Monday, August 21, 2017

STEADI-ing our older patients against falls

- Jennifer Middleton, MD, MPH

Falls can feel like an inevitable part of aging, but with just a little effort and teamwork we can help keep our older patients safe. The current issue of AFP reviews several evidence-based resources at our disposal in a feature article and an accompanying editorial, including the Centers for Disease Control's (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program.

The authors of the feature article, Preventing Falls in Older Persons, review the prevalence and risk factors for falls in the United States along with relevant Choosing Wisely recommendations. They provide an algorithm from the STEADI toolkit to identify patients at risk for falls using a patient checklist and the Timed Up and Go (TUG) test. Incorporating these 2 screening instruments into the Welcome to Medicare Visit fulfills the requirement to review functional ability and level of safety. Recommending physical therapy, reviewing medications, and ensuring home safety, visual correction, and appropriate footwear have been found to benefit patients at moderate to high risk of falling. Prescribing vitamin D is also recommended for some older adults, though Dr. Lin has written previously on the blog about the limited benefit of vitamin D supplementation for community-dwelling elders.

The accompanying editorial discussing the STEADI initiative reviews the costs for caring for older adults after a fall ($31 billion a year from Medicare alone) along with the development and components of the STEADI initiative: screen, assess, and intervene. A 2016 Community Blog guest post by Dr. Stephen Hargarten of the CDC reviewed each of these STEADI components. Plans to integrate STEADI screens and interventions in electronic health records (EHR) should assist physicians with incorporating falls assessment into our everyday workflow; while waiting for these build updates to arrive, creating a macro or template of the STEADI checklist within your own EHR might be useful.

Besides the printed materials available at the CDC's STEADI website, a quick search of your smartphone's app store will turn up an app or two for administering the TUG test; although I could not find any that were rigorously evaluated, the test is simple enough that a quick practice run using the app should demonstrate its utility. Family Practice Management has a topic collection on Medicare Annual Wellness Visits with tools for incorporating fall prevention into your practice, and there's an AFP By Topic on Geriatric Care that includes articles on gait and balance disorders as well as writing exercise prescriptions. Your office team might want to measure its progress with implementing these changes with a plan-do-study-act (PDSA) cycle, and the Institute for Healthcare Improvement has a video reviewing PDSA cycles along with a worksheet for charting the outcomes of your chosen intervention. You can obtain continuing medical education (CME) credit by completing the CDC's STEADI online course and/or by completing a Knowledge Self-Assessment (KSA) for the American Board of Family Medicine on Care of Vulnerable Elders.

Which of these resources have you and your office team found useful for helping reduce your elderly patients' fall risk? Which new resource are you eager to investigate?