Neurology Academy Offers Guidelines on Recognizing Fall Risk

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Neurology Academy Offers Guidelines on Recognizing Fall Risk

http://www.medpagetoday.com/PrimaryCare/Geriatrics/tb/8285

By Gever, Staff Writer, MedPage Today

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

ST. PAUL Minn., Feb. 8 -- The American Academy of Neurology has

developed practice parameters that suggest simple screening tests to

help guide members in assessing the degree of risk of falling by

patients.

Explain that the academy guideline recommends that patients with

identified risk factors should be asked if they have fallen in the

past year.

Explain that established risk factors include many neurological

conditions, stroke, reliance on canes or walkers, and difficulties

with gait, mobility, or vision.

Point out that the guidelines were developed on the basis of a review

of published studies.

The academy's practice parameters were developed by J. Thurman,

M.D., M.P.H., at the CDC, and colleagues there, and were published as

an evidence-based review in the Feb. 5 issue of Neurology.

Neurologists are well positioned to screen patients and offer

interventions to prevent falls because so many of the risk factors of

falling are conditions that bring people into neurology practices,

Dr. Thurman and colleagues wrote. These include dementia, stroke,

Parkinson's disease, peripheral neuropathy, reliance on canes or

walkers, and a history of falls.

Their guidelines recommend that all patients with any of the

identified risk factors be asked about falls during the past year.

They said that neurologists could also use some form of the " Get-Up-

and-Go " test, in which patients attempt to stand from a sitting

position, for screening.

Another tool is the Tinetti Mobility Scale, a measure of dynamic

stability while carrying out 14 tasks.

They said a variety of other tests and assessment scales have been

developed which could possibly be useful. However, they overlap

considerably in the neurologic functions covered.

Yet, Dr. Thurman and colleagues concluded, " there is insufficient

evidence to assess whether such measures offer benefits beyond that

offered by a standard comprehensive neurologic examination. "

The researchers identified the common risk factors and evaluation

methods from a systematic review of 86 published studies.

They found " level A " evidence -- the strongest level in the American

Academy of Neurology's system -- that patients who had previously

fallen in the past year or who had diagnoses of stroke, dementia, or

disorders of gait and balance were at high risk of falling.

Dr. Thurman and colleagues identified five high-quality studies that

calculated relative risks of 2.4 to 2.6 and odds ratios of 2.4 to 3.7

that people with a recent history of falling would have a new fall.

Ten lower-quality studies reported similar findings, although the

range of odds ratios was wider (ORs 1.8 to 16.0).

The CDC researchers found three high-quality studies pointing to

stroke as a significant risk factor for falling, with relative risks

of 1.9 to 2.4, although another found no significantly increased

risk.

Dr. Thurman and colleagues said the studies of fall risk in patients

with dementia or cognitive impairment used varying definitions of

these conditions. Nevertheless, they found high-level evidence from

12 studies that patients classified as impaired or demented are at

increased risk for falling.

The researchers reported level B evidence that Parkinson's disease,

peripheral neuropathy, lower extremity weakness or sensory loss, and

substantial loss of vision are associated with falling.

Other factors identified as contributing to fall risk, though without

the highest-quality evidence, included extreme age, general frailty,

arthritis, depression, use of psychoactive drugs, and impairments in

daily-living activities.

They recommended additional research to measure the ability of

individual and combined elements of a standard neurologic exam to

predict fall risk. Dr. Thurman and colleagues also called for

comparative studies on existing gait, balance, and mobility tests.

Connolly, M.P.H., an injury prevention specialist at the

University of Alabama at Birmingham, said she was pleased that

neurologists would have their own guideline for assessing fall risk.

" Elderly patients are likely to be seen by a neurologist, " she

said. " It's definitely something that's needed. " But she was

disappointed that it did not address interventions. For example, she

said, simple exercises have been proven to reduce falls. She also

said Dr. Thurman and colleagues might have found more studies if

their search had used other terms.

The CDC researchers used " accidental falls " as the principal search

term in their database search.

Connolly said the injury prevention literature often

uses " unintentional " in place of " accidental. "

The academy said the guidelines were not intended to include all

possible proper methods of care, nor to exclude reasonable

alternatives. It said the guideline should be not be interpreted as a

formal practice recommendation.