The management of elderly blunt trauma victims in Scotland: evidence of ageism?
Introduction
Trauma is the fifth most common cause of death for elderly patients in the Western world [1]. Currently, individuals aged over 65 years constitute 15% of the total population of Europe and this figure is set to rise well into the next century, reaching 30% by the year 2030 [2].
In the United States McKenzie et al. predict that by 2050, 40% of all trauma victims will be aged 65 or more [3]. In addition, elderly trauma victims consume a greater number of resources in bed days and overall costs compared to their younger counterparts [4]. Likewise in the United Kingdom (UK) 15.8% of the population are aged over 65 but account for 34% of hospital trauma admissions [5].
As advances continue to be made in the diagnosis and treatment of cardiovascular disease, diabetes and arthritis, more and more people are approaching their latter years in a better state of health, allowing them to continue with a more active lifestyle than was previously possible.
Survival following trauma is determined by the pre-morbid state of the patient, initial injury severity, time to definitive care and, lastly, the quality of that care. The greatest contribution from hospital medicine is likely to be the quality of care delivered to patients. In order to optimise outcomes for elderly traumatised patients, a number of researchers have highlighted the importance of aggressive management of the severely injured elderly, particularly in relation to resuscitation and admission to intensive care facilities [6], [7], [8], [9].
We hypothesized that current management of elderly blunt trauma victims might be less vigorous than that of younger patients. Therefore, the objectives of this study were to obtain an accurate picture of in-hospital mortality for seriously injured elderly patients and to determine whether age had an independent effect in key steps within the process of trauma care.
Section snippets
Materials and methods
This prospective study was carried out using data collected by the Scottish Trauma Audit Group (STAG); a centrally funded organisation dedicated to improving trauma management in Scotland. The study covered a 2 year time period, from 1 July 1996 until 30 June 1998. Twenty hospitals were contributing data to STAG at the time of the study. STAG collects data on all injured patients who are admitted for 3 days or more or who die within hospital. Criteria used in the study were those of the Major
Results
During the study period 12,873 cases of trauma eligible for inclusion into the STAG database presented to the contributing hospitals. This equates to approximately 0.81% of A&E new patient attendance over the study period. Data on 12101 (94%) of these cases (including all deaths, transfers and resuscitation room patients) were collected by STAG. Of these patients, 556 (4.6%) had sustained a penetrating injury. Penetrating injury is predominantly associated with the young, only 11 (2%) of such
Discussion
This is the largest prospective study of geriatric trauma undertaken in the UK to date and the mortality of our most seriously injured elderly patients, although high, is likely to be reflected elsewhere in the UK (M Woodford, Personal Communication, UKTARN).
Several previous reports have highlighted the greater mortality from trauma in elderly patients [17], [18], [19], [20]. There are many physiological reasons which contribute to this increased mortality. Elderly patients have a higher
Conclusions
Mortality for older patients who sustain severe injuries is high. Age itself appears to be an independent factor in trauma care in Scotland. Improved survival rates in elderly patients may be achieved by a more vigorous management strategy.
Acknowledgements
We would like to thank the many nurses and junior doctors who helped with data recording, all staff of the Scottish Trauma Audit Group and Miss Linda Russell for typing the manuscript.
References (39)
- et al.
Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care
Injury
(1993) - et al.
The association between seniority of Accident and Emergency doctor and outcome following trauma
Injury
(1999) - et al.
Increased survival after serious injury in patients admitted directly to critical care areas from the Accident and Emergency department
Injury
(1998) - et al.
Death in hospital after head injury without transfer to a neurosurgical unit: who when and why?
Injury
(1992) - et al.
Cancer in the elderly: why so badly treated?
Lancet
(1990) - et al.
Polytrauma in patients sixty-five and over: injury patterns and outcome
Int. Surg.
(1988) The 1991 Census
(1992)- et al.
Acute hospital costs of trauma in the United States: implications for regionalised systems of care
J. Trauma
(1990) - et al.
Do DRG payments adequately reimburse the costs of trauma care in geriatric patients?
J. Trauma
(1988) - Surti B. FCE's for elderly trauma patients. Hospital Episodes Statistics...
Aggressive trauma care benefits the elderly
J. Trauma
Multisystem geriatric trauma
J. Trauma
Long-term outcome of blunt trauma care in the elderly
Surg-Gynaecol-Obstet.
Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom Major Trauma Outcome Study
BMJ
The Abbreviated Injury Scale 1990 Revision
Evaluating trauma care: the TRISS method
J. Trauma
Applied multivariate techniques
Goodness of fit tests for the multiple logistic regression model
Commun. Statist. Theor. Mth.
Mortality of patients with head injury and extracranial injury treated in trauma centres
J. Trauma
Cited by (38)
Disparity in prehospital scene time for geriatric trauma patients
2022, American Journal of SurgeryCitation Excerpt :Similarly, the high base rate of medical comorbidities among older adults could cause EMS clinicians to initially attribute vital sign abnormalities to a medical condition that would benefit from on-scene treatment rather than due to traumatic injuries that would warrant expedited transport to a trauma center. Importantly, cognitive biases are not related to intelligence or cognitive ability and are present in healthcare providers across all levels of training, including among physicians caring for older adult patients admitted to the hospital with traumatic injuries.14,29,36 Delayed injury recognition and unconscious age bias point to areas for improvement within both trauma systems and EMS training courses.
Age-related injury patterns in Spanish trauma ICU patients. Results from the RETRAUCI
2016, InjuryCitation Excerpt :Younger patients were more likely to present high-energy trauma with significant injuries in different areas whilst elderly patients were prone to low-energy falls, complicated by antiplatelets or anticoagulants use, resulting in severe brain injury and increased mortality. Ageing appears as a determinant risk factor for poor outcome or mortality in trauma patients, since elderly patients are less likely to receive care in high-volume trauma centers, have limited cardiovascular reserve and additional comorbidities [1,3,16]. Therefore, in this study, we decided to analyse the injury patterns in trauma patients distributed by different groups of age.
Negative health outcomes and adverse events in older people attending emergency departments: A systematic review
2011, Australasian Emergency Nursing JournalCitation Excerpt :7.5% and 13% respectively experienced a nursing home admission within 90 days and six months23,48. Eight papers focused on triage, in relation to older ED patients57–64. Triage is the process of determining the order and priority of treatments based on the severity of patients’ conditions.
A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults
2021, Canadian Journal of SurgeryHigh-energy skeletal trauma in the elderly
2012, Journal of Bone and Joint SurgeryCitation Excerpt :Mortality rates in this population range from <5% to 42%46,47. Although it is difficult to draw conclusions on the sole basis of age and levels of injuries, most studies describe an in-hospital mortality rate of approximately 10%13,38,43,47. A review of the National Trauma Data Bank showed that patients who were sixty-five years of age or older who presented with severe chest and/or abdominal injuries, moderate to severe head injuries, a systolic blood pressure of <90 mm Hg at the time of presentation, and a considerable base deficit demonstrated mortality rates approaching 100%100.
Age still matters: Prognosticating short- and long-term mortality for critically ill patients with pneumonia
2010, Critical Care Medicine