Development of a Clinic for the Assessment of Risk of Falls in Elderly Patients

ABSTRACT

Unintentional injury, which almost always results from a fall, ranks as the sixth leading cause of death in the elderly population. Besides mortality, there is significant morbidity associated with falls. In the United States, 20% of older people who sustain a hip fracture from a fall will die within a year. Another 20% will be moved to an inpatient long-term care center for the first time. Of those who sustain hip fractures, 49% will die within 6 months. Elderly people who fall are ten times more likely to be hospitalized and are eight times more likely to die than are children who fall. Also, it is known that 75% of the deaths due to falls that occur each year occur in elderly people, who constitute 12% of the population. The cost of caring for the elderly people who fall has been estimated to be 10 to 12.4 billion dollars per year. Accordingly, falls in the elderly population are associated with significant morbidity, mortality, and expense to our health care system. It is possible that the human and monetary costs associated with falls could be managed if those at greatest risk for falling were identified ahead of time and measures were employed to reduce or eliminate the risks. These are the objectives of the Risk of Falls Assessment Clinic (RFAC) that we have developed and implemented at Henry Ford Hospital. In the RFAC, factors known to place elderly people at risk for falling are assessed systematically. Patient performance is evaluated against normative data. The product of the assessment is a description for the referring physician of those factors where the patient has demonstrated increased risk for falling and possible interventions to decrease the risk. This article describes this clinic, the assessment tools used, possible interventions, and provides a summary of our early experience.

KEYWORDS

Elderly population - falls - morbidity - mortality

REFERENCES

• 1 Rubenstein L Z, Robbins A S, Schulman B L. Falls and instability in the elderly.  J Am Geriatr Soc . 1988;  36 266-278
• 2 Thapa P B, Wray W A. Gait disorders and falls in the elderly. In: Bronstein AM, Brandt T, Woollacott M, eds. Clinical Disorders of Balance, Posture and Gait New York: Oxford 1996: 301-325
• 3 Cumming R G. Epidemiology of medication-related falls and fractures in the elderly.  Drugs Aging . 1998;  12 43-53
• 4 Wild D, Nayak U SL, Isaacs B. How dangerous are falls in old people at home?.  Br Med J . 1981;  282 2132-2133
• 5 Grimley Evens J, Prudham D, Wandess I. A prospective study of falls in an elderly population. I. Incidence and morbidity.  Age Ageing . 1979;  6 201-210
• 6 Tibbits G M. Patients who fall: how to predict and prevent injuries.  Geriatrics . 1996;  51 24-28
• 7 Tinnetti M E, Baker D I, McAvay G. A multifactorial intervention to reduce the risk of falling among elderly people living in the community.  New Eng J Med . 1994;  331 821-827
• 8 Lord S R, Sherrington C, Menz H B. Falls in Older People: Risk Factors and Strategies for Prevention. New York: Cambridge University Press; 2001
• 9 Herdman S J, Blatt P, Schubert M C, Tusa R J. Falls in patients with vestibular deficits.  Am J Otol . 2000;  21 847-851
• 10 Drachman D A, Hart C W. An approach to the dizzy patient.  Neurology . 1972;  22 323-334
• 11 Pavol M J, Owings T M, Foley K T, Grabiner M D. The sex and age of older adults influence the outcome of induced trips.  J Gerontol . 1999;  54A M103-M108
• 12 vanDijk P TM, Meulenberg O R M G, van de Sande J H, Habbema J DF. Falls in dementia patients.  Gerontologist . 1993;  33 200-204
• 13 Liu B A, Topper A K, Reeves R A, Gryfe C, Maki B E. Falls among older people: relationship to medication use and orthostatic hypotension.  J Am Geriatr Soc . 1995;  43 1141-1145
• 14 Poor G, Atkinson E J, O'Fallon W M, Melton L J. Predictors of hip fractures in elderly men.  J Bone Mineral Res . 1995;  10 1900-1907
• 15 Nygaard H A. Falls and psychotropic drug consumption in long-term care residents: is there an obvious association?.  Gerontology . 1998;  44 46-50
• 16 Folstein M, Anthony J C, Parhad I, Duffy B, Gruenberg E M. The meaning of cognitive impairment in the elderly.  J Am Geriatr Soc . 1985;  33 228-235
• 17 Pfefferbaum A, Ford J M, Roth W T, Kopell B S. Age differences in P3-reaction time associations.  Electroencephalogr Clin Neurophysiol . 1980;  49 257-265
• 18 Pfefferbaum A, Ford J M, Wenegrat B G, Roth W T, Kopell B S. Clinical application of the P3 component of event-related potentials. I. Normal aging.  Electroencephalogr Clin Neurophysiol . 1984;  59 85-103
• 19 Neutel C I, Hirdes J P, Maxwell C J, Patten S B. New evidence on benzodiazepine use and falls: the time factor.  Age Ageing . 1996;  25 273-278
• 20 Koski K, Luukinen H, Laippala P, Kivela S-L. Physiological factors and medications as predictors of injurious falls by elderly people: a prospective population-based study.  Age Ageing . 1996;  25 29-38
• 21 Herings R MC, Stricker B HC, deBoer A, Bakker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures.  Arch Intern Med . 1995;  155 1801-1807
• 22 Yesavage J A, Brink T L, Rose T L. Development and validation of a geriatric depression screening scale: a preliminary report.  J Psychiatr Res . 1983;  17 37-49
• 23 Maurer M. Hypotension (low blood pressure) in the elderly. The Health Report. Radio National. Broadcast March 12, 2001. Website: www.abc.net.au/ rn/talks/8.30/helthrpt/stories/s259120.htm
• 24 Chiappa K. Evoked Potentials in Clinical Medicine.  New York: Raven Press; 1990
• 25 Davis J W, Ross P D, Nevitt M C, Wasnich R D. Risk factors for falls and serious injuries among older Japanese women in Hawaii.  J Am Geriatr Soc . 1999;  47 792-798
• 26 Northridge M E, Nevitt M C, Kelsey J L. Non-syncopal falls in the elderly in relation to home environments.  Osteoporosis Int . 1996;  6 249-255
• 27 Topper A K, Maki B E, Holliday P J. Are activity-based assessments of balance and gait in the elderly predictive of risk of falling and/or type of fall?.  J Am Geriatr Soc . 1993;  41 479-487
• 28 Maki B E, Holliday P J, Topper A K. A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population.  J Gerontol . 1994;  49 M72-M84
• 29 Podsiadlo D, Richardson S. The Timed ``Up and Go'': a test of basic functional mobility for frail elderly persons.  J Am Geriatr Soc . 1991;  39 142-148
• 30 Downton J H, Andrews K. Prevalence, characteristics and factors associated with falls among the elderly living at home.  Aging . 1989;  3 219-228
• 31 Herdman S J. Vestibular Rehabilitation, 2nd ed. Philadelphia: FA Davis; 2000 . 
• 32 Jacobson G P, Newman C W. The development of the Dizziness Handicap Inventory.  Arch Otolaryngol Head Neck Surg . 1990;  116 424-427
• 33 Brandt T. Visual acuity, visual field and visual scene characteristics affect postural balance. In: Igarashi M, Black FO, eds. Vestibular and Visual Control on Posture and Locomotor Equilibrium Basel: Karger 1985: 98
• 34 Carl J R. Practical anatomy and physiology of the ocular motor system. In: Jacobson GP, Newman CW, Kartush J, eds. Handbook of Balance Function Testing San Diego: Singular 1997: 53-68
• 35 Close J, Ellis M, Hooper R. Prevention of falls in the elderly trail (PROFET): a randomized controlled trial.  Lancet . 1999;  353 93-97