Elsevier

Injury

Volume 46, Issue 9, September 2015, Pages 1765-1771
Injury

Injuries and outcomes associated with traumatic falls in the elderly population on oral anticoagulant therapy

https://doi.org/10.1016/j.injury.2015.06.013Get rights and content

Abstract

Introduction

Fall risk for older adults is a multi-factorial public health problem as 90% of geriatric injuries are caused by traumatic falls. The CDC estimated 33% of adults >65 years incurred a fall in 2011, with 30% resulting in moderate injury. While much has been written about overall risk to trauma patients on oral anticoagulant (OAC) therapy, less has been reported on outcomes in the elderly trauma population. We used data from the National Trauma Data Bank (NTDB) to identify the types of injury and complications incurred, length of stay, and mortality associated with OACs in elderly patients sustaining a fall.

Methods

Using standard NTDB practices, data were collected on elderly patients (≥65 years) on OACs with diagnosis of fall as the primary mechanism of injury from 2007 to 2010. Univariate analysis was used to determine patient variables influencing risk of fall on OACs. Odds ratios were calculated for types of injury sustained and post-trauma complications. Logistic regression was used to determine mortality associated with type of injury incurred.

Results

Of 118,467 elderly patients sampled, OAC use was observed in 444. Predisposing risk factors for fall on OACs were >1 comorbidity (p < 0.0001). Patients on OACs were 188% and 370% more likely to develop 2 and >3 complications (p < 0.0001); the most significant being ARDS and ARF (p < 0.0001). The mortality rate on OACs was 16%. Injuries to the GI tract, liver, spleen, and kidney (p < 0.0002) were more likely to occur. However, if patients suffered a mortality, the most significant injuries were skull fractures and intracranial haemorrhage (p < 0.0001).

Conclusions

Risks of anticoagulation in elderly trauma patients are complex. While OAC use is a predictor of 30-day mortality after fall, the injuries sustained are markedly different between the elderly who die and those who do not. As a result there is a greater need for healthcare providers to identify preventable and non-preventable risks factors indicative of falls in the anti-coagulated elderly patient.

Introduction

Falls are a major cause of morbidity and mortality in elderly trauma patients in the U.S. The Centers for Disease Control and Prevention estimate one in three adults ≥65 years experienced a fall in 2011, and 20% to 30% of those who fell sustained a moderate to severe injury. Ninety percent of all geriatric injuries are caused by traumatic falls, making this an important public health problem [1]. Additionally, there is a 50% mortality for those hospitalised due to severe injuries resulting from their fall that are greater than 65 years of age. Major sources of morbidity and mortality include intracranial haemorrhage (ICH), skeletal fractures, and thoracic or intra-abdominal visceral injury. Increased mortality after ICH has previously been shown in elderly patients on oral anticoagulation [1].

ICH, especially in elderly patients on oral anticoagulant (OAC) therapy, has been identified as an independent predictor of 30-day mortality after fall [1]. In one prospective cohort of patients sustaining an ICH while receiving warfarin, mortality was 52%, compared to 25.8% in those not taking warfarin [2]. In a review of elderly trauma patients with CT-documented ICH, those on OACs had a lower GCS on presentation and a higher 30-day mortality, which increased in a linear fashion as INR increased [3], [4], [5]. Elderly patients on antiplatelet agents, including aspirin or clopidogrel, have also been shown to have an increase in all-cause mortality [6], [7].

While much as been written about the overall mortality of elderly trauma patients on OACs, less has been reported on injuries and outcomes in the elderly trauma population. The objective of this study was to use data from the National Trauma Data Bank (NTDB) to identify the relative risks for types of injuries sustained and post-trauma complications incurred, length of stay (LOS), and mortality associated with OAC use in elderly patients with fall as their primary mechanism of injury.

Section snippets

Data

Data for this study were from the NTDB. The NTDB was created in 1989 by a collaborative group from the American College of Surgeons (ACS) Committee on Trauma, and related medical and governmental organisations to provide a better understanding of trauma care systems in the United States. As the largest aggregation of trauma registry data, the NTDB contains greater than 2.5 million records from more than 900 trauma centres in the U.S. and Puerto Rico. To collect and maintain trauma injury data,

Demographics and hospital characteristics

Patient characteristics stratified by OAC use (Table 1) show these groups were similar in demographic characteristics such as age (p = 0.05), and sex (p = 0.22). There were, however, some significant differences between the groups, suggesting risk factors for the need for OAC use. Seven percent of the OAC group were black vs 4.7% of the control group. Several co-morbidity variables such as congestive heart failure (p < 0.0001), current smoker (p < 0.0001). History of cerebrovascular accident (p < 

Discussion

Atrial fibrillation is the most common cardiac arrhythmia in the U.S. and is present in approximately 5% of people >65 years. As the geriatric population in the U.S. continues to grow, the prevalence and impact of this disease will continue to rise. Not only is the risk of stroke in elderly patients age >80 years with atrial fibrillation substantial at 23.5% per year, but so is the risk of mortality and functional deficits [7]. Therefore, anticoagulation therapy to prevent thromboembolic stroke

Conflict of interest statement

The authors have no conflicts of interest or sources of funding to disclose.

Acknowledgments

The content reproduced from the NTDB remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures. Committee on Trauma, American College of Surgeons. NTDB Version 1.2.2; 1.2.5. Chicago, IL, 2008–2011.

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