Elderly trauma: severe injury with misleading signs

An 84-year-old woman arrives at the emergency department brought in by her daughter. She slipped in the bathroom, hit her head on the sink and fell onto her bottom. She is awake, talking, remembers what happened and says she only feels pain in her hip. Her blood pressure and heart rate are within the range considered normal. On the triage form, the case looks mild. Her daughter mentions, almost in passing, that her mother takes a blood thinner because of an arrhythmia.

This scene sums up the problem of trauma in the older adult. The mechanism looks trivial, the vital signs look normal and the conversation looks reassuring, but the risk of serious injury is much higher than the picture suggests. This text shows what studies from several countries say about the undertriage of injured older adults, about the vital signs that mislead and about the factors that change the probability of a hidden injury.

Key points

• Older adults with severe trauma are often undertriaged, even at referral trauma centers.
• "Normal" blood pressure and heart rate can hide shock in those with less physiological reserve.
• A fall from standing height is the typical mechanism and is often underestimated.
• Anticoagulation, frailty and cerebrovascular disease change the probability of serious injury.
• Reasoning must start from the patient's risk, not only from the energy of the trauma.

Why older adults mislead in the trauma room

The aging body responds to trauma differently. Cardiac reserve is lower, vessels are stiffer, skin and bones are more fragile, and many long-term medications change the response to bleeding. An older person can have a major hemorrhage without the tachycardia the professional expects to see, either because the heart no longer speeds up as it once did or because the person takes a beta-blocker.

Another point is baseline blood pressure. Someone who has lived with hypertension for decades may have a usual systolic pressure well above average. A pressure of 120, which would look reassuring in a young adult, may represent a relevant drop for that person. The isolated value says little when the reference for what is normal for that patient is missing.

The mechanism that looks trivial

In young adults, triage criteria give a lot of weight to the energy of the trauma, such as high-speed collisions, falls from a great height or ejection from the vehicle. In older adults, serious injury often comes from a fall from standing height, a mechanism that almost never triggers the highest alert. Alshibani and colleagues note that prehospital criteria were designed to measure anatomical severity and trauma energy, which fits poorly with the reality of older adults, whose injuries add to multimorbidity and frailty (Alshibani and colleagues, 2021).

This difference has a practical consequence. An older adult who falls at home is usually taken to the nearest hospital, without advance notice, and may wait in the triage queue as a low-priority case. The text on baseline rate in diagnosis helps explain why the same mechanism has a different meaning in different populations.

Frailty and reserve

Frailty is a state of vulnerability in which small insults produce large consequences. It combines loss of muscle mass, slowness, fatigue, low activity and weight loss, and it is associated with worse outcomes after trauma. Alshibani and colleagues highlight that frailty assessment in prehospital care helped predict adverse outcomes in injured older adults (Alshibani and colleagues, 2021).

In practice, asking how the person lived before the fall is part of the examination. Did they walk alone? Did they need help to bathe? Had they fallen before? These answers change the weight of the same injury and help predict who will decompensate in the following hours.

The scale of undertriage

Undertriage is when a patient with serious injury receives a lower priority than they would need, for example by being treated without activation of the trauma team. In older adults, this error is common and has been measured in several countries.

Koch and colleagues followed trauma patients at 12 level 1 trauma centers in Germany and Switzerland from December 2020 to February 2021 (Koch and colleagues, 2025). Among 3753 patients, 1371 were 70 years or older (Koch and colleagues, 2025). The trauma team was activated for 15.8 per 100 older adults and for 31.8 per 100 younger patients, despite similar injury severity (Koch and colleagues, 2025). In the later analysis, 53.8 per 100 older adults who needed trauma care were undertriaged (Koch and colleagues, 2025). Mortality at 48 hours was 1.8 per 100 in older adults and 0.5 per 100 in younger patients (Koch and colleagues, 2025).

Who gets left out

Park and colleagues reviewed, at a level 1 trauma center in South Korea, older adults aged 65 or older with an injury severity score above 15 treated from 2016 to 2020 (Park and colleagues, 2025). Of the 512 patients, 111 were undertriaged (Park and colleagues, 2025). The factors linked to undertriage were female sex, a fall from standing height, a higher level of alertness at the scene and the presence of cerebrovascular disease (Park and colleagues, 2025).

The detail about the level of alertness deserves attention. The older adult who converses well at the scene seems less severe, and that impression leads the team to lower the priority. This is exactly the patient from the opening scene: awake, oriented and with an injury that has not yet shown itself. The text on cognitive biases and affective bias discusses how the first impression weighs on the decision.

Protocols that work less well in older adults

Benhamed and colleagues evaluated a prehospital protocol with three severity levels in 8888 patients treated by mobile medical teams from 2011 to 2021, of whom 14.1 per 100 were 65 or older (Benhamed and colleagues, 2023). The sensitivity of the highest level for predicting in-hospital death was 50.5 per 100 in older adults and 74.6 per 100 in younger patients (Benhamed and colleagues, 2023). The same protocol, therefore, recognized fewer of the older adults who would die.

Vital signs that mislead

Physiological triage criteria use thresholds designed for young adults, such as systolic pressure below 90. In older adults, this threshold arrives late. Boulton and colleagues did a systematic review of prehospital triage criteria specific to older adults and included 11 studies with 1,332,300 patients, all from the United States (Boulton and colleagues, 2021). All criteria used higher physiological thresholds for systolic pressure and the Glasgow coma scale (Boulton and colleagues, 2021). Sensitivity ranged from 44 to 93 per 100, with a median of 86.3, and specificity had a median of 54 (Boulton and colleagues, 2021).

This pattern is typical of anyone who shifts a cutoff point. By raising the pressure threshold, the rule catches more severely ill older adults, but it also flags more older adults who were fine. The trade-off between sensitivity and specificity appears in almost every decision rule, and the text on pretest probability shows how it depends on the population served.

New cutoff points

Su and colleagues studied 78,524 visits by patients aged 65 or older to an emergency department in Taiwan in 2016 and 2017 to define vital sign thresholds specific to older adults (Su and colleagues, 2022). The revised scale had an area under the curve of 0.76 versus 0.62 for the original scale in one of the validation databases (Su and colleagues, 2022). The gain came from reclassifying to more urgent levels part of the older adults whom the original scale left at lower priority (Su and colleagues, 2022).

The age-adjusted shock index

The shock index is the heart rate divided by the systolic pressure. Kim and colleagues evaluated this index in 45,880 trauma visits by patients over 65 years old seen at 20 emergency departments in Korea, from January 2008 to December 2013 (Kim and colleagues, 2016). The index multiplied by age had an area under the curve of 0.740 for in-hospital mortality, above the 0.674 of the simple shock index (Kim and colleagues, 2016).

The lesson goes beyond the formula. When the simple shock index looks normal, age still counts, and a modest value in an 85-year-old carries more risk than the same value in a 30-year-old. The text on clinical deterioration on the ward shows how vital sign scores help monitor worsening after admission.

Study	Population	Main finding	Source
Multicenter undertriage	1371 older adults aged 70 or over	53.8 per 100 of those who needed trauma care were undertriaged	(Koch and colleagues, 2025)
Factors in undertriage	512 older adults with severe injury	111 undertriaged, more in falls from standing height	(Park and colleagues, 2025)
Review of criteria for older adults	11 studies, 1,332,300 patients	Median sensitivity of 86.3 and median specificity of 54	(Boulton and colleagues, 2021)
Shock index and age	45,880 visits	Area under the curve of 0.740 versus 0.674	(Kim and colleagues, 2016)
Anticoagulation and mortality	4432 hospitalized older adults	Odds ratio for death of 1.92	(Patel and colleagues, 2023)

Falls from standing height and the head

Falls from standing height are the most common cause of head trauma in older adults. Dubucs and colleagues conducted a prospective study at five university emergency departments in Europe, from July 1, 2023 to June 30, 2025, with patients aged 65 or over, mild head trauma after a fall from standing height, and a head CT (Dubucs and colleagues, 2026). Among 1620 patients, with a mean age of 84.6 years, 72 had significant traumatic intracranial hemorrhage (Dubucs and colleagues, 2026). Five of them needed urgent neurosurgery (Dubucs and colleagues, 2026).

The authors identified eight signs linked to hemorrhage: visible impact on the forehead or scalp, Glasgow below the usual level, focal neurological deficit, sign of skull base fracture, acute confusion, vomiting, loss of consciousness and headache (Dubucs and colleagues, 2026). The derived rules would have reduced by 41.7 or 24.2 per 100 the number of patients sent to CT, depending on the rule used (Dubucs and colleagues, 2026). The authors themselves warn that the rules need external validation before use in practice (Dubucs and colleagues, 2026).

What the physical exam shows and what it hides

The study by Dubucs reinforces a useful idea: the history and the exam bring real clues, such as the hematoma on the forehead or the new confusion (Dubucs and colleagues, 2026). But these clues must be sought methodically. An older adult with prior dementia may look confused without this being new, and only the family or the caregiver can say whether the confusion has changed. The question "is he different from usual?" is worth as much as any score.

The text on signs, symptoms and history shows how to use the companion's account as clinical information. In the injured older adult, this account is often the only way to know the previous state.

Anticoagulants and hidden bleeding

Anticoagulant use is common among older adults and changes the reasoning after any blow to the head. Grewal and colleagues used population data from Ontario, Canada, and identified 77,834 patients aged 65 or over seen at emergency departments for head trauma (Grewal and colleagues, 2021). Among them, 5.9 per 100 had intracranial hemorrhage at the initial visit (Grewal and colleagues, 2021). Those using warfarin had a higher risk of hemorrhage than matched patients using direct oral anticoagulants, with a relative risk of 1.43, and than patients without anticoagulation, with a relative risk of 1.36 (Grewal and colleagues, 2021). The risk with direct oral anticoagulants was similar to that of those not using an anticoagulant (Grewal and colleagues, 2021).

Anticoagulation and mortality

Patel and colleagues reviewed 4432 older adults admitted to a level 1 trauma center in the United States from January 2018 to December 2020 (Patel and colleagues, 2023). Of these, 1592 were taking an anticoagulant on arrival and 165 died (Patel and colleagues, 2023). After adjusting for comorbidities, injury severity and arrival blood pressure, prior anticoagulation was associated with death, with an odds ratio of 1.92 (Patel and colleagues, 2023).

This finding is an association in a retrospective study. It is a reminder that the question about medications needs to come right at the start of care, together with the vital signs, because it changes how the rest of the picture is read.

The repeat CT scan

A frequent question is whether the older adult on an anticoagulant with a normal initial CT scan needs to repeat the exam. Mann and colleagues evaluated adults aged 65 or older who had a minor fall while taking an anticoagulant or antiplatelet agent (Mann and colleagues, 2018). Among 218 patients who had a routine repeat CT scan, one had delayed bleeding (Mann and colleagues, 2018). Of these 218, 42 were taking more than one anticoagulant or antiplatelet agent (Mann and colleagues, 2018). The authors advocate risk tools that avoid unnecessary repeat exams without missing severe bleeding (Mann and colleagues, 2018).

How to organize the reasoning

The evidence allows building a sequence of questions for the injured older adult. It helps reduce the weight of first impressions and to see the injury that has not yet shown itself. The review by the American Association for the Surgery of Trauma, led by Egodage and colleagues, points to opportunities to improve triage of older adults at three moments: before the hospital, in the trauma room and after admission (Egodage and colleagues, 2024).

• What was the patient's condition before the fall, including mobility, cognition and previous falls?
• Which medications does the patient take, with attention to anticoagulants, antiplatelet agents and beta-blockers?
• Are the vital signs normal for this patient, considering the usual blood pressure?
• Are there signs in the head, such as a forehead hematoma, new confusion, vomiting or headache?
• Who can tell whether the patient is different from usual?

With these questions, a case that looks mild gains a calculated risk. The text on how to organize the reasoning in the medical record shows how to record these answers so that the next team also sees them.

Where the reasoning usually fails

Three failures appear often. The first is anchoring on the mechanism: "it was just a fall". The second is trusting vital signs within the young adult range, without considering the beta-blocker or baseline hypertension. The third is attributing the confusion to dementia or age, without asking whether it is new.

Triage criteria in several countries are still under review, and Egodage and colleagues note that physiological parameters, laboratory markers, imaging findings and age itself may enter these criteria (Egodage and colleagues, 2024). Meanwhile, bedside judgment remains central. The text on diagnostic uncertainty helps decide when to observe and when to investigate further.

Reassess instead of discharge

The older adult who arrives well can worsen hours later. Slow abdominal bleeding, a growing subdural hematoma or a hip fracture that immobilizes and leads to complications are examples of evolution that only appears with time. Planning reassessments, recording the neurological status in a comparable way and agreeing on warning signs with the family close the loop.

Discussing cases of under-triaged older adults in morbidity and mortality sessions helps the team see repeating patterns, such as the underestimated fall or the question about anticoagulants that was left for later. The text on clinical decision-making completes this reflection on how to choose exams and approaches.

The conversation with the family and the shift handover

The family is usually the best source on the older adult's previous state. They know whether he walked on his own, whether he already forgot things, whether he took his heart medication every day and whether the fall was the first or one of several. This information changes how the exam is read: a mild confusion can be old in one person and new and worrying in another.

The shift handover is another weak point. The older adult who arrived stable, with a normal CT scan and tests in progress, risks being remembered as a resolved case. It is worth passing on the mechanism, the medication list, the baseline heart rate when known and what still needs to be assessed. A short sentence such as "older adult on anticoagulant, fall from standing height, reassess in a few hours" protects more than a long summary without focus.

It also helps to agree with the team on what triggers a new assessment: increasing drowsiness, pain that moves, a drop in blood pressure compared with the baseline value, vomiting or new confusion. When everyone knows what to look for, nursing calls earlier and the doctor reassesses with a clear question in mind.

The reasoning when facing an older adult with trauma is, at bottom, an exercise in organized distrust. The calm appearance, the numbers within range and the story of a simple fall form a coherent narrative, and it is precisely this coherence that needs to be tested. Asking what else could explain the picture and what is still hidden keeps the team alert.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code.

The limits of using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researchers explains how to get in touch. Professionals who write or review cases find information on Curator and on Creators, and institutions can learn about the proposal on the partnerships page. Training with differential diagnosis and clues and searching for the right ICD-10 code complete this practice.

Frequently asked questions

What is undertriage in trauma in older adults?

It is when an older adult with a severe injury receives lower priority than needed, and a study in 12 centers found undertriage in 53.8 out of every 100 older adults who needed trauma care (Koch et al., 2025).

Why do vital signs mislead in older adults?

Cardiac reserve is lower, baseline blood pressure is usually higher and some medications prevent tachycardia, which is why criteria for older adults use higher physiological thresholds (Boulton et al., 2021).

Is a fall from standing height a mild trauma?

It can be severe, and in a study with 1620 older adults after a fall from standing height, 72 had significant intracranial hemorrhage (Dubucs et al., 2026).

Does every anticoagulant increase the risk of bleeding after a blow to the head?

In Ontario, warfarin was associated with a higher risk, and the risk with direct oral anticoagulants was similar to that of those not using anticoagulants (Grewal et al., 2021).

How can triage of older adults be improved?

By asking about the previous state, the medications and the usual blood pressure, and by using physiological thresholds specific to older adults, such as those tested in Taiwan (Su et al., 2022).

Take-home messages

• The older adult with severe trauma can appear stable for hours.
• Undertriage is common, even in referral centers.
• Vital signs need to be read against the patient's own reference.
• A fall from standing height and anticoagulation change the probability of severe injury.
• Asking about the previous state and the medications is part of the exam.

References

1. Alshibani A, Banerjee J, Lecky F, et al. New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults. Open Access Emerg Med. 2021. PMID 33814934.
2. Benhamed A, Emond M, Mercier E, et al. Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults. Int J Environ Res Public Health. 2023. PMID 36767343.
3. Boulton AJ, Peel D, Rahman U, et al. Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review. Scand J Trauma Resusc Emerg Med. 2021. PMID 34461976.
4. Dubucs X, Even C, Guenezan J, et al. Risk stratification for significant acute traumatic intracranial hemorrhage in older adults after a ground-level fall: A prospective multicentre cohort study. PLoS Med. 2026. PMID 42574438.
5. Egodage T, Ho VP, Bongiovanni T, et al. Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee. Trauma Surg Acute Care Open. 2024. PMID 39021732.
6. Grewal K, Atzema CL, Austin PC, et al. Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study. CMAJ. 2021. PMID 35040805.
7. Kim SY, Hong KJ, Shin SD, et al. Validation of the Shock Index, Modified Shock Index, and Age Shock Index for Predicting Mortality of Geriatric Trauma Patients in Emergency Departments. J Korean Med Sci. 2016. PMID 27822945.
8. Koch DA, Becker L, Schweigkofler U, et al. Undertriage in geriatric trauma: insights from a multicentre cohort study. Scand J Trauma Resusc Emerg Med. 2025. PMID 40640930.
9. Mann N, Welch K, Martin A, et al. Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emerg Med. 2018. PMID 30142999.
10. Park J, Huh Y, Song S, et al. Undertriage of Severe Geriatric Trauma Patients: Who Are We Missing? Yonsei Med J. 2025. PMID 40551593.
11. Patel N, Kania T, Demissie S, et al. Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study. Ann Med Surg (Lond). 2023. PMID 37663698.
12. Su YC, Chien CY, Chaou CH, et al. Revising Vital Signs Criteria for Accurate Triage of Older Adults in the Emergency Department. Int J Gen Med. 2022. PMID 35898300.