Strategies to prevent falls in high-risk elderly patients

From the May ACP Observer, copyright © 2003 by the American College of Physicians.

By Bonnie Darves

SAN DIEGO—Patient falls are a serious issue for both elderly patients and the physicians who treat them. Between 35% and 40% of seniors age 65 and older—even those who are generally healthy—fall at least once a year. Five percent of seniors who fall require hospitalization, and 75% of all deaths from falls occur in people 65 and over.

At an Annual Session workshop on geriatric assessment, Sharon A. Levine, MD, associate professor of medicine, geriatrics section, at Boston Medical Center, provided simple steps physicians can take to help reduce the risk of falls among elderly patients.

Dr. Levine offered strategies for assessing patients' risk factors for falls, managing patients who have a history of falls and educating patients about what they can do to reduce those risks.

"Preventing falls is an important goal in primary care," Dr. Levine said, "not just because of injuries but also because patients tend to underreport falls." Patients often don't want to acknowledge that their physical control is declining or they fear losing their independence and winding up in a nursing home.

"Patients aren't always honest about the issue," she added, "so you have to stay one step ahead of them."

While the key risk factors for falls—balance disorders, cognitive impairment, visual deficits and polypharmacy, to name a few—are generally well-known, physicians have paid relatively little attention to the interaction among those risk factors, Dr. Levine said. She noted that 78% of patients who have four or more risk factors fall, compared to 27% of patients who have either one or no risk factors.

Dr. Levine explains a simple test to identify patients who have a high risk of falling.

"In geriatrics, health issues are always multifactorial," she said. "It's important to identify risk factors to improve management."

To better manage patient falls in primary care, Dr. Levine recommended providing both home-safety questionnaires and office-based assessments. She suggested educating staff, as well as patients and family members, using brochures that offer tips to make the home safer.

Another strategy to identify patients at risk: Ask office nurses to watch patients walk from the waiting room to the exam room and document what they observe. In addition, Dr. Levine recommended a simple exercise called the "Get Up and Go" test. Ask patients to rise from a chair with their arms crossed, walk across the room and return to a seated position with their arms still crossed.

"It's sort of a pass-fail test," she said. Patients who can't manage the action without becoming unsteady or reaching out for support are at risk for falling.

Once you identify high-risk patients, you should adjust their medications when appropriate, refer them to an ophthalmologist and suggest a professional home-safety evaluation. You can also recommend sturdy shoes and encourage patients to use handrails and other devices to help avoid falls.

Finally, Dr. Levine urged physicians to review the fall prevention guidelines jointly published by the American Geriatrics Society, the British Geriatrics Society and the American Academy of Orthopedic Surgeons. (The guidelines are available online.)

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