High Mortality and Medical Costs in Geriatric Trauma Patients: Surgical Treatment and Risk Factors from a Retrospective Cohort Study at a Level I Trauma Center

Article information

Ann Geriatr Med Res. 2025;29(4):430-439

Publication date (electronic) : 2025 October 27

doi : https://doi.org/10.4235/agmr.25.0124

Huei-Rong Tu¹, Tzu-Hsin Lin¹, Li-Min Hsu¹, I-Hui Wu^,1,2,3

¹Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan

²Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan

³College of Medicine, National Taiwan University, Taipei, Taiwan

Corresponding Author: I-Hui Wu, MD, PhD Department of Cardiovascular Surgery, National Taiwan University Hospital, No.7, Chung-Shan South Road, Taipei 100, Taiwan Email: aaronihuiwu@gmail.com

Received 2025 August 9; Revised 2025 October 20; Accepted 2025 October 22.

Abstract

INTRODUCTION

Trauma is a major global health issue. According to the World Health Organization, it causes around 4.4 million deaths annually, accounting for nearly 8% of all global fatalities. Additionally, trauma contributes to an estimated 10% of all years lived with disability, significantly impacting individuals and societies globally.1) With advancements in medical care, the aging population has grown rapidly. The proportion of older adults worldwide is projected to increase from 12% in 2015 to 22% by 2050.2) This demographic shift is primarily due to decreased disease-specific mortality and increased life expectancy.3) In Taiwan, the proportion of people aged ≥65 years reached 19.6% in July 2025,4) placing the country on the verge of becoming a super-aged society. The current life expectancy is 84.3 years for women and 77.4 years for men.5) Geriatric patients are particularly vulnerable to trauma, accident-related injuries being the most common among in this age group.6) These trends highlight the urgent need to address the unique challenges associated with aging populations and trauma care.

Previous reports indicate significant differences in injury mechanisms and patterns between older and younger individuals.7) Compared to younger patients, geriatric individuals have reduced physiological reserves and lower pre-injury functional capacities, making older age an independent risk factor for trauma mortality.8) Age-related physiological changes and chronic comorbidities further complicate trauma care in older adults, contributing to increased healthcare resource utilization and higher mortality.9) The aging population increases the burden on trauma systems and long-term care resources.10) Optimal trauma management through geriatric early diagnosis, effective treatment, and rehabilitation can improve quality of life, reduce mortality, and alleviate economic burdens.11,12)

The clinical characteristics and cost patterns of geriatric trauma in East Asian populations remain underexplored. This study addresses these gaps by conducting a retrospective cohort analysis to examine the demographics, injury characteristics, mechanisms, clinical outcomes, and expenditure categories among trauma patients, with a focus on geriatric individuals. The findings aim to inform healthcare strategies and improve trauma care preparedness for aging populations.

MATERIALS AND METHODS

Statistical Analysis

Continuous variables (e.g., age, revised trauma score, and cost) were analyzed with independent sample t-tests and reported as mean±standard deviation, while categorical variables (e.g., sex and GCS) were analyzed using chi-square tests and reported as frequency (%). Tables 1 and 2 summarize total expenditure comparisons by age group and in-hospital mortality, respectively. For the medical cost variable, cases with missing data were excluded. These exclusions were primarily due to emergency deaths, observation discharges, or missing billing records. Detailed category-specific costs are presented in Supplementary Tables S1 and S2, but were not included in the mortality model due to their post-admission nature and potential reverse causality. Furthermore, we assessed the association between clinical factors and the risk of in-hospital mortality using logistic regression models, separated by age group (<65 vs. ≥65 years). In the first step, a series of univariate logistic models was conducted to identify possible associated factors. Secondly, those variables with a p-value less than 0.15 in the univariate analyses were included in the multivariable logistic model to adjust for potential confounders. ISS was excluded from the multivariable model due to collinearity with the severe injury variables (e.g., head, face, and thoracic). All tests were two-tailed, and p<0.05 was considered statistically significant. Data analyses were conducted using SPSS version 26 (IBM SPSS Inc., Armonk, NY, USA).

Table 1.

Baseline and clinical characteristics of trauma patients by age group (<65 vs. ≥65 years)

Table 2.

Baseline and clinical characteristics of trauma patients according to age group (<65 vs. ≥65 years), stratified by mortality

RESULT

Predictors of Mortality in Younger Adults and Geriatric Patients

In the younger adult group (<65 years), several factors were significantly associated with increased mortality. These included older age (adjusted odds ratio [aOR]=1.03, 95% confidence interval [CI] 1.01–1.04), lower GCS (≤8) (aOR=14.10, 95% CI 5.38–36.92) and GCS 9–12 (aOR=7.18, 95% CI 2.88–17.91), and lower RTS (aOR=0.57, 95% CI 0.49–0.65). The presence of severe thoracic and extremity injuries, falls, and suicide was also associated with higher mortality. Conversely, patients undergoing neurosurgery (aOR=0.32, 95% CI 0.15–0.68), plastic surgery (aOR=0.11, 95% CI 0.02–0.53), or orthopedic surgery (aOR=0.01, 95% CI 0.004–0.06) had significantly lower mortality (Table 3, Fig. 1).

Table 3.

Multivariable logistic regression of factors associated with in-hospital mortality in younger and geriatric adults

Fig. 1.

Forest plot of the age-stratified predictors of in-hospital mortality among trauma patients. It shows adjusted odds ratios (aORs) and 95% confidence intervals for factors associated with in-hospital mortality among older and younger trauma patients. Red circles represent older patients (≥65 years) and blue circles represent younger patients (<65 years). Factors with aOR <1 indicate an association with lower odds of in-hospital mortality. Horizontal bars denote 95% confidence intervals. p-values are shown for each factor; aORs are plotted on a logarithmic scale. GCS, Glasgow Coma Scale; RTS, Revised Trauma Score; AIS, Abbreviated Injury Scale.

In the geriatric group (≥65 years), male sex and older age were independently associated with higher mortality. Similar to the younger group, lower GCS scores (≤8) (aOR=7.33, 95% CI 3.69–14.57) and lower RTS (aOR=0.73, 95% CI 0.63–0.84) were significantly associated with mortality. Severe head, thoracic, extremity, and appearance injuries also showed strong associations with increased mortality. Burn injuries also showed a significant correlation with increased mortality in this group (aOR=2.57, 95% CI 1.004–6.57). Mortality was significantly lower in geriatric patients undergoing orthopedic and thoracic surgeries (aOR=0.09, 95% CI 0.04–0.21 and aOR=0.21, 95% CI 0.07–0.63, respectively) comparing to other surgical interventions (Table 3, Fig. 1). The details of univariate logistic analyses were shown in the supplements (Supplementary Table S3).

DISCUSSION

This study provides a comprehensive analysis of demographics, injury mechanisms, severity patterns, clinical outcomes, and expenditure categories in both younger and geriatric trauma patients, aiming to address key gaps in understanding their care needs. Consistent with previous research, our findings confirm that older age is an independent predictor of mortality, even after adjusting for injury type and severity in geriatric trauma patients.8,18) Age ≥65 years represents a clinically significant threshold, as geriatric trauma patients have been shown to experience a threefold higher in-hospital mortality rate compared to younger adults.19) Older patients are particularly difficult to triage due to the lack of reliable indicators for injury severity and physiological reserve. As a result, they are frequently undertriaged, which contributes to increased risks of mortality and post-discharge disability.19) In addition, comorbidities are more prevalent in this population, further complicating clinical management and outcomes. Geriatric patients often present with complex needs and demand greater medical resources, which makes their management particularly challenging.10) These findings suggest that older trauma patients should be recognized as a group with unique care needs. A better understanding of age-related differences in injury patterns, clinical management, and outcomes could support the development of more effective and age-adapted care strategies that address the diverse and complex needs of the geriatric population.

Additionally, this study identified male sex as an independent predictor of mortality among older trauma patients, even though women constituted the majority of geriatric trauma cases. Although the association between sex and trauma-related mortality remains controversial, similar patterns have also been observed in trauma subgroups. Biological factors may contribute to this difference. Men often exhibit weaker clot formation and strength after trauma, and when coagulopathy is present, they have higher mortality than women.20) Females after trauma show lower mortality and better functional outcomes, which may be related to differences in immune response, inflammatory regulation, and the protective effects of sex hormones.21) A retrospective cohort study from Japan found that women with post-traumatic sepsis had lower in-hospital mortality than men, possibly due to the protective effects of estrogen on immunity and coagulation, genetics, and healthcare-related. This survival advantage persisted among patients aged ≥65 years.22) Some studies have shown that higher mortality in men relates to injury mechanisms. Men have higher mortality in high-energy incidents, such as motor vehicle collisions or falls.23-25) An exploratory comparison between older male and female trauma patients using available registry variables is provided in Supplementary Table S4. These additional data highlight differences in injury severity, mechanisms, anatomical distribution, and clinical outcomes, but were not part of the predefined objectives of this study. These findings suggest that sex-related differences in post-trauma outcomes should be considered in clinical evaluation and care planning. This association may be partially explained by differences in injury mechanisms, physiological responses, or comorbidity profiles between sexes. Further investigation is suggested for future studies.

Previous studies have shown that falls are the leading cause of mortality among older trauma patients.8,16) Among geriatric trauma patients in our study, falls were the most common mechanism (77.3%), followed by traffic accidents (16.6%). However, multivariable regression revealed that burn injuries are a significant mechanism of mortality in older patients. In our analysis, burn injuries were independently associated with an increased risk of in-hospital mortality (aOR=2.57, 95% CI 1.004–6.57). This may reflect differences in injury severity or healthcare response and shows the importance of recognizing burns as a high-risk injury. Burns were less frequent but showed high fatality in older adults.26) Similarly, Stanojcic et al.27) found that even small burns led to excess deaths in older patients due to delayed immune response and impaired inflammatory regulation. Furthermore, Cords et al.28) found a 12% in-hospital mortality rate and tenfold increase in long-term mortality for patients aged 65–74. These findings suggest that age-related frailty and reduced physiological reserve may drive burn-related mortality, rather than burn size alone.28,29) While burn extent and depth are often visually apparent, standard triage tools may underestimate mortality risk in older patients. Therefore, age-adapted evaluation frameworks that incorporate adaptive capacity and frailty indicators are essential for improving risk prediction and timely intervention. These findings emphasize the need for greater clinical attention in the care of geriatric trauma patients. Although burn injuries are relatively uncommon in this population, their high mortality rate deserves particular focus. Early identification of high-risk patients and appropriate resuscitation measures, such as fluid replacement and airway management, are essential. A multidisciplinary approach involving trauma surgeons, burn specialists, and geriatric care teams may further improve outcomes through coordinated and individualized care plans. In addition, implementing dedicated burn care and rehabilitation plans may help improve outcomes in older adults affected by this mechanism of injury.

Our study found that both GCS ≤8 (aOR=7.33) and RTS (aOR=0.73) were significant predictors of mortality in geriatric trauma patients. Although RTS includes GCS, the two scoring systems represent different clinical aspects. GCS reflects neurological status, while RTS combines GCS, blood pressure, and respiratory rate to indicate overall physiological stability. Both scores were strongly associated with mortality, showing that poor neurological function and physiological instability are key risk factors in these groups.8,18,30) In our study, geriatric patients often arrived at the emergency department with well-preserved RTS scores, suggesting mild injuries and stable vital signs. However, among those who died, older patients had lower injury severity scores than younger patients who died, yet the mortality rate among geriatric patients was higher. This observation suggests that older adults experience worse outcomes despite less severe injuries, likely due to an impaired ability to respond to physiological stress and multiple comorbidities.7,16) This aligns with previous findings indicating that any complication can independently increase mortality in geriatric trauma, with the impact magnified by age and injury severity. This discrepancy is attributed to the reduced physiological reserve and atypical presentation in older adults, which may mask the true severity of injuries in conventional scoring systems. These findings suggest that current assessment tools may have limitations in identifying risk among geriatric trauma patients, especially those who present with stable vital signs but are physiologically vulnerable. This could lead to under-triage and delayed treatment, potentially affecting clinical outcomes. Developing age-adapted evaluation tools may help improve early recognition and timely intervention in this geriatric population.

Our study found that orthopedic and thoracic surgical interventions were significantly associated with lower in-hospital mortality among geriatric trauma patients. However, relatively few studies have examined the association between specific surgical procedures and mortality outcomes in this population. Some studies have shown that early hip fracture surgery reduces postoperative mortality31,32) and improves short-and long-term survival through early ambulation in older adults.33) Other research also supports the benefits of timely surgical intervention and early mobilization in improving recovery and reducing complications after orthopedic surgery.34,35) A previous study has shown that rib fractures in older adults (age ≥45) have been associated with increased morbidity, including longer ICU stays and higher ventilator requirements.36) More recently, studies have suggested that rib fixation in selected older patients with chest trauma may improve pain control, respiratory function, reduce complications, and potentially lower mortality.37) Similar benefits in terms of pain relief and functional recovery have also been reported in the general trauma population.38) These findings support the potential clinical value of timely orthopedic and thoracic surgical procedures in reducing mortality and promoting long-term recovery in geriatric trauma. Early surgical management may mitigate the risks of postoperative complications, promote faster mobilization, and preserve respiratory function, all of which are critical factors in this vulnerable population. Future research should explore the optimal timing, patient selection criteria and effectiveness of surgical interventions in geriatric trauma care and timely procedures should be considered as part of standard care.

Our findings indicate that the costs associated with geriatric trauma patients were significantly higher across most categories. With the exception of surgical cost, the increased expenditure among older trauma patients can be attributable to longer hospital stays, higher ICU admission rates, more severe injuries, a greater prevalence of comorbidities and complications, and the need for more extensive medical care. Such care often involves additional equipment, assistive devices, medications, and acute critical care management.39,40) These findings indicate that geriatric trauma patients have higher medical costs, placing a heavy burden on families and society. To address this challenge, planning and allocation of healthcare resources are essential. It is necessary to develop care strategies tailored to the older adults in order to maintain the quality of care while ensuring cost-effective use of medical resources.

This study has several limitations. First, data were collected from a single urban Level I trauma center, which may limit the generalizability of the findings to rural settings with different trauma care resources and may not fully represent nationwide trauma care patterns. Second, the retrospective design may be subject to selection bias and unmeasured confounding. Third, registry constraints precluded adjustment for geriatric factors, including comorbidity burden, frailty, and pre-injury functional status. Therefore, residual confounding may remain. Fourth, our cost analysis was descriptive and did not involve multivariable adjustment or length-of-stay normalization. This approach was chosen to avoid post-treatment bias, including potential reverse causality, but it may limit the interpretation of cost comparisons. Future research should explore the impact of timely surgical interventions and the role of geriatric-specific assessment tools on trauma outcomes in older adults.

In conclusion, this study demonstrates the distinct clinical and resource challenges associated with geriatric trauma. Compared to younger adults, older trauma patients experience higher mortality. Older age, male sex, poor GCS scores, and lower RTS scores were key predictors of mortality. Injuries such as burns and severe head, thoracic, or extremity trauma tended to result in poorer outcomes in older patients. In contrast, orthopedic and thoracic surgical interventions were associated with significantly lower in-hospital mortality. With global aging trends, early identification of high-risk geriatric trauma patients is essential. Age-sensitive evaluation tools, integrated surgical strategies, and interdisciplinary care models may help improve clinical outcomes while ensuring more efficient use of medical resources in this geriatric trauma population.

SUPPLEMENTARY MATERIALS

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