Donald DoellDonald DoellSuzanne MorinSuzanne MorinJoanne CreagerJoanne Creager

Gary InglisGary InglisDanièle BenoitDanièle Benoit

Anita TonetAnita Tonet

Montreal General HospitalMontreal General Hospital

CATCHFallersCATCHFallersCritical Assessment in a Teaching Clinic for High-risk FallersCritical Assessment in a Teaching Clinic for High-risk Fallers

http://www.CATCHFallers.comhttp://www.CATCHFallers.com

ObjectiveObjective

Implement Implement a simple decisiona simple decision Tool for residents Tool for residents

IdentifyIdentify, , AssessAssess, , InterveneIntervene in cases of individuals at in cases of individuals at Risk of fallsRisk of falls

We believe this will improve We believe this will improve Case-identificationCase-identification of patients at risk for falls, of patients at risk for falls, Medical interventionsMedical interventions for fall risk reduction and increased number of for fall risk reduction and increased number of

ReferralsReferrals to specialized services to specialized services

OverviewOverview

1. Significance of falls in the elderly1. Significance of falls in the elderly2. Identification of High-risk Fallers2. Identification of High-risk Fallers3. Assessment for patients at high-risk for falls3. Assessment for patients at high-risk for falls4. Intervention can make a difference4. Intervention can make a difference

1. Significance of falls in the elderly1. Significance of falls in the elderly

● One out of every three individuals living in the community and One out of every three individuals living in the community and over the age of 65 will fallover the age of 65 will fall

● This rate will increase with more advanced age and among This rate will increase with more advanced age and among institutionalized individualsinstitutionalized individuals

● Unintentional injuries are the fifth leading cause of death in Unintentional injuries are the fifth leading cause of death in older adults with falls accounting for two thirds of these deathsolder adults with falls accounting for two thirds of these deaths

Falls result in significant morbidity Falls result in significant morbidity and mortalityand mortality

● 6% of falls will result in a fracture6% of falls will result in a fracture● Of all fallers approximately 1% will sustain a hip fractureOf all fallers approximately 1% will sustain a hip fracture

● The incidence of mortality after one year is 20-30% for hip The incidence of mortality after one year is 20-30% for hip fracturesfractures

● 60% will be left with restricted mobility60% will be left with restricted mobility● Other falls will result in significant soft tissue injury, head Other falls will result in significant soft tissue injury, head

injury, subdural hematomainjury, subdural hematoma● Falls lead to significant fear of fallingFalls lead to significant fear of falling● Falls lead to increased incidence of nursing home placement and Falls lead to increased incidence of nursing home placement and

loss of autonomyloss of autonomy

2. Identification of High-risk Fallers2. Identification of High-risk Fallers

● History of falls is most predictiveHistory of falls is most predictive● In particular history of recurrent fallsIn particular history of recurrent falls● Functional testing is useful in stratifying those who Functional testing is useful in stratifying those who

may be at riskmay be at risk

The Timed-up-and-go (TUG)The Timed-up-and-go (TUG)>35s >35s = High risk= High risk15-35s15-35s = Indeterminate risk= Indeterminate risk<15s <15s = Low risk= Low risk

RecommendationsRecommendations

● All persons over the age of 65 should be All persons over the age of 65 should be questioned once per year about fallsquestioned once per year about falls

● Any individual with a history of recurrent falls Any individual with a history of recurrent falls should have further assessmentshould have further assessment

● If there is a history of a single fall in the last year, If there is a history of a single fall in the last year, then further functional testing (i.e. TUG) should be then further functional testing (i.e. TUG) should be used to risk stratifyused to risk stratify

Other Risk factors of Other Risk factors of Particular NoteParticular Note

● Muscle weaknessMuscle weakness● Gait deficitGait deficit● Balance deficitBalance deficit● Use of assist deviceUse of assist device● Visual deficitVisual deficit● Arthritis Arthritis ● Limitation in > 1 ADL (activity of daily living)Limitation in > 1 ADL (activity of daily living)● DepressionDepression● Polypharmacy (greater than 4 medications)Polypharmacy (greater than 4 medications)

3. Assessment for patients at 3. Assessment for patients at high-risk for fallshigh-risk for falls

● Falls are multifactorialFalls are multifactorial● Approach to assessment and treatment must also Approach to assessment and treatment must also

be multifactorialbe multifactorial

Fall history and assessmentFall history and assessment

● History of the fall circumstancesHistory of the fall circumstances● Review of medicationsReview of medications

● Number of medicationsNumber of medications● Cardiovascular medicationsCardiovascular medications● Psychotropic medications (neuroleptics, Psychotropic medications (neuroleptics,

benzodiazepines, and antidepressants)benzodiazepines, and antidepressants)● Review of acute or chronic medical problemsReview of acute or chronic medical problems● Review of mobility statusReview of mobility status

Approach to exam for fallersApproach to exam for fallers● Exam of visionExam of vision

● Exam of gait & balanceExam of gait & balance

● Exam of lower extremity joint functionExam of lower extremity joint function

● Exam of basic neurological functionExam of basic neurological function

● Mental statusMental status● Muscle strengthMuscle strength● Lower extremity peripheral nervesLower extremity peripheral nerves● ProprioceptionProprioception● ReflexesReflexes● Tests of cortical, extrapyramidal, and cerebellar functionTests of cortical, extrapyramidal, and cerebellar function

● Exam of basic cardiovascular statusExam of basic cardiovascular status

● Heart rate and rhythmHeart rate and rhythm● Postural pulse and blood pressure Postural pulse and blood pressure ● If appropriate, heart rate and blood pressure responses to carotid sinus stimulationIf appropriate, heart rate and blood pressure responses to carotid sinus stimulation

4. Intervention can make a 4. Intervention can make a differencedifference

● Multifactorial approach is most effective (can reduce falls Multifactorial approach is most effective (can reduce falls as much as 43%) and includes:as much as 43%) and includes:

● Gait training and advice on the appropriate use of Gait training and advice on the appropriate use of assistive devices assistive devices

● Review and modification of medication, especially Review and modification of medication, especially psychotropic medicationpsychotropic medication

● Exercise programs, with balance training as one of the Exercise programs, with balance training as one of the components components

● Treatment of postural hypotensionTreatment of postural hypotension● Modification of environmental hazardsModification of environmental hazards● Treatment of cardiovascular disorders, including cardiac Treatment of cardiovascular disorders, including cardiac

arrhythmiasarrhythmias

Single most important Single most important interventionsinterventions

● Exercise – Most effective strategy (fall reduction 19%)Exercise – Most effective strategy (fall reduction 19%)● Environmental ModificationEnvironmental Modification● Medication review, reduction and modification for Medication review, reduction and modification for

psychotropic medicationspsychotropic medications

SummarySummary

The CATCHFallers Concept AgainThe CATCHFallers Concept Again

Implement Implement a simple decisiona simple decision ToolTool for residents for residents

IdentifyIdentify, , AssessAssess, , InterveneIntervene in cases of individuals at in cases of individuals at Risk of fallsRisk of falls

We believe this will improve We believe this will improve Case-identificationCase-identification of patients at risk for falls, of patients at risk for falls, Medical interventionsMedical interventions for fall risk reduction and increased number of for fall risk reduction and increased number of

ReferralsReferrals to specialized services to specialized services

About the toolAbout the tool

An online survey for residents to complete that will guide An online survey for residents to complete that will guide them through the proper assessment for high-risk fallersthem through the proper assessment for high-risk fallers

http://www.CATCHFallers.comhttp://www.CATCHFallers.com

The pre-study surveyThe pre-study survey

CATCHFallers - Pre Study QuestionsCATCHFallers - Pre Study QuestionsCritical Assessment in a Teaching Clinic for High-risk Fallers - ACritical Assessment in a Teaching Clinic for High-risk Fallers - A

pre-study survey for residentspre-study survey for residents

Pre-study questionsPre-study questions1 Approximately how many patients over the age of 75 have you specifically asked for a1 Approximately how many patients over the age of 75 have you specifically asked for a

history of falls in the last three months?history of falls in the last three months?Please write your answer here:Please write your answer here:

________________________________________

2 Approximately how many patients have you treated or investigated for an underlying2 Approximately how many patients have you treated or investigated for an underlyingmedical condition because of a possibly increased risk for falls in the last threemedical condition because of a possibly increased risk for falls in the last three

months?months?Please write your answer here:Please write your answer here:

________________________________________

3 Approximately for how many patients have you changed or reduced the number of their3 Approximately for how many patients have you changed or reduced the number of theirmedications because of a possibly increased risk for falls in the last three months?medications because of a possibly increased risk for falls in the last three months?

Please write your answer here:Please write your answer here:________________________________________

4 How many patients have you referred for outpatient specialized or mulitdisciplanary4 How many patients have you referred for outpatient specialized or mulitdisciplanaryassessment because of risk of falls (i.e. physiotherapy, CLSC services, occupationalassessment because of risk of falls (i.e. physiotherapy, CLSC services, occupational

therapy, geriatric consultation) in the last three months?therapy, geriatric consultation) in the last three months?Please write your answer here:Please write your answer here:

________________________________________

5 Approximately how many patients would you have liked to refer for outpatient services5 Approximately how many patients would you have liked to refer for outpatient servicesbut were were unable to because you were not aware how to or if these services werebut were were unable to because you were not aware how to or if these services were

available in the last three months?available in the last three months?Please write your answer here:Please write your answer here:

________________________________________

The CATCHFallers surveyThe CATCHFallers surveyPart I - Part I - Evaluation of riskEvaluation of risk

Evaluation of riskEvaluation of risk

Age What is the patient's age?Age What is the patient's age?About one out of every three individuals living in the community and over the age of 65 will fall. This rateAbout one out of every three individuals living in the community and over the age of 65 will fall. This rate

will increase with more advanced age.will increase with more advanced age.Plese write your answer here:Plese write your answer here:

________________________________________

Fall historyFall historyIs there a history of a fall in the past year?Is there a history of a fall in the past year?

All older persons should be asked at least once a year about falls. All older persons who report a single fallAll older persons should be asked at least once a year about falls. All older persons who report a single fallshould have a TUG.should have a TUG.

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

Multiple falls Multiple falls Is there a history of recurrent falls in the past year?Is there a history of recurrent falls in the past year?

Older persons who present for medical attention because of a fall or report recurrent falls in the past yearOlder persons who present for medical attention because of a fall or report recurrent falls in the past yearshould have a fall evaluation performed.should have a fall evaluation performed.

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

TUG TUG How long did it take the patient to perform a TUG (timed-up-and-go)?How long did it take the patient to perform a TUG (timed-up-and-go)?

The time it takes for an individiual to stand up from a chair, walk to a line 3 meters away on the floor usingThe time it takes for an individiual to stand up from a chair, walk to a line 3 meters away on the floor usingusual aids at a usual pace, turn around and walk back to the chair and sit down.usual aids at a usual pace, turn around and walk back to the chair and sit down.

TUG < 15s = low riskTUG < 15s = low riskTUG 15s-35s = indeterminate riskTUG 15s-35s = indeterminate risk

TUG > 35s = high riskTUG > 35s = high riskPlease write your answer here:Please write your answer here:

________________________________________

RiskRiskDo you think this patient might be at risk for falls?Do you think this patient might be at risk for falls?

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

The CATCHFallers surveyThe CATCHFallers surveyPart II - Part II - Evaluation of modifiable risk factorsEvaluation of modifiable risk factors

Evaluation of modifiable risk factorsEvaluation of modifiable risk factors

Number of meds Number of meds How many medications does this patient take?How many medications does this patient take?

Increased risk of falls has been demonstrated with greater than four medications.Increased risk of falls has been demonstrated with greater than four medications.Please write your answer here:Please write your answer here:

________________________________________

Barthel Barthel What is the Patient's Barthel Score?What is the Patient's Barthel Score?

link to an online calculator here: www.patient.co.uk/showdoc/40001654/link to an online calculator here: www.patient.co.uk/showdoc/40001654/Please write your answer here:Please write your answer here:

________________________________________

History findingsHistory findingsHave you identified a predisposing risk factor for falls in your history?Have you identified a predisposing risk factor for falls in your history?

Should include a history of fall circumstances, acute or chronic medical problems, and mobility levels. PayShould include a history of fall circumstances, acute or chronic medical problems, and mobility levels. Payparticular attention to muscle weakness, gait deficit, balance deficit, use of an assistive device, visualparticular attention to muscle weakness, gait deficit, balance deficit, use of an assistive device, visual

deficit, arthritis, depression, cognitive impairment, cardiovascular causes as risk factors.deficit, arthritis, depression, cognitive impairment, cardiovascular causes as risk factors.Please choose *only one* of the following:Please choose *only one* of the following:

o Yeso Yeso Noo No

Exam findingsExam findingsHave you identified a predisposing risk factor for falls in your exam?Have you identified a predisposing risk factor for falls in your exam?

Should include examination of vision, gait and balance, and lower extremity joint function; an examination ofShould include examination of vision, gait and balance, and lower extremity joint function; an examination ofbasic neurological function, including mental status, muscle strength, lower extremity peripheral nerves,basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves,

proprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function; and assessment of basicproprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function; and assessment of basiccardiovascular status including heart rate and rhythm, postural pulse and blood pressure.cardiovascular status including heart rate and rhythm, postural pulse and blood pressure.

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

MedicationMedicationHave you identified a predisposing risk factor in this patient's medications?Have you identified a predisposing risk factor in this patient's medications?

Pay particular attention to any psychotropic medication (neuroleptics, benzodiazepines, and antidepressants)Pay particular attention to any psychotropic medication (neuroleptics, benzodiazepines, and antidepressants)Please choose *only one* of the following:Please choose *only one* of the following:

o Yeso Yeso Noo No

The CATCHFallers surveyThe CATCHFallers surveyPart III - Part III - Documentation of Documentation of

InterventionInterventionDocumentation of InterventionDocumentation of Intervention

Medication changeMedication changeI have changed or modified this patient's medications, because of risk of falls.I have changed or modified this patient's medications, because of risk of falls.

Reduction in total number of medications if greater than four, or modification of medications especiallyReduction in total number of medications if greater than four, or modification of medications especiallypsychotropic medications.psychotropic medications.

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

Medical conditionMedical conditionI will investigate or treat an underlying medical condition that may be implicated inI will investigate or treat an underlying medical condition that may be implicated in

this patient's risk for falls.this patient's risk for falls.Pay particular attention to cardiovascular intervention, treatment and investigation of postural hypotensionPay particular attention to cardiovascular intervention, treatment and investigation of postural hypotension

and visual impairment.and visual impairment.Please choose *only one* of the following:Please choose *only one* of the following:

o Yeso Yeso Noo No

OutpatientOutpatientI have referred this patient for outpatient multidisciplinary assessment.I have referred this patient for outpatient multidisciplinary assessment.

Exercise programs areExercise programs areextremely effective in preventing falls and may be one of the singleextremely effective in preventing falls and may be one of the single

most effective preventative strategies, particularly when combined asmost effective preventative strategies, particularly when combined aspart of a multifactorial intervention.part of a multifactorial intervention.

Please choose *only one* of the following:Please choose *only one* of the following:o Yeso Yeso Noo No

Bottom LineBottom Line

● Exercise – Single most effective strategyExercise – Single most effective strategy● Environmental ModificationEnvironmental Modification● Medication review, reduction and modification for Medication review, reduction and modification for

psychotropic medicationspsychotropic medications

Bottom LineBottom LineIn the universe some things are constantIn the universe some things are constant

The elderly will continue to fallThe elderly will continue to fall

Falls can be prevented Falls can be prevented

Gravitational constant = 6.67300 × 10Gravitational constant = 6.67300 × 10-11-11 m m33 kg kg-1-1 s s-2-2

Bottom LineBottom Line

● Exercise – Single most effective strategyExercise – Single most effective strategy● Environmental ModificationEnvironmental Modification● Medication review, reduction and modification for Medication review, reduction and modification for

psychotropic medicationspsychotropic medications

ReferencesReferences● Laurence Z Rubenstein and Karen R Josephson Falls and their prevention in elderly people: Laurence Z Rubenstein and Karen R Josephson Falls and their prevention in elderly people:

what does the evidence show? 2006what does the evidence show? 2006

● Guideline for the prevention of falls in older persons. American Geriatrics Society, British Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. 20012001

● Kerri M Clough-Gorr and Thomas Erpen and Gerhard Gillmann and Wolfgang von Renteln-Kerri M Clough-Gorr and Thomas Erpen and Gerhard Gillmann and Wolfgang von Renteln-Kruse and Steve Iliffe and John C Beck and Andreas E Stuck Preclinical disability as a risk Kruse and Steve Iliffe and John C Beck and Andreas E Stuck Preclinical disability as a risk factor for falls in community-dwelling older adults. 2008factor for falls in community-dwelling older adults. 2008

● Ellinor Nordin and Nina Lindelöf and Erik Rosendahl and Jane Jensen and Lillemor Lundin-Ellinor Nordin and Nina Lindelöf and Erik Rosendahl and Jane Jensen and Lillemor Lundin-Olsson Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's Olsson Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's global judgement and fall history in evaluating fall risk in residential care facilities. 2008global judgement and fall history in evaluating fall risk in residential care facilities. 2008

● Anne Tiedemann and Hiroyuki Shimada and Catherine Sherrington and Susan Murray and Anne Tiedemann and Hiroyuki Shimada and Catherine Sherrington and Susan Murray and Stephen Lord The comparative ability of eight functional mobility tests for predicting falls in Stephen Lord The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. 2008community-dwelling older people. 2008

● Cameron G Swift The role of medical assessment and intervention in the prevention of falls. Cameron G Swift The role of medical assessment and intervention in the prevention of falls. 20062006

● Theodore Speroff and Gerald T O'Connor Study designs for PDSA quality improvement Theodore Speroff and Gerald T O'Connor Study designs for PDSA quality improvement research. 2004research. 2004

● www.aafp.org/afp//AFPprinter/20000401/2159_f1.jpg

● 1to3.livedoor.biz/archives/50358915.html1to3.livedoor.biz/archives/50358915.html