from 1988 through 1997.

SETTING

Data submitted from all designated trauma centers in Pennsylvania.

PARTICIPANTS

The data set yielded 38,707 patients with a mean age of 77.5 years with serious injury (mean number of injuries=3.6, mean number of body systems involved=2).

MEASUREMENTS

Key outcomes were mortality, complications, and discharge placement. Abbreviated Injury Score categorized injuries and Injury Severity Score (ISS) quantified anatomic severity of injury.

RESULTS

Mortality was 10%. Mean length of stay was 11.5 days. Just over half (52.2%) of survivors were discharged home; 25.4% were discharged to a skilled nursing facility. Injury severity, total number of injuries, complications, and increasing age were predictors of mortality (P <.01). The presence of preexisting comorbid medical conditions increased the odds of experiencing a complication over threefold. Increasing age, total number of injuries, injury to extremities or abdominal contents, injuries due to falls, and lower functional level predicted discharge to a skilled nursing facility (P <.01).

CONCLUSIONS

Traumatic injuries affect older adults of all ages and are typically multisystem and life threatening. The standard ISS does not fully capture the potential for mortality in older adults and does not predict discharge placement. The majority of older adults survive multisystem injury. Our findings indicate the need to examine outcomes beyond mortality and to make the identification and management of comorbid conditions a priority. A geriatric consultation service could be an important addition to the interdisciplinary trauma team.