Why are neuro checks performed in a skilled nursing facility after a fall, particularly in elderly patients with underlying medical conditions?

Why Neuro Checks Are Performed After Falls in Skilled Nursing Facilities

Neuro checks after falls in skilled nursing facilities are performed to detect occult head injury, intracranial hemorrhage, and neurological deterioration that may not be immediately apparent at the time of initial assessment, particularly in elderly patients who are at high risk for delayed complications.

Primary Purpose: Detection of Occult Intracranial Injury

The fundamental reason for serial neurological assessments after falls is that elderly patients can develop delayed intracranial hemorrhage or neurological deterioration hours to days after seemingly minor head trauma. 1 This is especially critical because:

• Elderly patients have age-related brain atrophy, which creates a larger potential space for blood accumulation before symptoms manifest 1
• Anticoagulation and antiplatelet medications (common in this population) increase bleeding risk and can lead to delayed hemorrhage 1
• Initial presentations may be deceptively benign, with serious injuries becoming apparent only through serial monitoring 1

What Neuro Checks Specifically Monitor For

Serial neurological assessments are designed to detect:

• Changes in level of consciousness or mental status - the earliest and most sensitive indicator of intracranial pressure changes 1
• New focal neurological deficits including weakness, sensory changes, or speech difficulties that suggest expanding hematoma 1
• Pupillary changes indicating brainstem compression or herniation 1
• Vital sign changes particularly Cushing's triad (hypertension, bradycardia, irregular respirations) suggesting increased intracranial pressure 1

The Evidence Behind Serial Monitoring

While the practice is widespread, the actual sensitivity of scheduled neurochecks is imperfect. Research shows that in stroke patients receiving hourly neurological assessments, deterioration was detected by scheduled neurochecks in only 45% of cases, with 26% detected outside scheduled assessments and 29% remaining undetected. 2 However, deterioration was significantly more likely to be detected during scheduled assessments than at other times (P < 0.05). 3

This imperfect sensitivity does not negate their value - rather, it emphasizes that:

• Scheduled assessments provide a structured framework that increases detection rates compared to no formal monitoring 3, 2
• Nursing staff awareness and vigilance between scheduled checks remains critical 2
• The alternative (no monitoring) would miss even more deteriorations 2

Fall-Specific Risk Factors Requiring Monitoring

All geriatric patients presenting after a fall require comprehensive head-to-toe evaluation for injuries, including those with seemingly isolated complaints, because occult injuries are common. 1 The assessment must determine whether the fall resulted from:

• Loss of consciousness or altered mental status - suggesting possible syncope, seizure, or intracranial event 1
• Neurological causes including stroke, seizure, or progression of underlying neurological disease 1, 4
• Mechanical causes in a patient who would not have fallen if they were a healthy 20-year-old 1

Patients with neurological causes of falls demonstrate more frequent falls, worse functional and mental status, and greater comorbidity compared to those with non-neurological causes. 4

Duration and Frequency of Monitoring

While specific protocols vary by facility, the critical monitoring period is typically:

• First 24-72 hours post-fall when delayed hemorrhage is most likely to manifest 1, 2
• Hourly assessments are common in acute settings, though evidence suggests this frequency may not be optimal for all patients 3, 2
• Higher-risk patients (those on anticoagulation, with witnessed head strike, or initial symptoms) warrant more intensive monitoring 1

Common Pitfalls to Avoid

Do not assume a normal initial examination excludes serious injury - delayed deterioration can occur even after initially normal presentations, particularly in anticoagulated patients. 1

Do not rely solely on scheduled neurochecks - nursing staff must maintain vigilance between scheduled assessments, as significant deterioration is often detected outside scheduled times. 2

Do not dismiss subtle changes - small alterations in mental status, new confusion, or mild focal findings may represent early signs of expanding intracranial hemorrhage requiring immediate imaging and intervention. 1, 2

Integration with Comprehensive Fall Assessment

Neuro checks are one component of comprehensive post-fall care, which must also include:

• Orthostatic blood pressure assessment to identify postural hypotension as a fall mechanism 1
• Medication review with attention to vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1
• Gait and balance evaluation by physical therapy, as all patients admitted after falls require PT/OT assessment 1
• Assessment for other injuries including fractures, particularly in patients unable to bear weight 1

The neurological monitoring specifically addresses the potentially life-threatening complications of head trauma, while the broader assessment addresses fall prevention and identifies the underlying cause. 1