ARTICLE IN BRIEF
A multidisciplinary panel of experts reviewed the medical literature on potential risk factors for falls and developed a consensus document offering guidance on detection of 31 specific risk factors for falls, including generic risks and those specific to Parkinson's.
Falls are a serious problem among elderly patients and those with neurologic disorders. However, few if any clinical guidelines have specifically addressed prevention and interventional strategies for patients with Parkinson's disease (PD) — despite the fact that half of all PD patients experience a fall within three months of their last visit to a physician, according to a meta-analysis.
In an effort to focus on the specific needs of Parkinson's disease patients, a multidisciplinary panel of experts reviewed the medical literature on potential risk factors for falls and developed a consensus document offering guidance on detection of 31 specific risk factors for falls — including generic risks — such as age, gender, and medication use — and those specific to PD. [See “Generic and Parkinson's-Specific Risks for Falls.”]
The document, published in the April issue of the journal Parkinsonism & Related Disorders, is intended as a clinical practice protocol to supplement existing formal guidelines, such as those issued by the AAN.
“Our main goal was to identify the most significant risk factors,” said one of the consensus document's authors, Michael S. Okun, MD, FAAN, a professor of neurology, neurosurgery, and neuroscience at the University of Florida College of Medicine's McKnight Brain Institute in Gainesville, and co-director of university's Center for Movement Disorders and Neurorestoration.
“We know that these falls cost Medicare, Medicaid, and the health care system billions of dollars, and our hope is that by addressing these risk factors, we can reduce this financial burden. Looking at it from my perspective, waiting for a patient to fall before they are seen to be at risk is too late,” he said.
STRATEGIES FOR REDUCING FALLS
Among strategies for reducing the risk of falls for people with PD, the authors recommended taking steps to avoid interaction between medications with sedative effects and halting or minimizing the use of (multiple) benzodiazepines. Levodopa levels may also need to be adjusted for patients who fall, they said, and reduced when violent dyskinesias are involved.
If slow mobility is contributing to falls, the authors advised increasing dopaminergic medication unless contraindicated, teaching cueing strategies, and strength training.
In terms of postural considerations, a stooped posture protects against backward falls, but may worsen festination and forward falls, the group found, while rising (transferring) from a chair or bed is also a recognized risk for patients.
Decreasing hypotensive medication, increasing dietary salt and fluid intake, elevating the head of a patient's bed, advising frequent small meals, using pressure stockings or an abdominal band, and other anti-orthostatic maneuvers can all be considered.
For patients with anxiety about falling, the researchers advised balance confidence training, cognitive behavioral therapy, mobility improvement training programs, and promotion of a more active lifestyle.
Where cognitive impairment is involved, the panel recommended using anticholinergics, reducing sedative medications, and minimizing potentially hazardous behavior. This might include training or avoiding multitasking; however, if a patient's mental impairment results in reckless or impulsive behavior, supervised gait and transfers from bed or chair are advised.
The report also recommended that neurologists work together with other members of the treatment team to coordinate messaging and detection of risks when PD patients are seen. These included geriatricians, pharmacists, PD nurse specialists, rehabilitation specialists, nurse practitioners, cardiologists, physiotherapists, and others.
“Although not infallible, we believe that our recommendations are an adequate reflection of the current evidence and expert opinion in the field,” Dr. Okun said. But he also emphasized the need for more research on the subject, especially large, randomized clinical trials and research testing the effectiveness of the individual components of the report as well as the cost-effectiveness and feasibility of the consensus panel's recommendations.
AAN QUALITY CARE REPORT
Eric Cheng, MD, FAAN, associate professor-in-residence in the department of neurology at the David Geffen School of Medicine of the University of California, Los Angeles, told Neurology Today that one of the benefits of the new consensus document is that it includes a checklist of risk factors that could provide an important way to categorize falls by risk-type.
Dr. Cheng was one of the authors of a set of quality measures developed by the Quality Measurement and Reporting Subcommittee of the AAN in 2010 to improve neurologic care for patients. A panel of 28 experts reviewed the available literature and issued a set of 10 steps for determining quality of care.
The AAN measures included a review of PD patients on an annual basis, including medications and the presence of atypical features. The analysis recommended that PD patients and caregivers be asked about falls every year. In addition, annual evaluation was recommended for psychiatric assessments including psychosis, depression, anxiety disorder, apathy, or impulse control disorder.
The review also advised physicians to regularly ask patients about symptoms of autonomic dysfunction, including orthostatic hypotension, constipation, urinary problems and urinary retention requiring catheterization, fecal incontinence, or persistent erectile failure, as well as sleep disturbances.
“Our AAN quality measures have evaluated potential reasons for falls, but this takes it even further,” Dr. Cheng noted. “If falls were analyzed by type and we could get more data on the most frequent causes it would be very helpful. Right now this data is not well known,” Dr. Cheng said.
“Only by having such a checklist can we begin to establish an algorithm for assessing risk in patients. It also reminds us that not all these risk factors are obvious and that multiple factors are often involved,” Dr. Cheng explained.
He added that although it would prove unwieldy for a single medical provider to assess all of the factors outlined in the consensus document, most can be done by one individual. “It's like stroke prevention, where it's possible to intervene beforehand to reduce risk.”
Most neurologists do not have the time to run through the entire risk checklist, Dr. Cheng noted, so dividing risks into general and PD-specific issues, as the consensus has done, is helpful.
“Most general practitioners can address generic and general issues, while neurologists can focus on PD-specific factors. Many of the problems identified do not require a movement disorders specialist, even though a single therapist might be better at evaluating patient transfer issues, something that is not usually done by MDs,” Dr. Cheng said.
A CRITICAL FIRST STEP
“I think that, given the multifactorial nature of falls in PD, putting together a laundry list of contributing factors is a critical first step in establishing an intervention plan for high-risk patients, and it highlights the roles of different health care and rehabilitation professionals to address the more challenging aspects of this risk,” said Michelle Burack, MD, PhD, an assistant professor neurology at the University of Rochester School of Medicine and Dentistry and Medical Center.
“Falls are a significant milestone in PD progression. Still, many patients who fall but are not severely injured do not mention such incidents to their physicians,” she told Neurology Today in a telephone interview. “Neurologists should ask patients about falls at every visit.”
Dr. Burack, a movement disorders specialist in University of Rochester's National Parkinson Foundation Center of Excellence, emphasized that PD affects a number of neurologic systems that can impair balance and gait. Moreover, poor impulse control is a common symptom in PD, so it is not unusual for patients to engage in activities that can increase the risk of falling, such as climbing ladders.
Dr. Burack took exception to the expert panel's preference for tailored screening based on specific fall types, with the only alternative being a comprehensive “one-size-fits-all” approach.
“I would favor a hybrid approach, with systematic screening in all patients for some of the more common contributing factors, like orthostatic blood pressure changes and peripheral neuropathy, and more targeted evaluation and treatment when the history suggests specific factors like cognitive impairment or dyskinesia,” she noted.
One critical problem with studying the subject is the lack of tools to reliably distinguish different types of falls, she said.
“The tailored approach will require well-validated tools to accurately identify fall types. Also, cooperation between the recommended multispecialty fields varies by location. In some areas there is a lot of cooperation, but not in others.”
Above all, Dr. Burack told Neurology Today, intervention should start as soon as possible in patients with early disease.
“They should be fully informed about the ability of regular physical activity to help prevent conditions that can result in falls later,” she said. “They need to exercise and stretch to maintain limb strength and posture, and to work on balance and gait by going to physical therapy programs before they fall. The best way to prevent falls is to be proactive.”
EXPERTS RESPOND TO CONSENSUS DOCUMENT ON PREVENTING FALLS IN PD