ARTICLE IN BRIEF
Responding to an article in JAMA on mobility limitations in older adults, neurologists outline strategies to screen for and reduce fall risk in neurology patients.
Individuals with neurologic conditions that impair mobility and/or cognition are at an inherently elevated risk for falls; for older patients, that risk is increasingly high — accounting for 21,700 deaths in 2010 in people over 65, according to the Centers for Disease Control & Prevention (CDC).
Now, a clinical review in the Sept. 18 issue of the Journal of the American Medical Association (JAMA) underscores the role that neurologists and other health professionals can play in screening for and preventing falls, as well as working with allied health professionals to improve patient safety and reduce the risk of falls.
The lead study author, Cynthia J. Brown, MD — an associate professor of medicine and interim director of the Gerontology Division at the University of Alabama at Birmingham — and colleagues based their suggestions on an overview of literature on mobility limitations in older adults published over the past 28 years.
Among strategies, Dr. Brown suggested, neurologists should work with “physiatrists, geriatricians, physical, and occupational therapists to develop treatment plans to address mobility limitations and disability.”
Physicians can also counsel patients about ways they can reduce their risk for developing mobility limitations, stressing the benefits of “increasing physical activity, weight loss, and smoking cessation.” Both strength and balance exercises have been shown to effectively improve patient mobility, she said.
WHO IS AT INCREASED RISK FOR FALLS?
Figure. DR. CYNTHIA ...Image Tools
Experts who reviewed the JAMA paper agreed that neurologists could be more attentive to the limitations and risks for falls in neurologic patients, and should collaborate, as needed with physical therapists to draw up plans to reduce their risk for falling. Any mobility limitations are likely to increase fall risk, said Judy A. Stevens, PhD, an epidemiologist at the CDC's National Center for Injury Prevention & Control, who was an author of the AAN's 2008 evidence-based review of fall risk in neurologic patients.
In fact, the Centers for Medicare and Medicaid Services Physician Quality Reporting System includes two measures pertaining to falls — assessing the risk for falls and documentation of a plan to reduce that risk. In addition, the AAN offers a practice improvement module as part of its NeuroPI series on reducing the risk of falls in neurologic patients.
“There are a number of validated risk assessment tools for clinicians and patients to use to identify fall risk,” Dr. Stevens said. She noted that the CDC has a brochure called “Stay Independent,” which a patient or caregiver can complete and score in order to identify individual key fall risk factors (www.cdc.gov/injury/steadi). In the office, she said, there are three assessments which can be performed, including the Timed Up and Go (TUG) test (http://1.usa.gov/16ZBzDW), 4-Stage Balance test (http://1.usa.gov/16Dmr4J), and Chair Stand test (http://1.usa.gov/16DmuxC).
Neurologists should also conduct a complete review of their patient's medications, including over-the-counter medications, “with the goal of minimizing the use of psychotropic medications and medications with sedative effects,” said Dr. Stevens, which may contribute to fall risk. Asking patients to bring in all the medications they use may be an easy way to do this, she said.
Joe Verghese, MBBS, professor of neurology and Division chief of Geriatrics at Albert Einstein School of Medicine in The Bronx, NY, pointed out that neurologists already routinely examine walking patterns and balance. “Hence, neurologists can determine fall risk without any additional resources, time (theirs' or the patients'), or elaborate equipment,” he said.
Frederick Marshall, MD, chief of the geriatric neurology unit and associate professor of neurology at the University of Rochester School of Medicine, told Neurology Today that there are some easy steps that patients and caregivers can take to reduce their risks of falls. Merely changing shoes and glasses — “putting on lace-up tennis shoes; taking off high-heels, loafers, and poorly fitting shoes; and taking off bifocals” — can all significantly reduce the risk of falls in neurologic patients. For example, he said, having two separate sets of glasses — one for distance and one for reading will reduce the risk. [Dr. Marshall authored a paper in Neurology Clinical Practice last year on elderly patients with gait disturbance.]
Dr. Verghese noted there is a dearth of neurology-based research on fall risk in older adults, since most of the studies have been conducted by geriatricians and rehabilitation specialists. In his experience, he said, “patients are often referred for rehabilitation by neurologists after a fall has taken place and not before. This is a missed opportunity.”
Going forward, “I think it's really important for us to understand or develop outcomes-based research around the relationship between falls, gait disorders, and health care utilization, and begin to develop more systematic ways of looking at interventions that bend those curves,” Dr. Marshall told Neurology Today. “When you think about the impact of falling on hospital admissions and rates of utilization of high-level, high-cost health care, just doing what we can as a community to reduce those risks would have a significant public health impact.”
STRATEGIES FOR REDUCING FALL RISK
Judy A. Stevens, PhD, an author on the AAN's practice parameter on fall risk in neurologic patients and an epidemiologist at the Centers for Disease Control & Prevention's National Center for Injury Prevention & Control, told Neurology Today that neurologists can improve patient safety by:
* Assessing patients' fall risk factors, such as taking a history of falls and evaluating gait and balance.
* Identifying and referring patients with gait or balance disorders to physical therapy.
* Referring patients who are at high risk of falls or who have fallen in the past year for an in-home assessment by an occupational therapist, who works with the patient to modify his/her behavior as well as alter the home environment to maximize functioning.
The key to motivating an older person to make changes in their home is to focus on maximizing independence, not “reducing falls,” she said. CDC has developed “Check for Safety,” an easy-to-read home safety checklist that covers common fall hazards room by room and how to correct them: http://1.usa.gov/Q4u35W
Among important items to stress:
* Putting railings on both sides of all staircases, both inside and outside the home.
* Improving lighting throughout the home and especially at the top and bottom of stairs.
* Installing grab bars both inside and outside (where you step in and out) of the tub or shower.
* Additionally, having a pharmacist review all the medications a person is taking can provide insight into possible drug interactions and side effects.
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