# Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults

Xavier Dubucs, Éric Mercier, Valérie Boucher, Samuel Lauzon, Frederic Balen, Sandrine Charpentier, Marcel Emond

► To cite this version:

Xavier Dubucs, Éric Mercier, Valérie Boucher, Samuel Lauzon, Frederic Balen, et al. "Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults." Journal of Emergency Medicine, 2024, 66 (5), pp.e606-e613. 10.1016/j.jemermed.2024.01.005. hal-04948699

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# Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults

Xavier Dubucs, MD, MSC,*,†,‡,§ Éric Mercier, MD, MSC,*,|| Valérie Boucher, MSC,* Samuel Lauzon,†
Frederic Balen, MD,‡,§ Sandrine Charpentier, MD, PHD,‡,§ and Marcel Emond, MD, MSC*,†

*Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada, †Université Laval, Québec, Québec, Canada, ‡Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France, §Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France, and ||VITAM, Centre de Recherche en Santé Durable de l'Université Laval, Québec, Québec, Canada

Reprint Address: Xavier Dubucs, MD, MSC, Pôle Médecine d'Urgence, Centre Hospitalier Universitaire Toulouse, Place du Dr Joseph Baylac, 31300, Toulouse, France

□ Abstract—Background: Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury. Objective: This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages. Methods: We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1–3), vulnerable-frail (CFS score 4–6), and severely frail (CFS score 7–9). Results: A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4–16.8]; *p* = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44–3.45; *p* = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41–13.6;

*p* = 0.34) in those considered severely frail. Conclusions: This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty. © 2024 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

□ Keywords—Older adults; Traumatic brain injury; Ground-level fall; Frailty

## Introduction

Head traumas are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury (1,2). The increasing incidence of this type of trauma in the geriatric population, including those living in nursing homes, has been described in recent literature (3,4).

Among older adult patients admitted to emergency departments (EDs) after a fall, head trauma is the most prevalent injury, reaching 25–42% (5,6). The literature is
still unclear on the potential predictive factors of head im-
pact. Some studies have suggested that fall mechanism,
preinjury cognitive impairment, iatrogenic events (i.e.,
antipsychotic, antidepressant), living place, and patient
mobility may be of interest (4,7–13).

In older patients, the presence of signs of trauma to the
head has been linked to several outcomes, such as cervi-
cal spine injuries, acute computed tomography (CT) scan
findings in older patients with delirium, and intracranial
hemorrhage (ICH) in older adults who sustained a head
trauma after a fall (14–20). Regarding ICH related to head
trauma, it was recently suggested that the impact location
(e.g., visible head injury, such as bruising, laceration, and
hematomas) might help to identify patients at higher risk
of ICH (21,22). Thus, according to impact location, ICH
prevalence among older patients who sustained a ground-
level fall-related head trauma is 3.5% in patients with
facial impact, 8.6% with frontal impact, and 13.6% in pa-
tients with temporal-parietal or occipital impact (23). In
addition, it has been suggested than the impact location
may be associated with ICH characteristics (24,25). For
instance, Post et al. reported an increased risk of incur-
ring a subdural hematoma in adult patients with frontal or
occipital regions, and parenchymal contusions in patients
with impact on the side of the head (25). In patients with
moderate or severe traumatic brain injury (TBI), Cepeda
et al. found a statistically significant association between
frontal ICH and impact sites located on the anterior area
of the head; the temporal ICH location was significantly
associated with impact located on the posterior head area
(24).

Frailty is prevalent in older ED patients (26). Often de-
scribed as a decline in physiologic reserve and function,
this multidimensional geriatric syndrome has been asso-
ciated with several outcomes, such as early readmission
after an ED visit, in-hospital mortality, poor clinical out-
come after cardiac arrest, or relocation in nursing homes
(27–29). Links among frailty, TBI, and falls among older
patients have not yet been well studied. The impact of
frailty on TBI has only been studied among patients with
ICHs. Tang et al. found that frail patients with ICH ex-
hibited a higher risk of complication and mortality (30).
A recent literature review indicated that frail older adults
were more likely to experience poorer long-term out-
comes from TBI (31). Furthermore, among older patients,
frailty was recently associated with readmission after in-
dex admission for fall trauma-related injury (32). These
results suggest that we need to detect the frailty of older
patients admitted to EDs for falls.

This study aimed to assess whether frailty is associated
with the head impact location among older patients who
sustained a ground-level fall-related, mild TBI. The sec-
ondary objective was to measure the association between
frailty and ICH.

**Materials and Methods**

Study Design and Setting

This was a planned sub-analysis of a prospective
observational study conducted in two urban university-
affiliated EDs (21). The aim of the main study was to
assess ICH prevalence among older patients admitted at
the ED after a mild TBI.

Participants

In this sub-analysis, only patients sustaining ground-
level fall–related, mild TBI were included. Patients 65
years and older with a head trauma and Glasgow Coma
Scale (GCS) score ≥ 13 on arrival were included. Patients
with head CT scan performed before arrival were not in-
cluded.

Data Collection and Study Variables

Upon initial ED presentation, the treating emergency
physician assessed patient eligibility and collected so-
ciodemographic data (i.e., sex, age, and living situation)
using a standardized form. Information regarding prein-
jury psychoactive drug use (i.e., benzodiazepines, antide-
pressants, neuroleptics, and antiepileptics) and cognitive
impairment in case of a recent (≤ 1 year) diagnosis in the
medical file with a Mini-Mental State Examination score
< 24/30 were reported (33). The suspected precipitating
factors of a ground-level fall were also compiled (e.g., en-
vironmental, faintness or vertigo, and syncope). Frailty
was also prospectively assessed in the ED by the treating
physician using the Clinical Frailty Scale (CFS), a widely
used and validated 9-item scale ranging from 1 (very fit)
to 9 (terminally ill) (34).

Outcome Measures

This study's main outcome, the impact location, was
systematically reported and categorized by the treating
emergency physician as follows: no cutaneous impact,
facial impact, frontal impact, temporal-parietal-occipital
impact (Supplementary Figure 1) (21). Head impact lo-
cation was reported by the treating physician before head
CT scan (21).

The secondary outcome was the presence of ICH on
head CT scan performed in the ED and interpreted by a
neuroradiologist as part of routine care.

Statistical Analyses

Patients were stratified into the following three groups
according to their CFS scores: robust (CFS score 1–
3), vulnerable-frail (CFS score 4–6), and severely frail
<table><caption>Table 1. Patient Characteristics on Emergency Department Admission.</caption><thead><tr><th>Characteristic</th><th>Overall<br>(n = 335)</th></tr></thead><tbody><tr><td>Age (years), mean ± SD (n = 335)</td><td>86.9 ± 8.1</td></tr><tr><td>Sex (female), n (%) (n = 335)</td><td>227 (67.8)</td></tr><tr><td>Living condition, n (%) (n = 335)</td><td></td></tr><tr><td>Community-dwelling</td><td>201 (60.0)</td></tr><tr><td>Nursing home</td><td>134 (40.0)</td></tr><tr><td>Antiplatelets, n (%) (n = 335)</td><td>127 (37.9)</td></tr><tr><td>Anticoagulants, n (%) (n = 333)</td><td>122 (36.4)</td></tr><tr><td>Cognitive impairment, n (%) (n = 324)</td><td>105 (32.4)</td></tr><tr><td>Psychoactive medication, n (%) (n = 328)</td><td></td></tr><tr><td>Benzodiazepine</td><td>93 (28.4)</td></tr><tr><td>Antidepressant</td><td>62 (18.9)</td></tr><tr><td>Neuroleptic</td><td>17 (5.2)</td></tr><tr><td>Antiepileptic</td><td>11 (3.3)</td></tr><tr><td>Frailty assessment, n (%) (n = 335)</td><td></td></tr><tr><td>Robust (CFS 1–3)</td><td>81 (24.2)</td></tr><tr><td>Vulnerable-frail (CFS 4–6)</td><td>239 (71.3)</td></tr><tr><td>Severely frail (CFS ≥ 7)</td><td>15 (4.5)</td></tr><tr><td>Mechanism of injury, n (%) (n = 335)</td><td></td></tr><tr><td>Environmental falls</td><td>164 (49.0)</td></tr><tr><td>Faintness or vertigo</td><td>26 (7.8)</td></tr><tr><td>Syncope</td><td>12 (3.6)</td></tr><tr><td>Unknown</td><td>133 (39.7)</td></tr></tbody></table>

CFS = Clinical Frailty Scale

(CFS score 7–9). The proportion of impact location was computed for each group. The odds ratio (OR) for each defined impact location were computed using univariate analysis and then adjusted for factors reported in the literature (e.g., sex, age, cognitive impairment, preinjury psychoactive drugs use, and mechanism of injury) using multivariable logistic regression (4,7–13). The ORs of ICHs were compared among the three groups using univariate analysis. All analyses were performed with Stata SE software, version 17.0.

## Ethics

Patients, or their relatives in case of pre-existing cognitive impairment, were informed that their data would be used in the study. The Toulouse University Hospital signed a commitment of compliance to the reference methodology MR-004 of the National Commission for Informatics and Liberties (CNIL number: RnIPH 2019–82). The Research Ethics Board of Toulouse University Hospital Center approved this study.

## Results

A total of 365 patients with mild TBI were included in the main study (21). Among those patients, 335 presented with a mild TBI after a ground-level fall and thus were included in our analyses. Mean ± SD age of our patients was 86.9 ± 8.1 years and 67.8% (n = 227) were women. Nursing home residents accounted for 40% (n = 134) of our cohort. Overall, 38.8% (n = 130) had taken at least one preinjury psychoactive drug (benzodiazepine [27.8%, n = 93], antidepressant [18.5%, n = 62], neuroleptic [5.1%, n = 17], antiepileptic [3.3%, n = 11]) (Table 1). Environmental falls were the main mechanism of injury, occurring in 49.0% of patients (n = 164), followed by faintness or vertigo (7.8%, n = 26) and syncope (3.6%, n = 12). The mechanism of fall was unknown in 133 patients (39.7%). Overall, 81 patients (24.2%) were considered robust, 239 patients (71.3%) were vulnerable-frail and 15 patients (4.5%) were severely frail.

Most of our included patients (89.9%, n = 301) had at least one external sign of head trauma and 116 patients had no external sign of head trauma.
<table><caption>Table 2. Odds Ratio of Frontal, Facial, and Temporal-Parietal-Occipital Impact Using Univariate and Multivariable Analysis.</caption><thead><tr><th rowspan="3">CFS Score</th><th colspan="4">Frontal Impact vs. Other</th><th colspan="4">Facial Impact vs. Other</th><th colspan="4">Temporal-Parietal-Occipital Impact vs. Other</th></tr><tr><th colspan="2">Univariate Analysis</th><th colspan="2">Multivariable* Analysis</th><th colspan="2">Univariate Analysis</th><th colspan="2">Multivariable* Analysis</th><th colspan="2">Univariate Analysis</th><th colspan="2">Multivariable* Analysis</th></tr><tr><th>OR (95% CI)</th><th>p Value</th><th>OR (95% CI)</th><th>p Value</th><th>OR (95% CI)</th><th>p Value</th><th>OR (95% CI)</th><th>p Value</th><th>OR (95% CI)</th><th>p Value</th><th>OR (95% CI)</th><th>p Value</th></tr></thead><tbody><tr><td>1–3</td><td>1</td><td>—</td><td>1</td><td>—</td><td>1</td><td>—</td><td>1</td><td>—</td><td>1</td><td>—</td><td>1</td><td>—</td></tr><tr><td>4–6</td><td>1.05<br>(0.93–1.20)</td><td>0.45</td><td>1.78<br>(0.98–3.22)</td><td>0.06</td><td>0.99<br>(0.86–1.15)</td><td>0.94</td><td>0.77<br>(0.4–1.47)</td><td>0.43</td><td>0.89<br>(0.75–1.05)</td><td>0.14</td><td>0.63<br>(0.34–1.18)</td><td>0.15</td></tr><tr><td>7–9</td><td>2.19<br>(0.85–5.67)</td><td>0.09</td><td>4.8<br>(1.40–16.81)</td><td>0.01</td><td>0.52<br>(0.13–2.1)</td><td>0.34</td><td>0.29<br>(0.05–1.55)</td><td>0.15</td><td>0.61<br>(0.19–1.98)</td><td>0.39</td><td>0.58<br>(0.14–2.47)</td><td>0.46</td></tr></tbody></table>

CFS = Clinical Frailty Scale; OR = odds ratio.

* Adjusted for sex, age, fall mechanism, cognitive impairment, and preinjury psychoactive drugs.
<figure><img src="image_4.png" /><figcaption>**Figure 1.** Impact location prevalence (%) according to Clinical Frailty Scale (CFS) score.</figcaption></figure>

tients (34.6%) had a wound requiring a suture. Impact locations were as follows: 23.9% facial (n = 80), 41.5% frontal (n = 139), and 24.5% temporal-parietal-occipital (n = 82). As shown in Figure 1, the proportion of frontal impact increased with the CFS score, whereas the proportion of temporal-parietal-occipital impact decreased with the level of frailty. As shown in Table 2, the multivariable analysis showed a significant association between severe frailty and the frontal impact (OR 4.8 [95% CI 1.4–16.8]; *p* = 0.01).

ICHs were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The ORs of ICHs were 1.24 (95% CI, 0.44–3.45; *p* = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41–13.6; *p* = 0.34) in those considered as severely frail.

## Discussion

Our results suggest that the head impact location in older adults who sustained a ground-level fall-related, mild TBI is associated with their level of frailty: frontal impact seems more prevalent in severely frail patients and temporal-parietal-occipital is less prevalent in those patients. Our results suggest that impact location can help physicians identify frail patients admitted for head trauma after a fall.

Several potential factors could explain this association between frailty and impact location. First, postural reflexes could be decreased among frail and severely frail patients. Based on video capture of real-life falls, some authors found that the lack of postural response, such as rotation to land sideways during the fall, was associated with an increased risk of head injury (10). A potential lack of rotation in frail and severely frail patients during a ground-level fall may increase the incidence of frontal impact in this population. Furthermore, age-related declines to the neck musculature may result in the inability of older adults to control their head during a fall (35). We can hypothesize that frail patients have less neck musculature, which explains their different impact location compared with robust patients. Other authors also suggested that the

odds of head impact were lower in nursing home residents who were holding on to objects (commonly chairs or wheelchairs) during their falls (7). Thus, compared with fit patients, frail patients might be unable to hold on to objects, thus explaining the difference in head impact location after a fall. Furthermore, fall direction was found to be associated with patient functional status; thus, the head impact location may partially reflect the initial fall direction (4,9).

Although not statistically significant, the prevalence of ICHs did seem to increase with the level of frailty. Among older patients, high level of frailty was recently linked as a predictor factor of 1-year mortality after traumatic injury (32). In addition, among patients with traumatic ICH, Tang et al. reported that frail patients exhibited a higher risk of complications (30). These results support the need to assess frailty in older patients admitted for TBI.

## Limitations

Our study has limitations. This was a sub-analysis of a larger prospective study, so the sample size was not calibrated for these analyses. This could explain a lack of power to show a significant difference in ICH according to the level of frailty. Also, the initial direction of the fall, or whether patients were holding on to objects, was not reported. In addition, a misclassification bias might have been introduced because CFS was measured during the ED stay (36).

## Conclusions

This is the first study aiming to assess whether frailty in older patients who sustained a ground-level fall-related, mild TBI is associated with the head impact location. Our results suggest that head impact location after a fall can help physicians identify frail patients; frontal impact seems more prevalent in severely frail patients and temporal-parietal-occipital is less prevalent in those patients. Further research is needed to determine the value of integrating these findings into the care of older adults after a fall.

## Declaration of competing interest

None.

## CRediT authorship contribution statement

**Xavier Dubucs:** Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. **Éric Mercier:** Methodology, Writing – original draft, Writing – review & editing. **Valérie Boucher:**
Formal analysis, Supervision, Writing – original draft, Writing – review & editing. **Samuel Lauzon:** Writing – review & editing. **Frederic Balen:** Methodology, Project administration, Writing – review & editing. **Sandrine Charpentier:** Supervision, Writing – review & editing. **Marcel Emond:** Formal analysis, Supervision, Writing – original draft, Writing – review & editing.

## Acknowledgments

Xavier Dubucs received a scholarship from the Centre d'Excellence sur le Vieillissement de Québec in 2023.

## Supplementary Materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jemermed. 2024.01.005.

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## Article Summary

**1. Why is this topic important?**

Mild traumatic brain injuries are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury. A high proportion of older patients who consulted in the emergency department are also frail, and this multidimensional geriatric syndrome has been associated with several outcome.

**2. What does this study attempt to show?**

The objective of this study was to assess whether frailty is associated with head impact location and intracranial hemorrhages among older patients who sustained a ground-level fall-related mild traumatic brain injury and were admitted at the emergency department.

**3. What are the key findings?**

This study found that the proportion of frontal impact increased with Clinical Frailty Scale score, and the proportion of temporal-parietal-occipital impact decreased with the level of frailty. Although not statistically significant, the prevalence of intracranial hemorrhage did seem to increase with the level of frailty as well.

**4. How is patient care impacted?**

Head impact location in older adults who sustained a ground-level fall was associated with their level of frailty. Our results suggest that impact location can help physicians identify frail patients admitted for head trauma after a fall. Patient care would benefit from frailty-level assessment in the emergency department to inform disposition and level of care required for older patients.