Jack lowers his head and presses his temples with his thumbs. He whispers, “Am I going crazy?”
In the weeks after his fall and trip to the emergency department, something has gone painfully awry. He’s been having episodes of anxiety when transferring from bed to chair as well as difficulty sleeping. His once unflappable optimism has been blunted by intrusive memories and ruminations about the fall and a sense of foreboding about the future.
Psychological Aftereffects of a Fall
Though he sustained no serious injury and had been quickly returned to the assisted living facility where he lives, the fall has left him with symptoms of posttraumatic stress disorder (PTSD). Most health care professionals are unaware that falls in the elderly can cause posttraumatic stress symptomatology, acute stress disorder, even PTSD. Indeed, in some settings falls occur frequently enough to insulate nurses and other medical staff from the awareness of how terrifying such an event can be or how it can undermine one’s sense of safety and control, particularly when it results in injury and/or invasive medical treatment.
Although Jack was under hospice care at the time of his fall, the facility sent him to the hospital because of its policy on ruling out head injury. Most hospices and facilities have protocols governing their response to falls. These typically include timely response times, contacting family members, physical assessment and intervention, developing a safety plan, and providing patient education for risk reduction. Most are exceedingly scrupulous about collecting and reporting detailed data, from which trends can be identified and interventions evaluated.
Assessing for Trauma
Unfortunately, these protocols often fail to assess for traumatic stress. Such stress can manifest behaviorally (insomnia, hyperreactivity, withdrawal or avoidance), cognitively (impaired concentration or memory), physically (shortness of breath, elevated heart rate or high blood pressure), and/or emotionally (fear, anger, shame or depression).
Failure to assess for traumatic stress can lead a patient’s medical team to misunderstand the origins of these symptoms and may compromise effective and supportive care or lead to an overreliance on pharmacologic remedies.
Falls as Potential Triggers for Old Traumas
In Jack’s case the picture was even more complicated. When a traumatizing event occurs, like a fall, it can activate older psychological traumas and/or intensify any preexisting patterns of posttraumatic stress. In the wake of his fall Jack started having nightmares and painful memories about combat during the Korean War. At times, he found himself overwhelmed by previously unexpressed grief related to friends who’d been killed or injured, as well as guilt about having survived when they “never made it back.”
Prior to Jack’s fall, the war had not come up during our conversations and hadn’t been a source of anguish. Whether its sudden emergence was connected with his fall or part of a natural process of life review and end-of-life processing was unclear, but the fall may have been a triggering event.
Jack asks again, “Am I going crazy?”
I shake my head, “No Jack. You’re not going crazy.”
We talk about the fall and the struggle he’s been having. I tell him about posttraumatic stress, how it works, what it looks like, how it originates in our nervous system’s natural response to danger. I tell him there are effective nonpharmacologic ways to lower the volume on the intense emotions, physiological sensations, and thoughts he’s been having. We discuss some of these and how he might find some peace. I ask if he thinks there’s a connection between the fall and the memories he’s been having about the war.
‘It Could Change in a Heartbeat’
“It’s the fear,” he responds. “Falling really shook me. It was terrifying. I could have cracked my head. Everything could have changed in a heartbeat. It happened so fast and I felt completely helpless.” His voice trails off and he looks out the window as if in contemplation. “That’s how I felt every day I was in that war.”
The impact of a single traumatic event can alter trust in one’s environment, self, and/or relationships. It can create painful feeling states and patterns of avoidance, hypervigilance and/or overreactivity. How posttraumatic stress intersects with other issues related to illness, medical care, aging, and earlier unresolved psychologically traumatic wounds can be nuanced and complex.
Nurses are on the front line when it comes to responding to patients who have fallen. They are often among the best positioned to make important observations in the aftermath. Those familiar with the ways posttraumatic stress can manifest after a fall will be leaders in raising awareness among other medical professionals, refining the care patients like Jack receive in positive and powerful ways.
Scott Janssen, MA, MSW, LCSW, is a hospice social worker trained in working with survivors of psychological trauma. His book, Standing at Lemhi Pass: Archetypal Stories for the End of Life and Other Challenging Times, explores the use of storytelling with hospice patients and families. See also his Viewpoint article in the September 2015 issue of AJN, “Letting Patients and Families Interpret Deathbed Phenomena for Themselves” (free).
Fall prevention strategies are so important. My organizations switched tot eh John Hopkins Fall Risk Assessment and the use of yellow to identify high fall risk patients. We examine every fall in the organization to continue learning how to prevent and anticipate the many possible situations that can happen on the different units. I have seen such devastation due to falls during my career. This article really shows the impact a fall can have on a person, especially the elderly.
Touching story which casts needed light on something many of us have intuited for a long time. Thank you for helping explicate the increased vulnerability after a fall.