Multiple Organ Dysfunction in Elderly Trauma
For the first time there are 11 million people aged 65 or over in the UK and the Office for National Statistics suggests that this is the fastest growing age-group nationally. As people live longer, the number of older people suffering traumatic injury is increasing. In those who survive the initial period after major trauma, a significant proportion goes onto develop adverse events such as multiple organ dysfunction (MODS).
MODs occurs as a result of an exaggerated systemic inflammatory response following major tissue trauma, and reports suggest that MODS affects between a third and a half of trauma patients admitted to critical care. Many younger injured people who develop MODS will recover quickly, whereas older patients appear to suffer prolonged organ dysfunction, which is complicated by persistent immunosuppression, infectious episodes and other adverse events. MODS in older people is associated with increased mortality, characterised by late, indolent death. It was not clear from the available international evidence if age-related characteristics or other factors such as frailty affect the development and severity of MODS. The epidemiology, burden and outcomes of MODS in UK trauma systems had not been reported prior to MODET.
MODET (Multiple Organ Dysfunction in Elderly Trauma) was a Pan London Trauma System prospective observational study, funded by the Dunhill Medical Trust. Patients were enrolled from the four Major Trauma Centres (Royal London Hospital, St Marys Hospital, Kings College Hospital and St Georges Hospital) over a two year period.
MODET aimed to:
- Identify the prevalence, severity and patterns of MODS in older patients (compared to younger controls)
- Determine predictors and risk factors of developing MODS for older patients (compared to younger controls)
- Identify age related characteristics that contribute to the development of MODS
- Examine the mode of mortality associated with MODS
- Analyse the relationship between MODS and longer-term recovery and quality of life for older patients (compared to younger controls)
Findings:
During the 18 month study period 1,435 consultees and patients were approached for enrolment. Seventy declined to participate, ten patients died within 24 hours and 39 were transferred for end of life care within 72 hours of admission (of which 32 [82%] were aged ≥65years).
1316 patients consented and one third (434) were aged ≥65 years. Incidence of MODS was high for both age groups (<65 years: 64%, ≥65 years: 70%).
There were few differences in severity, patterns and duration of MODS between cohorts, except for older TBI patients who experienced a prolonged course of MODS recovery (TBI: 9 days vs. No TBI: 5 days, p<0.01).
Frailty rather than chronological age had a strong association with MODS development (Odds Ratio 6.9, [95% Confidence Intervals 3.0-12.4], p<0.001) and MODS mortality (Odds Ratio 2.1 95% Confidence Intervals 1.31-3.38], p=0.02).
Critical care resource utilisation was not increased in older patients but MODS had a substantial impact on mortality (<65 years: 17%; ≥65 years: 28%).
The majority of older patients who did not develop MODS survived and had favourable discharge outcomes (Home discharge ≥65 years NoMODS: 50% vs. MODS: 15%, p<0.01).
Conclusion:
Frailty rather than chronological age appears to drive MODS development, recovery and outcome in older cohorts. The role of TBI in older trauma and prolonged MODS requires further investigation. Early identification of frailty in critical care may help to predict MODS and plan care in older trauma.
PUBLICATION
The primary publication from the MODET study can be found here
Study Documents
Study sites, protocol and flow diagram
Contact
For further information please email Chief Investigator Dr Elaine Cole
