Fall injuries among older adults are a major health challenge, with the most severe cases involving fractures and head injuries. The substantial increase in recorded head injuries for this group of the population prompts questions about how we should interpret the findings, treat the injuries and manage the growing demand for resources going forward.
Fall injuries constitute the third largest health burden in Norway in adults over the age of 75 (1), and the Norwegian Institute of Public Health ranks fall injuries as the second most costly health condition after dementia (2). Of those who experience severe consequences from falls, older adults make up by far the largest patient group, and the projected rise in fall injuries in the population is therefore concerning.
The findings presented by Sandvik in the Journal of the Norwegian Medical Association show a large increase in the number of primary care emergency consultations for head injuries in older adults in recent decades (3). This aligns with international studies, which have found a rise in recorded head injuries among older adults (4) alongside a decrease in the incidence of hip fractures (5).
The large increase in consultations resulting in a head injury diagnosis does not necessarily represent a corresponding rise in severe head injuries. Much of the increase in recorded consultations is likely attributable to the rise in people being assessed and followed up in accordance with new Scandinavian guidelines for head injuries, which recommend observation and CT scans following head trauma. More minor intracranial haemorrhages are being identified due to improved access to and sensitivity of CT imaging, resulting in increased follow-up. There has also been a notable increase in CT head scans due to the growing number of older adults taking anticoagulants.
Meanwhile, anticoagulants lead to more people with head injuries experiencing intracranial haemorrhages. Frail older adults now tend to live at home longer before moving to an institution, increasing the risk of falls and injuries. And although medications for osteoporosis halve the risk of severe fractures in those with the condition (6), they do not lead to a corresponding reduction in fall-related head injuries.
The ageing population, coupled with relatively fewer healthcare personnel, means that we need to do more to prevent falls and fall injuries to try and reduce the need for treatment
As we strive to structure healthcare services to improve the follow-up of older adults at high risk of fall-related head injuries, with a view to minimising individual health losses and optimising resource use, several pertinent questions arise: Should we implement stricter practices for the use of anticoagulants in frail older adults with a high risk of falling? Who and how many should be offered a place in a care institution, and should the risk of fall injuries be given more weight in this assessment? Should we further limit primary care emergency consultations, CT head scans and hospital admissions for observation in older adults in the later stages of life when surgery for intracranial haemorrhages is not an option?
The ageing population, coupled with relatively fewer healthcare personnel, means that we need to do more to prevent falls and fall injuries to try and reduce the need for treatment. These efforts should be based on the new national clinical guidelines for fall prevention among older adults (7). Consultations and admissions at primary care emergency services, minor injury outpatient departments and hospital departments that treat head injuries, fractures and other injuries should always trigger a referral for a comprehensive assessment of the fall and fracture risk by the appropriate department in the primary health service. Additionally, every local authority should establish a clear point of entry to ensure that staff identifying fall injuries know where to refer patients for further follow-up. In order to encourage doctors and healthcare institutions to focus more on preventive measures, these activities must be adequately funded through tariff codes and procedural codes.
We must deepen the understanding of healthcare personnel caring for older adults at risk of falls and fall injuries. Multiple contributory causes can lead to falls in older adults, and an assessment should be conducted of underlying factors, such as health conditions, medications, home environment and mobility. Preventing the causes of falls and reducing the risk of injuries through treatment for osteoporosis can significantly decrease the risk of severe fall injuries (8).
We must deepen the understanding of healthcare personnel caring for older adults at risk of falls and fall injuries
The Clinical Frailty Scale is a useful tool that can be employed throughout the health service to easily assess function in older adults (9). It can help to determine whether older adults in the later stages of life should be offered advanced diagnostics, intensive follow-up and surgical interventions, or if care and observation in familiar surroundings would be a better use of healthcare resources. Using the Clinical Frailty Scale for all referrals and in all communication between healthcare personnel and older adults will make it easier to tailor follow-up care to individual needs.
The increasing incidence of fall injuries among older adults, including head injuries, is leading to considerable health losses and costs. An increased focus on prevention and smarter choices in the later stages of life are needed.