Are there any guidelines for doing a CT scan of the head in an elderly patient with dementia who has no sign of head or other injury following a witnessed or unwitnessed fall? What is the standard of care in the nursing home/long-term-care setting?
—B.R. Manjunath, MD, Augusta, Ga.

Clinicians faced with calls from nursing homes about patients who have fallen could send all of them to hospitals via emergency services in an attempt to avoid liability, but obviously, this is in neither the patients’ nor the medical-care system’s best interest. Further complicating this scenario are the facts that demented patients often cannot give any history and the assessment skills of nurses in long-term-care settings vary widely. Moreover, patients may manifest no signs of injury immediately after the fall but may deteriorate later.

Any patients who develop new neurologic deficits, such as seizures, stupor, or hemiparesis, after a fall should be sent to a hospital for urgent evaluation. Patients on anticoagulation, especially with warfarin (Coumadin), may need urgent evaluation as well. Following a witnessed fall with no obvious injuries, patients may be observed at the nursing home if the clinician has confidence that the nursing staff will report changes in mental status or neurologic condition. Those remaining patients will require the best judgment of their clinicians to avoid both overtreatment and underdiagnosis.
—James P. Richardson, MD, chief of geriatric medicine, Union Memorial Hospital, and clinical professor of family medicine, University of Maryland School of Medicine, both in Baltimore (103-17)

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