Emergency. 2017; 5 (1): e78 DOI: http://dx.doi.org/10.22037/emergency.v5i1.18497 OR I G I N A L RE S E A RC H Demographics of Fall-Related trauma among the Elderly Presenting to Emergency Department; a Cross-Sectional Study Hamid Reza Morteza Bagi1, Sajjad Ahmadi2∗, Maryam Hosseini3 1. Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran. 2. Emergency Medicine Department, Maragheh University of Medical Sciences, Maragheh, Iran. 3. Faculty of Medicine, Tabriz University of medical Sciences, Tabriz, Iran. Received: August 2017; Accepted: August 2017; Published online: 12 September 2017 Abstract: Introduction: Falling is reported to be the most common cause of mortality due to trauma in individuals over the age of 75 years. The present study is designed with the aim of determining the demographics of fall-related trauma among the elderly presenting to emergency department (ED). Methods: The present prospective cross- sectional study was carried out on all elderly patients ≥ 60 years old presenting to ED of a major referral trauma center in North West of Iran during 1 year. Demographic data, location and height of falling, duration of hospi- talization, trauma severity and in-hospital outcome of the patients were gathered and reported via descriptive statistics. Results: 228 patients with the mean age of 70.96 ± 5.2 years were studied (53.9% female). Most patients were in the 66-70 years age range (32.6%) and had a history of hypertension (22.3%), who had visited following a fall inside the house (69.3%), due to slipping (73.7%), and from a height equal to or less than 2m (71.9%). 6 (2.6%) patients died in the hospital. Mean trauma severity of patients based on ISS, RTS, and TRISS were 10.65 ± 3.95 (3-19), 7.84 ±.21 (1.4-14.5) and 1.66 ±1.31 (-1.49-3.82), respectively. Regarding need for hospitalization, only ISS shows a significant difference between outpatients and inpatients (p = 0.023). Patients who died had a significantly higher trauma severity based on ISS (p < 0.0001) and RTS (p < 0.0001). Conclusion: Based on the findings of the present study, slipping and syncope are the most common causes of falling in the studied elderly that had mostly happened inside the house and from a height less than 2m. Therefore, most patients were in the mild to moderate range of trauma severity. ISS and RTS were significantly higher in the 6 (2.6%) patients who died. Keywords: Trauma severity indices; accidental falls; aged; demography; cross-sectional studies © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Morteza Bagi H, Ahmadi S, Hosseini M. Demographics of Fall-Related trauma among the Elderly Presenting to Emergency Department; a Cross-Sectional Study. Emergency. 2017; 5(1): e78. 1. Introduction I ncrease in life expectancy has led to a rise in the num- ber of elderly individuals all over the world and aging has become one of the most important challenges of public health in various countries. Due to their lower activity, old people are less likely to face injuries but if they get injured they have a higher mortality rate compared to young peo- ∗Corresponding Author: Dr. Sajjad Ahmadi; Department of Emergency Medicine, Amiralmomenin Hospital, North Moallem _ Nova Road, Maragheh, Iran. Postal code: 55391-41416 E-mail: dr.ahmadi96993@gmail.com Tel: 009837241597 ple because of disorders in physiological functions and body systems as well as presence of other medical problems. Cur- rently, trauma is the 5th cause of death among elderly peo- ple and falling is the most common cause of mortality due to trauma in individuals over the age of 75 years (1-3). In total, falling leads to about 40% of deaths due to trauma in old people (4). 20% to 28% of the elderly in Iran experience falling, and fear of falling leads to limited activity in 30% of old people (5, 6). Falling makes up 10-15% of emergency de- partment (ED) visits (4, 7, 8) and its outcome in old people varies from complete recovery to death. Duration of hospi- talization among the elderly also ranges from a few days to being permanently crippled (9-15). It seems that planning on This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Morteza Bagi et al. 2 prevention of the accident is the best and most cost effective measure in this regard. However, any planning requires in- formation on the epidemiologic characteristics and the situ- ation of the subject of planning. Therefore, the present study is designed with the aim of determining the demographics of fall-related trauma among the elderly presenting to ED. 2. Methods 2.1. Study design and setting The present prospective cross-sectional study was carried out on elderly patients (≥ 60 years old) presenting to ED of Imam Reza hospital, Tabriz, Iran, following trauma caused by falling, from April 2015 to March 2016 (during 1 year). This hospital is one of the major referral trauma centers in North West of Iran. The study was approved by the ethics com- mittee of Tabriz University of Medical Sciences and the re- searchers adhered to principles of Helsinki declaration and keeping patient data confidential. Oral consent was obtained from the patients for participating in the study. 2.2. Participants All patients, 60 years old or older, who had visited the trauma unit of the mentioned ED during the study period follow- ing falling and were willing to participate were included via consecutive sampling. Patients who had died before arriving at the ED or were discharged against medical advice (71 pa- tients), were excluded from the study. 2.3. Data gathering A checklist consisting of baseline characteristics (age, sex, underlying illnesses), location of falling, height of falling, duration of hospitalization, data required for calculation of trauma severity based on Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and injury severity score (TRISS), and in-hospital mortality was filled for all the pa- tients. The person in charge of data gathering and calcula- tion of trauma severity was a senior emergency medicine res- ident, under supervision of the corresponding attend. - ISS is calculated based on the severity of trauma to face, head, extremities, chest, and abdomen (13). If this score is equal to or higher than 16, the patient is deemed multiple trauma (14, 15). An ISS lower than 7, indicates mild physical injury, 7-12 moderate injury and more than 12 shows severe injury. - In RTS, trauma severity is calculated based on level of con- sciousness, systolic blood pressure and respiratory rate and is also used for triage of the patients (16). - TRISS indicates the prognosis of trauma patients and acts based on the physiologic and anatomic status of the pa- tient on admission to ED. This system of determining trauma severity is in fact a combination of ISS and RTS (17). Table 1: Baseline characteristics of the studied patients Variable Number (%) Sex Male 105 (46.1) Female 123 (53.9) Age (year) 60 – 65 39 (17.1) 66 – 70 74 (32.6) 71 – 75 64 (28.1) 76 – 80 45 (19.7) > 80 6 (2.6) Underlying disease Hypertension 51 (22.3) Ischemic heart disease 22 (9.6) Osteoporosis 23 (10.1) Diabetes 12 (5.2) Neurologic disease 12 (5.2) None 125 (54.8) Duration of hospitalization Outpatient 88 (38.6) < 5days 98 (43.0) > 5 days 42 (18.4) Table 2: Accident characteristics of the studied patients Variable Number (%) Location of fall Outside the house 70 (30.7) Bathroom 47 (20.6) Kitchen 45 (19.7) Steps 34 (14.9) Other 32 (14.0) Cause of fall Slipping 168 (73.7) Altered level of consciousness 51 (22.4) Other 9 (3.9) Height of fall (m) ≥ 2 134 (71.9) > 2 49 (21.5) Unknown 15 (6.6) 2.4. Statistical Analysis Data were analyzed by SPSS version 21. Quantitative data are reported as mean and standard deviation and qualitative ones are reported as frequency and percentage. To compare 2 groups, t-test and chi square tests were used and to calcu- late trauma severity based on the mentioned indices, med- ical calculator was used. Significance level in analyses was considered to be less than 0.05. 3. Results 3.1. Baseline characteristics 228 patients with the mean age of 70.96 ± 5.2 years were stud- ied (53.9% female). Tables 1 and 2 depict the baseline char- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e78 Table 3: Comparison of mean trauma severity between inpatients and outpatients as well as dead and alive patients based on ISS, RTS and TRISS indices Variable Trauma severity (mean ± standard deviation) ISS P value RTS P value TRISS P value Hospitalization Outpatient 9.9 ± 3.41 0.023 7.96 ± 2.42 0.295 1.52 ± 1.40 0.453 Inpatient 11.12 ± 4.20 7.64 ± 1.83 1.65 ± 1.23 Mortality Alive 10.55 ± 3.92 0.0001 7.86 ± 2.23 0.0001 1.60 ± 1.31 0.406 Dead 20.66 ± 6.68 13.50 ± 1.00 2.05 ± 0.91 acteristics of the patients and fall characteristics. Accord- ing to these results, most patients were in the 66-70 years age range (32.6%) and had a history of hypertension (22.3%), who had visited following a fall inside the house (69.3%), due to slipping (73.7%), and from a height equal to or less than 2m (71.9%). 6 (2.6%) patients died in the hospital and oth- ers were discharged from ED (38.6%) or from surgery depart- ment after a few days of hospitalization (61.4%). 3.2. Trauma severity Mean trauma severity of patients based on ISS, RTS, and TRISS were 10.65 ± 3.95 (3-19), 7.84 ±.21 (1.4-14.5) and 1.66 ±1.31 (-1.49-3.82), respectively. Trauma severity based on ISS was less than 7 in 60 (26.3%) patients, between 7 and 12 in 98 (43.0%) and over 12 in 70 (30.7%) injured patients. Table 3 compares mean trauma severity of the patients based on the 3 mentioned indices between patients who survived and those who died as well as outpatients and inpatients. As can be seen, only ISS shows a significant difference between out- patients and inpatients (p = 0.023). In addition, patients who died had a significantly higher trauma severity based on ISS (p < 0.0001) and RTS (p < 0.0001). 4. Discussion Based on the findings of the present study, slipping and syn- cope were the most common causes falling in the studied el- derly, who had mostly fallen from a height less than 2m and inside the house. Most patients were in the mild to moder- ate range of trauma severity. ISS and RTS were significantly higher in the 6 (2.6%) patients who had died. Statistics show that each year on average 28 to 35% of the el- derly over 60 years old fall and in those over the age of 70 years this rate rises to 32 to 42% and in half of the cases, it happens recurrently. This emphasizes the necessity of tak- ing preventive measures and applying plans to prevent this from happening again (18, 19). In a study carried out in 2004 by Schoenfelder et al., falling rate was higher in women com- pared to men (82.10% versus 17.90%) (4). Swanenburg et al. in 2010 also reported the higher prevalence of this problem in women (83% vs. 17%) (20). However, in the present study affected men and women were relatively equal. In Corsinovi et al. study on 620 elderly patients that were treated following a fall, no correlation was found between age and falling rate (14). Regarding quantitative trauma severity, findings showed that mean ISS was 10.67 and most patients had moderate injury. In a study by Zare et al. evaluating trauma in emergency pa- tients whose mean age was 29.60 years, the results showed that quantitative trauma severity was 16.98, which can show the higher severity of trauma and risky behaviors in young people compared to the elderly (21). In 2009, Hariharan et al. evaluated the clinical value of TRISS in 326 trauma pa- tients. Mean survival rate in adults was reported to be 98.50% in the study, which indicates 1.5% mortality in these patients. These researchers concluded that TRISS was not so accurate in predicting the prognosis of trauma patients (22). In ad- dition in 2004, Murlidhar et al. evaluated TRISS in a study of trauma patients’ outcome and reported that the predicted mortality rate in patients by this index was 10.89%. This rate was 61.60% and 16.60% for RTS and ISS, respectively but the real mortality rate was 21.26%. The researchers reported the cause of this vast difference to be the higher age of the pa- tients studied compared to other studies (23). Meanwhile, in another study conducted by Mitchell et al. in 2007 in Canada the ability of indices such as TRISS to predict the prognosis of trauma patients were evaluated and shown to be acceptable (24). The obtained results regarding trauma severity indices showed that TRISS did not correlate with hospitalization sta- tus and mortality of the patients; however, ISS correlated with hospitalization status and both ISS and RTS correlated with mortality of the patients. Studies show that falling happens following a complex inter- ference of risk factors that affect the health status of an el- derly individual, directly or indirectly. These factors are cat- egorized in 4 groups: biological, behavioral, environmental, and socioeconomic factors (18). Although in this study, these factors were not evaluated individually, the evidence shows that evaluating and controlling these factors is of great im- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Morteza Bagi et al. 4 portance. 5. Limitation Small sample size, being single-centered and the evaluated variables being few could be counted as the limitations of this study. However, considering the limited number of these studies in Iran, the findings of this study can help in under- standing the conditions ruling trauma due to falling in the elderly. 6. Conclusion Based on the findings of the present study, slipping and syn- cope are the most common causes of falling in the studied elderly that had mostly happened inside the house and from a height less than 2m. Therefore, most patients were in the mild to moderate range of trauma severity. ISS and RTS were significantly higher in the 6 (2.6%) patients who died. 7. Appendix 7.1. Acknowledgements All the ED staff members are acknowledged for cooperating during the project. 7.2. Author contribution All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. 7.3. 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