Another side of the issue of “Falls:” Traumatic Brain Injury

Much to the surprise of many of us, “falls” are the most common cause of trauma.  This is no joke.  For persons with chronic illness, temporary disabilities, and even for aging Baby Boomers, we all must pay attention to the risk factors presented by changes in our own health, our homes, and the places we go.

Let’s not forget that the issue is definitely more serious for our aging parents and loved ones over the age of 65.  According to Patricia Flemming PT, DSC, GSC in a recent training at the online Phillips Training Center:

Falls and related injuries are an enormous burden to individuals, society, and the health care system.

Among older adults, falls are the leading cause of injury related death.

What I found particularly fascinating was that most of the emphasis in fall-related injuries is on orthopedic injuries such as hip fracture (55%) and non-hip fractures (21%).  [Cohn Med 2009, Mar, 73(3): 131-45]  Even though traumatic head injuries comprise only 10% of the outcome and people tend to fear hip fractures more, only in recent years has there been a focus on prevention of head injuries in older adults.  The significance of traumatic brain injuries (TBI) in older adults is labeled by the Centers for Disease control as the “silent epidemic” and incidence increases with advancing age.  [Am Geriatric Soc 2006, Oct, 54 (10) p. 1]

The consequences of these figures impact the quality of life of older adults may include:  reducing independence, requiring long term rehabilitation or institutionalization, restricting mobility/sensation/cognition/communication, and affecting the emotional dispensation of affected individuals.  A TBI may increase risk for seizures, Alzheimer’s Disease, Parkinson’s Disease, and other neurological disorders all impacting the family in addition to the individual who is injured.  Are there ways to identify who is at risk and what can be done?  Yes, there are.

According to extensive research by Tinetti and others [1993, J Am Geriatr Soc, 41, 315-320] intrinsic risk factors include:

Decreased strength, balance, sensation, vision, and mental functioning.

Impaired vision.

Acute and chronic disease.

Postural hypotension (or a drop in blood pressure with a change in position).

And from the same source, extrinsic risk factors include:

Polypharmacy (especially taking 4 or more medications per day) and specific medications (such as anti-hypertensives, anti-coagulants, and benzodiazepines).

Environmental factors (such trip-n-fall hazards, lighting, inaccessible bathrooms).

Alcohol and drug abuse.

Difficulty performing daily activities (such as climbing stairs and caring for grandchildren).

Risk-taking behaviors (for example, improper use of ladders).

Ill-fitting footwear.

The focus of the Active Tips section of this website is largely the topic of fall and injury prevention, including the factors noted above.  The focus of the Gentle Moves TM section of this website is on keeping as active as possible to prevent the complications that can come from inactivity (such as deconditioning).  Please link to these sections for more detail on topics of interest.

From a medical perspective, our discussion here will include the care needed after as an injury has occurred and what to do to reduce the to reduce the risk for falls including TBI.  First, the first person to encounter the person who has fallen must identify the nature of the injury; denial of injury is common and the person may not show signs of a TBI for several hours or even days.  The host of this website did not develop dizziness until the next day after a biking accident in which she hit her head!  The injury may be obvious, for example, where there is bleeding, or not.  It is the recommendation of experts in the field of TBI that all blows to the head be considered a “911” event.

911, emergency, call for help, what to do for a fall, fallen and can't get up, falling, fall prevention, ambulance, paramedics, fire department policeI will repeat that.  All blows to the head need to be considered a “911” event and should seek medical attention and evaluation.  Rapid deterioration can occur with side effects that can include death!  The healthcare professional will determine the degree of damage (for example a concussion, contusion, hematoma or diffuse axonal injury), further testing and treatment that is indicated.  “Observation is crucial over the first 24 hours since symptoms of serious head injury could be delayed.”  Following the recommendations of the healthcare professional is key for proper pain management, rest, and levels of treatment that are indicated.

The evaluation of persons at risk for a TBI coincides with an evaluation of persons at risk for any type of falling.  Often formal scales will consider 1) the degree of confidence that an individual has in his or her abilities to avoid a fall, 2) his or her ability get up off of the floor without assistance in the event of a fall, 3) or access help when a fall does occur.  Consider these three points additional risk factors.  Coupled with the intrinsic and extrinsic factors noted above, the strategies needed to prevent falls and injuries become clearer.

Treatment of falls in general includes raising awareness of the signs and symptoms of TBI along with the benefits of treatment and avoiding the consequences noted earlier.  We must ask our loved ones periodically if he or she has ever had a fall or if he or she is concerned about the risk of falling.  How would the individual get help if he or she had a fall?  Simple strategies such as keeping a cell phone one one’s person at all times or wearing a medical alert button often makes a difference for everyone concerned!

Further, the literature finds that provision of strengthening programs and implementing a multi-component intervention (of exercises, home modifications, addressing low vision issues, withdrawal of psychotrophic medications, and use of pacemakers when indicated) are the most successful interventions fall and injury prevention.  Did you know that older adults can continue to gain strength even after age 90?  Yes, all of us can benefit from regular exercise!  [J Am Geriatr Soc, 49, 664-672]

In summary, let us remember the risk factors, the role of many contributing factors, the need for prompt medical attention, and the value of both safety strategies and daily exercise in reducing the incidence of falls, particularly those that result in traumatic brain injury.  Ongoing education and discussion is the responsibility of all of us to lead active lives over the years, young and old.

Julie, O.T.

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