Prevent Falling Patients From Falling Off the Radar: Resources for Building Your Falls Risk Protocol The impact of falls on patients and the burden of consequences due to falls on health care are increasing. A number of national and international organizations recognize this issue and efforts to better define, assess, and prevent falls are growing. While textbooks and research are available to guide clinicians in ... Article
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Article  |   December 29, 2016
Prevent Falling Patients From Falling Off the Radar: Resources for Building Your Falls Risk Protocol
Author Affiliations & Notes
  • Kelsey Hatton
    Vanderbilt University Medical Center, Bill Wilkerson Center, Nashville, TN
  • Disclosures
    Disclosures ×
  • Financial: Kelsey Hatton has no relevant financial interests to disclose.
    Financial: Kelsey Hatton has no relevant financial interests to disclose.×
  • Nonfinancial: Kelsey Hatton has no relevant nonfinancial interests to disclose.
    Nonfinancial: Kelsey Hatton has no relevant nonfinancial interests to disclose.×
Article Information
Hearing Disorders / Balance & Balance Disorders / Special Populations / Older Adults & Aging / Attention, Memory & Executive Functions / Part 1
Article   |   December 29, 2016
Prevent Falling Patients From Falling Off the Radar: Resources for Building Your Falls Risk Protocol
Perspectives of the ASHA Special Interest Groups, December 2016, Vol. 1, 14-25. doi:10.1044/persp1.SIG8.14
History: Received May 12, 2016 , Revised August 1, 2016 , Accepted August 1, 2016
Perspectives of the ASHA Special Interest Groups, December 2016, Vol. 1, 14-25. doi:10.1044/persp1.SIG8.14
History: Received May 12, 2016; Revised August 1, 2016; Accepted August 1, 2016

The impact of falls on patients and the burden of consequences due to falls on health care are increasing. A number of national and international organizations recognize this issue and efforts to better define, assess, and prevent falls are growing. While textbooks and research are available to guide clinicians in developing test protocols, this article aims to provide general tips and some practical discussion. A number of falls risk factors and their importance to an assessment will be reviewed. Potential screening methods with an estimation of their associated costs are also provided for each falls risk factor.

During childhood, we are conditioned through experience to believe our bodies are resilient following falls. This may be a reasonable expectation to a certain extent. Active and healthy people of all ages may fall often in certain settings like athletic competitions, and recover with little incident. However, falling frequently without a clear cause or environmental obstacle at any age warrants further investigation. The exploration of environmental and internal factors leading to falls is particularly important with the accumulation of health issues and age. In older populations, falling is associated with higher rates of comorbidity and mortality (Centers for Disease Control [CDC] 2006). At this point “being clumsy” can become limiting and truly problematic.
Defining and assessing falls is an important clinical step toward successfully preventing falls. A widely accepted definition of a fall is “an unexpected event in which the participant comes to rest on the ground, floor, or a lower level” (World Health Organization [WHO], 2007). This statement encompasses a wide variety of situations and does not distinguish benign or “near-falls” from severe falls. Scales to further differentiate falls by level of severity are in development, and may shape future definitions of falling for researchers and medical professionals (Davalos-Bichara et al., 2014; Lamb, Jorstad-Stein, Hauer, & Becker, 2005). While assessing falls is a complex task, audiologists are well-equipped to do so. We already assess vestibular impairment, a known risk factor for falling (Jacobson, McCaslin, Grantham, & Piker, 2008), and are qualified to perform many of the basic screenings for other risk factors which can help direct a patient's follow up care and intervention.
The audiology clinic I work in has established a guideline for falls testing which is the basis for the following discussion (Jacobson & Shepard, 2008). While textbooks and research should guide clinicians in developing a falls protocol, general tips and some practical discussion of possible options are also provided below. These suggestions are offered to help clinicians who wish to establish or expand an evidence-based falls risk assessment protocol. Our clinic considers 10 factors beyond vestibular function in the falls evaluation:
  1. Previous falls

  2. Medication history

  3. Vision

  4. Gait

  5. Cognition

  6. Depression

  7. Blood pressure disorder

  8. Peripheral neuropathy

  9. Maintenance of posture

  10. Reaction time

This article will review these factors and discuss why we are interested in screening them. Furthermore, potential test methods and a general estimation of their associated costs are included in the following format:
  • SUPPLIES: Equipment that can be utilized to assess each falls risk factor.

  • COST: Equipment cost estimates based on publicized prices from Internet search engine queries.

  • TIME: Projected time associated with each screening.

  • ASSOCIATED FALLS RISK: This is a percentage based on retrospective review of 271 falls evaluations performed at Vanderbilt from January 2007 to March 2016. Due to time limitations and patient ability, not every patient received every screening test. The total number of patients with information available to assess the associated risk percentage is included.

Previous Falls
It is estimated that more than one-third of community-dwelling individuals over age 65 will fall annually (Rubenstein, 2006); however, less than half of older adults who fall will discuss it with their health care providers (Stevens et al., 2012). Partly due to concern for under-reporting, the initial “Welcome to Medicare” examination requires interview about or formal evaluation of falls risk (Phelan, Mahoney, Voit, & Stevens, 2015). Even if a patient is not being seen for imbalance concerns, it is recommended that all health care providers routinely ask older adult patients annually if they are imbalanced or have experienced falls (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). This is especially important for audiologists, because many of us work with older patients for hearing and balance assessments. The majority of patients seen in an audiology clinic for falls risk evaluations have been referred following report of at least one fall to a provider.
During a case history, it is valuable to have the patient and family recount the situation surrounding the fall(s). Detailed descriptions help clinicians estimate potential intrinsic versus extrinsic factors influencing the patient's stability. Extrinsic factors usually include a loss of balance due to environmental obstacles such as: catching a foot on loose carpeting, tripping over a pet, or slipping on ice. Intrinsic factors often have distinctly different descriptions, discussed in their respective sections below. When reported, internal and external issues can help guide the assessment. However, oftentimes no clear recollection or direct observation of the fall can be provided. When causative factors cannot be clearly identified, it may be helpful to discuss the severity of the fall(s). Fall severity is often rated in terms of consequences. Families and patients tend to have better recall of physical harm or subsequent medical attention required following the incident (Davalos-Bichara et al., 2014). Additional questions may focus on the frequency of falling, environmental conditions, patient footwear and assistive device use, use of glasses, and the patient's expected support network.
  • SUPPLIES: None.

  • COST: Free to assess.

  • TIME: Contained within a case history (<5 minutes).

  • ASSOCIATED FALLS RISK: High—80% of 226 patients interviewed reported a history of falling.

Medications
It is important to discuss daily prescription medications for several reasons. First, the patient's current medications can indicate chronic health conditions that may be associated with specific falls risk factors (i.e., blood pressure regulation disorders). Certain classes of medications are associated with increased risk of falling, particularly psychoactive medications (Lord, Sherrington, Menz, & Close, 2007). Antidepressants, antipsychotics, sedatives, and benzodiazepines are particularly problematic, as they can alter sensory input and gait (Phelan et al., 2015). Audiologists must also keep in mind that central nervous system mediating medications can interfere with vestibular testing, as sedatives can inhibit the patient's ability to stay alert, participate in tasking, and keep his or her eyes open when necessary.
Secondly, as the number of daily prescription medications increases, so does the risk of falling. For each additional medication taken, the number of falls per person in a single year period increased by 1.14–1.31, depending on how many pre-existing diseases the person had (Damian, Pastor-Barriuso, Valderrama-Gama, & de Pedro-Cuesta, 2013). Although research has established a fairly linear relationship between number of medications and increase in falls risk, “polypharmacy,” or medication interaction, is generally not suspected until a patient is taking four or more daily prescription medications (Lord et al., 2007).
Finally, patients often associate dizziness as a medication side effect rather than a symptom of a disorder. Recent changes in a medication dose or compound that are time-locked with the development of and/or change in the quality of dizziness symptoms could be suspect for being associated with the patient's medications. Patients with chronic diseases affecting their blood pressure, thyroid, or headaches may report medication adjustments which affect their symptoms. If no risk factor is indicated as a source of dizziness during assessment, a medication review performed by the prescribing provider can be beneficial in determining medication role in patient symptoms.
  • SUPPLIES: None.

  • COST: Free to assess.

  • TIME: Contained within case history (5 minutes).

  • ASSOCIATED FALLS RISK: High—80% of 226 patients interviewed reported a history positive for four or more daily prescription medications.

  • NOTE: 90% of 226 patients in our clinic reported either a history positive for falling or for use of four or more daily prescription medications. The majority of patients (62%) fulfilled both criteria.

Somatosensory Impairment, and Neuropathy
Peripheral neuropathy is a common disorder, affecting an estimated 20 million Americans (National Institutes of Health [NIH], 2014). Nerve damage often develops secondary to physical stress on the nerves or deprivation of nutrients to nerves. Common stressors include swelling of the extremities, poor circulation, and heavy alcohol consumption. Patients with diabetes are at particularly high risk for peripheral neuropathy, with more than 50% developing polyneuropathies (Khanolkar, Bain, & Stephens, 2008). During a case history, it is common for patients with peripheral neuropathy to deny symptoms of dizziness and vertigo, but to report imbalance that is worst when standing or exacerbated by walking. In this case, an informal screening of sensory receptors is recommended. If positive, formal testing is typically performed by a neurologist.
Multiple sensory receptors in the skin are accessible for screening: mechanoreceptors, thermoreceptors, and nociceptors. Mechanoreceptors are sensitive to pressure or vibration and are favored for somatosensory screening because they do not require hot or painful stimuli to elicit a response (Khanolkar et al., 2008). Audiologists are especially equipped to test a patient's vibration threshold with audiometric bone oscillators. Bone oscillators are ideal for this task because they are widely available, standardized, and calibrated devices with discrete levels of output. Utilizing a low frequency vibration stimulus, clinicians can place the bone oscillator on specified sites and search for a vibrotactile response threshold in hearing level (dB HL). This method was inspired by Bergin, Bronstein, Murray, Sancovic, and Zeppenfeld (1995), who reported a significant relationship between poorer sensory perception at the ankles and increased postural sway.
While any audiometer with a bone oscillator works, our clinic uses a portable audiometer with a low frequency bone output at 250Hz up to 40dB HL. Lower extremity thresholds are obtained at the great toe, medial malleolus of the ankle, and tuberosity of the tibia bilaterally (Jacobson & Shepard, 2008). Upper extremity thresholds are tested at the thumb, bony protrusion of the wrist, and ulna/elbow. The majority of patients tested at our clinic from 2010 to 2016 who did not report unilateral impairment (i.e., stroke or unilateral knee/hip replacement) exhibited equivalent impairment on each side. Patients typically fail a lower extremity screening (i.e., no measurable response below 40dB HL at the great toe, ankle, or knee). It is uncommon for patients to fail an upper extremity screening (i.e., vibrotactile threshold greater than 35dB HL at the thumb, wrist, and elbow).
Alternatively, if a bone oscillator is unavailable, mechanoreceptors sensitive to touch and light pressure can be tested via filament test. This utilizes a pre-boxed set of fine plastic filaments meant to touch or be dragged across the skin on the area of interest. Using filaments of incrementally greater diameters, sites can be tested for the minimum filament thickness the patient can detect. Inability to detect a Semmes-Weinstein monofilament with 10 g of applied force is concerning for neuropathy (Khanolkar et al., 2008).
  • SUPPLIES: Audiometer with bone oscillator or a filament test kit.

  • COST: Free if you own an audiometer (portable audiometer with bone capability $800-2000; filament test kits $30–$550).

  • TIME: 5–7 minutes

  • ASSOCIATED FALLS RISK: High—91% of 267 patients tested had a previous diagnosis of peripheral neuropathy or failed screening for at least one extremity with the 250Hz vibration screening threshold (35dB HL).

Postural Maintenance
Some patients may describe difficulty standing without support, standing for an extended period, or standing with their eyes closed (i.e., while washing their hair in the shower). While postural deficits do not correlate with impairment in a single sensory system, assessments of posture provide an idea of functional performance (Whitney, Marchetti, & Schade, 2006). Postural maintenance appears to be an independent cause of instability and falls risk, but posture assessments cannot be interpreted as standalone diagnostic evaluations (Visser, Carpenter, van der Kooij, & Bloem, 2008).
If available, Computerized Dynamic Posturography (CDP) provides age group-based normative performance for comparison with individual patient data on the Sensory Organization Test (SOT) protocol. The SOT program evaluates posture in six different sensory environments providing dynamic changes while the subject tries to maintain stability. This evaluation is suitable for patients who can stand independent of assistance for the test duration. It is not suitable for patients who cannot stand without support, because testing on the CDP platform cannot accommodate the use of an assistive device.
When CDP testing is contraindicated, a screening of static posture may be appropriate. The 4-stage balance test described by the CDC may assist in determining postural maintenance ability (CDC STEADI kit). The test requires 10 seconds of standing in each of four increasingly difficult positions: feet side by side, feet staggered with arch/instep of one foot aligned with the ball of the other foot, feet lined up heel to toe, and standing on one foot. Patients who cannot complete all four conditions are considered at increased risk of falling.
  • SUPPLIES: Computerized posturography, or a chair and timer for 4-stage test.

  • COST: Computerized posturography >$50,000. Also note, testing is not reimbursed by insurance as a diagnostic tool. The 4-stage balance test is free.

  • TIME: 10–15 minutes, or <5 min for the 4-part balance test.

  • ASSOCIATED FALLS RISK: Moderate—67% of 133 patients tested had deficits in postural maintenance as measured by the sensory organization test (SOT). Static screening information was not available for review.

  • NOTE: Of the patients that were able to complete posturography, 62% also had somatosensory impairment.

Reaction Time
Postural maintenance in adverse environments is dependent upon the body's ability to react, adjust, and recover from a potential fall scenario. A mature body of research supports prolonged reaction times in older adults relative to younger adults, suggesting that reaction time is an age-related falls risk factor (Welford, 1977). Patients with poor reaction time may describe “seeing a fall coming” because they sense they are falling but cannot adjust their body fast enough to correct.
There are measures to assess either simple or choice reaction times. If available, CDP can again provide age group-based normative performance for comparison with individual patient data on the Motor Control Test (MCT). The MCT evaluates how quickly patients can compensate for small, medium, and large postural disturbances. Less dynamic tests of reaction time may be more appropriate for patients whose physical limitations prohibit the use of CDP equipment. Simple reaction time can be determined by how quickly a patient presses a button after a stimulus is presented. Patients who have fallen exhibit button-pressing delays that are significantly different from the performance of non-fallers (Lord et al., 2007).
  • SUPPLIES: Computerized posturography or reaction timer with pedal and button attachment.

  • COST: Computerized posturography >$50000, reaction timer $125–$200.

  • TIME: 5 minutes

  • ASSOCIATED FALLS RISK: Moderate—63% of 130 patients tested showed deficits in reaction time as measured by the MCT.

Vestibular Impairment
An evaluation of peripheral and central vestibular function is recommended for older patients with imbalance. The number of vestibular hair cells, vestibulo-ocular reflex gain, and Vestibular Evoked Myogenic Potentials (VEMP) amplitudes decrease with age, leading to heightened risk of vestibular impairment and interrelated risk of falling (Anson & Jeka, 2015). Patients may describe vertigo, lightheadedness, veering consistently to one side when walking, or difficulty focusing eyes on targets. If vestibular impairment is suspected, a consultation with otolaryngology and subsequent vestibular function testing may be recommended. In our clinic, vestibular rehabilitation is coordinated by the physical therapy team to improve compensation mechanisms and for additional gait training.
  • SUPPLIES: Videonystagmography (VNG) system, EP system with VEMP capability, rotational chair, and video Head Impulse Test (vHIT).

  • COST: No additional cost if you already own equipment. Starting from scratch is a considerable investment: VNG with irrigator >$30000, EP system $10,000-20,000, chair $50,000-150,000, and vHIT $5,000-$10,000.

  • TIME: 30 min to 1.5 hours dependent on components of test.

  • ASSOCIATED FALLS RISK: Moderate—61% of 271 patients tested showed a deficit in vestibular function.

Gait
When a patient endorses a fear of falling, exhibits unusual unsteadiness on his or her feet, or veers randomly when walking, a gait assessment may be considered. Physical therapists are typically experts in analyzing gait and can assess both qualitative and quantitative aspects of abnormal gait. Qualitative assessment is complex to the untrained eye, and can require extensive practice. Luckily, quantitative assessment of timed walking tasks can be performed with minimal training and has been established as reliable in identifying patients at risk for falling (Phelan et al., 2015).
One simple and favored measure is the Timed Up and Go (TUG) test (CDC STEADI kit). The patient begins in a seated position and is timed while he or she stands up and walks 10 feet, turns around, and returns to the original seated position. The patient is allowed to use assistive devices while completing the task. If the time between “bottom up” to “bottom down” equals or exceeds 13.5 seconds, the patient is considered at high risk for falling (Whitney, Lord, & Close, 2005). While the primary judgement is based on time to complete the task, the TUG form designed by the CDC provides eight descriptive statements that may be utilized for qualitative descriptions of gait.
  • SUPPLIES: Chair with standard arms, 3 meter or 10-foot-long walking space, a method to time seconds (stopwatch, wristwatch, wall clock, etc.).

  • COST: Free to assess.

  • TIME: 2 minutes

  • ASSOCIATED FALLS RISK: Moderate—42% of 222 patients tested were unable to perform the gait task within appropriate time limit.

Vision
Visual impairments can affect a patient's ability to judge spatial relationships and to maintain orientation within an environment. Vision screenings can be helpful if a patient describes difficulty navigating environmental obstacles, stepping off curbs, or judging distances. Traditionally, screenings of visual acuity are performed with a Snellen eye chart and may reveal cases of poor uncorrected vision as well as inadequately corrected vision (Lord et al., 2007). If best visual acuity is greater than 20/40 the patient may be at risk for refractory impairment or potential cataracts (US Preventative Services Task Force, 2016).
Similar screening charts or automated systems can be used to determine a patient's ability to detect contrasting shades or saturation level of color (contrast acuity) and depth perception. Impairments in these areas can be associated with age-related eye diseases and may warrant a visit with Ophthalmology rather than Optometry (Owsley, 2011).
  • SUPPLIES: Visual or contrast acuity charts, illuminated charts, computerized, or automated vision tests.

  • COST: Laminated chart ($5–$20); illuminated chart with stand ($200); automated vision screener ($2,500–$6,000).

  • TIME: 5 minutes

  • ASSOCIATED FALLS RISK: Moderate—40% of 256 patients tested showed a deficit in visual acuity and/or contrast acuity.

Blood Pressure Disorder
Gravity, changes in body position, and medications can significantly modulate how quickly the heart mediates blood pressure to maintain stability throughout the body. Tilt table testing can be performed by a cardiologist to explore blood pressure features and to determine appropriate treatment options. A basic repeated-measure screening can help identify a common position-induced drop in blood pressure called orthostatic hypotension (OH; CDC STEADI kit).
To perform this screening, have the patient lay supine for at least five minutes and then record his or her blood pressure. Next, assist the patient in standing up quickly and measure blood pressure a second time. An automated blood pressure cuff is helpful so the clinician has a hand to support the patient upon standing after this quick transition. A drop of more than 20 points in the larger, systolic blood pressure number or a drop of more than 10 points in the smaller, diastolic number are consistent with possible OH. Patients that are positive for OH often describe a lightheaded sensation upon sitting up or standing up that dissipates within a minute. Unlike patients with benign paroxysmal positional vertigo, they do not typically report lightheadedness when transitioning from standing to less stressing positions (i.e., sitting or lying down).
For patients with medication-induced hypertension or OH, adjustment of medications may not be possible. In these cases, it is beneficial to explain how blood pressure can influence lightheadedness and counsel patients on how to make “careful transitions” that allow their blood pressure to stabilize when changing positions.
  • SUPPLIES: Automated blood pressure cuff, reclining chair, or table patient can lay on.

  • COST: Cuff ($20–$40); chair/table ($500–$5,000)

  • TIME: 15 minutes laying, 5 minutes to take both measurements

  • ASSOCIATED FALLS RISK: Moderate—37% of 251 patients tested showed poor regulation/mediation of stable blood pressure when changing positions from laying 10 mins or more to standing.

Depression
Audiologists are aware of depression secondary to social isolation associated with hearing impairment (Dawes, et al., 2015). Similarly, depression can develop secondary to reduced physical activity, limited participation in activities, or loss of independence due to balance impairments (Harun, Li, Bridges, & Agrawal, 2016). Older patients are at increased risk of depression, even if they do not have hearing or balance concerns (Buchtemann, Luppa, Bramesfeled, & Riedel-Heller, 2012). Furthermore, the presence of depression can impact desire and ability to complete physical tasks, putting patients with depression at increased risk for falling.
Short pen and paper questionnaires are favored for assessing depression. The Geriatric Depression Scale (GDS) and Center for Epidemiologic Studies Depression Scale (CES-D) have long and short forms with high internal consistency and test-retest reliability to compare results with similarly-aged patients (Smarr & Keefer, 2011).
  • SUPPLIES: Pen and paper

  • COST: Free to administer

  • TIME: < 5 minutes

  • ASSOCIATED FALLS RISK: Lower—27% of 270 patients tested self-reported depression or depressive symptoms.

Cognition
Impaired cognition or dementia is an expanding problem amongst the world's aging population. Excluding individuals with headaches, more than 20% of adults age 60 or older have a mental or neurological disorder (WHO, 2016). Dementia and depression are identified as common causes of these cognitive impairments (WHO, 2016). Impaired cognition is believed to affect information processing speed, and delayed processing prevents patients from making appropriate postural corrections when unstable.
The Mini Mental Status Exam (MMSE), the most common screening metric for dementia, evaluates aspects of patient orientation, memory, language, attention, and visuospatial functions (Tsoi, Chan, Hirai, Wong, & Kwok, 2015). A cutoff score of 23 on the MMSE yields a sensitivity of 81% and specificity of 89% when used to identify patients with potential dementia (Tsoi et al., 2015).
  • SUPPLIES: Pen and paper

  • COST: Free to administer

  • TIME: <5 minutes

  • ASSOCIATED FALLS RISK: Lower—11% of 254 patients tested showed an abnormally poor score on the MMSE supporting poor cognition.

Recommendations, Counseling, & Collaboration
Falling can be a complicated problem to assess and a comprehensive examination can lead to numerous follow up recommendations. Primary follow up should be completed with the patient's referring provider and primary care physician. Falls assessment results also frequently generate recommendations to consult Otology, Neurology, Physical Therapy, Cardiology, and/or Optometry/Ophthalmology. Infrequent consult recommendations may be made to Neuro-Ophthalmology and Psychiatry/Psychology.
Assessing multiple falls risk factors can help expand counseling from an informational domain and transition into a preventative domain. Informational explanation of confirmed impairments is important in fostering knowledgeable consumption of health care. Confirmation of objective impairments that are consistent with a patient's subjective symptoms can have the added benefit of reducing mild forms of health anxiety. After educating families and connecting test findings with their experience, counseling can transition to strategies for navigating daily environments, and reasonable expectations of function. Discussion of at-home safety with examples of basic environmental modifications, like utilizing a night light or installing shower grab bars, can reduce potential falling hazards. Providing perspective on environmental adjustments that can help patients remain stable is an integral service for health care providers to complete according to the 2015 National Center on Aging (NCOA)  Falls Prevention Action Plan, aimed at reducing falls incidence across the United States.
Analyzing multiple tests also lends itself to the formulation of a prioritized action list. Navigating insurance, referrals, and recommendations can be confusing for many patients. Delineating which providers a patient might see to address each risk factor creates a potential plan of action. Having a plan can increase a patient's perceived control, and boosts patients who arrived feeling “hopeless” from the unpredictable nature of falls and stress acquired from their referral journey. Clearly communicated recommendations presented in both verbal and written formats can provide the family a way to translate and navigate the care process for medically complex patients. While awaiting referral and pending physician approval, patients interested in an interim plan may enroll in community-based or supervised exercise programs. Promoting age and ability-appropriate exercise is another service that health care providers can perform from the 2015 National Center on Aging (NCOA)  Falls Prevention Action Plan. Programs that incorporate resistance training, gaze stability training, and postural training are associated with lower rates of falling upon long term follow up (Okubo, Schoene, & Lord, 2016).
Finally, familiarity with falls risk factors opens up the possibility of engaging in inter-professional and collaborative practice. When we discuss falling patients with other providers, we increase our ability to learn from other specialties as well as how to communicate information in a clear manner. Cross training and observation of how different disciplines work with patients who have fallen is an integral part of both continuing education and graduate education models.
Overall, small adjustments in clinical protocol can help falling patients and lead to practices that prevent falls. By simply adding a few questions about falls and medications during a typical case history you may help identify patients at risk for falling, establish patient awareness, and initiate earlier intervention. In addition to expanding case histories, ideally we should include appropriate screenings when we encounter any older patient reporting relevant symptoms. A minimal investment of time identifying a problem like peripheral neuropathy can effectively put patients on the falls risk “radar.” Establishing patient awareness of falls risk and completing even minimal safety counseling can have a huge preventative impact on a patient's future health—which is ultimately the best return on the minimal time invested in these screenings. I hope you'll consider learning more about this topic and utilize the resources provided below.
Resources
Both national and international organizations have published guidelines and resources to encourage more widespread assessment of falling in hopes that identification and further research will reveal improved methods of falls prevention for aging populations. Both the WHO and CDC have built searchable websites which include resources specific to falls awareness for patients and falls assessment materials for health care providers:
Centers for Disease Control (CDC):
  • STEADI: Stopping Elderly Accidents, Deaths, and Injuries (CDC, 2016)

  • Fatalities and injuries from falls among older adults—United States, 1993-2003 and 2001-2005 (CDC, 2006)

National Council on Aging (NCOA):
  • Falls Free National Falls Prevention Action Plan (NCOA, 2015)

National Institutes of Health (NIH):
  • Peripheral Neuropathy Fact Sheet Number 15-4853 (NIH, 2014)

World Health Organization (WHO):
  • Falls Fact Sheet Number 344 (WHO, 2012)

  • Mental Health and Older Adults Fact Sheet (WHO, 2016)

  • WHO Global Report on Falls Prevention in Older Age (WHO, 2007)

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