Journal Club Podcast #18: November 2014
Chris Carpenter, Mike Galante, and I get together to talk about two things we all do eventually: growing old and falling down...
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Mrs. C., an 86-year old female, presents to your academic emergency department (ED) via ambulance after an accidental fall at home. She is a recent widower and lives alone, but she reports that she has two adult “children” that live nearby and check on her every day either in-person or by telephone. About 12-hours prior to ED presentation today she was walking to the bathroom from her bedroom when she tripped over something and fall onto her left side. She notes left wrist and left hip pain, but denies loss of consciousness, headache, chest pain, dyspnea, abdominal pain, or focal weakness. She was unable to lift herself off the floor last night and was found by one of her grandchildren in the morning. EMS reports a well-kept home without any obvious cause for her fall.
Her vitals are BP 160/85, P 60, RR 16, T 37.4°C, and her room air pulse ox is 100%. She is somewhat overweight and in no apparent distress, although she notes that her left hip and wrist hurt to touch or move. You note no contusions or swelling over the hip or wrist, nor does your physical exam demonstrate any other abnormal findings. Her x-rays of the hand/wrist/forearm/pelvis and hip are unremarkable, as is an x-ray of her C-spine. You are not concerned with an occult scaphoid fracture of her wrist. However, due to her persistent left hip pain you order a MRI of her hip/pelvis and no fracture is demonstrated. With adequate opioid analgesia, Mrs. C’s pain is well-controlled and she is able to ambulate with minimal discomfort so you plan discharge home. You notify Mrs. C and her son of these findings and plan, and call the referring physician to notify her. However, her son asks you how likely it is that Mrs. C will fall again and how to prevent future falls. You’ve just heard Dr. Sam Smith’s Washington University lecture about FOAMed and decide to listen to the Skeptics Guide to Emergency Medicine podcast “Falling to Pieces” about geriatric adult fall-risk stratification in the post-ED period. The podcast discusses a prognostic systematic review on this topic, which you decide to read to learn more. The systematic review provides you with a search strategy to find more published research on this topic.
PICO Question #1
Population: Geriatric patients in the ED
Intervention: Risk-stratification for falls and injurious falls in the months following an episode of ED care
Outcome: Sensitivity, specificity, likelihood ratios for fall-risk
PICO Question #2
Population: Geriatric patients in the ED
Intervention: Fall-prevention program + post-ED discharge standard care
Comparison: Post-ED discharge standard care
Outcome: Falls or injurious falls in the post-ED discharge period
You note that the systematic review provides exhaustive (3-pages!) PUBMED and EMBASE search strategies in Data Supplement 1. You decide to go another direction so you conduct a “broad” search using the prognostic study filter using PUBMED Clinical Query and the search term “geriatric fall*” yielding 5 citations, including the systematic review (see http://tinyurl.com/orjnsdk).You obtain the rest of the PICO Question #1 research manuscripts by reviewing the results and the bibliography of the systematic review. For PICO Question #2, you use the therapy study filter on PUBMED Clinical Query and the search term “fall prevention elderly” yielding 71 citations (see http://tinyurl.com/nkb4x9n).
Standing level falls are the number one cause of geriatric trauma-related mortality with 33% of those over age 65-years falling each year (increasing to 50% of those over age 80)! One-in-five falls results in an injury and 44% of individuals with fall-related hospital admissions are readmitted to the hospital within 1-year with 33% 1-year mortality. Fallers represent a population with substantial recurrent healthcare use. A history of falls also predicts post-operative complications in older adults undergoing major elective surgery. Elderly falls frequently precipitate a vicious circle of fear of falling, social isolation, diminished quality of life, and increased short-term mortality. Even those with minor fall-related injuries discharged home from the ED experience recurrent falls, functional decline, and ED returns within 3-months.
In 2010, EMRA, SAEM, ACEP, AGS, AMA, and ABEM published emergency medicine resident core competencies for geriatric ED care, which included
· In patients who have fallen, evaluate for precipitating causes of falls such as medications, alcohol use/abuse, gait or balance instability, medical illness, and/or deterioration of medical condition.
· Assess for gait instability in all ambulatory fallers; if present, ensure appropriate disposition and follow-up, including attempts to reach primary care provider.
· Assess and document the presence of comorbid conditions (e.g. pressure ulcers, cognitive status, falls in the past year, ability to walk and transfer, renal function, and social support) and include them in your medical decision-making and plan of care.
In addition, ACEP, AGS, ENA, and SAEM jointly wrote and released the “Geriatric ED Guidelines” in 2014 that includes protocol and quality improvement recommendations for fall management in the ED setting. Unfortunately, emergency physicians rarely evaluate fall risk and older adults who present to the ED for evaluation after a fall rarely receive guideline-directed management (Donaldson 2005, Naughton 2012).
Where is the disconnect between awareness that geriatric falls are a prevalent and clinically important problem? The Knowledge Translation Pipeline (Figure) provides a framework to understand. Awareness by ED providers that geriatric falls is probably not a large “leak” – but awareness that fall-risk screening tools exist, where to find them, and how to interpret them – likely is. The next “leaks” of acceptance and applicability are probably large “leaks” in the pipeline, since healthy skeptics legitimately challenge the quality of ED-based fall research and how valid these findings are for real-world settings. This Journal Club addressed many of those issues.
The PGY-I paper assessed fall-risk factors for community-dwelling geriatric patients presenting to (and discharged home from) one U.S. ED for any reason except a fall. They identified four risk factors (non-healing foot sores, past falls, inability to cut own toenails, self-reported depression – the “Carpenter instrument” – see box) as independently associated with 6-month fall risk, but this model/risk prediction instrument requires validation followed by feasibility and effectiveness testing before widespread use. They also noted that objective tests of gait and balance do not predict 6-month falls in ED populations, but these performance tests are reliable (Intraclass Correlation Coefficient = 0.95 for distinguishing “normal”, “borderline”, or “abnormal”).
The PGY-II manuscript described the “Tiedemann instrument”, a 2 question fall risk stratification tool. Unfortunately, the Tiedemann instrument does not significantly increase or decrease fall risk on individual patients who have been to ED for a fall-related compliant or with a history of multiple recent falls. As in the PGY-I study, they also found that current objective performance tests (like the timed Get up and Go) in the ED do not accurately predict future falls.
The PGY-III manuscript was a prognostic systematic review from the Academic Emergency Medicine Evidence Based Diagnostics series. This study found that no risk factor (including past falls and objective tests of gait/balance) accurately increase or decrease the risk of falls in the 6-months following ED discharge. In addition, the only ED fall-risk screening instruments that exist in 2014 are the Carpenter and Tiedemann instruments described above. Of these two instruments, a Carpenter score >1 has a negative likelihood ratio of 0.11 (95% CI 0.06-0.20) and most accurately identifies older adults at lower risk of falls. Neither instrument accurately identifies the subset at greater risk of falls. Based upon the sensitivity/specificity (93% and 61%, respectively) of the Carpenter instrument at threshold >1, benefit of fall-risk intervention derived from the PROFET study (20% absolute risk reduction), and hypothesized risk of fall-screening of 0.5% and risk of intervention in patient without fall-risk 2%, the test threshold was estimated at 7% and the treatment threshold at 27%. In other words, continuing to assess fall-risk in patients at less than 7% risk may harm more patients than are helped. Similarly, continuing to assess fall-risk in those with >27% risk may also harm more patients than are helped.
The PGY-IV manuscript evaluated a fall-prevention intervention in England, but their approach was not really ED-based and the resources available to these investigators via the British National Healthcare System are generally unavailable in the U.S. Nonetheless, they found that community-dwelling adults over age 65 who visit the ED following a fall demonstrate reduced fall rates (Number Needed to Treat to prevent one fall = 5) with an intensive medical evaluation and occupational therapy home safety assessment in the weeks following the index fall. Replication of these results necessitates a universal healthcare system where every patient has insurance and a primary care physician, as well as access to a one-stop shopping Day Hospital for multi-disciplinary assessment when indicated based on the medical evaluation. In addition to these system-level requirements, future studies should evaluate real-time ED based interventions, using validated fall-risk screening instruments, and assess frailty, dementia and health literacy as confounding variables.
Although this research fails to provide a definitive fall screening strategy recommended by AGS/BGS Fall Guidelines, ACEP/SAEM Geriatric ED Guidelines, and EM resident core competencies, the status quo is unacceptable and the quantitative summary estimates of fall incidence and risk factor accuracy and reliability provide an evidence basis on which clinicians, nursing leaders, administrators, educators, policy-makers, and researchers can build. Fall prevention (both risk stratification and interventions) in ED settings has been disappointing and largely unsuccessful. No single risk factor significantly increases or decreases the risk of 6-month falls for geriatric ED patients. In one single-center study, the “Carpenter instrument” identified low-risk patients (LR- 0.11), but additional research is needed to reproduce these results and no instrument accurately identifies high-risk patients. The ideal fall risk screening instrument would be accurate and reliable, sufficiently brief for routine ED use by clinicians, nurses, or ancillary staff, and not require equipment that is not routinely available in the average ED.
Accurate assessment of post-ED fall risk also has implications for fall prevention intervention studies. Since fall risk is unlikely to remain static throughout an episode of ED care (or for the 6-months following an episode of ED care), the fluid nature of fall vulnerability suggests that within-ED and post-ED repeat fall-risk assessment is logical (but never studied). In addition, since a one-size-fits-all approach to fall prevention has been largely unsuccessful, more accurate fall-risk stratification could provide feasible, targeted strategies upon which to focus interventions towards the unique fall profile of the individual patient using adaptive clinical trial design.
Several attendees at Journal Club suggested that health-literacy appropriate ED discharge instructions that educate patients about fall-risk factors in the home would be worthwhile. Figure 2 below (from Carpenter CR; Falls & Fall Prevention in the Elderly in Geriatric Emergency Medicine Principles and Practice; Kahn JH, Magauran BH, Olshaker JS (eds); Cambridge Medicine 2014, pages 345-346) Incorporating a version of this figure into our fall discharge instructions is a future resident Quality Improvement project.
Future ED fall risk instruments need to assess geriatric syndromes (dementia, delirium, depression, and frailty) objectively, evaluate more objective measures of fall outcomes (smart phones, body sensors, other passive monitoring devices), and employ readily available ED personnel for fall-risk screening to ensure external validity and reproducibility. Since not every fall is an injurious fall, developing a fall severity grading scale is also worthwhile. Multiple fall-risk instruments have never been assessed in ED settings, including ABCS, CAREFALL, FROP-COM, HOME FAST, Hendrich II, STRATIFY, University of Pittsburgh, New York-Presbyterian, Johns Hopkins, Maine Medical Center, Morse Fall Scale, and the Spartanburg Fall Risk Assessment Tool. In addition, future research should use accepted clinical decision rule methods for derivation & validation and STARD-criteria for the conduct and reporting of diagnostic research. SAEM, AGS, and the NIA published high-yield ED falls research priorities in 2011. Based on our review of the literature, this research agenda remains unchanged in 2015.
1) Can high-risk geriatric fallers who require admission or expedited outpatient evaluation be identified in the ED?
2) Can simple and feasible interventions reduce fall or injurious fall rates after the ED visit?
3) Could rapid response teams or special ED-associated units evaluating geriatric adults at increased risk for recurrent falls reduce fall-related injuries and improve the efficiency of inpatient resource utilization?
4) Can hospital-at-home models for management of high-risk fallers be developed, and what are the characteristics of models that successfully lower falls rates?
5) What are the key elements of electronic information systems that facilitate point-of-care risk stratification and communication of high-risk finds to emergency providers and primary care physicians?