British Journal of Oral and Maxillofacial Surgery xxx (2004) xxx—xxx
Falls in elderly people that result in facial injuries
6
7
8
9
Department of Oral and Maxillofacial Surgery, Maxillofacial Unit, Queen Alexandra Hospital, Cosham,
Portsmouth PO6 3LY, UK
KEYWORDS
Elderly;
Facial;
Injury
10
11
12
13
PR
14
15
16
17
18
19
20
24
25
26
27
28
29
30
31
32
33
34
35
UN
*Corresponding author. Tel.: +44-2392-286064;
fax: +44-2392-286089.
E-mail address: [email protected] (C.V. Wade).
1
2
increase morbidity and mortality in patients with
already limited physiological reserves.1
The annual incidence of falls in those over the
age of 65 years is 35—40%.4 There is also a seasonal variation as most falls occur in the winter.5
Many older people who fall do not ask for medical help.6 Of those who do, about 42% will need
admission to hospital.7 Falls can indicate poor
health and declining function. The mortality increases dramatically with age in both sexes and
in all ethnic groups, and falls account for 70%
of accidental deaths in people aged 75 or over.8
Falls are commoner in nursing homes and hospitals
than in the community, and 10—25% of residents
in nursing homes have a serious fall each year.
Annual incidence in community studies varies considerably, ranging from 217 to 630/1000 persons
at risk.4 Although they are in a minority, recurrent
fallers contribute substantially to the total number of episodes recorded.9 The risk of recurrent
EC
23
People are living longer in most Western countries.1
They are healthier, and have more active lifestyles.
As a result they are increasingly exposed to the risk
of injury.2 The annual occurrence of injuries in older
people has been reported to be as high as 29%.3
Trauma is now the fifth most common cause of death
in people over the age of 65 years, and old people
are more likely to die of their injury than younger
people.2
There are substantial differences in the response
to trauma between the old and the young. Compromise of the airway, reduction in lung compliance,
change in cardiovascular homeostasis, and the
prevalence of pre-existing disease all contribute to
RR
22
1. Introduction
CO
21
Summary Falls in elderly people are increasing. Injuries of the upper limb that
result from a fall usually suggest that an outstretched hand was used to curb the
fall. Conversely, maxillofacial injuries in elderly people may result from alterations
in consciousness as a result of a pre-existing medical condition.
We investigated the nature of falls in an elderly population and compared two
cohorts of patients–—those presenting with maxillofacial injuries, and those with isolated upper limb injuries, and there were 25 patients in each cohort. Comprehensive
personal data and medical history were recorded together with details of the fall.
We found a significant correlation between the nature of the injury and recollection
of the event (P < 0.01).
Patients who sustain facial injuries are less likely to recall the event. This may be
the result of the injury itself, but an underlying medical condition may have been
responsible for the fall and should be excluded.
© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
F
5
OO
4
C.V. Wade*, G.R. Hoffman, P.A. Brennan
TE
D
3
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0266-4356(03)00256-0
YBJOM 1927 1—4
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
2
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
67—97
80
4:21
60—93
75
6:19
Table 2 Details of maxillofacial injuries.
Facial injury
Number of
patients
Lacerations (intraoral and extraoral)
Zygoma fractures
Mandible fractures
Condyle fractures
Dentoalveolar segment
15
5
4
2
1
F
63
Age range (years)
Mean age (years)
Male:female ratio
Injuries to
upper limb
(n = 25)
Table 3 Details of orthopaedic injuries to the upper
limbs.
OO
62
Nature of injury
Number of
patients
Fracture of radius
Fracture of ulna
Fracture of carpal bone
Dislocated shoulder
Sprained wrist
Bruising of hand
13
4
1
2
2
3
PR
61
Maxillofacial
injuries
(n = 25)
25 patients with maxillofacial injuries recalled the
event (60%). There was a significant correlation between nature of injury and recollection of event
(P = 0.02).
The most common drug being taken by the patients was aspirin (N = 20), followed by anti-hypertensive drugs (Nz). Although 40% of patients were
taking aspirin, and a further patient was taking
warfarin, there was no case of chronic subdural
haematoma.
The most common medical condition recorded in
16 patients (32%), was cardiac disease followed by
hypertension in 14 (28%). Dementia was recorded
in 8 patients (16%).
A list of suggested investigations for an elderly
patient with maxillofacial trauma who does not recall the event is shown in Table 4.
TE
D
60
Table 1 Personal details of the patients studied.
2. Patients and methods
Twenty-five patients with maxillofacial injuries sustained from falls and resulting in referral to a specialist, and 25 patients with upper limb injuries
from falls were selected for this study. Personal data
and medical histories were recorded together with
details (if known) about the fall itself.
Results were compared statistically by Fisher’s
exact test.
EC
59
RR
58
falling increases with the increasing number of
falls.10
To our knowledge there are relatively few studies
that have reported maxillofacial injuries sustained
as a result of falls in elderly people. Gerbino et al.11
found that 56% of maxillofacial injuries in old people over a 10-year period were caused by falls. The
site most commonly injured was the middle third
of the face and nasal bones were commonly fractured in older people than in younger adults. Management of elderly patients may be complicated
by both associated injuries and underlying medical
problems. This may also account for their longer
median length of hospital stay.12 However, the principles of treatment, the outcomes, and the complications do not differ between young and old.11
Rehman and Edmondson concluded that most facial
injuries in older people can be treated conservatively unless the patient has functional problems.5
These results are also supported by those of another
study which found that 40% of elderly patients were
not operated on, compared with 9.5% of a control
group.11
We performed a prospective pilot study of falls
in elderly people, and compared two groups of
patients–—those with maxillofacial injuries, and
those with isolated upper limb injuries. We were
interested to see whether maxillofacial injuries
were more likely to be the result of pre-existing
medical conditions, associated with alterations in
levels of consciousness, compared with conscious
falls when the patients extend their arms in an
attempt to protect themselves as they fall.
3. Results
A total of 50 patients were included in this study.
Twenty-five patients had maxillofacial injuries and
25 patients had upper limb injuries. Personal details
are recorded in Table 1 and the types of injuries in
Tables 2 and 3.
Of the 25 patients who sustained upper limb injuries 23 (92%) recalled falling over, but only 15 of
CO
57
UN
56
C.V. Wade et al.
4. Discussion
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
Patients who sustain facial injuries are significantly
more likely not to recall the event. The reasons for
YBJOM 1927 1—4
124
125
Falls in elderly people
3
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
F
131
TE
D
130
EC
129
RR
128
CO
127
this are either that an underlying medical condition may have been responsible for the fall, or that
amnesia was sustained as a result of a closed head
injury.
Older people with cognitive impairment and dementia are at increased risk of falls. There is an
annual incidence of around 60% (twice that of cognitively normal people).15 The most common risk
factors for falls in patients with cognitive impairment and dementia are postural instability, drugs,
neurocardiovascular instability (particularly orthostatic hypotension), and environmental hazards.13
Eight of our patients had documented dementia.
In the population aged 65 years and over, 30%
are visually impaired.14 There is an association between falling and visual impairment in people over
75 years old. Such impairment is potentially treatable in 75% of cases, but, in the UK, only a quarter of
those with visual impairment are being treated.14
Only one patient reported having glaucoma. No formal data were collected regarding the patients’ visual acuity, and this is undoubtedly another factor
to investigate in future studies.
Other risk factors for falls include disturbances
of balance and gait, environmental hazards, drugs
(psychotropic, polypharmacy), cardiovascular risk
factors (orthostatic hypotension, cardioinhibitory
and vasodepressor carotid sinus hypersensitivity, vasovagal syncope), feet and footwear, medical problems, depression, and cerebrovascular
lesions.15 They have all been shown to be associated with recurrent falls.9,10
In those patients who are taking warfarin or antiplatelet drugs, particular attention should be paid
to the possibility of chronic subdural haematoma.
This is predominantly a disease of elderly people
and usually follows minor trauma. Asghar et al.16
found that falls (57%) and anti-thrombotic drugs
(33%) were the most common risk factors for chronic
subdural haematoma. This is a potentially serious
event that may occur as a result of a fall, and risk
factors and common signs must be identified.
There are a considerable number of elderly people who fall but do not seek medical help. A fall
UN
126
OO
Electrocardiogram to exclude cardiac events and
hypothermia21
Cardiac enzyme
Computed tomogram (if indicated by neurological
examination)
Core body temperature to exclude hypothermia
Skeletoneuromuscular examination22
Integrity of skin23
may be disregarded as an isolated event but could
be a ‘marker’ for a future event. There must also
be a number of elderly people who fall, seek medical help, and sustain minor facial injuries that are
never referred for a maxillofacial opinion. A random
24-h period was selected and all records in the Accident and Emergency department were examined
for that time. There were 191 attenders. Of these,
seven were elderly and had fallen and sustained
craniomaxillofacial injuries. Only one of these patients was referred for a specialist opinion, which
indicates that the present study may be an underestimate of the problem.
The type of injury depends on the nature of the
fall. In particular, if people are aware that they
are falling, they instinctively attempt to break their
fall. Falls on the outstretched arm may cause fractures of the wrist, forearm, or humerus. Such fractures account for approximately one third of fractures in elderly patients who have osteoporosis.
The risk factor for these fractures is reduced density of the femoral neck bone.17 The incidence of
common, fall-related fractures was investigated in
a Danish group of elderly people (over 64 years).
About 26/1000 had a fracture in a year, 47% being
hip fractures, and 33% fractures of the wrist. Patients with a fall-related fracture had a four-times
higher risk of getting another fracture.18
We found that injuries to the upper limb occurred almost exclusively in those patients who
were aware that they were falling. Many of these
had slipped or tripped (mechanical fall). In contrast
only 60% of patients with maxillofacial injuries
remembered falling.
Elderly patients who have had one injury are at
increased risk of subsequent injury. To reduce the
likelihood of recurrence, attention should be directed to those patients with chronic illnesses and
functional impairment.19 Strategies can be either
complex or single, and include reviews of medication, use of mechanical assistance, retraining of
gait, modification of environmental hazards, and
treatment of cardiovascular disorders.4 Treatment
is directed to the underlying cause of the fall and
can return the patient to baseline function.8 Exercise is the best single preventive of falls in for
older people, and the ideal strategy is to combine
it with other measures.20 In the UK, the National
Health Service Framework for older people specifically targets the prevention of falls in older people particularly in those who attend Accident and
Emergency departments after a fall.15 It has recommended that all hospitals should have a special
falls unit in place by 2004.4
In conclusion, maxillofacial trauma (as opposed
to upper limb injuries) is more likely to occur in pa-
PR
Table 4 List of suggested investigations.
YBJOM 1927 1—4
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
4
C.V. Wade et al.
229
233
We thank Miss Emma Odell for her help with the
preparation of the manuscript.
234
References
TE
D
1. Young L, Ahmad H. Trauma in the elderly: a new epidemic?
Aust NZ J Surg 1999;69:584—6.
2. Schwab CW, Kauder DR. Trauma in the geriatric patient.
Arch Surg 1992;127:701—6.
3. Marciani RD. Critical systemic and psychosocial considerations in management of trauma in the elderly. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1999;87:272—80.
4. Hamptom JL, Kenny RA, Newton JL. Effective interventions to prevent falls in older people. Br J Gen Pract
2002;52:884—6.
5. Rehman K, Edmondson H. The causes and consequences
of maxillofacial injuries in elderly people. Gerodontology
2002;19:60—4.
6. Stoddart H, Sharp D, Harvey I, Whitley E. Falls and the use
of health services in community living elderly people. Br J
Gen Pract 2002;52:923—5.
7. Sattin RW, Lambert Huber DA, DeVito CA, et al. The incidence of fall injury events among the elderly in a defined
population. Am J Epidemiol 1990;131:1028—37.
8. Fuller GF. Falls in the elderly. Am Fam Phys 2000;61:2159—
68, 2173—74.
9. Vassallo M, Sharma JC, Allen SC. Characteristics of single
fallers and recurrent fallers among hospital in-patients.
Gerodontology 2002;48:147—50.
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
RR
EC
300
CO
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
UN
232
F
Acknowledgements
228
OO
231
227
10. Luukinen H, Koski K, Laippala P, Kivela SL. Predictors for
recurrent falls among the home-dwelling elderly. Scand J
Prim Health Care 1995;13:294—9.
11. Gerbino G, Roccia F, De Gioanni PP, Berrone S. Maxillofacial
trauma in the elderly. J Oral Maxillofac Surg 1999;57:777—
82.
12. Falcone PA, Haedicke GJ, Brooks G, Sullivan PK. Maxillofacial fractures in the elderly: a comparative study. Plast
Reconstr Surg 1990;86:443—8.
13. Shaw FE. Falls in cognitive impairment and dementia. Clin
Geriatr Med 2002;18:159—73.
14. Legood R, Scuffham P, Cryer C. Are we blind to injuries in
the visually impaired? A review of the literature. Inj Prev
2002;8:155—60.
15. Shaw FE, Bond J, Richardson DA. Multifactorial intervention after a fall in older people with cognitive impairment
and dementia presenting to the accident and emergency
department: randomised control trial. Br Med J 2003;326:
73—5.
16. Asghar M, Adhiyaman V, Greenway MW, Bhowmick BK, Bates
A. Chronic subdural haematoma in the elderly–—a North
Wales experience. J R Soc Med 2002;95:290—2.
17. Nguyen TV, Center JR, Sambrook PN, Eisman JA. Risk factors for proximal humerus, forearm, and wrist fractures in
elderly men and women: the Dubbo Osteoporosis Epidemiology Study. Am J Epidemiol 2001;153:587—95.
18. Zieger K. Fractures following accidental falls among
the elderly in the county of Aarhus. Ugeskr Laeger
1998;160:6652—5.
19. McGwin Jr G, May AK, Melton SM, Reiff DA. Recurrent
trauma in elderly patients. Arch Surg 2001;136:197—203.
20. Anon. Exercise is the best way to prevent falls. Harvard
Womens Health Watch 2002;10:7.
21. Sgobba G, Nassisi G, Giannelli F, et al. Electrocardiographic changes in accidental hypothermia. G Ital Cardiol
1982;12:147—50.
22. Spinner RJ, Poliakoff MB, Tiel RL. The origin of ‘‘Saturday
night palsy’’? Neurosurgery 2002;51:737—41.
23. Mannesse CK, van Riet GJ, vand der Cammen TJ. Unusual consequence of a fall: pressure sores of both breasts
resulting in bilateral partial mastectomy. Neth J Med
1994;45:30—3.
PR
230
tients with an altered level of consciousness, perhaps resulting from a pre-existing medical condition. We put forward a list of baseline investigations
for all elderly patients who present with maxillofacial trauma with amnesia for the event.
226
YBJOM 1927 1—4