Trauma 2009; 11: 157–161

Major trauma in the elderly

Som N Sarkar

With people living longer and able to undertake more activities, any professional
involved in trauma care will inevitably be exposed to older victims of trauma.
Increasing numbers of older people are admitted to trauma units, presenting the
healthcare professional with challenges including altered physiology, polypharmacy
and ethical considerations which may lead to diagnostic and treatment dilemmas.
Rib fractures for example are associated with significant morbidity and mortality and
optimising analgesia may improve outcomes. There are conflicting views over
co-morbidities being associated with mortality, but mortality in UK intensive care units
appears to be high in elderly trauma victims. The EAST guidelines provide a thorough
management strategy of elderly trauma victims. Old age should not be a sole criterion
for limiting or withholding care in trauma patients.

Key words: elderly; trauma; intensive care; rib fractures; mortality; management

Introduction over 80 years – 2.75 million comprising 4.5% of the

Medical advances and lifestyle choices are allowing
more of us to live longer. Older people are able to
drive, partake in sport, travel and continue employ-
ment. Consequently, they are prone to the risks of
such activities, leading to major trauma. Elderly
trauma patients on average have greater resource
use and longer hospital stays (McKevitt et al.,
2003). On reviewing the literature, there is disagree-
ment whether old age is an independent factor for
mortality in trauma patients.
Increasing elderly populations result in more
pedestrians and motor vehicle users. It has been
shown that drivers aged 65 and over are more likely
to be involved in a fatal crash, with drivers aged
85 and older being 3.74 times more likely, than 40–
49 year olds (Preusser et al., 1998; Yee et al., 2006).
In the UK by mid 2007, 19% of the population
(11.5 million) were men aged over 65 years or
women over 60 years. (Office of National Statistics,
2009) The fastest growing age group are those aged
Department of Anaesthesia, Nottingham University Hospitals
NHS Trust, UK.
Address for correspondence: Som N Sarkar, Department of
Anaesthesia, Nottingham University Hospitals NHS Trust,
Hucknall Road, Nottingham NG5 1PB, UK.
E-mail: som.sarkar@nhs.net
population. It is predicted that by 2031, people over
65 years will account for 23% of the UK popula-
tion. In addition a 65-year-old male in the UK will
on an average have a life expectancy of a further
16.6 years and female, 19.4 years.
There are various definitions of the elderly. Some
divide age groups into middle age (50–64 years), late
age (65–79 years) and older age (80 and greater
years). The cut off point of age at which the term
elderly is defined varies in many studies from 50 to
80 years, but for most, age over 65 years, when most
people reach the end of their working lives, appears
to be the standard.
Table 1 Physiological changes in the elderly
Respiratory  reduced elasticity of airways and thoracic
cage
 alveolar collapse during tidal ventilation
 stiffened rib cage causing increased depen-
dence on diaphragm and increase like-
lihood of fracture
Cardiovascular  reduced arterial elastance, increased after-
load, ventricular hypertrophy
 reduced diastolic compliance altering dia-
stolic relaxation, increased left ventricular
end diastolic volume
 higher End Diastolic Pressure required to
provide adequate stroke volume

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158 SN Sarkar
 increased sensitivity to changes in preload
(e.g. loss of atrial ‘kick’ in atrial fibrillation)
 conduction system fibrosis: dysrhythmias
 decreased adrenergic function
 inability to adequately increase heart rate to
increase cardiac output [diastolic dysfunc-
tion limits the effect of tachycardia]
Renal  reduced response to vasopressin and
aldosterone
 reduced clearance
Polypharmacy  ACE inhibitor and diuretic use: hypotension
& electrolyte abnormalities
 Anticoagulants: increased haemorrhage
 anti hypertensives: exaggerated hypoten-
sion in haemorrhage
Nervous system  reduced brain mass and adherent dura to
skull: Subdural4Extradural Haemorrhage
(SDH can exist with relatively minimal
clinical symptoms)
 Cerebral Blood Flow: Autoregulation pre-
served but hypertensive patients have
‘right shift’
 reduced conduction: slower reactions
 increased sensitivity to drugs: delirium/
confusion/sedation
 dementia
 visual/auditory decline
Musculoskeletal  reduced bone density (females more than
males)
 arthritis
 reduced muscle mass and strength
 spinal column changes: compression frac-
tures, spinal stenosis
Chest wall injuries
Yee and colleagues (2006) reviewed retrospective
data from Australia. Mortality in those aged 65 years
and over was nearly double that of under 65s. The
older group had a greater number of chest injuries
(most commonly rib fractures, flail chest and sternal
fractures). In addition, mean length of stay in
intensive care units was greater (7.96 vs. 5.31 days).
Rib fractures occur in over two-thirds of cases of
chest trauma and are associated with underlying
pulmonary complications. In the elderly, they have
most commonly been seen as a consequence of
motor vehicle collisions and falls. Reduced chest
wall elasticity and bone density result in a greater
likelihood of fracture for a given force compared to
Trauma 2009; 11: 157–161
a younger person. On reviewing elderly patients
with rib fractures, Bergeron and colleagues (2003)
showed that after adjusting for trauma severity,
comorbidity and multiple rib fractures, patients
aged 65 years and older were five times more likely
to die when compared to under 65s.
The use of epidural analgesia has been associated
with improved morbidity and mortality (Wisner,
1990; Bulger et al., 2000). Better analgesia can lead
to improved ventilation and clearing of secretions.
Epidural analgesia has also been shown to reduce
mortality when compared to parenteral analgesia in
trauma patients aged over 60 years (Wisner, 1990).
Pre-existing disease and outcomes
Not all people age in the same fashion. Morbidity
and mortality have been stated to be more
dependent on number and extent of co-morbidities,
rather than chronological age per se. However, it is
difficult to separate age from co-morbidities in
calculating independent risk factors in outcomes
from major trauma.
The changes and limits of physiology secondary
to aging impair the response to trauma, with most
organs displaying reduced functional capacity.
Age-related deterioration in the cardiopulmonary
system is crucial to the reduction in oxygen delivery
in major trauma (Fairman and Rombreau, 1998).
Independent of age and severity score, trauma
patients having two pre-existing diseases have been
associated with a 15.5% mortality, with three or
more being associated with a 24.7% mortality
(Milzman et al., 1992). In a more recent study of
1172 patients, Bochicchio et al. (2006) showed that
increasing age, insulin-dependent diabetes mellitus,
hypertension and chronic obstructive airways dis-
ease were the most predictive factors of poor
outcome in trauma.
In a review of 326 trauma patients with average
age 72 years admitted to trauma centres in the USA,
factors that predicted mortality included low GCS
score, higher injury severity score (ISS), greater
transfusion and fluid requirement (Tornetta et al.,
1999). Patients who required non-orthopaedic
surgery (for abdominal, thoracic and head injuries)
were at higher risk for mortality. In addition, ISS
was predictive of developing acute respiratory
distress syndrome (ARDS), pneumonia and sepsis.

Long-term follow up
Battistella and colleagues (1998) followed up 279
trauma patients aged 75 years and older over a
minimum of 4 years. Most of these patients were in
motor vehicle collisions, suffered falls or were hit
pedestrians. At follow up, 47% had died. Poor
survival was predicted by pre-existing disease
(dementia, hypertension and chronic obstructive
airways disease) but not by age or trauma severity.
Encouragingly, 33% could be confirmed to be alive
at 4 years. Most common injuries among survivors
were rib fractures, closed head injuries, extremity
fractures and pelvic fractures. Regarding quality of
life, 57% of the survivors were able to carry out 12
out of 14 activities of daily life without difficulty.
Nineteen percent were lost to follow up and
consequently survival may have been underesti-
mated. Aggressive therapy in this group led to at
least 42% of these patients being alive at 4 years
post discharge and living independently.
Monitoring or not?
Scalea and colleagues (1990) found that elderly
multiple trauma victims who were classed as
‘clinically stable’ had haemodynamic compromise
once invasively monitored and promptly admitted
to the intensive care unit. It has been shown that
optimising cardiovascular parameters by invasive
monitoring in neck of femur fracture patients led to
a ten-fold decrease in mortality.
Intensive care outcomes in the UK
On review of Intensive Care National Audit &
Research Centre (ICNARC) data of patients
admitted to intensive care units with major trauma
as the primary reason for admission, whilst absolute
numbers of admissions have increased, the propor-
tion of total ICU patients has stayed similar, over
the past 10 years.
From Table 2, intensive care mortality appears to
improve over the 10-year period. Although there is
no breakdown of trauma diagnosis in these data, it
is apparent that in elderly trauma patients admitted
to receive intensive care in the UK, hospital
mortality is high, increasing with age.
Major trauma in the elderly 159
Evidence-based practice?
In response to the lack of clear guidelines, the
Eastern Association for Surgery in Trauma (EAST)
from the USA have created guidelines for managing
trauma in the elderly focussing on trauma triage,
resuscitation and outcome measurement (Jacobs
et al., 2003) The majority of evidence comes from
retrospective data analyses. An initial course of
aggressive treatment should be initiated in all
elderly trauma patients, regardless of age or injury
severity, with the possible exception of those
patients who arrive in a moribund condition.
Those who do not respond to aggressive resuscita-
tive efforts within an appropriate time frame are
likely to have poor outcomes even with continued
aggressive treatment. The ongoing intensity of
treatment provided to these ‘non-responders’
should be reconsidered. Responders to this treat-
ment have a good prognosis, not only for survival
but also for return to a pre-injury level of
functioning.
Summary of EAST Geriatric Trauma
Guidelines
 All other factors being equal, advanced patient
age is not predictive of poor outcomes following
trauma and therefore should not be used as the
sole criterion for denying or limiting care in this
patient population.
 Pre-existing medical conditions in elderly trauma
patients adversely affect outcome. However, this
effect becomes progressively less pronounced with
advancing age.
 In patients aged 65 years or more, GCS58 is
associated with a poor prognosis. If substantial
improvement in GCS is not seen within 72 h of
injury, consideration should be given to limiting
further aggressive therapeutic interventions.
 Post-injury complications in the elderly trauma
patient negatively impact survival and contribute
to longer lengths of stay in survivors and non-
survivors compared to younger trauma patients.
Specific therapies designed to prevent and/or
reduce the occurrence of complications (particu-
larly iatrogenic complications) should lead to
optimal outcomes in this patient population.
Trauma 2009; 11: 157–161
 160

Table 2 Outcome for major trauma admissions to critical care units in the CMPD in each age group

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total

All admissions 25 486 34 024 38 567 40 415 47 806 59 973 69 903 73 541 72 337 63 255 525 307
SN Sarkar

Age 565, years Admissions, 13 497 17 565 20 087 20 703 24 358 30 428 35 780 37 324 36:725 32 684 269 151
n (%) (53.0) (51.6) (52.1) (51.2) (51.0) (50.7) (51.2) (50.8) (50.8) (51.7) (51.2)
Trauma admissions, 1890 2504 2939 3103 3727 4655 5004 5031 4967 4280 38 100

Trauma 2009; 11: 157–161

n (%) (14.0) (14.3) (14.6) (15.0) (15.3) (15.3) (14.0) (13.5) (13.5) (13.1) (14.2)
Unit mortality, 264 314 320 405 416 479 501 468 460 405 4032
n (%) (14.0) (12.5) (10.9) (13.1) (11.2) (10.3) (10.0) (9.3) (9.3) (9.5) (10.6)
Acute hospital mortality*, 351 407 442 496 528 635 646 631 609 503 5248
n (%) (20.0) (17.6) (16.2) (17.3) (15.3) (14.7) (14.0) (13.7) (13.2) (12.6) (14.9)
Age 65–74, years Admissions, 6876 9334 10 172 10 339 11 721 14 513 16 859 18 025 17 411 14 738 129 988
n (%) (27.0) (27.4) (264) (25.6) (24.5) (24.2) (24.1) (24.5) (24.1) (23.3) (24.8)
Trauma admissions, 596 786 854 962 1024 1286 1493 1.571 1395 1255 11 222
n (%) (8.7) (8.4) (8.4) (9.3) (8.7) (8.9) (8.9) (8.7) (8.0) (8.5) (8.6)
Unit mortality, 165 219 196 235 244 282 326 323 253 235 2478
n (%) (27.7) (27.9) (23.0) (24.4) (23.8) (21.9) (21.8) (20.6) (18.1) (18.7) (22.1)
Acute hospital mortalitv*, 247 292 282 352 335 420 453 474 372 349 3576
n (%) (44.0) (40.3) (36.6) (40.1) (36.5) (35.4) (33.9) (33.3) (29.1) (30.2) (34.9)
Age 75–84, years Admissions, 4401 6023 7083 7938 9687 12 454 14 570 15 247 15 137 13 097 105 637
n (%) (17.3) (17.7) (18.4) (19.6) (20.3) (20.8) (20.8) (20.7) (20.9) (20.7) (20.1)
Trauma admissions, 510 672 810 897 1077 1373 1567 1607 1589 1313 11 415
n (%) (11.6) (11.2) (11.4) (11.3) (11.1) (11.0) (10.8) (10.5) (10.5) (10.0) (10.8)
Unit mortality, 148 202 236 269 323 401 453 439 399 310 3180
n (%) (29.0) (30.1) (29.1) (30.0) (30.0) (29.2) (28.9) (27.3) (25.1) (23.6) (27.9)
Acute hospital mortalitv*, 252 310 375 415 484 595 735 665 644 522 4997
n (%) (52.8) (48.4) (48.9) (48.4) (48.6) (46.7) (49.8) (43.9) (42.8) (42.3) (46.5)
Age 85 þ, years Admissions, 712 1099 1219 1433 2035 2575 2693 2944 3063 2736 20 509
n (%) (2.8) (3.2) (3.2) (3.6) (4.3) (4.3) (3.9) (4.0) (4.2) (4.3) (3.9)
Trauma admissions, 139 194 191 220 305 449 450 438 459 362 3207
n (%) (19.5) (17.7) (15.7) (15.4) (15.0) (17.4) (16.7) (14.9) (15.0) (13.2) (15.6)
Unit mortality, 42 45 45 69 99 112 139 119 105 86 861
n (%) (30.2) (23.2) (23.6) (31.4) (32.5) (24.9) (30.9) (27.2) (22.9) (23.8) (26.9)
Acute hospital mortalitv*, 71 93 92 113 172 225 239 217 211 167 1600
n (%) (52.6) (49.5) (49.7) (53.1) (58.9) (52.6) (54.4) (51.7) (47.0) (46.9) (51.5)

*Excluding readmissions within the same acute hospital stay.


Conclusion
The elderly are the fastest growing segment of
populations in developed nations. Whilst trauma is
only the seventh leading cause of death in the
elderly, the incidence of injury is significantly higher
when compared to younger people. The question of
pre-existing disease contributing to poor outcome
after injury has yet to be conclusively answered.
Unsurprisingly, several studies have indicated
that shock, respiratory failure, increasing base
deficit, infectious complications, worsening trauma
and injury severity scores are omens of a poor
outcome in the elderly. Consequently, the early use
of invasive haemodynamic monitoring may allow
the opportunity to improve survival. Although
injured elderly patients are more likely to die than
the younger patient, early aggressive and appro-
priate treatment may lead to regaining their pre-
trauma independence at discharge.
Acknowledgement
I would like to acknowledge Dr David Harrison
at ICNARC for permission to reproduce data in
Table 2 and for his advice.
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