Aug. 21, 2018

Frailty is a condition of decreased physiologic reserves. Falls, a common result of frailty, are associated with death and significant morbidity, including prolonged hospitalizations, premature nursing home placement, social isolation and fall-related anxiety syndrome. According to David C. Weber, M.D., a physiatrist who specializes in trauma and neuro rehabilitation at Mayo Clinic's campus in Minnesota, only 37 percent of elderly patients are asked about falls in the primary care setting. "There are multiple barriers preventing optimal care related to falls," says Dr. Weber.

Barriers to providing fall-related care include the fact that many patients have competing risks and priorities, the logistics associated with obtaining appropriate referrals, and patient resistance to behavioral change. The fact that fall risk is multifactorial can make assessment and prevention challenging.

"Falls are rarely due to a single cause or risk factor. More often, they are the accumulated effect of impairments in multiple domains," says Dr. Weber. They typically involve a predisposed host and multiple intrinsic and extrinsic factors and behaviors."

Multiple clinical practice guidelines recommend screening all adults age 65 and older for falls. Patients who have had a single fall should undergo a gait and balance assessment. And those who have had multiple falls within a year should be evaluated more thoroughly to determine their fall risks and to attempt to mitigate those identified risks.

Identified risk factors for falls

Intrinsic factors include blood pressure, orthostatics; cognition; vision; spasticity, rigidity; strength; sensory deficit, cerebellar, parkinsonism; and musculoskeletal issues, antalgia.

Extrinsic factors include medications, environment and other factors.

Behaviors include risk-taking, gait aid use and other behaviors.

Fall risk assessment

According to Dr. Weber, there are many tools available for quick assessment of fall risk. "These are important tools to have in your repertoire because patients are prone to underreporting falls, either for fear of losing their independent living status, or because of difficulties with memory and recall. I also tell providers not to perform these tests without someone else standing by the patient for safety," says Dr. Weber.

Multiple studies have shown an association between walking speed and survival, so many of these screening tests for falls involved timed movement. "At any given age in the elderly population, median survival is shorter for slower walkers than for faster walkers," notes Dr. Weber.

Office-based, timed assessments for fall risk typically used by Mayo Clinic providers include:

• Five Times Sit to Stand (5X STS): This test assesses strength. Have the patient start seated in an armless chair with a firm seat, ask him or her to stand up and sit down five times as quickly as possible, and record the time required to complete the five repetitions.
• Single Leg Stance (SLS): This test assesses balance. Have the patient stand on one leg, with arms crossed. Time how long the patient can remain in this position without touching the suspended foot to the ground, moving the hands away from the chest or displacing the weight-bearing foot.
• Time Up and Go (TUG): This test assesses gait. Have the patient start in a seated position, rise to a stand, walk three meters and return to a seated position in the chair, and record the time required to complete the exercise.

According to Dr. Weber, remembering the rule of 10s can help determine which patients should be considered for further evaluation. "Patients who take more than 10 seconds to do the 5X STS and TUG tests, and those who can balance for less than 10 seconds during the SLS probably require further scrutiny."

Dr. Weber cautions that these screening tests are functional, rather than diagnostic, and that no specific time cutoff, whether it's 10 seconds or other, is truly discriminative. "As with any test, the results should be interpreted in the context of a comprehensive evaluation, and performance observations are much more important than time measurements per se."

Patients who are determined to be at risk of falls can benefit from physical therapy (PT) and occupational therapy (OT) intervention. PT intervention can include gait aids, strength exercises, balance training, education about safety precautions and risky behaviors, and assistance with floor to chair transfers. OT intervention often focuses on addressing activities of daily living that involve balance, visuospatial impairments and cognitive impairments; use of adaptive equipment, such as grab bars, toilet seat risers and shower chairs; and providing home safety and behavioral education.

"Our therapists have developed detailed lists of safety tips and changes designed to reduce fall risks and improve home safety overall," says Dr. Weber. "Given that 30 to 40 percent of community-dwelling older adults will experience a fall each year, providers should have a good understanding of fall risk factors, how to screen for them and appropriate interventions."