Imaging Guidelines for Elderly Falls

Indications for Head CT

• The American College of Radiology recommends obtaining a noncontrast head CT in elderly patients (≥60-65 years) who fall and sustain head trauma if they have ANY of the following: loss of consciousness, post-traumatic amnesia, headache, vomiting, GCS <15, focal neurologic deficit, physical evidence of trauma above the clavicle, anticoagulant or antiplatelet therapy (excluding aspirin alone), or dangerous mechanism of injury 1, 2
• Age >60 years is considered a high-risk criterion that warrants head CT imaging even in the absence of other symptoms when loss of consciousness or post-traumatic amnesia is present (Level A recommendation) 1, 2
• For patients ≥65 years without loss of consciousness or amnesia, age alone is a Level B indication to consider head CT, particularly with additional risk factors 1, 2
• All three major clinical decision rules (Canadian CT Head Rule, New Orleans Criteria, and NEXUS Head CT) classify older age (60-65+ years) as high risk for clinically important brain injury 3
• Head CT is indicated if ANY of the following are present: headache 2, vomiting 1, drug or alcohol intoxication 1, deficits in short-term memory 1, physical evidence of trauma above the clavicle 1, post-traumatic seizure 1, GCS score <15 4, focal neurologic deficit 1, coagulopathy (anticoagulants or antiplatelet agents) 5
• The American College of Radiology recommends considering head CT if ANY of the following are present: focal neurologic deficit 1, vomiting 1, severe headache 2, physical signs of basilar skull fracture 4, GCS score <15 4, coagulopathy 1

Anticoagulation Considerations

• Patients on anticoagulants (warfarin, NOACs) or antiplatelet agents (clopidogrel, dual therapy) require head CT regardless of symptom severity 3, 6, 5
• Warfarin increases relative risk of significant intracranial injury by 1.88-fold 3
• Dual antiplatelet therapy (aspirin + clopidogrel) increases relative risk by 2.88-fold 3
• Aspirin monotherapy does NOT significantly increase risk (RR 1.29, not statistically significant), though some evidence suggests caution in patients >65 years 3, 6
• NOACs carry lower hemorrhage risk than warfarin (2.6% vs 10.2%) but still warrant imaging 5

Clinical Decision-Making

• If patient has ANY high-risk feature listed above → Obtain head CT immediately 1, 2
• Optimal detection of lesions occurs when CT is performed ≥5 hours post-trauma, but do not delay imaging if high-risk features are present 1, 2

Follow-Up Imaging

• If initial CT shows intracranial hemorrhage in anticoagulated patients, repeat imaging is indicated as these patients have 3-fold increased risk of hemorrhage progression (26% vs 9%) 5

Discharge Considerations

• Elderly patients without loss of consciousness, amnesia, anticoagulation, or other high-risk features do not require routine head CT 1, 2, 4
• Provide clear written and verbal discharge instructions about warning signs (worsening headache, vomiting, confusion, altered consciousness) 4
• Consider fall risk assessment and anticoagulation risk-benefit evaluation for outpatient follow-up 5

Imaging Recommendations for Elderly Patients After Falls

Indications for Head CT

• The American College of Emergency Physicians guidelines recommend considering head CT in patients with head trauma if there is age >60 years PLUS one or more additional risk factors, and a 100-year-old patient represents extreme age with significantly elevated baseline risk for intracranial injury after falls, even with seemingly minor mechanisms 7
• Elderly patients (>60 years) with GCS 15 and amnesia had 10% positive CT rate in one large study, with some requiring neurosurgical intervention 8
• Age >60 years had an odds ratio of 19.2 for intracranial injury in patients with GCS scores 14-15 7
• A GCS score of 15 and remains stable, and no focal neurologic deficits, are factors to consider when deciding to order a CT, but given the patient's extreme age, the threshold should be very low for obtaining imaging 7
• No signs of skull fracture is a factor to consider when deciding to order a CT, but the Canadian CT Head Rule would require CT if age ≥65 years is present with any other criterion, and a normal neurologic exam does not exclude intracranial injury 8

Considerations for CT Imaging

• The presence of a reliable caregiver for close observation is a factor to consider when deciding to defer a CT, but clear written and verbal discharge instructions about warning signs should be provided if CT is deferred 7