Fall Prevention…..Where are we at?
Hello again! So up until now, we have discussed the history of falls in the elderly and the policy related to preventing those falls. We have also discussed where the gap is in the current fall prevention process. So, what does the literature say about fall prevention? There are three levels to prevention. There is primary prevention that addresses the fall before it happens. This could be as simple as a primary care provider going through a person’s home medications and eliminating medications that are unnecessary and increase the risk of falls. Secondary prevention for falls focuses on the screenings that are in place for fall prevention. One example of this is the fall screening tool, STEADI, which has been mentioned in previous blog posts. Tertiary prevention is the interventions that happen AFTER a fall. If a person comes into the hospital with a broken hip because of a fall, the hospital will fix the broken hip and tertiary strategies will be used to prevent another fall in the future. The case manager may screen the patient for home assistant devices and help and physical therapy may recommend rehab for strengthening. That’s great!...... If we knew the patient fell. But what happens to the patient that fell in the community that may have not needed to go into the hospital for treatment? Where do they get the tertiary prevention strategies and how do we identify them?
Getting evidence for policy change........
When looking to change policy many policymakers look for systematic reviews of the literature to base the standards of policy (Fielding & Briss, 2006). Systematic reviews are one of the highest and most reliable levels of evidence. The United States Prevention Services Taskforce (USPSTF) is an organization that uses systematic reviews and recommends best practices and screenings for the prevention of many diseases. The USPSTF recommends risk assessments/screenings, exercise interventions, vitamin D supplementation, and multifactorial interventions for fall prevention in community-dwelling adults (Grossman et al., 2018). Multifactorial interventions include assessments and interventions for gate and balance, vision, cognition, medication, and environmental risks. The USPSTF does not support routine multifactorial screenings on everyone but does recommend it after fall (Grossman et al., 2018). How often are these tertiary interventions being missed because healthcare professionals are not aware that a patient has a fall? If we could identify as many patients in the community as possible that are having falls, we could assist those elderly people with the resources that are available for tertiary prevention. This could include the resources that Medicare and Medicaid offer for fall risk assessments and home modification assistance (Falls Prevention: National, State, and Local Solutions to Better Support Seniors Special Committee on Aging United States Senate, 2019; National Conference of State Legislatures, n.d.).
Helping the elderly after a fall
Primary and secondary fall prevention strategies are very well established in policy. The previous legislative work shows that the standard of care is for healthcare professionals to incorporate primary and secondary prevention strategies into their care of the patient. Exercise, screenings, and medication assessment is recommended (Falls Prevention: National, State, and Local Solutions to Better Support Seniors Special Committee on Aging United States Senate, 2019; Grossman et al., 2018). Not only are these interventions recommended, interventions like home-based exercise programs are shown to decrease falls in the future (Lui-Ambrose et al., 2019). The next step is to make sure that the elderly in the community are getting the post fall prevention care that they need and the first step to doing this is to make sure that we have a reliable strategy to identify who has fallen in the community. In people that are high risk and/or have had previous falls, multifactorial risk assessments should be completed and the patient should be referred to community exercise and community fall prevention groups (Van Voast Moncada & Mire, 2017). The referrals could come from the emergency department or primary care provider.
We need to create a policy where healthcare professionals are held accountable for
1) guaranteeing that we are screening for previous falls,
2) tracking previous falls in the community, and
3) making sure that the patients are getting the referrals and access to resources for tertiary fall prevention.
Only then we will be serving our elderly community members well.
A place to start
Now we have to identify the challenges to evidence-based policymaking: making innovative solutions, evaluation of those solutions, using the evidence, targeting outcomes, and organizing multidisciplinary collaboration (Liebman, 2013). A place to start this new policy is the primary care and the emergency department. A recent study found that screening all older adults when they come to the emergency department to see if the visit was related to a fall was reasonable for increasing the identification of falls in older adults (McFadden et al., 2020). Another study in the emergency department focused on pharmacy and physical therapy interventions in the emergency department after a fall in the community and then referral to primary care for a follow up (Goldberg et al., 2019). This is where the future of fall prevention should be headed and the first step to this is making sure that we are identifying more reliably who has fallen in the community so that we can support our highest risk population.
References
Falls prevention: National, state, and local solutions to better support seniors Special Committee on Aging United States Senate. (2019). https://www.aging.senate.gov/imo/media/doc/SCA_Falls_Report_2019.pdf
Fielding, J., & Briss, P. A. (2006). Promoting evidence-based public health policy: Can we have better evidence and more action? When the science base is adequate, policymakers can more rapidly translate results into decisions and then into actions. Health Affairs, 25(4), 969–978. https://doi.org/10.1377/hlthaff.25.4.969
Goldberg, E. M., Resnik, L., Marks, S. J., & Merchant, R. C. (2019). GAPcare: The geriatric acute and post-acute fall prevention intervention - a pilot investigation of an emergency department-based fall prevention program for community-dwelling older adults. Pilot and Feasibility Studies, 5(1), 106. https://doi.org/10.1186/s40814-019-0491-9
Grossman, D. C., Curry, S. J., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Kemper, A. R., Krist, A. H., Kubik, M., Landefeld, S., Mangione, C. M., Pignone, M., Silverstein, M., Simon, M. A., & Tseng, C. W. (2018). Interventions to prevent falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. JAMA - Journal of the American Medical Association, 319(16), 1696–1704. https://doi.org/10.1001/JAMA.2018.3097
Liebman, J. B. (2013). Building on recent advances in evidence-based policymaking. https://www.brookings.edu/research/building-on-recent-advances-in-evidence-based-policymaking/
Lui-Ambrose, T., Davis, J. C., Best, J. R., Dian, L., Madden, K., Cook, W., Hsu, C. L., & Khan, K. M. (2019). Effect of a home-based exercise program on subsequent falls among community-dwelling high risk older adults after a fall: A randomized clinical trial. JAMA - Journal of the American Medical Association, 321(21), 2092–2100. https://doi.org/10.1001/jama.2019.5795
McFadden, G., Hall, S., Gleason, L. J., Herrera, O., & Hogan, T. (2020). Identification of older adult fall occurence by brief emergency department triage screen. Journal of the American Geriatrics Society, 68(2), 442–443. https://doi.org/10.1111/jgs.16271
National Conference of State Legislatures. (n.d.). Elderly falls prevention legislation and statutes. Retrieved February 13, 2022, from https://www.ncsl.org/research/health/elderly-falls-prevention-legislation-and-statutes.aspx
Van Voast Moncada, L., & Mire, L. G. (2017). Preventing falls in older adults. American Family Physician, 96(4), 240–249.
Good afternoon Shurine!
First off, I would like to say that you have been very thorough on this topic and you have done a great job outlining current gaps in prevention and screening services currently available. I think falls is something everyone cringes to think of in the hospital setting, but working in pediatrics, I never thought about the difficulty of prevention in the community setting for the elderly. I was also not aware of existence of The United States Prevention Services Taskforce (USPSTF) organization, so thank you for that information. As you stated and according to the that special committee report you shared by Collins and Casey (2019), fall risk assessments and home modification assistance is available but no…