Geriatric Trauma: The Growing Challenge for Trauma Centers

For years, trauma programs have focused heavily on penetrating trauma, motor vehicle crashes, major blunt trauma, and the severely injured young adult.

But the trauma population is changing. Older adults are becoming an increasingly important and increasingly specialized population in trauma care. Geriatric trauma is no longer a niche topic. It is becoming a core component of trauma program quality.

So when does a trauma patient become “geriatric”?

The answer seems simple: 65 years old. That is the definition used by the American College of Surgeons (ACS) in its Best Practices Guidelines for Geriatric Trauma Management.

Other guidelines suggest that patients as young as 55 may warrant increased attention to geriatric-specific risk factors.

But age alone does not tell the whole story.

Falls Are Changing the Definition of "Trauma"

When people hear "trauma," they often picture a high-speed motor vehicle crash or penetrating injury.

At many adult trauma centers, falls have become the most common mechanism of injury, reflecting the changing age and injury patterns of the trauma population. The mechanism can be deceptively minor. A same-level fall can leave a young person uninjured but result in an intracranial hemorrhage, cervical spine injury, rib fractures, hip fracture, or other serious injury for an older adult.

Falls are the most common cause of injury and the leading cause of fatal injury among older adults. It is estimated that approximately 3 million older adults are treated in emergency departments each year for fall-related injuries, with more than 800,000 hospitalized.

The Trauma Population is Aging Because the Population is Aging

Adults age 65 and older are projected to represent one-fifth of the US population by 2040. The first Baby Boomers began turning 65 in 2011. By the end of the 2020s, the entire Baby Boomer generation will be 65 or older. At the same time, Americans are living longer. And those older adults are remaining active, driving, working, traveling, and living independently longer than previous generations.

Older adults will continue to experience traumatic injuries. And when they do, trauma programs need to be prepared to recognize that geriatric trauma is not simply trauma in an older person. It is a distinct clinical challenge.

The trauma centers that recognize this early can build the necessary infrastructure to care for these patients: appropriate triage criteria, geriatric-specific trauma protocols, frailty screenings, multidisciplinary collaboration, injury prevention, data tracking, education, and performance improvement.

The question for trauma program leaders is no longer whether geriatric trauma deserves attention. The question is whether your trauma program is prepared for how much of its trauma population will soon be geriatric.

So What Should Trauma Programs Be Doing?

As the population ages, understanding that difference will become an increasingly important part of trauma program quality, performance improvement and patient outcomes. A core principle of geriatric trauma care is recognizing that injury can have a very different impact depending on a patient's physiologic reserve, functional status, comorbidities, and ability to recover.

Your trauma program should be able to answer these six questions:

#1. Does your program define a geriatric trauma patient and have a geriatric-specific trauma activation or triage process?

Older adults don't always look as sick as they are and a low-energy mechanism of injury does not always equate to a low-risk patient. This is one of the most important differences in geriatric trauma.

Traditional trauma assessment relies heavily on mechanism, vital signs, and physiologic response. Aging changes the equation. An older adult may have limited physiologic reserve, medications that alter the normal response to injury, chronic disease that complicates assessment, or baseline cognitive impairment that makes changes difficult to recognize. A "normal" blood pressure or heart rate does not necessarily mean the patient is stable. Similarly, a seemingly minor injury can have significant consequences for an older adult who is frail or already functionally limited.

Research has identified undertriage as an important concern in geriatric trauma, with older adults sometimes receiving less aggressive triage despite having substantial injury risk.

#2. Are older patients screened for frailty?

Age alone does not tell the whole story. An active 80-year-old who lives independently is very different from a frail 70-year-old who requires assistance with activities of daily living.

That is why frailty has become an increasingly important concept in trauma care.

Frailty reflects a patient's physiologic vulnerability and ability to withstand a stressor such as trauma, surgery, infection, or prolonged hospitalization. For trauma programs, this creates a shift from asking: "How old is the patient?" to asking: "How resilient is this patient?"

That distinction can influence treatment decisions, goals-of-care discussions, anticipated recovery, discharge planning, and the resources needed during hospitalization.

Consider a ground-level fall. In an older adult with osteoporosis, anticoagulant use, sarcopenia, multiple medications, and limited physiologic reserve, a seemingly minor fall can result in a serious head injury, hip fracture, rib fractures, or other significant injury.

In a national study of more than 100,000 geriatric patients presenting after ground-level falls, frail patients had higher mortality and high risk of 30-day readmission compared with non-frail patients.

A 2023 prospective multicenter study of 1321 geriatric trauma patients across 17 ACS trauma centers found that frail patients had significantly higher odds of mortality, major complications, and discharge to rehabilitation or skilled nursing facilities. Frailty was also associated with higher odds of mortality, major complications, readmission, and recurrent falls at three months.

These studies illustrate why age should trigger attention, but frailty should help drive risk stratification.

#3. Does your program track geriatric-specific outcomes through PIPS?

The growing emphasis on geriatric trauma is not simply about adding another protocol to the trauma manual. It creates opportunities for trauma programs to examine whether their systems are appropriately identifying and caring for older patients.

Questions to consider include:

• Are older patients being appropriately triaged?

• Are geriatric trauma criteria being used?

• Are frailty and baseline function documented?

• Are anticoagulants rapidly addressed when appropriate?

• Are delirium prevention strategies incorporated?

• Are older patients receiving early mobility and appropriate nutrition?

• Are goals of care addressed early?

• Are patients being discharged to the most appropriate setting?

• Are geriatric trauma outcomes being tracked separately?

These are the kinds of questions that should become part of trauma program performance improvement and patient safety activities.

#4. Do you have geriatric-specific protocols for delirium, anticoagulation, pain management, mobility, nutrition, medication reconciliation, and discharge planning?

Trauma care is highly protocolized to ensure standardized, evidence-based care. But traditional trauma models do not always account for the unique risks faced by older adults.

Older patients are more likely to have complex medical histories and take multiple medications, including anticoagulant or antiplatelet agents. They also have increased risk of delirium, reduced ability to compensate for physiologic stress, and greater risk of losing independence after hospitalization.

Geriatric trauma protocols therefore need to extend well beyond the trauma bay. They should address early recognition, imaging, medication management, delirium prevention, pain control, nutrition, mobility, rehabilitation, discharge planning, fall prevention, and goals-of-care discussions. They should also involve more than surgeons and emergency physicians. ACS guidance supports early involvement of clinicians familiar with geriatric care and multidisciplinary teams.

The emphasis on geriatric-specific care is not simply theoretical. A systematic review and meta-analysis of geriatric consultation for older trauma patients found that geriatric consultation was associated with an average reduction in hospital length of stay of 1.11 days, although the available evidence did not demonstrate a mortality difference.

A 2025 scoping review also found that hospital-based geriatric interventions are an expanding area of trauma research, reflecting the growing recognition that older adults require targeted approaches to trauma care.

The evidence base is still developing, but the direction is clear: geriatric trauma care requires attention beyond the initial injury.

#5. Are geriatric medicine, pharmacy, rehabilitation, nursing, and case management integrated into the care model?

Trauma surgery alone cannot address all of the issues many older patients bring with them.

The patient may simultaneously need:

• Trauma surgery

• Emergency medicine

• Geriatrics or hospital medicine

• Orthopedics

• Neurosurgery

• Pharmacy

• Physical therapy

• Occupational therapy

• Nutrition

• Social work

• Case management

• Rehabilitation

• Palliative care or goals-of-care support

The ACS guidelines emphasize an interdisciplinary approach beginning in the emergency department and continuing throughout hospitalization. This is fundamentally different from thinking of trauma care as simply treating the injury. The goal is to treat the injured patient.

#6. Is your trauma program actively engaged in injury prevention beyond the basics?

Injury prevention is an important part of the trauma program's role, but simply distributing brochures or participating in an annual community event may not be enough.

A strong geriatric trauma program should use its own trauma registry, emergency department, and other local data to identify patterns and populations at highest risk. Falls may be the obvious starting point, but prevention efforts can extend to other mechanisms and risk factors affecting older adults.

For example, the program might:

• Identify high-risk populations, neighborhoods, or circumstances.

• Develop targeted fall-prevention programs in partnership with community organizations, senior centers, EMS, primary care, or home-health agencies.

• Connect patients with evidence-based exercise, balance, strength, and fall-prevention programs.

• Incorporate medication, vision, gait, balance, and home-safety assessments when appropriate.

• Use trauma and EMS data to identify opportunities for community education and prevention.

• Evaluate whether prevention efforts are reaching the populations identified through the program's data.

• Measure the impact of prevention activities rather than simply counting educational events.

  
  

The American College of Surgeons recognizes older adult falls as a major injury-prevention opportunity and supports comprehensive prevention efforts that extend into the community. The American Association for the Surgery of Trauma has likewise emphasized the role trauma centers can play in structured fall-prevention outreach, including partnerships with EMS and community organizations.

Your trauma program should be using its own data to identify preventable injuries and then actively working with the community to reduce them.

That is the difference between checking the injury-prevention box and making injury prevention part of the trauma program's mission.

Don't Neglect the "Oldest Old"

As mentioned throughout this article, not all trauma patients are the same. But not all geriatric trauma patients are the same, either. An 80-year-old is different from a 65-year-old, just as a 90-year-old may be very different from an 80-year-old.

Patients age 80 and older represent a substantial portion of the geriatric trauma population. In a national Medicare study of nearly 8 million injured adults age 65 and older, approximately 49% were older than 80. Importantly, undertriage increased with age, with patients older than 80 having 57% higher adjusted odds of undertriage than those ages 65–69. In a nationwide study of more than 131,000 geriatric trauma patients, 78.9% of patients age 80 and older were injured in falls, compared with 56.7% of patients ages 65–79.

This population presents particular challenges for trauma systems. In that same national study, the odds of undertriage increased progressively with age, reaching 57% higher odds among patients older than 80 compared with patients ages 65–69.

The implication for trauma programs is important: "geriatric" should not be treated as a single homogeneous category. As patients move into their 80s and 90s, frailty, functional status, cognition, medications, comorbidities, and goals of care may become increasingly important in determining risk and the resources needed for recovery.

Age should never be the sole determinant of treatment. But an older age -- particularly 80 or 85 and beyond -- should prompt trauma programs to look more closely at the patient's physiologic reserve, baseline function, and ability to recover from injury.

Bottom line

The rise of geriatric trauma is one of the most important changes occurring in trauma care.

As the trauma population ages, trauma centers will need to evolve from a model focused primarily on treating injuries to one that also accounts for frailty, function, cognition, comorbidities, goals of care, and the patient's ability to return to their previous life.

Geriatric trauma isn't a specialty topic anymore.

It is becoming part of mainstream trauma care.