An interdisciplinary approach to reducing fall risks and falls.

This article discusses the functional profile of veterans at high risk for falls, their fall rates and fall prevention treatment plan, summarizing compelling data for evidence-based interventions appropriate to this vulnerable population. This report is the result of a 2-year clinical

initiative grant nationally funded to deploy evidence-based fall prevention programs.

Functional profiling of a predominately male, outpatient population casts evidence of he need for national attention for Fall Prevention Programs that promote health, well-being, and successful aging among the elderly The availability of fall prevention programs are vital in this unique population as today's veterans' median age is higher than that of the general population and is continuing to grow. By 2030, the number of veterans age 85 or older is projected to be 1.03 million-54% more than in 2003 (VetPop2001, 2003).

National Significance

Falls among the elderly are common, costly, dangerous, and often preventable (Murphy, 2000). Approximately one-third of all adults over 65 years of age are reported to fall each year (Hausdorff, Rios, & Edelber, 2001; Hornbrook et al., 1994). Those living in institutions fall three times that rate (1.5 falls per bed per year), with as many as 25 percent of institutional falls resulting in fracture, laceration or need for additional hospital care (Doweiko, 2000; Hoskin, 1998; Rubenstein, Josephson, and Robbins, 1994; Rubenstein, Powers, & Maclean, 2001). Direct care costs of fall injuries for those age 65 and older is expected to reach $32.4 billion by the year 2020 (Englander, Hodson, & Terregrossa, 1996). Consequences of falls are devastating and include mild to severe injury, increased morbidity and mortality, loss of independence, fear, decreased activity, additional treatment expenses, and decreased quality of life (Brown, 1999; Clark, Lord, & Webster, 1993; Donald, & Bulpitt, 1999; Nevitt, 1997; Robbins, et al., 1989; Rubenstein, et al., 1994).

Many falls can be prevented through appropriately targeted assessment and interventions (Cumming, et al., 1999; Province, et al., 1995; Tinetti, et al., 1994). Evidence supports the implementation of multifactorial interventions, based on comprehensive fall risk assessment to reduce falls in community dwelling elderly and long term care populations (Tinetti, et al., 1994; Tinetti, McAvay, and Claus, 1996; American Geriatric Society (AGS) Guidelines, 2001).

Methods

Five Veterans Administration Fall Clinics throughout Florida and Puerto Rico participated in this project. Only data from patients who consented to participate in this clinical project are included in this report. The study was approved by the local Institutional Review Board and all patients that signed the informed consent were included in this project. Fall Clinical Teams provided an interdisciplinary, specialized, and individualized careplan for veterans' at-risk for falls and fall-related injuries. These teams consisted of a physician, nurse practitioner, clinical pharmacist and a rehabilitation therapist (physical or kinesio therapist) (Hart-Hughes, Quigley, Bulat, Palacios & Scott, in press).

Referral Source--Program Access

Primary Care Providers were the primary referral source, as they commonly treat veterans with fall risk factors (history of falls, gait and balance disorders, and concerns about falling). Other major referral sources included Neurology, Diabetes Clinic and Physical Medicine and Rehabilitation Services. Referral criteria were standardized throughout all sites to target those individuals who were most likely to benefit from this service. Inclusion criteria included the ability to undergo and cooperate with a comprehensive examination and current issues of impaired gait, polypharmacy or multiple medical problems which would benefit from a interdisciplinary fall team treatment approach.

Fall Clinical Team Evaluation Process

The Fall Clinic Team evaluation process includes assessment, diagnosis, treatment planning and information dissemination. First, Fall Team Clinicians assessed patients for severity of fall risk, determined the etiology of their falls, and generated individualized fall-risk reduction plans of care. The comprehensive assessment lasted two hours. During this time the clinical team completed medical, pharmacological, environmental and standardized functional performancemeasures commonly used in clinical practice. Specific tests performed are listed in Table 1.

Medical information was obtained from patient/family interview and was substantiated by chart review. Fall history in the prior three months was obtained by patient report and validated by the caregiver or significant whenever possible. Unfortunately, for the majority of our subjects, detailed fall incidence in the three months prior to their clinic visit was not recorded in the medical record, requiring us to rely on recall. For the purposes of our study, a fall was defined as "a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of body to the floor or ground and/or hitting another object like a chair or stair" (Clinical Practice Guidelines, 1996, p. 4). Assessment results were compiled during a brief team conference and a treatment plan was established and communicated both verbally and written to the patient, his family and his primary care provider.

Typical fall-risk reduction treatment plans consisted of a combination of direct patient interventions implemented by the team, and recommended treatment interventions suggested to the patient's primary care provider (Hart-Hughes et al., in press). Direct clinic interventions included the issuing of various types of prosthetic equipment, the generation of consults to various other specialty services (ie-neurology), the issuing of an individualized home exercise program and the ordering of various diagnostic tests (DEXA, blood tests, X-Rays).

Conversely, medical management recommendations to the primary care provider generally focused on medication adjustment. Additionally, the team assessment functioned as a "gateway" to a variety of other fall clinic intervention programs that consisted of various rehabilitative therapy services, which were generally site-specific based on resource availability. Ongoing intervention programs at various sites include group balance classes (Tai Chi, Functional Balance Class), individualized therapy (physical and occupational) and complex gait and balance biomechanical assessments for those patients whose underlying motor control problem cannot be adequately assessed by observational gait analysis and clinically based balance tests.

Data Collection

Data collection points included initial clinic visit and three months post visit via telephone. On three month phone call follow-up, patients self-reported occurrence of any falls or nears falls since their initial clinic visit, current functional status, progress with treatment recommendations and their satisfaction with the Falls Clinical Team. Seventy-three percent of subjects were contacted for follow-up. The remaining 27% were either unavailable/unreachable, relocated or deceased.

Results

Patient Demographics

During the 15 months of data collection, a total of 697 patients were enrolled in these five sites. The total number of patients seen in each facility varied according to available resources and ranged from 40 to 274. The following results reflect data from all consented patients (571 patients). The average age of consented patients was 73.5 years with a range from 31 to 100 years. The sample was primarily male (90.7%). Seventy-three percent of subjects were Caucasian and 61% were married.

Reason for Referral

Reason for patient referral (see Table 2) was extracted from the information provided by the referring physician. Although the provider could identify multiple reasons for referral, we examined up to three. The most prevalent reasons were identified as a history of falling (54%), followed by gait and balance deficits (44%) and multiple medical issues (30%).

Although the most prevalent reason for clinic referral was either a history of falling or gait/balance problems, over half of the patients (58.7%) reported no previous evaluation or treatment by rehabilitation services. Seventy-four percent of the patient reported the use of assistive devices. The most common assistive devices were canes (30%), walkers with wheels (19%), or wheelchairs (11 6%).

Clinical Diagnoses

The primary etiology related to each patient's falls were recorded (see Table 3), based on the Uniform Data System for Medical Rehabilitation Impairment Codes (UD[S.sub.MR]) (UD[S.sub.MR], 1996). Approximately half of the consented patients were categorized into three UDS impairment groups: neurologic (21%), debility (14%), and medically complex (14%).

Functional Evaluation Tests

The 8-Foot Up-and-Go Test (Rikli, & Jones, 2001; Rose, et al., 2002) and the Modified Clinical Test of Sensory Integration and Balance (mCTSIB) (Shumway-Cook & Horak, 1986) were key elements of the teams' basic assessment of functional performance. A mean score of 16 seconds (range 0-153 seconds) was calculated on the 8-Foot Up-and-Go Test. Recent research has shown that a score >8.5 seconds on this test indicates an elevated fall risk in community dwelling elderly (Rose, et al., 2002). Our mean score of 16 seconds would therefore indicate increased fall risk in our population. The mean mCTSIB score was 85 (range 5-120), suggesting that many patients had substantial difficulties with functional integration of visual, somatosensory and vestibular inputs with respect to balance mechanisms.

Falls Team Treatment Plan

Table 4 refers to the Falls Team treatment plan. The most common treatment recommended was medication modifications (50%). Ordering and distributing appropriate medical equipment (i.e. grab bars, walkers etc.) was the next second highest (45%) treatment intervention.

Fall Rates

A statistically significant reduction in the number of tails was reported by patients on three-month follow-up when compared to pre-intervention values, t(252)= -7.475, p<0.0001. Of the patients that reported a fall, the average number of falls was 1.1 (S.D.=2.757) during the three-months following their initial visit compared with a mean 3.2 falls three months prior to their initial visit (S.D.=3.984) (Table 5). Fifty-four percent of consented patients referred to the Falls Clinics had a sell-reported history of multiple falls in the three months prior to their initial visit. This is a marked contrast to 23% of the patient reporting multiple falls subsequent to their visit.

Furthermore, only 19% of patients reported having no falls within three months prior to their Falls Clinic visit, compared to the 64% that reported no falls in the three months following their visit. This was a three-fold reduction in the average number of falls when compared to pre-clinic values. Of those that reported a fall, only 29% (n = 33) sought medical attention for their fall. Forty-one percent of the fellers (n=47) did report their fall to their Primary Care Provider, as instructed by the Falls Clinic Teams.

Discussion

These findings concur with previous research suggesting the efficacy of multifactorial, individualized intervention programs to reduce falls among community dwelling elderly (Tinetti, et al., 1994; Tinetti, et al., 1996; AGS guideline, 2001). A three-fold reduction in falls was found in our high-risk subjects at three-month follow-up. This finding is encouraging because over half (54%) of the patients were identified as repeat fallers on initial evaluation.

While the two most prevalent reasons for clinic referral was either a history of falling or gait and balance problems, over 50% of the patient seen in clinic were not previously or currently enrolled in any form of rehabilitation. This statistic suggests underutilization of rehabilitation services by this high-risk population. It is unclear if this underutilization resulted from a lack of referral or inability to access rehabilitation services.

The use of various assistive devices is another point of interest in our data results. While a large pro portion of our subjects already used an assistive device to mobilize prior to their initial clinic visit; they continued to fall with 70.3% reporting 1 or more falls in the three months prior to their appointment. This finding reinforces the need for interdisciplinary team involvement in the management of patients at risk for falls. Isolated treatment of our subjects prior to their initial clinic visit by the issuing of an assistive device appeared to have had only limited success in preventing falls. Additionally, the second most common clinic intervention was the prescription of prosthetic devices. Those patients who needed an assistive device but did not have one were provided with one and those who presented with an inappropriate assistive device were provided with the correct one. Considering this data, the appropriateness of the assistive devices used by patients prior to their clinic visit comes into question. This finding may also identify the fact that while providers are sensitive to the need for the use of a walking aid in a patient with balance deficits, they may overlook the need for various other prosthetic devices (i.e.-grab bars, shower chairs) to optimize safety.

Implications for Rehabilitation

With the aging of our population, issues related to falls and fall-related injury will continue to grow. Rehabilitation providers have a strong background in dealing with mobility deficits and patients with multiple functional limitations. This experience places rehabilitation clinicians in an optimal position to address and successfully treat patients at risk for falls. However, rehabilitation clinicians must educate themselves on fall risk factors and evidence-based interventions that reduce risks for falls and fall-related injury. Armed with this knowledge, rehabilitation providers must begin to incorporate fall prevention principles into all aspects of patient care. Basic questioning regarding falls and simple testing procedures need to be incorporated into routine standards of care across the continuum of care.

Conclusion/Future Directions

Organizations can redesign existing care to increase patients' access to basic fall prevention strategies and resources. A specialized Fall Team that conducts an evidence-based assessment from which an individualized, multifactorial treatment plan is derived can decrease fall rates in a high-risk outpatient population. This discussion summarizes data that spans 5 Fall Clinics in one geographic area.

While great strides have been made towards the understanding of the complex nature of falls and the identification of fall risk; research in several associated areas remain in its infancy. Details regarding intensity, duration, dosage and type of exercise to address falls in various specific, high-risk populations and among different diagnostic groups remain unclear. Further details regarding variations in postural control and gait in different impairment groups need to be clarified to facilitate the development of effective treatment interventions. Technological solutions and administrative controls to prevent falls and fall-related injuries require further study to optimize safety in inherently high-risk patients. Cost effectiveness of an interdisciplinary Fall Team approach also warrants further investigation as while effective, this service does require substantial rehabilitative resources. Lastly, biomechanical and epidemiological analysis of fall-related injury also requires further investigation to assist in diminishing the functional decline related to this adverse event.

Falls remain a complex and widespread problem. While further research is required to shed light on unexplored aspects of this issue, providers need to be sensitized to basic treatment options and primary prevention strategies. Identification of this issue, prioritization of this problem and incorporation of appropriate treatment into routine care is encouraged to all rehabilitation providers. If assessment by an interdisciplinary team is not available; coordinated use of available resources is recommended to optimize patient safety in attempt to prevent functional decline and loss of autonomy.

Table 1
Examination Components

    Domain                            Description

Physiological:   Vital signs (including orthostatic BP)
                 Physical exam with emphasis on neurological testing
                   (cranial nerves, motor, sensory, reflexes, tone,
                   cerebellar signs)
                 Visual screen (acuity, depth perception)
                 Brief pain assessment

Fall History     Fall history (S.P.L.A.T.T.) (a)

Medications:     Medication review (including adherence)

Psychosocial     Folstein Mini Mental Status Evaluation (b)
                 Geriatric Depression Scale (short form) (c)
                 Social, medical and family history

Functional:      Basic range of motion (ROM) and strength screening
                 Functional Strength Measures: grip, chair stand, arm
                   curl test (d)
                 Modified Clinical Test of Sensory Integration and
                   Balance (e)
                 Multi-Directional Reach Test (f)
                 8-Foot Up-and-Go Test (d,g)
                 Gait Speed (h)
                 Observational gait analysis with assessment of
                   current assistive device use.

Environmental:   Home safety assessment/checklist

(a) Tideiksaar, 1993.

(b) Folstein, Folstein, & McHugh, 1975.

(c) Yesavage, Brink, & Rose, 1983.

(d) Rikli, & Jones, 2001.

(e) Shumway-Cook, & Horak, 1986.

(f) Newton, 2001.

(g) Rose, Jones, & Lucchese, 2002.

(h) Guralnik, et al., 1994

Table 2
Reason for Referrals

                              n       %

History of Falling           309   54.12
Gait/Balance Deficits        252   44.13
Multiple Medical Diagnoses   171   29.95
High Risk of Fallsa          109   19.09
Medication Evaluation         59   10.33
Other                         39    6.83
Unknown                        2    0.35

Note. Percentages do not add to 100%. Percentages are based
on unique patients not number of reasons for referrals

(a) Based on provider judgment

Table 3
Uniform Data System Impairment Groups-(UDS-1996)

                           n      %

Neurological Conditions   117   20.5
Debility                   77   13.5
Medically Complex          77   13.5
Arthritis                  54    9.5
Stroke                     51    8.9
Cardiac                    45    7.9
Pain Syndromes             42    7.4
Other                      84   14.8
Unknown                    24    4.2

Table 4
Fall Clinic Treatment Plan

                                       n       %

Medication Modification               287   50.3
Prosthetics/SPD                       255   44.7
Home Exercise                         144   25.2
Comprehensive Falls Clinic Referral   138   24.2
Rehabilitative Services Referral      136   23.8
Specialty Clinics Referral            102   17.9
Other (a)                              71   12.4
Home Evaluation                        58   10.2
Primary Care Clinic (PCC)              52    9.1
Hip Protectors                         47    8.2 (b)
Exercise/Education Classes             43    7.5
None                                   10    1.8

Note. Percentages do not add to 100%. Percentages
are based on unique patients not number of reasons
for referrals.

(a) Other category includes Neurology, X-Rays,
Pulmonary Function Tests, etc.

(b) It is hypothesized that this number is low due to
distribution and access issues. Hip protectors became
an available VA benefit at different time points at
each site.

Author's Note

The research reported/outlined here was supported by the Department of Veterans Affairs, Headquarters of Veterans Health Administration (NPI-20-006-1). Dr. Patricia Quigley (Project Director) is the Deputy Director of the Patient Safety Center of Inquiry at the James A Haley Veteran's Affairs Medical Center in Tampa, Florida. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.

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Stephanie Hart-Hughes

Veterans Integrated Service Network

Patricia Quigley

Veterans Integrated Service Network

Tatjana Bulat

Veterans Integrated Service Network

Polly Palacios

Veterans Integrated Service Network

Steven Scott

Veterans Integrated Service Network

Stephanie Hart-Hughes, Veterans Integrated Service Network, James A. Haley Veterans' Hospital, Physical Medicine and Rehabilitation Service, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612