Falls are every provider’s responsibility to prevent in every venue of practice. One out of every three older persons fall every year. Less than half tell their doctor. If you patient falls once, their risk of falling again doubles. One out of every five falls is associated with serious injury such as orthopedic or neurologic injury. Nationally, over 2.5 million older individuals visit emergency departments due to injuries sustained during a fall. Over 700,000 individuals are hospitalized due to injuries suffered in a fall. 95% of all hip fractures are due to falls, and falls are the most common cause of traumatic brain injury.
Over the last twenty years, the risk factors for falls have become better understood. These include:
- Vision impairment
- Gait and balance abnormalities
- Specific medications including sedatives, anti-depressants, anti-hypertensives, anti-convulsants
- Use of poor foot wear
- Home hazards
- Muscle weakness, especially of the lower extremities
ASK. What can you do to reduce the risk of falls in your patients? First, ask about falls. Nearly 50% of patients who have fallen never tell their physicians. You need to ask about falls at every visit including those due to a suspected injury. Educate your patients about falls. The Minnesota Fall Prevention program has educational materials for consumers on falls and fall prevention. www.mnfallsprevention.org/consumer/home.html
ASSESS. As part of your fall risk evaluation, there are five things you can do:
- Check vision. Include testing via eye chart for patients with risks for falls (which is nearly everyone who is 60 and older, and other individuals with specific impairments). Refer early to opthamology for cataract and retinal evaluation and/or to optometry for refraction and updating of corrective lens.
- Check for postural hypotension. Do formal orthostasis testing at least once a year, if not more often, particularly for patients with hypertension on beta blockers or diuretics, or cardiovascular disease.
- Check gait and balance. Consider including simple tests such as the Get Up and Go test to screen for gait and balance abnormality. Ask the patient to get up out of straight back chair, walk ten paces, turn around and return to the chair. Patients without significant gait or balance problems should be able to perform this task under ten (10) seconds. Consider referral to physical therapy for evaluation.
- Review Medications. At each visit, review the medication list as well as medications may be taking at home on their own. Where possible reduce the dose or eliminate all together medications that are associated with falls. These include hypnotics such as zolpidem, sedatives such as the benzodiazepines, anti-depressants especially the SSRIs, anti-convulsants, and anti-hypertensive drugs especially the beta blockers and alpha blockers.
- Evaluate home safety. If there are fall prevention resources in the community, engage them to evaluate home risks for patients. If not, consider engaging home health agencies for an in-home evaluation. This evaluation looks for clutter or tight quarters for navigation, presence of cords that can be tripped over, presence of pets, rugs, level of illumination, use of non slip mats and railings in the bathroom. The Centers for Disease Control and Prevention provides a checklist for home evaluation: cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf
MITIGATE. There are multiple, straight-forward interventions that you can initiate in your office, several of which are discussed above.
- Check vision and correct refractive errors, refer for cataract evaluation
- Eliminate or decrease dosing of drugs associated with falls
- Engage your patient in a low impact exercise and balance program
- Safe proof the patients home by eliminating cords/rugs/pets that pose danger, install railings and non-slip mats, encourage patients to wear non-slip shoes and slippers, clear pathways commonly transgressed, and improve lighting
Below are links to compendia produced by CDC on specific best practices in fall prevention by category.
Exercise:
Clinical Strategies
Home Safety Modifications
Multi-faceted Interventions
Remember that just as additional risk factors multiply fall risk, multiple safety intervention multiply fall risk prevention