Early Assessments for Improved Quality of Life — Protecting the Elderly

A problem that stands out most to me and hits home daily in my field of work is the lack of preventative care provided to Americans but more specifically, the elderly. For example, the elderly are known for falling often and acquiring an injury. Although we know this information, our healthcare system still lets the elderly down by not providing thorough yearly assessments before a fall or injury that could help determine if they are at risk for experiencing falls in the first place. If the healthcare system provided preventative assessments, the risk for falls could be found or ruled out. At that point, physical therapy could be utilized to further pinpoint the deficits that are affecting them, such as lack of strength, endurance, gait abnormalities, dizziness, or proprioception concerns.

At this current time (in Kansas), most insurances do not provide coverage for preventative annual physical therapy assessments. To attend physical therapy, an individual is required to have a present injury and a referral by their primary care physician. When an injury is not visibly noted or reported to their primary physicians, the physicians are unaware and do not ask the questions or make the needed assessments. This is usually due to the lack of time they have with each patient or the assumption that if falls are occurring or deficits are present, patients will notify them of these concerns. However, due to society and stereotypical views, most elderly patients believe that falls are a part of the course and are expected for the aging process. It is our duty to inform them that falls are, in fact, not a standard or acceptable part of the aging process.

The lack of preventative assessments on a routine basis is subjecting the elderly to a handful of risks, injuries, and death that are linked to falls primarily. When a person aged 65 and older experiences a fall that results in an injury, their recovery time is significantly increased. A great example of this is a broken hip. When a younger (than 65 years old) person experiences a fractured hip, they can go forth with surgical interventions and start the recovery process and heal well with minimal abnormalities following. When a person (65 and older) experiences a fall, they will go forth with surgical interventions if health allows them. At that time, they will then start their healing process, which takes 2–3x longer. During this long-time frame, they will typically experience loss of muscle tone, endurance and even begin to experience other health issues. More times than not, they will end up in rehabilitation centers or skilled living facilities, losing their motivation and independence. This is typically a turning point, where further decline is noted. If recovery does occur more times than not, their quality of life is forever altered, primarily due to fear. “Fallers often experience decreased mobility, independence, and fear of falling, which predisposes them to future falls” (Eckstrom et al., 2017) due to compensatory movements and actions.

The CDC (Centers for Disease Control and Prevention) has conducted several studies demonstrating the significant concern for the elderly regarding falls. In their research, they state that “Falls are the leading cause of injury-related deaths among persons aged >65 years, and the age-adjusted rate of deaths from falls continues to increase.” (Burns & Kakara, 2018) An initial study by the CDC was conducted in 2016 for individuals over the age of 65. The summarization indicated that “approximately one in four U.S residents” (Burns & Kakara, 2018) experiences a fall. In one year’, time “3 million ended up in fall-related emergency department visits, and 29,668 resulted in death.” (Burns & Kakara, 2018) In 2018 the study was reconducted with “over 3 million emergency department visits occurring, more than 950,000 of those visits requiring hospitalizations or transfers to trauma centers or rehab facilities and 32,000 deaths.” (Moreland et al., 2017) Due to these alarming statistics, the “CDC created the Stopping Elderly Accidents, Deaths & Injuries (STEADI) initiative.” (Moreland et al., 2017)

The STEADI initiative was created for the use of physicians, it “includes tools and resources for providers to screen their older patients for fall risk” (Moreland et al., 2017) and educates them on how to “intervene with evidence-based fall prevention interventions. These include medication management, vision screening, home modifications” (Moreland et al., 2017) and most importantly “referral to physical therapists who can address problems with gait, strength, and balance.” (Moreland et al., 2017) Prior to the STEADI assessment becoming published for public and clinical use, several studies were performed to gauge the risk of falls for patients during regular annual wellness checks. Twenty-four providers participated during this study, screening 773 patients over a six-month period. (Eckstrom et al., 2017) Out of the 773 patients, 109 of them were at high risk for falls and, in return, “received STEADI interventions (gait, vision, and feet assessment, orthostatic blood pressure measurement, vitamin D and medication review).” (Eckstrom et al., 2017) This study indicates the number of falls decreased after the use of the STEADI interventions. However, the study provided no exact numbers. It is essential to understand the algorithm of the STEADI assessment.

The following attachment by (CDC, National Center for Injury Prevention and Control, 2017) provides more in-depth information about what the STEADI assessment consists of and how it is given to a patient. This resource is utilized as guidance for physicians. It helps them determine which other assessments would be best to provide to the patient, such as the timed up & go test, 30-second chair stand test, 4-stage balance test, gait assessments, and strength assessments. This assessment is quick and easy, which is important as primary care physicians do not have much time to spend with the patients. The physician can then decipher whether the patient is at low, moderate, or high risk for falls from the assessment scores. Suppose a moderate or high risk is present. In that case, the physicians can then educate the patient on the importance of addressing these concerns by including the statistics on injuries, further decline, and even deaths. And above all, the importance of physical therapy interventions to prevent, decrease or even seize the risk for falls.

Primary care physicians have a decreased amount of time to spend on a one-on-one basis with patients. PCP’s do not specialize in muscle/balance/gait insufficiencies as physical therapists do, which is why the PCP’s should refer patients to therapy with a script that indicates the physical therapist should provide a whole body assessment to address all possible concerns. Once a patient begins treatment, various assessments concentrate on establishing a suitable plan of care for the patient to reduce the observed insufficiencies. A plan of care could include interventions to increase; lower extremity mobility and strengthening, overall standing endurance, cardiovascular endurance, static and dynamic balance, proprioception, muscle imbalances, gait abnormalities, and education in body mechanics and ergonomics. Most “plan of care” will work on these insufficiencies for 4–8 weeks and longer if needed. By utilizing preventative assessments, we can address all concerns before a severe fall and injury are sustained.

Conclusion:

“Every second of every day, an older adult — age 65 and older — falls. Many of these falls cause an injury, loss of independence and in some cases death.” (CDC, National Center for Injury Prevention and Control, 2016) Because of this terrifying fact, “health care providers should be aware that deaths from falls are increasing nationally among older adults, but that falls are preventable. Falls and fall prevention should be discussed during annual wellness visits, when health care providers can assess fall risk, educating patients about falls, and selecting appropriate interventions.” (Burns & Kakara, 2018)

There is no denying that aging is one of the inevitable occurrences that we must all face one day. As physicians and healthcare workers, it should be our top priority to make these changes as smooth as possible and to ensure that the elderly are being protected in advance. Proactive assessments can emphasize the importance of evaluating the components that can lead to increased falls. The CDC’s STEADI study showed that the STEADI evaluation “can be adopted in a busy primary care practice. With the STEADI algorithm embedded into the clinic workflow and could consistently implement the recommended interventions.” (Eckstrom et al., 2017) This easy incorporation is a no-brainer and should be incorporated in all healthcare facilities worldwide, as it is our number one job to protect the quality of life and health of the vulnerable — geriatric population.

References

Burns, E., & Kakara, R. (2018, May 17). Deaths from Falls Among Persons Aged ≥65 Years — United States, 2007–2016. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a1.htm?s_cid=mm6718a1_w.

Moreland, B., R. Kakara, & Henry, A. (2017, August 17). Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm.

Eckstrom, E., Parker, E. M., Lambert, G. H., Winkler, G., Dowler, D., & Casey, C. M. (2017, November 28). Implementing STEADI in Academic Primary Care to Address Older Adult Fall Risk. OUP Academic. https://academic.oup.com/innovateage/article/1/2/igx028/4669728?login=true.

Centers for Disease Control and Prevention National Center for Injury Prevention and Control. (2017). Resource Algorithm for Fall Risk Screening, Assessment, and Intervention. https://www.whca.org/files/2018/02/HechtSTEAD.pdf

Centers for Disease Control and Prevention. (2016, September 19). STEADI Helps Physical Therapists Incorporate Older Adult Fall Prevention in Routine Care. Centers for Disease Control and Prevention. https://www.cdc.gov/steadi/stories/routine.html.