Death by road accidents, suicides common among the elderly: Local research 

• Recommends road safety supervision and psychological counselling 

BY Ruwan Laknath Jayakody

Since the majority of unnatural deaths among the elderly are due to road accidents, where elderly victims were pedestrians, there is a need for supervised transportation, while the presence of a significant number of suicides among the elderly emphasises the need for counselling services targeting this group. 

These findings and recommendations were made in a research article on “Elderly victims dying of unnatural causes: A retrospective, descriptive study from Ragama” which was authored by I.D.G. Kitulwatte, S.S. Paranavithana, A.A.B.S. Perera and P.A.S. Edirisinghe (all attached to the Kelaniya University’s Medical Faculty’s Forensic Medicine Department) and published in the Sri Lanka Journal of Forensic Medicine, Science and Law’s Ninth Volume’s First Issue in July 2018. 

Many countries define old age as the retirement age i.e. 60 years (per the World Health Organisation [WHO]) or 65 years. According to the Census and Statistics Department, 2.5.million people or 12.5% of the total population are above 60 years, while by this year (2021), the elderly population would be an estimated 3.6 million or 16.7% of the total population. Kitulwatte et al. observed that the country is going to face many challenges due to this rapidly increasing ageing population. 

This is because frequently observed natural illnesses associated with old age such as Alzheimer’s disease (dementia progressively beginning with mild memory loss and possibly leading to the loss of the ability to carry on a conversation and respond to the environment, and involves parts of the brain that control thought, memory, and language), cardiovascular (circulatory system which is comprised of the heart and blood vessels and carries nutrients and oxygen to the tissues of the body and removes carbon dioxide and other wastes from them) diseases, cancers, arthritic (the swelling and tenderness of one or more joints) conditions and osteoporosis (weakens bones, making them fragile and more likely to break) and physical disabilities are expected to increase and thereby pose a significant burden to the health budget, while there are also many unnatural conditions causing ill health among the elderly which also consume a disproportionate quantum of medical resources due to physiological changes associated with ageing.

As studies (H.K. Bakke, T. Dehli and T. Wisborg’s “Fatal injury caused by low energy trauma – 10 year rural cohort”, W. Chang, S. Tsai, Y. Su, C. Huang, K. Chang and C. Tsai’s “Trauma mortality factors in the elderly population”, and P. Broos, A. D’Hoore, P. Vanderschot, P. Rommens and K. Stappaerts’s “Multiple trauma in elderly patients. Factors influencing outcome: Importance of aggressive care”) have shown, even low energy trauma can be lethal among the elderly due to pre-existing medical conditions, age associated with diminished respiratory and cardiovascular reserve and functions and the insufficient ability for systemic compensation. 

According to Kitulwatte et al., due to the serious, chronic illnesses suffered by old and frail victims, attending physicians are often happy to sign death certificates without personally investigating the circumstances of their deaths. Hence, T. Corey, B. Weakley-Jones, G. Nichols and H. Theuer note in “Unnatural deaths in nursing home patients” that unnatural deaths of the elderly are significantly underreported. It must however be also noted that the circumstances of other deaths in the elderly may be due to many natural conditions contributing towards such. 

Therefore, Kitulwatte et al. collected data (historical details, scene findings, autopsy findings, investigations, opinions and conclusions given) retrospectively for a period of three years, from hospital records and post-mortem reports of a tertiary care hospital, on persons over 60 years, who had died due to unnatural causes. 

In terms of the age distribution, 55 (59.8%) were male and 37 (40.2%) were female. This ratio follows the national statistics on the same per A. Satharasinghe’s 2016 Statistical Abstract quoted by the Census and Statistics Department in 2018. For Kitulwatte et al., this was also explained by the lifestyle and behavioural risks of men when compared to women. The majority (24-26%) were of the 65 to 69 years age group (in an age group considered independently mobile) followed by 23% in the 70 to 74 years age category. The frequency of deaths due to unnatural causes was less among persons over 75 years. 

Concerning the circumstances of death (accident, suicide, homicide), the majority were accidental (63-68%) followed by suicidal (21-23%).

When it came to the management (emergency care, emergency treatment unit/ward, specialised care/surgery/intensive care unit, brought to the hospital dead), the majority (43-47%) had received initial treatment at the emergency treatment unit or the surgical ward, while 41 (45%) were dead at the time of being brought to the hospital.

With regard to the location of the injuries (head/face/neck, chest/abdomen, multiple body parts, chest, abdomen, lower limbs, head/chest, head/chest/abdomen), they were located in multiple body parts (31-34%) and the head and neck (26- 28%).

Of the cause of death (cranio-cerebral [involving both the cranium [a single structure forming a case around the brain] and the brain] injury, snake bites, chest injury, abdominal injury, multiple injuries, neck compression, drowning, shock/haemorrhage, burn, poisoning), it was cranio-cerebral injuries in 34 (37%).

The presence of multiple injuries or cranio-cerebral injuries in the majority meant, Kitulwatte et al. pointed out that the majority had died on the spot or had lived until they got basic initial management, due to serious injuries. 

On the past medical history of significant illness (hypertension, diabetes mellitus/hypertension, ischemic heart disease [recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood], hypertension/diabetes mellitus/ischemic heart disease, ischemic heart disease/hypertension), there was a history of natural disease in the majority (51-55%) with many suffering from ischemic heart disease (34-37%). Natural pathology contributed to death in only eight (9%). The latter figure, according to Kitulwatte et al., confirmed the seriousness of the injuries where the injuries themselves were lethal enough to cause death. 

When the type of accidental death (road traffic accident, fall from a height, burns, drowning, railway accident, snake bites) was considered, the majority were due to road accidents (50-79.3%) followed by falls from a height (three – 4.8%), burns and drowning, but the numbers for the latter three types were significantly low.

Pertaining to the type of suicidal death (poisoning, hanging, drowning, burns, railway accident), the majority of suicides were due to poisoning (eight – 38.1%) followed by hanging (six – 28.6%), drowning (four – 19%) [which according to Kitulwatte et al. is due to the country having ample resources of water with easy access], rail track trauma (two – 9.5%) and burns (one – 4.8%). 

The victim profile in road accidents (pedestrian, driver, passenger) was that the majority were pedestrians (37-74%). This pattern per Kitulwatte et al. is due to the fact that many of the elderly do not engage in driving and because they have associated medical conditions or disabilities that make them more prone to accidents as pedestrians. 

In relation to the age distribution of the different types of accidental deaths, road accidents were commonly observed among the 65 to 74 years (54%) age group while there was no significant age preponderance in the other types of accidents. 

In connection with the age distribution of suicidal deaths, such was commonly observed in the 60 to 64 age group (29%) or just after retirement, and in a majority of the incidents, the reason for committing suicide was not known by the relatives.

Elderly victims who are subjected to trauma or violence, Kitulwatte et al. noted, have an increased risk of death and are more likely to die of medical complications. 

In the “Effect on the outcome of early intensive management of geriatric trauma patients”, D. Demetriades, M. Karaiskakis, G. Velmahos, K. Alo, E. Newton, J. Murray, J. Asensio, H. Belzberg, T. Berne and W. Shoemaker noted that the survival of elderly patients after trauma including injuries to the extremities could be improved with early intensive monitoring, evaluation and resuscitation. 

Elderly patients and in particular those with pre-existing medical conditions, S. Hollis, F. Lecky, D.W. Yates and M. Woodford explained in “The effect of pre-existing medical conditions and age on mortality after injury”, are known to be at an increased risk of mortality following injuries of minor to moderate severity.

As found in “The accidental injury in the geriatric population” by A. Kumar, A. Verma, M. Yadev and A. Srivastava, and “Mortality caused by accidental falls among the elderly: A time series analysis” by D. Antes, I. Schneider and E. d’Orsi, accidental falls are identified as an important cause of morbidity and mortality in the elderly. Further, M. Keck, D. Lumenta, H. Andel, L. Kamolz and M. Frey’s “Burn treatment in the elderly” mentioned that aged patients are vulnerable to burn injury, and have far worse treatment outcomes when compared to young adults.

Suicide in old age, as explained by M. Heisel and P. Duberstein in “Suicide prevention in older adults” is a much neglected area due to the lack of knowledge on the part of physicians. In Sri Lanka, during 2010 to 2012, there was, per D. Knipe, C. Metcalfe and D. Gunnell’s “WHO suicide statistics – A cautionary tale”, an increasing trend of suicides with age, in both men and women (per the WHO’s “2018 Mental health: Suicide data”). 

Elderly people, R.C. Abrams, P.M. Marzuk, K. Tardiff and A.C. Leon elaborated in the “Preference for a fall from a height as a method of suicide by elderly residents of New York City”, select the easily accessible modes as methods of suicide. 

In conclusion, Kitulwatte et al. pointed out that it is therefore important to study the unnatural circumstances of death among senior citizens so as to identify the reasons for their untimely, unnatural mortality in order to plan appropriate intervention strategies and create awareness among the public of such, and thereby give serious concern to the issue of unnatural deaths among the elderly. 

If you feel that you or someone you know may be affected by this content or may require help, the following institutions would assist you: 

The National Institute of Mental Health: 1926 

Sri Lanka Sumithrayo: 0112 682 535 

Shanthi Maargam: 0717 639 898 

Courage Compassion Commitment (CCC) Foundation: 1333