Elsevier

Injury

Volume 31, Issue 7, 1 September 2000, Pages 519-528
Injury

The management of elderly blunt trauma victims in Scotland: evidence of ageism?

https://doi.org/10.1016/S0020-1383(00)00038-3Get rights and content

Abstract

Health services are challenged with providing trauma care to an increasingly elderly population. The objectives of this study were to determine the in-hospital mortality for injured elderly patients, and by analysing key features of their management, to ascertain whether these trauma patients were managed less aggressively than their younger counterparts. Main outcome measures included; use of resuscitation room facilities, senior medical staff involvement, admission to intensive care units, transfers to regional neurosurgical centres and mortality. Three thousand seven hundred patients initially managed in a resuscitation room were significantly younger (mean age 43) than those not treated in this area (mean age 54, 95% CI 10.7–12.4). Considering seriously injured patients with a significant head injury (who did not present in coma) those transferred to neurosurgical care were younger (mean age 44) than patients who were not transferred (mean age 49, 95% CI 1.6–8.6). Logistic regression analysis showed that age did not have a significant independent effect on the seniority of medical response from key specialties. For the severely injured, the odds of being admitted to an intensive care unit when aged 70 in comparison to age 30 were 0.7436 (95% CI 0.5787–0.9559). Overall in-hospital mortality of the 290 elderly patients who had sustained major trauma was 42.1%. Significantly more of the elderly died than would be predicted. Age appears to be an independent factor in the process of trauma care in Scottish hospitals. We consider that outcomes for the injured elderly could be improved by a more dynamic approach to their management.

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)

  • E.J De Maria et al.

    Aggressive trauma care benefits the elderly

    J. Trauma

    (1987)
  • S.P Zietlow et al.

    Multisystem geriatric trauma

    J. Trauma

    (1994)
  • E.H Carillo et al.

    Long-term outcome of blunt trauma care in the elderly

    Surg-Gynaecol-Obstet.

    (1993)
  • D.W Yates et al.

    Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom Major Trauma Outcome Study

    BMJ

    (1992)
  • The Abbreviated Injury Scale 1990 Revision

    (1990)
  • C.R Boyd et al.

    Evaluating trauma care: the TRISS method

    J. Trauma

    (1987)
  • S Sharma

    Applied multivariate techniques

    (1996)
  • D Hosmer et al.

    Goodness of fit tests for the multiple logistic regression model

    Commun. Statist. Theor. Mth.

    (1980)
  • T.A Gennarelli et al.

    Mortality of patients with head injury and extracranial injury treated in trauma centres

    J. Trauma

    (1989)
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