Abstract
Introduction
Many elderly patients presenting to ED with falls and suspected head injury are anticoagulated. The current National Institute for Health and Care Excellence (NICE) guideline recommends patients on anticoagulation should have a CT head scan within 8 hours of head injury. An updated guideline was drafted for consultation in November 2022. The indication for CT head scan has not changed for patients on anticoagulation. There is currently a lack of evidence to inform best practice in the management of anticoagulated older patients who present with falls and head injury.
The Older Persons Assessment Service (OPAS) in Morriston Hospital offers Comprehensive Geriatric Assessment to patients age >65 years who have presented with frailty syndromes, including falls. The aim of this study is to evaluate the risk of ICH in the elderly population presented to OPAS on anticoagulation following falls and suspected head injury.
Method
A retrospective study was conducted on consecutive patients who presented to OPAS from 1st June 2020-18th May 2022. Data were collected on demographics, anticoagulant therapy, Rockwood Clinical Frailty Scale (CFS), Glasgow Coma Score (GCS) on presentation, evidence of external head injury and CT head findings.
Results
215 of 838 patients were on anticoagulation (median age 86(IQR: 81-90),56% Female).
The risk of ICH in patients presenting to OPAS who were on anticoagulation is 0.0186 (4/215, 95% CI 0.0051–0.0469); one patient’s CFS was 4(vulnerable) and three patients’ CFS were 5(mildly frail), all presented at their baseline GCS. Only one patient presented with evidence of external head injury.
Conclusion
The risk of ICH in elderly patients on anticoagulation presented to OPAS with falls is low. Those who had ICH were categorised as vulnerable and mildly frail. This study could support individualised decision-making for CT head scans, especially in moderate to severely frail patients following falls and head injury.
Comments
Did the CT lead to a change in management?
This is a huge burden of scans -- did a positive scan alter what was done to the four patients -- immediately and in terms of longer terms decisions over discontinuing anticoagulation?
No patient underwent neurosurgery.
All four patients' anticoagulant treatment was withheld. Three patients' anticoagulation was re-started later, and one patient (CFS 5) was discontinued.