Article appears in West Virginia Medical Journal

MORGANTOWN, W.Va. – As the elderly population of West Virginia increases, the number of patients with dementia who will require hospital admission for trauma will also increase as this population is at a higher risk of falls and injury. A recent study by the West Virginia University Department of Emergency Medicine shows that when these traumas occur, family members and healthcare providers must answer difficult questions in regard to the future care of the dementia patient.

According to Charles Whiteman, M.D., associate professor in the Department of Emergency Medicine and lead author of the study, the two most difficult questions for family members and caretakers of dementia patients to answer involve the patient’s driving privileges and whether the patient should be moved to a long-term care or nursing facility.

To conduct this study, Whiteman and his team used data from the trauma registry at WVU’s Jon Michael Moore Trauma Center from 2005 to 2008. During that time, there were 6,151 major trauma visits to the Center by patients at least 40 years old. Of those, 4.9 percent had dementia listed as a pre-existing condition and averaged 82 years old. The two most common injuries were those secondary to a fall – broken bones, head trauma, etc. – and motor vehicle accidents.

Although most injuries occurred from ground-level falls, 10 patients were injured in motor vehicle crashes. Six of the 10 were the driver of the vehicle. “The decision to terminate a person’s driving privileges can be a really ugly discussion to have. It’s really tough on everyone involved,” Dr. Whiteman said. “Family members are more likely to notice difficulty with driving than the patient’s primary care provider. The loss of driving privileges is a really big deal for any person regardless of age or medical condition. Family members need to have this discussion with the patient’s doctor when they notice changes in driving performance. It’s a very challenging and tricky discussion to have.”

Whiteman said that some patients in the early stages of their disease can be allowed to continue driving on familiar roads for short distances.

While no family member wants to take away a loved one’s independence, at some point as the disease progresses, the patient’s driver’s license should be pulled. “This is a public health issue,” Whiteman said. “It’s not just the patient who’s at risk but everyone else on the roads as well.”

Whiteman said that in the cases where the patients were injured as the result of a fall, most of them did not return home but were instead transferred to a nursing facility. “A lot of them were clinging onto residing at home, and the injury was the tipping point,” he said. “In addition to their cognitive impairment, they were then dealing with a physical impairment that often made it impossible for them to return to their homes.”

Whiteman’s team did encounter one surprise in conducting this study. Of the elderly trauma patients with dementia who were admitted for their traumatic injuries, 20 percent had intracranial hemorrhage, bleeding within the skull. Patients with dementia are susceptible to falls for many reasons – the dementia itself, medication effects, worsening vision and arthritis, among others. Ninety-five percent of the injuries in the study were the result of ground-level falls. And, when a person falls, the highest point – the head – reaches the highest velocity, resulting in injuries to the head, face and neck.

This finding presents a challenging treatment decision for healthcare providers. Many older people take aspirin or other anti-thrombotic medicines to treat atherosclerotic diseases, such as coronary artery disease and stroke. These medications increase the risk for an intracranial hemorrhage in even relatively minor traumas. The incidence of stroke and heart disease increase with age, just as the incidence of dementia increases with age. When an older person develops an unsteady gait and falls or is at risk of falling, the decision to start or continue anti-thrombotic therapy is a complex one for healthcare providers.

“This further complicates the treatment of these patients,” Whiteman said. “On one hand, they could die from the bleeding in their heads after a fall, but on the other hand, they could die of a stroke or heart attack. It can be a no-win situation.”

The 2000 census showed that 15.3 percent of West Virginia’s population was age 65 or older. That same year, the state’s Department of Health and Human Resources estimated 40,000 West Virginians suffered from Alzheimer’s disease, the most common form of dementia.

Co-authors of the study include Roger Tillotson, M.D., Nicolas Denne, M.D., and Stephen Davis, M.P.A., all from the WVU Department of Emergency Medicine. It appears in the May/June issue of the “West Virginia Medical Journal” as a continuing medical education article.