Managing Geriatric Syndromes: Falls

The baby boomers are coming—and bringing their geriatric syndromes with them.

Did you know that each day 8,000 baby boomers turn 65? Most primary care providers are aware of this or at least sense it from their own aging patient panels. The boomers are here, and with their increased ranks comes more and more pressure on physicians to find time to provide comprehensive primary care. As the number of elderly increases, it becomes an even greater challenge to address their often complex needs.

A recent article from Medical Clinics of North America provides a terrific review of the most common multifactorial problems that affect seniors, the so-called geriatric syndromes.1 In the outpatient setting, the syndromes most often encountered include falls, cognitive impairment, urinary incontinence, and frailty.

What Is a Geriatric Syndrome?

“A geriatric syndrome is a multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems. Geriatric syndromes have a devastating effect on the individual’s quality of life as they progress, may lead to significant disability, and are part of the ‘cascade to dependency’ that can often result in institutionalization,” the authors wrote.1

So how can you help best guide patients through these complex situations? Think like a geriatrician. Though it may seem the trendy answer today, a truly “patient-focused” approach will lead you to the correct scale of evaluation and range of remedies. Geriatricians know that every baby boomer is unique, enabling them to fashion care plans accordingly. It’s a patient-centered focus that leads to individually appropriate care that supports the desires of the patient.

Think like a geriatrician as you see patients in the coming weeks with various complaints or needs for screening. And think about it the following ways:

• Know your patient. Is he or she frail or functional?
• Know your patient’s goals and quality-of-life markers.
• Find what you can fix, what will make a difference for each specific patient, and what supports of his or her goals and quality-of-life markers.

Addressing Falls

Let’s use falls as an example. It is a sobering fact that approximately one-third of community-dwelling adults aged 65 and older have at least one fall per year. And falls increase as age increases. Injuries occur in about one-half of all falls.2 There are multiple risk factors, and in some cases unmodifiable factors that sometimes leave us feeling there is little to nothing that can really reduce numbers of older adults’ falls.

But the evidence is in: A 2012 Cochrane Database Systematic Review article reported that clinical assessment by a health care provider combined with individualized treatment of identified risk factors, referral if needed, and follow-up reduced the rate of falls by 24%.3

The US Preventive Services Task Force recommends exercise or physical therapy along with vitamin D supplementation to prevent falls in community-dwelling persons who are at increased risk for falls and aged 65 or older, offering a grade B recommendation.4

So we can make a difference for our elderly patients. Knowing these key interventions and applying them at the right time for the right patient is exactly the kind of patient-focused care that’s needed.

Even before thinking about falls specifically, as you encounter an elderly patient, have in mind answers to the following questions:

• Know your patient. Is he or she frail or functional? (A terrific review of identifying frailty is included in the Medical Clinics of North America article.)
• Know your patient’s goals and quality-of-life markers. (Does the patient value independence and activity above all? Or is this a patient with dementia who is slowly facing it but still finding quality in a simple, quiet life at home with a caregiver?)
• Find what you can fix, what will make a difference for each patient, and what supports of his or her goals and quality-of-life markers.

Responding to concerns around falls can be challenging; it may be difficult to identify the cause, or more often, causes. And in some cases there is no fix. But consider the following targeted evaluation and management focused precisely on the issue of finding modifiable issues and using evidence-based strategies to address them. A terrific algorithm for primary care clinicians was created via collaboration among the American Geriatric Society, British Geriatric Society, and the Centers for Disease Control and Prevention (CDC). Available for free use, the materials include a patient survey and brochure as well as clinician algorithm. I highly recommend that you work this into your practice. Its use is described well in the article “Assessment and Management of Fall Risk in Primary Care Settings.”2

Some key points to add to your usual intake of information include the following:

History

Use the Stay Independent CDC brochure that includes a survey for patients to complete and identify their risk for falling.

• Ask about key risk factors that can be modified such as balance, medications, vision, and home safety.
• Ask whether a patient has fallen in the past year. How many times? (If there is a history of falling, gather details about body position or activity prior to the fall. Is there a postural concern? Is syncope a factor? Are there environmental issues, such as home safety, lighting, flooring, stairs?)
• Ask whether he or she feels unsteady.
• Ask whether he or she experiences a fear of falling.
• Ask about vision concerns. (Are there cataract symptoms such as cloudy, fuzzy, foggy, or filmy vision or light glare?)
• Ask about medications, compiling a full list and determine whether medication timing may contribute to falls.

I like the following list showing the medication classes most likely to be related to falls:5

Physical

Assess vital signs including orthostatic check of blood pressure and heart rate three minutes after standing; cardiopulmonary function; vision; feet and shoes; and musculoskeletal and neurologic examination including cognitive assessment, gait, and balance. This may be a new element for you. A general survey of strength, gait, and balance can be observed by using the Timed Up and Go test.

In the Timed Up and Go test, the patient is asked to get up from an armchair without using his or her hands. Then he or she walks across the room (3 m), turns, walks back to the chair, and sits down. If this test takes more than 13.5 seconds to complete, then he or she is at risk for future falls.

Even if you don’t use the timed part of this test, you will glean much from observing this activity. Keeping track of this in your physical exam will allow serial assessment over time. I document it the following way:

Up from chair unaided: Y or N

Change of position trouble: Y or N

General gait assessment: normal, abnormal described, eg, antalgic, wide-based

Turning balance: good or poor

Speed: normal or slow or timed greater than or less than 13.5 seconds.

An easy way to test balance can follow the Timed Up and Go. I usually stand next to a patient and demonstrate the stances. This allows me to be nearby just in case.

The Four-Stage Balance test assesses static balance by having the patient stand in four positions, each progressively more challenging. Positions include the parallel, semitandem, tandem, and single-leg stand. Inability to perform a tandem stand (ie, heel of one shoe touching toe of the other) for 10 seconds predicts falls, and the inability to stand on one leg unassisted for five seconds predicts injurious falls.6

A terrific handout you can use in the office to describe/document the balance test can be found here.

When you’re unsure of your evaluation, consider physical therapy referral for evaluation as well as gait training and balance support.

If there are home-based issues of a homebound patient’s environment putting him or her at high risk for falls, consider Medicare-covered home care with physical and/or occupational therapy. A home safety assessment can provide evaluation of how the patient manages key activities of daily living in the bedroom, bathroom, kitchen, and interior and exterior stairways.

Laboratory tests should include a complete blood count to rule out significant anemia, a chemistry panel to rule out electrolyte abnormalities, and vitamin B12 and 25-OH vitamin D levels.

Once your evaluation is complete, follow the algorithm to identify the key management strategies for your patient. Remember these are syndromes with multifactorial etiologies and to address something that is multifactorial will take a number of strategies. Below are those with the best evidence of benefit:

Exercise

Exercise interventions that focus on improving strength and balance are the most effective single intervention for reducing falls and fall-related injuries.3

To be effective, exercise must focus on improving balance, be of moderate to high challenge and progress in difficulty, and be practiced a minimum of 50 hours, which equates to two hours weekly for 25 weeks.7

Depending on the resources in your area, consider referral to a physical therapist for balance and strengthening exercises. Tai chi has demonstrated evidence of benefit and is often available in community-based programs such as the YMCA.

Environmental Assessment

Engaging occupational therapists for home safety evaluation has been shown to be helpful. Identifying and modifying environmental factors is an effective intervention as part of a comprehensive multifactorial approach to preventing falls.8

Collaboration With a Pharmacist to Review and Adjust Medications

Medication is also a factor.9 Review with a pharmacist of all medications, dosages, and potential interactions can lead to a beneficial reconciliation and reduced fall risk.

Ophthalmology Evaluation

Evidence supports the fact that an initial cataract surgery can help to decrease a patient’s fall risk.3

Vitamin D

The recommended dose for fall prevention is 1,000 units per day.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, medical director of the Health First Aging Institute, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

References

1. Carlson C, Merel SE, Yukawa M. Geriatric syndromes and geriatric assessment for the generalist. Med Clin North Am. 2015;99(2):263-279.
2. Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015;99(2):281-293.
3. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;15(3):9:CD007146.
4. Moyer VA; US Preventive Services Task Force. Prevention of falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(3):197-204.
5. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952-1960.
6. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6):735-738.
7. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-2243.
8. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
9. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331(13):821-827.