An Interprofessional Approach to Fall Prevention: Strengths, Barriers & Future Directions

This educational session, facilitated by Dr. Jim Cavanaugh is the first in a series of annual IPE events focusing on Fall Prevention. This series highlights aspects of the problem of falls and fall-related injury in various populations and will emphasize an interprofessional prevention perspective. The session will include an interprofessional case conference discussion about a specific individual with a recent history of recurrent falls.

By the conclusion of the session, individuals in attendance should be able to:

• Identify potential medical, social, psychological, and economic consequences of recurrent falls.
• Discuss the imperative of comprehensive, interprofessional team management of an individual at high risk for future falls.
• Compare and contrast role and training of various health professionals involved in fall prevention.
• Suggest future directions to improve the effectiveness of fall prevention efforts.

Materials for Case Conference (added 9/21)

A 79-year old woman in stable medical condition is referred by her primary care physician to a Geriatric Fall Risk Assessment Clinic.  She has fallen twice in the last 3 months. One fall occurred at night during a trip to the bathroom.  She remembers feeling unsteady at the time.  The other fall occurred during the day while she was taking out the garbage.  Apparently she lost her footing on a step. She needed help to get up after each fall.  She sustained only minor bruising and joint pain, both of which resolved without complication. There were no reported prior falls.

Current Medical Conditions: Congestive heart failure, osteoarthritis, osteopenia, depression, and insomnia.  All conditions stable.  Past medical history is unremarkable.

Medications: antidepressant, a diuretic, an angiotensin-converting enzyme inhibitor, and a beta-blocker, as well as over-the-counter sleep and allergy medications:

Remeron 30 mg po qd
Zaroxolyn 10 mg po qd
lisinopril 10 mg po qd
Coreg CR 40 mg po qd
Sominex (OTC) as directed and needed for insomnia
Benadryl (OTC) as directed and need for allergies

Allergies
SULFA drugs
Olive trees, Bermuda grass

General Function: Independent in all basic self-care but reports having increasing difficulty getting in and out of the bathtub.  Walks independently around the house and in yard.  Walks 20 minutes every day “for exercise” in the neighborhood or at mall using a straight cane.  Does not engage in other forms of exercise.  Able to independently prepare simple meals and do light housework; usually prepares most of her meals.  Due to diminished confidence about her ability to see things well enough to be safe, she drives during day only to local market or church.   Ventures into community 3-4 days / week.

Social History:  Widowed x 10 years.  Catholic. Retired seamstress.  Smoked ½ pack cigarettes / day x 30 years (quit at age 50).  Does not drink alcohol. Now lives with daughter (divorced; age 45) and her 2 grandchildren (ages 16 and 13). 

Living Environment: One story house. Several steps with railings at each entrance. Has own bedroom.  Uses shared bathroom with tub shower. Daughter works full-time. Children attend neighborhood schools.

Available Lab Results: DEXA scan T score = - 1.0 at femoral neck and lumbar spine. 

Review of Systems:  Reports occasional unsteadiness especially when rising from a chair, bed, or commode; reports recent urge to urinate and worries about bladder control.  Reports eating “adequately” but with reduced interest in food due to trouble with her dentures.

Team Physical Exam (relevant remarkable findings): 
•    Vitals: BP (sitting): 130/82; HR: 87; RR: 16; Temp: 98.5 F; Pain: 2/10 left knee ache.

•    Appearance:  Well-dressed, endomorphic, elderly female in no apparent distress.  Height: 5’4”; Weight: 122#; BMI: 21.0. 

•    Oral Health:  Loose-fitting dentures.

•    Cognition:  Alert; Oriented x 4; Mini-Mental Status Exam: 25/30.

•    Mood:  Pleasant but somber; Geriatric Depression Score 6/15.

•    Cardiovascular:

 Supine x 5 minutes
Standing (1 minute)
Standing (3 minutes)

BP128/80110/78125/80

HR828383

Postural sway
n/aaccentuatednormal

SymptomsNone"unsteady"none

Mild edema both feet and ankles; dorsalis pedis pulses intact bilaterally.

•    Integumentary:  Small sores noted at corners of her mouth. Otherwise, skin is generally intact, warm, and dry throughout.  Fingernails well manicured; toenails need clipping.

•    Musculoskeletal:  Kyphotic posture; - 5 degrees hip extension bilaterally; 0 degrees ankle dorsiflexion bilaterally.  Gross strength 4/5 throughout. 

•    Neurological:  PERRLA.  Cranial nerves intact.  Deep tendon reflexes brisk throughout. Delayed but generally accurate response to vibratory testing bilateral great toes.  Loss of protective sensation on 10g monofilament testing at 1st, 3rd, and 5th toes and metatarsal heads bilaterally.

• Vision: Acuity (corrected wearing bifocals):  20/20 bilaterally; Acuity (uncorrected):  20/30 left; 20/60 right.  Evidence of cataract bilaterally.
• Gait / Balance / Mobility:  Timed Up and Go Test: 13 seconds (with cane); 15 seconds (without cane).  Cane is correctly sized for her height, and she uses the cane appropriately when walking. Rises from chair without using arms but 1-second hesitation before initiating gait; cautious, wide based turn; generally symmetrical gait; No retropulsion on posterior nudge. Functional reach = 7.” Unable to pick a penny off the floor without assistance. Able to remove shoes and socks independently.

Fall Prevention Awareness Day
http://www.healthyagingprograms.org/content.asp?sectionid=149

Ganz DA et al. Will my patient fall? JAMA 2007;297(1):77-85.
http://jama.ama-assn.org/cgi/reprint/297/1/77

UNE Library Resources on Preventing Falls in Older Adults:
http://www.une.edu/library/gethelp/courseguide/ptfalls.cfm

Center for Disease Control:  Falls Among Older Adults
https://www.cdc.gov/falls/

National Council on Aging: Falls Free Coalition
http://www.healthyagingprograms.org/content.asp?sectionid=113

Daal JO and van Lieshout JJ. Falls and medications in the elderly. Netherlands Journal of Medicine 2005; 63(3):91-96.
http://www.njmonline.nl/njm/getpdf.php?t=a&id=374

Woolcott JC et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009;169(21):1952-960.
http://archinte.ama-assn.org/cgi/reprint/169/21/1952

Carnahan RM. How to manage your patient’s dementia by discontinuing medications. Current Psychiatry 2010;9(7):34-37.
http://www.currentpsychiatry.com/article_pages.asp?AID=8779&UID=