Sudden death, defined as an unexpected natural death occurring within a short time from the onset of symptoms, often within 24 hours, poses a significant challenge in forensic medicine. While sudden death can affect individuals across all age groups, its occurrence in elderly individuals is particularly complex due to age-related physiological changes, multiple comorbidities and often-subtle clinical presentations.^1-3 The elderly population is rapidly growing worldwide, with increased life expectancy leading to a higher prevalence of chronic diseases, frailty and multimorbidity- all of which may contribute to sudden and unexplained deaths.^4,5

In forensic practice, the investigation of sudden deaths in elderly individuals requires careful consideration of both natural and unnatural causes. Cardiovascular diseases, particularly ischemic heart disease and arrhythmias are frequently implicated; however, other underlying pathologies such as pulmonary embolism, intracranial hemorrhages, infections and undiagnosed malignancies may also be responsible. Furthermore, external factors, including medication use, environmental hazards, elder abuse and neglect, can contribute significantly to mortality in this age group but are often underrecognized.^6,7

Understanding the epidemiological and pathological patterns of sudden death in elderly populations is crucial for multiple reasons: it aids in the accurate determination of cause and manner of death, informs preventive healthcare strategies and has medico-legal and public health implications. Yet, in many cases, these deaths are certified without autopsy, potentially overlooking critical forensic or clinical findings. Cross-sectional forensic studies that incorporate comprehensive postmortem examinations provide valuable insight into the spectrum of underlying causes and risk factors associated with sudden death in the elderly.^8,9

This study aims to bridge the knowledge gap by conducting a cross-sectional analysis of forensic autopsy cases involving sudden death in elderly individuals. Our objectives are to identify the predominant causes, examine associated risk factors and highlight patterns that may inform both forensic investigations and geriatric care strategies. Through this research, we hope to enhance the accuracy of death certification, improve clinical vigilance and contribute to a broader understanding of mortality dynamics in aging populations.

Study Design and Setting

This study was designed as a retrospective cross-sectional analysis conducted at tertiary care teaching hospital. The study period extended over a period of two years duration, during which all cases of sudden and unexpected deaths in elderly individuals (≥60 years of age) subjected to medicolegal autopsy were reviewed.

Inclusion and Exclusion Criteria:

All cases meeting the following criteria were included in the study:

• Age ≥60 years at the time of death.
• Deaths categorized as sudden and unexpected, defined as natural deaths occurring within 24 hours of symptom onset or without prior known life-threatening illness.
• Complete autopsy conducted, including gross and histopathological examination.

Exclusion criteria included:

• Elderly deaths with a known terminal illness or prolonged hospitalization prior to death.
• Decomposed bodies where cause of death could not be determined due to autolysis or putrefaction.

Data Collection:

Data were collected from postmortem reports conducted by the authors, histopathological findings, police inquest reports, hospital records (if available) and toxicological analysis results. A structured data collection form was used to systematically record the following variables:

• Demographic data: Age, sex, residential area.
• Circumstantial data: Location of death (home, hospital, public place), time and manner of death, any known medical history, substance use history and reported symptoms prior to death.
• Autopsy findings: Gross anatomical observations, weight and condition of internal organs, presence of any trauma or injuries and evidence of external contributing factors (e.g., neglect, environmental exposure).
• Histopathological findings: Microscopic examination of vital organs (heart, lungs, brain, liver, kidneys) to confirm or identify pathological changes.
• Toxicological findings: Screening for alcohol and common poisons where forensically indicated.

Determination of Cause of Death

The cause of death was established based on a comprehensive synthesis of gross autopsy findings, histopathological examination and toxicological analysis. Cases were categorized into major groups based on the principal pathological diagnosis:

• Cardiovascular causes (e.g., myocardial infarction, coronary artery disease)
• Respiratory causes (e.g., pneumonia, pulmonary embolism)
• Central nervous system causes (e.g., intracranial hemorrhage, stroke)
• Gastrointestinal/hepatic causes (e.g., cirrhosis, GI bleed)
• Miscellaneous natural causes (e.g., diabetes complications, malignancies)
• Unnatural or contributory factors (e.g., trauma, poisoning, neglect)

Statistical Analysis

All collected data were entered into Microsoft Excel and analyzed using SPSS software version 25. Descriptive statistics were used to summarize the data, including means, medians and percentages. Associations between categorical variables (e.g., age group, sex, location of death and cause of death) were assessed using the chi-square test or Fisher’s exact test as appropriate. A p-value of <0.05 was considered statistically significant. Where applicable, logistic regression analysis was performed to identify independent risk factors associated with specific causes of sudden death.

Ethical Considerations

The study involved retrospective analysis of deceased individuals for forensic purposes, informed consent from next of kin was not applicable. Confidentiality of personal data and sensitive information was strictly maintained.

Table 1 presents the demographic characteristics of the study population comprising 180 elderly individuals who experienced sudden death. The majority of cases (48.3%) were in the 60–69-year age group, followed by 36.1% in the 70-79 years group and 15.6% aged 80 years or older. Males constituted a larger proportion of the study population (60%) compared to females (40%), suggesting a potential gender disparity in vulnerability to sudden death among the elderly. Most of the deceased (63.9%) resided in urban areas, while 36.1% were from rural settings, indicating that sudden deaths among the elderly are more commonly reported in urban populations, possibly due to better reporting systems and healthcare access in those regions.

Table 1: Demographic Characteristics of the Study Population

Table 2 outlines the primary causes of sudden death as determined by forensic investigation and autopsy. Cardiovascular causes were the leading contributors, accounting for 50% of all cases, with myocardial infarction (28.3%) and coronary artery disease (16.1%) being the most prevalent subtypes. Respiratory causes were identified in 20% of cases, including pulmonary embolism (10%) and pneumonia (7.8%). Central nervous system (CNS) causes such as intracranial hemorrhage and ischemic stroke were also significant, accounting for 16.1%. Gastrointestinal and hepatic causes (7.8%), miscellaneous natural causes like undiagnosed malignancy (3.9%) and a small fraction of unnatural causes including poisoning and environmental neglect (2.2%) were also observed. These findings highlight the predominance of natural, particularly cardiovascular, causes in sudden elderly mortality.

Table 2: Primary Causes of Sudden Death

Table 3 provides insight into the circumstantial data surrounding the sudden deaths. Most deaths (60%) occurred at home, followed by hospitals (20%) and public places (16.1%), indicating that many of these events happened outside of a medical setting. Interestingly, a higher proportion of deaths occurred during nighttime hours (52.2%) compared to daytime (40%), which may reflect circadian influences on physiological stress responses. Regarding reported symptoms prior to death, chest pain was the most frequently mentioned (32.2%), followed by dyspnea (20%) and syncope (12.2%), while in 27.8% of cases no symptoms were reported or known. These findings emphasize the often-silent or sudden onset nature of fatal events in the elderly, with many experiencing minimal or nonspecific symptoms before death.

Table 3: Circumstantial Data Related to Sudden Death

Table 4 details the histopathological findings observed in major organs during autopsy. In the heart, myocardial fibrosis (40%) and acute infarction (23.9%) were the most common findings, confirming chronic and acute ischemic heart disease as major contributors to mortality. Pulmonary edema (20%) and embolism (10%) were frequently seen in the lungs, indicating compromised cardiopulmonary function. In the brain, intracranial hemorrhage and cerebral infarction accounted for 10% and 6.1% of cases, respectively. Interestingly, a large majority (83.9%) of brains showed no significant pathology, underscoring the difficulty of diagnosing CNS causes without imaging or subtle clinical clues. Fatty liver and chronic kidney disease were the most common findings in the liver and kidneys, though most of these organs (80%) appeared normal, suggesting they were not the primary contributors in many cases.

Table 4: Histopathological Findings in Major Organs

Table 5 summarizes the toxicological analysis results, revealing that alcohol was detected in 21.1% of cases, while poisons such as organophosphates and aluminium phosphide were found in 1.1% and 1.1%, respectively. Notably, no substances were detected in 76.7% of the cases, suggesting that toxic agents were not a major contributor to most sudden deaths.

Table 5: Toxicological Findings

Table 6 presents the results of chi-square tests assessing statistical associations between demographic and circumstantial variables and causes of death. A significant association was observed between sex and cardiovascular causes (p = 0.020), with males more frequently affected. Similarly, older age groups (≥80 years) were more likely to die from CNS-related causes compared to younger elderly groups (p = 0.045). Respiratory causes were significantly more common in hospital deaths (p = 0.011), possibly reflecting a delayed or terminal presentation. Chest pain showed a strong association with cardiovascular causes (p < 0.001), confirming its diagnostic importance. However, no significant association was found between residential area (urban vs. rural) and unnatural causes (p = 0.069). These associations provide a deeper understanding of risk patterns and may inform targeted preventive strategies.

Table 6: Statistical Associations (Chi-Square Test Results)

Sudden death in the elderly population presents a complex and multifactorial challenge to both clinicians and forensic experts. This cross-sectional study conducted to explore the underlying causes, risk factors and associated circumstances of sudden death in individuals aged 60 years and above. The findings offer significant insights into the patterns of mortality in the aging population and emphasize the pivotal role of forensic autopsy in elucidating the cause of death in such cases.

Our study revealed that the majority of sudden deaths occurred in the 60-69 years age group (48.3%), with a progressive decline in numbers with increasing age. This trend suggests that while older age is generally associated with increased mortality risk, sudden and unexpected deaths may be more prevalent during the earlier phase of elderly life, possibly due to unrecognized chronic illnesses or inadequate preventive care. Males represented a larger proportion of the deceased (60%), aligning with findings from prior studies that have consistently reported a higher incidence of sudden cardiac death in elderly men, potentially due to a greater burden of cardiovascular risk factors such as hypertension, smoking and diabetes.^10-13

A striking finding in our study was the predominance of cardiovascular causes, accounting for 50% of sudden deaths. Myocardial infarction and coronary artery disease together contributed to over 44% of all cases, reaffirming their well-established role as the leading causes of mortality in the elderly. The high incidence of myocardial fibrosis (40%) and acute infarcts (23.9%) observed histopathologically further supports the silent progression of chronic ischemic heart disease, often culminating in fatal arrhythmias or acute coronary syndromes. This highlights the critical need for early diagnosis, aggressive management of modifiable risk factors and regular cardiovascular screening in geriatric care settings.

Respiratory causes constituted the second most common group (20%), with pulmonary embolism and pneumonia being the principal contributors. The association of respiratory causes with in-hospital deaths (p = 0.011) suggests that these individuals may have presented late to healthcare facilities, possibly with acute decompensation. These findings emphasize the importance of vigilant monitoring of respiratory symptoms, especially during hospital admissions and underline the fatal potential of common respiratory illnesses in the elderly.

Central nervous system causes such as intracranial hemorrhage and ischemic stroke were responsible for 16.1% of sudden deaths, with a statistically significant association seen in the ≥80 years age group (p = 0.045). Age-related vascular fragility, uncontrolled hypertension and anticoagulant use are likely contributing factors. Notably, while brain pathology was observed in a subset of cases, over 83% of the brain specimens had no significant findings, illustrating the limitations of postmortem diagnosis in the absence of advanced neuroimaging and suggesting that subtle functional abnormalities (e.g., arrhythmogenic seizures or neurogenic shock) may also play a role.

The circumstantial data revealed that most deaths occurred at home (60%), indicating that many of these individuals did not seek or reach medical attention in time. Furthermore, the finding that a significant proportion of deaths occurred at night (52.2%) suggests a possible role of autonomic instability, nocturnal arrhythmias or reduced access to emergency care during night hours.

Symptomatically, chest pain was the most commonly reported complaint prior to death and was strongly associated with cardiovascular causes (p < 0.001), reinforcing its clinical importance as a warning sign in elderly individuals. Dyspnea and syncope were also notable precursors, yet nearly 28% had no known symptoms, highlighting the unpredictable and often silent nature of sudden death in the elderly. This diagnostic uncertainty further validates the utility of comprehensive autopsies in unexplained geriatric deaths.

Unnatural causes, though limited to just 2.2%, included poisoning. Toxicological analysis revealed the presence of alcohol was found in 21.1% of cases, while poisoning with substances like organophosphates and Almuminium phosphide were rare but significant. Importantly, no substances were detected in 76.7% of the cases, ruling out exogenous toxicity in the majority of sudden deaths.

From a statistical standpoint, this study revealed meaningful associations between variables such as sex, age, location and reported symptoms with specific causes of death. These associations can help guide risk stratification and targeted prevention strategies, such as focused cardiovascular monitoring in males and younger elderly individuals, heightened awareness of CNS events in the oldest old and improved respiratory care in hospital settings.

In conclusion, our study underscores that cardiovascular diseases remain the predominant cause of sudden death in elderly individuals, followed by respiratory and CNS causes. A significant portion of these deaths occur without prior symptoms or medical attention, often in home settings. The findings reinforce the indispensable value of medicolegal autopsies in determining cause of death and call for proactive, multidisciplinary approaches in geriatric healthcare-spanning medical, social and forensic domains. Future research with larger multicenter cohorts and integration of clinical, biochemical and genetic data could further illuminate the underlying pathophysiological mechanisms and enhance preventive strategies for sudden death in the aging population.

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