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