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SGEM#89: Preventing Falling to Pieces

SGEM#89: Preventing Falling to Pieces

Podcast Link: SGEM89
Date: October 5th, 2014

Guest Skeptics: Dr. Chris Carpenter. Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. C0-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules. @SAEMEBM

The goal of the SGEM continues to be to cut the knowledge translation window down from over ten years to less than one year. There are about 3,800 biomedical publications every day on PUBMED alone. Bastian et al published in PloS 2010 that there are about 75 RCT and 11 Systematic reviews released daily. They asked the question “How could anyone every keep up”?

The answer is no one could possibly keep up. No wonder it takes so long for high quality clinically relevant evidence to reach the bedside. A study by Morris et al in 2011 called discusses how it can take an average of 17 years for research evidence to reach clinical practice.

Screen Shot 2014-10-04 at 1.37.08 PM

Seventeen years is more than 10 years as we are always quoting on the SGEM. But we are going to try and shorten that KT window to less than 1 week using the power of Social Media.

The SGEM has entered into an arrangement with Society of Academic Emergency Medicine (SAEM) and the Canadian Association of Emergency Physicians (CAEP) to achieve that goal. SAEM publishes the Academic Emergency Medicine (AEM) Journal and CAEP publishes the Canadian Journal of Emergency Medicine (CJEM). I am calling SGEM Hot Off the Press, or SGEM HOP

Hot off the Press

  1. A paper that has been submitted, peer-reviewd, and ultimately accepted for AEM/CJEM is going to be picked. We will select these papers in conjunction with the Editorial Boards of each journal.
  2. The SGEM will then put a skeptical eye upon the manuscript using the BEEM critical appraisal tool. This is an instrument with published reliability and validity – the only such instrument that I am aware of in any specialty.
  3. One of the authors of the paper will be invited to discuss their work. This will be in order to defend the strengths/weakness/limitations/clinical application of the ideas and data that they propose.
  4. We will do a special SGEM Hot Off the Press podcast that will be posted the week the journal gets published. In essence, this is KT at the speed of social media!
  5. You the audience will get a chance to respond via the blog, twitter or on Facebook. Where else do you have this interactive opportunity to compliment or criticize research with the ear of the original author and the publishing editors?
  6. Another exciting component will be a summary of the SGEM critical appraisal because top social media feedback will be published in a subsequent issue of each journal. This process will leverage the content from original publication, secondary review, podcast dissemination, and social media interactivity and follow-up.

I am very excited about this new series. Just like Swami and the SGEM Classic episodes I hope the SGEM: Hot Off the Press episodes will be just as popular.

Case: 84yo woman (Mrs. C) who lives independently and alone in her own home presents to the emergency department via ambulance with a standing level fall. She was bending over to pick up a letter that had dropped off her desk, lost her balance and hurt her left, non-dominant arm. After the fall she was afraid to stand and could not reach her telephone so she laid on the floor calling for help until a neighbor heard her and called 911. She notes infrequent falls at home with no prior injurious falls. Her past medical history includes hypertension and a remote history of breast cancer, but she does not take anti-platelet or anticoagulant medications. An appropriate physical exam is performed and reveals an isolated left shoulder injury. The x-ray of her left shoulder is negative for any fracture. She is diagnosed with a minor contusion and provided with some acetaminophen. The daughter-in law arrives to take her home, but asks if Mrs. C is at risk for further falls in the future.

Question: Can healthcare personnel accurately identify subsets of geriatric adults at increased risk of falls or injurious falls in the months following an episode of emergency department care?

Background: In the geriatric population (all those over age 65), standing level falls are the #1 cause of traumatic mortality.

A fall can be defined as an unintentional, sudden descent to a lower level. This can be a fall from a bed or chair to the ground or down some stairs to a lower level of the home. In the vast majority of cases, we are not talking about falls from roofs or ladders.

For community dwelling adults over the age of 65 about 1/3 will suffer a standing-level fall. By the time you people reach 80 years of age that increases to half or 50%. Many of these people who fall end up in the ED.

These falls cause a lot of morbidity. They can cause contusions, lacerations and fractures. Fractures can obviously be any bony structure, but commonly include the spine, hip, pelvis, ankle, wrist and humerus. There are about 300,000 hip fractures every year in the US and by 2014 will probably have doubled.

These injuries must cost a lot of health care dollar.  In the USA standing-level falls cost about $19 billion a year.

As mentioned earlier, falls are the leading cause of traumatic mortality in this age group. Older adults who are admitted to the hospital after a fall (the sickest subset) will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year.

Article: Carpenter CR, Avidan MS, Wildes T, et al. Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review, Acad Emerg Med 2014

  • Population: Original prognostic research describing community-dwelling, non-critically ill geriatric adults after an episode of emergency department care.
  • Intervention: Falls and injurious falls risk stratification at 1- to 6-months evaluated in ED settings
  • Control: None
  • Outcome: Prognostic accuracy (sensitivity, specificity, likelihood ratios) for individual risk factors and prediction instruments to predict falls in the months following an episode of ED care.

Authors Conclusions: “This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk”.

checklist-cartoonQuality Check List for Systematic Review:

  1. The diagnostic question is clinically relevant with an established criterion standard. Yes. Comment: Geriatric falls represent the leading cause of traumatic mortality in older adults. Fall risk assessment is advocated as a geriatric emergency medicine core competency and quality improvement target. It is a key component of Geriatric Emergency Department Guidelines recently approved by the American College of Emergency Physicians, American Geriatrics Society, Society for Academic Emergency Medicine, and Emergency Nurses Association.
  2. The Search for studies was detailed and exhaustive. Yes Used a medical librarian and followed the MOOSE statement and PRISMA guidelines.
  3. The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes QUADAS-2 was used to evaluate the overall quality of the trial data
  4. The assessment of the studies were reproducible. Yes
  5. Three was low heterogeneity for estimates of sensitivity or specificity. NO
  6. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision making models. Yes

Key Results: 601 manuscripts with five papers met the inclusion criteria for a full review. Two articles did not include data to do a 2×2 table.  This left you three ED-based studies with 767 patients.

Two of the studies were prospective (660 patients) and one was retrospective (107). The two prospective studies contained 29 individual predictors. These predictors included past falls, number of medications used, self-reported dementia or depression, use of canes or walkers, ability to drive, sense of imbalance, and many others, as well as simple objective physical tests like the chair stand, chair sit, ability to raise feet while walking and turn 180º, and visual and auditory acuity.

The incidence of falls at 6 months was 31% for those who presented with a chief complaint of falls. The incidence of falls was about half (14%) if the chief complaint was something else.

The best positive likelihood ratio (+LR) was found in one of the two studies and had a result of 6.55 (95% CI 1.41-30.38). However, when that was combined in the meta-analysis gave a +LR of 2.54 (95% CI 1.62-3.98).

The best negative likelihood ratio (-LR) was if the patient could cut their own toenails –LR 0.57 (95% CI 0.38-0.86).

We described the Tiedemann and Carpenter fall-risk prediction instruments. Both instruments use a simple scoring system based upon two to four fall-risk factors. A Tiedmann score of three had a +LR 3.76 and a –LR 0.46 In contrast, the Carpenter score of >1 gave a similar +LR score, but proved much more useful to distinguish subsets at lower risk of falls with –LR of 0.11.

We opine that “although our results fail to provide a definitive fall screening strategy, the quantitative summary estimates of fall incidence and risk factor accuracy and reliability provide an evidence basis on which clinicians, nursing leaders, administrators, educators, policy-makers, and researchers can build.”

Dr. Chris Carpenter

Dr. Chris Carpenter

Comments: Clearly there is a need to figure out who is a greater risk in this geriatric population. These types of falls cause significant morbidity/mortality, cost a lot of money, and we simply lack the resources to treat every older adult as high-risk for future falls.

Risk assessment in aging adults is advocated by multiple professional organizations and licensing bodies. Nonetheless, geriatric patients rarely receive guideline directed care for falls following an episode of ED care.

Multiple barriers exist between contemporary ED management of community-dwelling senior citizens and optimal injurious falls prevention. The first and most prominent obstacle is the lack of ED-validated risk stratification instruments to distinguish low-risk from non-low-risk for falls. If we cannot identify the “at-risk”, how can we efficiently and cost-effectively proactively work to prevent future falls? Funding agencies need to recognize this conundrum, too.

There are some non-EM guidelines committees and prominent funding agencies opine that fall-risk stratification risk factors and instruments from office-based settings, hospital wards, and nursing homes ought to extrapolate to the ED. However, evidence based medicine proponents argue that validation in the ED is essential. The current meta-analysis from the Academic Emergency Medicine Evidence Based Diagnostics series takes an essential first step toward this objective.

One limitation of this study was its English only search. This was due to lack of funding resources.  The English search did identified  601 abstracts to review. Dr. Carpenter did attended the International Association of Gerontology and Geriatrics meeting in Seoul Korea in June 2013. This meeting brought together the world’s medical and non-medical experts in the care of an aging population. He sought expertise in ED-based falls prevention, cognitive assessment, frailty, and functional vulnerability during my week in Korea. Dr. Carpenter also serve as the Chair of the American College of Emergency Physicians Geriatric Section and founding member of the International Consortium for Emergency Geriatrics. Based upon these exposures and leadership positions, he is not convinced that there is a novel EMERGENCY DEPARTMENT based fall-risk stratification protocol somewhere else in the world.

  • Why limit the systematic review to only the English language?  My research lab lacks funding or capacity to translate hundreds of abstracts in dozens of languages to find the few manuscripts that might require translation. Remember that our English-language only search identified 601 abstracts to review. In addition, I attended the International Association of Gerontology and Geriatrics meeting in Seoul Korea in June 2013. This meeting brought together the world’s medical and non-medical experts in the care of an aging population. I sought expertise in ED-based falls prevention, cognitive assessment, frailty, and functional vulnerability during my week in Korea. I also serve as the Chair of the American College of Emergency Physicians Geriatric Section and founding member of the International Consortium for Emergency Geriatrics. Based upon these exposures and leadership positions, I’m not convinced that there is a novel EMERGENCY DEPARTMENT based fall-risk stratification protocol somewhere else in the world.
  • Limited search of the “grey” literature? We did conduct a hand search of unpublished abstracts in Academic Emergency Medicine and Annals of Emergency Medicine. Admittedly, we could have hand-searched various other scientific assembly research abstracts including the Journal of the American Geriatrics Society, Canadian Association of Emergency Physicians, and the European Society for Emergency Medicine.
  • Where you disappointed in the quantitative conclusions of this systematic review? I was disappointed for clinicians and educators seeking a definitive answer on the question. However, I strongly feel the results are still useful. More importantly, this research ought to serve as a siren song to emergency medicine investigators and funding agencies that we need to devote more time, energy, and resources to solving older adult acute care questions. If we cannot accurately identify older adults at increased risk for the #1 cause of traumatic mortality, what else are we missing: dementia, delirium, frailty, functional decline, etc.?
  • Why do you think that these results are still useful? We explored 29 commonly referenced risk factors across two prospective ED-based studies. None of the risk factors, including objective tests of function like the elements of the “get-up-and-go test”, accurately predicted falls at 6-months. However, two risk prediction instruments were described. One (Carpenter Rule) significantly reduced the post-ED fall risk with a negative likelihood ratio 0.11 (95% CI 0.06-0.20).
  • Why do you think you got unsatisfactory results? The reasons are likely multifactorial. Falls represent a complex relationship between an aging individual’s senescent physiology interacting with intrinsic and extrinsic stressors. The risk of falls for an individual are neither static from day-to-day nor comparable to the next patient of similar age and illness severity. Furthermore, existing trials did not use STARD criteria, including the lack of an explicit and uniformly accepted definition of “falls”. Future trials must do so, while employing more definitive gold standards for fall occurrence, including smart-phone fall detectors.

The Bottom Line: Persons 65 years or older are an increasing percentage of the total population. These people fall, get injured and even die. We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.

Case Resolution: This lovely 84yo woman (who was my grandmother in 1995) is treated conservatively for her minor contusions and is discharged home with her daughter-in law. She is advised to follow- up with her PCP in the next week and return to the ED if she has increasing pain, decreasing function or is otherwise concerned. Of concern, Sirois et al noted that 15% of these patients (community dwelling geriatric standing level fall, discharged home from the ED with minor injuries) will experience significant functional decline at 3-months

Clinical Application: ED-based fall-risk screening for older adults should use the most accurate risk-stratification instruments available until better tools are developed and validated in ED settings. Using other instruments like STRATIFY or HENDRICH II in the ED leaves clinicians, patients, payers, and policy-makers without valid, evidence-based estimates of post-ED fall risk. Funding agencies and researchers should more aggressively pursue more definitive and clinically useful fall-risk stratification.

What do I tell patients/families: Standing level falls are very common and can even cause death in people over age 65. There is about 1/3 chance your mother-in law will fall again in the next 6 months. Unfortunately, there is no single fall risk factor that we know of that can predict who will or will not fall. However, there is some information I can give you to try and prevent another fall. Click on this link to get the document downloaded. SGEM falling to pieces Figures

Keener Kontest: Last weeks winner was Loice Swisher from Ambler PA.  She knew the major adverse effects of procainamide to watch for were cardiac in nature. Specifically watching for hypotension and prolonged QRS and QT intervals. The infusion should be stoped if the QRS or QT prolongs by more than 50% from baseline.

Listen to the podcast for this weeks Keener question. Sent your answer to TheSGEM@gmail.com. Put “keener” in the subject line. The first correct answer will receive a cool sceptical prize.

Upcoming conferences: SkiBEEM January 26th-28th in Sun Peaks BC

 

Stay tuned for the next episode of the SGEM-HOP with Dr. Chris Bond and the Canadian Journal of Emergency Medicine.

Remember to be skeptical of anything you learn,

even if you heard it on the Skeptics’ Guide to Emergency Medicine.

  • Luciano Pilla

    This SGEM HOP initiative is a great idea. Thanks for your effort to share knowledge with everybody. This is invaluable, Dr Ken.

    • TheSGem

      Thanks Luciano, we think it is a good idea too. We are also happy to start with such an important topic that needs to be discussed. It was a privilege to have Dr. Chris Carpenter on the SGEM. He is a world expert in the field of geriatric EM and EBM.

  • Anand Swaminathan

    Ken – SGEM HOP an amazing idea. Collaboration with traditional academic medical resources is clearly one of the next steps in the development of FOAM. This along with Michelle Lin’s joint venture with Annals of EM represent an amazing opportunity for future directions.

    As far as the details of the podcast and article, very interesting. This isn’t something we spend a lot of time discussing but as the population ages, we clearly need to focus on it. In our ED, we often used to admit older patients with falls as “cannot rule out syncope” in order to get them further assessment by rehabilitation and visiting nursing services. Now, however, changes in admitting policies makes this difficult. Many of these patients now go into observation protocols. What likely needs to be added to these protocols are mandatory PM&R assessment and assessment for home services in patients over a certain age.

    With the growing number of geriatric EDs, I hope that more researchers will begin to look into this topic.

    Thanks to you and Chris for the great work. Looking forward to more!

    • TheSGem

      Swami:
      It is the best of both worlds:) Traditional strengths combined with the power of social media.

      Honoured to be mentioned in the same sentence as Michelle Lin and the amazing work she is doing with Annals and ALiEM.

      It was a very interesting topic to put a skeptical eye upon. Need to raise awareness on the topic. I did not know ground level falls were the #1 cause of traumatic mortality in the elderly. This caught me by surprise. Such a serious problem deserves our attention.

      Our population is increasing in age. We will be seeing more and more of these types of cases. Need funding agencies to support work by smart guys like Dr. Chris Carpenter.

      The best evidence we have right now is not very good. We need better evidence to make good decisions. Our elderly patients expect and deserve more. The status quo should not be an option.
      Ken

  • Meghan Groth

    Hey Ken, thanks for discussing this important issue! One thing I wish they would have looked at in this investigation was not just the number of medications that patients were taking, but the type of medication and whether or not this medication appears on the Beers Criteria list. This list is published by the American Geriatrics Society, and is intended to help identify potentially inappropriate medication use in the elderly. I see a lot of elderly patients come in taking something that seems harmless, say an over the counter acetaminophen with diphenhydramine combination, and the anticholinergic effects can put them at an increased risk of falls. We have an unique opportunity in the ED to identify potential medication-related causes for their visit and talk with them about stopping medications that can be harmful (or recommend they have that conversation with their PCP). We’re really good at prescribing drugs, but I think there’s some room for improvement on the de-prescribing end of things to avoid the all too common scenario of “polypharmacy,” and the elderly are especially susceptible to this.

    • TheSGem

      Meghan, I have said it before and I will say it again. I wish there was an EM pharmacist like you working on every shift.

      Medications can be a precipitating factor for falls. We should look carefully at the prescriptions geriatric patients who present to the ED with a fall are taking. It is a potential opportunity to prevent a devastating and life threatening fall.

      We need to choose wisely. Like you point out this may require “de-prescribing”.

      Appreciate your comments and expert insight into a problem that needs addressing.
      Ken

    • ACEP Geriatric Sect

      Meghan:

      Excellent questions and well worth contemplating. I’ll confess that despite advocating for the Beer’s criteria in the new ACEP-AGS-ENA-SAEM Geriatric ED Guidelines (see http://pmid.us/25117158 and http://pmid.us/24890806 and http://pmid.us/24746437), there is ongoing debate in the Geriatric ED investigator community about whether the Beer’s criteria apply in whole (or in part) to the unique ED environment where prescriptions are meant for short-term, acute condition specific care (see http://pmid.us/18606324). In fact, one of my colleagues at University of Alabama-Birmingham who co-authored this geriatric falls systematic review with me (Alex Lo) is investigating an ED version of the Beer’s Criteria via a Delphi process that will include quantitative estimates of Number Needed to Treat and Number Needed to Harm for short-term ED-type prescribing of common geriatric conditions — so stay tuned.

      I do agree that future ED-based fall risk-stratification studies need to assess more than the raw number of medications. Assessing pharmacological subclasses of medicine’s association with fall-risk is a compelling question. In conjunction with the NIH and SAEM, geriatric investigators also highlighted the following issues as high-priority medication related geriatric research questions (see http://pmid.us/21676064):

      1) Can efficient ED systems be developed to identify potential interactions with warfarin when new medications are prescribed?

      2) Can systems be developed to enhance appropriate benzodiazepine prescribing from the ED and minimize adverse effects like falls?

      3) Do gastroprotective agents reduce short-term gastrointestinal (GI) complications when prescribed concurrently with nonsteroidal anti-inflammatory drugs (NSAIDs) in the ED?

      Thanks for your interest in Geriatric EM and the new SGEM/AEM Hot Off the Presses podcast. Emergency Medicine has much to learn about “polypharmacy” and de-prescribing in an aging society so as to first avoid doing harm.

      Chris Carpenter
      @SAEMEBM
      @GeriatricEDNews

    • Lauren Westafer

      I think you bring up a great point about something that is, presently, partially under control of the provider – a medication history. Patients often have their big shopping bag of medication that we can pilfer through (my favorite), a family member with a list (fairly reliable), or old records in the EMR (of variable utility, as it’s often outdated or reflects what a patient should be taking, not what they are, in fact, taking). As I discussed in a blog post a couple of years ago (http://shortcoatsinem.blogspot.com/2012/09/never-trust-your-patients-med-list.html), medication histories are often inadequate and a safer, more reliable alternative is needed (…And commercially in development http://www.ncbi.nlm.nih.gov/pubmed/?term=23688770). This is only peripherally related to falls, but a patient’s home medications may contribute to their presenting fall or serve as a warning sign for future falls (whereby a provider could prompt patient to discuss with their PCP or d/c the medication under the right circumstance). Furthermore, when prescribing in the ED, I think we can, in the absence of scores, protocols, and consultants think about the medications we’re prescribing to elderly patients who are going home to unmonitored settings and discuss fall precautions with patients (perhaps more useful than the stock line – don’t drive or operate machinery while you take this medication).

      • TheSGem

        Thank you for the comments Lauren. Enjoyed reading your description of medication lists. We have all experienced similar situations. What are they really taking?

        Appreciate you including the link to your Short Coat Blog which is excellent.

        I also enjoyed reading your recent post in ALiEM on how you work smarter. http://www.aliem.com/lauren-westafer-how-i-work-smarter/

        Keep up the FOAMy goodness with Jeremy Faust on your podcast series http://www.FOAMCast.org Don’t FOAM it alone Y’all.
        Ken

    • Don Melady

      Meghan — Thanks for spending some time on medications and the older patient. A lot of the time we are happy (as in younger patients) to take a quick glance at the often nurse-acquired med list (“see list”) and leave it at that. However in the ED assessment of important conditions in the the older patient (especially delirium, weakness, and falls), medications are usually “where the money is” (as drug companies learned long ago!) I teach and use the concept of the “brown bag biopsy” — I usually get more surprising and helpful information by a careful bottle by bottle review of that big bag of pills than by any other part of the H and P. Another helpful concept that I learned from geriatrician colleagues is “medication debridement” — although it needs to be practised judiciously, if we identify a potentially or likely inappropriate medication (eg. the THIRD beta-blocker recently added by yet a different consulting specialist) that we can causally link to new or increasing falls, the Emerg physician should fell empowered to “cut away” the dead tissue that is preventing healthy living. For more thoughts on this topic, check out our accredited CME website on Medication Management in the Older ED Patient: http://geri-em.com

      Don Melady
      Mount Sinai Hospital Toronto
      @geri_EM

  • Esther Choo

    Who do you envision doing these assessments/calculating the score (once we have a robust prediction instrument)? MDs? Nurses? Case managers? As with every prevention / public health initiative, a key part of our role, but important to know how we will implement this routinely in the ED.

    • ACEP Geriatric Sect

      Esther:

      Great question and well worth contemplating. In fact, I personally believe that efficient, cost-effective methods for geriatric screening in ED settings is an important study question by itself, regardless of what is being screened for (fall risk, dementia, delirium, vulnerability, etc.). In conjunction with SAEM, AGS, and the NIH, geriatric EM investigators prioritized the highest yield research questions for geriatric adults (see http://pmid.us/21676064 and http://pmid.us/21498881). In addition, the John A. Hartford Foundation and AGS derived and published the geriatric “Research Agenda Setting Process” and the New Frontiers project in 2003 with updates in 2008 (see http://newfrontiers.americangeriatrics.org/chapter.php?ch=16). High yield research questions pertinent to ED screening of older adults included:

      What are the key elements of electronic information systems that
      facilitate point-of-care risk stratification and communication of
      high-risk findings to emergency providers and primary care physicians?

      EmergMed 4 (Level A): Following
      evidence-based identification of target areas for improvement,
      controlled studies of the effect of alterations in the micro-environment
      on outcomes for older emergency department patients should be
      performed. Such studies likely cannot be based on random assignments of
      individuals to interventions; rather, whole micro-environments will have
      to be compared.

      EmergMed 9 (Level B): Development and
      testing of measures for functional assessment that are feasible and
      valid in elderly emergency department patients are needed.

      EmergMed 16 (Level B): Studies are needed
      to develop brief screening instruments for specific conditions for use
      with older patients in the emergency department.

      EmergMed 17 (Level A): Screening
      for asymptomatic conditions in older patients in the emergency
      department should be done only if detection of the abnormality results
      in treatment of the disorder and this treatment results in improvement
      in outcomes. Randomized interventional trials are needed to assess
      short- and long-term outcomes of patients who have screening and
      treatment for these conditions.
      So what answers (or at least ideas) can I provide? Tim Platts-Mills and I provided several ideas in one recent essay (http://pmid.us/23177599), including exploration of non-nurse, non-physician “geriatric technicians” (see http://pmid.us/22224145), which could be students or senior citizen hospital volunteers, whom we too often engage working in the gift shop or greeting patients rather than proactively engaging them in the healthcare delivery process. Very little evidence exists upon which to declare that these out-of-the-box screening methods/personnel can or will work, but they offer viable, testable alternatives to simply asking over-burdened ED nurses and physicians to do more. Keep in mind that Geriatric Emergency Department Guidelines endorsed by ACEP, AGS, ENA, and SAEM now exist (see http://pmid.us/25117158 and http://pmid.us/24890806 and http://pmid.us/24746437) and geriatric-specific EDs are popping up across the United States (see http://pmid.us/24628759 and http://pmid.us/24301394) so proactive solutions are needed. Once accurate screening instruments and feasible ED strategies (?geriatric technician?) are identified, implementation science will need to be engaged to assess adaptability, local cultural capacity for change, and sustainability of geriatric case-finding efforts.

      Thank you Esther for helping to launch the AEM-SGEM Hot Off the Presses series! This collaboration is going to be fabulous to beginning merging traditional peer-reviewed press with the world of social media and FOAMed.

      Chris Carpenter
      @SAEMEBM
      @GeriatricEDNews

      • TheSGem

        This just shows why you are one of the smartest guys in the world on this subject. Thank you for responding to these tough questions on such an important issue.
        Ken

  • Eve Purdy

    Hi Ken,

    Thanks for the great HOP initiative!!! Remarkable 🙂

    I am going to play the skeptic for a second about what you say to families when with “there is some information I can give you to try and prevent another fall”.

    The trouble comes in that the evidence is relatively inconclusive in terms of whether we can actually prevent falls with current prevention programs and we have essentially no evidence to suggest that we can prevent injury from falls with such programs. http://summaries.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-people-living-in-the-community . I think the statement puts an unfair amount of responsibility on the patient and family (which might add guilt when another fall happens) without good evidence to support. It would be like saying “take this drug to prevent another MI” when there is no evidence showing benefit.

    I am encouraged that this study is trying to stratify risk because targeted interventions, rather than population-based interventions, will probably be a wiser use of healthcare dollars. We recently performed a population-based retrospective analysis of all patients presenting to the ED with falls. We looked at the presence of factors currently targeted by fall prevention programs to better understand whether the presence of risk factors were related to injury severity. Moral of the story, they were not. Hopefully we can get the results out soon to add to the growing body of (skeptical) fall prevention research.

    • TheSGem

      Glad you are playing the skeptic. Will get Dr. Chris Carpenter in on this to try and respond to this excellent feedback.

    • ACEP Geriatric Sect

      Eve:

      Excellent skeptical perspectives (in the spirit of the SGEM) that merit discussion. I agree that we cannot provide false assurances to family that EM personnel can either accurately identify older adults at increased risk for falls or be certain that identification of fall-risk provides definitive management options for their loved ones. Nonetheless, what is our alternative — to maintain the status quo, which is essentially do no screening and ignore the guidelines (see http://pmid.us/22224145 and http://pmid.us/15982758)

      As we note in the manuscript and as we briefly debate on the podcast and as you wisely highlight, we most definitely do need more research on the topic of geriatric falls based in ED settings. In fact, in conjunction with the American Geriatrics Society and the National Institutes of Health, geriatric EM researchers prioritized what research is needed most quickly in 2011 (see http://pmid.us/21676064) summarized as:

      1) Can high-risk geriatric fallers who require admission or expedited outpatient evaluation be identified in the ED?

      2) Can simple and feasible interventions reduce fall or injurious fall rates after the ED visit?

      3) Could rapid response teams or special ED-associated units evaluating geriatric adults at increased risk for recurrent falls reduce fall-related injuries and improve the efficiency of inpatient resource utilization?

      4) Can hospital-at-home models for management of high-risk fallers be developed, and what are the characteristics of models that successfully lower falls rates?

      5) What are the key elements of electronic information systems that facilitate point-of-care risk stratification and communication of high-risk findings to emergency providers and primary care physicians?

      As emphasized on the SGEM-HOP podcast, it is now time for funding agencies to put their money where their mouth is. Despite representing the #1 etiology of traumatic mortality in geriatric adults worldwide, the new Academic EM systemic review demonstrates that we know very little about how to risk stratify geriatric adults for post-ED future fall risk. Without this knowledge, interventional trials will likely demonstrate disappointing results until we can focus fall prevention strategies on higher risk subsets using adaptive trial designs that target specific fall prevention interventions at fall risk unique to the patient.

      My word of advice to SGEM skeptics worldwide about the topic of geriatric falls prevention comes from the mouth of the 1930’s American cowboy philosopher Will Rogers “It ain’t so much what you know that gets you into trouble as what you know that ain’t so.” Remember that — despite the lessons that we’ve been taught about the “Get Up and Go” test and the disappointing Cochrane results regarding fall prevention trials — EMs evidence basis for fall risk screening and targeted interventions is very inadequate. With appropriate funding and dedicated EM-based researchers and prospective study research collaboration I am confident that we can alleviate this scourge of aging for our ambulatory, community dwelling patients to maintain independence and healthy living.

      Thanks for listening.

      Chris Carpenter
      @SAEMEBM
      @GeriatricEDNews

      • Eve Purdy

        Thanks Dr. Carpenter for your perspective, seems like we are on the same page! More funding is needed and more high quality research performed. Preferably with patient-centred outcomes fuelling the results.

  • Andrew Worster

    I just wanted to drop a line to say how impressed I am with some of the challenging questions posed below on whether we can actually make a difference and, if so, how and with what resources. I don’t know the answers to these questions but it’s our younger generation of emergency physicians who will be dealing with these and other geriatric issues for the duration of their emergency medicine careers. To that end, it’s imperative that we keep these and similar discussions going. By doing so, we can educate and influence research policymakers and funding agencies on the issues most important to emergency medicine.

    • TheSGem

      Great to have the EBM master and founder of BEEM commenting on this issue. Thank you Dr. Worster.

  • jay banerjee

    great comments! personally, only treat immediately reversible causes and then leave the rest to the MDT falls clinics (common in the UK). evidence is not great. bottom line is that we cannot stop most people from falling. hence all the more we should NOT try to institutionalise fallers to reduce risk. fallers themselves have varying opinion. we need to be more mindful of these especially given the not-so-great evidence for interventions. it is more about person-centred targeted care rather than management of falls.
    http://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Health-and-wellbeing/Falls%20prevention%20-%20Dont%20Mention%20the%20F-Word%202012.pdf?dtrk=true

  • Judy Lowthian

    An excellent initiative to translate research findings and facilitate international interdisciplinary discussion.
    Risk stratification is vital in the ED, with our quest to reduce older folks’ re-exposure to the numerous harms of hospitalisation. It also enables development of a tailored person-centred intervention.
    One concern I have with fallers is that uptake of falls prevention strategies recommended by ED clinical staff has been poor for a variety of reasons.
    We are currently conducting a trial to try and improve participation:
    http://injuryprevention.bmj.com/content/early/2014/06/23/injuryprev-2014-041271.abstract?sid=caa48b1d-712c-4c24-b405-509887129544

    • Judy: Excellent news about your ongoing falls secondary prevention trial. This is the future for efficient, effective falls prevention and I hope that the United States (and the rest of the world) follows a similar path to fund ED-based falls prognostic and intervention studies — soon! Hearing about the falls research underway in Australia and the UK confirms my belief that this is a global health issue, which adds support for a worldwide geriatric EM collaborative! It already exists! See http://www.iceg.info/

      Cheers!

      Chris
      @SAEMEBM
      @GeriatricEDNews

  • Angie LeGresley

    Was the single leg stance stability test included in this research? http://www.youtube.com/watch?v=PJ227yZHVyA

    • TheSGem

      Thanks for the question and link to the YouTube video. I will get Dr. Carpenter the world expert on the issue to respond.

      • Angie and Ken:

        No, we published the only eligible study that assessed any objective (functional) tests in ED settings (http://pmid.us/19281493) and we did not assess the single leg stance stability test. We did assess the Chair stand, Chair sit, ability to raise feet while walking (very similar to the video of the single leg stance stability test), and ability to stop-and-turn 180 degrees while walking (see below). Has the single leg stance stability test been assessed for fall-risk prognostic accuracy (sensitivity, specificity, likelihood ratios)?

        Chris
        @SAEMEBM
        @GeriatricEDNews

  • Don Melady

    Ken and Chris have done a fantastic job of opening the discussion on an essential topic in EM of the future. Most of us, without acknowledging it, work in Major Trauma Centres: we see a lot of older patients with often multi-system injury (blow to the head, soft tissue injury to the chest and wrist fracture) from a simple fall — which can have major morbidity and mortality consequences that change quality- and quantity-of-life outcomes for the patient. However mostly we behave as if it “just another fall” and send the person home with a pat on the head and good wishes!

    As Chris’s excellent and timely SR regretfully points out, there is not a lot of evidence to guide practice in this field. However clinicians focussing on ED care of older patients do emphasise the need to move beyond the “just fix what’s broke” approach to trauma to a more geri-friendly approach which sees the ED as a part of a continuum of care for older people. I teach a four-part approach to falls:
    1. what caused the fall?
    2. what are the consequences of the fall?
    3. what can be done to prevent future falls (the subject at hand)?
    4. what is a safe discharge plan?

    The last two are the ones that Emerg folks least often see as their responsibility. But a geri-friendly ED needs to be a site not only of acute care but also of primary care with an emphasis on prevention that is tied to the community in which we and the patient are located. While I fully agree with Eve and Chris below that “more research is needed,” in the meantime clinical judgement dictates that some interventions are likely worth implementing AND studying:

    1. involving a multi-disciplinary ED-based team in the assessment of the patient (older people are too complex for one Emerg doc’s brain to handle!),
    2. establishing strategies for communication with community-based care providers (can we arrange for someone to get into the patient’s home to assess them),
    3. easy and standardized referral to specialist clinics for further assessment (it should be as easy to access a Falls Clinic for a high-risk faller as it is a Chest Pain Clinic or a Stroke Prevention Clinic for high-risk chest pain or possible TIA.)

    I’d like to make a plug for my belief that “more education is needed” for us Emerg folks about older people. Please check out the module “Trauma and Falls” on our RCPSC/AMA accredited website: http://geri-em.com

    Great work guys!

    Don Melady
    Mount Sinai Hospital Toronto
    @geri_EM

    • Don: All excellent perspectives which I heartily affirm. For those reading this blog, take a moment to check out http://geri-EM.com. It is an extremely well-developed and up-to-date web-learning experience with credit available.

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  • Ken Milne

    #SGEMHOP on Geri Falls: One of top articles ever in AEM journal
    Demonstrates the power of #SoMe for KT
    #FOAMed #MedEd

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