It’s a common scenario—you stumble, fall and hit your head…or you bang it on a kitchen cabinet after getting something out of a lower cabinet. Fortunately, you’re able to get up on your own or with the help of a friend, and you think that you are relatively unscathed—no cuts, no blood, no giant goose egg.
But how do you know if it’s really safe to continue on with your day…or if you should be checked out by a doctor?
We all thought about this same question in the months following comedian Bob Saget’s death from head trauma sustained during a fall in his hotel room. He was 65 at the time—noteworthy because adults over age 65 have a 27% chance of falling in any given year.
Every year, people ages 65 and up experience 36 million falls—in fact, falls are the most common source of traumatic injury in this age group. One out of five of these falls will result in a serious injury, including head trauma. And these falls usually happen at home and involve tripping over rugs…shoes, boxes or other things on the floor…pets…cords and wires…or in slippery tubs or showers. And outside, falls can occur on curbs or slippery sidewalks.
What happens when you hit your head: You may develop a visible bump caused by blood, interstitial fluid or both, sometimes called a goose egg, that can form shortly after the trauma. Patients on blood thinners may notice that the bump, also called a hematoma, continues to grow over some hours. Or you may have obvious bleeding, as in a cut or scrape…or hidden bleeding in the brain or the layers of tissue surrounding the brain. Other types of head injuries include skull fractures and concussions, meaning that the brain has been shaken.
A head injury that results in bleeding in the brain or the layers surrounding the brain typically is classified as a subarachnoid hemorrhage…subdural hematoma…epidural hematoma…or intraparenchymal hemorrhage, depending on where in or around the brain the bleeding occurs. All of these injuries are serious and potentially dangerous. Subdural hematomas (bleeding on the surface of the brain) and intraparenchymal hemorrhages (bleeding within the brain itself) are the most common types of brain bleeds in older adults.
Brain bleed symptoms can include confusion, nausea and vomiting, changes in vision, slurred speech, drowsiness and/or a headache that doesn’t go away. Without treatment, the bleeding can compromise oxygen flow to the brain, causing oxygen-deprived brain tissue to die and damaging any functions controlled by that particular tissue (breathing, vision or limb movement, for instance).
Dangerous problem: Brain bleeds don’t always have obvious symptoms. Subdural hematomas may not make themselves known for hours or even weeks. And with epidural hematomas, which most often happen as a result of a skull fracture tearing a blood vessel, the injured person usually will lose consciousness immediately after the fall or bump, followed by a period of awareness called the “lucid interval” during which he/she appears to have emerged unscathed. Many people mistake this lucid interval for a sign that no damage has occurred, but the injured person will swiftly deteriorate. This is how actress Natasha Richardson died following a ski accident in 2009.
Symptoms for concussions are similar to those of brain bleeds, along with sensitivity to light and noise, dilated pupils and mood changes. Loss of consciousness from a concussion is uncommon.
Several factors conspire against older individuals to make even seemingly minor falls and head injuries dangerous or potentially catastrophic.
Medications may increase bleeding risk. Several age-related conditions are treated with anticoagulation medications—drugs that thin the blood and help prevent blood clots. While blood thinners can be lifesavers for patients with atrial fibrillation, pulmonary embolism, deep vein thrombosis and other heart or blood conditions, they increase the chance of severe bleeding. Aspirin is another commonly used medication that has blood-thinning effects.
Fact: As many as 10% of elderly patients who show up at urgent-care facilities with a traumatic injury are taking warfarin (Coumadin), the most commonly used anticoagulant. Use of newer anticoagulant drugs, such as dabigatran (Pradaxa) and rivaroxaban (Xarelto), is increasing, too, and have the same risks.
Age-related brain shrinkage. As we get older, our brains naturally atrophy, or shrink. This occurs even in cognitively healthy adults but is accelerated in people with dementia. As this happens, the space between the dura—a protective fibrous layer of connective tissue that sheaths the brain—and the brain itself shrinks. Result: If you hit your head and develop a brain bleed, it may take a while for symptoms such as headache, nausea or vomiting, or tingling, numbness, weakness or paralysis in a limb or the face to show up, because there is more space for blood to collect before it starts pressing on the brain.
Also, the veins in the membranes between the skull and brain begin to stretch and grow fragile with age. These veins are more likely to tear during a head injury—even a minor one, such as a fall out of a chair onto a carpeted floor. Reminder: Older adults have more trouble maintaining their balance and poorer vision, both of which increase risk of falling and risk for a head injury.
Even falling and landing on your knees or butt can be enough to rattle the brain inside the skull, as can whiplash from a car accident.
Anyone who falls into the following categories should seek help at your local emergency room…or an urgent-care facility equipped with CT machines…
Over age 65 and on a blood-thinning medication. These medications increase the chances of a dangerous bleed. About one-quarter of older adults on an anticoagulant who develop a brain bleed will die as a result, versus 9% of elderly patients who are not on anticoagulation therapy. Even if the exam—usually a head computerized tomography (CT) scan—finds no evidence of a bleed, the patient may be asked to stay at the medical facility for several hours so that a second scan can be performed to check for delayed bleeding.
Experiencing clear-cut symptoms of a head injury, brain bleed or concussion—a headache that doesn’t go away, drowsiness, confusion, nausea and vomiting, changes in vision and slurred speech.
Loses consciousness or experiences a seizure. Patients may not be certain if they passed out. If so, err on the side of caution and get medical assistance.
Suspected concussions don’t usually require a CT scan. The doctor will check your vision, balance, strength, hearing, reflexes and memory to determine whether you need a CT scan.
If you don’t fall into these categories: Ask yourself, How do I feel? Most people realize when something feels off. If you didn’t lose consciousness…can stand up from the fall by yourself (or with minimal assistance)…and don’t have any concerning symptoms, you likely are in the clear. If your neck, shoulder, hip or another body part hurts, that could be a sign of a fracture.
Small bleeds might not require significant treatment—smaller amounts of blood may be slowly reabsorbed by the body without causing complications. In these cases, you may be monitored in the hospital for 24 hours, then sent home to rest. Tylenol typically is prescribed for headache. And patients should follow up with their doctors for medication reassessment and management.
If a CT scan reveals a larger bleed, surgery may be necessary. But not everyone is physically healthy enough to survive a brain operation—your physician will weigh the pros and cons and decide if a wait-and-see approach might be safer.
Concussions usually are not life-threatening, so rest—physical rest as well as resting your brain by avoiding reading, TV, computer screens and the like—often is sufficient for healing.
