Fall Prevention as a Value Creator
by Dr. Jon Hart
Chronic conditions have rightfully gotten a lot of attention over the past few years. We know the gradual, progressive degradation to a person’s health and well-being that diabetes or heart failure can cause. There are acute issues that can cause serious and rapid setbacks for our patients, though, like a sudden onset of an infectious disease. (Certainly, chronic conditions also magnify the effects of an acute condition.)
From an acute condition perspective, we spend a fair amount of time counseling about and actively preventing as many infectious diseases as possible through vaccination to help keep our seniors healthy. Besides infection, another acute condition exists that can also be quickly devastating to older folks is falls.
The consequences of a fall can be bad in even the healthiest person, but they, too, are worsened in people with chronic fragile conditions. Unlike some infectious diseases, we cannot inoculate patients to keep them from falling, but we can – and should – actively engage in fall prevention.
Falls are a leading cause of hospitalization and institutionalization for older adults in the U.S. About one in four people over 65 years old fall every year, with nonfatal falls costing Medicare almost $30 billion per year and Medicaid almost $10 billion.
Beyond the cost impact of falls, there are quality of life issues to consider, as well. No one wants to fall, be injured by a fall (temporarily or permanently), or require rehab services after a fall. One study found that 80 percent of older women would prefer to die due to a "bad" hip fracture rather than have it result in nursing home admission.
The fear of falls is real, and it negatively impacts our pre-fall patients.
For these reasons, CMS started asking beneficiaries about their falls and fall risk via an annual survey in 2002, and this fall screening process has since become a quality measure for many PCP practices.
Despite this effort to screen for fall risk, the incidence of falls in the elderly has not decreased. In fact, in some areas, it’s increased, likely due to several reasons including people living longer with chronic diseases, increased activity among older people (Pickleball!), increased prescribing in medications with higher fall risk, etc.
The Medicare Fall Risk Screening (coded as part of an AWV or other visit using the 1100F and 1101F codes) is comprised of balance/gait assessment AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. All components do not need to be completed during one patient visit but should be documented in the medical record as having been performed within the past 12 months.
Of course, fall risk screening is VERY different from fall prevention. It helps to know who’s at risk for a fall (including those who have had a fall within the past 12 months), but stopping with the assessment, as is true in most things medical, doesn’t address or impact the problem.
So, what tools do we have to help prevent falls – both primary and secondary prevention?
Exercise (strength and balance, in particular) in older adults was found to significantly reduce the risk of falls. Tai Chi has been specifically called out as statistically significant in its change of risk. Yoga and Dancing have had some suggestion of helping but have not been proven in trials.
Physical Therapy – If potential strength, balance, or proprioception issues are identified in a fall risk screen, a preemptive round of visits with a PT to work on these issues may help in primary prevention of a fall. PT as secondary prevention has proven benefit after a fall.
Medication – as has been discussed many times, we need to consider de-prescribing medicines, especially centrally active meds or those that cause postural hypotension (anticholinergic medicines like tricyclic antidepressants, antipsychotics, benzodiazepines, etc.). Easier said than done, but another reason to frequently do a medication reconciliation.
Home safety evaluation and assistive technology (not assistive devices) have shown to be effective in decreasing rate of falls. Folks are generally pretty receptive to grab bars and higher toilets, etc. One stumbling block in home evaluations (pun very much intended) is getting people to change sentimental things in their home. Be prepared to explain the why and have the team come up with creative ways around keeping the rug that Aunt Millie made still visible without it being a fall hazard.
There are examples of technology playing an expanded role in fall prevention in senior living with so-called “Smart Apartments.” These units are equipped with
auto-sensor lighting (to avoid tripping over things in the dark)
automated doors and cabinets (to assist with opening, avoiding awkward positions, and to ensure they’re closed to avoid running into them)
voice command assistance
location tracking (where is the person?)
geofencing (keep them out of harm’s way)
motion trackers (to see when and how often someone is moving around, getting up at night)
Sounds a bit big-brotherish, but it can help prevent falls.In cold climates, non-slip shoe covers worn in winter have been shown to decrease falls.
There is no randomized trial data looking at assistive devices (walkers, wheelchairs, scooters, etc.) as fall prevention. Observationally (and a bit of a Captain Obvious statement) people using walkers fall more (well yes, since their mobility is already impaired).
Vitamin D supplementation in at-risk populations has not been shown effective in fall risk prevention. In fact, it’s been shown to possibly increase fall risk at high doses.
Vision improvement has not been shown to decrease risk.
There is no one best-and-only solution to the fall prevention issue. Exercise seems to be a must-do, but there are many other approaches that can further reduce risk, optimizing health and well-being. As is usual in primary care, a multimodal, multifactorial, multidisciplinary approach seems to work best.
Find your resources. Build a team. Encourage a local fitness or senior center to start Tai Chi classes. De-prescribe appropriately. Don’t try to prevent falls alone in your office during your 7-minute conversation. Impact your patients outside of your walls!
References:
Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. “Medical Costs of Fatal and Nonfatal Falls in Older Adults.” Journal of the American Geriatrics Society, 2018 March, DOI:10.1111/jgs.15304
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System. https://www.cdc.gov/falls/data/index.html
Kakara R, Bergen G, Burns E, Stevens M. “Nonfatal and Fatal Falls Among Adults Aged ≥65 Years—United States, 2020–2021”. MMWR Morb Mortal Wkly Rep 2023;72:938–943. DOI: 10.15585/mmwr.mm7235a1.
Moreland B, Kakara R, Henry A. “Trends in Nonfatal Falls and Fall-Related Injuries Among Adults Aged ≥65 Years—United States, 2012–2018.” MMWR Morb Mortal Wkly Rep 2020;69:875–881. DOI: http://dx.doi.org/10.15585/mmwr.mm6927a5
Bailey, Laura. “More Adults are falling every year, despite prevention efforts.” University of Michigan News, February 23, 2022. https://news.umich.edu/more-adults-are-falling-every-year-despite-prevention-efforts/#:~:text=Falls%20affect%204.5%20million%20older,More%20information:
US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW Jr, Kemper AR, Krist AH, Kubik M, Landefeld S, Mangione CM, Pignone M, Silverstein M, Simon MA, Tseng CW . “Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement.” JAMA. 2018;319(16):1696.
Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Cumming RG, Herbert RD, Close JCT, Lord SR. “Exercise to prevent falls in older adults: an updated systematic review and meta-analysis.” Br J Sports Med. 2017;51(24):1750. Epub 2016 Oct 4.
Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, Quine S. “Quality of life related to fear of falling and hip fracture in older women: a time trade off study.” BMJ. 2000;320(7231):341.
Does yoga reduce the risk of falls in older people? BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3246 (Published 03 September 2020)
