Road Traffic Injuries and their Outcome in the Elderly Patients 60 years and above. Does Age make a Difference?

Advancing age is known to increase adverse outcome after road traffic accidents. Despite an overall lower incidence of traumatic injuries in elderly, the mortality is comparatively high in the geriatric patients [1]. Since there is an increased incidence of associated co-morbidities of varying severity as well as decreased physiological reserve, the elderly are claimed to have poorer outcomes in traumatic injuries and need an aggressive management [2,3]. Elderly patients are reported to sustain different types of injuries compared to their younger counterparts due to trauma as well as a mortality of 50% above that of general population [4-6]. It is yet to be confirmed whether this difference in outcome is due to decreased physiologic reserve, co-morbidities or some other factors. An aggressive management is recommended by most of the authors to improve outcome in road traffic traumatic injuries in the elderly patients [7].


Introduction
Advancing age is known to increase adverse outcome after road traffic accidents. Despite an overall lower incidence of traumatic injuries in elderly, the mortality is comparatively high in the geriatric patients [1]. Since there is an increased incidence of associated co-morbidities of varying severity as well as decreased physiological reserve, the elderly are claimed to have poorer outcomes in traumatic injuries and need an aggressive management [2,3]. Elderly patients are reported to sustain different types of injuries compared to their younger counterparts due to trauma as well as a mortality of 50% above that of general population [4][5][6]. It is yet to be confirmed whether this difference in outcome is due to decreased physiologic reserve, co-morbidities or some other factors. An aggressive management is recommended by most of the authors to improve outcome in road traffic traumatic injuries in the elderly patients [7].

Patients and methods
This retrospective descriptive study compared an almost equal number of elderly patients (60 years and above designated as Group-A) and younger patients (< 60 years ,designated as Group-B) admitted with history of road traffic accident demanding hospitalization during a span of 7 years in a teaching hospital. All patients were referred through casualty department with varying degrees and proportion of injuries. The patients were initially resuscitated and examined thoroughly for injuries and using the Abbreviated Injury Score (AIS) categorized into minor, moderate, serious and severe injuries. The organ injury scales were also referred for those who had abdominal injury demanding laparotomy as well as those who had chest trauma. After resuscitative measures and establishment of the diagnosis, the patients were managed accordingly. The variables studied in both groups were demographics, mechanism of injury, injuries sustained, co-morbidities, treatment instituted, total hospital stay, and outcome of the treatment. The co-morbidities meant any chronic disease/ diseases for which patient is taking medicine on regular basis such as diabetes mellitus, hypertension etc. as well as any cancer or history of a major operation in the near past.
The details of each patient were recorded on a proforma and data was statistically analyzed using SPSS version 17.

Results
Group-A included 149 patients (Mean age 66.91, Std 6.859, Males n=115, Females n= 34), admitted with history of road traffic accident with varying injuries. This group of elderly trauma victims is compared to a similar number of patients in group-B (Mean age 35.52, Std 13.814, Males n= 140, Females n= 11) and managed during the same duration. Majority of the patients in both groups were brought to hospital within 12 hours of the incidence while overall 15% patients including both groups reported after more than 24 hours. There was a rise in the incidence of road traffic trauma in the elderly patient during the study period, as evident from Table 1.

Co-morbidity
A significantly higher proportion of group-A (n=96, [64.42%]) had one or the other co-morbidities such as diabetes mellitus, hypertension, and IHD, compared to their younger counter-parts as shown in Table  2.

Mechanism of injury
In both the groups, the majority of the patients received injuries by a variety of vehicles ranging from motorcycles to cars and bus/trucks etc. Majority (74.49%) of group-A victims were passengers (Vehicle occupants) where as 63% of group-B patients were drivers. The major trauma distribution and injuries sustained in both groups was different as shown in Table 3.

Pattern of injuries
There is a significantly high incidence of chest wall injuries with rib fractures and haemo-pneumothorax in the elderly patients (P<0.001) compared to their younger counterparts. Similarly, the incidence of limb and hip bone fracture is significantly higher (P<0.001) in the elderly patients as compared to the younger age group. The chest injuries in elderly are associated with an increased incidence of complications like basal atelectasis and pneumonia Patients with rib fractures and associated haemo-pneumothorax needed chest intubation, antibiotics and adequate analgesia while six of them needed multiple blood transfusions and had severe respiratory distress with a flail segment. These patients died within 4 hours of admission in the ward before they could be shifted to ICU. The remaining patients were discharged after successful recovery. The abdominal injuries requiring laparotomy were much more common in the younger age group patients (89 vs. 33) and the pattern of injuries was also different in two groups as shown in Table 4. The total number of patients treated in ICU included 79(53%) patients of group-A compared to 23(15%) of the group-B (<0.05). The ISS for group-A was significantly less than group-B as shown in Table 5.

Mortality
Of the total number, 22(14.76%) patients of group -A died despite low ISS score compared to 7(4.63%) of group -B patients (p<0.001) as shown in Table 6. Of the total patients died in Group-A, seventeen (77%) had one or the other co-morbidity while 2(29%) of the 7 fatalities in Group-B had one or the other concurrent disease (P<0.001). The severe pain in rib fractures was found to decrease the respiratory volumes with development of basal atelectasis and infection. Comorbidities were seen in most of the fatalities in the elderly patients who died either within 24 hours of the incidence or post-operatively.

Discussion
Road traffic injuries are among the common causes of physical handicap, morbidity and mortality all over the world [8][9][10]. The actual incidence of such injuries is supposed to be much higher than reported in the literature [11,12]. A number of reports have cited an increase in the elderly trauma victims regardless of whether they are drivers themselves, pedestrians, or occupying the vehicles as passengers [13][14][15][16][17]. The current study compares the incidence, management and outcome of road traffic injuries in elderly patients (60 years and above) to those below 60 years of age. We found co-morbidities in a significant majority of elderly patients in our study compared to their younger counterparts (65.77% V 13.4%). This finding is consistent with a number of similar studies from different parts of the world [6,[18][19][20]. Although a number of studies [17,21] found co-morbidities to be a major determinant of outcome of trauma in the elderly, Preston SD et al. [22], Mathilda HH [23] et al. and Milzmann DP et al. [24] did not find pre-existing diseases to be a determinant of outcome in elderly RTA victims. Occupants of vehicles, either private or public transport were common victims of group-A (74.49%) while majority of group-B victims were drivers (62.9%). A number of these younger drivers were claimed and found to be intoxicated and others were on their cell phones just before the collision. Similar factors are mentioned by other similar reports blaming careless and ruthless driving as a significant factor leading to fatal road traffic injuries [25]. The group -A patients received significantly high proportion of the chest injuries including haemothorax, pneumothorax, haemo-pneumothorax and rib fractures compared to group-B patients. This is consistent with results of other reports [19] and is attributed to increased vehicle occupancy by the elderly, using seat belts, osteoporosis, and decreased muscle mass etc [26,27]. In our study there is a high proportion of limb and hip bone fractures among group-A patients and majority of them were pedestrians compared to group-B patients. This is consistent with the observation of Cheng CH et al. [28] claiming an increased incidence of injuries to extremities and significantly less abdominal injuries. This again coincides with our results. We, however, have a remarkably low incidence of splenic rupture in group-A patients compared to group-B patients. This is contrary to the results of other similar reports with high splenic rupture proportions in the elderly patients [1]. The vast majority of elderly victims in our study were vehicle occupants. There were few elderly drivers in our study who sustained injuries in road traffic accidents. This may be attributed to an unduly safe driving or because of a short distance driving by the elderly people in general and mostly in the day time. We observed a high mortality in the elderly group despite a comparable ISS score. This may be explained on the basis of a significantly high incidence of co-morbidities in the elderly victims in our study. A substantial body of literature also confirms this observation in elderly trauma patients [28][29][30]. The observations made in this study indicates a need to emphasize on aggressive and prompt management plan for elderly road traffic injury victims keeping in view their poor physiological reserves, associated co-morbidities and poor ability to tolerate trauma. Well-equipped trauma centers with trained trauma personnel need to be established in all major cities keeping in view the alarmingly increased incidence of fatal road traffic accidents in the developing world.

Conclusion
There are an increasing number of elderly patients fatally traumatized in road traffic accidents in our society. Keeping in view their less tolerability to trauma, the geriatric patients need a very special care with very prompt and aggressive treatment. A significant improvement can be achieved by establishing trauma centers with advance equipment and trained trauma care personnel especially in developing countries like Pakistan.