We hope you have added to your knowledge skills and attitudes about Trauma and Falls in the Older ED Patient. The next time you are managing an older person who has been the subject of major trauma – MVC, struck by a car, fall from a height – perhaps you will keep in mind some of the subtle ways that aging physiology, comorbidities, and medication affect the nature of the resuscitation.
On almost every ED shift we see older people who have fallen. Our job is not just to assess and manage the injuries caused by the fall. Perhaps you have added to your strategies for addressing the possible causes of the fall – medication, functional decline, comorbidities, age-related causes of syncope – which may have a huge impact on preventing another even more serious fall.
You may recognize that new or increasing falls may be a symptom of another inter-current illness.
It may be clear now that there is little firm evidence or guidelines to inform the management of the most common injury of a fall – a head injury. But your awareness of changing neuro-anatomy and the consequences of anticoagulation may cause you to be more attentive to the head injured older person who “looks fine.”
Finally you may have a new understanding of the role of other members of the health care team in providing a more complete assessment of the older person who has fallen.
You may want to review the modules on Functional Assessment and Discharge Planning as well as Medication Management which both have specific relevance to this topic.
Review the Learning Objectives before proceeding to the Knowledge Check.
At the end of this module you should be able to:
- Define special trauma management issues in the older patient regarding patterns of injuries and assessment of shock – the components of ATLS that are different over 65;
- Describe an approach to a patient who has fallen, identifying potential causes of falls (identified by history, physical examination and functional assessment) as well as management of injuries, coordination of a discharge plan, and prevention of future falls.
- Understand the importance of an interdisciplinary team in assessing older patients with falls.
- Communicate the key components of a safe discharge plan for older patients who have fallen (e.g., accurate medication list, plan for follow-up).
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Considering age when assessing injuries as well as comorbidities, medications, and the patients ability to report pain or describe the event as in dementia.
Utilization of an interdisciplinary team for geriatric assessment even for fall from standing to evaluate for fall prevention interventions.
I will think more about what is happening in the home. I will also be more aggressive with evaluation of the geriatric fall patient.
try and be more wholistic esp when it comes to falls. get more information about what they were doing before the fall to see if there is a pattern. get more information about their actual daily life like the guy who had resorted to recent sponge bathing due to fear of falling in bathtub. he never would have volunteered that and i would never have known about it via my usual questioning but it is important info to have. i think i am going to talk to my bosses about potentially considering getting PT involved in the dept both for gait evals and also other CLBP pts which is a nice option i had in a sister hospital to where i am now.
I enjoyed this module and had several take-home points from this
provide adequate outpatient follow up
social work help
very well done module illustrating many helpful areas in the management of geriatric patients
Great reminder on how to care for the geriatric patients’.
Discharge planning for the geriatric patient is important, and taking a good history and exam is very important.
I have definitely been reminded about the difference in resuscitation and vital signs between older persons and younger patients and to put this into consideration when managing older trauma patient
awareness of elderly trauma and risks and benefits of multi-disciplinary team involvement when assessing and discharging patients at risk for falls.
This module brings to light many aspect to concern in elderly trauma and Falls.
This is great module and we have many aspect to concern in elderly trauma and Falls.
This is great module and we have many aspect to concern in elderly trauma and Falls.
I think this module is a great reminder for drilling home that discharge planning something you need to think about the moment you interact with your patient, to ensure you have a safe discharge plan esp. when it involves an elderly person who came in with a trauma. I think we also have to remember to work as a team and get observations from the rest of your team (RN, PT, GEM nurses) as well as contact family and listen to patient – re supports, ADLs and what may have now changed to ensure a safe dc.
Always address etiology of falls and look for pharm/non-pharm approaches. Fear of falling is a perpetuating factor (e.g. involve D/C planner to identify needed supports; order initial nursing visits for gen. ax and support).
Inquire more about home life
fully investigate patient environment
Ensuring you are thorough leads to better outcomes as one fall can be fatal in the elderly
Not going to change much b/c we’ve already had it drilled into us that there are a million subtle and difficult to detect reasons for falls and an equal number of difficult to detect injuries that may be sustained as a result. Transport for head CT / X-rays
Not a lot of evidence for guidelines in elderly after falls. I will use more clinical judgement.
the elderly require a particularly specific degree of assessment that differentiates them from other age groups; keeping this in mind will make assessments have a higher level of relevance and accuracy
Investigate falls more thoroughly through medication examination, in depth hx gathering, attention to prior medical histiry
trauma and falls in geriatric populations require special considerations
fractures are common in the geriatric population.
TBI and vertebral fractures, consider different resources and support systems for the patient at home
Gives new ideas, resources in dealing with both the cause and prevention of falls
Thoroughly investigate all falls in elderly patients for cause etc, and do thorough physical examinations.
learned a great deal about falls in the elderly population to help assist me with my differential diagnosis for applying to my patient CARE. Especially with no patient carries lift assists only
exploring more deeply geriatric related factors such as: decreased cerebral blood flow in population (syncopes), comorbidities, carotid sensitivities, muscle wasting/ weakness and medication regiment
learned great deal about causes of falls in elderly, prevention and action plans after discharge. good info
Have a high suspicion for TBI and and vertebral fractures
learned different ways different health care departments assess these pts which is interesting because I only know how my and my coworkers go about this
REfer elderly trauma patients to help prevent future falls.
This module has changed the way i will asses the elderly pateint and more considrate of other factors
enlist more detailed questions and follow up with support
nO NORMALIN THE ELDERLY
transport elderly trauma patients
Question all falls.
I agree with Bubbles
more investigation into ADLs and IADLs
Question more the context of the fall and risks factors.
thanks for the knowledge
look deeper into Pt history and medications
check medications and stop precipitating medications, check orthostatic vitals talk to family, and walk test.
good review and information
Ask about normal ADLs and changes to medications
I will pay more attention to patients vital signs and realizing what appears to be normal may not be their normal. Assess for co0-morbidities
Learned about a different perspective from elderly and falls from the ER standpoint
The ATLS changes that are different over 65
Recognizing that ‘normal’ vitals may be abnormal, consider medication effects, assess for recurrent falls, IADLs and ADLs
Med rec at d/c, review VS more regularly and physiology important to review
I learned that I should always have a post discharge plan for a geriatric patient. Have a team involvement in the plan for the patient.
Likely avoid carotid sinus massage to check function
awareness of fall prevention
A thorough assessment is necessary when working with an older adult who has fallen
Consider seriousness of falls in elderly
I learned that there are so many things to consider when assessing because older adults’ baseline is different from a much younger one.
making sure that I find all of their injuries, and that they are truly safe to be discharged home if that disposition is planned.
COMPLEXITY RISES AS AGE INCREASES. IT TAKES A TEAM APPROACH WITH FORETHOUGHT ABOUT PHYSICAL BARRIERS TO SUCCESSFUL OUTPATIENT MANAGEMENT.
teamwork and more thorough assessment
Teamwork, prevention, physiology
yes, very good review
Learned a lot
always be extra vigilent of traumas in elderly
interesting elderly physiology
Preventing falls – tips from the ED perspective.
Importance of an IDT with falls.
I will be sure to ask more about frequency of falls rather than focusing on the fall that brought the patient to the ED that day.
Physiology that can impact assessment of traumas/falls in elderly
I think I have a more complete understanding of the discharge process and all the parties that could/should be involved to ensure the best patient outcome.
Nothing to add
Honestly, not a lot.
Medication dose and administration
Almost always multidisciplinary team is needed
Good to consider the geriatric aspects of trauma care
Good information on assessing elderly patient’s vital signs and remembering that normal ranges for the elderly are not always normal. Carotid massage as an assessment is something new to think about. Orthostatics, mobility, and medication assessments are so very important in the elderly patients.
I’m still on the fence about doing a carotid massage on any patient to check for carotid hypersensitivity… other than that the rest of the material is very informative.
Knowing that the vitals signs on an ederly patient that may be “normal” are actually showing distress. And to assist the family in getting proper items in place to help prevent falls.
The geriatric assessment team is a very nice resource for ED who are large enough to support the consults and extra staff
Lots of stuff
learned a lot
a detailed history and physical examination is important in assessing a fall. to gather all pertinent details.
vital may mask the true picture so always know the baseline of the patient.
know the medication the person may taking.
be aware of teh normal changes in aging and differentiate it from how the patient presents
1. proper history of current fall and history of previous falls are very important
2. several factors including vitals, medication use, baseline, neurological status are important in management
3. older patients are at higher risk of skeletal injuries, soft tissue injuries, cranial injuries, blood loss, solid organ injuries, altered mental status
4. symptoms of brain injury can be delayed in a patient seeming normal, neuroobservation and proper head injury instructions is important
5. team work is necessary for complete management
Vital signs being masked by medications.
further assessment of falls
learned a lot
I think I will involve family and family physician in patients who are planning to discharge. Unfortunately we do not have the liberty of having a geriatric came in the emergency room.
Not to be falsely measured by “normal vitals”
Discharge planning is more complex than other ED visits
Reminder of the low maximum heart rate in elderly patients is always helpful.
Keeping in mind the previous information and incorporating into my daily plan
Continue to have a low threshold to do a CT head when a geriatric patient presents after a fall, involve allied health professionals in safe discharge planning, and do a good med review.
assess frequency of falls, time of day, weakness during mobility, use of assistive device: glasses, walker. Assess vitals while up and walking- educate re orthostatic changes, meds currently taking, nutritional intake. stairs at home
reminder to consider fall prevention and home resources
The importance of assessing the presenting patient history of falls, medeication regime, ADLs and IADLs especially if her or she is living alone
great learning points
I will be more inclined to asses the patients ADLs and IADLs as part of discharge planning.
need for thorough evaluations and interdisciplinary aid
The different and inter-disciplinary causes that can contribute to a fall. It takes a team to assess, treat, and prevent falls.
learned about the importance of a head injury routine
I am more aware of the reasons falls can occur in the geriatric population
great module. learnt a lot.
comprehensive MDT approach needed
Comprehensive assessments are very important, and need a full hcp team discussion
More likely will obtain head CT and not rely on normal v.s
really appreciate the full team and holistic functional approach
using all disciplines to help the patient
I will look beyond the current fall to the history and pattern of them.
This is something i assess about 5 times a day at work, liked the input from the OT about how to get out of bed.
extensive hx taking. Consideration of seemingly normal vitals
all falls require much assessment, planning, and support
use of head cts and bedside ultrasounds.
Doing a through assessment is key to understand causes and complications, prevention methods is key in ED not just treatment, use of interdisciplinary team.
be more thorough, advocate
aware of medications that patients are taking and importance of completing assessment from all different health care team
To include MDT approach on discharge, be mindful of drugs causing falls.
developing a multidisciplinary approach would be very beneficial
More careful assessment of ADL/iADLs with discharge
collateral history is key
normal bp is hypotension in the elderly until proven otherwise
the value of multidisciplinary apporoach
Learned wider variety of causes of falls to consider in eval and management.
there are a lot of things to consider for elederly falls than just treating itself. Home situation, follow up, services medication.
more aggressive about evaluation of cause of fall, even if patient states it was mechanical, especially if no witnesses available to confirm mechanism.
Lower ct scan threshold
Treating the injuries caused by a fall is only the beginning, true success is preventing the next fall. This requires an interdiscplinary team to look through each of their lens of expertise to add to an overall successful discharge plan of care, unique for that patient
importance of multidisciplinary approach to assessment and discharge planning
this modual has helped me understand how I can i work with other healthcare providers to have a safe discharge for the older population. has helped me understand the pathology of the older population and what to look for when assess them.
the topic was very interesting and presented in an easy to read way. I particularly found it interesting to see how the physiological changes that occur during aging can affect our resuscitation of them.
Enjoyed this a lot for placement!
great module review on falls
Learning how to assess clients after they have fallen.
learning how to asses post-fall
assessment is key to help clients maintain their function
mental health assessment
assessment of falls and injuries, knowing ADL and IADLs
I learned to not forget the 3Ds in the mental health assessment
The significance of consulting other members of the healthcare team and assessing the cause of the fall and all other related factors contributing to it (meds, injuries sustained, adls, etc.)
importance of adl assessment prior to discharge.
Prévention of new falls as an aspect of my job at the ER.
There are easy questions to ask or suggestions to give
améliorer l’évaluation de la cause de la chute
Learned many particularities of geriatric trauma. Specific pattern of injury, physiologic changes, etc.
good review of elderly physiological changes and reminder on importance of asking questions
do a better job assessing pre-fall risks
a GEM team would be nice…
Learned Geri issues in trauma management
-consider how vital signs may be abnormal but look normal in elderly patient
-consider the approach for head injury assessment: if on warfarin and minor injury CT/antidote/monitor; if no warfarin – monitor only
-always check the med list
-take a thorough fall history including isolation secondary to fear of falling
– team approach.
– Assess the pre fall risk.
– Monitor post fall safety
Remember that even if no injuries are present on initial exam and imagining, pt/ot assessment is still required before safe discharge from the ED. Usually, I do not walk test patients myself if no injuries but will start to do so to observe any difficulties.
History, including family. Health care team is very important.
Remember about falls prevention – might save myself, or colleagues, a second presentation.
Be more mindful of reviewing history of previous falls
Engage members of team readily to facilitate patient’s independence
Definitely do a more thorough job of assessing for fall risk and ensuring fall risk prevention.
Take times to evaluate the elderly.
spend more time evaluating ADLS
Cause of falls, physiology
I will spend more time and energy around the question of “Is this patient safe to return home?”
Special attention to more focussed falls assessment. I already ask around number of falls in the past 12 months but probably don’t elucidate the details around these enough. Also a more thorough review of medications regarding contribution to falls not just problems associated with injuries post fall.
Incorporate more involvement with pharmacy in performing med reconciliation for patient’s with anticipated discharge. Out patient OT/PT evaluation and recommendations to PCP
Good review of the altered physiology of normal aging. We learn this in great detail for paediatrics and pregnancy so it’s good to catch up in my knowledge of geriatrics
Is the patient safe to discharge?
If so, what the patient needs to be safe on discharge?
What are the departments/allied health needs to be contacted and how to get help from them to keep the patient safe?
I have learned a systematic approach towards a geriatric trauma patient which include baseline functional assessment, fall assessment, gait and mobility assessment and detailed history regarding substance abuse, current medication review, previous hospitalization, pain and stiffness and to look for Geriatric syndrome. A systematic discharge plan which include review by members of Geriatric team like Geriatric nurse, Physiotherapist, occupational therapist, Pharmacist.
It is always helpful to learn more about the bigger picture so when dealing with a geriatric trauma patient I will inclined to gather a more thorough history and assessment so that treatment, discharge and prevention can be more appropriate and effective. As a team approach working outside the hospital I can offer a different perspective and insight that might not be available in an ED department setting.
First many causes of falls so need to explore underlying reasons. As one ages and has more comorbidities falls likely to increase and greatest predictor of a future fall is previous falss.
fresh interpretation of vitals in the elderly
fragile points of injuries
increase referrals/consults to OT, PTand EMP services
MDT to obtain complete collateral and piece all the information together to form an outcome
team approach is vital for patient care
comprehensive interprofessional team much needed in ED
i will do cognitive assessments and ask about patient’s home re: risk for further falls
takes a team work to assess, for me medications would a piece to review more and include pharmacist’s help more often
Hr and Bp can be deceptive in elderly falls pt
incorporate idea of future falls prevention into discharge planning
Modifications to assessment:
– ask about frequency of falls
– remember that many falls/syncope histories are not accurate
– importance of thinking about relative hypotension and max heart rate (220 – age)
– check for carotid hypersensitivity
– lower threshold to CT Head +/- C spine
Modification to management:
– Review & modify high risk meds
– Coordinate inpatient/outpatient OT/PT assessment
Careful consideration of how medications taken by the patient will impact falls risk, but also how they affect their vitals and how we manage them as ATLS patients. Also doing a more comprehensive falls risk assessment.
always think about atypical presentations, also that elder take a lot of pills, that can make it worst
Taking more effort with a medicines review
multidiciplinary team approach
importance of team approach
history of the patient,history of the falls ,team approch
Helpful hints from PT in the Mr Cooper case.
Good overview of how to approach trauma in the older person, things to be on alert for, not to assume things but always consider possible atypical presentation and how patient’s unique physiological changes/changes due to meds/polypharmacy may be contributing to what we are seeing.
Checking for medications causing falls
History, assessment, and remember the differences in the geriatric population.
I learned that there are more professions that can play a role in a patients fall prevention. they should be consulted.
history, good assessment, and good investigations
history and question whether normal vitals are really normal for this patient.
history history history
This has been a great review! I will pay more attention to the subtle vital sign changes and definitely spend more time searching for the cause of the event. Low threshold for CT head.
Keep calm and be a Unicorn.
multi disciplinary always safer
Reminded me of the importance of falls as a mechanism of injury in older people, and the need for careful evaluation of all falls patients.
follow up of elderly pt after complete assessment in the emergency department
Thorough history of the current fall and the previous falls if any. Assessment of the causes, co morbidities, medication history.
Follow up when discharge with the involvement of the multiple team approach. communicating with the primary care physician in order to give detail information about the patient’s condition.
thorough assessment, underlying conditions, history of social status, support and how a fall can be an impact not only physically but also socially mentally and emotionally
be more mindful of the risk of falls in the elderly and how it affects morbidity and mortality after injury
Need to generate a team to coordinate patient care on discharge as well as to address all the potential risk factors and causes of a fall.
preparación continua de los equipos de trabajo para manejar a estos pacientes
integral evaluation, try to change the concept of falls in de service, not only treat the injuries, search for risk factors for falls
learned of education, recognition of warning signs
team evaluation, more careful when sending a patient home
This module highlighted that I may need to investigate the services we have available for the elderly in the public health care system.
It also encourages me to be more thorough in my assessment of past history of falls and fear of falling.
I have a better understanding of the physiology and what might be age related changes after a trauma vs non-age related.
Understanding the physiology behind falls in older patients will help me make a more thorough assessment of these patients.
I have now learnt to have a broad based thinking approach to the older patient who has had a fall, other than just assessing for the cause of the fall and the extent of injuries. Knowin the atypical presentation of head injuries in elderly will prompt me to be more cautious of port of patient disposition after ensuring the input of a multidisciplinary team and inter communication with other professional for the best and safest plan of management for the elderly who has had a fall.
I will be looking for functional assessment tools to assist with a better initial assessment.
Falls assessment, falls prevention and interdisciplinary team input.
important information was reviewed
Very great review
VS in the older adult must be interpreted cautioulsy
I hope to do a more thorough assessment of elderly people who present as falls
will check for intracranial bleeds
assess re cause and prevention, especially something the GP can do in the office
One important point I added,Understand the importance of an interdisciplinary team in assessing older patients with falls.
Senior physiology review was great
I will use the 4 point appraoch to falls – why did pt fall, what are the injuries, safe discharge planning, fall prevention
geriatric pathophys, team approach, comprehensive assesment
very helpful module. I would add that collateral history is always key, even if the patient has no family, I often will fu with the LTC charge nurse.
Was aware of physiology changes in the elderly but this module provided a very good review.
learned quite a few things particularly around elderly physiology
the learning issues are that the elderly falers need a thorough history taking including social status and supports, a medical and medication history, head injury protocol and functional assessments
Enjoyed this module. Take home is that for elderly patient with falls, ensuring that we are thorough is important. Also important to ensure these patients have access to all the necessary resources in order to improve patient outcomes.