Falls and Brain Injury in Older Adults

Barbara’s Story

In my book, Shaken Brain, I present a story about Barbara, a 72-year-old retired college professor who fell in the bathroom of her home. She had atrial fibrillation and took warfarin, an oral anticoagulant, to prevent a stroke. Barbara moved in with her daughter Diane when she began to develop memory problems. One morning, Barbara tripped and fell, hitting her head on the bathroom sink’s granite counter. Diane heard a noise and rushed into the bathroom. Barbara had a gash on her forehead, but she was conscious and seemed to be thinking and speaking coherently. Diane helped her mother to her feet and nursed her cuts and bruises from the fall.

The following day, things had changed. Diane had to shake her mother to rouse her from sleep. When the paramedics arrived, Barbara was disoriented, and when she got to the hospital, she could no longer speak. Barbara was slipping into a coma.

Barbara had experienced a subdural hematoma. This term means that the blood pooled under the dura, the brain’s rigid membrane, because of ruptured blood vessels. It gradually expanded during the night. In older people, subdural hematomas may occur more often than in younger people because the aging brain tends to atrophy and shrink. The blood vessels also shrink and become thinner and tauter—and thus more susceptible to tears.The anticoagulant warfarin also increased Barbara’s risk of having a brain bleed. (See Figure 8 in Shaken Brain)

Subdural Hematomas

A subdural hematoma may form very slowly and diagnosis can be delayed. Symptoms may be mild like those experienced after a concussion. Some people with a small subdural bleed have no symptoms initially, leading caregivers, patients, and even health care providers to believe that the injury is not serious enough to require treatment. Some occur without a blunt head injury or any history of trauma. Sometimes they are found on a CT scan of the brain ordered for other reasons.

Elderly patients have different physiological and psychological needs than younger patients. Some research suggests that even mild TBIs may worsen cognitive decline, including earlier onset of dementia, in the years following the injury. Elderly patients also tend to have several health factors or medications already in play when they fall, complicating the initial injury and ultimately their ability to recover. 

Emergency neurosurgery to remove the subdural hematoma saved Barbara’s life. But healing from this injury for an older person remains a longer-term proposition. You can read more about Barbara’s story in my book, Shaken Brain. 

Preventing Falls for Older Individuals / Seniors

Falls are the leading cause of traumatic brain injuries (TBIs) in the U.S., and older people like Barbara, especially those with physical or cognitive issues, are most at risk. Falls lead to nearly half of the TBI-related hospitalizations and account for the majority of TBI-related deaths in adults 65 years of age and older. Many older adults have patterns of frequently falling, too. What makes older people more likely to fall, and how can these falls be prevented?

Falls in older individuals are often caused by more than one factor. Older individuals have age-related changes such as vision, hearing, and cognitive impairments. They may have reduced sensation in their feet, poor postural control and balance problems, generalized weakness, and other neurologic or muscle and joint problems that can put them at risk of falling. Medications that cause issues with awareness, balance, or reaction-time can contribute to a risk of falling. Environmental factors such as an uneven floor, rug, or pavement surface can also contribute to risks. Situational factors such as moving too quickly or not turning lights on when entering a room might be part of a risk equation. Living alone and a diagnosis of depression were associated with higher fall risk in some studies. If there is a suggestion that the older person lost consciousness and then fell, perhaps from a drop in blood pressure or other cause, a further workup for a cause or causes is imperative.  

Here are some specific factors that may contribute to falls in older people that are amenable to interventions:

• Mobility problems(related to gait, balance, strength, flexibility, endurance, pain):

  Physicians must carefully examine motor and sensory function and joints, especially in the legs and feet, and provide treatments. Physical and occupational therapists and podiatrists can help to evaluate and recommend preventive strategies. Sturdy, anti-slip footwear and mobility aids such as canes or walkers might be essential interventions. 

• Medication review

  Physicians should determine if all medications are necessary and discontinue those not needed. Reducing doses of required medications that may contribute to risk can be critical, too. Patients on platelet aggregation inhibitors and oral anticoagulants should be closely monitored.

• Bladder and bowel function and nutrition assessment

  Bedtime diuretics should be discontinued if possible. Low blood pressure or orthostatic hypotension (a drop in blood pressure when standing up) can contribute to falls. Inadequate nutrition or dehydration may contribute to low blood pressure.

• Vision and hearing evaluations

  Are eyeglass prescriptions up-to-date? Are progressive lenses causing problems? Would cataract surgery help? Would a hearing aid help to increase awareness of surroundings and prevent injuries?

• Diagnosis of mood disorders 

  Depression is a risk factor for falls. Physicians should screen for depression and refer for treatment. 

• Environmental assessment

  A home assessment should include the evaluation of furnishings and flooring, especially rugs. Removal of throw rubs and the addition of grab bars in the bathroom may be very beneficial. Alert systems and motion detectors for lighting systems can be preventive, too. 

There is more information about preventing falls in older people on the CDC and Academy of Physical Medicine and Rehabilitation (AAPM&R) websites: 

• https://www.cdc.gov/steadi/
• https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
• https://now.aapmr.org/fall-prevention-in-the-elderly/