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Perceptions of Family Physicians About Fall Risk Screening, Fall Risk Assessment, and Referral Practices for Fall Prevention in Malaysia

Jaafar, Mohamad Hasif PhD; Mat, Sumaiyah PhD; Mackenzie, Lynette PhD, MEdStud; Tan, Maw Pin MD, MRCP

Author Information
Topics in Geriatric Rehabilitation: January/March 2020 - Volume 36 - Issue 1 - p 38-43
doi: 10.1097/TGR.0000000000000252
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Abstract

The annual prevalence of falls among older individuals is reported at 66% across low- and middle-income countries and ranges from 73% in Russia to 44% in Ghana.1 Participants with a history of falls in these countries are more likely to be older, women, residing in rural areas, and have poorer health status.1,2 Although not all falls are injurious, about 31% of participants with a history of falls sustain at least 1 fall-related injury.2,3 In a study conducted in a large primary care clinic in Malaysia, 47% of older individuals 60 years and older reported falls in the preceding year, and 61% of them experienced fall-related injuries that needed medical attention.4 For the purposes of this study, older people are defined as those older than 60 years. Falls are known to lead to functional decline, increased risk of morbidity and mortality, and increased health care costs.5,6 The rates of falls and their related complications increase steadily with age, with the highest rates in those 70 years or older.2,6

Managing falls in older people is challenging due to the presence of numerous potential contributing factors such as environmental hazards, home hazards, underlying illness, physical impairment, and medications.7,8 To accurately identify and effectively address fall risk factors in individuals, it is necessary to have systematic risk assessments and appropriate interventions including exercise, medication, environment modification, and health education.9

Despite the high prevalence of falls and serious adverse consequences associated with falls among older people, prevention receives little attention in clinical practice.1 A systematic review reported that clinicians did not consider older people to be knowledgeable about or aware of fall prevention.9 They also had doubts whether family members were able to properly identify fall risk. Conversely, advice on falls given by clinicians was often viewed as insulting and dictatorial by older people who still saw themselves as experienced and competent in their daily functioning.9

The complex issues highlighted earlier suggest that a primary care focus on falls in the older people is essential. American and British Geriatric Society guidelines recommend that family physicians should ask all older patients at least annually whether they have fallen within the previous year and whether they have difficulties with walking or balance.10 Fear of falling is also associated with poor balance and gait in older adults, especially when older people use “stiffening” strategies to control their posture and therefore increase fall risk.11 While asking about fear of falling is not specifically mentioned as a screening item in guidelines, it needs to be explored with older people as it is highly prevalent and is linked with falls.12 Therefore, the aim of this study was to identify and explore factors that influence the implementation of fall prevention programs from the perspectives of the family physician (FP).

METHODS

We conducted a national survey among FPs across Malaysia. Initially, a telephone interview was considered by selecting registered FPs using computer-generated random numbers from the FP registries. However, it was decided that a survey study using a hard copy questionnaire was more likely to gain access to more participants. A standardized pretested questionnaire was used, which comprised 20 questions enquiring about the perceptions, knowledge, and routine practice of FPs associated with identifying, screening, and assessing fall risks in their patients, their fall management and referral practices, as well as barriers and facilitators to effectively preventing falls in their older patients.13

Information about years of experience and average number of patients seen each week was collected from all respondents through the questionnaire. To maintain confidentiality of respondents, the questionnaire was anonymous and no personally identifiable information was collected within the questionnaire.

Data collection

The study was approved by the Medical Ethics Committee of the University Malaya Medical Centre. Hard copies of the survey questionnaires were disseminated through the Academy of Family Physicians, Malaysia, which agreed to post the questionnaires with self-addressed return envelopes to all FPs registered with the academy. Return of a paper survey was considered as informed consent to participate. The survey questionnaires were not distributed among retired FPs or those who were no longer practicing as FPs.

Statistical analysis

Data analyses were conducted using SPSS version 20 (IBM, Armonk, New York). Descriptive statistics were used for analysis. Data on years of experience were not normally distributed and therefore expressed as a median with interquartile ranges. Categorical variables were presented as frequencies and percentages. Open texts of written answers were categorized, and themes were identified on the basis of the issues identified by respondents and were also counted as frequencies with percentages.

RESULTS

Respondents

The questionnaire was distributed to all 1800 registered members of the academy. A total of 112 FPs returned the survey (response rate = 6.2%). The majority of the respondents were male (59%), had 5 to 10 years of experience (34%), and practiced in Selangor (18%). Nine (8%) respondents had previous experience working overseas, of which half of them reported having practiced in India (4.5%). Most FPs employed a nurse at their clinics (74%). The self-reported demographics and practice characteristics of FPs are presented in Table 1. Table 2 shows the state of origin of the 112 respondents compared with the population distribution of Malaysia according to the 2016 national census.14 All states of Malaysia were represented within the survey.

TABLE 1 - Family Physician Characteristics (N = 112)
n (%)
Male gender 66 (58.9)
Experience, median (IQR), y
<5 y
5-10 y
11-20 y
>20 y
12.5 (7-27)
15 (13.4)
38 (33.9)
23 (20.5)
36 (32.1)
Experience working overseas
Australia
India
Indonesia
Singapore
United Kingdom
9 (8.0)
2 (1.8)
5 (4.5)
1 (0.9)
1 (0.9)
1 (0.9)
Employed a nurse 83 (74.1)
No. FPs in the same workplace, mean (SD) 4 (8.7)
No. patients seen each week, mean (SD)
<50
50-100
101-200
201-300
>300
224.3 (202.24)
7 (6.3)
19 (17.0)
24 (21.4)
26 (23.2)
21 (18.8)
No. older people seen each week, mean (SD) 51.66 (56.34)
No. older peoplea seen each week at risk of falls, mean (SD) 20.92 (28.48)
A
bbreviations: FP, family physician; IQR, interquartile range.
a
Older than 60 years, not living in a nursing home.

TABLE 2 - State of Origin of Respondents Versus Population Distribution by State
States No. Family Physicians (%) Population Distribution of Malaysia
Johor 14 (13) 11%
Kedah 4 (4) 7%
Kelantan 3 (3) 6%
Kuala Lumpur 15 (13) 6%
Melaka 3 (3) 3%
Negeri Sembilan 5 (5) 3%
Pahang 4 (4) 5%
Penang 6 (5) 5%
Perak 12 (11) 8%
Perlis 1 (1) 1%
Putrajaya 2 (2) 0%
Sabah 7 (6) 12%
Sarawak 15 (13) 9%
Selangor 20 (18) 20%
Terengganu 1 (1) 4%
Total 112 (100) 100%

The mean estimated weekly caseload of patients was 224.34 (standard deviation [SD] = 202.24), with a mean estimated number of individuals 60 years or older seen each week of 51.66 (SD = 56.36). They also estimated they saw a mean of 20.92 (SD = 28.48) older people each week who were at risk of falling and would benefit from fall prevention intervention.

Screening for fall risk in general practice

Sixty (54%) FPs did not routinely ask older people whether they had a fall, and 75 (67%) of them did not ask about fear of falling when they presented for a consultation. Seventy-nine FPs (71%) were unfamiliar with any guidelines for screening for fall risk. The most common screening practices used by FPs to detect older people at risk of falls were to identify patients taking antihypertensive medication (71%), determine patients taking 4 or more medications (57%), and verify whether patients were taking sedatives (55%). Thirty-seven (13%) FPs would conduct a Timed Up and Go (TUG) test as a screening assessment.

Fall risk screening assessment practices

The majority of FPs believed that they should conduct the following assessments related to fall risk: gait and balance impairment (94%), visual acuity (88%), multiple medications (86%), fall history (85%), postural hypotension (83%), and muscular strength deficits (83%). The least common fall assessments reported by FPs were identifying vitamin D deficiency (31%), foot/footwear problems (31%), depression/anxiety (36%), and hearing loss (41%). Twenty-four FPs (21%) did not have any idea about the screening tools (Table 3).

TABLE 3 - Fall Risk Screening Practices
n (%)
FPs who routinely ask older people (aged 60+ y) if they have had a fall when they present for a consultation 52 (46.4)
FPs who routinely ask older people (aged 60+ y) if they are fearful of having a fall when they present for a consultation 37 (33.0)
Familiarity with fall risk screening guidelines
Unfamiliar with any guidelines for screening for fall risk
Familiar but do not utilize them
Familiar with any fall guideline and implement in practice

79 (70.5)
20 (17.9)
12 (10.7)
Fall risk factor screening methods currently used by FPs
Identify patients taking antihypertensive medication
Identify patients taking 4 or more medications
Identify patients taking sedatives
Asking about falls in the last 12 mo
Identify patients taking antipsychotic medication
Conduct a vision test
Asking about fear of falls
Conduct a TUG test

80 (71.4)
64 (57.1)
61 (54.5)
53 (47.3)
51 (45.5)
48 (42.9)
38 (33.9)
14 (12.5)
Most important fall risk factor to address in FPs routine practice to identify older people at risk of falls
Gait/balance impairment
Visual acuity
Multiple medications
Past fall history
Postural hypotension
Muscular strength deficits
Dizziness
Home environmental hazards
Psychoactive medications
Parkinson disease
Syncope
Use of mobility aid
Arthritis
Frequent slips and trips
Peripheral neuropathy
Alcohol/drug use history
Diabetes
Osteoporosis
Inadequate nutrition
Urinary incontinence
Sedentary lifestyle/low exercise levels
Sleep impairments
Hearing loss
Depression/anxiety
Foot/footwear problem
Vitamin D deficiency

105 (93.8)
98 (87.5)
96 (85.7)
95 (84.8)
93 (83.0)
93 (83.0)
88 (78.6)
85 (75.9)
83 (74.1)
82 (73.2)
80 (71.4)
78 (69.6)
76 (67.9)
70 (62.5)
70 (62.5)
67 (59.8)
61 (54.5)
58 (51.8)
55 (49.1)
52 (46.4)
48 (42.9)
47 (42.0)
46 (41.1)
40 (35.7)
35 (31.3)
35 (31.3)
A
bbreviations: FP, family physician; TUG, Timed Up and Go.

Key barriers to fall prevention practice

Most FPs perceived that the main barriers to fall prevention practice would be time constraints in clinical practice (71%), more immediate demands when the patients attended a consultation (57%), and lack of personal general practitioner (GP) training in fall prevention screening, assessment, and management (53%). Moreover, some of them thought barriers were no incentives (13%) for them to do fall prevention and that payment for FPs was too low for them to do the screening tests (16%) (Table 4).

TABLE 4 - Key Barriers in Providing Fall Risk Screening as Part of Routine Practice
Barriers n (%)
Time constraints in clinical practice 79 (70.5)
More immediate demands 64 (57.1)
Lack of personal training in fall prevention screening, assessment, and management 59 (52.7)
Lack of educational resources on fall prevention to give patients 55 (49.1)
Too many other diagnoses to attend to 46 (41.1)
Too many other patients 42 (37.5)
No nurse to delegate screening tasks to 35 (31.3)
Patient denial they are at risk 23 (20.5)
Patient reluctance to discuss 19 (17.0)
Issue too complex for one surgery visit 19 (17.0)
Payment for GPs is too low to do this 18 (16.1)
No incentives to do this 14 (12.5)
A
bbreviation: GP, general practitioner.

Immediate course of action in patients with fall risk

The majority of FPs reported that the first thing they would do if they encountered a patient with fall risk was to give advice and obtain support from family (57%), advise on precautions (17%), investigate the cause for falls (15%), and perform a screening assessment (15%). Few would refer a patient to an orthopedic surgeon (1%), a geriatrician (1%), or a physiotherapist (3%). Two percent of FPs were not sure what to do (Table 5).

TABLE 5 - First Step Taken in Patient With Fall Risk
Steps n (%)
Give advice and get support from family 64 (57.1)
Advise on precaution 19 (17.0)
Investigate for cause of falls 17 (15.2)
Perform fall assessment 17 (15.2)
Refer to occupational therapist 8 (7.1)
Suggest home environment modification 4 (3.6)
Get a walking aid 3 (2.7)
Check blood pressure 3 (2.7)
Refer to physiotherapist 3 (2.7)
Not sure 2 (1.8)
Refer to geriatrician 1 (0.9)
Refer to orthopedic surgeon 1 (0.9)

Local contacts for fall prevention assessment or interventions

Half of the respondents (51%) did not know how to access local services for fall prevention assessment or interventions. Others would refer to hospital (30%), search online (5%), and ask a colleague (1%). Ten percent of FPs perceived that no local service could be contacted.

Educational needs for evidence-based fall prevention

Most respondents believed that short courses needed to be introduced in order to put this into practice (49%). Besides that, some of them would prefer printed educational materials in the forms of posters or flyers (21%), standard guidelines (21%), online materials (8%), and to hold talks or seminars (5%).

DISCUSSION

This study presents information about the issues faced by FPs in initiating and providing access to fall prevention services for older people in Malaysia. The majority of our respondents did not routinely screen for a history of falls and were unfamiliar with published fall guidelines. However, many stated that they believed they should be screening for fall risk including past fall history. This would not be possible if their older patients were not routinely asked about falls.

There were other inconsistencies in responses such as high numbers of FPs indicated they should screen for gait impairments, yet few indicated they would use a simple standardized test, such as the TUG test, which is easily applied in the general practice setting. To perform the TUG test, the patient is timed to walk at a comfortable and safe pace to a line on the floor 3 m away, turn, walk back to the chair, and sit down again, with or without walking aids.15 The TUG test has been recommended as a routine screening test for falls in several published guidelines.16,17 Possible explanations for most FPs not using this test are a lack of awareness of guidelines,13 limited space in clinics, time constraints, and no nurse to delegate the screening task to. However, a recent meta-analysis has suggested that a poor TUG score did not predict falling.18 A previous study has also reported that clinicians had problems in assessing falls in older people who suffered from other chronic diseases.19

Most of the FPs appeared to focus their fall prevention efforts on monitoring and reviewing medications and stated that their key screening methods for patients at risk of falls were mainly to review those taking certain types of medications. This may mean that several other fall risks were not taken into account during any screening processes undertaken. Many commonly used medications, both prescribed or over-the-counter, may have anticholinergic activity, which then increases the probability of falling among older adults.20,21 The relationship between anticholinergic burden and falls is dose dependent and is also related to a greater likelihood of functional decline, cardiovascular risk, and increased mortality.22 The Malaysian Falls Assessment and Interventional Trial recruited participants with a history of falls from the emergency department, primary care, and geriatrics clinics and reported that older participants with a history of falls were significantly more likely to be consuming medications with anticholinergic properties than nonfaller controls.23 However, most FPs indicated that they would review antihypertensives. A recent Malaysian study has, however, found that the use of antihypertensives was not significantly associated with falls. Furthermore, withdrawal of antihypertensives could affect blood pressure control and subsequently lead to an increased risk of stroke.24 There is also limited evidence to support medication review alone as an effective intervention for falls.25

The FPs identified that their key barriers to practicing fall prevention assessments were related to the demands of routine clinical practice, workload, and a lack of training on fall prevention rather than a lack of willingness by their older patients. Time limitations appeared to be the most significant barrier to adopting fall prevention practices, with most participants indicating they would mainly give advice or seek support from the family rather than performing further assessment or referring on to other fall prevention service providers. Family support is important as previous studies reported that lack of this support was a barrier to fall management.7,26 Family members can help older people at risk of falls by encouraging them to attend follow-up clinics regularly. They can also participate in treatment decisions, help provide a more accurate history of falls, and assist with the investigation of medication effects. The low rates of conducting further investigations or fall risk assessments could be influenced by FPs being unaware of other services to refer to or there being no services in existence locally. Effective use of fall services require familiarity with allied health professionals specializing in fall interventions and an understanding of the requirements for home safety assessments and outpatient rehabilitation services.26 Our study has, therefore, revealed major gaps in the delivery of fall prevention practice by Malaysian FPs.

International guidelines have recommended that FPs should ask older people about falls at least once per year.16 However, in this study, this was not undertaken by the majority of FPs. These findings are consistent with a recent study published in Australia that reported that routine fall histories are not sought with older people in general practice.13 Many FPs cite clinical time constraints and more immediate demands of patients as barriers to conducting screening for fall risk. As many FPs employ nurses, the practice nurse may be a potential candidate to make fall screening more of a routine practice among older people13 as well as to ensure that fall prevention guidelines are adopted by the practice.

FPs recognized that a significant proportion of the older people attending their clinics were at risk of falls and would benefit from fall prevention interventions. To effectively address the growing problem of falls in older people, public health policies and prevention programs are needed to implement evidence-based strategies.27 In the round table meeting organized at the International Association of Gerontology and Geriatrics World Congress in Seoul, in 2013, regional experts agreed that the community-dwelling older people should use an effective fall prevention program and environmental modifications were also suggested, especially for those at high risk of falls.27 Advice on physical therapy such as well-designed exercise programs and Tai Chi intervention programs have been reported to be effective in the treatment of balance, gait, and reducing the risk of falling.25 With published regional guidance advocating the fall prevention approaches recommended in international fall prevention guidelines, Malaysian FPs should be confident that the existing guidelines are applicable to the Malaysian setting.

The low response rate to this postal survey may be of concern; however, it is comparable to response rates of other external, untargeted surveys for GPs. Low response rates to surveys of GPs are very common, and many studies reported their response rates were below 10%.13,28 Because of the limitation of resources, and the reluctance of the academy to release telephone numbers, it was not possible to send reminders or provide incentives to boost the response rate. While responses may be related to FPs who are more interested in caring for older adults or falls as they are more likely to respond, if this is the case, actual practice may be worse. However, the distribution of our respondents closely matched the population distribution of Malaysia across the different states of Malaysia, suggesting that our sample was representative to a certain extent.

CONCLUSION

This study identified the gap in the knowledge of FPs on fall prevention. It has also provided invaluable information on fall prevention practice and barriers to achieving good practice in fall prevention. The lack of knowledge, skills, time, and manpower led to inability of FPs to effectively address fall prevention. Furthermore, the accessibility to local fall services appears limited. The development of effective educational programs is now required. Systematic approaches for fall prevention are also required to integrate policies, preventive measures, and evidence-based clinical practices.

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Keywords:

accidental falls; aged; primary care; risk assessment

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