The Multifactoral Nature of Falls: A Fall Assessment Conducted by Senior Care Pharmacists

Within the senior population, the fear of falling follows only fear of cancer and of Alzheimer’s dementia. Survey evidence indicates that approximately 50% of nursing home residents and 30% of community-dwelling individuals over the age of 65 years fall at least once each year. The importance of this high frequency is underscored by three important facts: (i) that among the elderly, falls are the most common cause of injury visits to emergency rooms and the sixth leading cause of death; (ii) that over the age of 80 years, one fall in every ten results in hip fracture; and (iii) that falls are an indicator of mortality among the elderly to the extent that half of individuals requiring hospitalization for falls die within 12 months.

From the perspective of long-term-care facilities, falls constitute a major reason for admission and a glaring liability. Approximately 40% of all nursing home admissions relate to falls, and 20% of lawsuits against nursing homes nationally involve falls or injuries sustained as a result of falling. The fear of falling may cause older individuals to decrease their physical activity and mobility leading to physical “deconditioning” and an increase in faulty balance, thus increasing the risk of falling. Routine light activity and fall prevention strategies are, therefore, important components of care. For the consultant pharmacist, minimizing the use of agents that impair balance and proprioception and those that induce postural hypotension or psychomotor deficiencies is a necessity for protecting both patients and institutions.

This symposium was supported by an unrestricted educational grant from the Johnson & Johnson Long-term Care Group.

Diagnostic Indicators of Risk of Falling

After emphasizing the importance of fall prevention strategies by way of the preceding data, Malcolm Fraser, MD, CMD, Medical Director of Bay Geriatrics in St. Petersburg, FL, discussed the principal indicators of risk for falling by citing demographic and historical factors as well as physical, visual, neurological, and hearing deficits and other factors including environmental hazards and risky behaviors. Individuals who have fallen previously are at particular risk as are patients with neuromuscular disorders and those who take four or more medications. Osteoporosis increases the risk of falling if a fracture occurs when rising or walking. Thus osteoporosis may be either the cause or the result of a fall. Neurologic changes such as postural instability, slowed reaction time, diminished sensory awareness, and decline of central integration of visual, vestibular and proprioceptive senses all figure prominently in the frequency of falls in the nursing home population. Table 1 lists pharmacologic agents that increase the risk of falling. Research-based odds ratios for falls associated with specific drug classes appear in Table 2.

Although the evidence is anecdotal, there is cause to think that the frequency of falls may be reduced by as much as 67% by the use of two simple interventions: (i) a thorough pharmacy evaluation to determine if drugs or drug combinations may contribute to an individual patient’s overall risk and (ii) physical therapy screening to determine if therapy will reduce an individual’s risk.

In his discussion of institutional liability for falls, Dr. Fraser pointed out that not all instances in which patients are found on the floor need be recorded as falls. If an event is not reported specifically as a fall and results in no injury, the presumption of a fall may skew institutional data unnecessarily and affect its rating for accreditation or reaccreditation, or it may needlessly increase the institution’s risk of liability in an individual’s lawsuit. Similarly, he noted that because osteoporotic hip fracture may be either a cause or a consequence of a fall, a copy of hip x-rays should be attached to an incident report in defense of any claim that fracture resulted from the fall. Finally, he noted that strategies to reduce institutional liability associated with falls should include (i) recording adequate assessment of falls and fall risk, especially on admission and after falls; (ii) minimizing the use of psychoactive medications and physical restraints; (iii) individualizing care plans for patients at risk for falling; (iv) reassessing and altering care plans for patients who have fallen; and (v) avoiding patterns of negligent care over time.

Evaluating Risk for Falling

Richard A. Marasco, BS Pharm, FASCP, CGP, a consultant pharmacist with Pharmaceutical Care and Management Services in St. Petersburg, FL and Stephanie Hart-Hughes, BSc PT, Director of the Gait and Balance Laboratory at the James A. Haley Veterans Administration Hospital in Tampa, FL, addressed techniques for assessing risk for falling. (Ms. Hart-Hughes is a physical therapist and specialist in vestibular and balance disorders.) They also illustrated the techniques with the assistance of Ms. Helen Williams, a volunteer patient.

Because falls may be multifactoral in nature, Multi-disciplinary Falls Team Assessments are often most helpful at identifying individualized multiple factors leading to falls. When these are not available, risk should be assessed according to the examiner’s area of expertise with sensitivity to the potential need to refer to specialists of other disciplines.

Mr. Marasco began by taking Ms. Williams’ vital signs with particular attention to blood pressure taken while sitting and then standing after ascertaining that standing did not induce dizziness. Abnormal responses to standing include a drop in systolic pressure of 20 mm Hg or more, a drop in diastolic of 10 mm Hg or more, and a rise in pulse rate of 20 beats or more. Ms. Williams has hypertension that is well controlled with medication, and she exhibited neither systolic nor diastolic orthostasis at the time of the examination.

Because “dizziness” is an unspecific term that denotes anything from unsteadiness to losing consciousness, Ms. Hart-Hughes urged that any patient reporting dizziness be encouraged to be specific about symptoms. True vertigo is generally associated with underlying vestibular disorder that may be acute (less than 1 month’s duration) or chronic. A blood pressure reading taken upon standing helps to distinguish between dizziness resulting from orthostatic hypotension and dizziness from head motion associated with vestibular disorders. Failing to make this distinction may result in improper short-term treatment with H1 histamine receptor blockers such as meclizine hydrochloride. In a patient whose dizziness is not vestibular in origin, these agents may increase the risk of falling because of central nervous suppressor activity.

The second emphasis was on pain assessment and management. Assessment of pain entails the patient’s history with respect to injuries, chronic diseases and surgery. The patient is asked to describe current pain (e.g., throbbing, burning, shooting) along with its frequency (e.g., constant, intermittent), its location, its intensity on a 10-point scale, and the current and recent trends of its intensity. The patient should also be asked to describe activities or interventions that intensify or relieve pain. In addition to these subjective reports, the examiner should be alert to evidence of the clinical and social consequences of pain. Because many falls occur in association with moderate or severe pain, intensity of pain may be a predictor of risk for falling.

Mr. Marasco described the three-tier schema for pain management beginning with non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2-specific inhibitors for mild pain to opioid analgesics for severe pain, commenting about efficacy, toxicities, and potential complications of combination therapies. He noted the increased risk of falling associated with pulse doses of opioids. In contrast, extended release formulations such as oxycodone and the fentanyl transdermal system decrease peak response and, thus, reduce the risk for falls.

Cognitive assessment is typically conducted by use of the Mini Mental Status Exam (MMSE) using simple questions of time and location and repetition of simple word sequences. Recognizing the limits of this method, however, Ms. Hart-Hughes recommended the “walk-talk” test in which the deterioration of gait or halting during conversation may indicate a dual-task cognitive deficit. Because this is a functional test assessing the impact of low-level cognitive activity on gait stability, it may be more predictive of risk for falling than a unidimensional test. Mr. Marasco addressed the work-up for suspected cases of Alzheimer’s disease, and presented comparative evidence regarding the respective affects of donepezil, rivastigmine and galantamine — all acetylcholinesterase inhibitors — on cognition, function and behavior. Response to these agents with respect to these parameters helps to assess the risk for falling among patients with Alzheimer’s disease.

Assessment of risk for falling also includes a fall history that determines the number, frequency and causes of falls and the incidence of fractures. The objective is to seek clues as to the potential physiologic and environmental circumstances underlying falls. (Ms. Williams, for example, reported that her two falls in the last year resulted from stubbing her toe on the edge of carpet, an obvious reversible environmental hazard.) It is important to learn whether or not the patient felt light-headedness, palpitations or pain at the time of falling and how long after standing up each fall occurred. The time of day or night at which falls have occurred, the type of surface on which the patient was standing, and medications the patient was taking at the time of falling may all provide clues of potential neuropathy. Mr. Marasco summarized the history of falling as the SPLATT test, consisting of symptoms, previous falls, location, activity, time and trauma.

Sleep assessment is also an integral part of assessing a patient’s risk of falling. The assessment is designed to detect evidence of primary sleep disorders such as obstructive sleep apnea, restless legs syndrome and periodic leg movements during sleep, and to assess the objective sleep parameters of sleep latency, frequency of awakenings and total sleep duration. Elderly individuals with primary or secondary insomnia may arise during the night and have falling accidents. Furthermore, disrupted sleep and poor sleep quality are associated with cognitive and psychomotor impairment the following day. These may be implicated in daytime falls.

The examiner should determine whether or not the patient wears appropriate footwear at all times. For preventing falls, footwear should envelop the foot completely (i.e., sandals and shoes without heels are inappropriate), provide adequate friction on all surfaces, and support the ankle. Walking devices such as canes and walkers may be indicated for some patients with histories of falling. The patient should be observed walking casually for potential gait irregularities that may contribute to fall risk.

Bathing habits should also be explored, as the bathtub is inherently dangerous and the heat associated with bathing and showering may induce vasodilation and hypotension. The floor of a shower or bathtub should have a non-skid surface, grab bars should be available, and patients vulnerable to falling should shower sitting on a stool.

The assessment should also include a brief examination of the cranial nerves designed to evaluate the patient’s strength, the integrity of reflexes and the positioning of joints with eyes closed (see Table 3). The examiner should be vigilant for signs of Parkinson’s disease, extra-pyramidal symptoms and tardive dyskinesia.

With Ms. Williams’ help, Ms. Hart-Hughes demonstrated a physical therapy assessment. Because the reliability of manual muscle testing is questionable, Ms. Hart-Hughes prefers standardized functional tests of strength. These include testing grip strength with the use of a hand-held dynamometer and testing arm strength using the repeated curl test. In the latter, the number of curls the patient can do in 30 seconds is a functional measure of strength. For each of these tests, the dominant side should be used. The repeated chair stand test — the number of times the individual can stand from a sitting position without use of hands — is a useful measure of functional lower extremity strength.

Following these tests of strength, Ms. Hart-Hughes examined Ms. Williams’ balance after explaining that balance — awareness of and adjustment to one’s physical relationship to one’s spatial environment — is determined by central processing of optical, vestibular and somatic sensory signals. Having processed these signals, the brain recruits the appropriate muscles to adjust to the environment. Thus balance testing has both sensory and motor components.

Evaluation of central processing of sensory input is performed with the Clinical Test of Sensory Integration and Balance. Initially, the patient is asked to stand on a firm surface with eyes open for 30 seconds. This is repeated with eyes closed to test the somatosensory system, and the patient is observed for unsteadiness and sway. Third, the patient is tested for balance standing on a foam pad, first with eyes open then with them closed. Foam conditions are repeated a maximum of three times to establish potential for motor learning if the patient is initially unsuccessful at balancing for 30 seconds.

Next, the Reach in Four Directions Test is performed to assess the patient’s ability to control the movement of the center of gravity voluntarily. In this test, the patient is instructed to reach forward as far as possible without taking a step or falling, following which she/he reaches backward, then to the left and to the right. Twelve inches is the threshold for fall risk in the forward direction, but the test has yet to be standardized for patient height and should be used, therefore, in conjunction with other tests of postural control. In the “8-foot up-and-go” test, the patient attempts to rise from a sitting position, walk around an object 8 feet away and resume sitting. Failure to complete the test in 8.5 seconds or less is associated with a high fall risk. Finally, reflexive motor control is tested by the “backward release maneuver” in which the patient attempts to regain balance after the hand against which she/he has been leaning backward is removed.

Assistive and Protective Devices
Elderly patients who are at risk for falling may require assistive devices such as canes, crutches and walkers. In addition to the single-point cane with or without a special arthritic grip, quad (“four-prong”) canes may be appropriate for some patients. A newer version has a pivoting base. Walkers are also available in numerous designs ranging from no wheels to four having or not having hand brakes. Gait belts with straps that serve as handles may be used to steady the patient during mobility tasks.

Because non-modifiable risk factors make it impossible to eliminate all falls, protective devices may be indicated for some patients. These include such things as helmets, floor mats and body pillows. Anecdotal evidence suggests that hip protectors, soft pads with or without exterior hard shells sown into garments similar to bicycling pants and worn over the greater trochanter, may significantly reduce the risk of hip fracture. Protective devices may be rejected by patients because of pride or dignity issues, and it may require several short-term trials or training sessions to persuade patients of their value. Some patients may ultimately reject them despite repeated trials.

Behavior Management in the Nursing Home
Dementia accompanied by disruptive behavior is very common in long-term-care facilities. Several pharmacologic interventions are now available for managing this problem, but concern remains that medication may increase the tendency to fall or lead to treatment-related Parkinson’s disease or tardive dyskinesia. Clinical evidence suggests, however, that patients may be treated safely with risperidone. In a randomized and placebo-controlled study of 625 patients (mean age=82.7 years) with dementia treated for psychotic and behavioral symptoms, the frequency of extra-pyramidal symptoms in patients receiving risperidone 1.0 mg per day was not significantly greater than in the placebo group (Katz IR et al. J Clin Psychiatry 1999;60(2):107). In a retrospective study of 730 patient records, data were collected on the frequency of falls among patients not known to have fallen prior to long-term treatment with either risperidone or olanzapine for behavioral disturbances. The sample sizes were equivalent for the two treatment groups. The mean age was 81 years (range=55-106 years). The review indicated that 8% of patients treated with risperidone experienced falls compared with 19% for patients taking olanzapine (Martin H et al. Meeting of Amer Assn Geriat Psych, 2001) as is shown in Figure 1. These and other trials are now providing substantial evidence-based information for the selection of agents for use in senior care.

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