INTRODUCTION: The older adult population is the world's fastest-expanding demographic, presenting unique issues to trauma teams. Age-related physiological changes, such as decreased reflexes and diminished functional reserve, predispose elderly individuals to poor outcomes after trauma. One study in high-income countries reported a long-term mortality of 33% in older adults. There is a lack of evidence for long-term mortality after trauma in older adults in low- and middle-income countries. This study aims to report the long-term mortality rates and identify risk factors contributing to increased mortality among elderly trauma patients. METHODS: We conducted a prospective cohort study with a multi-center trauma registry in Pakistan. The registry collected data on all adult (>18 y) trauma patients admitted to the ward, high dependency unit, and intensive care unit, warranting a stay of >24 h in 2 tertiary care hospitals in Karachi from December 2021 to May 2023. These patients were followed at 1, 3, 6, and 12 mo. We defined older adult patients as those aged 60 y and above. Logistic regression was used to obtain the odds ratio (OR) and 95% confidence interval (CI) for mortality. RESULTS: A total of 651 patient records (mean age of 69.23 + 8.28 y, 382 [59%] males) of older adults with trauma were analyzed. The main mechanism of injury was falls (64%), followed by road traffic crashes (RTCs) (36%). Most of the patients had a moderate injury (58%), and a considerable number had a severe injury (19%). Extremity injuries were the most common (n = 368, 58%), followed by head and neck (n = 239, 38%). Nearly half of the patients received surgical intervention (49.31%). The in-hospital mortality rate was 17%. By the end of 1 y, 39% of the patients remained alive and 33.6% died; after accounting for 27% loss to follow-up, the cumulative mortality recorded was 46.2%. The RTC victim type showed that 45% of RTC victims were Pedestrians. Of the patients acquiring head injuries, 71.51% experienced mortality. RTCs, severe injuries, no surgical intervention, and abnormal pulse had higher mortality. Multivariable analysis showed significantly higher odds of mortality among >70 y (adjusted OR [AOR]: 2.56; 95% CI: 1.44-4.68), head injury (AOR: 2.27; 95% CI: 1.03-5.0), severe injury severity score (AOR: 2.39; 95% CI: 1.04-5.54), and no surgical intervention (AOR: 1.79; 95% CI: 1.05-3.03). CONCLUSIONS: This study reports that approximately one-half of the older adult patients die within 1 y after trauma.