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CATCHFallers
Critical Assessment in a Teaching Clinic for High-risk Fallers
Donald Doell
Suzanne Morin
Joanne Creager
Gary Inglis
Danièle Benoit
Anita Tonet
Montreal General Hospital
http://www.CATCHFallers.com
Objective
Implement a simple decision Tool for residents
Identify, Assess, Intervene in cases of individuals at Risk of falls
We believe this will improve Case-identification of patients at risk for falls,
Medical interventions for fall risk reduction and increased number of
Referrals to specialized services
Overview
1. Significance of falls in the elderly
2. Identification of High-risk Fallers
3. Assessment for patients at high-risk for falls
4. Intervention can make a difference
1. Significance of falls in the elderly
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One out of every three individuals living in the community and
over the age of 65 will fall
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This rate will increase with more advanced age and among
institutionalized individuals
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Unintentional injuries are the fifth leading cause of death in
older adults with falls accounting for two thirds of these deaths
Falls result in significant morbidity
and mortality
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6% of falls will result in a fracture
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Of all fallers approximately 1% will sustain a hip fracture
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The incidence of mortality after one year is 20-30% for hip
fractures
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60% will be left with restricted mobility
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Other falls will result in significant soft tissue injury, head
injury, subdural hematoma
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Falls lead to significant fear of falling
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Falls lead to increased incidence of nursing home placement and
loss of autonomy
2. Identification of High-risk
Fallers
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History of falls is most predictive
In particular history of recurrent falls
Functional testing is useful in stratifying those who
may be at risk
The Timed-up-and-go (TUG)
>35s = High risk
15-35s
= Indeterminate risk
<15s = Low risk
Recommendations
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All persons over the age of 65 should be
questioned once per year about falls
Any individual with a history of recurrent falls
should have further assessment
If there is a history of a single fall in the last year,
then further functional testing (i.e. TUG) should be
used to risk stratify
Other Risk factors of
Particular Note
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Muscle weakness
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Gait deficit
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Balance deficit
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Use of assist device
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Visual deficit
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Arthritis
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Limitation in > 1 ADL (activity of daily living)
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Depression
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Polypharmacy (greater than 4 medications)
3. Assessment for patients at
high-risk for falls
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Falls are multifactorial
Approach to assessment and treatment must also
be multifactorial
Fall history and assessment
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History of the fall circumstances
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Review of medications
Number of medications
● Cardiovascular medications
● Psychotropic medications (neuroleptics,
benzodiazepines, and antidepressants)
● Review of acute or chronic medical problems
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Review of mobility status
Approach to exam for fallers
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Exam of vision
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Exam of gait & balance
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Exam of lower extremity joint function
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Exam of basic neurological function
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Mental status
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Muscle strength
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Lower extremity peripheral nerves
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Proprioception
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Reflexes
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Tests of cortical, extrapyramidal, and cerebellar function
Exam of basic cardiovascular status
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Heart rate and rhythm
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Postural pulse and blood pressure
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If appropriate, heart rate and blood pressure responses to carotid sinus stimulation
4. Intervention can make a
difference
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Multifactorial approach is most effective (can reduce falls
as much as 43%) and includes:
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Gait training and advice on the appropriate use of
assistive devices
Review and modification of medication, especially
psychotropic medication
Exercise programs, with balance training as one of the
components
Treatment of postural hypotension
Modification of environmental hazards
Treatment of cardiovascular disorders, including cardiac
arrhythmias
Single most important
interventions
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Exercise – Most effective strategy (fall reduction 19%)
Environmental Modification
Medication review, reduction and modification for
psychotropic medications
Summary
The CATCHFallers Concept Again
Implement a simple decision
Tool for residents
Identify, Assess, Intervene in cases of individuals at Risk of falls
We believe this will improve Case-identification of patients at risk for falls,
Medical interventions for fall risk reduction and increased number of
Referrals to specialized services
About the tool
An online survey for residents to complete that will guide
them through the proper assessment for high-risk fallers
http://www.CATCHFallers.com
The pre-study survey
CATCHFallers - Pre Study Questions
Critical Assessment in a Teaching Clinic for High-risk Fallers - A
pre-study survey for residents
Pre-study questions
1 Approximately how many patients over the age of 75 have you specifically asked for a
history of falls in the last three months?
Please write your answer here:
____________________
2 Approximately how many patients have you treated or investigated for an underlying
medical condition because of a possibly increased risk for falls in the last three
months?
Please write your answer here:
____________________
3 Approximately for how many patients have you changed or reduced the number of their
medications because of a possibly increased risk for falls in the last three months?
Please write your answer here:
____________________
4 How many patients have you referred for outpatient specialized or mulitdisciplanary
assessment because of risk of falls (i.e. physiotherapy, CLSC services, occupational
therapy, geriatric consultation) in the last three months?
Please write your answer here:
____________________
5 Approximately how many patients would you have liked to refer for outpatient services
but were were unable to because you were not aware how to or if these services were
available in the last three months?
Please write your answer here:
____________________
The CATCHFallers survey
Part I - Evaluation of risk
Evaluation of risk
Age What is the patient's age?
About one out of every three individuals living in the community and over the age of 65 will fall. This rate
will increase with more advanced age.
Plese write your answer here:
____________________
Fall history
Is there a history of a fall in the past year?
All older persons should be asked at least once a year about falls. All older persons who report a single fall
should have a TUG.
Please choose *only one* of the following:
o Yes
o No
Multiple falls
Is there a history of recurrent falls in the past year?
Older persons who present for medical attention because of a fall or report recurrent falls in the past year
should have a fall evaluation performed.
Please choose *only one* of the following:
o Yes
o No
TUG
How long did it take the patient to perform a TUG (timed-up-and-go)?
The time it takes for an individiual to stand up from a chair, walk to a line 3 meters away on the floor using
usual aids at a usual pace, turn around and walk back to the chair and sit down.
TUG < 15s = low risk
TUG 15s-35s = indeterminate risk
TUG > 35s = high risk
Please write your answer here:
____________________
Risk
Do you think this patient might be at risk for falls?
Please choose *only one* of the following:
o Yes
o No
The CATCHFallers survey
Part II - Evaluation of modifiable risk factors
Evaluation of modifiable risk factors
Number of meds
How many medications does this patient take?
Increased risk of falls has been demonstrated with greater than four medications.
Please write your answer here:
____________________
Barthel
What is the Patient's Barthel Score?
link to an online calculator here: www.patient.co.uk/showdoc/40001654/
Please write your answer here:
____________________
History findings
Have you identified a predisposing risk factor for falls in your history?
Should include a history of fall circumstances, acute or chronic medical problems, and mobility levels. Pay
particular attention to muscle weakness, gait deficit, balance deficit, use of an assistive device, visual
deficit, arthritis, depression, cognitive impairment, cardiovascular causes as risk factors.
Please choose *only one* of the following:
o Yes
o No
Exam findings
Have you identified a predisposing risk factor for falls in your exam?
Should include examination of vision, gait and balance, and lower extremity joint function; an examination of
basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves,
proprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function; and assessment of basic
cardiovascular status including heart rate and rhythm, postural pulse and blood pressure.
Please choose *only one* of the following:
o Yes
o No
Medication
Have you identified a predisposing risk factor in this patient's medications?
Pay particular attention to any psychotropic medication (neuroleptics, benzodiazepines, and antidepressants)
Please choose *only one* of the following:
o Yes
o No
The CATCHFallers survey
Part III - Documentation of
Intervention
Documentation of Intervention
Medication change
I have changed or modified this patient's medications, because of risk of falls.
Reduction in total number of medications if greater than four, or modification of medications especially
psychotropic medications.
Please choose *only one* of the following:
o Yes
o No
Medical condition
I will investigate or treat an underlying medical condition that may be implicated in
this patient's risk for falls.
Pay particular attention to cardiovascular intervention, treatment and investigation of postural hypotension
and visual impairment.
Please choose *only one* of the following:
o Yes
o No
Outpatient
I have referred this patient for outpatient multidisciplinary assessment.
Exercise programs are
extremely effective in preventing falls and may be one of the single
most effective preventative strategies, particularly when combined as
part of a multifactorial intervention.
Please choose *only one* of the following:
o Yes
o No
Bottom
Bottom Line
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Line
In the universe some things are constant
Exercise – Single most effective strategy
Environmental
Modification
Gravitational
constant
= 6.67300 × 10-11 m3 kg-1 s2
Medication review, reduction and modification for
psychotropic medications
The elderly will continue to fall
Falls can be prevented
References
Bottom Line
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Laurence Z Rubenstein and Karen R Josephson Falls and their prevention in elderly people:
what does the evidence show? 2006
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Guideline for the prevention of falls in older persons. American Geriatrics Society, British
Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention.
2001
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Exercise – Single most effective strategy
Kerri M Clough-Gorr and Thomas
Erpen and Gerhard Gillmann and Wolfgang von RentelnEnvironmental
Modification
Kruse and Steve Iliffe and John C Beck and Andreas E Stuck Preclinical disability as a risk
factor for falls in community-dwelling older adults. 2008
Medication review, reduction and modification for
Ellinor Nordin and Nina Lindelöf and Erik Rosendahl and Jane Jensen and Lillemor LundinOlsson Prognostic validity
of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's
psychotropic
medications
global judgement and fall history in evaluating fall risk in residential care facilities. 2008
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Anne Tiedemann and Hiroyuki Shimada and Catherine Sherrington and Susan Murray and
Stephen Lord The comparative ability of eight functional mobility tests for predicting falls in
community-dwelling older people. 2008
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Cameron G Swift The role of medical assessment and intervention in the prevention of falls.
2006
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Theodore Speroff and Gerald T O'Connor Study designs for PDSA quality improvement
research. 2004
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