Trauma as a critical condition in the very old: assessment, care pathways and outcome differences.

Trauma in very old adults represents a growing and distinct form of critical illness, reflecting demographic aging and increasing levels of frailty, multimorbidity, and dependency. Unlike younger populations, where trauma is typically driven by high-energy mechanisms, injury in older adults most commonly results from low-energy falls. Despite this, the consequences are often severe, with high rates of hemorrhage, traumatic brain injury and thoracic trauma, and subsequent multi-organ dysfunction requiring critical care. Age-related physiological changes, combined with multimorbidity and polypharmacy, alter responses to injury and may mask early signs of deterioration. As a result, commonly used triage systems frequently underestimate injury severity in older patients, contributing to under-triage and delays in access to specialist trauma care. Frailty is increasingly recognized as a key determinant of outcomes, influencing survival, length of stay, and functional recovery, and should be routinely assessed early in the patient pathway. Assessment of frailty and intrinsic capacity in the Emergency Department is often challenging, particularly when relatives or caregivers are unavailable to provide collateral history. Older adults should receive an in-depth assessment and documentation of pre-injury status and prior wishes; however, this is inconsistently performed in routine trauma practice. Management of older trauma patients is complex and often fragmented across specialties, with significant variability in care pathways. Decision-making is further complicated by prognostic uncertainty and the need to align interventions with patient values and baseline function. While ICU admission may improve outcomes in selected patients, survival is frequently accompanied by complications, such as delirium, sarcopenia, and long-term functional impairment. Optimizing outcomes requires a coordinated, multidisciplinary approach that integrates trauma and geriatric principles, emphasizing early recognition, tailored resuscitation, comprehensive assessment of frailty, and patient-centered care. Future priorities include improving triage accuracy and injury recognition, standardizing care pathways, and focusing on meaningful recovery in this vulnerable population.