With the aging of the population, the number of elderly trauma is increasing, which brings great challenges to the treatment of trauma. In this study, several databases were used to describe the age changes of trauma patients, further confirming the increasing number of elderly trauma patients. At the same time, this study compared the predictive value of different scoring tools for in-hospital mortality of elderly trauma patients. We found that the ISS, NISS, and TRISS scores were better than the SAPS Ⅱ and APACHE II scores at predicting in-hospital mortality in older trauma patients. And the NISS may be the best scoring tool.
Currently, injury is the seventh leading cause of death in the elderly (https://webappa.cdc.gov/). In addition to the United States, Germany, a number of other countries have reported an increase in the number of elderly trauma patients [21, 22]. Dealing with these patients is challenging. Firstly, several studies reported that most geriatric trauma patients were under-triaged, which may be associated with a higher risk of death . Some studies have reported that adding age to triage criteria may improve outcomes in older traumatic patients [24, 25]. Moreover, Guidelines recommend lowering criteria for initiating trauma teams in older trauma patients to improve the outcome of such patients . Therefore, future studies should establish a more accurate pre-hospital triage criterion for older trauma, which should include at least the following indicators: age, comorbidities, and physiological reserve, etc. Secondly, in recent years, frailty has been used more in the elderly. Frailty is defined as a syndrome of low physiologic capacity, decreased resistance to stressors, and increased vulnerability . Frailty is not equal to age and more effective than age  In non-trauma patients, frailty has been demonstrated to be associated with poor health outcomes . However, this relationship in geriatric trauma patients has not be comprehensively studied. Current tools to predict the risk of poor prognosis are inadequate, as they fail to include the effects of physiological capacity among geriatric trauma patients. It is necessary to define frailty correctly and measure frailty using an effective tool. Although general or geriatric trauma specific frailty index have been proposed, and were reported to be independently associated with poor prognosis, and could be used for risk stratification of geriatric trauma patients [30, 31]. But it is complex and time-consuming. Further studies focus on developing trauma specific frailty index and evaluating its effects on decision-making process. Finally, the complex comorbidities and medications use make the management of these patients more challenging. There is approximately 31 million people aged more than 65 use anticoagulant agent, and this number would raise to 68 million by the year 2020 in the United States . Several studies have shown that pre-injury use of anti-platelet or anticoagulant agents are associated with poor outcomes . Therefore, it may be necessary to identify these patients and revisal appropriately. Due to paucity of high quality studies, the standard management of these patients remain unclear . In conclusion, ageing population brings great challenge to the management of trauma patients. A dedicated geriatric trauma protocol is required for quality improvement .
It is essential to accurately predict the prognosis of elderly patients with trauma. This is an important part of the conversation between doctors and patients their surrogate decision maker, but also an important basis for decision-making. Several scoring systems have been proposed for predicting mortality in trauma patients . In 1974, the ISS was proposed, primarily based on the AIS score. Later, some researchers pointed out the shortcomings of ISS and proposed NISS. Although studies suggest that NISS is better at predicting mortality in trauma patients than the ISS score, NISS is not widely used clinically [37–39]. Currently, TRISS is a classic scoring tool for predicting mortality in trauma patients. The coefficients come from Major Trauma Outcome Study (MTOS) database. TRISS uses age, ISS, and RTS (physiological parameters: GCS, systolic blood pressure, and respiration rate). In 2010, the Schluter et al. updated its coefficients based on the NTDB database. But compared to the original TRISS, the updated is not widely used. A Severity Characterization of Trauma (ASCOT) is another potential tool for evaluating the prognosis of trauma patients. Unlike the TRISS, the ASCOT incorporates all AIS scores for each body part. Therefore, the calculation is relatively complex, and there may be great differences among different evaluators. The APACHE Ⅱ score and the SAPS Ⅱ score are routinely used to assess the severity and prognosis of patients with general critical illness, not just trauma. Although some studies have also assessed the ability of these physiologically-sensitive scoring systems to predict outcome in patients with trauma, the results suggest no significant advantage[43–52]. None of the scoring tools mentioned above are specific to older trauma patients. Both the anatomical scoring system and the physiological parameter scoring system have been reported to predict the prognosis of elderly patients with trauma[14, 53, 54]. But no studies have compared these scoring systems in older patients with trauma. This study compared the ability of ISS, NISS, TRISS, APACHE, and SAPS scores to predict in-hospital mortality in elderly trauma patients by secondary analysis. Our results suggest that the predictive power of ISS, NISS, and TRISS scores may be superior to APACHE Ⅱ and SAPS Ⅱ scores. NISS seems to be the best. These results suggest that anatomical injury is more important for the prognosis of elderly patients with trauma. We have already mentioned the specificity of the treatment of trauma in the elderly, so assessing the prognosis of elderly trauma patients may be more complex.
Geriatric Trauma Outcome Score (GTOS) was proposed specifically for predicting the prognosis of elderly trauma patients . Using the variables of ISS, age, and performance of packed red blood cell (PRBC) transfusion within 24 hours of admission, GTOS was developed through a single center study and validated in a following multi-center study . And in order to predict the unfavorable discharge in geriatric trauma patients, GTOS Ⅱ was developed. Compared with GTOS, GTOS Ⅱ uses the same parameters but has different coefficients . Some studies have compared GTOS with TRISS, and the results suggest that GTOS does not show a significant advantage in predicting accuracy[14, 15]. Unlike TRISS, the physiological parameters obtained for the first time are required. The construction of trauma database makes it possible to obtain a large number of trauma data. On this basis, the popularization of artificial intelligence and deep learning algorithms have promoted the accurate prediction of trauma patients' clinical outcomes. It has been pointed out that the advanced deep learning algorithm can better predict the adverse outcomes of critically patients than the traditional regression algorithm [57, 58]. Therefore, in the future, we hope to optimize the trauma database and build advanced deep learning algorithm by incorporating more variables, to achieve accurate prognosis of elderly trauma patients.