Abstract
Objective
To determine the demographic and epidemiological characteristics of geriatric patients with forensic trauma admitted to the emergency department of our hospital and to examine factors associated with forensic events in our country.
Methods
The data of individuals aged 65 years and older who were admitted to the emergency department of our hospital due to forensic events between 2013 and 2023 were retrospectively analyzed. The patients’ demographic characteristics, date and nature of the forensic incident, injury zones, final diagnoses of the forensic patient, and nature and content of the forensic report were examined from the forensic records.
Results
Of 173,080 geriatric patients admitted to the emergency department during the study period, 679 were forensic cases. Most patients were men (n=481, 70.8%). The most common type of forensic incident was falls (37.4%), followed by assault (18.1%). Half of the intoxication cases were caused by carbon monoxide. The most frequently injured body areas were the head and neck (39.8%), followed by the upper limbs (27.4%) and lower limbs (19%). Forensic admissions were most common during the summer months (August, July, and June).
Conclusion
In this study, falls were the most common cause of geriatric forensic trauma. Therefore, potential fall-related complications can be prevented by carefully evaluating older adults at high risk of falls and taking necessary precautions.
Introduction
The older population is growing in Turkey and worldwide. The geriatric population in Turkey was 7,186,204 in 2018 and increased by 21.4% over the last 5 years to 8,722,806 in 2023. The proportion of older adults in the population rose from 8.8% in 2018 to 10.2% in 2023. According to population projections, this rate is expected to increase further to 12.9% in 2030, 16.3% in 2040, 22.6% in 2060, and 25.6% in 2080(1).
With this growth of the older population, increased participation in active lifestyles(2, 3) and age-related physiological changes, such as decreases in perception and attention, visual acuity, and mental and motor activity, as well as postural changes, can increase rates of trauma and injury in older adults(4). Epidemiological studies have shown that 23% of all trauma admission involve geriatric patients(2).
Trauma is the fourth most common cause of death after heart disease, cancer, and stroke in all age groups(5) and the fifth most common cause of death in the geriatric population(2, 6). Geriatric traumas are mostly caused by falls (from a height or at the same level) or motor vehicle accidents (driver, occupant, pedestrian, or cyclist)(7, 8). Trauma is associated with high morbidity and mortality and has more severe consequences in older adults than in other populations because of the presence of concomitant diseases and limited physiological reserves(8, 9).
Our aim in this study was to determine the demographic and epidemiological characteristics of geriatric forensic trauma patients admitted to the emergency department of our hospital and to contribute to the literature by examining the factors associated with forensic incidents in our country.
Materials and Methods
In this retrospective cross-sectional study, we examined the records of individuals aged 65 years who presented to the emergency department of the Atatürk University Faculty of Medicine Hospital due to forensic incidents between 2013 and 2023. The patients’ demographic characteristics (age, gender, occupation, education level, cohabitation, marital status, place of residence), chronic diseases, and drugs used were obtained from the hospital information system and patient files. The date, nature, and setting of the forensic incident, injury zones, related outcomes (hospitalization, mortality), diagnosis of the forensic patient, and the nature and content of the forensic report were examined from the forensic records. In addition, we recorded the mode of admission to the emergency department, the consultations requested in the emergency department, the mode of discharge, and the length of stay in the emergency department and hospital if admitted.
Statistical Analysis
The data were analyzed using SPSS version 21.0 (IBM, USA). Categorical descriptive data were expressed as frequency distribution and percentage; continuous variables were expressed as mean, standard deviation, median, and range. The independent samples t-test, Fisher’s exact test, and Pearson’s chi-square test were used for intergroup comparisons of categorical data, and p≤0.05 was considered statistically significant.
Permission to conduct the study was obtained from the Atatürk University Faculty of Medicine Clinical Research Ethics Committee (date: 07.09.2023, approval no: 6/11).
Results
Of the 173,080 older adults admitted to the emergency department during the study period, 679 were forensic cases. The median age of the patients was 71 years (range, 65-107 years), and 481 (70.8%) were male. The demographic characteristics and chronic diseases of the participants are presented in Table 1. The most common chronic comorbidities were hypertension (n=306; 45.1%) and diabetes mellitus (n=117; 17.2%). The median number of diseases was 2 (range, 0-12) and the median number of drugs used was 1 (range, 0-6).
The distribution of the mode and time of admission and incident type of geriatric forensic cases evaluated in the emergency department is presented in Table 2. We observed that 51.3% of the patients were transported by ambulance, whereas the rest were transported by personal means. The most common type of forensic incident was falls (n=254; 37.4%), followed by assault (n=123; 18.1%). Of 20 traffic-related incidents, 8 (40.0%) were drivers/occupants, and the rest were pedestrian/cyclist (n=12; 60.0%). Of the 10 intoxications, 6 (50.0%) occurred as a result of carbon monoxide (CO), 3 (25.0%) as a result of chemical inhalation, and 1 (8.3%) as a result of fungus, food, or drug exposure.
The distribution of forensic case presentations by months is presented in Figure 1. These cases occurred most commonly in the summer months of August (13.7%), July (12.4%), and June (11.9%). The injury zone distribution according to incident type is shown in Table 3. The most common injury site was the head and neck (n=270; 39.8%), followed by the upper limbs (n=186; 27.4%) and lower limbs (n=129; 19.0%). The most common sites of injury according to incident type were as follows: Head and neck in traffic accidents (n=10; 50.0%), lower limbs in firearm injuries (n=8; 61.5%), upper limbs in sharp trauma (n=8; 61.5%), head and neck in assault (n=82; 66.7%), head and neck in falls (n=106; 41.7%), upper limbs in occupational accidents (n=14; 48.3%), upper limbs in dog attacks (n=9; 62.2%), and the thorax in other animal attacks/kicks (n=27; 37.0%). The limbs of two patients with burns and electric shock were affected.
The injury type by incident type distribution is presented in Table 4. The most common types of injury were soft tissue trauma (n=251; 36.9%), bone fracture (n=170; 25.0%), and skin/mucosa laceration (n=163; 24.1%). The most common injury types according to incident type were as follows: Bone fracture in traffic accidents (n=9; 45.0%), soft tissue trauma in firearm injuries (n=7; 53.8%), skin/mucosa laceration in sharp trauma (n=30; 60.0%), soft tissue trauma in assault (n=50; 40.7%), bone fracture in falls (n=96; 37.8%), skin/mucosa laceration in occupational accidents (n=14; 48.3%), skin/mucosa laceration in dog attacks (n=13; 100%), and soft tissue trauma in other animal attacks/kicks (n=27; 37.0%).
The length of stay in the emergency department, treatments/consultations, and outcomes of the forensic cases are presented in Table 5. Only 13 patients (1.9%) had life-threatening injuries upon admission, and almost half had injuries that could be treated with simple medical interventions (n=329; 48.5%). The three most frequently consulted clinics were orthopedic, neurosurgery, and thoracic surgery. In total, 409 (60.2%) were discharged as outpatients, 212 patients (31.2%) were hospitalized.
Discussion
A total of 173,080 geriatric patients presented to the emergency department of our hospital during the study period, of which 679 were forensic trauma patients. The majority of patients were male (70.8%). The most common types of forensic incidents were falls (37.4%), assault (18.1%), and sharp trauma (7.4%). The rate of traffic accidents was 2.9%, and the majority were drivers/occupants. The most common cause of intoxication (50.0%) was CO poisoning.
With the aging of the global population, the number of older people with active lifestyles has increased. This is associated with an increase in older patients admitted to hospitals because of trauma(10-13). A study by Chang et al.(14) showed that extreme efforts are needed to diagnose and treat older adults. Therefore, traumatic injuries are less frequently overlooked.
In addition, population aging also brings about an increase in individuals with cardiovascular, pulmonary, neurological, and cognitive disorders, malnutrition, osteoporosis, electrolyte imbalance, and polypharmacy(15). For these reasons, posttraumatic complications also increase. Delirium and infections are among the most common posttraumatic complications(15). Low cardiac output, perioperative hypotension, postoperative hypoxia, time spent in surgery, excessive postoperative analgesia, immune suppression, and the presence of chronic comorbid diseases are factors that increase the risk of posttraumatic delirium and infection(16, 17). All of these factors necessitate close observation and multidisciplinary management of this population. In our study, we observed that consultation was frequently requested from the orthopedic, neurosurgery, and thoracic surgery departments after trauma.
Falls are among the most common causes of trauma in the elderly population. Approximately one-third of older adults die annually(18, 19). Risk factors contributing to falls include physical and mental disorders, such as osteoarthrosis, osteoporosis, visual impairments, polypharmacy, balance and gait disturbances, depression, vertigo, cognitive impairment, diabetes, and sarcopenia(20). The frequency of osteoporosis and sarcopenia is higher in the geriatric population, thereby increasing the risk of traumatic fractures. Moreover, this procedure leads to a protracted hospitalization and rehabilitation process after injury(21). In studies conducted in the early 2000s, the most common cause of injury in seriously injured geriatric patients was falls (50-60%), followed by motor vehicle accidents (pedestrian or driver/occupant) (9-20%)(22, 23). However, recent epidemiological studies on trauma in geriatric patients have shown a decline in the rate of injuries due to vehicle accidents and an increase in fall-related injuries(11, 24). Our study is similar to the recent literature, with falls being the most common cause of trauma (37.4%) and traffic accidents being relatively less prevalent (8%). This decline in traffic accidents as an etiology of trauma worldwide and in our country may be related to more careful urban planning and road construction and better implementation of traffic rules. In contrast, the increasing rates of assault are related to social and moral factors and are thus more difficult to regulate. Similar to our study, traffic accidents are decreasing but assault rates are increasing in countries such as South Africa(25). In addition, because livestock farming is common in our country and especially in the region where this study was conducted, most blunt traumas in relation to animals occur in rural areas. In countries where animal husbandry is common, there is also a high rate of animal-related trauma, which is similar to the results of our study(26).
The most commonly injured parts of the body in patients with geriatric trauma are the head and neck, upper limbs, and lower limbs(27-29). Head and neck trauma is important for older adults because of the risk of traumatic brain injury. An increase in the frequency of falls is associated with an increase in brain injuries. The subgroup of older adults aged 75 years and older constitutes the highest risk of hospitalization and mortality(30-32). Older adults with head trauma may present with mild symptoms. These patients can develop intracranial hematomas without any neurological deficits(33). This may cause diagnostic delays and poor outcomes(30) and can be even more complicated in individuals using anticoagulants, such as vitamin K antagonists(34).
Geriatric patients are usually exposed to blunt rather than penetrating trauma(35). Animals such as cattle or horses that can kick, crush, and cause head and facial injuries are characteristically the most common causes of blunt trauma. Agricultural workers in particular face a risk of fatal injuries involving the head and body(36). Cattle cause a significant number of trauma-related deaths worldwide. Behavior can be unpredictable even among domesticated animals, and attacks by individuals or herds are possible. Trauma due to kicking, trampling, goring, or crushing can often cause head or chest injuries. The risk of trauma and trauma-related death is higher among men living in rural areas(37). In our study, the most frequently injured body areas were the head and neck at a rate of 39.8%, consistent with other studies, followed by the upper limbs at a rate of 27.4% and the lower limbs at a rate of 19%. We found that the head and neck region and upper limbs were most frequently affected by blunt trauma, sharp trauma, falls, dog attacks, and traffic accidents. In attacks and kicks, the thoracic region was the most frequently affected area.
In our study, 12 patients presented with intoxication, and most of these cases were CO poisoning. CO is an odorless, colorless, tasteless, non-irritant gas that is also a highly reactive and flammable molecule that mixes with air. Gas can be produced from natural or anthropogenic sources, especially as a result of incomplete fossil fuel combustion or biomass combustion. It is extremely poisonous(38). CO exposure and poisoning can occur in environmental, occupational, and domestic settings. The causes of home exposure include fires, malfunctioning heating systems, and suicide attempts. CO poisoning and related deaths should be considered in workplaces with machines in closed and poorly ventilated areas(39). Although there is no gender-based difference in the incidence of CO poisoning, mortality rates are twice as high in men. The prevalence showed two distinct peaks between the ages of 0-14 and 20-39 years. The mortality rate among these patients also increases with age, peaking in those 80 years and older(40). The geriatric status is an independent factor associated with increased mortality in CO poisoning cases. With aging, individuals become frail, and adaptive responses to stressors decrease because of increased rates of comorbid diseases and decline in physiological reserves(41). Cardiorespiratory capacity decreases and the half-life of CO elimination increases in the elderly because of increased cardiovascular and respiratory system diseases(42). For these reasons, older adults are more severely affected by CO poisoning and often cannot be saved due to late diagnosis. Unfortunately, sufficient studies on this topic have not been conducted in the geriatric population. Factors that may explain the high frequency of CO intoxication include the long, severe winter season and the living conditions associated with the socio-economic level in our region.
Although women outnumber men in older populations, trauma cases are more common in men(23, 24, 43-46). In our study, the majority of individuals who presented with forensic cases were men. Similar rates have also been reported in the literature. This pattern of older men being disproportionately affected by trauma may be related to their more active work and social lives.
When the seasonal distribution of the forensic cases was evaluated, we observed that most cases occurred in summer (August, July, and June). Another study showed that accident rates peaked between June and September, the hottest period of the year, and decreased in the winter months(47). We attribute this decrease in our study to the severe winter in our region and the limited social activity during this season.
Nearly one-third of the forensic patients in our study were hospitalized after trauma (31.2%). This rate was found to be 58.4% and 57.4% in other studies conducted in our country by Yildiz et al.(48) and Akköse Aydin et al.(49), respectively. Our findings may have differed from those of the other studies because most patients were followed up and treated in the emergency department observation room of our hospital.
Study Limitations
The main strengths of our study are that it covers a long period (10 years) and includes a large number of patients. The limitations of the study are that it was retrospective and conducted in a single center; the etiology of falls in the patients was not determined; and the medications used by the patients were not examined.
Conclusion
The geriatric population is more affected by trauma than other age groups, and trauma-related morbidity and mortality are high among older adults. Older patients presenting with trauma should be closely followed. In our study, falls were the most common cause of geriatric trauma. Potential post-fall complications can be prevented by carefully evaluating older adults at high risk of falls and taking the necessary precautions.
