Doctors get tips on patient falls prevention

Physicians are asked to assess and tailor treatment to avert falls in their older patients.

By Victoria Stagg Elliott, amednews staff. May 28, 2001.

The 89-year-old woman came to Daniel Brauner, MD, a Chicago-based geriatrician, saying she was falling often and without an obvious cause, such as tripping over an electrical wire or a hole in the sidewalk.

Like many elderly patients, she was on numerous medications and walked with an unsteady gait caused by severe arthritis in her legs. Dr. Brauner assessed her medications and considered that the anti-hypertensive may have been making her blood pressure too low and making her more vulnerable to a fall.

How to cut falls
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He recommended an exercise program to help balance. He referred her to a nursing agency that inspected her home and decided to discard all throw rugs, and he recommended a pacemaker to keep her heartbeat steady.

"She has a significant history of falls. The frequency of her falls has markedly decreased," Dr. Brauner said. "And the pacemaker would probably reduce them further."

Looking for ways to reduce falls in the elderly is common practice for geriatricians, but it is far from common among other doctors, who see the majority of those over 65.

To change this, a coalition of medical societies released falls prevention guidelines this month to reduce the mortality and morbidity associated with such incidents. All physicians should assess older patients for falls risk and intervene by providing gait training. They should also review medications, recommend exercise programs that include balance training, and refer for home evaluations, say guidelines released by the American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons.

"Falls are one of the most common, serious and devastating problems faced by the older population," said Laurence Z. Rubenstein, MD, MPH, co-chair of the committee that wrote the guidelines and chief of geriatric medicine at Sepulveda, Calif., VA Medical Center.

About 40% of those over 65 fall annually. But the problem is not so much the fall itself as an elderly person's increased injury risk because of common age-related conditions such as osteoporosis and impaired reflexes. About 5% of the elderly who fall require hospitalization, and three-quarters of deaths due to falls occur in those over 65. Even if a person is not injured, the event can still cause significant consequences, such as loss of self-confidence. Falls account for 40% of nursing home admissions.

Falls are a complex problem that have bedeviled attempts to create a comprehensive strategy for prevention. Causes include muscle weakness, instability, declining vision, arthritis, depression, cognitive impairment, cardiac issues and joint problems.

"Sometimes there's a hazard, but usually that's only part of the cause," Dr. Rubenstein said. "You really have to figure out what might have contributed, like vision problems or the fact that they don't pick their feet up very high anymore because of weakness. If it's an unexplained fall, then you really have to look for the cause."

But making falls prevention a routine part of elder care faces barriers. Reimbursement for a falls assessment is uncertain. Patients also tend to lie about incidents because of embarrassment or a fear of institutionalization.

"They tend to minimize the importance of the fall," Dr. Rubenstein said. "It's important for physicians to ask about falls and instability and to look at walking. Watch the patient walk, stand up from a chair and walk from the waiting room to the doctor's office."

Panel members also said the guidelines were just the beginning of a long-term plan to address the issue. More research is needed to gain information about the cost effectiveness of various strategies. Research also will help to develop a better understanding of how to properly stratify patients and implement falls prevention in the hospital setting.

ADDITIONAL INFORMATION:

How to cut falls

Ask patients and caregivers about falls during routine visits.
If a patient is taking more than four medications regularly, assess the medications as possible contributing factors and modify them to cut risks.
Refer patients for home assessments to identify environmental hazards.

Source: "Guideline for the Prevention of Falls in Older Persons," Journal of the American Geriatrics Society, May 2001