Fall Prevention

Falls are the leading cause of injuries and injury deaths in the elderly population. Almost forty percent of the geriatric population experience a fall each year (Hausdorff, Rios, Edelberg, 2001) Falls leading to hip fracture often result in premature institutionalization and death, as well as enormous health care costs. Approximately 40% of elderly American patients with hip fractures die within one year or are placed in long term care. Clearly, this is a staggering health care problem, which will increase dramatically as the elderly population increases. No one argues that we, as health care and medical professionals, should intervene. The questions are rather, “What to do?” and “Will it actually make a difference?”

Much attention has been paid to this subject in recent years, and systematic evaluation and intervention is on the rise in the United States. In fact, there is currently a bill before the US Congress titled the “Elder Fall Prevention Act of 2002″ with the stated goal “to expand and intensify programs with respect to research and related activities concerning elder falls.”
Poor balance and instability in the elderly has been described as a “geriatric syndrome”, because the specific cause of these complaints is often not obvious to the examiner. This is primarily because poor balance in the elderly is most often multi-factorial, with no single clinical abnormality responsible. The risk factors for increased likelihood of falling have been identified, and intervention for these risk factors has been shown to significantly reduce the risk of falling. Obviously, intervention can not eliminate the possibility of an injurious fall, but research indicates that systematic evaluation and intervention can dramatically reduce the likelihood of a fall.

Tinnetti et al (1994) studied a group of elderly (at least 70 years old) subjects with known risk factors for falling. By applying interventions aimed at specific risk factors, the intervention group had significantly fewer falls than the untreated control group. Specifically, subjects identified with “balance impairment” had the greatest reduction in falls (over 50% fewer). 

Close et al (1999) followed a group of elderly (65 plus) patients that had presented to an emergency room after a fall injury. After medical and occupational therapy assessment, the intervention group received care for identified risk factors for falling. At one year follow-up, the control group had more than twice as many falls than the intervention group.

Jacobson (2002) expanded on these findings by developing an assessment protocol to identify risk factors in patients that had fallen or had fear of falling. At the first author’s facility (Blue Ridge Hearing and Balance Clinic, Bluefield, WV), we have modeled our Fall Prevention Clinic (FPC) after the protocol outlined by Jacobson. With the cooperative effort of Otolaryngology and Physical Therapy, we began a program to identify at the primary care level those at risk for falling, provide assessment for known risk factors for falling, and provide education, intervention and environmental modification when indicated.

SCREENING IN PRIMARY CARE
Elderly patients may not be aware that they are at increased risk for falling. Unfortunately, examinations to determine the cause of fall injuries, if done at all, typically take place after the fact. The known risk factors often develop independently and insidiously. A simple screen for risk factors at the primary care level may identify some of the known risk factors, and intervention can begin. The questionnaire in table was developed for use by primary care physicians. Since some physicians may be unfamiliar with the implications of a positive response to some of the questions, we developed a “Physicians Guide” to help interpret the answers to the screener questions.

Fall Risk Questionnaire
Please answer all questions with a “yes” or “no”.
  1. Have you had a fall or near fall in the past year?
  2. Do you have a fear of falling that restricts your activity?
  3. Do you experience dizziness or a sensation of spinning when you lie down, tilt your head back, or roll over in bed?
  4. Do you feel uneasy or unsteady when walking down the aisle of supermarket, or in an area congested with other people?
  5. Do you have difficulty walking in the dark, or on uneven surfaces such as gravel or a sloped sidewalk?
  6. Do your feet or toes frequently feel unusually hot or cold, numb or tingly?
  7. Do you wear bifocal or trifocal glasses, or is your vision notably better in one eye?
  8. Do you experience loss of balance, or a lightheaded/faint feeling when you stand up?
  9. Do you take medication for depression, anxiety, nerves sleep or pain?
  10. Do you take four or more prescription medications daily?
  11. Do you feel like your feet just won’t go where you wan them to go?
  12. Do you feel like you can’t walk a straight line, or are pulled to the side while walking?
  13. Has it been longer than six months since you participated in a regular exercise program?
  14. Do you feel that no one really understands how much dizziness and balance problems affect your quality of life?
  15. Are you interested in improving your balance and mobility?
Physicians Guide to the Fall Risk Questionnaire
Question # 1 and 2: A previous fall may indicate increased risk for future falls. Inquire as to the circumstances of the fall. Fear of falling can lead to restricted activity

Questions 3,4 and 5: A positive response to any of these questions indicates the possibility of a vestibular disorder. Patients with Benign Paroxysmal Positional Vertigo (BPPV) are at risk for falling if they tilt their head back. Patients with vestibular disorders tend to be more reliant on vision for postural control. When the visual feedback is unreliable (moving visual scene) or unavailable (dark) they are at risk for loss of balance and falling. Vestibular evaluation may be indicated (e.g., ENG, Posturography, Rotary Test).

Questions 5 and 6: The sense of touch is an important contributor to balance and orientation. The stretch receptors in the legs, the fingertips, and the soles of the feet, all provide sensory feedback for balance. An assessment for peripheral neuropathy may be indicated.

Question #7: Vision plays an important role in balance, and patients with visual deficits have greater risk for falls. Visual problems associated with decreased postural stability include: 1.) visual acuity less than 20/50, 2.) asymmetric vision impairing binocular vision and depth perception, 3.) slow pupillary reaction causing increased adaptation time when going from a lighted to a dark room, and vice versa, and 4.) impaired peripheral vision. Multifocal glasses have been shown to increase the risk of falling (Lord et al, 2002). Ophthalmology evaluation may be indicated.

Question #8: Orthostatic hypotension may result in an increased risk of falling when assuming the upright position. Diabetes and many medications used to regulate heart rate and blood pressure can lead to orthostatic hypotension.

Question 9 and 10: The use of four or more daily prescription medications or the uses of tri-cyclic anti-depressants and/or benzodiazapines are associated with increased risk for falls (Tinnetti et al, 1994).

Questions #11 and 12: Poor motor control is a sign of possible cerebellar dysfunction. The integration of vestibular, visual and somatosensory information takes place in the cerebellum. Cerebellar dysfunction can result in slow or inappropriate reaction to self movement or external visual stimuli.

Question #13: Inactive patients may have accelerated decrease in muscle mass, and decreased reaction time when faced with a possible fall

Question #14: Physicians often underestimate (compared to the patient) the impact that a balance problem has on the patient’s quality of life (Honrubia et al, 1996).

Question 15: Therapy for improved balance requires motivation and commitment. Patient compliance is important to a successful fall prevention program.
References

Lord SR, Dayhew J, Howland A. (2002) Multifocal glasses impair edge contrast sensitivity and depth perception and increase the risk of falling in older people. J Am Geriatr Soc, Nov;50(11):1760-6
Tinetti, et al. (1994) A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med, 331(13):821.
Honrubia et al (1996) Quantitative evaluation of dizziness characteristics and impact on quality of life. Am J Otol, 17(4), 95-102

ASSESSMENT
When a patient is referred for a Fall Risk Assessment, we follow an evaluation protocol to assess many of the known risk factors. Following a thorough history interview, the patient undergoes a series of tests of hearing and vestibular function (Audiogram, ENG, Rotary chair test and Posturography). Evaluation for orthostatic hypotension and a computerized review of medications and interactions is performed. We work with Physical Therapists in the region to provide a comprehensive assessment of known risk factors that are out of the scope of audiology practice. Examination for strength, sensation and range of motion of the lower extremities is performed. Screening tests for depression and cognition are completed. The patient’s lifestyle, goals, and concerns are reviewed. A report is then forwarded to the referring physician with recommendations for intervention. The PCP is provided with a checklist (figure 21-__) of applicable risk factors, along with suggestions for intervention. This checklist quickly allows the PCP to view risk factors that have been identified in that particular patient, a brief description of how and why that factor affects balance, and a suggestion on intervention strategy. With the multi-factorial nature of dysequilibrium of aging, the PCP must be the center point of coordinated intervention.

INTERVENTION
Name ___________________________________ Date _______________
Referring Physician __________________________________________
The following have been identified as possible factors in increasing this patients risk for future falls
___Vestibular Pathology - see dictated report - an impairment of the vestibular system can cause the patient to become dizzy or off balance associated with certain movements and certain visual environment. Vestibular rehabilitation can minimize the effects of this impairment
___Polypharmacy - see attached PDR Report - The use of four or more prescription medications or the initiation of a new medication or dosage have been associated with an increased risk of falling. A review of all medications by the primary care physician is indicated
___Use of tricyclic anti-depressants or benzodiazepines are associated with increased risk of falls. SSRI anti-depressants may have fewer side effects, but it is not clear that they result in a reduced risk of falling compared to tricyclics and benzodiazepines. A review of the patient’s medications is indicated.
___Orthostatic (Postural) Hypotension - Postural pre-syncope associated with orthostatic hypotension may result in an increased risk for falling when assuming the upright position. Diabetes and many medications used to regulate the heart rate and blood pressure can suppress the carotid sinus reflex and result in temporary cerebral hypoperfusion. Increased fluids, support hose and/or brief exercise (fist clenching, etc.) before standing can reduce the effect of OH. A review of medications is indicated.
___Impaired Proprioception (Somatosensation) - The sense of touch is an important contributor to balance and orientation. The stretch receptors in the legs, the finger tips, and the soles of the feet, all provide feedback. Balance retraining therapy can help these patients use vestibular and visual feedback to compensate for loss of proprioceptive information. Vestibular rehabilitation is recommended.
___Cerebellar Dysfunction - The integration of vestibular, visual and proprioceptive information takes place in the cerebellum. Cerebellar dysfunction can result in slow or inappropriate reaction to self movement of external visual stimuli. Vestibular rehabilitation can maximize these patients potential, but benefit is often limited. Environmental assessment and reduction of fall hazards is recommended.
___Hearing Loss - see attached audiogram -Hearing loss reduces ones orientation and awareness of ones surroundings. A person with hearing loss is more likely to be startled by movement in the visual field as they have fewer auditory warning signals. Amplification may be helpful
___Impaired Vision - Vision plays an important role in balance, and patients with visual deficits have greater risk for falls. Visual problems associated with decreased postural stability include: visual acuity less than 20/50, asymmetric vision impairing binocular vision and depth perception, slow pupillary reaction causing increased adaptation time when going from a lighted to a dark room and vice versa, impaired peripheral vision. Opthalmologic or Optometric evaluation is recommended.
___Depression - Depressed patients may be more internally (therefore less externally) aware. The use of antidepressant and anxiolytics increase the risk of falling. Psychiatric or Psychological evaluation is recommended.
___Impaired Cognition - Patients with impaired cognition may be less aware of their surroundings or more likely to engage is risky activities. Neurologic evaluation is recommended.
___Impaired Reaction Time - Many fall avoidance strategies are dependent on reaction time when postural stability is challenged. Slower reaction time may increase the risk of falls when the patient’s limits of stability are exceeded. Neurologic evaluation is recommended.