ORIGINAL ARTICLE
Characteristics of elderly patients presenting to theemergency department with injury
William Ng,* Seitaro Fujishima, Masaru Suzuki, Keiji Yamaguchi, Katsunori Aoki, Shingo Hori andNaoki Aikawa
Department of Emergency and Critical Care Medicine, School of Medicine Keio University, Tokyo, Japan(Received for publication on November 27, 2001)

Abstract. hBackgroundi In Japan, emergency departments (ED) receive a large proportion ofelderly patients each year. As such, injuries in the elderly are a common reason for presentation
to the ED. Knowledge about the characteristics of injuries presenting to the ED would be invaluable in devising strategies to prevent injury in the elderly. hObjectivei To analyze the characteristics of injuries in the elderly presenting to the ED and compare them with those of the younger population. hSettingi The ED at Keio University Hospital, a large inner city teaching hospital located inTokyo. hMethodi A retrospective analysis of data extracted from the ED database of the Keio University Hospital. Information regarding patients aged 65 years or above presenting with injury was
analyzed and compared with those aged less than 65 years. Prehospital triage by emergency personnel
was adopted as the severity of patients, namely ‘‘life-threatening’’ or ‘‘non life-threatening’’. hResultsi
20% of all ED presentations of elderly patients were injury related compared to 39% of non-elderly.
Compared to the non-elderly, elderly patients presenting to the ED with injury were more likely to befemale, sustained injury from trauma unrelated to motor vehicle accidents (MVA) and requiring hospital admission as a result of ‘‘non life-threatening’’ injuries. They were less likely to have injuries from
MVA or burns. The number of ‘‘life-threatening’’ injury cases and mortality in both groups were similar. There was evidence that the number of ED presentations relating to injury is increasing in theelderly population. hConclusioni Elderly injury patients are a distinct group with distinctive demographics, mechanism of injury and outcomes. This information would be useful in the planning of
injury prevention programs, with particular emphasis on elderly females and MVA-unrelated trauma.
(Keio J Med 51 (1): 11–16, March 2002)
Key words: elderly, injury, prevention, emergency department

often regarded as a disease of the young, the repercussions of injury are much more signiﬁcant in the elderly.
Injuries in the elderly result in an increased rate of
hospital admission,4 greater length of stay,5 as well asa higher mortality and morbidity rate compared toyounger age groups.6,7 Whilst the elderly only constitute 14% of the population in the United States, theyutilize one-third of all trauma healthcare resources.3
The magnitude of this problem is expected to increaseas the aging population continues to grow.
Injury is a common reason for presentation to the
ED. However, little is known about the epidemiology
of injuries in older people that present to the ED.

Introduction
The growing elderly population will have a signiﬁcant impact on the health care sector world-wide. It isestimated that by the year 2050, the population above
60 years in developed nations will double, whereas
in underdeveloped nations this ﬁgure will triple.1 In
Japan, whose citizens enjoy a relatively high life expectancy, the ratio of elderly people is expected to reachthe highest level in the world.2
Injuries are a serious health problem for elderly
people. They represent the seventh leading cause ofdeath in patients over 65 years.3 Although injury is

Reprint requests to: Dr. Seitaro Fujishima, Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35
Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan* An exchange medical student from University of Tasmania, Australia
1112

Ng W, et al: Elderly patients with injury in ER

Studies on the characteristics of injuries in the elderly
would be invaluable in identifying priorities for further
research and intervention. Here, we present our ﬁndings of the pattern of injuries in elderly patients that
presented to the ED of a large urban teaching hospitalin Tokyo.
MethodKeio University Hospital is a major private teaching
hospital located in inner Tokyo. As a tertiary referral
center, it receives a wide variety of emergency casesby ambulance each year. As such, Keio University
Hospital provides an appropriate setting to examine thedemographics and statistical information regarding
injuries sustained by elderly patients.
To facilitate research purposes, an ongoing computerized database has been established since 1988 tocollect information on ED admissions to the hospital.
The database holds individual records of each patientthat presented to the ED. For each patient presenting
to the ED, a predetermined dataset was recorded fromthe medical record. This includes demographic information such as name, age and gender, as well as thepresenting complaint, mode of arrival, triage, diagnosis
and outcome. The data entry is completed by the consulting doctor responsible for the patient. Thus, thedatabase is a rich source of information with respect toinjury epidemiology and surveillance.
A retrospective analysis was performed using theabove-mentioned ED database of the Keio University
Hospital. Analysis was conducted on ﬁve years of data:
January 1996 to December 2000. For purposes of comparison, ‘‘elderly’’ persons were deﬁned as those aged
65 or above, whilst patients less than 65 years werereferred as ‘‘non-elderly’’. Injuries were arbitrarily divided into those arising from motor vehicle accident(MVA), those not related to MVA, burns and selfinﬂicted injuries.
In this study, elderly and non-elderly patients presenting with injury were compared using different
parameters. These include the number of injury presentations in each group over the ﬁve-year study period, gender distribution, nature of injury, severity of
injury determined by prehospital personnel and shortterm outcomes of these patients. Data were analyzed bya Chi-square test. Signiﬁcance was accepted at p < 0.05.
Results
During the ﬁve-year period from 1996 to 2000, a
total of 17,578 patients presented to the ED at Keio
University Hospital (Table 1). Just over one-third ofthese presentations (35.5%) were injury-related. In
total, there were 3,968 patients aged 65 years or above,

Table 1 Comparison of the Number of Elderly and Non-elderly
Patients Presenting with Injury
Year

1996

1997

1998

1999

2000

Total

Total patients 3,373
3,364
3,487
3,563
3,791
17,578
(%)
(100)
(100)
(100)
(100)
(100)
(100)
Total injuries
1164
1219
1208
1265
1349
6,205
(%)
(34.5)(36.2)(34.6)(35.5)(35.6)(35.3)--------------------------------------------------------------------------------Elderly*
787
759
776
776
870
3,968
(%)
(23.3)(22.6)(22.3)(21.8)(22.9)(22.6)
With injury
125
148
180
163
197
813z
(%)
(3.7)
(4.4)
(5.2)
(4.6)
(5.2)
(4.6)
--------------------------------------------------------------------------------2,586
2,605
2,711
2,787
2,921
13,610Non-elderlyy(%)(76.7)(77.4)(77.7)(78.2)(77.1)(77.4)
With injury
1,036
1,070
1,021
1,066
1,141
5,334
(%)
(30.7)(31.8)(29.3)(29.9)(30.1)(30.3)* Elderly: Persons aged 65 or above. y Non-elderly: Persons aged lessthan 65. z Incidence of injury in the elderly was signiﬁcantly less in theelderly compared to the non-elderly (813 injury cases among 3,968
elderly patients ¼ 20%, 5,334 injury cases among 13,610 non-elderly
patients ¼ 39%, odds ratio 0.40 [95% CI 0.37–0.43]).

Table 2 Comparison of Injury and Non-injury Related Presentations
to the ED between 1996–1997 and 1999–2000
No. in1999–2000(%)

No. in1996–1997(%)

Odds ratio(95% CI, p value)

Elderly
1,646 (100) 1,546 (100)
Injury related
360 (21.9)
273 (17.7) 1.31
presentation(1.10–1.56, p F 0.003)--------------------------------------------------------------------------------Non-elderly
5,708 (100) 5,191 (100)
Injury related 2,207 (38.7) 2,106 (40.6) 0.92
presentation(0.85–0.997, p F 0.04)

comprising approximately 23% of all patients presenting to the ED during the study period. Of these 3,986
elderly patients, 813 (4.6%) presented to the ED withinjury. Thus, it can be seen that around 20% of all ED
presentations of elderly patients were injury related.
With respect to non-elderly patients, i.e. those aged lessthan 65 years, there were 13,610 presentations to the
ED in the ﬁve-year period with 5,334 (30.3%) cases of
injury recorded. Thus, injury represented 39.2% of all
emergency presentations in the non-elderly group. It
was found that the occurrence of injury was signiﬁcantly
less in the elderly than the non-elderly (odds ratio; 0.40,
95% CI; 0.37–0.43).
Trends in the number of injury-related presentations
were examined for the study period (Table 2). In theinterval between 1996 and 1997, there were 273 casesof injury-related presentations in the elderly group,
making up approximately 17.7% of all elderly ED

Keio J Med 2002; 51 (1): 11–16

13

Table 3 Gender Distribution of Elderly and Non-elderly Patients
Presenting with Injury to the ED

Elderly (%)
Male (%)

Injuryrelated

Not injuryrelated

813 (100)
376 (46.2)

3,155 (100)1,749 (55.4)

Table 4 Nature of Injury Presentations to the ED in the Elderly andNon-elderly Populations

Odds ratio(95% CI, p value)

0.69 (0.59–0.81,
p H 0.0001)--------------------------------------------------------------------------------Non-elderly (%)
5,334 (100)8,276 (100)Male (%)
3,610 (67.7)
4,425 (53.5)
1.82 (1.69–1.95,
p H 0.0001)

presentations in the two-year period. In comparison,
360 cases of injury were documented in the interval
between 1999 and 2000, accounting for 21.9% of allelderly ED presentations. This represented a statistically signiﬁcant increase in the number of injury-relatedpresentations to the ED in the elderly (odds ratio; 1.31,
95% CI; 1.10–1.56). Subsequent analysis of the nonelderly group revealed a decrease in the number of
injury-related presentations to the ED (odds ratio;
0.92, 95% CI; 0.85–0.997) between the periods 1996–
1997 and 1999–2000.
The gender distribution of injury-related presentations was also examined (Table 3). Of the 813 elderly
patients who presented with injury during the ﬁve-year
study period, 437 (57.8%) patients were women compared with 376 (42.2%) men. This represented a significant difference in the proportion of female and maleelderly patients presenting with injury (odds ratio; 0.69,
95% CI; 0.59–0.81). In the non-elderly group, 3,610(67.7%) men and 1,724 women (32.3%) were recordedin the study period, out of a total of 5,334 injury-relatedpresentations. Thus, there were a signiﬁcantly greater
proportion of males than females presenting with injury
in the non-elderly population (odds ratio; 1.82, 95% CI;
1.69–1.95).
The nature of the injuries sustained was subsequently
analyzed with respect to the two study groups (Table4). In the elderly group, MVA-unrelated trauma was
the main cause of injury, with a total of 587 cases during
the ﬁve-year period (72% of all injuries in the elderly).
MVA was responsible for 172 cases of injury, making
up 21% of injuries in the elderly. Deliberate self-injury
contributed to 39 injury-related presentations, whilst 15
cases of burns were recorded. These modes of injury
represented approximately 5% and 2% of all cases of
injury in the elderly respectively.
In comparison, the principal reason for injury presentation to the ED in the non-elderly group was MVA.
There were 3,015 cases of MVA, accounting for approximately 57% of all injuries sustained by non-elderly
patients. MVA-unrelated trauma contributed to 2,106
cases of injury (39% of all injuries). Deliberate self-

No. of patients (%)
Total no. of injuries

Elderly*No. (%)

Non-elderlyy
No. (%)

3,968 (100)813 (20.5)

13,610 (100)5,334 (39.2)

Statistics
Odds ratio (95%
CI, p value)

0.40 (0.37–0.43,
p H 0.0001)--------------------------------------------------------------------------------MVA*
172 (4.4)
3,015 (22.2)
0.16 (0.14–0.18,
p H 0.0001)
MVA-unrelated
587 (14.8)
2,061 (15.1)
0.97 (0.86–1.08,
p ¼ 0.61)
Burns
15 (0.4)
94 (0.7)
0.55 (0.32–0.94,
p F 0.04)
Self-injury
39 (1.0)
164 (1.2)
0.81 (0.57–1.16,
p ¼ 0.29)* MVA: Motor vehicle accident.

Table 5 Patients with Injury Considered as ‘‘Life-threatening’’(Third Level) by Emergency Personnel at Pre-hospital Setting

Total no. of patients‘‘life-threatening’’
No. of injuries‘‘life-threatening’’*

ElderlyNo. (%)

Non-elderly
No. (%)

Statistics
Odds ratio (95%
CI, p value)

3,968

13,6102.62 (2.19–3.14,
p < 0.0001)

199
813 (100)

269
5334 (100)

12 (1.5)

97 (1.8)

0.81 (0.38–1.72)* Life-threatening: Patients considered by emergency personnel in
pre-hospital setting to be at high risk of death and needing urgent
medical attention (third level).

injury and burns had a relatively low occurrence. There
were 164 cases of self-injury and 94 cases of burns contributing 3% and 1.8% to injury related presentations
to the ED respectively. Statistical analysis of the injuries
between the elderly and non-elderly group revealed asigniﬁcantly greater number of MVA in the non-elderly
than elderly group (odds ratio; 0.16, 95% CI; 0.14–0.18)
as well as burns (odds ratio; 0.55, 95% CI; 0.32–0.94).
MVA-unrelated trauma and self-injury did not differ
signiﬁcantly between the two groups.
The number of patients triaged as ‘‘life-threatening’’by emergency personnel in the pre-hospital setting
was also determined (Table 5). In the ﬁve-year study
period, 12 cases were triaged as ‘‘life-threatening’’ inthe elderly group. Thus, injury was responsible for 6.0%of the total number of severe cases in the elderly. In the
non-elderly group, there were a total of 97 severe cases
due to injury. This was approximately 36% of all ‘‘lifethreatening’’ cases in the non-elderly. Comparison of

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Table 6

Ng W, et al: Elderly patients with injury in ER
Short-term Outcomes of Injury Presentations to the ED
ElderlyNo. (%)

Non-elderly
No. (%)

Statistics
Odds ratio (95%
CI, p value)

Total no. of injuries
813
5,334
--------------------------------------------------------------------------------‘‘life-threatening’’
12 (100)
97 (100)
Death in ED
3 (25.0)30 (30.9) 0.74 (0.18–2.97,
p ¼ 0.75)
Hospitalized
9 (75.0)67 (69.1) 1.34 (0.34–5.22,
p ¼ 0.86)
Discharged from ED
0 (0.0)0 (0.0)--------------------------------------------------------------------------------‘‘non life-threatening’’
801 (100) 5,237 (100)Death in ED
4 (0.5)18 (0.3)
1.46 (0.49–4.36,
p ¼ 0.50)
Hospitalized
60 (7.5)
159 (3.0)
2.57 (1.91–3.47,
p H 0.0001)
Discharged from ED 737 (92.0) 5,060 (96.6) 0.40 (0.30–0.54,
p H 0.0001)

the number of ‘‘life-threatening’’ cases revealed no statistically signiﬁcant difference between the two groups(odds ratio; 0.81, 95% CI; 0.38–1.72).
Lastly, the short-term outcome of injury presentations to the ED was examined (Table 6). In elderly
patients who were injured and triaged as ‘‘lifethreatening’’ (n ¼ 12), 25% died in the ED whilst 75%
were hospitalized. In the non-elderly, 30.9% of patientstriaged as in ‘‘life-threatening’’ condition (n ¼ 97) diedin the ED and 69.1% were hospitalized. Most of thepatients who died in the ED were in the condition ofcardiopulmonary arrest on arrival. There was no statistical difference between the elderly and non-elderly inthe number of deaths in the ED or admissions as a result of ‘‘life-threatening’’ injury.
In the remaining elderly patients who presented with‘‘non life-threatening’’ injury (n ¼ 801), 0.5% (n ¼ 4)
died in the ED whilst 7.5% (n ¼ 60) were hospitalized.
Although the four patients were undertriaged by the
emergency personnel, the majority of elderly patientswith ‘‘non life-threatening’’ injury were discharged fromthe ED. This was also true in non-elderly patients, with
96.6% discharged from the ED, whilst 0.3% and 3.0%
died in the ED or were hospitalized respectively. The
proportion of elderly patients hospitalized as a resultof non-threatening injury was signiﬁcantly greater than
the non-elderly group (odds ratio; 2.57, 95% CI; 1.91–
3.47).
Discussion
As the population of the developed world ages,
injury to the elderly will become an increasingly important public health issue. Deterioration in sensory

perception, weakness, poor coordination and balance
predispose the elderly to injury.8 Once they have sustained an injury, their mortality rate is markedly greaterthan that of the young.6,7,9 Their functional capacity
could be adversely affected by injury, leading toincreased dependency and decline in quality of life.
Thus, injury has been recognized as a priority area for
public health intervention.10 As such, investigation into
the characteristic of injuries to the elderly as they present to the ED would provide valuable information in
implementing injury prevention.
This study examined the characteristics of elderly
patients presenting with injury to the ED, and compared those with younger patients. It revealed distinct
differences in the injury proﬁle between the elderly andthe non-elderly. Notably, there were less injury-related
ED presentations in the elderly, being almost half thenumber in the non-elderly. This is consistent with thenotion that injury is mostly a ‘‘disease’’ of the young.
Older people are less physically active than their
younger counterparts, therefore are less likely to be exposed to potential trauma.
Though the elderly showed a substantially lower
number of injury presentations to the ED than theyoung, the number of elderly injury presentations
increased considerably from 273 in 1996–1997 to 360 in
1999–2000. Our ﬁnding is perturbing, as it may be indicative of an ongoing upward trend in the elderly injury
rate. Although the gradual growth of the elderly population may have contributed to some of the increase,
it cannot account for the disproportionate rise in thenumber of injury presentations. A possible explanationis the well-recognized problem of elderly falls.10 It has
been reported that fall-induced injuries have increased
substantially that cannot be ascribed to demographic
changes alone.11,12 Thus, it is possible that an increasein the incidence of falls may have contributed to theincrease in ED injury presentations. Interestingly, thenumber of injury presentations in the non-elderly
declined in the study period in contrast to the elderly
population.
Elderly females were found to be more at risk frominjury than males. Previous studies have demonstrated
similar ﬁndings.9,10 Davis et al. found an increased incidence of falls amongst Japanese women in their prospective study of Japanese elderly living in Hawaii.13
Elderly females also form a higher proportion of trauma admissions to ICU.9 It is difﬁcult to provide a clear
explanation for this phenomenon, though it has been
postulated that female susceptibility to osteoporosis
may make them more vulnerable to fall-related injuries.14 In contrast, the non-elderly showed a greater
proportion of male patients than females. This is likely
to be a reﬂection of the occupational hazards & risktaking activities of males in the younger age group.

Keio J Med 2002; 51 (1): 11–16

The nature of injury presentation also differed between the elderly and non-elderly. Notably, the elderly
demonstrated a signiﬁcantly lower number of MVA
compared to the non-elderly. This is likely to be due toover-representation of MVA as a cause of injury in theyoung.15 However, MVA remained the second mostcommon cause of injury in the elderly, a ﬁnding consistent with other reports.3,5 Burns were also signiﬁcantly
fewer as a cause of injury in the elderly than nonelderly. Whilst this is reassuring to some extent, elderly
people suffer the highest fatality rate of any age group.5
By far, MVA-unrelated trauma represented the mostcommon cause of injury presentation to the ED within
the elderly group. Although our study did not examine
the exact mechanism of MVA-unrelated trauma, falls
have been widely documented as a common presenting
complaint to the ED16 and a major cause of trauma
in this population.17 As mentioned previously, falls
related injuries have increased, and may account for
the high proportion of MVA-unrelated trauma in theelderly. Researchers have sought to reduce the impactof falls through prevention & rehabilitation,14,16 but it
remains the major cause of non-fatal and fatal injury
in the elderly.10 Although the exact nature of trauma
requires further evaluation, our ﬁnding that trauma(with falls as the most likely underlying cause) as themost common injury presentation has implications forinjury prevention.
Regardless of the type of injury sustained by theelderly, it has been reported that their outcome ispoorer compared to their younger counterparts. We
investigated this possibility by looking at the proportionof injured patients that died in the ED or were hospitalized as a result of their injuries. Our ﬁndings
revealed that the vast majority of injury presentations
were ‘‘non life-threatening’’, with less than 2% of cases
deemed ‘‘life-threatening’’ in each group. The incidenceof ‘‘life-threatening’’ injuries in the ED at Keio University Hospital is similar to that of the Tokyo metropolitan area (1.9% in 1999). In these small number ofpatients placed in the ‘‘life-threatening’’ category, older
adults had a similar number of hospitalizations anddeaths when compared to the young. Regardless of age,severe injury resulted in similar adverse outcome.
In the majority of injuries that were triaged as ‘‘nonlife-threatening’’, death was an uncommon outcome,with comparable small number of deaths in the elderly& non-elderly. However, there were a signiﬁcantly
greater number of elderly persons hospitalized than
younger persons as a result of their injury. Higher injury hospitalization rates in elderly people compared to
the young had been previously documented.4 It is most
likely that elderly patients had other comorbidities thatinﬂuenced the decision to admit an elderly patient withinjury. In a study reviewing 27,000 patients, 31% of

15those over the age of 65 had pre-existing disease, which
contributed to a length of stay more than twice that ofyounger adults.1 In addition, their relative inability tocope with injury and the high incidence of complications after injury are considerations that may have alsoprecipitated the need for hospital admission.
Previous studies have noted an increased mortality inthe elderly with injury.6,9 Our study did not demonstrate an increased number of elderly deaths in the ED
from injury compared with the young. It is possible thatdeath may have occurred during the hospitalization period, which was not accounted for in our study. It has
been reported that elderly patients are more likely tosuffer later death compared to an uninjured cohort.18,19
In one study which stratiﬁed mortality into early anddelayed (>24 hours), most of mortality in elderly trauma
patients was delayed, unlike in younger patients, inwhom mortality occurred early after injury.7
In summary, this study has utilized the databaseof the ED of Keio University Hospital to identify thecharacteristics of older patients with injuries. This
study has shown that older patients comprise a small
proportion of all ED injury patients. However, they area distinct subgroup and several important differences
between older and younger patients have been highlighted. In particular, when compared to the younger
population, a higher proportion of older patients werefemale, presented with trauma unrelated to MVA,
and were more likely to be admitted for ‘‘non lifethreatening’’ injuries. These ﬁndings provide important
information for the future planning and implementationof injury prevention in Japan.

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