Balance, Postural Control, and Falls in Older AdultsPage 5 of 11

3. Healthcare Providers: Differing Approaches to Falls

How healthcare providers approach the problem of falls and fall risk in older adults can be profoundly profession-centric, largely because training, education, and research focus differs from profession to profession. Compounding this problem—and despite the existence of ample evidence that falls can be reduced or even prevented—assessing fall risk in high-risk patients is often ignored by clinicians of all stripes.

Several studies by Mary Tinetti and her colleagues at the Connecticut Collaboration for Fall Prevention (CCFP) have attempted to discern why medical professionals are reluctant to incorporate fall prevention into their practices. Among the reasons given:

  • Ignorance of falling as a preventable condition
  • Competing time demands
  • Perceived lack of expertise
  • Insufficient reimbursement
  • Inadequate referral patterns among clinicians (Tinetti et al., 2008)

A 2008 study by the CCFP attempted to address this issue by encouraging clinicians involved in home care, outpatient rehabilitation, and senior centers to adopt fall risk assessments and develop strategies to reduce falls among their clients. Participating clinicians and facilities were asked to incorporate evidence from the Yale-based study, “Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT),” and other trials into their practices (Tinetti et al., 2008).

The study assessed the rates of (1) fall-related injuries, and (2) fall-related medical services among older adults in an intervention group and a usual-care group. Participating clinicians (physical and occupational therapists, emergency department physicians and nurse managers, and primary and home care providers) were given fall-related training and offered educational materials to share with their patients.

Recommended fall prevention strategies included: a reduction in medications; management of postural hypotension; management of visual and foot problems; hazard reduction; and balance, gait, and strength training. Clinicians were encouraged to incorporate assessments, treatments, and referrals into their practice as appropriate to their discipline and setting. Following these interventions, a 9% decrease in fall-related injuries and an 11% decrease in fall-related use of medical services were noted in the intervention group (Tinetti et al., 2008).

A significant number of study participants said they have adopted fall prevention practices. Among primary care clinicians, 50% reported referring patients for balance disturbances, and 88% reported performing medication reviews. Among home care clinicians, more than 80% reported addressing postural hypotension, balance disturbances, multiple medications, and home hazards for at least some patients. Similar rates for adopting balance and gait treatments were reported by outpatient rehabilitation (Tinetti et al., 2008).

Mary Tinetti Video (2 min, 29 sec)

Video: Geriatric Physician Mary Tinetti: 2009 MacArthur Fellow (2 min, 29 sec). http://www.youtube.com/watch?v=13LCLKpSKqY

A Washington State Department of Health telephone survey assessed current knowledge of, attitude toward, and provision of best practices for preventing falls among older adults. Fifty healthcare workers, including physicians, nurses, therapists, and nursing assistants, were asked how much they know about fall prevention practices. They were also asked about the importance of providing fall prevention services (or referring a patient to another clinic that provides fall preventions services) and whether they have an understanding of the barriers or the main reasons for not providing fall prevention services (Laing, 2011).

Not surprisingly, a majority of respondents identified falls to be an urgent or very urgent issue facing older adults. When asked about the perceived importance of and regular use of the following six fall-prevention services, two-thirds rated the prevention practices listed below as “very important”:

  • Individual fall-risk assessments
  • Strength and balance training programs
  • Home safety assessments
  • Medication review and management
  • Assistive device training
  • Fall prevention education

When asked about their own level of knowledge, a little more than one-third (38%) felt “very knowledgeable” about recommended fall prevention practices, and 58% perceived themselves to be “somewhat knowledgeable.” More than one-third (38%) of respondents said strength and balance training and fall prevention education were the services used most often regularly. When asked about available resources, survey participants felt that insufficient resources and funds were the main barriers to regular provision of fall prevention services (Laing, 2011).

Although nearly 60% of respondents rated themselves as somewhat or very knowledgeable about fall prevention practices they identified a lack of trained personnel as a barrier to the regular provision of a fall prevention services. They also identified low organizational priority and low awareness of the importance of fall prevention (Laing, 2011).

Source: Laing, 2011.

Attitudes and Provision of Fall Prevention Services Among Community-Based, Senior-Serving Organizations, n=50

Fall prevention practice

Practice perceived as very important (%)

Provision of service on a regular basis (%)

Provision of service sometimes (%)

Referral to outside organization to provide service (%)

Individual risk assessment

74

16

36

26

Strength, balance training

94

38

28

24

Home safety assessment

76

14

34

40

Medication review and management

84

10

22

44

Assistive device training

68

8

25

42

Fall prevention education

74

38

30

20

Fall Prevention: Nurses

Among all healthcare professionals, nurses are perhaps most responsible for the overall safety of the patient. Nurses provide advice, education, screening, and coordinated medical referrals to the primary care physician, geriatrician, optometrist, physical therapist, occupational therapist, and other professionals. Nurses’ ability to identify fall risk and either address the problem or make a referral to another healthcare professional is critical to the success of a falls prevention program.

As part of their regular duties, nurses are responsible for assessing the environment for extrinsic risk factors, screening patients for fall risk, providing staff with instructions regarding what to do if a patient falls, identifying patients who need additional safety precautions or referral to a specialist, and developing a interdisciplinary plan of care to prevent falls (HIGN, 2012).

A recent Norwegian study looked at the nursing staff’s opinions of caring for older persons with dementia with the focus on causes of falls, fall-prevention interventions, and routines of documentation and reports. The study also looked at the nursing staff’s experiences and reactions when falls occur, and compared opinions of registered nurses and enrolled nurses (similar to licensed practical nurses) and staff with less than 5 and more than 5 years of employment in care units (Struksnes et al., 2011).

Causes of falls are, according to the study participants, most often related to the individual’s condition. Four causes were cited as the most important factors associated with falls:

  • Forgetfulness related to physical impairment
  • Impaired mobility
  • Anxiety
  • Inability to call for help (Struksnes et al., 2011)

The participants felt that impaired short-term memory and dementia often causes residents to forget their physical impairments, and falls can occur when they are getting up from the bed or a chair. Those who can get up from a chair, but cannot stand upright or sit down unaided, are particularly exposed to fall-risk (Struksnes et al., 2011).

Anxiety was reported “often” to cause falls by the respondents. These results are in line with other studies showing that anxiety and confusion are symptoms that can precede falls. The respondents felt that the disturbing behavior of another resident “sometimes” precipitated falls among residents with dementia. Although many studies have found that residents who wander are at high risk of falling, the nursing staff in this study did not report wanderers as a risk group for falling (Struksnes et al., 2011).

Environmental factors were not reported as a frequent cause of falls by the respondents. By comparison, some studies have suggested that external physical factors cause about 8% of falls in residential care facilities, while others have found that 14.5% of falls are associated with environmental factors. The respondents in the Norwegian study did not emphasize this issue, perhaps because the facilities in the nursing homes studied are well designed for persons with dementia (Struksnes et al., 2011).

Staffing and the number of experienced nurses on duty were also associated with a decrease in falls in U.S. healthcare facilities. A review of data by researchers at the National Database of Nursing Quality Indicators (NDNQI) looked at the effect of nursing experience and staffing on fall rates at more than 1400 healthcare organizations in the United States. The data indicate that for every increase of one year in average RN experience, the fall rate was lowered by 1%. A higher percentage of experienced RNs was also associated with lower fall rates (Hill, 2010).

Fall Prevention: Rehabilitation Therapists

Rehabilitation therapists—physical and occupational therapists—are trained to identify and assess fall risk, design programs to reduce the risk of future falls, recommend assistive devices, design exercise programs, and complete home evaluations to reduce hazards in the home. Physical therapists (PTs) in particular are educated to complete comprehensive balance assessments and establish fall prevention strategies in older adults who are at risk for falls.

A discrepancy exists, however, between what PTs view as their professional responsibility and how they practice. While they believe it is their professional responsibility to routinely review medications, screen for vision deficits, and complete home safety evaluations, PTs may not be routinely doing this in practice (Monson, 2011).

A survey of 362 physical therapists practicing in Kansas looked at attitudes and beliefs about fall prevention strategies in older adults and whether the respondents regularly include certain strategies in their practice. The study found that more than 90% of respondents feel that falls are a significant public health problem and that screening for fall risk should be a routine part of a physical therapy evaluation in older adults (Monson, 2011).

The vast majority (>90%) also indicated they feel it is their professional responsibility to ask older adult patients about medications, vision deficits, exercise habits, strength and balance, and home safety. When asked about current practice habits however, although about 90% said they routinely ask about history of falls, exercise habits, and strength and balance exercises, only 35% frequently reviewed medications for fall prevention, only 22% routinely asked about vision screenings, and only about half routinely recommended a home safety evaluation (Monson, 2011).

In a Connecticut Collaboration for Fall Prevention survey of 94 physical therapists that had been exposed to a fall prevention program, researchers asked participants if exposure to the program had changed practice behavior with respect to fall prevention practices. The participants were asked to name as many preventable risk factors for falls in older adults as they could think of and as many interventions or treatments that might help prevent falls in their older patients. Environmental hazards, gait and balance impairment, and multiple medications were the most commonly cited fall risk factors. Only 11% were able to name an intervention for sensory-perceptual deficits even though many studies have shown them to be key contributors to falls.

Source: Brown et al., 2005.

Knowledge of Risk Factors and Interventions for Falls

Risk factor

Named a risk factor

Named an intervention to address the risk factor

Environmental hazards

86%

71%

Gait or balance impairments

78%

96%

Multiple medications

77%

48%

Sensory and perceptual deficits

57%

11%

Foot and footwear problems

47%

37%

Postural hypotension

30%

15%

A one-year followup survey by CCFP found that more than two-thirds of the physical therapy providers reported using fall reduction strategies increasingly in their older patients. More than half of the study participants had adopted strategies for reduction of fall risk factors that they had not used in the past. These strategies included an increase in the use of referrals to other healthcare providers, increased use of exercise, and increased education of patients about their fall risk factors (Brown et al., 2005).

Fall Prevention: Physicians

Physicians are responsible for managing a patient’s care, identifying patients who are at increased risk of falling, and referring the patient to a physical or occupational therapist or other balance specialist for treatment. They are generally not involved in designing or implementing exercise programs or completing home assessments.

Primary Care

In a study using a structured interview of 18 primary care physicians (PCP) by the Connecticut Collaboration for Fall Prevention (CCFP), a CCFP physician visited the PCPs and discussed risk factors for falls in older adults. The CCFP physician suggested treatment strategies to reduce the risk of falls and provided the PCPs with checklists to focus their evaluation of fall risk, educational materials to use with patients, brochures, and information about billing for fall risk evaluation and treatment (Chou et al., 2006).

The goal of the study was to encourage the physicians to incorporate fall risk assessment and treatment into their office practices. During the visit, emphasis was placed on:

  • Identification of patients at risk for falls
  • Treatment of balance and gait problems
  • Assessment of postural hypotension
  • Medication review and reduction

The participating physicians reported several factors that influence their ability to incorporate routine fall risk assessment into their evaluations of their older adult clients. They described, among other factors, competing risks and priorities, the need to use clinical time to address more pressing health issues, concern about referring a patient with complex medical problems to another healthcare provider, and awareness that their training emphasizes a disease approach rather than a multifactorial approach needed to address fall risk (Chou et al., 2006).

The PCPs also cited patient factors that influence their approach to fall risk assessment, particularly patient underreporting of falls and conflicting attitudes among some patients about discontinuing medications that the patient feels is needed but the physician has identified as associated with fall risk.

The PCPs said they were concerned about referring to another healthcare provider because many of their patients lack transportation to get to other appointments. They also cited lack of reimbursement for time-consuming fall risk assessments and pointed out the need for family involvement with fall risk reduction recommendations.

Assisted Living and Residential Care

Nearly 1 million people live in an estimated 38,000 residential care or assisted living facilities in the United States and are under the direct care of a PCP. These facilities are less regulated than nursing homes and are increasingly admitting older adults with serious cognitive and physical impairments. Residents have a mean age of 85 years and an average of 4.6 chronic health conditions; 55% are diagnosed with dementia or Alzheimer’s disease and 67% take 10 or more mediations a day (Nyrop, 2010).

A survey of physicians in North Carolina (Nyrop, 2010) looked at physician attitudes about fall prevention in assisted living and residential care settings and asked physicians about four fall risk assessment and management practices:

  • Assessing residents for fall risk
  • Reviewing medications for potential side effects related to falls
  • Talking to and working with staff to reduce fall risk
  • Communication and collaboration between the physician and residential care staff regarding patients at high risk for falls

Thirty-six physicians completed the survey and estimated that, for their patients in the residential care or assisted living setting, in the past six months they had:

  • Conducted fall risk assessments of 47% of their patients
  • Reviewed medications for potential side effects related to falls for 73% of their patients
  • Talked to or worked with facility staff to reduce the fall risks for 36% of their patients at high risk for falls (Nyrop, 2010)

Physicians expressed strong support for fall risk assessments and believed they have the expertise to conduct these assessments. However, they felt that facility staff bore greater responsibility for conducting fall risk assessments than the physicians themselves (Nyrop, 2010). By contrast, the physicians believed they were best qualified to review medications that might be related to fall risk.

Attitudes About Falls Among Older Adults

Older adults themselves have conflicting attitudes about fall risk, including underreporting of falls to their healthcare providers. In the Washington State Department of Health survey mentioned above, surveyors interviewed 101 at-risk older adults, 48% of whom had fallen in the last year. Within this group, one-third said that falling was their least important health concern and most had little knowledge of proven fall prevention practices. Those who felt that fall prevention was important were more likely to participate in activities that addressed risk assessment and medication management (Laing et al., 2011).

Study participants identified “not feeling at enough risk for falling” as the primary barrier to participating in most fall prevention practices. They reported being motivated to participate actively in fall prevention practices when “something happened to increase their perception of risk,” or if they began “falling frequently;” these factors were the primary motivation for participation in three of the six fall prevention practices (medication review, home assessment, and individual risk assessment) (Laing et al., 2011).

When asked about specific fall prevention practices, awareness of best practices was generally low. A large number of participants named gait-related activities (moving slowly, wearing safe shoes, and using canes or walkers) and home safety improvement as important prevention practices. None mentioned medication management without being prompted. Those who perceived falls to be an important health concern were significantly more likely to engage in the practices about which they had awareness such as medication management and risk assessment (Laing et al., 2011).

When prompted, participants had good awareness of strength and balance training, home safety improvement, and medication management as fall prevention practices. They were least likely to have an awareness of assistive devices designed to improve balance. Fewer than 10% rated avoiding risk of fall injury to be of highest importance. Many did not consider themselves as having a high fall risk even though they understand that falls are preventable (Laing et al., 2011).

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