Senate Special Committee on Aging (Senators Collins and Casey) has requested input from the the fall prevention community on the needs/best practices in local areas to reduce falls.

 

See reply from Dr Atanelov, Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute. Please feel free to reach out to Steady Strides via email or social media if you have comments/suggestions/concerns or other ideas to help improve care of older Americans at risk of falls.

 

Reporting and Follow-Up. To what extent are falls unreported among older Americans? What strategies can be employed to encourage patients to promptly notify their health care provider or caregivers of a fall? How can follow-up with appropriate healthcare providers be improved after a visit to an emergency department for a fall?

 

Falls are dramatically under-reported, studies show, and this is true also clinically in my experience, that only under 30% of people who fall report falls.

One reason this does not happen is because healthcare providers, specifically physicians, are not well educated about mechanical falls, which constitute 90% of falls. As a physician who has spoken about this subject with multiple other physicians, mechanical fall etiology is ABSENT from the medical school curriculum. Most physicians even in residency training get either none or very specialty specific, not comprehensive training for fall mechanical prevention. Vast majority of practicing attending physicians, including primary care and emergency medicine doctors, even at the finest of US institutions do not have the training to thoroughly assess etiology for mechanical falls and to prevent them. Though CDC STEADI Algorithm has been created and is slowly being introduced to physicians at large, even this tool is very incomplete for diagnosing why elderly Americans fall.

Falls are difficult to diagnose because they may be due to cardiac, pulmonary, vestibular, neurological and orthopedic conditions. Most seniors have majority of these conditions, and most primary care physicians are not educated on how to identify comprehensively all of these conditions or prioritize these diagnoses. Furthermore, primary care doctors are ill trained in different specialty specific rehabilitation techniques that should be prescribed for the specific diagnoses in a tailor-made fashion. One-size-fits-all approach does not work, and we lack specialists adequately trained in tailor-made approach for mechanical falls (syncopal falls are well studied, but are a vast minority). The reason we lack specialists is because falls encompass an array of current medical specialties and none fully embraces mechanical falls adequately or tests on medical board exams thoroughly. Physicians are also not adequately educated on how to use community based resources for fall prevention.

 

In practice, many patients that fall never speak up. If they do, they may be sent to a neurologist, physical therapist, cardiologist, pulmonologist, geriatrician, physiatrist, ENT physician, an orthopedic or neurosurgery specialist. No one of these specialists traditionally has the tools to help prioritize and definitively diagnose and undertake a comprehensive  treatment plan for fall prevention.

 

In my opinion, geriatricians and physiatrists are the best suited specialties with best overall training and research in their respective fields to spearhead fall prevention specialty clinics.

 

Occupational, Physical and Speech Language Pathology specialists have a vital role in managing falls, but unfortunately only physical therapists feel prepared to handle falls, and other therapy specialists in practice tend do shy away from handling falls in a comprehensive fashion.

 

Overall, falls are hard, there should be a specialty multi-disciplinary clinic with well trained physiatrist or geriatrician working closely with multiple therapy disciplines to help prevent falls.  Recommendation is to A) incorporate mechanical fall prevention education for physicians across all specialties; B) add additional training for geriatricians and physiatrists by their respective accrediting bodies for comprehensive fall prevention strategies; C) invest in research in multi-disciplinary fall prevention clinic models to help generate the most efficient high quality low cost option for fall prevention strategies with predictable time frame for specific results (e.g. 20-50% reduction of baseline rate of falls at 3-6 mo prior to initiative, over the next 3-6 mo).

 

Tools and Resources. What learning tools, resources or techniques can be used to empower patients to change their home environment or modify risk factors to reduce the risk of falls? What are the opportunities and limitations surrounding assistive technologies? Are there are any federal policy barriers that make it difficult to offer tools and resources to patients to prevent falls?

 

Learning tools include community based evidence based programs, CDC Steady handouts, and other on-line resources. Unfortunately, since falls are hard to diagnose even for physicians, it is often inadequate without tailor-made clinician driven protocol.

 

Medicare. How can the “Welcome to Medicare” visit or the “Annual Wellness” visits be improved to better assess fall risk and fracture prevention and ensure appropriate referrals? How can Medicare coverage and reimbursement for falls prevention and fall-related services be improved? How are existing Medicaid waivers being utilized for falls prevention and fall-related services? Are there demonstrations or pilot programs that the Center for Medicare and Medicaid Innovation should consider?

 

Annual wellness and welcome to Medicare visits currently inquire about falls, unfortunately primary care providers need to be educated how to handle falls or be given resources of which specialists to refer patients to (see answer to question 1 above). Coverage should be based on value, which is defined as quality over cost. Quality should be based on baseline burden of disease, e.g. patient who falls once a year should not be compared to a patient who falls 3 times a day. Pilot program for comprehensive fall prevention program at Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute had been very successful based on preliminary data.

 

Evidence-Based Practices. Are there evidence-based practices that reduce the rate of additional bone fractures among those older Americans who have fallen and broken or fractured bones? Are there regional differences in the utilization of these services, evaluations, or screenings? Are there models (such as the Million Hearts Campaign) for other health conditions that have applicability to reducing the overall rate and impact of falls among the elderly?

Evidence based practices exist and are well known in the general community, however training is lacking in applying them adequately. For instance, falls and fractures can be prevented by treating osteoporosis and removing medications known to cause falls. However this is a general blanket statement. A particular patient may be taking medications associated with falls, but this may not be the reason patient is falling, for this particular patient may be falling and breaking bones because she or he had suffered from a stroke causing spastic hemiparesis, not because they have medications associated with falls. Again, see answer to question 1,  having the correct diagnosis is the key, and training physicians in obtaining  this correct diagnosis can be the game changer. Similarly, community based fall prevention programs have shown efficacy in preventing falls, but not every such program is appropriate for every patient at risk of falls. Pilot program for comprehensive fall prevention program at Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute had been very successful based on preliminary data.

Polypharmacy. What recommendations do you have to ensure prescribers take into account the relationship between polypharmacy and falls risk when making both initial and follow-up clinical decisions for high-risk patients? Is there a need for increased research on the link between polypharmacy and falls-related deaths and/or injuries?

 

Polypharmacy is associated with falls based on associative, not causative studies in most publications. Evidence is highly inconsistent with reducing falls after removing a particular pharmaceutic agent or reducing polypharmacy as an intervention. 2015 Updated Beers Criteria do not provide adequate guideline of when and how to adjust which medication. Again, recommendation is to train providers to identify for which particular patient polypharmacy is the high priority risk factor that needs to be modified. See answer to question 1 above for more detail. Yes there is need for more research on this, but only in context of comprehensive tailor-made patient specific model of fall prevention care.

 

Transitions of Care. How can the transitional period from a hospital or skilled nursing facility to the home be improved in assessing the home for fall risks? What more could be done by government agencies to support fall risk assessments and the implementation of protocols that could be used to prevent falls in the home care population?

 

Patients after discharge from hospital and nursing facilities are at increased risk of falls, highest at the first 2 weeks, but lasting up to 3 months based on different studies (this needs more studies). There is some research that this may be caused by hospitalization and bed-rest. Hospitals and nursing facilities currently, as a standard of care, assess patients' risk of falls using tools that predict falls in hospital, not after discharge from the facility. Patients are identified to be at high risk of falls while in hospital and inadequate measures are taken to reduce falls after discharge. This is unconscionable, how would you feel if your loved one were told that they are at high risk of cardiac events and did not have at the very least outpatient follow up at a specialty cardiac clinic? This is what is being done for patients at risk of falls. They are told that they are at high risk of falls and at best they are sent to primary care doctors or physical therapists to address fall prevention concerns. This is inadequate, for PCPs are not properly trained in the field of fall prevention and physical therapists do not have adequate diagnostic bandwidth to address this complex patient population. Patients at risk of falls should be sent to outpatient comprehensive fall prevention programs

 

Post-Fracture Care. What can be done to create a care pathway for patients post-fracture to ensure proper follow up care and prevention of future fractures? Are there best practice models that can provide implementation opportunities? Are there any federal policy barriers to implementing best practices in post-fracture care?

 

Post fracture care should include a comprehensive fall prevention clinic assessment, see answer to question 1 above.

 

L. Atanelov, Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute