New Guideline Focuses on Accidental Falls

Patients with diagnoses associated with an increased risk of falling should be screened by neurologists to help prevent subsequent injury or death, according to a new guideline developed by the Quality Standards Subcommittee of the American Academy of Neurology. Those diagnoses, according to the guideline, include stroke, dementia, and walking and balance disorders. Assessments of a patient’s ability to stand unassisted from a sitting position and walk, and of dynamic stability, should also be included as a part of the comprehensive standard examination, recommended the guideline authors. The results of their literature review were published as a practice parameter in the February 5 Neurology.

David J. Thurman, MD, MPH, a neurologist and medical epidemiologist with the National Center for Chronic Disease Prevention and Health Promotion at the CDC in Atlanta, and colleagues searched the MEDLINE database for studies that addressed falls occurring without prior loss of consciousness and that analyzed falls as a principal outcome, rather than fall-related injuries. This limited the search results to studies in which falls were accidental but not due to environmental hazards (eg, icy walkways) or unusual activities or events (eg, playing sports or being shoved) that would place a person at high risk; studies in which the causes were seizures or syncope were also excluded, as the management of such falls is usually considered in separate publications, noted the authors. A total of 86 articles met the criteria for relevance.

NEUROLOGIC DIAGNOSES AS RISK FACTORS

“All of the patients with any of the fall risk factors … should be asked about falls during the past year,” asserted the researchers. Among five class I and 10 class II studies, a recent history of falls (typically within one year, but as short as three months and as long as two years) significantly predicted future falls. In addition, pooled data from six prospective class I and II studies yielded a combined sensitivity of 50% and a specificity of 80%, with a relative risk of 2.4 and an odds ratio of 4.2. “Given a history of falls, the pooled absolute risk of falling during follow-up was 55%,” added the researchers. Established (level A) risk factors included diagnoses of stroke, dementia, and disorders of gait and balance, and the use of assistive devices for ambulation; probable (level B) risk factors were diagnoses of Parkinson’s disease, peripheral neuropathy, lower extremity weakness or sensory loss, and substantial loss of vision.

“If further assessment of the extent of fall risk is needed, other screening measures to be considered include the Get-Up-And-Go Test or Timed Up-and-Go Test … and the Tinetti Mobility Scale,” recommended Dr. Thurman and his coauthors. Although the evidence was deemed to be “of probable value,” five studies suggested the usefulness of the Get-Up-And-Go Test or Timed Up-and-Go Test in assessing risk of falling in various populations; sensitivities of the tests ranged from 77% to 91%, with specificities ranging from 22% to 93%. Studies of a more simple “standing unassisted” test reported odds ratios for falling of 3.3 for participants who failed the test and 3.0 for those who required two or more seconds to stand.

The Tinetti Mobility Scale measures dynamic stability while participants perform 14 tasks, and four class II studies yielded sensitivities between 62% and 96%, and specificities between 11% and 96%, for various cutoffs and with varied versions of the scale.

PRACTICAL SCREENING TOOLS, INTERVENTIONS NEEDED

The authors noted the need for future investigations to focus on assessing predictors of fall risk among a broader spectrum of patients—especially those with specific neurologic conditions that affect gait, mobility, or balance—as well as to develop practical screening tools that neurologists can perform quickly and easily in the office or at the bedside.

“Because many patients at risk of falling seek neurologic consultations, neurologists have opportunities to identify those at greatest risk, document risk factors, and offer interventions that may prevent falls among patients with chronic disease,” said Dr. Thurman and colleagues. They noted that such appropriate interventions have been described in other evidence-based guidelines; treatment of the underlying disorder should also be considered.

NR