History and physical exam predictors of intracranial injury in the elderly fall patient: A prospective multicenter study

Published:October 23, 2018DOI:



      A prior single-center study demonstrated historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population.


      This is a prospective observational study of patients ≥65 years presenting after a fall to three EDs. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anticoagulants/antiplatelet use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients.


      723 patients (median age 83, interquartile range 74–88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulation/antiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6–94) with a specificity of 38.8% (CI 35.1–42.7). The positive predictive value in this population was 10% (CI 7.5–13.3) with a negative predictive value of 97.3% (CI 94.4–98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed.


      In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bergen G.
        • Stevens M.R.
        • Burns E.R.
        Falls and fall injuries among adults aged ≥65—United States, 2014.
        MMWR. 2016; 65: 993-998
        • Gardner R.C.
        • Dams-O'Connor K.
        • Morrissey M.R.
        • et al.
        Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions.
        J Neurotrauma. 2018 Feb 15;
        • Gerber L.M.
        • Ni Q.
        • Härtl R.
        • Ghajar J.
        Impact of falls on early mortality from severe traumatic brain injury.
        J Trauma Manag Outcomes. 2009; 3: 9
        • Hruska K.
        • Ruge T.
        The tragically hip: trauma in elderly patients.
        Emerg Med Clin North Am. 2018; 36: 219-235
        • Adhiyaman V.
        • Asghar M.
        • Ganeshram
        • et al.
        Chronic subdural haematoma in the elderly.
        Postgrad Med J. 2002; 78: 71-75
        • Meldon S.W.
        • Delaney-Rowland S.
        Subdural hematomas in the elderly: the great neurological imitator. AHC media.
        • Depreitere B.
        • Van Lierde C.
        • Sloten J.V.
        • et al.
        Mechanics of acute subdural hematomas resulting from bridging vein rupture.
        J Neurosurg. 2006; 104: 950-956
        • Gennerelli T.
        • Thibault L.
        Biomechanics of acute subdural hematoma.
        J Trauma. 1982; 22: 680-686
        • Aschkenasy M.
        • Rothenhaus T.
        Trauma and falls in the elderly.
        Emerg Med Clin North Am. 2006; 24: 413-432
        • Brinjikji W.
        • Kallmes D.
        • Cloft H.
        Rising utilization of CT in adult fall patients.
        AJR. 2015; 204: 558-562
        • Melnick E.R.
        • Szlezak C.M.
        • Bentley S.K.
        • et al.
        CT overuse for mild traumatic brain injury.
        Jt Comm J Qual Patient Saf. 2012; 38: 483-489
        • Borade A.
        • Kempegowda H.
        • Maniar H.H.
        • et al.
        External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.
        Injury. 2017; 48: 1594-1596
        • Maniar H.
        • McPhillips K.
        • Torres D.
        • et al.
        Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.
        Injury. 2015; 46: 2185-2189
        • Government Accountability Office (GAO)
        Medicare part B imaging services: rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices.
        U.S. Government Accountability Office, Washington DC2008
        • Stiell I.G.
        • Wells G.A.
        • Vandemheen K.
        • et al.
        The Canadian CT head rule for patients with minor head injury.
        Lancet. 2001; 357: 1391-1396
        • Haydel M.J.
        • Preston C.A.
        • Mills T.J.
        • et al.
        Indications for computed tomoagraphy in patients with minor head injury.
        N Engl J Med. 2000; 343: 100-105
        • Jagoda A.S.
        • Bazarian J.J.
        • Bruns J.J.
        • et al.
        Clinical policy: neuroimaging and decision making in adult mild traumatic brain injury in the acute setting.
        Ann Emerg Med. 2008; 52: 714-748
        • Mower W.R.
        • Hoffman J.R.
        • Herbert M.
        • et al.
        Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients.
        J Trauma. 2005; 59: 954-959
        • Hamden K.
        • Agresti D.
        • Jeanmonod R.
        • et al.
        Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury.
        Am J Emerg Med. 2014; 32: 890-894
        • Nursing Home Compendium
        • Gray L.C.
        • Peel N.M.
        • Costa A.P.
        • et al.
        Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study.
        Ann Emerg Med. 2013; 62: 467-474
        • Centers for Disease Control and Prevention (CDC)
        Self-reported increased confusion or memory loss and associated functional difficulties among adults aged ≥60 years – 21 states, 2011.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 347-350
        • Mack L.R.
        • Chan S.B.
        • Silva J.C.
        • Hogan T.M.
        The use of head computed tomography in elderly patients sustaining minor head trauma.
        J Emerg Med. 2003; 24: 157-162
        • Rathlev N.K.
        • Medzon R.
        • Lowery D.
        • et al.
        Intracranial pathology in elders with blunt head trauma.
        Acad Emerg Med. 2006; 13: 302-307
        • Riccardi A.
        • Frumento F.
        • Guiddo G.
        • et al.
        Minor head injury in the elderly at very low risk: a retrospective study of 6 years in an emergency department.
        Amer J Emerg Med. 2013; 31: 37-41
        • Dusenberry M.
        • Brown C.
        • Brewer K.
        Artificial neural networks: predicting head CT findings in elderly patients presenting with minor head injury after a fall.
        Am J Emerg Med. 2017; 35: 260-267
        • Gangavati A.
        • Kiely D.
        • Kulchycki L.
        • et al.
        Prevalence and characteristics of traumatic intracranial hemorrhage in elderly fallers presenting to the emergency department without focal findings.
        J Am Geriatr Soc. 2009; 57: 1470-1474
        • Claudia C.
        • Claudia R.
        • Agostino O.
        • et al.
        Minor head injury in warfarinized patients: indicators of risk for intracranial hemorrhage.
        J Trauma. 2011; 70: 906-909
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • et al.
        Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database.
        J Trauma. 2007; 63: 519-524
        • Franko J.
        • Kish K.J.
        • O'Connell B.G.
        • et al.
        Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma.
        J Trauma. 2006; 61: 107-110
        • Karni A.
        • Holtzman R.
        • Bass T.
        • et al.
        Traumatic head injury in the anticoagulated elderly patient: a lethal combination.
        Am Surg. 2001; 67: 1098-1100
        • Brewer E.S.
        • Reznikov B.
        • Liberman R.F.
        • et al.
        Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication.
        J Trauma. 2011; 70: E1-E5
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • et al.
        Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients.
        J Trauma. 2007; 63: 525-530
        • Gage B.F.
        • Birman-Deych E.
        • Kerzner R.
        • et al.
        Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall.
        Am J Med. 2005; 118: 612-617
        • Kennedy D.M.
        • Cipolle M.D.
        • Pasquale M.D.
        • Wasser T.
        Impact of preinjury warfarin use in elderly trauma patients.
        J Trauma. 2000; 48: 451-453
        • Garra G.
        • Nashed A.H.
        • Capobianco L.
        Minor head trauma in anticoagulated patients.
        Acad Emerg Med. 1999; 6: 121-124
        • Nishijima D.K.
        • Gaona S.D.
        • Waechter T.
        • et al.
        The incidence of traumatic intracranial hemorrhage in head-injured older adults transported by EMS with and without anticoagulant or antiplatelet use.
        J Neurotrauma. 2017 Nov 6; ([Epub ahead of print])
        • Bullock M.R.
        • Chesnut R.
        • Ghajar J.
        • et al.
        Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas.
        Neurosurgery. 2006; 58: S16-S24
        • Bullock M.R.
        • Chesnut R.
        • Ghajar J.
        • et al.
        Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute epidural hematomas.
        Neurosurgery. 2006; 58: S7-15
        • Bullock M.R.
        • Chesnut R.
        • Ghajar J.
        • et al.
        Surgical Management of Traumatic Brain Injury Author Group. Surgical management of traumatic parenchymal lesions.
        Neurosurgery. 2006; 58: S25-S46
        • Yokobori S.
        • Yamaguchi M.
        • Igarashi Y.
        • et al.
        Outcome and refractory factor of intensive treatment for geriatric traumatic brain injury: analysis of 1165 cases registered in the Japan Neurotrauma Data Bank.
        World Neurosurg. 2016; 86: 127-133
        • Shimoda K.
        • Maeda T.
        • Tado M.
        • et al.
        Outcome and surgical management for geriatric traumatic brain injury: analysis of 888 cases registered in the Japan Neurotrauma Data Bank.
        World Neurosurg. 2014; 82: 1300-1306
        • Wutzler S.
        • Lefering R.
        • Wafaisade A.
        • et al.
        TraumaRegister DGU. Aggressive operative treatment of isolated blunt traumatic brain injury in the elderly is associated with favourable outcome.
        Injury. 2015; 46: 1706-1711
        • Paniagua M.A.
        • Malphurs J.E.
        • Phelan E.A.
        Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention.
        Am J Emerg Med. 2006; 24: 413-417
        • Sterling D.A.
        • O'Connor J.A.
        • Bonadies J.
        Geriatric falls: injury severity is high and disproportionate to mechanism.
        J Trauma-Injury, Infect Crit Care. 2001; 50: 116-119