By Frances W. Sills, RN, MSN, ARNP
© 2008 The Medical-Legal News
Falls are one of the most common adverse events in the senior population, and the consequences can be devastating. Most people fear breaking a hip when they fall, but a U.S. government study indicates that when an elderly person hits his or her head it can have deadly consequences.
Brain injuries account for half of all deaths from falls. A study conducted by the U.S. Centers for Disease Control and Prevention (CDC), reveals that, in individuals over 65, such injuries resulted in 56,000 hospitalizations in 2005 and almost 8,000 deaths. The report says that one in every three Americans age 65 and older falls each year and 30% of those falls cause enough injury to warrant medical attention.
Of the 1.8 million seniors treated in emergency settings in 2005, 433,000 resulted in hospitalizations and almost 16,000 resulted in death (8,000 from brain injury).
Even when the fall results in a non-fatal head injury, the results can be permanent and devastating. Other deaths were due to a variety of causes including heart failure, stroke, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.
The consequences of such falls include additional physical and emotional impairments over and above what the individual may have had prior to the fall, and also the loss of cognitive function.
Many factors exist that increase the risk of falling in the older population including the aging process itself. As the individual ages, mobility issues caused by muscle weakness, unstable balance and diminished sensation in the feet occur. Ongoing changes in vision can also contribute to the risk of falling, as do many chronic medical conditions and the side effects of drug interactions between the medications prescribed to treat the medical conditions.
A lot of people do not think a fall is serious unless they have broken a bone, that is, they do not think about or worry about their heads. As individuals age, veins and arteries can be torn more easily during a sudden blow or jolt to the head. This can result in a fatal brain bleed. Other factors can contribute to bleeding, such as the use of blood thinners and prophylactic low-dose aspirin.
The severity of the brain injury is not always immediately apparent, and some individuals may not lose consciousness. There have been many situations where an individual comes to the ER alert and talking, but dies an hour or two later. The same scenario can occur within the hospital, clinic and long-term care facility or at home.
Previous CEC research has shown that the U.S. death rate from falling has risen dramatically — about 55% — in senior adults since the 1990s. The new study highlights the role that brain injures play in such deaths.
When one reviews medical records in cases that involve falls that have resulted in an injury, one thing that stands out is the limited, and most of the time inadequate, initial assessment.
This continuing education offering reviews the basic neurologic exam that should be done on any individual who has fallen in order to rule out the possibility of a possible brain injury.
The GCS scale
Immediately after a fall the individual should be assessed for cuts, bruises, possible fractures and mental status. Since its introduction into the literature in 1974, the Glasgow Coma Scale (GCS) has been widely used as a measure to record the level of consciousness in a number of patient populations, and particularly in patients who have sustained a possible or actual trauma brain injury (TBI).
Because the GCS score is one of the first things assessed at the time of injury and continues to be assessed throughout the course of treatment in TBI patients, much research is being done that examines the relationship between the GCS scores and certain outcomes for patients who have sustained blows to the head which result in TBIs. The use of the GCS is seen mostly in major trauma cases and neurological conditions where there is an apparent decreased level of consciousness. However, because of the predictive ability of the GCS, it is an excellent assessment tool to use when assessing patients following falls in which there is a possibility that the patient struck his or her head.
The GCS was developed by Teasdale and Jennett (1974) as a standardized method for healthcare professionals to evaluate and describe the degree of altered consciousness or coma in patients who had sustained head injuries. It is based on the theoretical model of the levels of consciousness that had been proposed by Plum and Posner (1972). They described level of consciousness as a continuum of different degrees of human responsiveness. At one end of the continuum is normal consciousness, where the human responsiveness is characterized by maximum degrees of awareness and arousal. As the continuum progresses downward, the levels of awareness and arousal decrease, representing the states of clouding consciousness, delirium and stupor. At the end of the continuum is coma, which possesses no measurable degree of awareness or arousal.
In their research evaluating the levels of consciousness, Plum and Posner have asserted that there are five clinical parameters that can be used to identify the cause and anatomic location of the injury. These parameters include:
• State of consciousness;
• Respiratory status;
• Pupillary size and reactivity to light;
• Eye movements and ocular reflexes;
• Motor responses.
The simplified model (GCS) which measures the key aspects of level of consciousness consists of:
• Eye opening response, including pupillary assessment;
• Verbal response,
• Motor response.
The scoring of each component provides a baseline at the time of injury and can be used by various members of the healthcare team. It also can be used repeatedly at different time periods to measure changes in level of consciousness in the head-injured patient. It also provides a mechanism to quickly evaluate the presence and severity of a head injury and provides a means to communicate this information effectively to other members of the healthcare team.
The GCS neurological assessment of consciousness
Consciousness is defined as the state of being aware of physical events or mental concepts.
Conscious patients are awake and responsive to their surroundings. A manifestation of altered consciousness implies an underlying brain dysfunction. Its onset may be sudden, for example following a fall where a patient hits his head and the blow results in the tearing of blood vessels in the brain, or it may occur more gradual, such as in hypoglycemia. There are a range of situations that can lead to altered consciousness, particularly in the senior population. These can include, but are certainly not limited to:
• Profound hypoxemia;
• Cerebral hypofusion;
• Recent administration of sedatives or analgesic drugs;
• Epidural/subdural hemorrhage.
It is not possible to directly assess the level of consciousness; it is assessed by observing the patient’s behavioral response to different stimuli.
Pupillary assessment is an important part of the neurological assessment because changes in the size, equality and reactivity of the pupils can provide vital diagnostic information in the patient. Both pupils should be the same shape and size, and equal in response to light. Although not an actual part of the GCS, examination of the pupils is an essential adjunct to it, especially if the patient’s level of consciousness is impaired. In many healthcare facilities it is included in the documentation of the GCS.
It is important to understand the basic anatomy and physiology of this assessment due to its importance. The pupil, being the “black hole” in the center of the iris, is a flattened muscular diaphragm which is attached to the ciliary body. Relaxation and contraction of the muscles of the iris causes it to dilate (in darkness) or constrict (in bright light). Evaluation of this reaction is effectively an assessment of the third cranial nerve which controls the constriction of the pupil. Compression of this nerve will result in fixed, dilated pupils. Changes in the patient’s pupillary reaction, size or shape, together with other neurological signs, are an indication of raised intracranial pressure and compression of the optic nerve which is a sign of impeding brainstem herniation, respiratory arrest and death.
Pre-existing factors that can alter pupillary responses are cataracts, false eyes, previous eye injuries and medications that cause dilation or constriction. These need to be considered when doing a pupillary assessment.
Back to the GCS…
The GCS assesses the two aspects of consciousness:
• Arousal or wakefulness (being aware of the environment);
• Awareness (demonstrating an understanding of what has been said).
The 15-point scale assesses the patient’s level of consciousness by evaluating three behavioral responses and adding the individual category scores. By assigning a numerical value to the level of response to the individual criterion in each section, three figures are obtained which add up to the maximum score of 15 and the minimum score of 3. Communication of information about a patient should be based on the three separate responses of the three sections. For example, if the patient’s GCS score is 12, the communication would be E4, V4, and M4. If you are only reporting the total score, the denominator should be specified, for example 12/15.
A patient with a score of < 15 should be assessed immediately and a patient with a score of less than or equal to 8 may require airway management or resuscitation.
A reduction in motor score by one or an overall deterioration of two is significant and should be reported. Other indications for urgent medical review include:
• Development of agitation;
• A sustained (at least 30 minutes) drop of one point in the GCS;
• A drop of three or more points in the eye-opening or verbal response scores or a drop of two or more in the motor response score;
• Development of severe or increasing headache or persisting vomiting;
• New or evolving neurological symptoms or signs, for example inequality or asymmetry of limb or facial movement.
GCS eye opening response
Assessment of eye opening involves the evaluation of arousal (being aware of the environment).
• Score 4 — eyes open spontaneously.
• Score 3 — eyes open to speech.
• Score 2 — eyes open in response to pain only, for example a trapezium squeeze.
• Score 1 — eyes do not open to verbal or painful stimuli.
It should be documented if the patient is unable to open his or her eyes because of swelling, ptosis or a dressing.
GCS verbal response
Assessment involves evaluating awareness.
• Score 5 — oriented. Patient knows who and where they are, and why, the year, season and month.
• Score 4 — confused conversation. Patient responds in conversational manner, with some disorientation and confusion.
• Score 3 — inappropriate speech. Random or exclamatory speech, with no conversation.
• Score 2 — incomprehensible speech. No words uttered, only moaning.
• Score 1 — no verbal response.
It should be documented if the patient is dysphasic or has a tracheal tube or tracheostomy and is unable to verbally respond.
GCS motor response
Assessment of motor response is designed to determine the patient’s ability to obey a command and to localize, withdraw or assume abnormal body positions in response to a painful stimulus.
• Score 6 — obeys commands. Patient can perform two different movements when asked.
• Score 5 — localizes to central pain. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of a painful stimulus.
• Score 4 — withdraws from pain. The patient flexes or bends the arm toward the source of the pain but fails to locate the source of the pain (no wrist rotation).
• Score 3 — flexion to pain. The patient flexes or bends the arm, characterized by internal rotation and adduction of the shoulder and flexion of the elbow much more slowly than normal flexion (decorticate posturing).
• Score 2 — extension to pain. The patient extends the arm by straightening the elbow and may be associated with internal shoulder and wrist rotation (decerebrate posturing).
• Score 1 — no response to painful stimuli.
GCS painful stimuli
A true localizing response to pain involves the patient bringing an arm up to chin level. Painful stimuli that can elicit this response include pressure on the nail bed, trapezium squeeze or sternal rub. When applying painful stimuli, the least obnoxious technique that will elicit a response from the patient will be used.
Each year, millions of individuals sustain some level of head injury. Most of the injuries are minor because the skull provides the brain with considerable protection. The symptoms of minor head injuries usually go away on their own.
More than half a million head injuries in a given year, however, end up requiring hospitalization. With the senior population increasing, seniors’ falls on the increase and the sobering statistic that TBIs are accounting for 50% of the unintentional deaths as a result of falls, the importance of accurate assessment of the patient who has fallen cannot be over-emphasized. Early recognization of a potential head injury following a fall possibly can prevent some long-term cognitive, emotional and functional impairment in our senior population.
“What you want are facts, not opinions…. The most important practical lesson that can be given to nurses is to teach them what to observe — how to observe — what symptoms indicate improvement — which is of none — which are the evidence….” Nightingale, 1859, p. 105. •
Frances W. (Billie) Sills, RN, MSN, ARNP, is an assistant professor at ETSU College of Nursing in Tennessee;firstname.lastname@example.org.