Following the Six Es

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June 2005

By Lance P. Van Arsdell, PT, MSPT

Fall prevention can be achieved by implementing common sense principles

Fall is the four-letter word seniors fear most. More than 90° of hip fractures are the result of falls. Most of these falls are preventable, but typically little is done to prevent them and their devastating, painful, and even life-threatening consequences. One in five persons who break a hip dies within 1 year, and many never walk again following a hip fracture.

As health care professionals and managers, we often make individual efforts against the problem but seldom have the time to assure good long-term results. Once clients are discharged from therapy, they frequently fall and become repeat business, which helps our bottom line—hospital rehab estimates could be as high as $30,000/fracture—but does little for our credibility with client families, referral sources, and third-party payors. Well-intentioned community oral presentations with home safety videos and fall risk factor prevention pamphlets have been found to be ineffective.¹ Vetter et al found single health care visits—with screening and recommendations/referral for nutrition, medical conditions and medication evaluation, environmental hazards, and exercise—to be ineffective, and speculated that it is potentially precipitative of more falls when clients were advised to take more exercise.² It is important to keep in mind the big picture of all vital categories of fall prevention interventions to assure the success of patients. In this instance, the picture (see Figure 1) provided is an Ishikawa diagram that bears considerable likeness to a fish. To understand this “fish,” we must dissect it, and identify and recall the bones (causes) that point toward the head (effect of fewer fall injuries). Recalling the six Es of fall injury prevention—education, evaluation, elixir/medication management and reduction, exercise, environment, and equipment—will help you create a healthy pool of repeat referrals, no matter your practice setting.

FIGURE 1.

THE FIRST E: EDUCATION
Therapists without patients are like fish without water. Knowledge is no good without application. This rear dorsal fin of the fish should really be like an eel’s fin wrapping through the other interventions. Though client education on its own does not decrease falls, free fall risk screenings may win your clinic the referrals to accomplish two more vital “Es”—evaluation and elixirs review, ie, a doctor decreasing the patient’s ethanol/alcohol (ETOH) and medication dependence.

As client education has no CMS-reimbursable CPT code, I recommend using public education as the bait to start the referral stream going as you angle for needy clients. (The good news about education is that beginning in 2006 there will be a CMS-reimbursable CPT code.) Mark Zajac, PT, of Lancaster, NH, included a demonstration of how to get up from the floor in a talk to the women’s guild of a local church. He immediately got invited back for a second talk and within a week had a client returning from the doctor with a prescription for Zajac Physical Therapy in hand.

Even before your client is “hooked,” you must educate all involved in the client’s care. This includes rehab/medical staff, families, and caregivers. The latter two may notice a fall or stumble and start the evaluation process. They can help you get and then keep the client in the low fall risk pool, which is the top rung of the fish ladder (see Figure 2). Faithful exercise and good monitoring are needed to keep your patient from slipping down the “cascade” of ever-increasing fall risk. The “middle rung” (prevention interventions) of the fish ladder diagram represents the time needed for the interventions to take effect. The vital exercise intervention takes about 4 weeks for significant effect in most cases. Slipping back to the decreased/low safety pool takes only a brief stopping of exercises or an acute illness.

FIGURE 2.

Advise clients to eat a good breakfast daily and quit bad habits like smoking and drinking. Medicare will help with the smoking cessation. If your screening finds a client to be in the high fall risk pool, advise them to go to their doctor to begin the next “E”—evaluation.

THE SECOND E: EVALUATION
Find a doctor who can see a potential client quickly. Doctors should evaluate thoroughly and rule out multiple medical disorders—infections, abnormal blood pressure, thyroid disorders, diabetic neuropathy, decreased vision—and multiple medication balance challenges. Make it easy for the doctor to refer back to your facility via brochures and preprinted prescription pads.

A physical or occupational therapist should evaluate any time there is a fall or a near fall. The therapist should note the location of the fall, activity being performed, time of day, and what happened after the fall, eg, the client got up from the floor independently or how long they lay on the floor until help arrived. A very good flowchart algorithm on fall prevention is available from the American Geriatrics Society.

Check for muscle weakness, fall history, gait deficits, balance deficits, assistive device usage, visual deficits, arthritis, depression and cognitive impairments, nutritional status, acute or chronic illness, and the number and type of medications taken.

Use functional repeatable measures. At a minimum, track the client’s normal gait speed and stride or step length using the same shoes for subsequent tests. A usual gait speed of 0.56 meters per second or less is indicative of fall risk.³ This is best checked in the middle 10 meters of a 20-meter course. For transfers, check and time the client’s transfer ability/inability from measured high seats to the lowest surface possible. Do these tests on every patient when possible. Isolated gait asymmetries should be noted and addressed if they are a likely risk factor. The number of steps required to complete a 360° turn is repeatable and objective. Retest these measures periodically on a sheet with columns to grade your therapy and your client‘s progress. Even third-party payors can relate to these types of measures.

Although few of the current balance and gait assessment tools are strongly predictive of future falls, one should choose the best tool for a given population. The Short Physical Performance Battery www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126356&dopt=Abstract) takes little time to complete and has some predictive validity for mobility and ADL (activities of daily living) disability. In the home health environment, use the falls risk assessment tool (FRA).

Other helpful evaluations may include a nutritionist and counselor as well.

THE THIRD E: ELIXERS/MEDICATION REVIEW
Decreasing medications to only those necessary can decrease fall risk. Specific medications that often contribute to falls in the elderly include diuretics, antihypertensives, long-acting sedatives, and narcotic analgesics. Physicians are unlikely to take exception to clearly written, courteous reports of patient symptoms and test results, even when adverse, that enhance their pharmacologic management of that patient.

THE FOURTH E: EXERCISE
Exercise is beneficial. Tailor-made exercise is best. Progressive strength and balance exercises that are regularly performed are best but do not scare clients off. Scores of well-meaning health educators have unwittingly kept many couch potatoes firmly planted on their sofas by recommending exercise programs designed for athletes.

Here is how you might best get your clients started. Do your own exercise program regularly. Be genuine. Speak encouragingly from your own experience. In 14 years of physical therapy practice as well as my own life, I have learned that the only effective exercise program is the one that is actually performed and carried out year round.

Design a program that your clients will likely get hooked on and will continue for the long term. Initially have clients exercise only with the therapist. Keep the home program shorter than their favorite TV shows and scheduled to their preference of two or three times per week. Remember the goal is for your clients to have more energy left for living and loving—not just for exercise. What they do at other times can be a bonus.

As most elderly persons gradually lose active and passive dorsiflexion, I recommend starting with this safe exercise that potentially prevents both fracture-causing falls to the rear and trips to the front. For clients with orthostatic hypotension, advise them to take their time when rising from bed. Have them sit on the edge of the bed, shrug their shoulders, raise their arms, dorsiflex their ankles, extend their knees, smile, and say a favorite inspirational quote before getting up from bed. This will help put them in a good mood and give their blood pressure time to adjust to the new posture. For a good program, see the eight exercises that will make you strong in “Strong Women [and Men] Stay Young” by Miriam Nelson, PhD. That program is similar to the program I tailor to clients in their homes and faithfully do myself with a few modifications. If your client is large and/or has an extremely high risk of falling even during a therapy session, begin with balance exercises in the water. Initial improvement will be slower, but I have never heard of a patient hip fracture or therapist shoulder dislocation being caused by a therapy session in the water.

THE FIFTH E: ENVIRONMENT
Environment cannot be neglected but must be approached with tact and an open mind. In the home care environ-ment, apparent risks are easier to see. Remove electrical cords and throw rugs from pathways. A slippery bathroom throw rug or poorly placed electrical cord can mean a lot of pain and grief if it causes a fall. Advise clients to use sufficient lighting especially between the bed and bathroom.

THE SIXTH E: EQUIPMENT

Use a soft helmet for the highest risk clients. Recommend they use low broad-heeled shoes with firm soles, which should be worn by many in a highest fall risk category,^4,5 and then you have your client ready to exercise safely.

Long sleeves can decrease minor skin tears to the elbows and forearms. Protective hip pads, which are not noticeable under street clothes, can decrease the risk of hip fracture.⁶ Remember that the injury, not the fall, is what is most important to prevent. It has been found that immobilizing even young adult males immediately increases urinary calcium excretion so use restraints with extreme caution. More research is needed regarding restraint use. Selecting and fitting proper assistive device(s) is important and easily done. This is another great courtesy service to provide in order to build loyalty in referral sources.

With a plan and persistence, your program will make your clients safer and happier, and help your facility or practice to swim with the big fish.

Lance P. Van Arsdell, PT, MSPT, is owner of AtHomeMedRehab.com/Restoracare Inc, and provides in-home strengthening and fall prevention to seniors in Mesa, Ariz.

REFERENCES

1. Steinberg M, Cartwright C, Peel N, Williams G. A sustainable programme to prevent falls and near falls in community dwelling older people: results of a randomised trial. J Epidemiol Community Health. 2000;54:227-232.

2. Vetter NJ, Lewis PA, Ford D. Can health visitors prevent fractures in elderly people? BMJ. 1992;304:888-890.

3. VanSwearingen JM, Brach JS. Making geriatric assessment work: selecting useful measures. Phys Ther. 2001;81:1238.

4. Lord SR, Bashford GM. Shoe characteristics and balance in older women. J Am Geriatr Soc. 1996;44:429-33.

5. Robbins S, Waked E, Krouglicof N. Improving balance. J Am Geriatr Soc. 1998;46:1363-70.

6. Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med. 2000;343:1506-13.

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June 2005