More than just a fall: fall evaluation and timely recognition of complications in older adults in the emergency department

Opening Vignette An 80-year-old man with hypertension, vascular dementia and atrial fibrillation on apixaban presented to the emergency department following an unwitnessed fall, preceded by 1 week of functional decline. His speech and ambulation were slower than usual, and he required assistance with walking. Post-fall, he exhibited bilateral upper limb weakness and paraesthesia, and right lower limb weakness. Examination revealed a Glasgow Coma Scale score of 14, slow responses in answering questions and motor deficits (upper limbs 3/5 bilaterally, right lower limb 4/5, left lower limb 5/5). Bruising was noted over the forehead. Pupils were reactive to light bilaterally, with evidence of pseudophakia. Gait could not be assessed, as he was too unsteady. Computed tomography of the brain demonstrated bilateral acute-on-chronic subdural haemorrhages Figure 1a-c. Magnetic resonance imaging of the cervical spine performed emergently showed central cord oedema at C4–C6 Figure 1d.Figure 1: (a (b) review of medical complexities in older adults; (c) outline of the importance of a multidisciplinary approach to managing falls in older adults, including safe and appropriate disposition; and (d) management of subdural haemorrhage (SDH) and central cord syndrome (CCS) in older adults. EVALUATION OF FALLS Falls in older adults are often multifactorial.4 It is crucial to identify and address the underlying causes of a fall, implement interventions to prevent future falls, and not focus solely on treating the resulting injury. Causes of falls can be classified into predisposing and precipitating factors Box 1.Box 1: Fall evaluation and management in older adults.The sudden urge to urinate or defecate, combined with mobility limitations, can lead to rushed trips to the bathroom, thus increasing the likelihood of falls. It can also cause self-imposed fluid restriction, resulting in dehydration and postural hypotension. Additionally, the fear of falling may restrict activity, leading to further deconditioning and exacerbating fall risk. Given these modifiable predisposing and treatable precipitating factors, we should actively elicit such causes in the primary care setting or emergency department (ED), by taking a detailed history and performing a careful physical examination, including a complete neurological examination and gait assessment. Otherwise, there is a risk of missing feared complications in these patients.6 The SPLATT mnemonic is a useful clinical tool to evaluate the circumstances surrounding a patient’s fall, particularly in older adults, to identify risk factors and prevent future incidents Box 2.7Box 2: SPLATT mnemonic.MEDICAL COMPLEXITIES Medical complexities in older adults arise from the interplay of multiple chronic conditions, polypharmacy and drug–drug interactions, age-related physiological changes and reduced functional reserve. This is evident in our case who has multiple chronic illnesses such as atrial fibrillation, vascular dementia and hypertension, and polypharmacy. Sarcopenia, a major component of frailty, is a well-recognised predisposing factor for falls.8 Cognitive impairment can hinder history taking; therefore, corroborative history from caregivers is crucial for obtaining an accurate picture of the incident. Malnutrition and dehydration due to impaired thirst mechanism can further exacerbate intercurrent illness. Care coordination may also be challenging due to multiple caregivers. Urinary and bowel incontinence can affect older adults’ quality of life, while psychiatric conditions and social isolation may limit access to healthcare. Additionally, older adults may present atypically or underreport their symptoms, leading to delayed diagnosis and increased mortality. MULTIDISCIPLINARY APPROACH Clinicians should recognise that complex interactions among various risk factors can exist. Interventions and prevention strategies Box 3, which have been extensively studied, are usually multi-pronged and involve multidisciplinary teams. Treatment of comorbidities—including conditions such as osteoporosis, which increases fracture risk after falls—is important. Although some studies have not shown a statistically significant reduction in the number of injurious falls with multifactorial interventions, exercise interventions have significantly reduced the number of falls, fallers and fall-related injuries.9 The practical tips to manage falls in older adults include (a) obtaining a corroborative history of the fall from the witness or caregiver; (b) assessing gait—unsteady gait increases fall risk and warrants admission; (c) exploring social support to determine suitability for home discharge; (d) identifying any reversible predisposing or precipitating factors with timely intervention; and (e) adopting a multidisciplinary team approach to achieve a good outcome.Box 3: Multidisciplinary targeted intervention.COMPLICATIONS OF FALLS Subdural haemorrhage Presentation of SDH in older adults is often non-specific10 and may include (a) functional decline such as urinary incontinence and gait disturbances (e.g., unsteady gait, increased falls or walking more slowly); (b) speech difficulties (e.g., speaking more slowly); (c) headache; (d) altered mental status (e.g., hypoactive, hyperactive or mixed delirium); and (e) seizures. In older adults, age-related brain atrophy predisposes to tearing of the bridging veins, even with minor impact, leading to SDH. Intracranial pressure does not increase rapidly, as the atrophied brain allows more space for blood to accumulate. This explains the non-specific presentation in older adults, as seen in our case, who presented with ‘slowing down’. It is also important to note that older adults may not remember their fall incidents due to dementia, or they may play down their symptoms. As such, one should not rely solely on a history of head trauma to consider SDH in the context of altered mental status. Our case has both acute and chronic SDH, likely due to recurrent falls. Medications such as antiplatelet agents or anticoagulants also increase the risk of SDH in older adults.11 Diagnosis can be made with a non-contrast computed tomography (CT) of the brain. Acute SDH typically appears as a hyperdense, crescent-shaped collection along the convexity of the brain, between the dura mater and arachnoid mater, usually within 72 hours of the injury. Subacute SDH (3–14 days) can appear isodense, which is similar to brain tissue, making it harder to detect on plain CT of the brain. Chronic SDH (>14 days) appears as a hypodense (dark) collection due to clot liquefaction. Layering (fluid–fluid level) may be seen if there is recurrent bleeding. Management includes burr-hole drainage for symptomatic or large SDH, correction of coagulopathy, fall prevention and rehabilitation. The Society for Critical Care Medicine and the Neurocritical Care Society recommend discontinuing apixaban and administering four-factor prothrombin complex concentrate for intracranial haemorrhage in these patients, to limit haematoma expansion,12 provided the haemorrhage occurs within 3–5 terminal half-lives of drug exposure. This is similar to the guidelines of the American Heart Association/American Stroke Association.13 Central cord syndrome Older adults are at higher risk of developing spinal injuries after a fall. Of note, a fall on the face with hyperextension of the neck—in the setting of degenerative changes such as cervical spondylosis or spinal stenosis narrowing the spinal canal—may cause compression of the central part of the spinal cord with/without vertebral damage, leading to oedema and compression of the corticospinal tracts and spinothalamic tracts. As the upper limb motor fibres are more medially located in the spinal cord, the injury disproportionately affects the upper limbs more than the lower limbs, as in our case. There is an upper motor neuron deficit below the level of injury with spastic paralysis and urinary retention and a lower motor neuron deficit at the level of injury. Motor function is more severely impaired than sensory function. Patients may experience varying degrees of loss of pain and temperature sensation. This is known as CCS, the most common form of incomplete traumatic spinal cord injury.14 The diagnostic modality of choice is magnetic resonance imaging. Features include increased T2 signal intensity within the central portion of the spinal cord at the affected level, indicating oedema, with accompanying cervical spondylosis or spinal stenosis changes. Management of CCS depends on the severity, presence of spinal instability and the overall health of the patient. The goal is to reduce cord compression, ensure adequate spinal cord tissue perfusion, promote neurological recovery and improve function. Acute management includes pain control and rigid immobilisation15 of the spine to prevent further damage. The use of steroids in acute spinal cord injury is controversial, with significant trend changes. In a 2012 Cochrane review of randomised controlled trials on steroid treatment for acute spinal cord injury, methylprednisolone was shown to improve neurologic outcome when administered within 8 hours of injury using a specific regimen, with no evidence of significantly increased complications or mortality.16 However, recent systematic reviews and meta-analyses of later studies have demonstrated evidence of increased risk of complications such as hyperglycaemia and pneumonia, with no significant short- or long-term improvement in neurological function with the administration of methylprednisolone.17 Major guidelines, including the 2013 American Association of Neurological Surgeons/Congress of Neurological Surgeons guidelines, recommend against the routine use of steroids for acute spinal cord injury. The AO Spine 2017 guidelines allow for methylprednisolone as a valid option in acute cervical spinal cord injury, not as standard of care.18 There is no guideline or high-quality randomised trial to support the use of dexamethasone in acute cervical spine injury.19 The consensus of another systematic review on the management of acute traumatic CCS was that in the absence of high-quality prospective randomised controlled trials comparing surgical and conservative management, patients ‘can be given the options to undergo either surgical management, especially in selected cases with substantial neurological deficit (ASIA Impairment Scale Grade C) in the presence of ongoing cord compression, or an initial conservative management followed by surgery at a later date, if there is a neurological deterioration or a plateau of neurological recovery’. Besides the judgement of the physician, there should be shared decision‐making with the patient and family. The consensus also extends to the timing of surgery, i.e., early (24 h). The systematic review found no difference in the incidence of complications in both surgical groups.20 Rehabilitation is of paramount importance to improve function, strength and mobility. Older adults with severe pre-existing cervical stenosis or multiple comorbidities tend to have poorer functional recovery.21 Recovery usually starts with motor power in the lower limbs, followed by the bladder and upper limbs, with fine finger movements recovering last. There is no set pattern of recovery for variable sensory loss. Urologic recovery is favourable. Neuropathic pain and spasticity may occur and can be treated with gabapentin/pregabalin and baclofen, respectively. DISPOSITION Older adults presenting to the ED with minor injuries, good home care support and a low risk of another fall (e.g. steady gait with no serious predisposing or precipitating factors) may be discharged back to the community after a comprehensive geriatric emergency medicine review. Appropriate interventions can be carried out in the community or outpatient setting as indicated. At the other end of the spectrum, management may include end-of-life care. In our case, as the patient was able to speak and ambulate, his dementia was likely mild to moderately severe. However, older adults with more severe dementia and/or frailty (e.g. Clinical Frailty Scale score 7–8) and nearing the end of life trajectory may require goals-of-care discussions with the family and next of kin when considering invasive procedures such as burr-hole drainage or spinal surgery, as they may not align with the patient’s preference and values at this stage of life.22 In summary, older adults are at risk of serious injuries, such as SDH and CCS. Medical complexities can make diagnosis and management challenging. Careful evaluation and a multidisciplinary approach are needed to achieve the best outcome, and intensive rehabilitation may help patients regain function and reduce the likelihood of future falls.23 TAKE HOME MESSAGES A fall in the older adult is a common presentation in the ED and can result in significant morbidity and mortality. It is crucial to identify predisposing and precipitating causes of a fall and implement interventions to prevent future falls. Medical complexities in older adults make diagnosis and management challenging, requiring a multidisciplinary approach to achieve the best outcome. In older adults, SDH can present with non-specific symptoms such as cognitive or functional decline. Older adults are at risk of developing CCS after a fall with hyperextension of the neck due to degenerative cervical spine disease. Central cord syndrome typically presents with weakness and paraesthesia of the upper limbs. The Clinical Frailty Scale should be used to guide shared decision-making regarding invasive procedures, not just disposition. Closing Vignette The patient was referred to the neurosurgery department for consideration of burr-hole decompression of subdural haemorrhage (SDH), and the orthopaedic surgery department for central cord syndrome. Dexamethasone and prothrombin complex concentrate were administered intravenously. His SDH was managed conservatively. The patient underwent C6 complete laminectomy, posterior cervical laminoplasty at C4/5 and C5/6, and posterior instrumentation of C5–7. He was subsequently transferred to a community hospital for intensive rehabilitation. At the orthopaedic specialist outpatient clinic review 6 months later, the patient was wheelchair-bound and power in both upper limbs was 3/5.Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 15 May 2026