by Dana Martin
As people age, a number of factors make them more susceptible to falls – these include certain medicines, vision problems, lower extremity weakness and environmental issues.
Falls are of such concern because they often cause injuries that lead to loss of independence and, in some cases, result in death. Older adults with cognitive impairment have an especially high risk of falls. (To learn more, see the companion story, “Tips for Reducing Fall Risk in Older Adults with Cognitive Impairment.”)
University of Washington researcher Dr. Elizabeth Phelan established and now directs Harborview Medical Center’s Fall Prevention Clinic. The clinic offers comprehensive fall risk-factor assessment and management and has been in operation for about two years.
The clinic’s goal is to bring a clinical service that is evidence-based to the general public.
Dr. Phelan felt it was particularly important for Harborview to have a focus on fall prevention because it is a major trauma center. This means Harborview takes care of many injuries that result from falls and, as a referral trauma center, patients from all over the region are seen.
“Many of those who suffer from an injurious fall never regain their independence. They go from a state of independent living, to having a hip fracture and being institutionalized, for example,” Phelan says.
A nurse practitioner sees patients in the clinic. The initial meeting includes a full assessment of all factors that can contribute to fall risk, using a one-page algorithmic protocol. A cognitive screen is performed as part of the initial assessment. For each risk factor identified, standard recommendations are provided on what to do about that risk factor.
As part of the initial assessment, each patient is asked to complete a Timed Up and Go Test. This test quantifies the degree of fall risk. In this test, the patient stands up from a chair and walks 10 feet, then turns around and sits back down. The longer it takes to perform the test, the higher the risk of falls. Any patient whose risk of falling is high is offered a referral to a physical therapist.
Vitamin D levels are checked on everyone seen in the clinic. Patients with low levels are instructed that they can take an oral vitamin D supplement. “In the past three years or so, there has been an emerging literature on the association between low levels of vitamin D and an increased risk of falls,” says Phelan. “It seems that normal levels of vitamin D are necessary for adequate muscle strength and low levels may contribute to muscle weakness.”
Clinic patients are seen again at the discretion of the nurse practitioner. At follow-up visits, the nurse practitioner assesses how well patients have adhered to her initial recommendations. Further recommendations are made at that time. The Timed Up and Go Test is repeated to provide an objective measure of whether there was any decrease in fall risk. Vitamin D levels are also followed up.
Dr. Phelan says there is a lot of research that looks at factors that are associated with falling in older adults and how to prevent those falls. “There are quite a few intervention studies now – randomized trials looking at how to intervene on risk factors to reduce a person’s risk of falls.”
But, she adds, there is very little in the way of work that translates what has been learned from these studies about fall-risk reduction into actual practice.
Dr. Phelan and her graduate research study assistant Meghann Moore are conducting a study of the Fall Prevention Clinic to determine whether those seen at the clinic have reduced fall risk. This study of the clinic’s effectiveness spanned from June through December 2005. Patients seen in the Fall Prevention Clinic during that time period were matched to patients not seen – on age, gender and race. All patients included in the study were cared for by geriatricians in the Senior Care Clinic at Harborview.
There were 43 patients seen in the Fall Prevention Clinic from June through December 2005. These 43 patients served as “cases” for study purposes and were matched to 86 “control” patients who were not seen in the Fall Prevention Clinic during that time period. These study participants had a mean age of 79 years, 70 percent were female, and about a third were non-white.
One novel aspect of the study is that it is being done in the context of the usual health care environment, as opposed to being an intervention imposed on a health care delivery system, as is often done in clinical trials. As Dr. Phelan says, “I wanted to actually have something real-world up and running and then evaluate it.”
The study is unique because, while most fall studies focus on number of falls as a main outcome, this study is looking in particular at injurious falls, meaning those that result in injury, such as hip fracture. According to Dr. Phelan, it is injurious falls that lead to loss of independence, morbidity, disability and even death.
This study is so recent that the results have not been written up as of the printing of this newsletter, but Dr. Phelan reports that the preliminary data suggest that being seen in the Fall Prevention Clinic significantly reduces the percentage of patients with injurious falls. Additional analyses of the data are still being conducted, but according to Dr. Phelan, “It looks as if the clinic is benefiting people who are being seen by reducing the chance of someone having a fall with injury.”
Highlights of this research will eventually be reported on the clinic website.
To learn more about the clinic, visit www.uwmedicine.org/PatientCare/MedicalSpecialties/SpecialtyCare/HARBORVIEW/falls/index.htm
Cognitive impairment is one factor that increases an older adult’s risk of falls. University of Washington researchers Drs. David Buchner and Eric Larson found that in a group of AD patients, 50 percent either fell or became unable to walk during a three-year period, and the fracture rate of those with AD was three to four times that of the general population.
What can be done to reduce your fall risk?