We have analyzed an eleven-year geriatric (defined by age ≥ 55 years) trauma population treated at the national trauma center of Qatar, a Middle Eastern state with nearly 3 million people, with the majority living in urban areas (93–96%). These patients comprise one out of eleven trauma admissions (9.2%), with a male predominance (80%) and a mean ISS of 13. Falls are the leading mechanism of geriatric trauma in Qatar (46%), with one-third happening at home (35.2%), but the road was the leading location of injury (46.5%), and RTIs came in as the second leading MOI (45%). The chest was the most injured region, and one in twelve (8%) of them succumbed to their injuries.

There is no consensus on the age that defines a geriatric population, although 65 years has been the traditional cutoff point [9,10,11,12]. However, many recent reports note significantly higher mortality for trauma patients, starting at ages as low as 45–55 years [4, 9, 11, 24]. “Rather than having a derogatory connotation, the term geriatric represents the statistically significant inflection point in patients’ morbidity and mortality for a given injury compared with a younger patient” [25]. This other point is the rationale for collecting our data a decade earlier than the traditional, most-referred-to cutoff age of 65.

The mortality rate in our study analysis (8%) was lower than that of reports from many Western countries [9, 12, 15, 26, 27]. Mangram et al. reported that a one-year study with small a sample size of 393 patients after the institution of a dedicated geriatric unit (DGU) with a multidisciplinary team led by trauma surgeons compared to an earlier control sample of 280 patients. The majority were blunt injuries related to falls. There was a lower mortality (3.8% vs. 5.7%, p = NS) in those who were treated in the DGU [28]. An earlier National trauma databank-based study over ten years reported that the elderly (> 60 years) have a 5-fold increase in mortality with minor ISS (0–9), whereas they have a 4-fold increase in mortality with major ISS (10–15) [29].

However, closer attention must be paid to the ‘expected’ findings when comparing survivors with non-survivors [Table 5]. Non-survivors are statistically sicker or more severely injured than the survivors. However, mortality, ICU LOS, and ventilator days were comparable between both age groups. Apparently, the significantly higher prevalence of co-morbidities in the older age group is offset by the higher percentage of younger patients with head, chest, and abdominal injuries. Traditional predictors of trauma mortality, like age, co-morbidities, chest, abdominal, and head injuries, and even ISS, should be viewed with a new lens due to the complex interaction of both age and mechanism-dependent factors. Older patients are ‘expected’ to have more co-morbidities and suffer from more complications [29]. Patients from the younger age group, however, are more likely to be victims of the transfer of higher energy from RTIs, ergo incurring more injuries to the head, chest, and abdomen and requiring more intervention. This evidence supports the ‘new’ definition of geriatric trauma because while their paths may differ, all of these patients have similar outcomes. Therefore, all of these trauma patients, 55 years and older, should be selectively cared for by multi-disciplinary teams who will implement clinical trauma protocols that are best suited for this unique trauma population; furthermore, we might consider age as a criterion for level of trauma activation as reported before that activation level impacts outcomes [28, 29] and age of 55 and above is an independent predictor of multiorgan failure [30].

When applying the 5-Factor Modified Frailty Index, clearer patterns of injury emerge. The severely frail (score ≥ 3) are more likely to suffer from low-energy falls from standing at home, while the least frail (score = 0) are victims of high-energy transfer RTIs while on the street. Despite statistically significant differences between physiological parameters, head injuries, complications, and interventions, the mortality rates for the non-frail and the most severely frail were not significantly different [p = 0.49] in Table 7.

In an earlier U.S. report (2008), Geriatric trauma patients, those 65 years and older, comprised 14% of trauma-related ED visits, with an increasing trend [25, 27, 31, 32]; this is projected to reach 20% in 2050 [33]. Florio et al. reported a higher percentage (up to 20%) in Europe [28]. Both are higher than our cohort-reported proportion of 9.2%. Notice that we applied a lower cutoff of 55, which reflects a much lower incidence in our population compared to the rest of the published world data. This low figure may represent an underestimation simply because our data represent only those who needed hospital admission and because the ratio of Qatar’s population is much lower than that of the U.S. or Europe.

Frailty, or the reduced physiological reserve commonly associated with aging, is often linked to a range of comorbid conditions. This relationship is captured by tools such as the modified Frailty Index-5 (mFI-5) used in this study [18]. The modified mFI-5 index used in this study is effective across all trauma patients, regardless of age, though its prevalence and severity increase with older age groups. This corresponds to observed adverse outcomes, including higher rates of mortality, morbidity, longer hospital stays, unplanned events, and non-home discharges, as also reported in other surgical populations like the general surgery studies [31, 32, 34,35,36]; arthroplasty [37], multiple orthopedic trauma [38]; and more recently in the trauma population [19, 39]. Our cohort reflects a common phenomenon, with severely frail patients comprising approximately 25% of the total group.

Qatar’s population is aging like the rest of the world, with [24,25,26, 33, 40,41,42], reflecting better health care and healthier, active lifestyles. In this cohort, we documented a recent increase in both selected age groups, those ≥ 65 and those 55–64 years old. The incidence of injuries per 10,000 has increased among the elderly compared to the younger age group (55–64), making them a particularly high-risk group, conforming to published evidence. The global estimate is that people > 65 will represent a fifth of the world population, especially in developed countries with better life expectancy and care [26, 33, 41, 42].

Interestingly, our data showed a male predominance across the entire age spectrum. This male dominance is well known for younger trauma patients but not for geriatric trauma. On the other hand, the percentage of females in the classic geriatric age group (≥ 65y) is at a near-normal sex distribution. Higher levels of physical activity and a predominance of male drivers could explain the persistent male predominance in the geriatric trauma population, while home falls are more in elderly females [42]. Nevertheless, another possible explanation is that patients with only ‘hip’ fractures, a classic female majority population, are not included in this analysis because they are not admitted to the trauma service or captured in the trauma registry. Nevertheless, previously published local data on hip fractures in Qatar do not support this, as male predominance is also observed in the hip fracture population [43].

The study revealed a near-exclusive blunt mechanism of injury (penetrating was < 0.5%), with most falling from a standing position at ground level. The literature reports the similar pattern. Though with higher percentages [1, 2, 5, 15, 16, 26, 42, 44, 45]. The underlying physiological changes, comorbidities, and treatments may all affect gait stability and balance, putting the elderly at a higher risk for this mechanism even at the ground level and in homes [27, 44,45,46]. Assaults, self-inflicted injuries, and elder abuse were very few, in contrast to a relatively higher percentage in Western data [46, 47].

The home was the most reported location for the injuries, reflecting that most are in post-retirement and partly explaining the absence of the weekend and off-hours effects in this cohort. A similar home location for elder falls dominates reports from the rest of the world [5, 48,49,50,51]. Furthermore, the Al-Ain Hospital in the UAE showed that falls represented 55% of the observed mode of injury and had more falls in females than males [52]. The falling percentage was 47% overall; our lower age limit might explain the lower rate in males and the higher number of females involved in this mechanism (64% compared to 42% males), a finding that compares to the rest of the world. A prior study from the USA showed that the risk of fall increased with age, with an OR 1.52 for age 70–79 and an OR 3.40 for ≥ 80, whereas females fell 1.2 times more [53]. At the same time, the second mechanism was the MVC in a quarter, which is like other international reports [42, 51].

The chest was the most injured region in this cohort; Ferrah et al. reported a similar predominance in chest injuries among elderly trauma patients, who attributed that to the liberal use of computed tomography in recent data compared to historical data [54].

Geriatric injured patients represent 20% of TICU admissions in Spain [53], less than we observed in this cohort (30%). The higher percentage of critical care admissions may be due to our cohort’s higher incidence of TBI and medical comorbidities; it may also reflect more generous admission criteria, leaning toward safety and the fact that the ICU is under the trauma service management and leadership. There was no significant difference between the younger (55 - <65) and ≥ 65y in mortality and other clinical outcomes except for the total hospital LOS, which supports our newly designated cutoff age of 55years going with previously mentioned resources suggesting this new definition for geriatrics [9, 11, 12].

The most common discharge destination was home (81.5%). Around a fifth were discharged to a long-term rehabilitation facility, reflecting that some geriatric trauma patients cannot immediately regain their pre-injury functional status [53]. The relatively low percentage of rehab disposition compared to other higher rates can be partially explained by the lower capture point of 55 and may reflect different social support systems.

This report indirectly reflects the higher cost of caring for this population, considering the higher length of hospital and ICU stay with a frequent need for operative orthopedic fixation in the elderly, the associated comorbidities and their treatments, and the need for rehabilitation and long-term services [11, 51].

Although the retrospective registry data collection was well maintained, this study is not without limitations. The retrospective design, the documentation errors, and the unidentified cofounders may affect outcomes. We only included admitted patients, so the study data does not include those who died at the scene upon arrival to the ED, those discharged after the ED assessment, or those who died after the discharge. We do not routinely document geriatric-specific assessments like the frailty index or futility, pre-injury location, and geriatric trauma outcome score, and our registry lacks functional results at discharge. Although we lack a DGU, we recently instituted a geriatric service consult for all admitted injured patients above 65 years and for a selected group of younger patients (≥ 60). Moreover, data suggest that the modified FI-5 performs well and aligns with more comprehensive tools like the original FI or its modification, the mFI-11; it is easily obtainable from the TQIP database at admission and is simple to calculate. However, it cannot gauge the severity of each item, which represents an inherent limitation and may account for some of the contradictory findings.

One strength of this first report from the state of Qatar, and, to our knowledge, the most extensive description of the Middle East, is that there is sparse literature on this crucial and growing subpopulation at high risk for severe trauma in the region (Arab Middle East). We have used our findings to develop local clinical protocols to help clinicians take better care of these patients and increase their awareness of how age affects their outcomes and disposition. Furthermore, the recommendations for the ACS-COT [55] and others [56,57,58] have galvanized us to form a Geriatric Trauma Care Program within our trauma system. There is excellent potential for providing specialized care with close monitoring to impact mortality, functional outcomes, and associated costs of care.

These findings have also provided evidence for targeted injury prevention initiatives that will better address safety at home for the geriatric population of Qatar. The prevention of falls at home that affect the elderly has been prioritized by the Public Health Department of the Ministry of Public Health as it begins the process of creating national injury prevention guidelines. Similarly, the U.S. Department of Health and Human Services (DHHS) launched an initiative (Healthy People 2030) that identified the prevention of falls in the elderly as a national priority to reduce ED visits from this crucial mechanism [59]. In future perspectives, this work could help regionally investigate this vital problem and contribute to understanding its complexity and implications. We also believe that the age cutoff for geriatric trauma should be 55. There is a need to develop quality indicators, study these patients, and generate robust evidence to inform care and prevention. Lastly, females represented only 17.5% of the study population, which could indicate a gender-biased result; however, this is a real reflection of the gender distribution among injured patients in Qatar [60, 61].