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ELDERLY FALL PREVENTION
Screening
In the past couple of years various organizations have attempted to create algorithms to address screening and intervention. There are two reasons to screen. Primary prevention would help determine which patient were at high risk for falls. Secondary prevention would evaluate patients that have fallen or patients that are deemed high risk for possible intervention. Currently there is no standard set of screening tools that consistently predict fallers and non-fallers. The predictive value of different tools depends on the environment: community-dwelling seniors, assisted living, nursing home, and acute care. A review of various screening method studies found that few tools cross more than one setting.[13]
In the long-term care setting, the Mobility Interaction Fall Chart had positive predictive value for the classification was 78% (95% CI 67-87%) and the negative predictive value was 88% (95% CI 79-95%). Two tests are conducted. The first observes whether the patient stops walking when a casual conversation is started. The second calculates the difference between the Timed Up and Go (TUG) test alone and a second TUG carrying .5 dl of water. “The TUG is the time it takes to rise from a chair, walk 3 m, turn, walk back and sit down again”. A person is considered at high risk of falling if they cannot walk and talk, or if there is a difference >4.5 seconds between the TUG alone and with water.[14]
The following are summaries of two consensus papers for screening fall risk and interventions to reduce the risk.
Impaired Muscle and Mobility: The Road From Menopause to Frailty[6] (Link to article is finicky through Pubmed and Ovid. Try using the PMID to search: 17762425)
This paper presents an algorithm to assess frailty and fall risk, then determines the need for referral. A consensus working group describes frailty as the presence of 3 or more of the 5 core findings of: muscle weakness, poor endurance, weight loss, low physical activity, and slow gait speed. After menopause the loss of muscle mass increases leading to frailty. These place the patient at risk for falls. People who have lost muscle strength but have not yet lost mobility, and those that have lost both muscle strength and some mobility but are not yet totally dependent are good candidates for interventions that can reverse the downward trend. By screening for the beginnings of functional decline, clinicians can refer patients for therapies that can help prevent falls and disability. Self-reported declines in mobility are not always accurate as patients may have found unconscious compensatory measures. Additionally, some studies have indicated that patients inaccurately report falls in the previous year. Therefore, screening for “pre-clinical decline” in mobility should include both history and physical exam measures. A study identified 51% of seniors who fell over the subsequent year using (1) whether an individual has had a fall in the previous year, (2) symptoms suggestive of a high risk of falling (balance difficulty or dizziness), and (3) a finding of abnormal mobility on a physical examination. This model worked better than the traditional history and physical exam.
Screening should begin with questions regarding the patient’s ability to conduct activities of daily living (ability to transfer to or from a bed or chair, bathe, shop, cook, light housework, walk ½ a mile, and climb 10 stairs). The patient should be asked about his or her subjective sense of mobility (difficulty walking or climbing stairs, use of assistive devices, difficulty getting into and out of a chair, fear of falling). The patient should then be observed getting up from a chair and walking to evaluate for the core findings of frailty (3 of 5 present suggest frailty): muscle weakness, poor endurance, weight loss, low physical activity, and slow gait speed. (Physician visit screen for frailty) If one or two are present the patient is determined to be “pre-frail” and should be further evaluated for rehabilitation. A “pre-clinical disability” may be present if the patient must modify activities to accomplish them, or the patient may already be disabled and dependent on assistance The presence of either of these should prompt a comprehensive fall evaluation.
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