A preliminary study of the effectiveness of an otolaryngology-based multidisciplinary falls prevention clinic.

Abstract

Because the cause of falls is often multifactorial, efforts to identify risk factors and promote prevention would benefit from a multidisciplinary approach in which the contributions of a broad range of body systems are considered. We describe the practices and procedures followed at the otolaryngology-based multidisciplinary Falls Prevention Clinic at Henry Ford Hospital in Detroit. Our team is made up of an otolaryngologist, an audiologist, an internist, and a physical therapist. Our multidisciplinary approach involves evaluations of vestibular and balance function, cardiovascular function, and visual function; lower-extremity strength and sensation; cognition and mood; and medication use. We also assess a number of nonmedical risk factors. Evaluations are made over the course of two clinic visits. To assess the effectiveness of our approach, we conducted a preliminary study based on chart reviews and telephone interviews of 52 patients who had been referred to our clinic for evaluation and counseling. The basis of our study was a comparison of the number of falls that patients had experienced during the 6 months prior to their first visit to our clinic and the number of falls they experienced during the 6 months after their second visit. We found that among "true fallers" (i.e., those who had actually experienced a fall at some point during the study), 64.7% reported that they had experienced fewer falls after their clinic visits than before (p < 0.001). Also, 59.1% of patients who had been "frequent fallers" prior to their clinic evaluation (i.e., [greater than or equal to] 3 falls during the previous 6 mo) reported that they had not fallen at all during the 6 months following their last visit. Finally, our evaluations identified a substantial number of risk factors in individual patients that had been missed previously, including many nonvestibular factors that might not have been detected without a multidisciplinary approach. We conclude that the results of this preliminary study demonstrate the potential that a comprehensive falls prevention clinic can have in reducing the number of falls among outpatients at risk, and we believe that further study is warranted.

Introduction

It is well known by those who work with falling or dizzy patients that finding the causes of falling and dizziness is often a daunting task. Even though it is well known that falls can be caused by a variety of intrinsic and extrinsic factors, (1-3) many falls prevention clinics focus only on a limited number of body systems. One reason for this may be that a particular specialist attempts to identify only those causes and risk factors that pertain to his or her specialty. When those disorders are ruled out, a cause is often framed in terms of what it is not--for example, a "nonvestibular" cause or a "noncardiogenic" cause. As a result, patients are often shuffled from one specialist to another in the hope that he or she will eventually visit the right one. In the otolaryngology/audiology setting, some falls prevention clinics are no more than vestibular laboratories that work in conjunction with physical therapists.

It seems to us that a better framework for a falls prevention effort would involve a single-site multidisciplinary clinic in which the contributions of multiple body systems are considered, lust such a clinic exists at the Henry Ford Hospital in Detroit. In this article, we describe the operation of our Falls Prevention Clinic (FPC) and the results of our preliminary study of its effectiveness.

Clinic description

The FPC at Henry Ford Hospital is located within the Department of Otolaryngology. Most of our referrals are made by otolaryngologists and family practitioners. Since the inception of the FPC, it has been our philosophy and our practice to evaluate multiple body systems. (4) Our multidisciplinary team consists of an otolaryngologist, an audiologist, an internist, and a physical therapist.

Over the course of two visits, we evaluate patients' vestibular and balance function, cardiovascular function, and visual function; lower-extremity strength and sensation; cognition and mood; and medication use. We also assess nonmedical risk factors for falling, such as home and other environmental conditions, as well as personal habits.

At the end of each visit, we discuss with patients the results of their testing and we provide them with a copy of a personalized falls risk report. This report includes recommendations on exercise, assistive equipment, physical therapy when appropriate, and referral back to the primary care provider for follow-up when necessary. In-home physical therapy may be recommended for patients who are unable to attend an outpatient therapy facility. An evaluation of the home environment for risk factors may also be recommended.

Rationale for testing

When we originally chose which tests to administer at our FPC, we tried to consider all of the known major risk factors for falls. Our selection was based on published studies and on the recommendations of appropriate subspecialists in the Henry Ford Health System.

Vestibular and balance function. Formal vestibular testing is conducted with a rotational chair test, computerized dynamic platform posturography, electronystagmography/videonystagmography (ENG/VNG), and the Dix-Hallpike test. These tests are performed and interpreted by an audiologist experienced in vestibular testing. The criterion for a vestibular anomaly is either an abnormal result on the Dix-Hallpike test or an abnormal result on at least two of the other three tests (rotational chair test, posturography, or ENG/VNG).

Informal balance function tests--the Romberg test, (5) the Fukuda stepping test, (6) and the Tinetti test (7)--are conducted for purposes of counseling and to show patients what their balance limitations are (these findings were not included in the results of this study).

Patients also undergo a hearing test and consultation with an otolaryngologist if such has not previously been performed.

Cardiovascular function. Orthostatic hypotension is a cause of falls, and it is common among the elderly. (8) We obtain the standing blood pressure reading immediately upon standing rather than waiting the usual 60 seconds before measuring. The criterion for a diagnosis of orthostatic hypotension is a drop in systolic blood pressure of 20 mm Hg or more. We also look for any pulse irregularities and other cardiogenic anomalies in the history and the patient's chart.

Visual function. Visual deficits of various types have been identified as a contributor to falls. (8-10) Our threshold for abnormal visual acuity deficient enough to constitute a risk factor for falls is 20/50 or poorer, binocular, with correction. The criterion for abnormal contrast vision is a score of 19 or more on the Melbourne Edge Test. (11,12)

Lower-extremity strength and sensation. Screening for lower-extremity muscle weakness is accomplished with a subjective assessment of muscle strength on a scale of 1 (very weak) to 5 (very strong). Screening for peripheral neuropathy is conducted by light-touch testing, 125-Hz tuning-fork testing at the big toe or ankle, administration of pinpricks along the legs and feet from the knees to the toes, and touching of the lateral ankle with graded filaments. The criterion for an abnormal result on testing for peripheral neuropathy is a positive finding on any two tests. When results are equivocal or when the patient has not been previously diagnosed with peripheral neuropathy, an on-call neurology technician measures neural conduction time.

Somatosensory balance dysfunction is determined by an abnormal score on either the "motor control" portion of the posturography test or by an abnormal "somatosensory" pattern on the "sensory organization" portion of posturography. (13)

Proprioception is assessed by the "big toe up or down?" test, in which the patient is required to determine whether the examiner has moved the patient's toe up or down without looking at it. Other foot anomalies observed on examination are noted as possible risk factors for falls; they include hammertoe, deformities, or pain that could result in an abnormal gait.

Cognition. Cognitive impairment is a predisposing factor for falls. (14) Because of time constraints, we use only informal screening measures. The finding of an abnormality is based on a combination of portions of the Mini-Mental State Examination, (15) hand and foot reaction times, (16) and the presence of previously diagnosed dementia or memory problems reported by the patient or a caregiver.

Mood. While mood-altering medications can be a risk factor for falls, depression itself has also been implicated as a risk factor. (17) We screen for mood disorders with the Geriatric Depression Scale (short form) (18) or by reviewing previous diagnoses and self-reports.

Medications. A regular drug regimen that includes four or more prescription medications, regardless of type, is a risk factor for falls. (19) Anxiolytic and sedative drugs are also associated with falling. We ascertain medication use during the history and by reviewing the medical record.

Physical therapy evaluation. During one of their two visits, patients are evaluated by a physical therapist. In addition to testing lower-extremity strength and feeling and gait, the therapist assesses environmental factors by interview. A list of environmental hazards that predispose to falls is reviewed with the patient. Emphasis is placed on the bathroom, stairs, toileting activities, night lights, walking aids, and alerting devices such as cordless telephones.

Patients and methods

Initial visit. Our initial patient population was made up of 69 consecutive patients who had presented to our FPC. One of the questions we asked during the history at this initial visit concerned the number of falls that each patient had experienced during the preceding 6 months. This information was later used in a postassessment comparison to evaluate the success of our falls prevention measures.

[FIGURE OMITTED]

Follow-up interview. Six months or more following each patient's second clinic visit, we attempted to contact each for a follow-up telephone interview. We were able to contact 52 of the 69 patients--12 men and 40 women, aged 29 to 95 years (mean: 74; median: 74). Thus, our final results were based on a population of 52. During this interview, we asked each patient how many falls they had experienced during the 6 months following their last clinic visit. We then compared these figures with the preassessment figures.

Data analysis. The Wilcoxon signed-rank test was used for statistical analysis. (20,21)

Study approval. This study was approved by the Institutional Review Board at Henry Ford Hospital.

Results

During the 6 months prior to their first FPC visit, 31 of the 52 patients (59.6%) had experienced one or more falls. Even though a substantial percentage had not experienced a fall, they had been judged to be at risk for falling by another clinician, and thus they had been referred to us.

At the follow-up interview, only 15 of the 52 patients (28.8%) reported that they had fallen during the 6 months following their last FPC visit--a decrease of 51.6%.

Subgroup analyses. Because falls are often an infrequent event in many patients, the low rate of falls among our patients 6 months following their clinic visits (28.8%) may not necessarily have been a reflection of the benefits of our FPC; indeed, it is possible that the low rate was actually the result of chance alone. Therefore, we also looked at the number of falls that had occurred in a subgroup of "true fallers," defined as those who had fallen at least once either during the 6 months prior to their FPC visits or during the 6 months thereafter (n = 34), as well as a subgroup of "frequent fallers," defined as those who had fallen 3 or more times prior to their FPC visits (n = 22).

True fallers. Of the 34 true fallers, 22 (64.7%) reported that they had experienced fewer falls after their clinic visits than before (figure); this reduction in falls was statistically significant (p < 0.001). Five true fallers (14.7%) said they had fallen about the same number of times, and 7 (20.6%) said they had fallen more often. An increase in the number of falls in some of these patients would be expected in view of their generally deteriorating condition.

Frequent fallers. Of the 22 frequent fallers, 13 (59.1%) reported that they had not fallen at all during the 6 months following their last visit.

Risk factor identification. Our FPC evaluations led to the identification of a substantial number of newly identified individual risk factors (n = 131)--that is, conditions that had not been previously mentioned in the referring physician's notes (table). These included 96 instances of nonvestibular risk factors.

Discussion

The results of this preliminary study demonstrate the potential that a comprehensive falls prevention clinic can have in reducing the number of falls among outpatients at risk. The high number of previously unidentified nonvestibular risk factors (n = 96) found during visits to our FPC is evidence of the importance of considering multiple body systems. These risk factors would not have been found if we had considered only vestibular factors.

Further study is necessary to determine if improvements in falling rates would be sustained over a longer period of time. One limitation of our investigation is that our observational study design did not allow us to directly assess the possible contribution of regression to the mean toward fewer falls. A formal randomized, controlled trial would likely be required to obtain strong evidence of the effectiveness of a falls prevention clinic. On the other hand, it is likely that some patients in an aging group would be deteriorating medically over time, which would tend to increase the number of falls as time went on.

The otolaryngology clinic is an ideal setting for a program that takes into consideration multiple body systems and risk factors for falls. At Henry Ford Hospital, the participation of an internal medicine specialist and a physical therapist is an important factor in the success of the FPC. Also, our audiologists are trained and proficient in conducting vestibular testing and rehabilitation, and they are well qualified to participate in and coordinate our testing and prevention efforts.

References

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Lynn S. Alvord, PhD; Michael S. Benninger, MD; Brad A. Stach, PhD

From the Division of Audiology, Department of Otolaryngology, Henry Ford Hospital, Detroit (Dr. Alvord and Dr. Stach), and the Head and Neck Institute, The Cleveland Clinic (Dr. Benninger).

Corresponding author: Dr. Lynn Alvord, Division of Audiology, Department of Otolaryngology, Henry Ford Hospital, 2799 W. Grand Blvd., K-8, Detroit, MI48202. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Table. Identified risk factors that had not been noted
by the referring physician

Risk factor                                  n (%) *

Vestibular disorder (n = 52) ([dagger])     35 (67.3)
Multiple medications (n = 51)               32 (62.7)
Lower-extremity weakness (n = 45)           15 (33.3)
Lower-extremity neuropathy (n = 43)         11 (25.6)
Use of a specific medication (n = 51)       12 (23.5)
Visual disturbance (n = 49)                 10 (20.4)
Cognitive impairment (n = 52)                9 (17.3)
Postural hypotension (n = 43)                7 (16.3)

* Some patients had more than one newly discovered risk factor.

([dagger]) The "n" indicates how many patients were evaluated
for each particular risk factor; not all patients underwent
each evaluation.