What are the complications of an elderly patient hitting their head from a fall?

Complications of Elderly Patients Hitting Head from Fall

Elderly patients who hit their head from a fall face life-threatening complications including intracranial hemorrhage (occurring in 7-9% of cases), with particularly high mortality risk in those on anticoagulation, where 29% develop intracranial bleeding even with minor trauma and normal mental status. 1, 2

Immediate Life-Threatening Complications

Intracranial Hemorrhage

• Subdural hematoma is the most common intracranial injury, occurring even from ground-level falls due to brain atrophy creating increased space for bridging vein tearing 3, 2
• Subarachnoid hemorrhage is the second most frequent injury pattern in elderly fall victims 2
• Ground-level falls—despite being "low-energy" mechanisms—account for 34.6% of all trauma deaths in patients ≥65 years 1, 3
• Mortality rates from ground-level falls reach 7% in this age group, with 10-30% sustaining polytrauma 1

Anticoagulation Dramatically Amplifies Risk

• 30% of elderly patients who died from ground-level falls were on anticoagulation (aspirin, warfarin, clopidogrel, heparin, or combinations) 1, 3
• Among patients on anticoagulation with minor head injury (GCS 15), 29% developed intracranial hemorrhage 1
• Clopidogrel carries the highest mortality risk (OR 14.7) after traumatic intracranial hemorrhage, with 3.25 times higher odds of requiring long-term facility care 1
• Warfarin use significantly increases mortality in patients >65 years even with mild head injuries (GCS 14-15) 1

Delayed Deterioration and Occult Injury

Physiologic Masking of Severity

• 42% of elderly trauma patients have occult hypotension despite "normal" vital signs by standard criteria 1
• Standard physiologic triage parameters (blood pressure, heart rate) are unreliable predictors of mortality or need for intervention in elderly patients 1
• Mortality increases when systolic blood pressure drops below 110 mmHg (not the standard 90 mmHg) in patients ≥65 years 1, 3
• 14.8% of elderly patients with significant injuries present with no high-risk clinical criteria beyond age alone 2

Rapid Decompensation Pattern

• Anticoagulated patients with head injury can undergo rapid decompensation even when initially stable 1
• Clinical evaluation frequently fails to identify patients with significant injuries, requiring low threshold for imaging 2

Skeletal and Multi-System Injuries

Fracture Patterns

• 6% of ground-level falls result in fractures, with elderly patients particularly prone to cervical spine, rib, hip, and extremity fractures 1
• Rib fractures can exacerbate preexisting cardiopulmonary disease, increasing risk of pneumonia and respiratory failure 1

Short-Term Recurrent Fall Risk

Repeat Fall Complications

• 14.1% of elderly fall patients return to the ED within 14 days, with 2.6% sustaining a new injury 4
• Patients with dementia have 3-fold increased odds (OR 3.02) of sustaining a new injury leading to repeat ED visit within 14 days 4
• History of stroke increases repeat fall risk (OR 2.12) 4
• A history of falls is the strongest risk factor for future falls (relative risk 3.0, range 1.7-7.0) 5

Poor Functional Outcomes After Intervention

Neurosurgical Intervention Outcomes

• Among elderly patients requiring neurosurgical intervention, only 16.4% return home 2
• 32.1% require extended facility care (nursing home or rehabilitation) 2
• 41.8% die from their injuries despite neurosurgical intervention 2

Long-Term Morbidity

• Falls are associated with considerable morbidity, reduced functioning, and premature nursing home admissions 5
• Falls are the leading cause of injury-related death among adults ≥65 years in the USA 5

Critical Undertriage Problem

System-Level Failure

• Elderly patients have 49.9% undertriage rate compared to 17.8% in younger patients 1
• Transport to trauma centers decreases starting at age 50 (OR 0.67), with further decrease at age 70 (OR 0.45) 1
• Trauma team activation occurs less frequently for patients >65 years despite higher injury severity 1

High-Risk Clinical Features Requiring Immediate Action

Predictors of Intracranial Injury

• Loss of consciousness (OR 2.02-2.8) and signs of head trauma (OR 2.6-13.2) are the strongest predictors of intracranial injury 6, 7
• Combined sensitivity of these features is 86.5% with negative predictive value of 97.3% 7
• Notably, history of head strike, headache, and anticoagulant use alone were not independently predictive of intracranial injury in multivariate analysis 6, 7

Comorbidity Amplification

Baseline Vulnerability

• 80% of geriatric trauma patients have at least one chronic disease (hypertension, arthritis, heart disease, pulmonary disease, cancer, diabetes, stroke history) 1
• Comorbidities combined with frailty create vulnerability to stress that younger patients can tolerate 1
• Age-related anatomical changes (decreased muscle mass, bone density, joint flexibility) and physiological changes (decreased vision, hearing, slower reflexes, impaired balance and cognition) make even minor trauma potentially catastrophic 1

Common Pitfalls to Avoid

• Do not use standard vital sign cutoffs—systolic BP <110 mmHg represents shock in elderly patients, not <90 mmHg 1, 3
• Do not dismiss ground-level falls as "low-risk"—they account for over one-third of elderly trauma deaths 1, 3
• Do not rely on normal mental status to exclude serious injury—14.8% of patients with significant injuries have no high-risk features except age 2
• Do not delay imaging in anticoagulated patients—transport immediately to facilities capable of rapid CT and anticoagulation reversal 1
• Do not assume normal initial presentation means safety—occult hypotension is present in 42% despite normal vital signs 1