Fall Risk Assessment:
Domain of the Podiatrist?
Part 1

Recently, I had the pleasure of reading Dr. Atul Gawande's new book Being Mortal: Medicine and What Matters in the End. This is another exceptional and thoughtful book in an increasing line of excellent medical literature. If you haven't read any of Dr. Gawande's books, I highly recommend any of them. In case you're unaware who he is, Atul Gawande is a Harvard trained general surgeon who is also a writer for the New Yorker Magazine and has written several books about various topics of modern medicine.

Dr. Gawande's most recent book, Being Mortal, focuses our attention on the role of the medical profession in patient care at the end of life. He discusses various topics such as prolonged life span with modern medical treatment, hospice care, and assisted living, among others. Dr. Gawande also provides various anecdotes to highlight his views, and during one of these stories – while discussing the role of debility and weakness in the elderly and the role of geriatrician specialists – he mentions a geriatrician referring a patient with a fall history to a podiatrist as part of the multispecialty care his patient received.

I found this statement interesting in a couple of ways as it relates to podiatry. First, good for the geriatrician for referring his patient to podiatry. Second, good for Dr. Gawande to include our humble specialty in his book. Third, and most important, this discussion highlights the importance of fall prevention in our patients, especially when most of us see older patients.

		Tonight's Premier Lecture is Precision Osteotomies in Podiatric Surgery Jerome Slavitt, DPM, FACFAS

My question to you, then, is what do you do to assess fall risk and prevent falls in your elderly patients?

My response to this question is a somewhat sheepish "very little." At the risk of receiving criticism, I'll admit that I don't generally do a fall risk assessment. I dispense diabetic shoes, educate my patients about appropriate shoe gear, debride nails, dispense orthoses, and occasionally prescribe physical therapy for global body strengthening in addition to the surgical part of my practice.

But in the past – up to recentlyl when I increased my awareness through Dr. Gawande's writing – I did not have a formal program for fall risk assessment. As a result, I've been doing research about creating a fall risk assessment and prevention program in my own practice. I'll say at the outset that fall risk assessment is one of the components of the Patient Quality Reporting System (PQRS) on which I've previously reported. For the interested, I'm including the reporting measures that you might consider adding to your PQRS reporting.

What's important and significant about this is that podiatry as a profession is uniquely situated to contribute to overall health improvement in much the same way that we have contributed to the improved care for diabetic patients. We made the diabetic foot and the lower extremity an area of dominance simply by paying attention and applying the skills we already had to the problem.

In much the same way, we have a significant potential impact on the geriatric population through this very important preventive measure. Currently, physical therapists are the principle specialty involved in fall risk assessment and for obvious reasons. When it comes to preventing falls, making patients physically stronger is an important step.

As it so happens, though, it's not just about strength. Falls – and their large negative health impacts - occur as a result of many factors such as osteoporosis, vision loss, proprioceptive problems, foot deformities, and poor shoe gear among others. Podiatrists, as specialists with a unique understanding of medicine, surgery, and biomechanics, are well situated to contribute in a major way to our elderly patients' health.

The big question, then, is how does the busy podiatrist incorporate a rapid and reasonably detailed fall risk assessment and prevention plan into current practice? Based on some preliminary research I've been doing, we'll discuss here a rapid fall risk assessment. In next week's issue, we'll review some of the treatment options that have been shown to help our patients at greatest risk for falls.

Rapid Fall Risk Assessment

This risk assessment consists of two basic parts: a history and physical. For the history portion, consider asking the following questions:

Fall History

1. Ask all elderly about fall history.
1. If they've had falls, ask about frequency, circumstances, balance problems → perform multifactorial risk assessment.
2. If one fall → assess balance, gait. → if fail assessment → multifactorial risk assessment.
2. Ask about dizziness standing (postural hypotension).
3. Review the medication list. All of the following drugs have been associated with increased falls.¹
1. antiarrhythmics
2. digoxin
3. diuretics
4. antidepressants
5. benzodiazepines
6. antipsychotics
4. Ask about home environment (thresholds, stairs, slippery surfaces, poor or dazzling lighting) and walking aid use (canes, walkers, etc).

In certain situations, a much more comprehensive evaluation may be necessary (ie, the "multifactorial risk assessment"). For the interested, a multifactorial risk assessment includes the following components:²

Focused History

1. History of falls: Detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences
2. Medication review: All prescribed and over-the-counter medications with dosages
3. History of relevant risk factors: Acute or chronic medical problems, (eg, osteoporosis, urinary incontinence, cardiovascular disease)

Fall Physical Examination

1. Detailed assessment of gait, balance, and mobility levels and lower extremity joint function
2. Neurological function: Cognitive evaluation, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function
3. Muscle strength (lower extremities)
4. Cardiovascular status: Heart rate and rhythm, postural pulse, blood pressure, and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation
5. Assessment of visual acuity
6. Examination of the feet and footwear

There are any number of fall risk assessment examination methods, but any reasonable one will assess balance, gait, lower extremity and core strength, and deformities. For the average podiatrist, this will boil down to your regular lower extremity biomechanical, manual muscle strength examinations, a footwear examination and a couple of extra methods.

Core strength may be easily tested by having the patient cross his arms across the chest and then attempt to rise from a seated position without use of his upper extremities. If able to do this repeatedly in 30 seconds, he has adequate core strength.

Proprioception may be tested by a slow tandem walk and single limb stance. Always supervise carefully to prevent falls. Again, there are several specific named methods that may be easily found on the internet to assist with fall risk assessment.

For the subset of you that love being extra comprehensive and want to examine patients for orthostatic (postural hypotension), you would do the following.

1. Measure BP and heart rate after five minutes in the supine position
2. Have the patient stand
3. Remeasure BP and heart rate at one and three minutes after standing
4. The patient has orthostatic hypotension if the systolic drops > 20mmHg systolic, >10mmHg diastolic, or both

*Caution: watch out for orthostatic signs during the test such as dizziness, lightheadedness, or loss of vision. Patients that can't fully stand may sit upright on the chair.

Once you've completed your fall risk assessment you will be able to categorize the patient into a mild/moderate/high risk of falls. Based on a relatively rapid history and physical examination (they get quicker with practice) you will have taken the first major step to preventing falls in your elderly patients. That, my friends, is the start of 1,000 pounds of prevention!

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

REFERENCES

1. Hartikainen S, Lonnroon E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol. 2007;62A:1172-1181.

2. AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. Last accessed 11/20/2014.

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