Neurologists should routinely ask older patients and those with conditions associated with increased risk of falling about any recent falls, and should examine those with conditions recognized as having higher risk, according to new practice guidelines developed by the AAN Quality Standards Subcommittee.
Evidence-based guidelines for interventions that can reduce the risk of falls in the elderly have been published, but do not fully address increased risk in persons with chronic neurologic disorders, nor do they fully evaluate the effectiveness of methods to find those most at risk. To address these issues, the panel carried out an extensive literature search and included 86 articles or relevant studies.
Neurology Today asked the lead author of the subcommittee report, David J. Thurman, MD, of the CDC, to discuss the panel's findings. The full report was published in the Feb. 5 issue of Neurology.
WHICH NEUROLOGIC CONDITIONS ARE ASSOCIATED WITH INCREASED RISK OF FALLING?
Relatively specific diagnoses that carry an increased risk of falling compared to the general population include stroke, dementia, Parkinson disease, and polyneuropathy. Less specific diagnoses include disorders of gait and balance. And neurologic findings associated with increased risk include leg weakness or sensory loss, substantial loss of vision, or use of assistive devices for walking.
ARE THERE PRACTICAL CLINICAL SCREENING METHODS FOR NEUROLOGISTS THAT CAN ACCURATELY IDENTIFY PATIENTS AT HIGH RISK OF FALLING?
Simple screening methods are effective in identifying a high risk of falls, including basic elements of history-taking and examination. Inquiring about a history of falls in the last year is important. For new patients, asking about a history of neurological conditions likely to impair leg functions or balance (such as stroke, Parkinson disease, or polyneuropathy) is also important.
Finally, assessing mental status, vision, gait, and leg functions (including strength, sensation, and coordination) covers the elements of functional screening for falls. With the possible exception of asking about a history of falls, neurologists already routinely include these basic screening elements as part of their initial patient evaluations. Over time, it may be important to re-evaluate some patients with periodic re-screening.
HOW PREDICTIVE IS A HISTORY OF FALLS?
Pooled data from several studies indicate that a history of falls increases the risk of falling by more than two-fold, that is, the relative risk is 2.4. The absolute risk of falling was 55 percent for these subjects during follow-up, which was about a year for most studies. Not surprisingly, some data indicate that the risk of future falls is greater among people with a history of multiple falls compared to those with a single fall.
WHAT OTHER INFORMATION SHOULD NEUROLOGISTS ASK PATIENTS ABOUT?
In addition to routine history-taking for neurological disorders predisposing to falls, patients should be asked about other conditions that might cause falls, such as arthritis and depression, and they should be asked about all medications they use — routinely or occasionally — because several of them could increase the risk of falls.
WHICH MEDICATIONS ARE ASSOCIATED WITH INCREASED RISK?
The evidence is strongest for sedatives, antidepressants (mainly tricyclics), and neuroleptics. Weaker associations have been found for diuretics. And concurrent use of multiple drugs increases the risk of falls.
IS IT POSSIBLE TO RANK THE RISK OF FALLING FOR THE MORE COMMON NEUROLOGICAL DISORDERS?
Published data do not provide conclusive comparisons of the relative risk of falling among different neurological conditions. First, most published comparisons describe risks compared to general or control populations, and the spectrum of severity for each condition also must be considered.
It seems likely that the nature and severity of a condition is a stronger determinant of the risk of falls than the diagnostic category per se. For Parkinson disease and dementia, some data indicate that severity is an important determinant of risk. The same is likely for other conditions, although published data do not describe this well. For example, residual impairment after stroke varies greatly by severity and location. Leg weakness may be mild or severe, diffuse or focal, and may or may not be accompanied by other deficits.
ARE THERE ANY SIMPLE ASSESSMENTS THAT NEUROLOGISTS CAN FOLLOW?
First, ask about how many falls, if any, occurred during the past year. A single fall indicates a higher risk of future falling, while multiple falls indicate even higher risk. Near-falls and expressed fear of falling may also indicate increased risk. Falls that occur under extraordinary conditions (for example, on icy walkways or rough terrain) or activities (such as sports) may be discounted.
The so-called “get-up-and-go” test (GUGT) is a brief screening maneuver that involves asking patients to rise from a chair, walk 3 meters to a wall, turn without touching the wall, walk back, turn again, and sit down. The performance is scored from 1 (normal) to 5 (highly abnormal with immediate risk of falling). Criteria for impaired performance include hesitancy, slowness, or instability (for example, swaying or stumbling). Variations of this maneuver include a timed test (normal is 12 seconds or less, clearly abnormal is 25 seconds or more, after allowing one practice trial), and assessing whether or not the patient has to use the arms to push off from the chair when rising.
HOW MUCH DO MULTIPLE DEFICITS INCREASE RISK?
Mary Tinetti, who pioneered research in this area, has found that among seniors living in the community, as the identified number of risk factors increases from 0 to 6 or more, the risk of falling increases linearly nearly 10-fold. The risk factors she described include impairments of leg strength or sensation, gait and balance, and cognition, as well as sedative use.
ARE THERE ANY COGNITIVE OR PHYSICAL FUNCTIONAL ASSESSMENT TOOLS AVAILABLE AND HOW ACCURATE ARE THEY?
Several of the studies we reviewed relied on the Mini Mental Status Examination to assess cognition. Apart from the assessments of leg function and gait and balance that are a part of a routine neurological examination, the GUGT can be considered — it is simple to do, requires little time, and seems to perform reasonably well in terms of sensitivity and specificity. One validation study indicated that it correctly predicted falls in about 90 percent of community-dwelling seniors.
A more extensive screening tool that has been validated is the Tinetti Balance/Mobility Scale (TMS). This asks patients to perform several maneuvers, including arising from an armless chair, standing with eyes open and closed, standing while receiving a light sternal push, walking, turning 360°, and sitting down. There is a standardized scoring protocol. A disadvantage is that the measure is estimated to require 10 to 15 minutes to complete.
SHOULD THESE BE PART OF ROUTINE NEUROLOGICAL EXAMS?
Obviously, the GUGT and TMS contain maneuvers that overlap considerably with elements of a standard neurologic examination, and it is not clear that they are better tools for identifying patients at risk of falling than is a standard exam. Still, both may have a place in practice — the GUGT is an especially quick screen, and may be especially useful when patients are reassessed after a period of follow-up to see if functions have changed, and the TMS is useful when a more careful rating of fall risk is desired.
WHERE CAN NEUROLOGISTS GET MORE INFORMATION ON RISK OF FALLS?
Useful systematic reviews and guidelines addressing the risk of falls and its management include:
Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664–672.
Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews 2003:CD000340.
• Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141–158.
• Rubenstein LZ, Powers CM, MacLean CH. Quality indicators for the management and prevention of falls and mobility problems in vulnerable elders. Ann Intern Med 2001;135:686–693.
THE LATEST AAN PARAMETERS ON FALLS AVAILABLE ON PODCAST
Look for a more in-depth discussion of the new guidelines on risks for falls online in a special podcast interview at www.neurology.org. Dr. David Thurman will discuss the parameters in greater detail in an interview with John Morgan, MD, assistant professor of neurology at the Medical College of Georgia, and Shanna Patterson, MD, a neurology resident at Columbia University.