Julian A. Waller

Falls among the elderly—Human and environmental factors

A study was made of 150 persons age 60 or older in Chittenden County, Vermont who were treated in an emergency department for injuries from falls, and compared them with 150 elderly neighbors not known to have such injuries. About 19 out of every 1000 elderly persons in the county are treated for falls annually but at least a third of persons in this age range have falls each year, usually not requiring treatment. A third of the treated falls were precipitated by an acute health problem, usually an exacerbation of a more chronic condition, and an additional 8% involved impairment attributable to alcohol, commonly by a person with a history of frequent, heavy drinking. Problems with canes, walkers or wheelchairs appeared to contribute to several falls among impaired persons. Persons with falls because of acute impairment had chronic limitations of mobility, vision or sensorium significantly more often than did persons with other falls or with no falls. Over half of the falls not attributable to acute impairment were caused by slippery or uneven ground. The data do not support the hypothesis that falls of the elderly commonly occur because of fractures of hips or vertebrae, but they do suggest that brittleness of bone, small muscle mass or both are substantial contributors to fractures in the elderly once the fall has been initiated. The nature of the surface struck is less important, but not entirely irrelevent, in determining the severity of injury to persons in this age range. Once injury occurred appropriate first aid was rarely provided and the injured commonly delayed for six hours or longer before seeking care and used methods of transportation to the hospital that were not conducive to limiting exacerbation of the injury. Forty-four per cent of the injured were hospitalized and, of these, 22% died within a year after injury, usually within 3 months. However, the fall injury was only rarely listed on the death certificate as an associated cause of death or significant other condition although it probably should have been listed in most cases.

Trauma registry and trauma center biases in injury research

Trauma centers and trauma registries have become important sources of data for trauma research. In their present form, both have serious biases in data selection, however, that can affect epidemiologic research results. This prospective study of 601 woodworking-related injuries seen at a trauma center involved a diverse population, a wide range of severities, both inpatients and outpatients, and primary versus referred patients. Eighty-eight per cent were outpatients and thus excluded by traditional trauma registries. Only 6% of primary patients, but 43% of referred patients, were hospitalized. Eighty-nine per cent of outpatients, and 28% of inpatients had AIS of 1. However, among primary patients 79% or more of lost or altered days of work, home, or recreational activity during 6 months postinjury occurred among ambulatory patients. Substantial differences were shown between hospitalized and ambulatory patients, and between primary and referred patients, in type of activity at time of injury, and in anatomic location and injury type. Trauma registry collection and analysis methods for epidemiologic research need substantial restructuring if they are to truly represent the tremendous problem of injury in our society.

Management issues for trauma patients with alcohol.

An estimated 20-25% of patients treated in emergency departments or as inpatients for trauma have been drinking and most of them have BACs of 0.10 gm/dL (22 mmol/L) or higher. Many are problem drinkers or alcoholics, smokers, and also abuse other drugs. Both acute ingestion and chronic abuse of alcohol increase the frequency and severity of injury, and may complicate patient management by mimicking head trauma, masking intra-abdominal injury, causing circulatory collapse, reducing immune response, altering hepatic metabolism, or causing delirium tremens. Proper management of a trauma patient with alcohol includes BAC determination, careful history taking for alcoholism with referral for further evaluation or treatment when indicated, and determination whether other drugs are also being misused. Failure to do these may put a physician at legal risk both for improper care of the patient and for exposing others to injury if the patient crashes after being discharged from the emergency department while still impaired by alcohol.

Hearing loss prevalence and management in nursing home residents

To determine the prevalence and management of hearing loss and hearing handicap among non‐demented nursing home residents.

Nonhighway injury fatalities—I. The roles of alcohol and problem drinking, drugs and medical impairment

Abstract Presence of alcohol, alcoholism, drugs other than alcohol and medical impairment was studied among persons age 15 or older who died of nonhighway injury. Where relevant they were compared with persons who died after acute episodes of illness. Alcohol was present in 42 per cent of injury fatalities and 18 per cent of those who died of illness. Amont persons who died of falls or fire respectively 70 and 64 per cent had alcohol present, usually in very high concentration. Most persons with alcohol had an actual diagnosis or at least one indicator of problem drinking. Impairment attributable to other drugs appeared to play only a minor role in death from injury. However, 10 per cent of fatal injuries were initiated by episodes of altered consciousness and another 7 per cent by other forms of medical impairment.

Alcohol and Unintentional Injury

Injury has three faces—that deliberately directed against others (assault, homicide), that deliberately turned against oneself (suicide), and that which is unintentional (so-called accidents). According to official mortality statistics, these three types of injury lead to almost 150,000 deaths annually in the United States, 112,000 from unintentional injury, 12,000 from homicide, and 22,000 from suicide. A more accurate estimate, however, is that as many as 50,000 deaths per year are suicides (Anonymous, 1968). An additional 50 million people annually have unintentional injuries serious enough to require medical treatment or to result in loss of a day or more of usual activities (National Safety Council, 1971a). Unintentional injury vies with heart disease as the leading medical cause of lost man-years of productivity in the United States and is the most common cause of death under age forty.

Trauma center-related biases in injury research.

OBJECTIVES Most studies from trauma centers analyze and present combined data on patients from their surrounding communities and patients referred for specialized services from service areas of other hospitals. Information is needed about the effect of combining data from the two groups on conclusions about injury in the community. METHOD All injured patients seen in a trauma center emergency department of 30% of days over one year were studied concerning referral status, age, sex, type of activity when injured, injury type and severity, hospitalization, and prior medical history. RESULTS Combining data for both groups suggested an older, more medically impaired population, with more severe injuries, more frequent hospitalization, more serious head and spine injuries, fewer extremity fractures, and fewer household-related and more transportation-related injuries than were actually occurring in the community. CONCLUSIONS Data from local and out-of-area referred patients at trauma centers should be analyzed and presented separately in studies from this source if an accurate representation is to be provided of the role of injury in the population at large of the community.

The injury impairment scale as a measure of disability

Scores on the Injury Impairment Scale (IIS) were compared with reported disability for work or school, household activities, and activities of daily living during the first 18 months after injury for 2,194 persons treated in an emergency department or hospitalized for their injuries. Persons whose most severe injury was more life-threatening or who had larger numbers of injuries more often had higher IIS scores for their most life-threatening injury than did persons with fewer or less life-threatening injuries. Hospitalized patients had higher IIS injuries more often than did emergency department patients. As IIS increased, duration of disability also increased. However, many high IIS patients either reported no disability or disability of only short duration, suggesting only limited association between disability and IIS as it is currently designed.

Emergency department care and hospitalization as predictors of disability.

Duration of complete and partial disability for work, school, and home activities and activities of daily living during the first 18 months after injury were compared for 2,043 emergency department (ED) patients and 151 hospitalized patients from 22 northwestern Vermont communities who received their initial medical care for injury at the Medical Center Hospital of Vermont and were subsequently interviewed. Larger proportions of hospitalized patients than ED patients had any disability or prolonged disability. During almost all time frames, and even among patients who still had ongoing disability at 18 months, the majority of persons with disability had required ED treatment only. These data suggest that, based on disability, ED patients should not necessarily be considered to have merely minor injuries.

TREATED INJURIES IN NORTHERN VERMONT

OBJECTIVES To study characteristics of injury events and injuries requiring treatment in a Vermont population. METHOD A one year 30% prospective sample was studied of persons from 22 communities who received first physician care for injury at the Medical Center Hospital of Vermont. RESULTS Modal injuries were-superficial involving skin only among children below age 10, overexertion injuries among 10-59 year olds, and fractures among older persons. Among interviewed males ages 20-59, 31% of injuries were work related. Among females 26% were work related. Examining hospitalized cases only would have overemphasized falls, chemical injuries, leg fractures, transportation and nursing home injuries, and undercounted overexertion injuries, especially to the back, arm fractures, and injuries during recreation, work and home activities. Most common products/materials in use when injured were recreational equipment (24%) and motor vehicles (9%). Those most often causing injury were ground (20%) and home structures/construction materials (17%). No product was involved in 39% of injury event initiation and 15% of injury causation. CONCLUSION In order to adequately reflect the distribution of treated injuries in the community by anatomical area, age, and event type studies must examine both emergency department and hospitalized cases and use a data collection system capable of recording several parameters to describe injury events and products/materials involved.