July 11, 2023

    Why (and How) We Should Assess Fall Risk More Regularly

    In the US alone, non-fatal falls cost $50 billion annually, with fatal falls accounting for an additional $754 million. At the individual level, more than one out of four older adults (65+) fall each year. Falling just once doubles a patient's chances of falling again, yet less than half of patients inform their doctor when a fall occurs (1).

    growing falls burden

    While these numbers are staggering, with our growing older adult and elderly (80+) population, these numbers will likely significantly increase (1). This epidemic is even more personal for those directly impacted by a friend or loved one falling. Every 19 minutes, an older adult dies from a fall (7).

    Relevant Risk Factors

    A combination of risk factors causes most falls. Some of these are "intrinsic" risk factors, such as lower body weakness, cognitive impairment, vision problems, low activity levels, difficulties with walking or balance, and even the use of some medications (including OTC). Other common risk factors are "extrinsic," meaning they are more external instead of internal. These include environmental risk factors such as clutter around the home, footwear, lighting, and even the local climate. Independently diagnosed acute and chronic illnesses (comorbidities) such as depression, diabetes, Alzheimer's, TBI, and fluctuations in blood pressure can also increase the risk of falls and affect balance. However, not all risk factors are equal:

    "The leading risk factors for falls are lower body weakness,  impaired balance and/or gait (walking), and global cognitive impairment. This is generally agreed upon in the scientific literature." - Dr. Debbie Rose, Leading Fall Risk Expert & Sparta Science Advisor

    Click to read the Balance: The Time is Now to Embrace this Key Vital Sign

    Fall Risk Screening

    Given the complexity of balance and the wide range of factors related to falls, screening patients for fall risk should be holistic. Comprehensive assessment requires multiple pieces of data or information about a patient to be synthesized together to provide the most complete picture for both patient and provider.

    The CDC provides caregivers and patients with various resources from their Stopping Elderly Deaths, Accidents, and Injuries (STEADI) Toolkit to assess for and even reduce fall risk. Many of these risk factors are modifiable, meaning that early identification and intervention are critical to addressing and reducing the risk of falling for our loved ones. The CDC also recommends yearly fall risk screening for individuals over 65, but does this happen in practice?

    Very little information is available about the prevalence of screening or fall risk evaluation in the older adult and elderly populations. A 2006 review states that "the proportion of at-risk Medicare beneficiaries who presently receive fall-risk evaluation and management is unknown," though annual fall risk assessment is a requirement for Medicare Annual Wellness Visits (2,5). The lack of data is also supported by recently published guidelines in 2022 for fall prevention and management, which defaults to expert recommendations about the frequency and justification of screening without high-quality evidence (3).

    According to David C. Weber, MD, who specializes in neurorehabilitation at the Mayo Clinic, only 37% of elderly patients are asked about falls in the primary care setting (5).

    A 2018 study that surveyed Primary Care Providers indicated that while 96% agree that all older adults should be assessed for fall risk, only 52% believed they had the expertise to perform a fall risk assessment, and surprisingly only 14% were even aware of the CDC’s STEADI Toolkit (8). As an interesting corollary, another study from 2018 suggests that among those older adults screened for fall risk, subsequent utilization of rehabilitation services is relatively low, even in high-risk individuals, and most often does not explicitly address falls or balance training (4).

    Even simpler, try asking some friends or family members over 65 how often or when they last received a fall risk assessment from their doctor. In our experience, assessment is most often done reactively: patients are usually only asked if they've fallen in the last year; if not, they are not considered "at-risk." But should we really just wait for our loved ones to suffer a fall and THEN start to pay attention? If falling once doubles the chances of falling again, does it make sense to wait until the risk is even higher?

    Why Fall Risk Should Be Assessed More Frequently

    At the most fundamental level, we believe fall risk should be assessed more frequently than once a year because:

    • The evidence suggests a significant gap between expert recommendations and clinical practice regarding the frequency of assessment.
    • When patients are screened for fall risk, it is typically reactive, not preventative.
    • Due to our sizable aging population (Baby Boomer generation), the burden and impact of falls will only increase.
    • An individual's fall risk is not consistent but variable based on various changing and interacting (complex) risk factors.

    As most falls are caused by a combination of acute and chronic risk factors, an individual's actual risk of falling likely will not remain the same for 365 days. For example, fall risk may increase during winter and in colder climates due to shorter amounts of sunlight and increased environmental risks like ice and snow. Things like anxiety and medication use are not stagnant but can ebb and flow monthly, weekly, and even daily. Some risk factors, like vision, may not be assessed by a physician or included as part of a primary fall risk screening and, therefore, are likely to be omitted from a more comprehensive risk assessment if this information is not shared between healthcare providers. Additionally, most (if not all) of the risk factors are not all-of-a-sudden applicable once a patient turns the critical age of 65. For example, some research suggests that cognitive decline can be recognized in patients as early as 45! Falls, balance, and mobility are not relevant only to seniors but applicable to all patients' comprehensive health.

    "Our best opportunity to have a measurable impact on addressing and reducing the risk of falling is to earlier identify individuals who are at moderate risk of falling, and then identify appropriate interventions that lower or simply maintain that risk later in life."
    - Dr. Debbie Rose, Leading Fall Risk Expert & Sparta Science Advisor

    A comprehensive assessment of risk requires a variety of different types and sources of data to account for these complex risk factors. How is this possible without significantly burdening our healthcare providers?

    How Fall Risk Can (Realistically) Be Assessed More Frequently

    The answer lies in better leveraging data and technology. Perhaps more explicitly, leveraging technology to systematically synthesize and optimize data streams for meaningful insights and operational utility. Let us explain.

    In reality, much of the data and information related to a patient's fall risk already exists but is stored in disparate, siloed records or documents that don't allow for automated aggregation and analysis to provide primary care providers with a valid comprehensive risk assessment. Existing medical records between primary care providers, specialists (e.g., optometry, oncology, psychiatry, physical therapy, otolaryngology), pharmacies, and insurance companies aren't systematically analyzed or aggregated. Existing fall risk screens or questionnaires are often performed ad hoc and often not well documented until after a fall occurs. An enormous amount of data is passively generated from wearables, cell phones, cars, and other everyday interactions with technology that can provide insight into activity levels, dietary habits, social interactions, and sleep.

    "We often see a decline in social function as one of the earliest indicators of fall risk, prior to any signs related to physical impairments like balance and gait," says Jocelyn Rempel, Chair in Older Adult Health at Mount Royal University.

    Of the leading risk factors for falls, balance is best positioned to be objectively and systematically measured in a feasible manner. While more subjective tests of balance tend to be used in practice, unfortunately, these tests have pretty significant limitations in their application. As a 2017 study states, "The most regularly used tools are not comprehensive and do not assess balance components that are important for fall prevention" (6). These tools are often praised for being simple; however, balance and fall risk are inherently complex. Dr. Debbie Rose, fall risk expert, and Sparta Science advisor, states: "People want to simplify an issue that is not simple. It requires complex solutions."

    Inexpensive balance measuring sensors found in force plates and weight scales can collect reliable and valid balance data optimized specifically for fall risk considerations. When normative data exist, healthcare providers can benchmark their patients relative to their peers. This capability allows primary care providers and senior living facilities to consistently and feasibly assess balance in a more objective and less burdensome manner.

    fall risk survey

    However, these care providers do not have the time, nor necessarily the tools, to independently assess a patient for ALL these vital risk factors consistently, much less annually. By passively (automated) analyzing balance capabilities along with existing medical records, activity levels, and periodic surveys or validated questionnaires (delivered by caregivers or directly to patients) to assess fear of falling, environmental factors, and cognitive decline, we can dynamically update fall risk for patients in real-time as more up-to-date information becomes available. This level of connectedness, or interoperability, is not merely inspirational; with ongoing advancements in technology and data science, it is becoming a reality.

    Take Homes

    • Fall risk is a growing concern and must be prioritized and proactively assessed.
    • Balance is one of the primary risk factors related to falls and can be feasibly and systematically assessed using currently available objective technology.
    • A connected analysis platform can combine existing risk factors in an automated way, allowing for continuous analysis and dynamic evaluation of fall risk for patients of any age.
    1. https://www.cdc.gov/falls/facts.html
    2. Tinetti, Mary E., et al. "Fall-risk evaluation and management: challenges in adopting geriatric care practices." The Gerontologist 46.6 (2006): 717-725.
    3. Montero-Odasso, Manuel, et al. "World guidelines for falls prevention and management for older adults: a global initiative." Age and ageing 51.9 (2022): afac205.
    4. https://www.mayoclinic.org/medical-professionals/physical-medicine-rehabilitation/news/evaluating-patients-for-fall-risk/mac-20436558
    5. Phelan, Elizabeth A., et al. "Assessment and management of fall risk in primary care settings." Medical Clinics 99.2 (2015): 281-293.
    6. Oates, Alison, et al. "Balance assessment practices of Saskatchewan physiotherapists: a brief report of survey findings." Physiotherapy Canada 69.3 (2017): 217-225.
    7. https://www.nsc.org/community-safety/safety-topics/older-adult-falls
    8. Howland, Jonathan, et al. "Older adult fall prevention practices among primary care providers at accountable care organizations: A pilot study." PLoS One 13.10 (2018): e0205279.

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