Geriatric trauma: resource use and patient outcomes
===================================================

* Elaine C. McKevitt
* Eric Calvert
* Alex Ng
* Richard K. Simons
* Andrew W. Kirkpatrick
* Leanne Appleton
* D. Ross G. Brown

## Abstract

**Introduction:** Elderly patients who suffer trauma have a higher mortality and use disproportionately more trauma resources than younger patients. To compare these 2 groups and determine the outcomes and characteristics of elderly patients, we reviewed patients in these 2 groups admitted and treated in our tertiary care provincial trauma centre.

**Methods:** From the provincial trauma registry we selected a cohort of 40 geriatric patients (group 1) (≥ 65 yr of age) with an ISS of 16 or more who were admitted to and spent time in our trauma service for more than 48 hours and compared them with a similar randomly selected cohort of 44 patients (group 2) aged 20–30 years. Family physicians were contacted for follow-up of these patients 2 years after discharge. **We considered** length of hospital stay, complications, disposition of the patients and use of consultation services.

**Results:** Patients in group 1 had a mean age of 72.1 years (range from 65–98 yr) and a mean ISS of 27.3 (range from 17–50). Patients in group 2 had a mean age of 26.3 years (range from 22–29 yr) and a mean ISS of 26.3 (range from 17–54). Hospital stay was significantly longer in the group 1: 34.5 days (95% confidence interval [CI]: 24–44 d) versus 21.6 days (95% CI: 15–28 d). More elderly patients experienced complications (35 v. 13, *p* < 0.001) and required medical consultations (35 v. 26, *p* < 0.001). In-hospital death rates were 8% (3 of 40) and 4% (2 of 44) respectively (*p* = 0.3). Fewer geriatric patients could be discharged home (35% [14 of 40] v. 27% [22 of 44], *p* = 0.056) or to rehabilitation facilities (28% [11 of 40] v. 34% [15 of 44], *p* = 0.3). Five geriatric patients were discharged to nursing homes (*p* = 0.007). Of the geriatric patients discharged to rehabilitation facilities or home, 75% were independent 2 years after discharge.

**Conclusions:** Aggressive care for geriatric trauma patients is warranted, and resources should be directed toward rehabilitation. Based on our findings, we expect that creating a directed care pathway for these patients, targetting complications and earlier discharge, will further improve their outcomes.

Demographic studies have shown that geriatric trauma makes up a small proportion of trauma admissions. 1–3 Trauma in the elderly, however, is associated with higher mortality (despite less severe injuries), prolonged hospitalization and an increase in the number and severity of complications.1,4–6 Elderly patients consume a disproportionate amount of trauma resources relative to their injuries.1,2,4 Although many studies have shown that death rates are higher for geriatric patients, others have shown that the majority of severely injured elderly patients who survive their initial insult return to independent living.7,8 These findings have been used to support aggressive trauma care policies for the elderly patient. Multidisciplinary care pathways have demonstrated benefits for both medical and surgical geriatric patients,9–13 although there have been no studies looking at such a strategy in trauma patients.

We undertook a retrospective, cohort controlled study to determine the characteristics and outcomes of elderly trauma patients. From this we have attempted to determine what outcome measures future multidisciplinary care pathways should target.

## Patients and methods

Vancouver Hospital and Health Sciences Centre, Vancouver General Hospital Site, is a 900-bed tertiary care teaching hospital with full specialty and subspecialty services. In addition to being the regional trauma centre, Vancouver General Hospital is also designated as the Adult Provincial Trauma Centre for British Columbia. All multidisciplinary trauma patients are admitted to a trauma service staffed by trauma surgeons (R.K.S., A.W.K., D.R.G.B.).

We reviewed the charts of trauma patients admitted to Vancouver General Hospital between July 1997 and March 1998 who were identified from the British Columbia Provincial Trauma Registry. The criteria for inclusion were as follows: patients sustaining multisystem trauma and aged 65 years or older or aged 20–30 years (the most frequently injured age group), an Injury Severity Score (ISS) of 16 or greater, and a hospital stay exceeding 48 hours. Because we were interested in knowing the outcomes of significantly injured elderly patients who survived the insult yet required hospitalization, we excluded patients admitted for less than 48 hours and those who died within 48 hours (6 elderly patients who died within 24 hours of admission during the study period and 8 younger patients who died).

Patient demographics, length of hospital stay (LOS), complications, disposition, time to disposition, use of consultation services, level of function on discharge and follow-up were analyzed. Patients’ family physicians were contacted by phone or by letter 2 years after discharge to determine patient’s level of function.

Findings were analyzed by the *t-*test for continuous variables and the χ2 test for discrete variables. Significance was set at *p* < 0.05.

## Results

We identified 40 patients aged 65 years or older who met study criteria (group 1). Thirty-nine patients were living independently at the time of admission. Forty-four younger patients meeting all other study criteria were randomly selected from 96 patients aged 20–30 years admitted during the same time period (group 2). All were functioning independently at admission. Patient demographics are outlined in Table 1.

View this table:
[Table 1](http://canjsurg.ca/content/46/3/211/T1)

Table 1 
Demographic Information for the Study Patients

Twenty group 1 patients and 12 group 2 patients experienced complications (Table 2). Seventeen group 1 patients experienced serious organ dysfunction (including respiratory failure, cardiac dysfunction, pneumonia, renal failure, delirium and alcohol withdrawal) compared with 6 group 2 patients (*p* < 0.001).

View this table:
[Table 2](http://canjsurg.ca/content/46/3/211/T2)

Table 2 
Complications Experienced by 20 Elderly Patients (Group 1) and 12 Younger Patients (Group 2) After Multisystem Trauma

Group 1 patients, who survived more than 48 hours, had a similar in-hospital death rate to group 2 patients (8% [3 of 40 patients] v. 4% [2 of 44 patients]). The causes of death in group 1 were myocardial infarction (1 patient), head injury (1 patient) and aspiration (1 patient). The 2 deaths in group 2 were attributed to acute respiratory distress syndrome. Initially, there was a higher death rate for the elderly patients (13% v. 8%, *p* < 0.001), but when patients who survived the initial insult were adjusted for, there was no significant difference (8% v. 4%, *p* = 0.29).

A total of 24 group 1 patients and 22 group 2 patients required medical consultations (Table 3). Group 1 patients often required multiple subspecialty consultations (35 medical consults for 24 patients), whereas group 2 patients often required only a rehabilitation consultation (26 consults for 22 patients). Subspecialty medical consultations were all obtained for complications arising during hospital admission, except for 1 cardiology consultation that was for pre-existing disease. Two general medical consultations and 2 geriatric consultations were obtained for pre-existing conditions. Rehabilitation consultations were obtained in patients who were expected to require rehabilitation before discharge. These consultations addressed both medical and mobilization issues. Nine elderly patients and 8 younger patients required psychiatric consultations.

View this table:
[Table 3](http://canjsurg.ca/content/46/3/211/T3)

Table 3 
Consultations Obtained for the Study Patients

The average LOS was 34.5 days (95% CI: 24–44 d) for group 1 patients compared with 21.6 days (95% CI: 15–28 d) for group 2 patients (*p* = 0.05). Seven (18%) group 1 patients and 11 (25%) group 2 patients required admission to the intensive care unit (ICU) (*p* = 0.22). The mean number of days spent in the ICU were 1.65 for group 1 and 2.79 for group 2 (*p* = 0.70). Discharge level of care is outlined in Table 4. Five patients were transferred to a nursing home. Of these, 4 were older than 80 years.

View this table:
[Table 4](http://canjsurg.ca/content/46/3/211/T4)

Table 4 
Functional Status of Study Patients at Time of Admission and Discharge

The time to discharge for patients who remained in acute care surgical beds and who were designated as “alternate level of care (ALC),” (i.e., requiring rehabilitation or admission to a long-term care facility) was also recorded. The attending physician, in consultation with the patient care manager, made this ALC designation when the patient no longer required an acute care surgical bed. Eighteen group 1 patients and 9 group 2 patients were designated as requiring ALC (*p* < 0.001). The elderly waited a mean of 30.7 days for transfer, the younger patients 16.8 days.

When we contacted patients’ family physicians 2 years after discharge, we found follow-up information was available for 12 of the 25 patients discharged to either rehabilitation facilities or home. Of these 12 patients, 9 (75%) still lived independently, 2 patients had died and 1 patient was living in a nursing home. Follow-up was unavailable for the remainder of the patients because either there was no family physician listed on the chart or the patient was no longer being cared for by the same family physician.

## Discussion

This study has confirmed that geriatric trauma patients have a different mechanism of injury, more complications and greater resource requirements per admission (as measured by LOS and number of consultations) than 20–30-year-old patients with a similar ISS. However, this study failed to confirm an increased adjusted death rate. The elderly patients who survived the initial insult had a similar death rate to younger patients. This is in contrast to the findings from the Major Trauma Outcomes Study (MTOS),3 which showed a higher case fatality for the elderly with respect to every mechanism of injury and region of injury. However, the MTOS included patients with isolated hip fractures and isolated head injuries. Both of these are known to be associated with poorer outcomes in the elderly. Furthermore, the mean ISS in the MTOS study was 13.3 (both in elderly and younger patients). This group is not directly comparable to our study group of patients having multisystem injuries and a mean ISS of 27.3.

Functional outcome for geriatric patients has been debated in the literature. Oreskovich and colleagues14 reported that 88% of their elderly trauma patients (age > 70 yr) did not return to their previous level of independence and that 72% required full nursing care. Other studies have had more favourable results, with 57%15 and 67%7 returning to independent living, and 78% returning home.8 DeMaria and associates15 attributed the marked difference in outcome between their patients and those in the series of Oreskovich and colleagues14 in part to the higher number of patients with falls in the latter series. Our 2-year follow-up showed that the geriatric patients who were discharged to either rehabilitation facilities or home retained their independence 75% of the time. Only 8.3% of patients were living in a nursing home. Our findings support the more optimistic view that a good functional outcome is possible after geriatric multisystem trauma.

A previous series of elderly trauma patients reported that the subgroup of patients older than 80 years had a poorer outcome than the patients aged 65–79 years.2 Of our 6 patients older than 80 years, 2 were discharged home, and 4 required nursing home care. These 4 patients waited an average of 30.8 days for nursing-home placement. Their average LOS was 45.5 days. These patients clearly have a worse outcome after multisystem trauma but represented only a small proportion (15%) of our geriatric trauma patients.

The increased LOS in elderly trauma patients has been attributed to an increased incidence and severity of complications, underlying health problems and the requirement for ongoing care. As expected, the elderly also required more alternative care resources (rehabilitation and extended care) and had to wait longer to access these resources. This is partially owing to a lack of rehabilitation resources available for the elderly in our region. There are long waiting lists for nursing home beds, but only 5 of our patients were awaiting transfer to extended-care facilities. The remaining 13 patients were awaiting rehabilitation resources. Although fewer younger patients wait for placement, the wait is shorter, which suggests a greater availability of resources for this age group.

At present, the elderly make up a small proportion of trauma admissions. However, our data suggest this group consumes a disproportionate amount of resources. Some series report that elderly patients consume 25%–30% of trauma dollars.1,16 Although it is recognized that the elderly suffer different mechanisms of injury, respond differently to a given mechanism of injury and experience more complications, relatively little research has been done on trauma in the elderly. As our population ages, there will be a growing number of elderly trauma patients to be cared for. It may be necessary to develop different guidelines for these patients, as we have done for children. Elderly patients are able to return to independent living after serious trauma, and their specific care and rehabilitation requirements need to be addressed.

Studies looking at costs and cost-effectiveness in elderly orthopedic patients with hip fractures have shown that comprehensive discharge planning programs, psychiatric consultation and multidisciplinary teams have led to earlier discharge and significant financial savings.10–13 Landefeld and associates9 have shown that geriatric medical patients cared for in a special geriatric unit are less likely to require long-term care facilities than those cared for on standard medical wards. Developing multidisciplinary care pathways for elderly trauma patients may similarly result in improved outcomes and cost savings.

## Conclusions

Geriatric trauma patients who survive their initial insult require a longer hospital stay and experience more complications than younger patients. Only a small proportion seem to require nursing home care, and after 2 years many patients will remain independent. The use of multidisciplinary care pathways to reduce complications and improve access to alternative care facilities may decrease the LOS and improve geriatric trauma outcomes. Aggressive trauma care for the elderly appears to be warranted.

## Footnotes

*   Presented at the Pacific Coast Surgical Association Scientific Meeting, Banff, Alta., February 2001.

*   **Competing interests:** None declared.

*   Accepted January 13, 2003.

## References

1.  MacKenzie EJ, Morris JA, Smith GS, Fahey M. Acute hospital costs of trauma in the United States: implications for regionalized systems of care. J Trauma 1990;30: 1096–103.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/00005373-199009000-00005&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=2213943&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1990EA83300005&link_type=ISI) 

2.  DeMaria EJ, Kenney PR, Merriam MA, Casanova LA, Gann DS. Survival after trauma in geriatric patients. Ann Surg 1987;206:738–43.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/00000658-198712000-00009&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=3689009&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1987L074700009&link_type=ISI) 

3.  Champion HR, Copes WS, Buyer D, Flanagan ME, Bain L, Sacco WJ. Major trauma in geriatric patients. Am J Public Health 1989;79:1278–82.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.2105/AJPH.79.9.1278&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=2764207&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1989AR62700014&link_type=ISI) 

4.  Smith DP, Enderson BL, Maull KI. Trauma in the elderly: determinants of outcomes. South Med J 1990;83:171–7.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=2305297&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1990CP54300010&link_type=ISI) 

5.  Ross N, Timberlake GA, Rubino LJ, Kerstein MD. High cost of trauma care in the elderly. South Med J 1989;82:857–9.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=2749355&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1989AH06200016&link_type=ISI) 

6.  Zietlow SP, Capizzi PJ, Bannon MP, Farnell MB. Multisystem geriatric trauma. J Trauma 1994;37:985–8.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=7996616&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1994PY53600020&link_type=ISI) 

7.  van Aalst JA, Morris JA, Yates HK, Miller RS, Bass SM. Severely injured geriatric patients return to independent living: a study of factors influencing function and independence. J Trauma 1991;31:1096–102.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=1875435&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1991GC68700007&link_type=ISI) 

8.  Broos PL, D’Hoore A, Vanderschot P, Rommens PM, Stappaerts KH. Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury 1993;24:365–8.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1016/0020-1383(93)90096-O&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=8406738&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1993LN70500002&link_type=ISI) 

9.  Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RG, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995;332:1338–44.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1056/NEJM199505183322006&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=7715644&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1995QX85700006&link_type=ISI) 

10. Ogilvie-Harris DJ, Botsford DJ, Hawker RW. Elderly patients with hip fractures: improved outcome with the use of care maps with high quality medical and nursing protocols. J Orthop Trauma 1993;7: 428–37.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/00005131-199310000-00005&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=8229379&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1993ME65100005&link_type=ISI) 

11. Strain JJ, Lyons JS, Hammer JS, Fahs M, Lebovits A, Paddison PL, et al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am J Psychiatry 1991;148:1044–9.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1176/ajp.148.8.1044&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=1853954&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1991FY56400011&link_type=ISI) 

12. Farnworth MG, Kenny P, Shiell A. The costs and effects of early discharge in the management of fractured hip. Age Ageing 1994;23:190–4.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1093/ageing/23.3.190&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=8085502&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1994NN64800005&link_type=ISI) 

13. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med 1994;120:999–1006.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.7326/0003-4819-120-12-199406150-00005&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=8185149&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1994NQ96400005&link_type=ISI) 

14. Oreskovich MR, Howard JD, Copass MK, Carrico CJ. Geriatric trauma: injury patterns and outcome. J Trauma 1984; 24:565–72.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/00005373-198407000-00003&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=6748116&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1984TC69500003&link_type=ISI) 

15. DeMaria EJ, Kenney PR, Merriam MA, Casanova LA, Gann DS. Aggressive trauma care benefits the elderly. J Trauma 1987;27:1200–6.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=3682032&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1987L165900002&link_type=ISI) 

16. Mueller MS, Gibson RM. Age differences in health care spending, fiscal year 1975. Soc Secur Bull 1976;39(6):18–31.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=828778&link_type=MED&atom=%2Fcjs%2F46%2F3%2F211.atom)