Keywords
old aged - neurotrauma - India - severity - mortality - traumatic brain injury - women
Introduction
Aged population is rapidly growing in both developed and developing countries.[1]
[2]
[3] In India drastic improvements in public health and medical advance in the prevention of many diseases has led to increase in percentages of aged population. The size of old-aged population has risen from 12.1 million (5%) in 1901 to 77 million (7.4%) in 2001.[2] As per National Commission on Population 2011, the senior citizen accounts for 8.3% of total population.[3] Based on the reports from the United Nations Population Fund and Help Age International, the number of old-aged population will shoot up to 360% that is expected to increase to 323 million, constituting 20% of total population by 2050.[3] Indian has already tagged under aging nations as per 2011 census. Aging is chronic issue and it will become more severe in next decades. Old aged are more vulnerable to communicable diseases (CD) as well as noncommunicable diseases (NCD). Trauma threats in last few decades of life have made them dependants in all respects, physical, financially, etc.
The growth of aged population has become an increasing problem and presents a challenge to the present health care system. In fact, neurotrauma is one of the leading causes of neurologic disability in our country.[4] Age is one of the most significant factors in prediction of outcome after head injury.[5]
[6]
[7]
[8]
[9]
[10] Increasing age with decreased physiologic reserve, diminished metabolic, and hormonal response are well-recognized risk factors for poorer outcomes after head injury.[5]
[6] Despite increased and adverse outcomes among brain injuries in old aged, very little epidemiologic information is available from our country. In the present study, we aim to describe the pattern of injuries and factors that determine outcome among neurotrauma patients older than 60 years.
Methods
Towards Improved Trauma Care Outcome (TITCO) is prospective observational trauma database collected from four Indian government hospital was considered in this study. TITCO data was collected for the period from October 1, 2013 to September 30, 2015. Patient details of trauma cases were recorded by trained data collectors at each pre-identified centers. For the present study, data of trauma patients aged 60 years or older were considered. In India old-aged or senior citizen means any person who has attained 60 years or above as per National Policy on Older Persons, 1999, and also as per Maintenance and Welfare of Parents and Senior Citizens Act, 2007.[2]
[3] The demographic characteristics, trauma mechanisms, trauma severity scores, and outcome were analyzed. Patients in productive age group between 19 and 59 years are compared with old-aged age group.
Statistical Analysis
Statistical computations were performed using SPSS version 24.0 (SPSS Inc., Chicago, IL, United States) for Windows and Microsoft Excel version 16. Descriptive statistics was used to report the percentages, proportions, and frequencies of demographic and outcome variables. The chi-square test was used for comparisons of the means and to test for diagonal table analysis. p Values < 0.05 were considered significant.
Results
The number of trauma patients' data collected during study period was 16,047. A total of 1,629 (10.2%) of these were aged 60 years or older. Mean age was 68.2 ± 7.6 years (60–97 years). Approximately 1,150 were (71%) men and 479 were (29%) women. Falls was most common cause of head injury accounting for 860 (53%), followed by road traffic accident (RTA) 490 (30%). Approximately 1,226 (75%) of patients were bought by ambulance. Mean Glasgow coma scale (GCS) was 11.01. There was statistically significant (p = < 0.0001) difference between GCS of dead and survived old aged with an average of 7.94 and 12.68, respectively. About two-third 1,136 (70%) of patients underwent computed tomographic (CT) scan. Approximately 435 (27%) of patients underwent emergency surgery for blood evacuation. For details refer [Table 1].
Table 1
Demographic, severity, and investigation details of old-aged TBI patients
|
Variables
|
Total n (%)
|
|
Sex
|
|
Male
|
1,150 (71)
|
|
Female
|
479 (29)
|
|
Injury mechanism
|
|
Assault
|
52 (3.5)
|
|
Burns
|
70 (4.5)
|
|
Falls
|
860 (53)
|
|
Railway
|
41 (2.5)
|
|
RTA
|
490 (30)
|
|
Pedestrian
|
61 (3.5)
|
|
Others
|
49 (3)
|
|
Transport mode
|
|
Ambulance
|
1,226 (75)
|
|
Carried by man
|
3 (0.2)
|
|
Police
|
77 (4.8)
|
|
Private car
|
130 (8)
|
|
Auto
|
167 (10)
|
|
Not available
|
26 (2)
|
|
Glasgow coma scale[a]
|
|
Mild
|
921 (56)
|
|
Moderate
|
259 (16)
|
|
Severe
|
449 (28)
|
|
Computed tomography scan
|
|
Done
|
1,136 (70)
|
|
Not done
|
493 (30)
|
|
Brain surgery
|
|
Done
|
435 (27)
|
|
Not done
|
1194 (73)
|
|
Deaths
|
588 (36)
|
Abbreviations: RTA, road traffic injuries; TBI, traumatic brain injury.
a Data not available for 216 (13%) patients.
Approximately 588 (36%) of old-aged patients expired. In 8th (men 37 vs. women 46%) and 10th (men 33 vs. women 43%) decades, frequency of women deaths is more than that of men ([Fig. 1]). Adverse physiologic findings were present in 105 (6%) for systolic blood pressure (< 90 mm Hg), 261 (16%) for tachycardia (> 100 beats/min), 140 (9%) for lesser hemoglobin level (< 10 mg/dL), 19 (1%) for tachypnea (> 20 cycles/min), and 16 (1%) for lesser blood glucose level (< 70 mg/dL). [Fig. 2A], [B] shows outcome details (alive or death) during various days and months, respectively. The outcome in different days of a week and months of a year is not statistically significant.
Fig. 1 Distribution of outcome among men and women in different age groups.
Fig. 2 Percentages of outcome (alive or death) during various days of a week (A) and months of a year (B).
From the same TITCO data, we analyzed 19 to 59 years (productive age group) of age group that accounted for 10,621/16,047 (66%). Mean age was 48.8 ± 4.7 (18–59 years). There was statistically significant difference between the mortality of old aged and productive age group. Also, the deaths among sex (male and female), injury cause (RTA and fall], GCS (moderate and severe), requirement of CT scan, and surgery differed significantly between the two groups. See [Table 2] for details.
Table 2
Comparison of death rates among older (≥ 60 years) versus productive age groups (19–59 years) among different variables of TBI patients
|
Older age group
n (%)
|
Productive age group
n (%)
|
p Value
|
|
Total deaths
|
588/1,629 (36)
|
2,534/10,621 (24)
|
0.0001
|
|
Sex
|
|
Male
|
409/1,150 (36)
|
1,955/77,548 (25)
|
0.0001
|
|
Female
|
179/479 (37)
|
552/1,917 (29)
|
0.02
|
|
Injury cause
|
|
RTA
|
200/490 (41)
|
1,320/4,350 (30)
|
0.0001
|
|
Falls
|
262/860 (30)
|
552/2,429 (23)
|
0.0001
|
|
Glasgow coma scale
|
|
Mild
|
108/921 (12)
|
575/5,695 (10)
|
0.14
|
|
Moderate
|
74/259 (29)
|
253/1,284 (20)
|
0.0002
|
|
Severe
|
306/449 (68)
|
1,372/2,448 (56)
|
0.0001
|
|
Computed tomography scan
|
|
Done
|
379/1,136 (33)
|
1,446/7,654 (19)
|
0.0001
|
|
Brain surgery
|
|
Done
|
136/435 (31)
|
613/2,583 (24)
|
0.001
|
Abbreviations: RTA, road traffic accident; TBI, traumatic brain injury.
Discussion
TBIs in old aged vary from countries to countries. A study from Bursa city reported 3.9%,[11] China reported 19.1%,[12] and data from 15 states of the United States reported 155.9 per 100,000 populations.[13] A single institutional study from our country reported that 8.8% of TBI patients belong to old-aged age group.[14] The percentages of TBI in old aged reported by various studies are specific to cause of injury such as falls, pedestrian, etc. The present study reports 10.2% of TBIs in old aged due to any mode of injuries. In our country, old aged people account for 8.3% of total population and 10% of total TBIs. The rapid growth of old-aged population and their TBIs caution the Indian health care system for better strengthening and improving or else its consequences are likely to take it by surprise.
To our knowledge, the present study analysis is the largest report of geriatric TBI population from our country. Our results report that men are 2.4 times more affected than women, but the death rates are almost equal in both sexes. Interestingly in 8th and 10th decades, percentage of women deaths is greater than that of men ([Fig. 1]). An epidemiologic study from our country reported that female TBIs have significantly higher number of severities and deaths as compared with male TBIs, especially in old-aged age group.[15] A prospective study from Scotland reported that TBI-induced death at 1-year follow-up among females (13.5%) was more than males (8.5%).[16] With increasing age, women are more prone to adverse outcome, though their total population is less than men.
Falls are the most common mechanism of brain injury in old-aged population followed by RTAs.[9]
[17] In developed countries such as the United States and United Arab Emirates, the falls are leading cause of TBI among old-aged patients, accounting for 51 and 55%, respectively.[9]
[17] RTAs are the second most common mechanism of brain injuries accounting for 9% in the United States[9] and 32% in United Arab Emirates.[17] Our study results are consistent with findings from developed country where falls are major cause (53%) followed by RTAs (30%). However, deaths are more among RTAs (41%) than falls (30%), in our study. The injuries due to RTA will be much more severe than falls. The old-aged patients are more susceptible for RTAs because of associated medical conditions before injury and decreased body functioning as an aging process.[9]
[13]
Our study analysis reports almost same percentage of old-aged patients (70%) and productive age group (72%) require CT scan for any abnormal brain findings as consequence of injury. However, the deaths are almost twice among old aged as compared with productive age group who have undergone CT scan (old-aged: 33%, productive age: 19%, p = 0.0001). Studies have reported that old-aged patients require CT scan in approximately 77 to 83% of total TBIs.[14]
[18] Our study reports that 27% of old-aged patients required surgery for evacuation of intracranial hematoma. Studies report 20 to 25% of intracranial brain surgeries for old-aged TBI patients.[14]
[19] A single institute study from Newark, United States, reported that 164/823 (20%) of old-aged patients require brain surgery.[19] Our study results report that percentage of deaths among old-aged patients (31%) who had undergone brain surgery is significantly (p = 0.001) higher than productive age deaths after surgery (24%).
The present study reports that old-aged patients had 44% of moderate to severe injury as per GCS, which is more than productive age group 35%. Deaths among old-aged population in moderate to severe GCS were more and statistically significant (p = 0.0001) than productive age group ([Table 2]). The old-aged death in our study group is 36%, which is higher than that in productive age group (24%), which is significant (p = 0.0001). The mortality among old-aged trauma varies between 10 and 34%.[11]
[14]
[20] Old-aged population is at risk for greater severity of injury and deaths after TBI.[7]
[8]
[9]
[10] The possible reasons may be anatomical changes such as the dura more adherent to the skull, cerebral atrophy with greater intracranial volumes, and also routine management for associated comorbid conditions.[9]
[10]
[12]
[21] Increase in old-aged population and greater mortality among old-aged TBI make this group for special attention in management aspects by clinicians and framing preventive measures by stakeholders.
Our study has so few important limitations in data source that no follow-up details are available. The study demonstrates that in-hospital mortality has an adequate measure of outcome. The study is hospital based where population-based study would have been better for generalization. Detailed variables for TBI are limited, but the basic details are provided.
