Donald Doell

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Donald Doell Suzanne Morin Joanne Creager Gary
Inglis Danièle Benoit Anita Tonet Montreal
General Hospital
CATCHFallersCritical Assessment in a Teaching
Clinic for High-risk Fallers
http//www.CATCHFallers.com
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Objective
Implement a simple decision Tool for
residents Identify, Assess, Intervene in cases
of individuals at Risk of falls We believe this
will improve Case-identification of patients at
risk for falls, Medical interventions for fall
risk reduction and increased number of Referrals
to specialized services
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Overview
1. Significance of falls in the elderly 2.
Identification of High-risk Fallers 3. Assessment
for patients at high-risk for falls 4.
Intervention can make a difference
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1. Significance of falls in the elderly

• One out of every three individuals living in the
  community and over the age of 65 will fall
• This rate will increase with more advanced age
  and among institutionalized individuals
• Unintentional injuries are the fifth leading
  cause of death in older adults with falls
  accounting for two thirds of these deaths

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Falls result in significant morbidity and
mortality

• 6 of falls will result in a fracture
• Of all fallers approximately 1 will sustain a
  hip fracture
• The incidence of mortality after one year is
  20-30 for hip fractures
• 60 will be left with restricted mobility
• Other falls will result in significant soft
  tissue injury, head injury, subdural hematoma
• Falls lead to significant fear of falling
• Falls lead to increased incidence of nursing home
  placement and loss of autonomy

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2. Identification of High-risk Fallers

• History of falls is most predictive
• In particular history of recurrent falls
• Functional testing is useful in stratifying those
  who may be at risk

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The Timed-up-and-go (TUG)
gt35s High risk 15-35s Indeterminate
risk lt15s Low risk
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Recommendations

• All persons over the age of 65 should be
  questioned once per year about falls
• Any individual with a history of recurrent falls
  should have further assessment
• If there is a history of a single fall in the
  last year, then further functional testing (i.e.
  TUG) should be used to risk stratify

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Other Risk factors of Particular Note

• Muscle weakness
• Gait deficit
• Balance deficit
• Use of assist device
• Visual deficit
• Arthritis
• Limitation in gt 1 ADL (activity of daily living)
• Depression
• Polypharmacy (greater than 4 medications)

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3. Assessment for patients at high-risk for falls

• Falls are multifactorial
• Approach to assessment and treatment must also be
  multifactorial

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Fall history and assessment

• History of the fall circumstances
• Review of medications
• Number of medications
• Cardiovascular medications
• Psychotropic medications (neuroleptics,
  benzodiazepines, and antidepressants)
• Review of acute or chronic medical problems
• Review of mobility status

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Approach to exam for fallers

• Exam of vision
• Exam of gait balance
• Exam of lower extremity joint function
• Exam of basic neurological function
• Mental status
• Muscle strength
• Lower extremity peripheral nerves
• Proprioception
• Reflexes
• Tests of cortical, extrapyramidal, and cerebellar
  function
• Exam of basic cardiovascular status
• Heart rate and rhythm
• Postural pulse and blood pressure
• If appropriate, heart rate and blood pressure
  responses to carotid sinus stimulation

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4. Intervention can make a difference

• Multifactorial approach is most effective (can
  reduce falls as much as 43) and includes
• Gait training and advice on the appropriate use
  of assistive devices
• Review and modification of medication, especially
  psychotropic medication
• Exercise programs, with balance training as one
  of the components
• Treatment of postural hypotension
• Modification of environmental hazards
• Treatment of cardiovascular disorders, including
  cardiac arrhythmias

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Single most important interventions

• Exercise Most effective strategy (fall
  reduction 19)
• Environmental Modification
• Medication review, reduction and modification for
  psychotropic medications

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Summary
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The CATCHFallers Concept Again
Implement a simple decision Tool for
residents Identify, Assess, Intervene in cases
of individuals at Risk of falls We believe this
will improve Case-identification of patients at
risk for falls, Medical interventions for fall
risk reduction and increased number of Referrals
to specialized services
17
About the tool
An online survey for residents to complete that
will guide them through the proper assessment for
high-risk fallers
http//www.CATCHFallers.com
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The pre-study survey
CATCHFallers - Pre Study Questions Critical
Assessment in a Teaching Clinic for High-risk
Fallers - A pre-study survey for
residents Pre-study questions 1 Approximately
how many patients over the age of 75 have you
specifically asked for a history of falls in the
last three months? Please write your answer
here ____________________ 2 Approximately how
many patients have you treated or investigated
for an underlying medical condition because of a
possibly increased risk for falls in the last
three months? Please write your answer
here ____________________ 3 Approximately for
how many patients have you changed or reduced the
number of their medications because of a possibly
increased risk for falls in the last three
months? Please write your answer
here ____________________ 4 How many patients
have you referred for outpatient specialized or
mulitdisciplanary assessment because of risk of
falls (i.e. physiotherapy, CLSC services,
occupational therapy, geriatric consultation) in
the last three months? Please write your answer
here ____________________ 5 Approximately how
many patients would you have liked to refer for
outpatient services but were were unable to
because you were not aware how to or if these
services were available in the last three
months? Please write your answer
here ____________________
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The CATCHFallers survey Part I - Evaluation of
risk
Evaluation of risk Age What is the patient's
age? About one out of every three individuals
living in the community and over the age of 65
will fall. This rate will increase with more
advanced age. Plese write your answer
here ____________________ Fall history Is there
a history of a fall in the past year? All older
persons should be asked at least once a year
about falls. All older persons who report a
single fall should have a TUG. Please choose
only one of the following o Yes o No Multiple
falls Is there a history of recurrent falls in
the past year? Older persons who present for
medical attention because of a fall or report
recurrent falls in the past year should have a
fall evaluation performed. Please choose only
one of the following o Yes o No TUG How long
did it take the patient to perform a TUG
(timed-up-and-go)? The time it takes for an
individiual to stand up from a chair, walk to a
line 3 meters away on the floor using usual aids
at a usual pace, turn around and walk back to the
chair and sit down. TUG lt 15s low risk TUG
15s-35s indeterminate risk TUG gt 35s high
risk Please write your answer here ______________
______ Risk Do you think this patient might be
at risk for falls? Please choose only one of
the following o Yes o No
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The CATCHFallers survey Part II - Evaluation of
modifiable risk factors
Evaluation of modifiable risk factors Number of
meds How many medications does this patient
take? Increased risk of falls has been
demonstrated with greater than four
medications. Please write your answer
here ____________________ Barthel What is the
Patient's Barthel Score? link to an online
calculator here www.patient.co.uk/showdoc/4000165
4/ Please write your answer here ________________
____ History findings Have you identified a
predisposing risk factor for falls in your
history? Should include a history of fall
circumstances, acute or chronic medical problems,
and mobility levels. Pay particular attention to
muscle weakness, gait deficit, balance deficit,
use of an assistive device, visual deficit,
arthritis, depression, cognitive impairment,
cardiovascular causes as risk factors. Please
choose only one of the following o Yes o
No Exam findings Have you identified a
predisposing risk factor for falls in your
exam? Should include examination of vision, gait
and balance, and lower extremity joint function
an examination of basic neurological function,
including mental status, muscle strength, lower
extremity peripheral nerves, proprioception,
reflexes, tests of cortical, extrapyramidal, and
cerebellar function and assessment of
basic cardiovascular status including heart rate
and rhythm, postural pulse and blood
pressure. Please choose only one of the
following o Yes o No Medication Have you
identified a predisposing risk factor in this
patient's medications? Pay particular attention
to any psychotropic medication (neuroleptics,
benzodiazepines, and antidepressants) Please
choose only one of the following o Yes o No
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The CATCHFallers survey Part III - Documentation
of Intervention
Documentation of Intervention Medication
change I have changed or modified this patient's
medications, because of risk of falls. Reduction
in total number of medications if greater than
four, or modification of medications
especially psychotropic medications. Please
choose only one of the following o Yes o
No Medical condition I will investigate or treat
an underlying medical condition that may be
implicated in this patient's risk for falls. Pay
particular attention to cardiovascular
intervention, treatment and investigation of
postural hypotension and visual
impairment. Please choose only one of the
following o Yes o No Outpatient I have referred
this patient for outpatient multidisciplinary
assessment. Exercise programs are extremely
effective in preventing falls and may be one of
the single most effective preventative
strategies, particularly when combined as part of
a multifactorial intervention. Please choose
only one of the following o Yes o No
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Bottom Line
Bottom Line
In the universe some things are constant

• Exercise Single most effective strategy
• Environmental Modification
• Medication review, reduction and modification for
  psychotropic medications

Gravitational constant 6.67300 10-11 m3 kg-1
s-2
The elderly will continue to fall
Falls can be prevented
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Bottom Line
References

• Laurence Z Rubenstein and Karen R Josephson Falls
  and their prevention in elderly people what does
  the evidence show? 2006
• Guideline for the prevention of falls in older
  persons. American Geriatrics Society, British
  Geriatrics Society, and American Academy of
  Orthopedic Surgeons Panel on Falls Prevention.
  2001
• Kerri M Clough-Gorr and Thomas Erpen and Gerhard
  Gillmann and Wolfgang von Renteln-Kruse and Steve
  Iliffe and John C Beck and Andreas E Stuck
  Preclinical disability as a risk factor for falls
  in community-dwelling older adults. 2008
• Ellinor Nordin and Nina Lindelöf and Erik
  Rosendahl and Jane Jensen and Lillemor
  Lundin-Olsson Prognostic validity of the Timed
  Up-and-Go test, a modified Get-Up-and-Go test,
  staff's global judgement and fall history in
  evaluating fall risk in residential care
  facilities. 2008
• Anne Tiedemann and Hiroyuki Shimada and Catherine
  Sherrington and Susan Murray and Stephen Lord The
  comparative ability of eight functional mobility
  tests for predicting falls in community-dwelling
  older people. 2008
• Cameron G Swift The role of medical assessment
  and intervention in the prevention of falls. 2006
• Theodore Speroff and Gerald T O'Connor Study
  designs for PDSA quality improvement research.
  2004
• www.aafp.org/afp//AFPprinter/20000401/2159_f1.jpg
• 1to3.livedoor.biz/archives/50358915.html

• Exercise Single most effective strategy
• Environmental Modification
• Medication review, reduction and modification for
  psychotropic medications