Jarrod Shapiro, DPM
Fall Risk Assessment:
Domain of the Podiatrist?
Part 2

I always love to find out how topical our online podiatric discussions can be. After writing last week's Part 1 of our fall risk assessment editorial, I heard an interesting story about just the same topic on National Public Radio. The fact that we talked about it, Dr. Atul Gawande discussed it in his excellent book Being Mortal: Medicine and What Matters in the End, and now NPR is covering this issue tells us just how significant the topic really is.

Here are the Facts

One out of three older adults (those aged 65 or older) falls each year, but less than half talk to their healthcare providers about it.¹
Among older adults, falls are the leading cause of both fatal and nonfatal injuries.²
In 2012, 2.4 million nonfatal falls among older adults were treated in emergency departments and more than 722,000 of these patients were hospitalized.²
In 2012, the direct medical costs of falls, adjusted for inflation, were $30 billion.³

Not something podiatrists should worry about you say? Let's compare the medical costs of falls with that of something we as podiatrists spend a lot of time trying to prevent: nontraumatic limb amputations. There are approximately 82,000 nontraumatic limb amputations in diabetics yearly (possibly as many as 100,000)⁴ with a per amputation cost of around $42,000.⁵ Do the math and you come up with $3.69 billion.

Tonight's Premier Lecture is
Porcine Derived Urinary Bladder Matrix for Chronic Wounds
Cameron Field, DPM, ABPS

$3.7 Billion Versus $30 Billion

Which one looks bigger to you? You think preventing limb amputations is important, right? I'd say preventing falls in the elderly ranks up there as important too, don't you think?

In last week's Practice Perfect, we discussed assessment methods the podiatric physician can employ in his or her practice. This included focused questions to ask during a patient history and certain physical examination methods we already do or can easily incorporate into our practices. The bottom line here is to rapidly evaluate subjective patient factors such as medications and environment that contribute to increased fall risk and then screen the patient for muscle weakness, loss of postural control, and poor balance. Additionally foot deformities and shoes must be assessed.

Addressing the Problem

We've talked about "assessment;" now let's discuss "addressment."

I know...that's not a word. I couldn't resist!

What can the podiatric physician do to help patients at increased risk for falls? Here are some options to consider.

Education. Podiatrists have a great opportunity to educate our patients about falls during the patient encounter.
Surveillance. Since we see our palliative care patients more frequently than their primary care physicians, we can watch out for worrisome changes in patients' activities or environments and survey them for at risk medications.
Footwear. Prescribing appropriate shoes that are stiff-soled with flat outsoles provide better stable support during gait. Additionally, modifications to shoes, such as adjustments for limb length discrepancy and frontal plane deformities are greatly helpful to decrease falls.
Referral. If a patient requires proprioceptive improvement for better balance and postural control, it is a simple thing to refer the patient to physical therapy. Similarly, if you note medications that increase fall risk, quick communication to the primary care provider may prevent a life-shortening fall.
Bracing and orthoses. There are various bracing options we can apply to our at risk patients. Take, for example, the elderly patient with a foot drop after CVA. If this isn't a fall risk I don't know what is. A simple low profile ankle foot orthotic with or without dorsiflexion assist modification may be just what the doctor ordered to prevent that fall.
Deformity correction. If bracing fails, podiatric physicians have another instrument in the toolbox to help: surgery. With an appropriate neuromuscular evaluation, a common tendon transfer may reduce or eliminate the need for a brace. In some cases, an ankle fusion may be in order to treat a recalcitrant foot drop. Similarly, other foot deformities such as pes cavus or hammertoes may also be resolved surgically with positive patient benefits.

Each of these methods is well within the scope and training of the average podiatric physician. Successfully mitigating the risk of falls for these patients simply requires our attention, focus, and desire to do more.

When it comes to your patients as risk for falls just remember... Assess and Address for Success

Your patients will be so much better off for your comprehensive care.

Best wishes,

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

REFERENCES

Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare Population. American Journal of Preventive Medicine 2012;43:59–62.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013.
Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention. 2006a;12:290–5.
Reiber GE: Epidemiology and health care costs of diabetic foot problems. In The Di-abetic Foot. Veves A, Giurini JM, LoGerfo FW, Eds. Totowa, NJ, Humana Press, 2002, p. 35–58.
Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clinical Infectious Diseases. 2004;39(Suppl 2):S132–139.