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Functioning and health-related quality of life in older people following

traumatic injury a systematic literature review

Katherine Brown1, Ian Cameron2, Lisa Keay1, Kristy Coxon1, Rebecca Ivers1
1 The George Institute for Global Health, Sydney Medical School, University of Sydney;
2 John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School Northern, The University of Sydney


Figure 1: PRISMA flow diagram [9]

Australia has an ageing population and workforce: [1] [2]




14% aged >=65

25% aged >=65



24% aged >=55

34% aged >=55

The Australian Government is gradually increasing the aged pension eligibility age from the current age of
65 years, to 67 years by 2023, and 70 years by 2035. [3]
The burden of injury in older people is a significant issue
126,000 hospital admissions in people aged >=65 years (Australia, 2011-12). [4]
Short- and long term effects for the injured person, their family, friends, support services, workplace
and engagement in the wider community e.g. carer responsibilities.
As the problem of injury in older people increases, so will the demand for high quality, evidencebased research in this area, at both patient and population level.
Research has been carried out into functional and health-related quality of life outcomes post-acute
injury in the younger population, however there is scant evidence on generic health-related quality of life
post-injury in older people

A systematic literature review was undertaken to assess the evidence regarding functioning and healthrelated quality of life (HRQoL) following traumatic injury in older people.


Discussion and Conclusions

Inclusion criteria

Limited research was found that described functional outcomes and quality of life in older people following injury

Subjects aged>=65 years, or reported as aged, older, senior, elderly or geriatric

No evidence was found about the impact of injury on older people in terms of voluntary work, caring duties, and
participation in paid work.

Traumatic injury requiring hospitalisation or medical treatment (excluding burns, poisoning and drowning)
Prospective cohort, follow-up, prognostic course or prognostic factor studies
Study outcome measure/s measured general functioning or health-related quality of life, and had
previously been used in research in general injury populations:
Glasgow Outcome Scale (GOS) or Glasgow Outcome Scale Extended (GOS-E)

Population-based studies are available, but the absolute numbers of older subjects are generally very small or
results are not presented by age, limiting the conclusions that can be drawn.
Based on the available evidence, older people have poorer functional and health-related quality of life outcomes
More research is required, specifically prospective cohort studies of functioning and health-related quality of life
following injury focused on older people that use standardised, consistent definitions and measures for older
people, functioning and health-related quality of life.

European Quality of Life 5D (EQ-5D)

World Health Organisation Quality of Life Survey BREF (WHOQOL-BREF)
Short Form Health Survey 36 (SF-36) or Short Form Health Survey 12 (SF-12)

English language publications between January 1995 and September 2014

Search databases were Medline, Embase, PsycINFO and Cinahl, and for grey literature Google Scholar,
ScienceDirect, reference lists and SafetyLit reports.

Previous research has identified preferred health-related quality of life outcome measures in general injury
populations, for example, the GOS-E, SF-36 and EQ-5D [6] [7] [8]. This review provides information as to which
functioning and HRQoL measures are used in current research on injury in older people, however more research is
necessary to determine the most appropriate measures to use in the older population.


Comprehensive search strategies were developed for each database based on the inclusion and exclusion
criteria (see above).
PRISMA [6] reporting guidelines were used to conduct the search and report the results.
Records were screened on title and abstract for eligibility, and those meeting criteria underwent full-text
assessment by two independent reviewers.

The first author is a current PhD student at The George Institute for Global Health and is the recipient of an Australian
Postgraduate Award (APA) scholarship with additional support from the NSW Motor Accidents Authority (MAA). The
authors declare they have no competing interests.
For further information please contact Katherine Brown:

The QUIPS critical appraisal tool [7] was used to determine the quality of the studies.

18 records met the inclusion criteria for the review (see Figure 1).
55% of publications were specific to older people.
Meta-analysis was not possible due to heterogeneity of results.
Large variation between studies in terms of study population, setting and inclusion criteria; injury type,
mechanism and severity and and outcome measures. Some studies used multiple outcome measures.
8 studies (44%) reported an association between increasing age (and one or more of): slower recovery,
residual disability, decreased functional outcome or reduced HRQoL. [10] [11] [12] [13] [14] [15] [16] [17]
6 studies (33%) compared outcomes in older and younger people, of these, 5 studies reported poorer
outcomes in older people compared to younger people.

2 studies reported poor HRQoL outcomes for vertebral fractures [17] [18], 1 study reporting worse 7 year
HRQoL outcomes for vertebral but not hip fractures. [18]
The site of fracture appeared to influence outcome, with poorer outcomes reported in hip fractures [19]

Table 2: Number of publications

by injury type







EuroQOL / EQ-5D

Fall-related injury


FIM motor



FIM / modified FIM

MVC injury



Any injury



Moderate & major trauma






Table 1: Number of publications by

outcome measure/s used

1. The Australian Government the Treasury, Realising the economic potential of senior Australians, Advisory Panel on the Economic Potential of Senior Australians, Editor. 2011:
ACT, Australia.
2. Department of Family and Community Services, NSW Ageing Strategy. 2012, Department of Family and Community Services, Office for Ageing 2012: Sydney NSW Australia.
3. The Commonwealth of Australia, Budget 2014/15 Overview. 2014, Commonwealth of Australia 2014: ACT, Australia.
4. Tovell A. Hospitalised injury in older Australians, 201112. Injury research and statistics series no. 90. Cat. no. INJCAT 166. 2014 August 19, 2014]; Available from:
5. Hayden, et al., Assessing Bias in Studies of Prognostic Factors. Annals of Internal Medicine, 2013. 158(4): p. 280-286.
6. Neugebauer, et al., Quality of life after multiple trauma--summary and recommendations of the consensus conference. Restorative neurology and neuroscience, 2002. 20(3):
p. 161-167.
7. Gabbe, et al., Choosing outcome assessment instruments for trauma registries. Academic Emergency Medicine, 2005. 12(8): p. 751-8.
8. Gabbe, et al., Population-based capture of long-term functional and quality of life outcomes after major trauma: the experiences of the Victorian State Trauma Registry. Journal
of Trauma-Injury Infection & Critical Care, 2010. 69(3): p. 532-6; discussion 536.
9. Moher, et al., Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. International Journal of Surgery, 2010. 8(5): p. 336-341.
10. Gomez, et al., Age and outcome after severe head injury. Acta Neurochirurgica, 2000. 142(4): p. 373-80; discussion 380-1.
11. Gonzalez, et al., Health-related quality of life and functionality in elderly men and women before and after a fall-related wrist fracture. International Journal of Clinical Practice,
2014. 68(7): p. 919-928.
12. Hsieh, et al., Comparing Rehabilitation Services and Outcomes Between Older and Younger People With Spinal Cord Injury. Archives of Physical Medicine & Rehabilitation, 2013.
94(s4): p. S175-86.
13. Inaba, et al., Long-term outcomes after injury in the elderly. Journal of Trauma-Injury Infection & Critical Care, 2003. 54(3): p. 486-91.
14. Rainer, et al., Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: A multicentre, prospective cohort study. Injury, 2014.
45(5): p. 902-909.
15. Rothweiler, Temkin, and Dikmen, Aging effect on psychosocial outcome in traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 1998. 79(8): p. 881-887.
16. Utomo, et al., Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury. Injury, 2009. 40(9): p. 973-7.
17. Yang, et al., Factors that predict poor outcomes in patients with traumatic vertebral body fractures. Injury, 2010. 41(2): p. 226-230.
18. Hallberg, et al., Health-related quality of life after vertebral or hip fracture: a seven-year follow-up study. BMC Musculoskeletal Disorders, 2009. 10: p. 135.
19. Chiu, et al., Effect of fracture type on health-related quality of life among older women in Taiwan. Archives of Physical Medicine and Rehabilitation, 2012. 93(3): p. 512-519.
20. Dijkers, et al., Inpatient rehabilitation for traumatic brain injury: The influence of age on treatments and outcomes. Neurorehabilitation, 2013. 32(2): p. 233-252.
21. Hartholt, et al., Societal consequences of falls in the older population: Injuries, healthcare costs, and long-term reduced quality of life. Journal of Trauma - Injury, Infection and
Critical Care, 2011. 71(3): p. 748-753.
22. Lee, Chua, and Howe, One-year outcome of hip fracture patients admitted to a Singapore hospital: Quality of life post-treatment. Singapore Medical Journal, 2007. 48(11): p.
23. Mosenthal, et al., The effect of age on functional outcome in mild traumatic brain injury: 6-Month report of a prospective multicenter trial. Journal of Trauma - Injury, Infection
and Critical Care, 2004. 56(5): p. 1042-1048.