Mortality
Although traumatic injury is a common presentation among geriatric emergency patients, this population is overall less likely to be involved in a traumatic event compared to other age groups. However, when injured, geriatric trauma patients are more likely to have fatal outcomes.
As previously noted, falls are the most common mechanism of injury in patients older than age 65 years. The trend of fall-related mortality increases with advanced age. It has been estimated that 36% of geriatric patients who fall will require a repeat ED visit or will die within 1 year following the fall.11 Previous reports have demonstrated that mortality is associated with advanced age, injury severity score, shock index, transfusion, head injury, hypotension, and treatment site.12-16
Cerebral Hemorrhage
In the study conducted at the authors’ institution, most patients receiving a head CT scan had at least one abnormality.10 Subdural hemorrhage was the most commonly reported abnormality followed by subarachnoid and intraparenchymal hemorrhages, respectively.10
Falls are a common cause of intracranial hemorrhage, and 30% to 40% of patients over age 65 years will experience at least one fall each year.17 Consistent with these statistics, fall was the most common mechanism of injury in the patient population at the authors’ institution. Intracranial hemorrhage can cause altered mental status by increasing the intracranial pressure and decreasing the cerebral perfusion pressure. These abnormalities are often amenable to medical and/or surgical treatment if identified in time.18
Hyperglycemia
Hyperglycemia was one of the most common diagnostic test abnormalities associated with altered mental status in the authors' study.10 Although increased blood glucose is part of the stress response to injury, geriatric patients experience a higher incidence of stress hyperglycemia and are unable to mount an adequate insulin response in trauma.19,20 High-glucose levels are associated with significantly higher mortality rates among trauma patients.21-24
Alcohol Intoxication
Alcohol intoxication was common among the patients in the author’s study.10 In contrast, a smaller percentage of patients were tested and found to be positive for opioids or benzodiazepines. The risk of a traumatic brain injury (TBI) increases significantly if the patient sustained the injury while under the influence of alcohol.25 Alcohol increases the mortality after trauma especially in patients over the age of 40.26 Alcohol-related TBIs are associated with poorer outcomes with increasing age.27 Falls at ground level after alcohol consumption are associated with more casualties than nonalcohol-related falls.28,29
Differential Diagnosis
As the case in this review illustrates, among geriatric trauma patients with altered mental status, the most common mechanism of injury is fall. The differential diagnosis should be considered, including intracranial hemorrhage, alcohol intoxication, nonprescription drug use, prescription-drug effects, infection, and/or metabolic or endocrine disorders. Appropriate laboratory and radiographic tests should be obtained, and may include CT of the brain and cervical spine, chemistry profile, complete blood count, chest X-ray, urinalysis, alcohol level, and toxicology screen.
Conclusion
This case represents one of many common presentations of trauma among geriatric patients. There was evidence of multiple falls by chart review and physical examination. Evidence of multiple traumatic events of various stages should raise the suspicion of neurological deficits, substance or prescription-medication effects, or physical abuse of the elderly patient. The ED workup should include brain CT, electrolytes, complete blood count, chest radiograph, and urinalysis. The patient should be admitted for observation and workup for medical and traumatic etiologies of multiple falls. When discharged, home-health services or rehabilitation services should be considered.
The results of the authors’ chart-review study confirmed that falls are the most common mechanism of injury in geriatric trauma patients presenting to the ED with altered mental status.10 The most common diagnostic test abnormalities associated with altered mental status in this study included hyperglycemia, abnormal CT results, anemia, and alcohol intoxication. Future studies are needed to access relations between ethanol or opioid intoxication and the presence of positive CT findings to guide clinicians’ judgment when ordering CT scans and other tests.
Dr Marco is a professor of emergency medicine and surgery, Wright State University Boonshoft School of Medicine, Kettering, Ohio; and an emergency physician at Miami Valley Hospital, Dayton, Ohio. Ms Edgell, Ms Eggers, and Mr Fagan are students at Wright State University Boonshoft School of Medicine, Dayton, Ohio. Dr Olson is the director of the research laboratory and professor of emergency medicine at Wright State University Boonshoft School of Medicine, Kettering, Ohio.