Grimm, Dawn RN, MSN, CCNS, CCRN; Mion, Lorraine C. RN, PhD
Falls among older adults are common and dangerous, with known significant morbidity and mortality.1 Approximately one-third of community-dwelling older adults will fall each year. Twenty percent to 30% of falls result in moderate to severe injuries, including traumatic brain injury (TBI), cervical fractures, and spinal injury.2 Falls are the most common cause of hospital admissions for trauma among older adults and are the fifth leading cause of death in older adults. Older adults injured from falls and admitted to the hospital are significantly more likely to be discharged to long-term care than other age-matched patients admitted to the hospital from the emergency department (ED) for other conditions.2,3 In 2000, $19 billion was spent on fall-related injuries for people aged 65 years and older.2 By 2030, nearly 1 in 5 Americans will be aged 65 years or older. The oldest old, age 85 and greater, is expected to double from 7 million in 2020 to almost 14 million in 2040.4 With the “graying” of America, falls in the older adult population will continue to rise and impact the health care system. As a result, the annual direct and indirect costs from falls among older adults are expected to reach $54.9 billion by 2020.2
Not only are falls common among older adults residing in the community, but they are also common and significant adverse events in hospitals. About 2% to 3% of hospitalized patients fall during their stay, resulting in more than 1 million hospital falls annually.5 Among older adults, falls are especially dangerous with known morbidity and mortality. This is especially worrisome because adults who are 75 years and older now comprise 22% of all hospital admissions.6 Approximately 10% of hospital falls result in serious injury, impacting 100 000 adult patients annually.5
Significant costs are associated with hospital falls including health care costs, increased length of stay (LOS), and liability. One study found that hospital patients who fell and sustained an injury stayed 12 days longer and had concomitantly higher costs than comparison patients, after adjustment for potential clinical and nonclinical confounders.7 In 2008, the Centers for Medicare and Medicaid Services eliminated payment to hospitals for costs incurred in treating injuries resulting from hospital falls.8 Thus, hospital administrators and clinical leaders strongly promote fall-prevention strategies. Nurses are the primary health care professionals who determine a patient's risk for falling and implement fall-prevention strategies.5 This article provides an overview of trauma injuries in community-dwelling older adults who fall, specifically TBI and cervical spine fracture, and nursing challenges in this critical care population.
Mechanism of injury (MOI) is an important factor in classifying and treating injured patients. Mechanism of injury refers to the forces of mechanical energy transferred to the body during the traumatic event and the effect of that energy on the body. With falls, the height from which the person fell, the angle of the fall, the energy absorption of the surface, and the deceleration at the time of impact all contribute to the MOI.9 For example, a fall from 20 ft onto concrete while wearing summer clothes versus a fall from 20 ft into a snow bank while wearing layers of winter clothing will result in differing severity of injury. Various definitions have been used to describe low-impact or low-MOI falls, such as ground level falls, low-impact falls, or falls from standing.10–13 Falls have also been described by height of the fall, as less than 2 to 3 m, less than 20 ft, or less than 15 ft.14–17
Although the term low-impact fall might suggest a less severe injury due to a lower energy MOI, this is not always the case among older adults. Older adults can sustain a significant injury, such as cervical spine fracture, with a lower MOI compared with younger individuals.16 Although the MOI may suggest that the person may not require trauma services, older adults should be monitored closely after a fall and considered for transfer to a trauma center.16
Scope of Traumatic Injury From Falls
In 2008, the incidence of falls was second in number to motor vehicle traffic crashes and represented the MOI for more than 30% of all injuries; 43% of the falls were in those aged 65 years or older.18 The greatest percentage of older adults who fell were among those aged 75 years or older.18 Those older than 70 years with a ground-level fall had a mortality rate of 4.4% compared with 1.6% for younger patients.11
Within the older population, there are subpopulations at greater risk of injury and adverse outcomes. Women have a higher number of falls and a slightly higher rate of fatality than men.18 Because older adults comprise an age range that spans decades, researchers and demographers split older adults into 3 subpopulations on the basis of age. The oldest old, that is, those aged 85 years or older, tend to be the most frail because of the increased prevalence of physical and psychologic diseases as well as diminished physiologic reserves due to aging.19 Among the oldest old, injury rates are 4 to 5 times higher for fracture/contusion/abrasion, laceration, strain/sprain, and internal injury when compared with the same MOI for adults aged 65 to 74 years (ie, the young old).18
For trauma admissions, low-height falls resulted in higher admission rates and hospital occupied bed days than motor vehicle crashes or high falls.15 Three-fourths of older adults who are seen in the ED for a fall from standing are admitted to the hospital with 40% admitted to the intensive care unit (ICU) during their stay.20,21 Once admitted to the hospital after a fall, the median LOS is 4 days. If an ICU stay was required, the median LOS increased to 5 days. Older adults have a longer LOS in the hospital with more cognitive, functional, and emotional impairments than younger survivors with fewer than 40% able to return home without services such as home health.20,21 Thus, the trauma critical care nurse is likely to care for older adult patients who are admitted following an injurious fall.
Traumatic Brain Injury
Falls are the leading cause of TBI for older adults.1 In turn, TBI accounted for 46% of fatal falls.1 Mortality begins rising in the TBI population at age 30 and increases over the decades.21 Studies report overall mortality ranging from 21% to 80% for older adults following TBI.20–22
The most frequent body parts injured in older adult falls are the head and neck.22 Injury to the brain following a fall occurs from the direct force at impact, the subsequent injury to the brain opposite the direct force (contre coup), shearing forces that tear axons with twisting or rotational injury, or a combination of forces.9 The forces may cause primary damage to neurons or blood vessels that then contributes to the secondary injury related to structural changes, decreased perfusion that results in decreased delivery of oxygen and glucose, as well as decreased removal of free radicals and other cellular by-products.9
With normal aging, changes to the brain begin in the fourth decade with gradual loss of brain size.21 The skull does not change size, so the space that was once occupied entirely by the brain is now less filled. The dura becomes more adherent to the skull. Because of these structural changes, a low MOI such as a fall from standing or sitting may interrupt a blood vessel that leaks into a larger space, thus delaying the onset of focal symptoms. Other changes with aging include the presence of atherosclerosis, which results in decreased blood flow carrying oxygen and glucose, and decreased free radical clearance. Last, because of multiple chronic illnesses, older adults may be taking medications that diminish their ability to respond to injury, such as β-blockers, or that can contribute to the extension of injury, such as antiplatelets or anticoagulants.21
Currently, medical and surgical management of TBI in older adults follows the same intervention as for younger patients as it pertains to intracranial pressure management. However, older adults often require more complex management of multiple comorbidities.21,23
Skeletal Spine Injury
In addition to TBI, older adults who fall are also at risk for sustaining a skeletal spine injury. The spinal cord is protected by the meninges, spinal fluid, bone structure of the vertebral bodies, and ligamental support. The space within the vertebral body is occupied by the spinal cord, meninges, and spinal fluid. Any changes to the size or shape of the vertebral bodies or the intervertebral discs may place pressure or physically transect the spinal cord, depending upon how much space exists and how much damage occurs. Impingement of the spinal cord from edema, blood clot, projectiles, or bone fragments may occur as the cord passes through the vertebral bodies.
Falls may result in an extension injury if the person falls forward and, for example, strikes his or her head on a table or step, resulting in damage to the anterior ligaments or bone dislocations. A backward fall results in a flexion injury, which may include ligament tears or teardrop, odontoid, or transverse process fractures.24
Structurally, older adults have degenerative changes, which are thought to contribute to skeletal spine fracture patterns that are different from those in younger patients.25,26 Older adults sustain fractures to the C1-C2 and cranial axial junction more frequently than younger patients. The mid portion of the cervical spine C4-C5 is less flexible than that in younger patients and less likely to move with the MOI. Thus, among older adults the C1-C2 is the most mobile and predisposed to atlanto axial injury.27 C2/type 2 odontoid fractures are more common in those aged 75 years and older.25
Several clinical conditions, when present, place older persons at significant risk for serious neurologic sequelae.28–32 Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) reduce the space within the vertebral body for the spinal cord. Rheumatoid arthritis often causes degenerative changes to the skeletal spine related to osteoporosis. Ankylosing spondylitis, the least prevalent of these conditions, affecting 130 of 100 000 persons, can develop in young adulthood, sometimes as early as late adolescence. The chief symptom is lower back pain and stiffness. Ankylosing spondylitis is a chronic inflammatory disease that calcifies ligaments of the spine and joints of the sacroiliac, and fractures occur most commonly between C5 and C7.29
Diffuse idiopathic skeletal hyperostosis is a rheumatologic disease that is more common in men than in women and begins in the fifth decade. Prevalence is 25% in men and 15% in women older than 50 years.30 Although persons with DISH may be asymptomatic, they may also experience symptoms similar to AS including spinal pain and stiffness, decreased range of spinal motion and postural deformity with forward stooping of the neck, kyphosis of the upper back, and loss of lumbar lordosis.31 Typically, there is no evidence of degenerative disc disease, but x-rays reveal bone changes across at least 4 vertebral bodies. This ossification can also include the anterior and posterior longitudinal ligament but does not include the sacroiliac joint. Serious disability from rheumatoid arthritis occurs in approximately 10% of the population, and these patients may also experience skeletal spine fractures with mild traumatic force. Presence of these conditions not only puts the older patient at risk for neurologic sequelae but also can impact the treatment of injuries from a fall.
History and Assessment
The increasing numbers of older trauma patients will create a greater demand for a nursing workforce that is trained in geriatric-specific competencies. As frontline providers, nurses are significant contributors to care of hospitalized older trauma patients, yet many nurses have little to modest knowledge in geriatric care.33,34 Although medical conditions and diagnoses of older adults vary, common geriatric syndromes and conditions exist, including functional decline, cognitive impairment, and depression. These conditions impact the delivery of care as well as outcomes.
The standard history and differential used for assessment of an adult who presents to the ED with changes in mental status or behavior changes without focal neurologic signs typically focus on medical conditions (eg, cardiopulmonary conditions, infections), medications, or metabolic disorders. Inquiry regarding history of traumatic injury may not be made or the patient or family may not recall, having dismissed the injury as too remote or insignificant to be of consequence. It is important to maintain a level of suspicion for traumatic injury when an older adult presents with cognitive changes. The history of any preexisting dementia, Alzheimer disease, or other neurologic condition must be evaluated along with possible TBI to lead to a more timely diagnosis.21,23
The initial neurologic assessment for cognitive, motor, and sensory function must be detailed. With older adults, a thorough history must be obtained to gather baseline information about strength, physical function, and cognitive function prior to the fall. Careful interview of a primary caregiver is warranted. Medical history, including medications, provides information regarding the person's risk for secondary injury, such as the use of warfarin, history of atherosclerosis, osteoporosis, previous neck or back pain, history of cognitive changes or presence of dementia, previous motor or sensory deficits, eye surgeries, or eye medications.
A history of falling indicates that the patient is at a risk for continued falls.35 Critical care nurses need to decrease the risk of falls in the critical care environment for these patients. Several tools are available to assess a patient's risk for falls in the hospital setting. See Table 1 for one example of a fall risk assessment tool developed by the US Department of Veterans Affairs.36
Table 1: Fall Risk A...Image Tools
Standard practice for prehospital or hospital staff following a traumatic injury is to place a rigid cervical collar on the person to stabilize the vertebral column. Typically, the hard cervical collar is fitted to provide support for the neck by using the shoulders and chin. The fit of the collar is intended to put the patient in a neutral position with the head over the shoulders and the neck neither flexed nor extended.
For adults with postural deformities that occur with AS or DISH, their neutral position may be a neck in a flexed position. To attempt to place the rigid collar as customary without adjusting for the older individual's anatomy could result in injury to the spinal cord where none existed before or can cause an extension of the primary injury.29 Adjustments may include changing the length of the front piece of the collar and using a support behind the head and neck to maintain a comfortable position for the patient that avoids extension. Nurses need to be wary of such conditions as AS or DISH when an older adult complains of increased pain or sensation changes with the placement of a neck collar.29
Many older adults with cervical spine injuries have either no neurologic deficit or incomplete neurologic deficit and can be managed nonoperatively; most do not require intubation or tracheostomy.25–27 However, despite many having a good prognosis, mortality is as high as 25% for older adults with cervical fracture. Significant morbidity can also occur, with only 44% of older adults discharged to home or rehabilitation.25–27
With spinal cord injury, the concern for respiratory function exists up to 3 weeks postinjury based upon potential for the continued ascending loss of spinal cord cells due to edema. Approximately 1 of the 5 older adults with spinal cord injury below C4 requires tracheostomy due to poor respiratory function, respiratory weakness, or poor cough.37 Early mobilization, when not contraindicated, is encouraged to avoid respiratory complications.27 External stabilization using cervical orthotic or halo immobilization can be used rather than surgical intervention in more than 80% of cervical fractures in older adults. Without postoperative recovery, mobilization can occur earlier. Surgery may be required for unstable fractures, or in cases of nonunion/delayed union or loss of reduction with external stabilization.27
A growing body of evidence suggests that early mobilization of critically ill patients has numerous physiologic, physical, and psychologic benefits.38–40 However, many critical care clinicians view their patients as unable to tolerate physical activity and thus prolong the patient's immobilization.40 In addition, these studies have excluded trauma patients, and nurses cite concerns for physiologic stability, maintenance of equipment, and patient safety as reasons for not progressively moving the patient from the supine position to eventual ambulation. Whether factors specific to older patients, such as prehospital functional ability, influence nurses' decisions is unknown. Further study needs to be conducted on the safe introduction of early mobilization for older critical-care trauma patients.
Management of Agitation
Critical care nurses perform neurologic examinations designed to seek early, subtle changes that may require medical intervention. Level of consciousness is an important assessment parameter particularly in the presence of a neurologic injury. Patients who are alert, oriented, cooperative, and able to follow commands provide the nurse with an important threshold from which to evaluate for worsening neurologic status. However, when the patient's baseline status is cognitive impairment from a preexisting dementia, Alzheimer disease, or cerebral vascular disorders, the nurse's ability to detect subtle changes is challenged. It is paramount to obtain a history and baseline of cognitive function from a primary caregiver for older trauma patients. If there is new onset agitation, the differential becomes increasingly difficult for older patients. Typically, agitation and inability to cooperate in younger adults are related to the TBI. Agitation in older adults may also be due to an underlying dementia, new onset delirium, pain, or a combination of all 3.
Historically, the options for managing agitated trauma patients in the ICU have been sedation and/or physical restraint. Sedation agents used in this population ideally have a short half-life and limited residual effects so that the neurologic examination is not obscured. Propofol and more recently dexmedetomidine are 2 such agents. Other agents such as antipsychotics and benzodiazepines have been used extensively in critical care units for the management of agitation. Multiple studies suggest that limiting the use of benzodiazepines decreases ventilator time, LOS, and long-term brain dysfunction.41–44 Use of sedation interruption is part of the routine care for ventilator patients as recommended by the Institute for Healthcare Improvement, and the target level for sedation should result in a patient who is calm, cooperative, and easy to arouse.44
Restraint use is no longer an automatic option for the care of patients in the intensive care environment. Involuntary immobilization is considered not only an infringement on patient's rights45 but also a well-known stressor that can result in patient harm, including new or increased agitation, new onset delirium, soft-tissue injury, and even death.46,47 Because of the known deleterious effects of physical restraint, both the Centers for Medicare and Medicaid Services and The Joint Commission have implemented guidelines for their use. A number of professional organizations have established guidelines for the use of physical restraints, including the Society of Critical Care Medicine.48
For a number of years, the evidence has mounted that physical restraint does not reduce fall rates and instead can increase the risk of fall injuries.49 The nurse must balance the need to promote early mobilization with preventing a fall-related injury. One of the strongest interventions to prevent falls is exercise and mobility. Unfortunately, many of our hospital fall-prevention strategies further restrict the patient's mobility and function, which, in turn, leads to even greater decline.50 Nurses need to make a concerted effort to avoid fall-prevention strategies that further immobilize and decondition the patient.
When attempting to limit the use of sedation and restraints to manage the agitation of a TBI patient in the ICU, the nurse needs a variety of tools to support the delivery of safe, evidence-based nursing care. Nonpharmacologic strategies are especially important to implement. Attention to the environment and reducing environmental stimuli of noise, lighting, and temperature have shown some modest effect on the patient's behavior.49 Communication strategies, although largely untested, may also decrease the ICU patient's anxiety, stress, and confusion.49 Ensuring patients' glasses and hearing aids are available helps them better interpret the environment. Nonpharmacologic comfort measures, when not contraindicated, can include repositioning, back rubs, visual distraction, music, and aromatherapy. Encouraging family visitation has also been promoted as a strategy to reduce fear and anxiety among critical care patients.51 Technology is also playing an increasing role in tools that are important in the prevention of falls52 (see Table 2).
Table 2: Sample Tech...Image Tools
A number of nursing care issues for this population continue to need further study; indeed, there is a dearth of studies examining the effects of geriatric best practices for the hospitalized older adult trauma patient. Nurses need to examine the best ways to assess neurologic function among older trauma patients in the presence of preexisting dementia or cognitive changes. Second, nurses need to examine interventions that best decrease respiratory complications among older adults with cervical immobilization. Third, pain management among TBI patients is complex, especially for older adults with preexisting cognitive impairment and preexisting physical conditions. Last, strategies to either promote or maintain physical and cognitive function in this patient population are needed.
Critical care nurses will care for a growing number of older adults who sustain TBI and spinal fracture postfall. Hospitalized older trauma patients are a vulnerable yet understudied population. The dearth of studies examining the effects of geriatric best practices on older trauma patient outcomes limits nurses' ability to provide quality cost-effective care. Nurses are in a pivotal position to contribute knowledge of best practices related to the care of patients postfall as well as preventing falls in critically ill older patients. Specifically, strategies that address delirium, pain, agitation, and fall prevention need to be studied for the geriatric trauma patient. Working closely with the interdisciplinary team, nurses can advance better care for critically ill older adults post–traumatic fall.
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older adults; falls; skeletal spine injury; trauma; traumatic brain injury