Intracranial Hemorrhage in Older Adults: Implications for Fall Risk Assessment and Prevention

Every second, an older person in the United States falls; and every 20 minutes, one of them dies. Falls are one of the leading causes of morbidity and mortality from injury in the older population. Approximately one in four Americans older than 65 years falls each year, accounting for approximately 27,000 deaths, 2.8 million emergency department (ED) visits, 800,000 hospitalizations yearly, and 50 billion dollars in medical costs. Fall prevention can be successfully implemented on a population basis by encouraging healthcare providers to use evidence-based interventions. However, these efforts are often inadequate, and physicians need to do more to effectively use existing guidelines and tools to prevent these potentially devastating and costly events. Among the worst outcomes from a fall are traumatic brain injury (TBI) and intracranial hemorrhage (ICH). TBI in older patients is due to falls in 70% of cases and increases to 85% in patients older than 85 years. Mortality in older TBI patients is as high as 16%. Moreover, TBI occurrence in older people has increased disproportionately compared to population growth. Because an increasing number of older people are also being treated with anticoagulant medications for a variety of conditions, increased morbidity and mortality from ICH is a growing concern. In this issue of the Journal of the American Geriatrics Society (JAGS), two articles raise important questions about ICH related to falls in the older population. First, how common is ICH after a fall? Second, does anticoagulation increase the risk of ICH after a fall? Third, what is the appropriate evaluation and management strategy for older people who fall and present to the ED? Both studies included large cohorts of older (aged >65 years) patients who fell, and reveal substantial rates of ICH (5% and 6.9%) from “low-impact” falls. The vast majority were ground level falls. Previous research has reported a 2.3% rate of ICH in low-risk head injury patients (Glasgow Coma Scale of 15, no neurologic findings, no visible wounds, and no coagulation diseases or medications) and 11% in hospitalized head trauma patients. Despite this potential for ICH in older adults, falls from ground level are often perceived as minor. This type of injury involves relatively low energy, especially compared to other mechanisms, such as motor vehicle accidents. Consequently, these events often are overlooked as opposed to being a red flag for potential TBI and ICH, or an opportunity to assess fall risk and prevention of future recurrences. One of the most frequent clinical conundrums in the practice of geriatrics is patients at high risk for falls who also have indications for anticoagulation. Clinicians often discontinue anticoagulants in older people who fall, especially among those who fall recurrently, out of concern for ICH and severe hematomas in other parts of the body. Prior research on the risks of anticoagulation in patients who experience head injury has reported mixed results. Some studies suggest that the incidence of ICH is more common and outcomes are worse when they occur in patients on anticoagulation. Others report that the incidence of ICH with anticoagulation is unchanged. These studies, in general, are limited as most are retrospective, have relatively low numbers of subjects, or have other methodologic limitations. Both studies in this issue of JAGS showed no association between anticoagulation and ICH after a fall—although they were limited by relatively low numbers of ICH in patients on anticoagulation. While there continues to be controversy, the critical issue surrounding the use of anticoagulation centers around risk and benefit. Patients with atrial fibrillation have a stroke risk of approximately 6% to 8% per year. The risk of ICH after minor head trauma from a fall in an anticoagulated patient is approximately 9%. Some data suggest that when an ICH occurs on anticoagulation, the morbidity and mortality is worse than among patients not on these drugs. Although the question of risk/benefit for anticoagulation is still not answered, the two new studies add information regarding this issue, and highlight the need for additional studies examining ICH risk in older patients on anticoagulants who are at risk for falls. What are the implications of these studies for the management of older people presenting to the ED after a fall? The American College of Emergency Physicians has a guideline for the establishment of geriatric EDs (GEDs) with specific recommendations about the management of older patients who have fallen. The recommendations include a head-totoe assessment of all patients, even those with a seemingly Editorial Based on JAGS 0912 and JAGS 1466