Our retrospective study of a provincial trauma registry showed that the median age of Canadian trauma patients constantly increased and that their injury pattern has mutated over the years. The severity of older patients’ injuries, but interestingly we showed a decrease in mortality in both age groups, even in the most severe trauma patients.
Older trauma patients are now more numerous than younger adults, which is also consistent with reported international information2,3,21−27. Our results also confirm previous findings that falls are the most common injury mechanism among older adults28,29. Falls are also very prevalent in younger adults as they have interchangeably been the leading cause of trauma with MVC in that population.
The proportion of older patients who sustained severe injuries to the head, thorax, and spine increased considerably over time. An Australian study reported a significant increase in the population-adjusted incidence of thoracic injury (8%/year), with the greatest increase being in patients aged ≥ 85 years (14%/year)30. Other authors also reported an increasing number of older adults with spine injuries29. which are mostly the result of low-energy trauma and predominantly affect the axial cervical spine. A possible explanation to this phenomenon is the increased sensitivity and specificity of computed tomography (CT) for spine injuries over conventional radiography31–33. Conversely, we observed a decrease in the proportion of older adults with an upper or lower extremities injury. This was also reported by Kalbas et al., however their results were possibly related to the decreasing incidence of high-energy traumas (i.e. road traffic accident), which was not the case in our population31. The decreasing incidence of hip fractures, one the most frequent lower extremity injuries in older adults34, may partially explain our findings. This was recently supported by other authors and could potentially be attributed to improved osteoporosis treatment but also to healthier lifestyle choices35. The evolution of injury pattern may also be attributed to improvements in diagnostic radiology26 combined with the recent democratization of whole body computed tomography (WBCT) which became standard practice in many centres in the last two decades29,36.
The proportion of severe trauma patients considerably increased, especially among older adults. This has also been observed in the English Trauma Audit Research Network database37 and in another large US cohort study22. Despite the increased severity and comorbidity burden, we noted a slight decrease of mortality in both age groups. Dinh et al. reported a 2.2% standardised mortality drop per year in older adults. The authors explained this was related to a decline in pedestrian injuries, who commonly sustain more severe injuries and have higher mortality rates but also to improved prehospital and acute care2. We also found that older trauma patients experienced longer in-hospital LOS, which is in line with the results reported by other authors38–40. This could be related to the higher incidence of complications in this population41–44. However, we cannot rule out that these complications may also be the consequence of longer LOS. In addition, we noted a major increase in bed-day consumption per year among older adults. Compared to younger adults, older patients were more frequently admitted to rehabilitation centres or short/long term care facility. All these are important driver of increased healthcare costs.
Our large multicentre cohort includes consecutive trauma patients who consulted or were transferred to any of the province’s three Level-I trauma centres between 2003 and 2017, which is a non-negligeable strength. Furthermore, the little missing data mainly pertained to comorbidities (appendix 5). This epidemiological study is a reliable overview of the Canadian trauma population as a whole, as other studies have focussed on specific trauma mechanism45, or population25,28,46. In addition, studies exploring temporal changes in injury pattern and severity are sparse26,28,29. At last, because advanced age has been associated with undertriage6–8 (inaccurate triage that results in a patient who requires higher-level care not being directly transported to a Level-I or Level-II trauma centre) we also included secondarily transferred patients.
This study has limitations. First, only patients admitted or transferred to a level-I trauma centre were included, which may have overestimated trauma severity and mortality. Nevertheless, we focused on patients with significant trauma, since minor injuries are often discharged home and do not generate the same burden in terms of mortality and healthcare costs. Some of the increases in injuries to specific body regions may be explained by the increased use of CT/WBCT. However, this may impact older and younger adults alike. The incidence of some specific injuries may have been underestimated in the early 2000’s and this was a factor we could not account for. Finally, because of our study’s retrospective design some variables such as complications, may have been underestimated in cases where they were not reported in the patients’ charts.
These results should be considered by health policy makers and trauma care providers to offer high-quality trauma care, a more dedicated pathway of care and senior-friendly triage tools. Concurrently, interventions shown to reduce falls must be actively deployed.
The changing characteristics of Canadian trauma patients, and the economic impact associated with these changes need to be further studied. The differences between the old (65–74 years), older (75–84 years) and oldest (≥ 85 years) patients may also need further investigation, as some differences have previously been highlighted47,48 but have yet to be investigated in a Canadian population.