Written by Amanda Matthews
This external validation of the Falls decision-making tool for older adult patients with head trauma had high sensitivity and negative predictive value while reducing unnecessary CT scans by almost 32%.
Does the “Falls” rule fall short?
This study sought to externally validate the “Falls” decision rule for older adults with ground-level falls. The original study of 4000 patients demonstrated that the rule had high sensitivity (98.6%) in excluding clinically important intracranial bleeding. CT could be avoided if: (1) they did not hit their head during the fall as determined through patient history or witness accounts; (2) no new neurological abnormalities; (3) the patient recalls events surrounding the fall; and (4) clinical frailty scale score below 5.
Patients ≥65 within 48 hours of a ground-level fall regardless of head impact were included. Decision to obtain a CT scan was made by independent clinicians. Clinically important bleeding was defined as that requiring medical (stopping anticoagulation, hospital admission, etc.) or surgical intervention within 42 days of the original fall, or resulting in death.
800 patients were enrolled, with a mean age of 79 years. 67.6% (n=541) patients had a head CT performed at initial visit, and 43 patients were diagnosed with intracranial bleeding. Four patients had an initial negative head CT and were later diagnosed with bleeding at follow-up, and two patients had no initial imaging and were later diagnosed with bleeding at follow-up. When the Falls decision rule was applied, one case of intracranial bleeding was misclassified as not requiring head CT and achieved a sensitivity of 98.0% (95%CI 89.2–100.0) and a negative predictive value of 99.6% (95%CI 97.2–99.9) with a specificity of 32.0% (95%CI 28.6–35.4). Overall, the rule would have been able to reduce unnecessary CT scans by approximately 31.9% in this cohort.
How does this change my practice?
I am not sure that elderly patients with falls are the population where I would cut back on imaging. “Falls” does not include anticoagulant use, which matters. Head CTs are fairly quick, and radiation risk in the elderly is less worrisome. I will continue to use NEXUS II and Canadian to determine the need for head imaging.
Source
Validating the falls decision rule: optimizing head CT use in older adults with ground-level falls. CJEM. 2025 May 13. doi: 10.1007/s43678-025-00937-y. Epub ahead of print. PMID: 40360963
