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|Falls in the Community-Dwelling Elderly|
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Northeast Florida Medicine, Vol. 69, No. 2, August 2018
Date of Release: August 1, 2018
Date Credit Expires: August 1, 2020
Estimated Completion Time: 1 hour
The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Falls in the Community-Dwelling Elderly” authored by Reetu Grewal, MD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.
Reetu Grewal, MD, Clinical Associate Professor, Community Health & Family Medicine, UF College of Medicine – Jacksonville and Medical Director, UF Health Baymeadows Family Medicine.
The American Geriatrics Society recommends at least annual screening for falls in the elderly population. Medicare is also requiring fall screening as a HEDIS measurement. Despite these requirements, screening rates are low. Additionally, the multifactorial nature of falls makes it difficult for clinicians to sort through the causes of falls in any given patient unless they have a framework for evaluation.
1. Discuss the multifactorial nature of falls in the elderly.
CME Credit Eligibility:
A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact Kristy Williford at 904-355-6561 or email@example.com.
Reetu Grewal, MD reports no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.
Disclosure of Conflicts of Interest:
St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.
Joint Sponsorship Accreditation Statement:
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.
Falls are a substantial source of morbidity and mortality in the community-dwelling elderly, leading to physical and psychological injury, increased healthcare costs, and risk of long-term care admission. There are multiple risk factors for falls, including a hazardous home environment, increasing age, a history of falls, and polypharmacy. Physicians caring for elderly patients should perform annual risk assessments and be prepared to provide advice on fall-risk modification strategies.
Falls are a common occurrence among the elderly, with greater than one in four community-dwelling elderly falling each year.1 Falls are a significant source of morbidity and mortality in the elderly, and are the leading cause of death from injury in persons older than 65 years.2 In Floridians greater than 65, unintentional falls are the leading cause of fatal and non-fatal injuries.3 Falls in the elderly can cause physical injuries including fractures, lacerations, traumatic brain injury, and wounds. Recurrent falls increase the risk of long-term care institution admissions, and may lead to a fear of falling and patients imposing functional limits on themselves.4 Falls in the elderly are also expensive, with Medicare costs for falls in 2015 costing over $31 billion, mostly due to hospital-associated costs.5
There are many risk factors for falls, and the combination of such factors cause an increased likelihood of falling.6 The leading cause of falls is a hazardous environment, with increasing age, a history of falls, lower extremity weakness, arthritis, use of a cane or other assistive device, and visual and cognitive impairment.4,7 Certain medications increase the risk of falls including antidepressants, anti-hypertensives such as diuretics, antipsychotics, anti-convulsants, benzodiazepines, sedatives, and hypnotics.8 Polypharmacy, in particular the use of more than four medications, increases the risk for falls.9 The American and British Geriatrics Societies recommend routine screening for falls at least yearly, with a brief screening for low-risk populations.4 Patients who present with a history of falls, or who display gait and/or balance abnormalities on examination should undergo a more thorough evaluation. Discussing and managing fall risk is also an annual Medicare Healthcare Effectiveness Data and Information Set (HEDIS) requirement.10
The evaluation of falls in the community-dwelling elderly is primarily based on the history and physical. Given that falls are usually multifactorial, a detailed history and physical can help to differentiate the extent to which external, environmental factors and intrinsic, personal factors contribute to a fall or history of falls.6 The evaluation of a patient with a history of falls should begin with a comprehensive history. One of the most important parts of the history should be a detailed account of the patients’ previous falls. The provider should ask about the location and time of the most recent and previous falls.6 It is important to note the activities in which the patient was engaged prior to and during the falls. Providers should also inquire about the patient’s history of chronic diseases, such as osteo-arthritis, chronic musculoskeletal pain, and diabetes, and the status of these diseases.11 Providers should thoroughly review the patients’ medications list. Studies have shown sedatives and hypnotics, antidepressants, and benzodiazepines to be significantly associated with falls.12 Other classes of medications including antihypertensive agents, neuroleptics, narcotics, and nonsteroidal anti-inflammatory drugs also increase the risk of falls.13 Additionally, patients on more than four medications are at an increased risk for falls.14 A patient’s neurological status including cognitive status should also be assessed. Cognitive impairments can be determined during the history.6 The patient’s evaluation of their ability to complete the activities of daily living should be noted.15 The history should also include questions about the patient’s home environment and social supports.16 The physical examination also plays an important role in the evaluation of an elderly patient with a history of falls. It should hone in on the intrinsic factors that may play a role in falls and include assessment of the patient’s vital signs along with a vision and hearing screening. A comprehensive neurological examination should also be performed including an assessment of the patient’s gait and muscular strength. The patient’s postural stability and coordination can be evaluated using a variety of tests such as the Timed Up and Go Test, Tinetti’s Mobility Scale, or the Physical Performance Test.15 The Timed Up and Go Test is widely used. With this test, patients are timed while covering a fixed distance after rising from a standard chair, covering the required distance and then returning to a seated position in the chair. The patient’s recorded time is compared to the mean time for other adults in their age group.17 The Tinetti’s Mobility Scale is a 16-item assessment of a patient’s gait and balance. The patient’s gait and balance are gauged in a variety of situations including transferring and changing directions. The Physical Performance Test helps identify functional and physical changes in elderly adults. Laboratory studies should be directed by the results of the history and physical and may include a complete blood count, BUN/creatinine, thyroid stimulation hormone, Vitamin B12, and 25-0H Vitamin D levels.6,15,16 These studies may rule out reversible causes of falls including anemia, dehydration, and nutritional deficiencies. Radiological studies and other diagnostic tests are often not needed; however, imaging of the brain and/or spine, echocardiography, and Holter monitoring may be recommended.
Fall-risk modification counseling for all elderly patients is recommended by the U.S. Preventive Services Task Force.18 Due to the multifactorial risk factors for falls, there is no single superior method to prevent falls. While interventional approaches targeting a single risk-factor are effective, numerous studies validate that a multifaceted, yet individualized, approach to interventions is most effective.19,20,21 Physicians who are unable to coordinate a multifactorial intervention from their office may consider a referral to a fall prevention program. Exercise programs including targeted muscle strengthening, walking programs, and gait and balance training, when performed under the supervision of a physical therapist, significantly reduce fall-risk.19 Fall prevention programs incorporating balance retraining, including Tai-Chi & the Otago exercise program, are most effective.19,22,23 Patients requiring assistive devices should undergo an occupational therapy evaluation to ensure they are using the correct device and in an appropriate manner.24 Referral to an optometrist or ophthalmologist is indicated for any patient displaying a vision impairment on examination. It should be noted, however, that patients undergoing correction for a visual problem may initially experience an increase in falls as they adjust to their improved sense of vision and perception. Since hazardous living environments are the leading cause of falls, a home safety assessment is an important part of a fall risk modification. An assessment should be performed by family members instructed on safety measures or a home health agency as part of a comprehensive falls prevention program. Identified hazards should be removed, and the home environment modified (Table 1).
Appropriate home safety assessment and modification was shown to decrease risk of falls by 20 percent in patients recently discharged from the hospital.24 A patient-oriented home safety checklist is available on the Centers for Disease Control and Prevention’s website.25
Falls are a significant source of physical and psychosocial morbidity, and increased financial costs amongst the elderly. Physicians should perform screening for falls on their elderly patients at least yearly, and the evaluation for fall risk should include a review of medications, co-morbid conditions, physical examination including gait evaluation, and laboratory or other studies for select patients. Fall prevention programs should be multifactorial in nature including physical strengthening and balance programs, home safety assessment and modification, and medication review and modification.
1. Stevens JA, Ballesteros MF, Mack KA, et al. Gender differences in seeking care for falls in the aged Medicare Population. Am J Prev Med. 2012 Jul;43(1):59–62.
2. Centers for Disease Control and Prevention. Falls among older adults: an overview [Internet]. Atlanta (GA); 2017 Feb 10 [cited 2017 Jul 5]. Available from: http://www.cdc.gov/Homeandrecreationalsafety/falls/adultfalls.html.
3. Florida Department of Health. Older Adult Fall Prevention [Internet]. Tallahassee (FL); [cited 2017 Jul 10]. Available from: http://www.floridahealth.gov/%5C/programs-and-services/prevention/older-adult-falls-prevention/index.html.
4. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001 May;49(5):664-72.
5. Burns EB, Stevens JA, Lee RL. The direct costs of fatal and non-fatal falls among older adults—United States. J Safety Res. 2016 Sep;58:99-103.
6. Fuller GF. Falls in the elderly. Am Fam Physician. 2000 Apr 1;61(7):2159-68, 2173-4.
7. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002 May;18(2):141-58.
8. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009 Nov 23;169(21):1952-60.
9. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999 Jan;47(1):40-50.
10. NCQA. Fall Risk Management [Internet]. 2016 [cited 2017 Jul 5]. Available from: http:// www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2016-table-of-contents/ fall-risk.
11. Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ. 2003 Sep;327(7417):712.
12. De Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Ther Adv Drug Saf. 2013 Aug;4(4):147-54.
13. Ziere G, Dieleman J, Hofman A, et al. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol. 2006 Feb;61(2):218-23.
14. Kiel DP. Falls in older persons: risk factors and patient evaluation [Internet]. UpToDate. 2016 Nov 30. Available from: https://www.uptodate.com/contents/falls-in-older-personsrisk-factors-and-patient-evaluation.
15. Akyol AD. Falls in the elderly: what can be done? Int Nurs Rev. 2007 Jun;54(2):191-6.
16. Podsiadlo D, Richardson S. The timed “Up&Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-48.
17. US Preventive Services Task Force. Guide to clinical preventive services: report of the US Preventive Services Task Force. 2nd ed. Baltimore (MD): Williams and Wilkins; 1996.
18. Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions for preventing falls in elderly people living in the community. Cochrane Database Syst Rev 2009; (2): CD007146.
19. 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.
20. Close J, Ellis M, Hooper R, et al. Prevention of falls in the elderly trial (PROFET): a randomized controlled trial. Lancet. 1999 Jan 9;353(9147):93-7.
21. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. J Am Geriatr Soc. 1996 May;44(5):489-97.
22. National Council on Aging. Evidence Based Falls Prevention Programs [Internet]. Arlington (VA); 2017 [cited 2017 Jul 10]. Available from: https://www.ncoa.org/healthy-aging/ falls-prevention/falls-prevention-programs-for-older-adults/.
23. Rao SS. Prevention of Falls in Older Patients. Am Fam Phys. 2005 Jul 1;72(1):81-8.
24. Cumming RG, Thomas M, Szonyi G, et al. Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Geriatr Soc. 1999 Dec;47(12):1397-402.
25. Centers for Disease Control and Prevention. Check for Safety: A home fall prevention checklist for older adults [Internet]. 2005 [cited 2017 Jul 15]. Available from: https://www.cdc. gov/HomeandRecreationalSafety/pubs/English/booklet_Eng_desktop-a.pdf.
26. Campbell AJ, Robertson MC, Gardner MM, et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled tiral. J Am Geriatr Soc. 1999 Jul;47(7):850-53.
27. Kenny RA, Richardson DA, Steen N, et al. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol. 2001 Nov 1;38(5):1491-96.
28. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary reference intakes for calcium and vitamin D. Washington (DC): National Academies Press; 2011.
29. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people and nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005465.
30. Favus MJ. Bisphosphonates for osteoporosis. N Engl J Med. 2010 Nov 18;363(21): 2027-35