The American Journal of Surgery (2016) 212, 1237-1242

Southwestern Surgical Congress

The effect anticoagulation status on geriatric fall

trauma patients
Julia Coleman, M.D., M.P.H.*,1, Mustafa Baldawi, M.D.,
David Heidt, M.D.

Department of Surgery, University of Toledo, 3000 Arlington Avenue, Toledo, OH 43614, USA

KEYWORDS: Abstract
Fall; BACKGROUND: This research study aims to identify the effect of anticoagulation status on hospital
Trauma; course, complications, and outcomes among geriatric fall trauma patients.
Geriatric; METHODS: The study design is a retrospective cohort study, looking at fall trauma among patients
Anticoagulation; aged 60 to 80 years from 2009 to 2013 at a university hospital in the United States. The statistical anal-
Clopidogrel; ysis, conducted with SPSS software with a threshold for statistical significance of P , .05, was strat-
Warfarin ified by anticoagulation status and then further by type of anticoagulation (aspirin, warfarin,
clopidogrel, enoxaparin, and dipyridamole). Outcomes variables include mortality, length of stay
(LOS), intensive care unit (ICU) admission, and complications.
RESULTS: The total number of patients included in this study was 1,121. Compared with patients
not on anticoagulation, there was a higher LOS among patients on anticoagulation (6.3 6 6.2 vs 4.9
6 5.2, P 5 .001). A higher LOS (7.2 6 6.8 vs 5.0 6 5.3, P 5 .001) and days in the ICU
(2.1 6 5.4 vs 1.1 6 3.8, P 5 .010) was observed in patients on warfarin. A higher mortality (7.1%
vs 2.8%, P 5 .013), LOS (6.3 6 6.2 vs 5.1 6 5.396, P 5 .036), and complication rate (49.1 vs
36.7, P 5 .010) was observed among patients on clopidogrel.
CONCLUSIONS: In this study, a higher mortality and complication rate were seen among clopido-
grel, and a greater LOS and number of days in the ICU were seen in patients on warfarin. These dif-
ferences are important, as they can serve as a screening tool for triaging the severity of a geriatric
trauma patient’s condition and complication risk. For patients on clopidogrel, it is essential that these
patients are recognized early as high-risk patients who will need to be monitored more closely. For pa-
tients on clopidogrel or warfarin, bridging a patient’s anticoagulation should be initiated as soon as
possible to prevent unnecessary increased LOS. At last, these data also provide support against pre-
scribing patients clopidogrel when other anticoagulation options are available.
Published by Elsevier Inc.

There were no relevant financial relationships or any sources of support

in the form of grants, equipment, or drugs.
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 11-614-406-8829; fax: 11-303-724-2682.
E-mail address: Julia.e.roberts@ucdenver.edu
Manuscript received March 18, 2016; revised manuscript September
13, 2016
1
Present address: University of Colorado Anschutz Medical Campus,
Academic Office One Building Room 5401, 12631 East 17th Avenue,
C302, Aurora, CO, 80045, USA.
The elderly population (.65 years old) currently
accounts for approximately 14.2% of the population but
is expected to account for more than 25% by 2060, with a
growth rate significantly exceeding that of the rest of the
population.1 This represents a large and expanding subset
of the health care patients with unique needs in the United
States. This is particularly true within the realm of trauma,
as elderly constitute 28% of traumatic deaths2 and 75% of

0002-9610/$ - see front matter Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.amjsurg.2016.09.036
1238
fall-related death.3 Trauma and injuries in the elderly pop-
ulation are directly associated with falls specifically, which
account for most injuries in the elderly and more lengthy,
complicated and expensive care.4,5
Falls represent the most common cause of injury in the
geriatric patient population, with an annual incidence of
33% in those greater than 65 years old and 50% in those
greater than 80 years old.6 In comparison to their younger
counterparts, most literature has indicated that elderly pa-
tients have a higher injury severity and higher mortality
(up to 7% higher) with the same fall mechanism.6,7 Further-
more, this relationship has been observed in a linear
fashion, such that the most elderly patients fare worse
than the ‘‘younger’’ elderly patients (65 to 75 compared
to .75 years old), starting at as early as 50 years old.8
The reasons for this are numerous, but one proposed culprit
is the higher percent of the elderly population on anticoagu-
lation, whether for cardiac stents, atrial fibrillation, or prior
cerebrovascular accidents. Ultimately, it is essential as cli-
nicians to understand the compounded risk of increased age
and anticoagulation status on trauma outcomes.
Due to the frequency of fall trauma among geriatric
patients and high percentage of these patients on anti-
coagulation, this study aims to identify and better under-
stand the effect of anticoagulation status on fall trauma
outcomes. Through retrospective chart analysis, this
research study aims to identify the effect of anticoagulation
status on complications, hospital course, outcomes, and
disposition status among elderly patients who present to a
trauma hospital status after fall. The hypothesis of the study
is that those on anticoagulation will have a higher rate of
mortality, length of stay (LOS), emergency department
(ED) time, complications, procedures required, intensive
care unit (ICU) admission, and skilled nursing facility or
rehabilitation disposition status.
Methods
The study design is a retrospective cohort study, looking
at fall trauma among patients aged 60 to 80 years in the past
5 years at University of Toledo Medical Center. The
statistical analysis, conducted with SPSS software, was
stratified by anticoagulation status and then further strati-
fied by type of anticoagulation. Anticoagulation and type
were ascertained by history and/or review of the patient’s
electronic medical record. Outcomes variables include
Injury Severity Score (ISS), mortality, LOS, ED time,
complications, procedures required, ICU admission, and
disposition status. Controlled variables included history of
seizures, history of falls, atrial fibrillation, history of
psychiatric disease, dementia, peripheral vascular disease,
chronic kidney disease, cerebral vascular accident or
transient ischemic accident, osteoarthritis or osteoporosis,
diabetes mellitus, hypertension, coronary artery disease,
The American Journal of Surgery, Vol 212, No 6, December 2016
congestive heart failure, steroids, previous history of deep
venous thrombosis (DVT) or pulmonary embolism (PE),
asthma or chronic obstructive pulmonary disease, steroid
use, alcohol use, and tobacco use. Comparison of contin-
uous data (ISS, LOS, ICU time, ED time, and so forth) was
done by nonparametric test, and comparison of categorical
data was done by chi-square test. Statistical significant was
determined by a P value less than .05.
Results
The total number of patients included in this study was
1,121, 483 (43.1%) of which were males and 638 (56.9%)
female. The average age was 70.2 6 6.1 years old. Data
were originally stratified by gender (for the initial analysis
and anticoagulation analysis), and there were no significant
differences in our outcomes between genders. A total of 336
of the total patients (30.0%) were taking some form of
anticoagulation as a home medication. Ninety-eight of the
patients (29.1% of the patients on anticoagulation) were
taking aspirin as a home medication, 102 (30.4%) were
taking warfarin, 112 (33.3%) were taking clopidogrel,
20 (5.9%) were taking enoxaparin, and 4 (1.2%) were
taking dipyridamole. For the patients on warfarin, indica-
tions were as follows: 82 patients (80.2% of patients on
warfarin) had a history of atrial fibrillation, 11 patients
(10.4%) had a history of thromboembolic disease, 8 patients
(8.3%) had a history of cerebrovascular accident, and
1 patient had a history of mechanical heart valve. For
patients on enoxaparin, though Factor Xa levels were not
available for all patients, they were all therapeutic in nature
(as bridging therapy while warfarin was restarted). Of note,
reversal of anticoagulation status was only undertaken for
patients with a supratherapeutic international normalized
ratio (INR; .4.0), who were actively hemorrhaging or who
were undergoing emergent operation with INR less than 2.0.
On stratification by anticoagulation status, there was no
statistically significant difference in ISS (average of 6.8 for
patients not on anticoagulation and 6.5 for those on
anticoagulation, P 5 .215; Table 1). There was no statisti-
cally significant relationship between overall mortality
(P 5 .063), ICU admission rate (P 5 .547), number of
ICU days (P 5 .187), or complication rate (P 5 .065).
Please note in terms of ICU admission, patients were
admitted to the ICU for a myriad of reasons including he-
modynamic instability and respiratory failure, but there is
no particular protocol in place for geriatric fall trauma pa-
tients on anticoagulation at our facility (however, all pa-
tients over 65 with intracranial hemorrhage (ICH) are
admitted to the ICU for observation for 24 hours regardless
of anticoagulation status).
Compared to patients not on anticoagulation, there was a
higher LOS among patients on anticoagulation (6.3 6 6.164
vs 4.9 6 5.189, P 5 .001). Interestingly, contrary to what
J. Coleman et al. Effect of anticoagulation on geriatric fall trauma 1239

there was no statistically significant relationship between

Table 1 Outcome variables stratified by anticoagulation
status rates of subarachnoid hemorrhage or subdural hematomas
or bleeding on any of the patients on anticoagulation.
No P While there were adverse outcomes related to anticoagula-
Outcome variable anticoagulation Anticoagulation value
tion, there also appeared to be beneficial outcome differ-
N 834 287 ences. For example, patients on enoxaparin and
Mortality (%) 22 (2.6) 14 (4.9) .063 dipyridamole had significantly lower rates of pulmonary
ISS 6.8 6 5.391 6.5 6 5.041 .215 embolism and deep venous thromboses (10.0% vs 2.2%,
SAH/SDH (%) 95 (11.4) 32 (11.1) .907
P 5 .021 and 25.0% vs 2.2%, P 5 .003, respectively).
LOS 4.9 6 5.189 6.3 6 6.164 .001
ICU admission (%) 141 (16.9) 53 (18.5) .547
Total ICU days 1.1 6 3.824 1.4 6 4.525 .187 Comments
Complication (%) 303 (36.4) 122 (42.5) .065
Bleed (%) 10 (1.2) 3 (1.0) .834
PE/DVT (%) 15 (1.8) 11 (3.8) .048 Geriatric fall trauma represents a significant and under-
estimated public health problem. This topic became of
ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5
research interest in the late 1980s, when trauma research
length of stay; PE/DVT 5 pulmonary embolism/deep venous throm-
bosis; SAH/SDH 5 subarachnoid hemorrhage/subdural hematoma. evolved from a focus of a ‘‘disease of the young’’ to a unique
disease of the elderly as well. This transition was ushered by
the Major Trauma Outcome Study,9 a research study spon-
would be expected, those who were taking some form of an- sored by the American College of Surgeons Committee on
ticoagulation had higher rates of pulmonary embolism and Trauma in 1989. This large-scale study compared data
deep venous thrombosis, occurring in 3.8% vs 1.8% of those from elderly patients to their younger counterparts to iden-
not on anticoagulation (P 5 .048). This relationship was tify differences in outcomes and ‘‘the implications for injury
noted even when controlling for previous DVT or PE his- prevention, triage, treatment, outcome evaluation, reim-
tory. When stratifying by type of anticoagulation, there bursement, and additional research.’’ The results demon-
was no single agent that accounted for the higher rate of strated an increased mortality with age across all
DVT or PE (2 incidences with patient on aspirin, 3 on categories of the trimodal death curve: the immediate at
warfarin, 2 on enoxaparin, and 1 on dipyridamole). the scene, early within the first 48 hours and delayed after
If anticoagulation status is further stratified into aspirin, 48 hours. This mortality disparity was particularly pro-
warfarin, clopidogrel, enoxaparin, or dipyridamole, some nounced when associated with falls and related hip fractures,
of the more subtle differences between anticoagulants leading to a new era of research focused on geriatric fall
reveal themselves (Table 2). For example, a higher LOS trauma. This focus has evolved over the past decade with
(7.2 6 6.800 vs 5.0 6 5.299, P 5 .001) and days in the the surge in use of new and novel anticoagulants.
ICU (2.1 6 5.373 vs 1.1 6 3.844, P 5 .010) were observed Long-term anticoagulation, most commonly with
in patients on warfarin. A higher mortality (7.1% vs 2.8%, warfarin, is prevalent in the elderly population, principally
P 5 .013), LOS (6.3 6 6.159 vs 5.1 6 5.396, P 5 .036), due to atrial fibrillation which occurs in 6% of those greater
and complication rate (49.1 vs 36.7, P 5 .010) were than 65 years old10 and 9% of those greater than 80 years
observed among patients on clopidogrel. Interestingly, old.11 The literature on geriatric trauma has been

Table 2 Outcome variables stratified by anticoagulation agent

Outcome variable ASA Warfarin Clopidogrel Enoxaparin Dipyridamole
N 98 102 112 20 4
Mortality (%) 2 (2.0) 6 (5.9) 8 (7.1)* 0 (.0) 0 (.0)
ISS 5.7 6 3.655* 7.0 6 5.491 6.8 6 5.871 7.0 6 3.118 7.0 6 2.944
SAH/SDH (%) 8 (8.2) 17 (16.7) 14 (12.5) 0 (.0) 0 (.0)
LOS 5.2 6 5.927 7.2 6 6.800* 6.3 6 6.159** 6.8 6 6.820 8.2 6 6.850
ICU admission (%) 11 (11.2) 28 (27.5) 20 (17.9) 3 (15.0) 0 (.0)
Total ICU days .9 6 3.672 2.1 6 5.373** 1.8 6 5.110 1.8 6 7.135 .0 (.0)
Complication (%) 39 (39.8) 39 (38.2) 55 (49.1)*** 11 (55.0) 2 (50.0)
Bleed (%) 1 (1.0) 1 (1.0) 1 (.9) 1 (5.0) 0 (.0)
PE/DVT (%) 2 (2.0) 3 (2.9) 4 (3.6) 2 (10.0)* 1 (25.0)*
*P 5 .028 *P 5 .001 *P 5 .013 *P 5 .021 *P 5 .003
**P 5 .010 **P 5 .036
***P 5 .010
ASA 5 Aspirin; ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5 length of stay; PE/DVT 5 pulmonary embolism/deep venous thrombosis;
SAH/SDH 5 subarachnoid hemorrhage/subdural hematoma.
1240
controversial regarding a relationship between anticoagula-
tion and risk of overall bleeding complications, sponta-
neous ICH, and mortality in the context of trauma. While
some literature has indicated increased morbidity and mor-
tality among geriatric trauma patients on anticoagulation
including warfarin, aspirin, and clopidogrel,12–15 other in-
vestigations have found no such statistically significant
relationship.16,17 For example, in a retrospective study
including analysis of 49,464 multi-institutional sample of
admissions related to falls in elderly patients, researchers
found that long-term anticoagulation was associated with
a 50% increased likelihood of traumatic ICH and a 57% in-
crease in likelihood of subsequent mortality.6 Yet, another
retrospective study involving data from several different
studies found no increased adverse complications or out-
comes related to bleeding.18 Although our study does not
show an increased mortality, increased rates of subarach-
noid hemorrhage or subdural hematomas or bleeding com-
plications in patients on overall anticoagulation, the results
do indicate a greater LOS, significant due to its expense to
the hospital and patient in terms of finances and hospital ac-
quired infections.
On stratifying by types of anticoagulants, the subtle
differences in anticoagulant agents become apparent. A
higher mortality and complication rate were seen among
clopidogrel, which is significant as the literature has been
conflicting in terms of the mortality rate with this agent.19
Clopidogrel irreversibly inhibits adenosine disphosphate-
induced platelet aggregation and impairs platelet function
for at least 3 days after drug withdrawal.20,21 A unique
quality of clopidogrel is that there is currently no specific
agent for reversal, posing a greater potential risk and higher
mortality rate, as implicated by our study. We also identi-
fied a greater LOS and number of days in the ICU in pa-
tients on warfarin. This increased LOS among patients on
warfarin has been reported anecdotally among physicians
and also in literature22 which both explain this increased
stay due to achieving therapeutic INR levels before
discharge. Although LOS may not seem as important as
increased mortality, it can be costly not only to a hospital,
but to a patient who is further at risk for developing a
hospital-related complication such as an acquired infection
or thromboembolic event.
Conclusions
These differences in outcomes among warfarin and
clopidogrel are important, as they can serve as a screening
tool for triaging the severity of a patient’s condition and
complication risk. For one, if a patient is on anticoagula-
tion, our research indicates that they typically have a
greater LOS, often due to achieving appropriate antico-
agulation status (whether measured as INR or otherwise).
For patients on clopidogrel, it is essential that these patients
are recognized early as high-risk patients who will need to
be monitored more closely and considered for automatic
The American Journal of Surgery, Vol 212, No 6, December 2016
admission to the ICU. For patients on clopidogrel or
warfarin, bridging a patient’s anticoagulation should be
initiated as soon as possible to prevent unnecessary
increased LOS. Lastly, these data also provide support
against prescribing patients clopidogrel when other anti-
coagulation options are available.
This study has several limitations. Although INR levels
were drawn on all patients on warfarin, we did not account for
the INR level in our statistical analysis (the same applies to
those on enoxaparin and factor Xa levels, which were not
drawn for all patients). For patients on anticoagulation, we
did not identify when the last dose was administered. Lastly,
we did not account for reversal of anticoagulation in our
statistical analysis. These data points would have strength-
ened our analysis and conclusions, allowing for better
appreciation as to the level of anticoagulation. Also, for
patients admitted to the ICU, we did not examine the reason
for ICU admission, whether hemodynamic instability, hem-
orrhagic shock, or otherwise. These areas not included in our
study are interesting points to consider in future research on
this topic. However, despite these limitations, we believe that
this research is an important contribution to the ever-evolving
body of literature focused on the effects of anticoagulation on
trauma patients.
The elderly population constitutes a significant and
rapidly expanding portion of the patient population,
particularly among trauma patients. As such, it is essential
trauma is not only viewed as a ‘‘disease of the young’’ but
also a unique disease of the elderly, associated with higher
morbidity and mortality, increased costs, and lengthy,
complicated hospital stays and dispositions. This is partic-
ularly pronounced in fall patients, especially those on
anticoagulation including warfarin and clopidogrel. Due
to the high morbidity associated with falls and related
injuries, anticoagulation status should be key factors in
decision making, whether during triage, on the floor
management or discharge with geriatric fall trauma pa-
tients. If an elderly patient on anticoagulation, particularly
warfarin or clopidogrel, presents to a primary care setting
or trauma center, a multidisciplinary, aggressive risk factor
screening and intervention should be considered.
Acknowledgments
As first author, Julia Coleman, I would like to thank my
coauthors: my advisor David Heidt who provided mentor-
ship and support, and my colleague Mustafa Baldawi who
provided editing and statistical analysis services. The
author would also like to thank the University of Toledo
College of Medicine and Hospital, as well as the Depart-
ment of Surgery, for their support of this project. Specif-
ically, the author would like to thank Dr. Gerald Zelenock
and Dr. Munier Nazzal for their continued support of
research endeavors in the department. At last, the author
would like to thank Claudia Davis for helping to coordinate
the project logistics and communication.
J. Coleman et al. Effect of anticoagulation on geriatric fall trauma
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Discussion
Please note that at the time of this discussion, first author
Julia Coleman’s name was Julia Roberts.
Discussant
Dr. Brian Eastridge (San Antonio, TX): This is a com-
posite of Dr. Bellal Joseph’s comments and mine. He had to
return to Arizona.
First and foremost, I would like to thank the Congress
for the privilege of discussing this work.
Geriatric falls have become a really significant public
health issue in trauma across the nation. The authors have
done a comprehensive job in comparing the effects of a
number of different anticoagulants on outcomes in this
geriatric fall population. And if this comes to fruition, this
may help in the risk stratification of patients based on the
type of anticoagulation that they are receiving.
After reading the manuscript and hearing the presenta-
tion, I have a couple of comments and questions for the
authors. Question 1, how was the deleterious effect of
anticoagulation related to specific injury patterns? For
instance, was this all traumatic brain injuries and bleeding
in closed spaces? Solid organ injury, soft-tissue injury, and
so forth. This is important since the type and severity of
injury after geriatric fall are major determinants of their
ultimate outcomes of mortality and morbidity.
Question 2, since the inherent risk of anticoagulation is
hemorrhage; it would be useful to evaluate the associated
outcomes, such as a requirement for blood transfusion, the
need for operative intervention based on hemorrhage, and
the need for anticoagulation reversal. Please comment.
At last, question 3, it was interesting that you noted a
higher incidence of pulmonary embolus and deep venous
thrombosis in those actually on anticoagulation, on antico-
agulant therapy. Obviously, this seems counterintuitive. Let
us know what your thoughts are on this issue. You alluded
to the potential that this was just from the reversal of
anticoagulation in patients at risk. Was this the only factor?
Again, I would like to commend the authors on this very
interesting study on a very important topic. Once again, I
would like to thank the Program Committee for the
privilege of the podium to discuss.
Dr. Julia Roberts (Aurora, CO): Thank you so much
for those excellent questions. I think, first, looking at the
mechanism of injury is not something that we specifically
did. I think that would be very telling.
In relation to your first question, specifically, we did
look at ISS, not necessarily as an outcome variable but
something that we wanted to compare and see if it was
different between the patients on anticoagulation or not to
include in a regression analysis, which we are doing. I think
1242 The American Journal of Surgery, Vol 212, No 6, December 2016

that we did not see ultimately a statistically significant
difference in ISS between these 2 groups. We did not
specifically look at the presence of a TBI. I think that would
be interesting and the mechanism of injury.
Second, I already touched on why I think we see this
higher rate of pulmonary embolism or deep venous
thrombosis. So I will refer to what I said earlier in the
sake of time.
And then at last, I think if we were able to look again at
what exactly are these complications with Plavix, we would
be able to tease out more of these specific complications
you discussed. We did look at, when I mentioned anemia,
that was anemia requiring transfusion. But, again, looking
at the actual hemorrhage rate and operative indication as
hemorrhage I think would be interesting as well. So, we are
in the process of doing that. Thank you.