Capstone Fall Prevention Program Project Literature Review
37The Permanente Journal/ Fall 2013/ Volume 17 No. 4
ORIGINAL RESEARCH & CONTRIBUTIONS
Special Report
Preventing Falls in the Geriatric Population Aimee Lee, MD; Kuo-Wei Lee, MD; Peter Khang, MD, MPH, FAAFP Perm J 2013 Fall;17(4):37-39
http://dx.doi.org/10.7812/TPP/12-119
Introduction The word “fall” does not usually strike
fear in the hearts of most people. But it should. Falls are all too common in the geriatric population, and they have devastating consequences. They are the leading cause of injury and death by injury in adults over the age of 65 years.1 One of 3 community-dwelling older adults falls each year, with 24% of those who fall sus- taining serious injuries and 6% sustaining fractures.2 In the year 2000, falls cost the US health care system more than $19 bil- lion, a number that is expected to increase to $54.9 billion by 2020.3 A person who falls may subsequently experience pain, hospitalization, surgical intervention, admission to a nursing home, decreased overall functional ability, poorer quality of life, or a fear of falling.
Fear of Falling Fear of falling is a defined geriatric
syndrome that may contribute to further functional decline in an already frail pa- tient. When people experience something unpleasant, their natural response is an aversion to that experience. People may begin to limit their activities after a fall or as they become weaker and less agile with increasing age. This leads to a more sedentary lifestyle and physical atrophy, which further predisposes them to falls. Successful encouragement to maintain or increase physical activity may promote the ability to avoid falling or to catch oneself before a fall.
Why Patients Fall Normal gait and balance requires freely
moving joints; muscles contracting at the right time with the appropriate strength; and accurate visual, vibratory, and pro- prioceptive input. As patients age, they may experience stiffened joints, decreased muscle strength, and impaired neurologic feedback. These changes, in combination with other risk factors, increase the likeli- hood of falls. The strongest independent risk factors for falls are previous falls, weakness, gait and balance impairments, and use of psychoactive medications. The risk of falling increases with the number of risk factors present (see Sidebar: Risk Factors for Falls). One study showed that a patient with 4 risk factors has a 78% chance of falling.4
Screening for Falls The most important first step that clini-
cians can take in preventing falls is to ask about history of falls. In 2010, the Ameri- can and British geriatrics societies released
updated clinical practice guidelines for fall prevention in older adults. The guidelines state that all patients age 65 years or older should be asked yearly about previous falls.5 Patients who report a fall or gait and balance difficulties should undergo an in-office assessment such as the Timed Up and Go test (Figure 1).
Timed Up and Go Test This is a quick and easy test that can
be performed by a trained health care team member in ambulatory care settings within a few minutes. The patient should wear regular footwear, use their usual walking aid if needed, and start by sitting back in a chair with armrests. The patient is timed while s/he rises from the chair, walks three meters, turns around, walks back to the chair, and sits back down. Postural stability, gait, stride length, sway, and steppage should be observed. Kaiser Permanente uses the operational value of 14 seconds or less. (The normal value is 10 seconds or less; and 20 seconds or more is considered abnormal.) If the result of the
Aimee Lee, MD, is a Graduate of the Geriatrics Fellowship in the Department of Geriatrics, Palliative Medicine, and Continuing Care at the Los Angeles and West Los Angeles Medical Centers in CA. She currently works in primary care and telemedicine at Banner Health. E-mail: aimee.lee@bannerhealth.com. Kuo-Wei Lee, MD, is the Geriatrics Program Director in the Department of Geriatrics, Palliative Medicine, and Continuing Care at the Los Angeles and West Los Angeles Medical Centers in CA. E-mail:
kuo-wei.x.lee@kp.org. Peter Khang, MD, MPH, FAAFP, is the Physician in Charge of the Department of Geriatrics, Palliative Medicine, and Continuing Care at the Los Angeles and West Los Angeles Medical Centers in CA. E-mail: peter.s.khang@kp.org.
Risk Factors for Fallsa
• previous falls • decreased strength • gait/balance impairments • use of psychoactive medications • visual impairment • polypharmacy • depression • dizziness • orthostasis • functional limitations • age > 80 years • female sex • low body mass index • urinary incontinence • cognitive impairment • arthritis • diabetes • undertreated pain
a Risk factors in bold indicate strongest independent risk factor.
Actions to be Taken for Patients at High Risk for Falls
1. Ask about history of falls and patient’s assessment of his/her functional ability.
2. Review medications and medical history.
3. Perform gait assessment; physical examination (especially neurologic, cardiac); assessment of orthostatic vital signs; visual acuity examination; cognitive evaluation; examination of feet and footwear; home safety evaluation.
credits available for this article — see page 96.
38 The Permanente Journal/ Fall 2013/ Volume 17 No. 4
ORIGINAL RESEARCH & CONTRIBUTIONS Preventing Falls in the Geriatric Population
Timed Up and Go test is abnormal, tar- geted interventions selected from Table 1 and a comprehensive risk assessment may be warranted.
Risk Assessment and Interventions
In community-dwelling adults, use of multifactorial assessments and interven- tions has led to a decrease in fall rates by 25% to 40%.4,6 (see Sidebar: Actions to be Taken for Patients at High Risk for
Falls.) Depending on the results of this risk assessment, appropriate multifactorial interventions for preventing ambulatory falls may include any or all of the follow- ing (Figure 1): 1. exercise/physical therapy programs
aimed at improving balance, gait, and strength
2. withdrawing or minimizing psycho- active medications
3. management of orthostatic hypotension 4. management of foot problems
5. changes in footwear 6. modification of home environment 7. patient and caregiver education 8. vitamin D supplementation in pa-
tients with vitamin D deficiency or high risk of fall
9. expedited cataract surgery (selected patients)
10. dual chamber cardiac pacing (selected patients).
There is insufficient evidence to sup- port use of these interventions in the long-term-care setting or for patients with dementia.5 To reduce the risk of fall-relat- ed fractures, patients should be screened for osteoporosis at the appropriate age and the relevant medications should be prescribed if necessary.
Fall Prevention in Hospitals Physicians and other health care team
members should be aware that in hospitals, nurses perform fall prevention assessments for every patient using standardized tools. Tools for assessing risk for falls include: the Morse Fall Scale, the Hendrich II Fall Risk Model, the Briggs Risk Assessment Form, and the Conley Risk Assessment Tool, among others. Kaiser Permanente uses the Schmid Fall Assessment Tool. It in- volves evaluation of the patient’s mobility, mentation, toileting, fall history, and use of psychoactive medications. A score of three
Preventing Falls in the Geriatric Population: Physician Pocket Reference Risk Factors for Falls Previous falls Decreased strength Gait/balance impairments Use of psychoactive medications Visual impairment Polypharmacy
Depression Dizziness Orthostasis Functional limitations
Age > 80 years Female sex
Low body mass index Urinary incontinence Cognitive impairment Arthritis Diabetes Undertreated pain
Screening for Falls • Ask about a fall history every year. • If a patient reports a fall or gait and balance problems, perform an in-office
gait evaluation such as the Timed Up and Go test.
Timed Up and Go Test • Observe postural stability, gait, stride length, sway, and steppage. • A normal time is 14 seconds or less.
Ask the patient to: 1. rise from the chair 2. walk three meters 3. turn around 4. walk back to the chair 5. sit back down
Risk Assessment Ask about
history of falls patient’s assessment of his/her
functional ability Review
medications medical history
Perform gait assessment physical exam (esp neurologic, cardiac) assessment of orthostatic vital signs visual acuity exam cognitive evaluation examination of feet and footwear home safety evaluation
Ambulatory Interventions 1. Exercise/physical therapy programs
aimed at improving balance, gait, and strength
2. Withdrawal or minimization of use of psychoactive medications
3. Management of postural hypotension
4. Management of foot problems 5. Changes in footwear
6. Modification of home environment 7. Patient and caregiver education 8. Vitamin D supplementation in
deficient or high fall risk patients 9. Expedited cataract surgery (selected
patients) 10. Dual chamber cardiac pacing
(selected patients)
Hospital Interventions (based on Schmid Fall Risk Assessment) 1. Appropriate reorientation strategies 2. Access to patient’s hearing aids or
glasses 3. Call bell 4. Access to patient’s personal items 5. Use of patient’s walking aids 6. Frequent comfort rounds
7. Patient and family education about fall risk
8. Early and frequent mobilization 9. Nonslip footwear 10. Elimination of barriers to transfer or
ambulation 11. Minimization of use of restraints 12. Use of bed alarm when necessary
Table 1. Interventions for abnormal results of the Timed Up and Go test Observation Significance Intervention Difficulty rising from chair
Proximal muscle weakness
PT referral for lower extremity strengthening
Staggering or reported dizziness upon rising
Possible orthostasis Check orthostatic vital signs; review medications that may contribute to orthostasis
Pill-rolling tremor, stooped posture, shuffling/festinating gait
Possible parkinsonism Consider neurology referral
Increased sway, magnetic gait
Possible normal pressure hydrocephalus
Ask about urinary incontinence and memory issues. If these are highly suspected, consider head CT
Path deviation Possible peripheral neuropathy, cerebrovascular disease
Consider neuropathy workup, examination of feet, PT referral for assistive device
Slow, antalgic gait Pain from osteoarthritis, peripheral neuropathy, podiatric disorders
Pain control, examination of feet
CT = computed tomography; PT = physical therapy.
Figure 1. Physician Pocket Reference.
This pocket reference is available to download and print at: www.thepermanentejournal.org/files/Fall2013/PreventingFallsPhyscianPocketReference.pdf.
39The Permanente Journal/ Fall 2013/ Volume 17 No. 4
ORIGINAL RESEARCH & CONTRIBUTIONS Preventing Falls in the Geriatric Population
or more indicates an increased risk for falls requiring the following interventions: 1. appropriate reorientation strategies 2. access to patient’s hearing aids or
glasses 3. call bell 4. access to patient’s personal items 5. use of patient’s walking aids 6. frequent comfort rounds 7. patient and family education about
fall risk 08. early and frequent mobilization 09. nonslip footwear 10. elimination of barriers to transfer
or ambulation 11. minimization of use of restraints 12. use of bed alarm when necessary.
Conclusion Given the devastating effects falls have
on patients and the increased burden on family members and the health care system, screening and assessment for fall risk are paramount priorities. Screening may be easily performed in the ambulatory and hospital settings, with simple interventions produc- ing meaningful results. Physicians should coordinate with other health care team members to provide effective multifactorial interventions to their patients (see Sidebar: Online Resources for More Information). With each fall that is prevented, the patient, their family members, the health care team, and the health care system all benefit. v
Disclosure Statement The author(s) have no conflicts of interest
to disclose.
Acknowledgment Leslie Parker, ELS, provided editorial
assistance.
References 1. Injury prevention & control: data & statistics
(WISQARS) [Web page on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Preven- tion and Control; updated 2013 Sept 20 [cited 2013 Sept 25 ]. Available from: www.cdc.gov/ injury/wisqars/.
2. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons liv- ing in the community. N Engl J Med 1988 Dec 29;319(26):1701-7. DOI: http://dx.doi. org/10.1056/NEJM198812293192604
3. Costs of falls among older adults [monograph on the Internet]. Atlanta, GA: Centers for Dis- ease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention; updated 2013 Sept 20 [cited 2013 Sept 25 ]. Available from: www.cdc.gov/HomeandRecreationalSafety/ Falls/fallcost.html.
4. Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off.” JAMA 2010 Jan 20;303(3):258-66. DOI: http://dx.doi. org/10.1001/jama.2009.2024
5. Prevention of falls in older persons. Clinical practice guidelines [monograph on the Internet]. New York, NY: American Geriatrics Society; 2010 [cited 2012 Aug 12]. Avail- able from: www.americangeriatrics.org/ health_care_professionals/clinical_practice/clini- cal_guidelines_recommendations/2010/.
6. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994 Sep 29;331(13):821-7. DOI: http://dx.doi. org/10.1056/NEJM199409293311301
Suggested Reading • Schmid, NA. 1989 Federal Nursing Service
Award Winner. Reducing patient falls: a research-based comprehensive fall prevention program. Mil Med 1990 May;155(5):202-7.
• Gongoll R, editor. Progress, challenges and next steps. Proceedings of the 2007 California Fall Prevention Summit; 2007 Dec 5-6; Long Beach, CA. Los Angeles, CA: The Fall Prevention Center of Excellence, University of Southern California; 2009.
• Chang JT, Ganz DA. Quality indicators for falls and mobility problems in vulnerable elders. J Am Geriatr Soc 2007 Oct;55 Suppl 2:S327- 34. DOI: http://dx.doi.org/10.1111/j.1532- 5415.2007.01339.x
• Ganz DA, Bao Y, Shekelle PG, Ruben- stein LZ. Will my patient fall? JAMA 2007 Jan 3;297(1):77-86. DOI: http://dx.doi. org/10.1001/jama.297.1.77
• Moncada LV. Management of falls in older persons: a prescription for prevention. Am Fam Physician 2011 Dec 1;84(11):1267-76.
• Rubenstein LZ, Solomon DH, Roth CP, et al. De- tection and management of falls and instability in vulnerable elders by community physicians. J Am Geriatr Soc 2004 Sep;52(9):1527-31. DOI: http://dx.doi.org/10.1111/j.1532- 5415.2004.52417.x
• Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997 Oct 30;337(18):1279-84. DOI: http://dx.doi. org/10.1056/NEJM199710303371806
Online Resources for More Information
For patients and their families: NIHSeniorHealth is a Web site that provides aging-related health information in an easy- to-understand format. It was developed by the National Institute on Aging (NIA) and the National Library of Medicine (NLM). http://nihseniorhealth.gov/falls/aboutfalls/01.html.
For clinicians: American Geriatrics Society, British Geriatrics Society Clinical Practice Guideline. www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guide- lines_recommendations/prevention_of_falls_summary_of_recommendations.
Sympathy
The most effective therapeutic weapon at the disposal of a physician in the care of the aged is sympathy.
— Richard A Kern, MD, 1891-1982, Allergist and Professor of Medicine at Temple University