Objectives Falls: Screens vs. Balance and Falls SIG: Neurology & Health Policy and Administration Sections of the APTA Jacqueline Osborne PT, DPT, GCS, CEEAA Geriatric Residency Coordinator Brooks Institute of Higher Learning Brooks Rehabilitation Jacksonville, Florida Describe differences among screenings assessments, and outcome measures. Identify specific screenings, assessments and outcome measures for balance and falls. Understand the constructs involved in creating/utilizing a valid tool to assess balance and identify fall risk. More Details Please All older people should be given a short screen for fall risk and, if at risk referred on to further detailed assessment and intervention. (AGS, BGS, AAOS 2001;2010) What is the definition of screen? What is the definition of short? What items should be in the screen? Do all older people get the same screen? What does further detailed assessment and intervention include? Who should be doing the assessment? Where does the assessment take place? How are the results measured? Definition: Screen A process used to determine preliminary suitability for further classification Definition: Assessment A determination of the value of the characteristics of a person, place, or thing A process that determines who is at risk for falls and who should receive a multifactorial evaluation (Chen 2013, Ganz 2007) An in-depth measure of the potential causes of falls in a particular individual in enough detail to make decisions on which factors require intervention (Ganz 2007) used without permission. 1
Definition: Outcome Measure A means to collect data that supports best practice in the delivery of a service A tool that provides evidence for the effectiveness of a chosen intervention Evidence-based information that has the capacity to change/improve the standard of care for a given population Confusing Terminology Risk Factors/Predictive Variables age, gender, prior history of falls, poor visual acuity, unstable gait, cognitive impairment Clinical Prediction Rules/Prognostic Tools/Multifactorial Assessments may be derived from identified risk factors OR may use an existing tool that was developed for an alternative assessment US Preventative Services Task Force (USPSTF) USPSTF Recommendations Fall Risk Screening Form for non-medical personnel FRAST Fall Risk Stratification Medicare s IPPE Medicare s PQRS AGS/BGS/AAOS Guideline (2001; Revised 2010) STEADI Toolkit Community dwelling older adults identified as at risk for falls if: Reported history of falls Reported history of mobility problems Poor performance on the TUG Interventions Exercise Physical Therapy Vitamin D Supplementation US Preventative Services Task Force. Prevention of Falls in Community Dwelling Older Adults. http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/fallsprevsum.htm Fall Risk Screen for Non-medical Personnel (Chen 2013) Participants: 12 females & 1 male Nurses, Social Workers, Personal Care Assistants, Outreach Workers Setting: 1 agency Day Center, Home Care, Case Management, and Outreach to Potential Clients Purpose: to gather information on the content and features most useful for fall screening to individual geriatric health care workers Enable the worker to quickly alert others to the risk of falls and make referrals as appropriate Fall Risk Screen for Non-medical Personnel (Chen 2013) Have you fallen during the last 3 months? Do you use any assistive walking devices such as a walker or a cane? Are you afraid of falling? used without permission. 2
Fall Risk Assessment and Screening Tool: FRAST (Renfro 2011) FRAST Multifactorial tool developed: For community dwelling older adults 65 To be administered by minimally trained staff with a follow up interpretation by a trained primary care provider Contains previously validated measures TUG Modified Falls Efficacy Scale Home Safety Checklist Mood Scale Score : 5/30 = PCP review FRAST Fall Risk Stratification Tool (Buatois 2010) Health Check Up 2,735 consecutive community dwelling volunteers 1,357 women and 1,378 men 65 years and older Follow-up Questionnaire How many times had participant experienced a fall since visit; circumstances/ consequences of the fall(s) Control Group = nonfallers and 1x fallers Experimental Group = recurrent fallers Fall Risk Stratification Tool (Buatois 2010) 4 determinants for recurrent falls: History of falls 8 Living alone 3 Taking 4 medications/day 3 Being female 2 Low risk = 0-4; moderate risk = 5-10; high risk = 11-16 Perform an in-depth multifactorial assessment for those in high risk category and moderate risk who fail the FTSS (>15 sec) Welcome to Medicare Preventative Visit Initial Preventative Physical Examination (IPPE) One-time benefit within 1 st 12 months after effective date of 1 st Medicare Part B coverage period Effective January 1, 2011 Performed by MD, DO, NP, PA, CNS http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/ MLNProducts/downloads/MPS_QRI_IPPE001a.pdf used without permission. 3
IPPE Use any appropriate screening questions or PMH, PSH, Medications, family history standardized questionnaires recognized by History of alcohol, tobacco, national professional or drug use medical organizations to review, at a minimum, the following areas: Diet and physical activity Hearing impairment Risk factors for depression Activities and other of daily mood living disorders Falls risk,and Review functional ability Home and safety level Height, weight, blood pressure Visual acuity screen BMI Other factors based on medical and social history and current clinical standards End of life planning http://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf Physician Quality Reporting System --PQRS Voluntary outcomes incentive-based reporting program January 2015 non-participating providers receive 1.5% reduction in Medicare reimbursement #154 and #155 -- Includes follow-up assessment and plan of care for individuals with a history of 2 falls or 1 fall with injury in the past year Landis S 2012; MAHEC Division of Healthcare Innovation http://sys.mahec.net/media/nccha/fallassessment.pdf PQRS #154 Falls: Risk Assessment Measure % of those 65 with h/o falls who had risk assessment in previous year 1. # of falls? 2. Injuries? Have you fallen in the past 12 months? YES NO Screening Complete PQRS #154 If + fall history, then fall risk assessment and POC follow Multifactorial Assessment: 1. Gait, balance, and mobility assessment (TUG) 2. Orthostatic Hypotension (supine and standing) 3. Vision (self-report) 4. Environmental Hazards in home (checklist) 5. Medications (Beers Criteria) Landis S 2012; MAHEC Division of Healthcare Innovation http://sys.mahec.net/media/nccha/fallassessment.pdf Landis S 2012; MAHEC Division of Healthcare Innovation http://sys.mahec.net/media/nccha/fallassessment.pdf PQRS #155 Falls: Plan of Care Measure % of those 65 with h/o falls who had a POC for falls documented in previous year AGS/BGS Clinical Practice Guidelines for Fall Prevention Sidebar: Screening for Falls Questions 1. Two or more falls in prior 12 months? 2. Presents with acute fall? 3. Difficulty with walking or balance? Multifactorial POC: 1. Assistive device needed? 2. Balance/strength/gait training (Refer to physical therapy or community based exercise program) Landis S 2012; MAHEC Division of Healthcare Innovation http://sys.mahec.net/media/nccha/fallassessment.pdf used without permission. 4
AGS/BGS Clinical Practice Guidelines for Fall Prevention AGS/BGS Clinical Practice Guidelines for Fall Prevention New in 2010 1. History of falls a) Frequency b) Symptoms c) Injuries 1. Obtain relevant medical history, physical examination, cognitive and functional assessment 2. Determine multifactorial fall risk: a) History of falls b) Medications c) Gait, balance, and mobility d) Visual acuity e) Other neurological impairments f) Muscle strength Standardized tests: 1. TUG 2. BBS 3. POMA g) Heart rate and rhythm h) Postural Hypotension i) Feet and footwear j) Environmental hazards AGS/BGS Clinical Practice Guidelines for Fall Prevention New in 2010 Developed by the CDC to assist primary care providers to incorporate fall risk assessment and individualized interventions into their clinical practice Launched in 2011 to pilot in 3 states over 5 years (Oregon, New York and Colorado) 1. Functional Assessment including use of AD 2. Feet and footwear 3. Perceived functional ability 4. Fear of Falling 5. Environmental Hazards Based on the Clinical Practice Guidelines for Fall Prevention developed by the AGS and the BGS http://www.cdc.gov/homeandrecreationalsafety/falls/steadi/index.html Algorithm for Fall Risk Assessment & Interventions Stay Independent Brochure Score 4 points = may be at risk for falling TUG; 30s Chair Stand; 4 Stage Balance Test Determine # of falls If 1 fall = multifactorial assessment http://www.cdc.gov/homeandrecreationalsafety/falls/steadi/index.html Multifactorial Risk Assessment: Review Stay Independent brochure Falls history Physical exam Postural dizziness/postural hypotension Cognitive screening Medication review Feet & footwear Use of mobility aids Visual acuity check Integrating Fall Prevention into Practice via STEADI Toolkit http://www.cdc.gov/homeandrecreationalsafety/falls/steadi/index.html used without permission. 5
Gait Speed: The 6 th Vital Sign (Fritz & Lusardi 2009) Fall Risk Screen If the purpose of the screen is to determine fall risk, the literature does not recommend that screens include measures of: Orthostatic Hypotension Visual Impairment Medication Review ADLs Cognitive Impairment Tandem Stand Observational Gait Analysis Muir 22010; Ganz 2007? Once, the at-risk person has been identified via a screen, how will we know which outcome measures to use to measure the effectiveness of our interventions for reducing falls?? (Sullivan 2013) Contribute to a more thorough examination Assist with POC development Allow for clinicians to compare data to norms to determine prognosis Allow for clinicians to track patient status Facilitate communication between care settings Increase efficiency of practice Enhance reimbursement Allow for the creation of benchmarks across settings and clinicians May improve research methodology for determining clinical significance? What does it mean to use an outcome measure appropriately?? Population Setting Ease of use Scoring Cost Clinician expertise Method of delivery Availability of the measure Considerations used without permission. 6
Psychometrics (Pardasaney 2013) Reliability Validity Minimal floor and ceiling effects for the intended population Adequate sensitivity and specificity when used for diagnosis Adequate sensitivity to change and responsiveness when used to assess clinical change Property Definition Measure Reliability How much error is associated with a measure Correlation coefficients; SEM; MDC Internal Consistency Validity Responsiveness Ceiling/Floor Effects The degree to which sub-sections or items within a scale measure the same concepts within the instrument Indicates if the tool is measure what it is intended to measure A tool s ability to detect a clinically meaningful change over time How often the maximum (ceiling) or minimum (floor) score occurs Cronbach s alpha (α) P-values; Sn; Sp; LRs ES, SEM, MID Frequency measures Take Home Messages Screens, assessments, & outcome measures are distinct in terms of how they are used to measure imbalance and falls. Several factors must be considered when choosing the appropriate screen, assessment, and outcome measure. Thank you! Jackie.Osborne@Brooksrehab.org PTs must communicate with primary care providers to relay the importance of a detailed multifactorial assessment to direct fall prevention intervention. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664 672. http://www.americangeriatrics.org/health_care_profe ssionals/clinical_practice/clinical_guidelines_recomme ndations/2010/ Buatois S et al. A Simple Clinical Scale to Stratify Risk of Recurrent Falls in Community Dwelling Adults Aged 65 Years and Older. Phys Ther. 2010;90:550-560. Chen S et al. Qualitative assessment of component specific, fall-risk screening procedures to create a fall risk screening form. J Geriatr Phys Ther. 2013;36(4):155-161. Fritz S & Lusardi M. White paper: Walking speed: the sixth vital sign. J Geriatr Phys Ther. 2009;32(2):1-5. Ganz D et al Will My Patient Fall? JAMA. 2007;297:77-86. used without permission. 7
Landis S. Mountain Area Health Education Center. Division of Healthcare Innovation. http://sys.mahec.net/media/nccha/fallassessment.p df Accessed October 27, 2013. Medicare IPPE. http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/MPS_QRI_IPPE001a. pdf Accessed October 27, 2013. Muir SW, Berg K, Chesworth B, et al. Balance impairment as a risk factor for falls in community dwelling older adults who are high functioning: a prospective study. Phys Ther. 2010;90:338 347. Pardasaney P et al. Conceptual limitations of balance measures for community dwelling older adults. Phys Ther. 2013;93:1351-1368. Renfro MO & Fehrer S. Multifactorial screening for fall risk in community dwelling older adults in the primary care office: development of the fall risk assessment screening tool. J Geriatr Phys Ther. 2011; 34(4):174-183. Sullivan J et al. Outcome measures for individuals with stroke: process and recommendations from the American Physical Therapy Association Neurology Section Task Force. Phys Ther. 2013;93:1383-1396. STEADI Toolkit. http://www.cdc.gov/homeandrecreationalsafety/fall s/steadi/index.html Accessed on October 27, 2013. US Preventative Services Task Force. Prevention of Falls in Community Dwelling Older Adults. http://www.uspreventiveservicestaskforce.org/uspst f11/fallsprevention/fallsprevsum.htm Accessed October 27, 2013. used without permission. 8