Injury Patterns and Outcomes of Trauma in the Geriatric Population Presenting to the Emergency Department in a Tertiary Care Hospital of South India.

BACKGROUND: The geriatric population is more prone for injuries with complications due to their associated comorbidities. This study was done to understand the mode, severity, and outcome of injuries among geriatric patients presenting to the emergency department (ED).
MATERIALS AND METHODS: This retrospective study included all patients >60 years who presented with trauma between October 2014 and March 2015. Details of the incident, injuries, and hospital outcome were noted.
RESULTS: Among 8563 geriatric patients, who presented to the ED during the study, 427 (4.9%) patients were trauma related. The mean age was 69 (standard deviation: 6.76) years with 87.6% being young-old (60-79 years) and 12.4% being old-old (>80 years). Majority (63.2%) were Priority 2 patients. The median time between the incident and ED arrival among Priority 1 patients was 3 h (interquartile range: 2-5). Common modes of injuries were slip and fall (37.4%), two-wheeler accidents (25.8%), fall from height (9.1%), and pedestrian (8.9%). The ED team alone managed 25.8% of patients. Specialty departments referred to included orthopedics (48%), neurosurgery (18.3%), plastic surgery (4.2%), HLRS (4%), and others. Injuries due to slip and fall were significantly more among the old-old (P = 0.001), and two-wheeler accidents were more among the young-old (P = 0.001), respectively. Superficial head injuries (28.8%), extremity (24.8%), facial (18.7%), and traumatic brain injuries (17.8%) were common presentations. Thoracic injuries were significantly more among the old-old (P < 0.001). Half (46.3%) of the young-old were discharged stable (P = 0.017). In-hospital mortality rate was 0.7% (3/427), while 12.9% (55/427) left against medical advice due to poor prognosis.
CONCLUSION: Our study demonstrates the pattern of injury seen in the elderly in an urban setting in India. From this, we perceive the need for a prospective study evaluating the causes for geriatric trauma, which would help work on ways to prevent and minimize injuries in the elderly.

INTRODUCTION

Trauma is a major cause of morbidity and mortality in both developed and developing countries. Emergency departments (EDs) and trauma centers across the country need to be prepared with adequate resources to handle the increasing number of trauma victims. Elderly trauma victims pose a unique challenge with multiple comorbidities and a lesser tolerance to sudden physical trauma.[1] It is difficult to accurately determine the severity of injury and physiological derangement because of differences in biology due to advanced age. Hence, it is important to understand the injury profile of this special age group to be better prepared to handle emergencies.[2] Lifestyle of the geriatric population in a developing country with predominantly consanguineal family units is very different from the western world where families are generally nuclear, and the elderly are independent.[345] Although injury pattern among the elderly is described in literature from the west, there exists minimal data from the developing countries. Therefore, we undertook this study was to improve the understanding of the mode of trauma in the geriatric population, severity of injuries, and outcome in our hospital so that effective prevention and comprehensive management strategies could be made.[67] We also studied the accuracy of physiologic variables such as respiratory rate, Glasco coma scale (GCS), and systolic blood pressure which are used in the revised trauma score (RTS) in predicting mortality.[891011]

MATERIALS AND METHODS

The retrospective study was done in the adult ED of Christian Medical College (CMC), Vellore, which is a 45 bedded department in South India with an average of 200 admissions daily. We recruited all patients more than 60 years of age who presented to the ED with trauma between October 2014 and March 2015. The inclusion criteria were all patients who had sustained trauma through road traffic accidents (RTA), industrial incidents, electrical injuries, fall from height or level ground, or trauma related to assault, sports, and animals. Patients aged below 60 years presenting with trauma and adult patients who were dead on arrival were excluded from the study.

Data of the patients were obtained from the electronic hospital records. Details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: demographics, mode of injury, time of injury and time of presentation, triage priority, severity of injury, type of injury, and proportion of patients requiring admission. The triage priority level was defined as follows:

Triage Priority 1: Patient with airway, breathing or circulation compromise, or head injury with GCS <8

Triage Priority 2: Patient with stable airway, breathing, and circulation with long-bone injuries, dislocations, stable abdomino-thoracic injuries, head injury with GCS 9 or more

Triage Priority 3: Hemodynamically stable patients with minor trauma.

All patients had routine blood investigations and relevant radiological tests based on the initial primary and secondary surveys. The severity of injury was assessed using the RTS. The region of the body affected was noted, and injuries were classified as superficial and deep. All abrasions, superficial lacerations, and minor soft-tissue injuries were considered as superficial injuries. All penetrating injuries, fractures, dislocations, head injuries, and other internal organ injuries were classified as deep injuries. After initial stabilization by the ED team, the patients were handed over to the necessary surgical departments for further management if necessary. Patients with minor injuries were discharged by the ED team after a short observation period and those who required surgery or prolonged observation were admitted to the respective wards. In-hospital outcome of all the admitted patients was noted.

Statistical analysis was performed using Statistical Package for Social Sciences software for Windows (SPSS Inc., Released 2007, version 16.0. Chicago, USA). Mean (standard deviation [SD]) or median (interquartile range) was calculated for the continuous variables and t-test or Mann–Whitney test was used to test the significance. The categorical variables were expressed in proportion, and Chi-square test or Fisher's exact test was used to compare dichotomous variables. Univariate analysis was performed to identify the differences between the young-old (60–80 years) and the old-old (>80 years) age groups. For all tests, a two-sided P ≤ 0.05 was considered statistically significant. This study was approved by the institutional review board (IRB), and patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.

RESULTS

During the study, the ED attended to 32,952 patients with 26% (8563) in the geriatric age group (>60 years). Among these 8563 geriatric patients, 427 (5%) were trauma related. Only 12.4% were in the old-old (>80 years) age group [Figure 1]. The baseline characteristics, including comorbidities, triage priority level, and the time of presentation since the time of injury are shown in Table 1. The mean age was 69 (SD: 6.76) years. There was a male predominance (59.1%). Of the RTA, 76.8% were in elderly men. 59.3% of patients who slipped and fell were women. Injuries due to slip and fall were significantly more among the old-old (P = 0.001), and two-wheeler accidents were more among the young-old (P = 0.001). Majority (63.2%) were Priority 2 patients. The median time between the incident and ED arrival was the shortest for Priority 1 patients (3 h [interquartile range: 2–5]).

Figure 1

Region of injury and triage priority level

Table 1

Baseline characteristics of geriatric patients with trauma presenting to the emergency department

Characteristics	Value (n=427)
Demographic (years), n (%)
Age, mean±SD	69±6.76
Young-old (60-79)	374 (87.6)
Old-old (>80)	53 (12.4)
Gender, n (%)
Males	256 (59.9)
Females	171 (40.1)
Admission pattern, n (%)
Weekdays (Monday-Friday)	300 (70.2)
Week end (Saturday, Sunday)	127 (29.8)
Triage priority, n (%)
Priority 1	63 (14.8)
Priority 2	270 (63.2)
Priority 3	94 (22)
Triage priority time of presentation since injury (h), median (IQR)
Priority 1	3 (2-5)
Priority 2	4.17 (2-14.5)
Priority 3	5 (1-6)
Co-morbidities, n (%)
Diabetes mellitus	176 (41.2)
Hypertension	155 (36.3)
Asthma/COPD	17 (3.9)
Chronic kidney disease	10 (2.3)
Stroke	9 (2)

IQR: Interquartile range, COPD: Chronic obstructive pulmonary disease, SD: Standard deviation

Common modes of injuries were RTAs (41.9%), fall on level ground (37.4%), and fall from a height (9.1%) [Table 2]. Comparison of the examination findings, mode of injury, and the region of the body involved between the young-old and the old-old is shown in Table 3. The severity of injury was calculated by the RTS with a mean of 7.63. RTS score of <5 was seen in only six patients. Seventeen patients (0.04%) presented with a systolic blood pressure <100 mmHg. Three hundred and ninety-three (92%) of them were found to be tachypneic at presentation. The patients' sensorium was assessed at presentation, and 85.7% of them were found to have a normal Glasgow coma scale (GCS). Mild head injury (GSC of 13 and 14) was seen in 0.06%, 0.05% suffered from a moderate head injury (GCS between 8 and 13), and 0.03% had a severe head injury (GCS of <8).

Table 2

Mode of injury (n=427)

Mode of injury	n (%)
Two wheeler	110 (25.8)
Four wheeler	25 (5.8)
Auto	6 (1.4)
Pedestrian	38 (8.9)
Fall on level ground	160 (37.4)
Fall from height	39 (9.1)
Others	49 (11.5)

Table 3

Comparison of young-old and old-old patients on arrival to the emergency department

Characteristics	Young-old (n=374)	Old old (n=53)	P	95% CI
Age (years), mean±SD	66.9±5.38	84.28±4.05	<0.001	−18.87-−15.85
RTS	7.63±0.69	7.65±0.6	0.828	−0.22-0.17
Systolic blood pressure, mmHg	128.3±27.56	137.36±27.18	0.025	16.99-−1.12
Respiratory rate/min	22.09±6.9	21.28±4.39	0.415	−1.134-2.74
GCS	14.35±2.04	14.15±2.38	0.515	−0.403-0.80
Mode of injury, n (%)
Two wheeler	106 (28.3)	4 (7.5)	0.001	0.07-0.59
Four wheeler	24 (6.4)	1 (2)	0.34	0.04-2.12
Pedestrian	28 (7.5)	10 (18.9)	0.016	1.31-6.32
Fall from height	35 (9.4)	4 (7.5)	0.86	-0.06-0.11
Slip and fall	129 (34.5)	31 (58.5)	0.001	1.54-4.98
Auto	4 (1)	2 (3.7)	0.64	0.65-20.3
Others	48 (12.8)	1 (1.8)	0.019	0.02-0.97
Region of body involved, n (%)
TBI	67 (17.9)	9 (17)	1.0	0.5-2.3
Head	113 (30.2)	10 (18.9)	0.10	0.90-3.8
Face	69 (18.4)	11 (20.7)	0.70	0.42-1.76
Neck	14 (3.7)	0	0.23	1.11-1.19
Thorax	28 (7.4)	15 (28.3)	<0.001	0.10-0.42
Abdo and pelvis	18 (4.8)	3 (5.6)	0.73	0.24-2.96
Extremity	99 (26.5)	7 (13.2)
Spine	15 (4)	2 (3.7)	1.0	0.24-4.81
Vascular	2 (0.5)	0	1.0	1.1-1.2
Crush	25 (6.6)	0	0.058	1.1-1.2

n: Number of patients with that finding; values in parenthesis indicate percentage unless specified, SD: Standard deviation, CI: Confidence interval, RTS: Revised trauma score, GCS: Glasgow coma score, TBI: Traumatic brain injury

A quarter of the patients were managed solely by the ED team. Based on the injuries noted, the patients were referred to specialties for further management of injuries. Orthopedics (48%), neurosurgery (18.3%), plastic surgery (4.2%), and hand surgery (4%) were the main units involved [Figure 2].

Figure 2

Departments involved

For stabilization, some patients needed intubation. Three were intubated from outside before admission to our hospital, 31 were intubated in our ED.

In-hospital mortality rate was 0.7%, while 12.9% left against medical advice due to poor prognosis.

DISCUSSION

Trauma is a major problem in India with severe and wide-ranging consequences for individuals and society as a whole. Geriatric population is growing internationally and more recently in India. It has become increasingly difficult for them to access the medical services provided to the general public by hospitals. Hence, there is a need for studies to evaluate the common emergencies with which they present, so that, better quality care can be given to them. As of now, only a small percentage of patients that present with trauma are of the geriatric age group, but there is a foreseen exponential increase because of the general improvement in quality of life of the elderly. As medical facilities increase and national health-care improves, the need to evaluate the requirements of this specific group of people, who are different from the pediatric and the normal adult population has been identified. Most studies done for the evaluation of diseases do not include the geriatric population as they are old, frail, and unable to make decisions on their own and have many comorbidities.[12] Hence, the data generated on the management of these people is very sparse as compared to that in the other populations, making it difficult for the physicians to give them quality care. Thus, there is a resultant rise in unnecessary procedures done and in-hospital stay.[13]

In this study, we considered people above the age of 60 years as the geriatric population and classified them as young-old and old-old with their mean ages being 66.9 + 5.38 years and 84.28 + 4.05 years, respectively. Their comorbidities such as diabetes mellitus, hypertension, asthma/chronic obstructive pulmonary disease, chronic kidney disease, and stroke were considered. We found a male prevalence of 60%. In our study, three-fourth of RTA were in men. A study done in Ontario shows a different ratio, with RTA being 65% in men and 34% in women.[7] We noted in our ED that more women suffered from fall at level ground, while more men were a part of the RTA. Hence, we presume this is because in the Indian Society, elderly women spend most of their time at home. There have been studies done in the West, which show that hypothermia, fall, and cardiovascular problems are the major causes of geriatric emergency.[814] Complications such as aspiration pneumonia, cardiovascular, and respiratory sequelae were seen in some patients. In our study, the largest percentage was reported to be due to slip and fall, followed by two-wheeler injuries and fall from height.

The analysis was done using a simple RTS, which has been shown to correlate well with mortality.[15] The RTS is a physiological scoring system, with a high inter-rater reliability.[16] In our study, very few patients presented with a very low RTS of six and below. We postulate that because we are a tertiary care center, some of the very severe trauma where mortality is in a few hours may not have reached our center in time. Most other patients would have received first aid at a local center, and hence, the RTS is relatively higher at presentation to our ED.

In a tertiary center such as CMC, primary care, and triaging were done by the ED, and the patients were referred to the respective departments for specific care. ED alone managed about a quarter of the cases whereas the maximum numbers of cases were seen by the orthopedics department followed by neurosurgery since fracture head of the femur and traumatic brain injury and head injuries were the most common presentations.

There have been very few studies, in India, which look at the outcome of geriatric trauma. A study in the Chinese population aged above 60 years in 2012, i.e., in about 14.3% of the population, showed the prevalence of trauma to be 8.5%.[14] They observed that there was a higher rate of mortality in this geriatric population. In our study, we compared the results among the young-old and old-old and found that almost half of the young-old was discharged stable.

A limitation was that our study was conducted in a single center, and hence, the patient population may be biased by patient selection and referral pattern. Since this was a retrospective survey, some data were missing.

Our study highlights the burden of geriatric trauma in the EDs of India. It gives us an idea of the difference in the mode of injury, presentation, severity, and outcome. Through this, we see the need for addressing the elderly under a separate bracket with respect to health care, including trauma. As our country grows, the older population will also grow, and hence the need to cater to their different problems effectively.

CONCLUSION

Our study demonstrates the pattern of injury seen in the elderly presenting to the ED from an urban population of India. It shows the differences between the young-old and the old-old age groups. From this, we perceive the need for a prospective study evaluating the causes for geriatric trauma, which would help work on ways to prevent and minimize injuries in the elderly.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by enhancing the quality and transparency of health research network. The authors also attest that this clinical investigation was determined to require IRB/Ethics Committee Review, and the corresponding protocol/approval number is IRB Min. No. 10219 dated 08.08.2016. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.