Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders

Falls and mobility problems are two of the most common and serious concerns facing older adults. In addition to reducing function and causing considerable morbidity and mortality, falls and instability precipitate premature nursing home admissions. Impaired gait and balance, which rank among the most significant underlying causes of falls, are also common consequences of falls. Because older adults often do not report these problems to physicians, they may go undetected until after preventable injury and disabilities have occurred. Falls and mobility problems generally result from multiple, diverse, and interacting causes. After detecting a problem, clinicians must use careful and thorough diagnostic approaches to identify the most likely causes, contributing factors, and associated comorbid conditions, many of which will respond to intervention. Epidemiologic Considerations Both the incidence of falls and the severity of fall-related complications increase steadily after 60 years of age. Accidents are the fifth leading cause of death in older adults, and falls account for two thirds of these accidental deaths. Approximately 75% of deaths due to falls in the United States occur in the 14% of the population who are 65 years of age and older (1). Fall incidence varies among settings and populations. In persons 65 years of age and older, the lowest fall rates are reported among community-living, generally healthy elderly persons, between 30% and 60% of whom fall each year, for an overall annual rate of about 0.7 falls per person (1, 2). After 75 years of age, the rates increase markedly. Although most falls result in no serious injury, approximately 5% of elderly community dwellers who fall in a given year experience a fracture or require hospitalization, a proportion much higher than among younger persons who fall (1). Incidence rates for falls in nursing homes and hospitals (about 1.6 falls per bed annually) are two to three times greater than in the community, and complication rates are also considerably higher. Ten percent to 25% of institutional falls result in fracture, laceration, or need for hospital care (1). Thus, a key issue of concern is not simply the high incidence of falls in elderly persons, since children and athletes also have a very high incidence of falls, but rather the combination of a high incidence and a high susceptibility to injury. The injury susceptibility in older adults stems from a high prevalence of comorbid diseases (for example, osteoporosis, sarcopenia) and age-related decline (for example, slowed reflexes), which make even a relatively mild fall dangerous. Fear of falling and the post-fall anxiety syndrome result in loss of self-confidence and self-imposed functional limitations in both home-living and institutionalized elderly persons who have fallen (3). National data indicate that falls are the largest single cause of restricted-activity days among older adults (4), are a leading precipitating cause of nursing home admissions (1), and account for 6% of all medical expenditures for persons 65 years of age and older. The related problems of gait and balance disorders are also extremely prevalent among elderly persons and can have a similarly profound effect on physical health, quality of life, and capacity for independent living. Detectable gait abnormalities affect 20% to 40% of persons 65 years of age and older, approximately half of whom have a grossly abnormal gait (5). Gait problems are even more common in older subgroups; 40% to 50% of those older than 85 years of age are affected (5). In a large study of community-living persons 75 years of age and older, 10% needed assistance to walk across a room, 20% were unable to climb a flight of stairs without help, and 40% were unable to walk a half-mile (6). The important interaction between mobility disorders and falls is further highlighted by epidemiologic casecontrol studies conducted to identify risk factors that increase the likelihood of falling. Taken together, these studies indicate that lower extremity weakness, gait and balance disorders, previous falls, functional impairment, visual deficits, cognitive impairment, depression, and polypharmacy (defined as taking 5 prescription medications) are the most important risk factors for falls. For example, data summarized from 17 studies suggest that persons with readily identifiable leg weakness have a four- to fivefold increase in risk for falls, and persons with impaired gait or balance have approximately a threefold increase (1). Seven additional studies have identified specific risk factors for injurious falls (1, 7). In general, these risk factors are the same as those for noninjurious falls, with the addition of factors associated with osteoporosis (for example, being female, having decreased bone density, and being underweight) and the use of physical restraints. Perhaps as important as identifying individual risk factors is appreciating the interaction and probable synergism among several risk factors. Several studies have shown that the risk for falling increases dramatically as the number of risk factors increases. For example, three separate studies have reported that 65% to 100% of elderly persons with three or more risk factors fell in a 12-month observation period, compared with 8% to 12% of persons with no risk factors (1, 7-9). Clinical Approaches Numerous clinical approaches have been advocated for ameliorating the complex and serious concerns of falls and mobility problems in older persons. Many of these approaches have demonstrated efficacy and have become part of evidence-based guidelines, while others are still in the testing phase. The indicators described in this paper, which reflect the literature in this area, can be grouped roughly into three categories: 1) detection of the problem or problems; 2) diagnosis or evaluation of the problem or problems; and 3) treatment, with an aim toward preventing recurrence. The Figure illustrates a model linking detection, evaluation, and intervention and shows the relationship of each of the indicators to the overall picture of diagnosis and management. Figure. Falls and mobility problems: detection, evaluation, and intervention. Methods The methods for developing these quality indicators, including literature review and expert panel consideration, are detailed in a preceding paper (10). For falls and mobility problems, the structured literature review identified 4913 titles, from which relevant abstracts and articles were identified. On the basis of the literature and the authors' expertise, 10 potential quality indicators were proposed. Results Of the 10 potential quality indicators, 6 were judged valid by the expert panel process (see the quality indicators) and 4 were not accepted. The literature review that supports each of the indicators judged to be valid is summarized below. Quality Indicator 1 Inquiring about Falls ALL vulnerable elders should have documentation that they were asked at least annually about the occurrence of recent falls BECAUSE falls are common, often preventable, frequently unreported, and often the cause of injury and unnecessary restriction of activity, which results in a reduction in overall health and quality of life. In addition, a recent history of falls is a strong predictor of future falls. Supporting Evidence. While no controlled trials or observational studies directly demonstrated the benefit of inquiring about the occurrence of recent falls, a convincing chain of indirect evidence supports this practice: 1) Falls are frequently undetected; 2) people who fall are at increased risk for recurrent falls; and 3) falls are potentially preventable. Therefore, detecting falls is likely to reduce the likelihood of future falls. Several studies indicate that many problems (including falls) in the elderly population go undetected (11-13). In addition to causing injury, falls can be strong indicators of accelerating frailty and the presence of underlying, treatable risk factors (6, 14). Moreover, if no injury has occurred, patients and providers alike often ignore falls, thus missing important opportunities for potentially life-saving evaluation and treatment. A cornerstone of most fall-prevention programs is identification of risk factors, one of the strongest of which is previous falling. Inquiring regularly about recent falls can help detect this risk factor and lead to appropriate intervention. One study has shown that fewer falls go undetected (that is, fewer persons who fall are mislabeled as persons who do not fall) when the patient is asked about falls that occurred in the previous 1-year period than when he or she is asked about a shorter period, such as 6 months (11). The ultimate effectiveness of this screening strategy for improving outcomes has yet to be tested with controlled trials. Such trials are unlikely to take place, since most screening and case-finding studies in older adults are multifactorial and involve simultaneous screening for many different conditions, including falls. While most of these studies have shown positive benefits, disentangling the specific role of the fall-detection component is probably impossible (15). Quality Indicator 2 Detecting Balance and Gait Disturbances ALL vulnerable elders should have documentation that they were asked about or examined for the presence of balance or gait disturbances at least once BECAUSE normal balance and mobility are important to health and quality of life, and underlying, treatable problems often go undetected. Supporting Evidence. No controlled trials or observational studies could be found that directly demonstrated the benefit of routinely inquiring about or examining for the presence of balance or gait disturbances. Nevertheless, a convincing chain of evidence supports this practice: 1) Balance and gait disturbances are frequently undetected; 2) people with these problems are at increased risk for falls and