Initial Assessment for a 75-Year-Old Who Fell and Hit Their Head
The initial assessment for a 75-year-old who fell and hit their head must include a head CT scan, neurological examination, assessment of vital signs with special attention to orthostatic changes, medication review with focus on anticoagulants, and evaluation of fall circumstances.
Immediate Clinical Assessment
Neurological Evaluation
- Perform detailed neurological examination including:
- Glasgow Coma Scale (GCS) assessment
- Pupillary response
- Motor and sensory function
- Focal neurological deficits
- Signs of head trauma (contusions, lacerations, hematomas)
- Mental status assessment (even if at baseline)
Vital Signs Assessment
- Complete set of vital signs with special attention to:
- Blood pressure (note: SBP <110 mmHg might represent shock in older adults) 1
- Orthostatic vital signs (significant drop may indicate volume depletion or autonomic dysfunction)
- Heart rate and rhythm (to detect arrhythmias)
- Respiratory rate and oxygen saturation
History Elements
- Detailed fall circumstances:
- Medication review:
- Past medical history:
- Previous falls in the past year
- Comorbidities (dementia, Parkinson's, stroke, diabetes, depression) 1
- Visual or neurological impairments
Imaging
- Non-contrast head CT scan is indicated for all 75-year-old patients with head trauma, regardless of severity, based on the following criteria 1:
- Age >60 years is a Level A recommendation for CT in patients with head trauma
- Age >65 years is a Level B recommendation even without loss of consciousness
- Patients on anticoagulants/antiplatelets require CT scan regardless of trauma severity 1
Physical Examination
- Complete head-to-toe examination (even for seemingly isolated injuries) 1
- Musculoskeletal assessment:
- Joint range of motion
- Muscle strength testing
- Gait pattern evaluation
- Mobility assessment:
- "Get Up and Go Test" - observe as patient stands from chair without using arms, walks several paces, and returns 1
- Patients with difficulty or unsteadiness require further assessment
Laboratory Testing
Consider targeted laboratory testing:
- Complete blood count
- Comprehensive metabolic panel
- Coagulation studies (especially if on anticoagulants)
- Cardiac markers if cardiac symptoms present
Special Considerations
Anticoagulation
- Patients on anticoagulants with head trauma are at high risk for rapid deterioration 1
- Lower threshold for admission and extended observation
- Consider repeat head CT if on anticoagulants, even with initial negative scan
Occult Injury Risk
- Older adults may have severe injuries despite "normal" vital signs 1
- Consider occult hypotension (decreased perfusion not evident by standard vital signs) 1
- Low-energy mechanisms (ground-level falls) can result in severe injury in older adults 1
Disposition Decision
- Consider admission for:
- Abnormal head CT findings
- Anticoagulant/antiplatelet use with head trauma
- Inability to safely ambulate
- Inadequate home support
- Focal neurological deficits
- Persistent symptoms
Follow-up Planning
- Expedited outpatient follow-up including home safety assessment for discharged patients 1
- Fall prevention education
- Medication review and adjustment
- Consider physical therapy referral for gait/balance issues
Remember that older adults are at higher risk for undertriage and occult injuries. The presence of signs of head trauma and history of loss of consciousness are the strongest predictors of intracranial injury in this population 2.