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Date: November 16th, 2021

Reference:  Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021

Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. 

Case: Mid-shift, you realise that the next patient you are about to see is the third in a row aged over 70 who has fallen at home, and that this is her third attendance for a fall in the last two months. You wonder if any emergency department (ED)-based interventions would help her and people like her be safe.

Background: We looked at geriatric falls on an SGEM Xtra in 2015. Back then we found that at one academic site older adults attending ED with falls didn’t receive guideline-based assessment, risk stratification or management.

Dr. Chris Carpenter

In 2014 the SGEM looked at a systematic review by Dr. Chris Carpenter, which concluded that there wasn’t a good tool to help us predict which ED patients are at risk of recurrent falls (SGEM #89).

Close to three million adults aged 65 and over visit American EDs annually after a fall [1]. Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [2]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [3-5].

The SAEM Geriatric Emergency Medicine Task Force recognized fall prevention as a priority over 10 years ago. There is the Geriatric Emergency care Applied Research (GEAR) network, which is trying to improve the emergency care of older adults and those with dementia and other cognitive impairments. GEAR looks to identify research gaps in geriatric emergency care support research and evaluation of these areas. GEAR 2.0 has recently been launched with funding opportunity in conjunction with EMF.

There are three other GEAR 1.0 manuscripts which have been published:

  • Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings AEM 2020
  • Care Transitions and Social Needs AEM 2021
  • Research Priorities for Elder Abuse Screening and Intervention J Elder Abuse Negl 2021

Clinical Question: In older patients presenting to ED with falls do risk stratification or fall prevention interventions influence patient-centered or operational outcomes?

Reference:  Hammouda et al. Moving the Needle on Fall Prevention: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. AEM November 2021

This publication presents two related but different scoping reviews so there are  two PICOs.

PICO #1

  • Population: Systematic search that found 32 studies of fall prevention interventions for patients aged 60 or over who presented to ED with a fall.
    • Exclusions: Abstracts repeating data already included in full, not original research.
  • Intervention: Fall prevention interventions including multifactorial risk reduction, medication review, exercise training, models of care like Hospital-at-Home.
  • Comparison: Standard of Care.
  • Outcomes: Quality of care ED metrics, ED operational outcomes like length of stay, patient-centered outcomes like ED returns, further falls, fear of falling, functional decline, institutionalization.

PICO #2

  • Population: Systematic search that found 17 studies of risk stratification and falls care plans in patients aged 60 or over in ED or pre-ED settings.
    • Exclusions: As review 1.
  • Intervention: Risk stratification and falls care plan.
  • Comparison: No risk stratification and falls care plan.
  • Outcomes: ED referral (from pre-ED setting), quality of care ED metrics, ED operational outcomes, patient-centered outcomes.

This is an SGEMHOP episode which means we have the honour of having the lead author, Dr. Elizabeth (Liz) Goldberg, on the show. She is an Associate Professor of Emergency Medicine and Health Services, Policy and Practice at Brown University. Her specific areas of interest include improving care for older adults and public health interventions to enhance longevity and healthy aging.

Dr. Elizabeth Goldberg

Authors’ Conclusions: “Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.”

Quality Checklist for Scoping Systematic Reviews:

  1. Did they provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives? Yes
  2. Was a rationale for the review in the context of what is already known provided? Yes
  3. Was there an explicit statement of the questions and objectives being addressed with reference to their key elements? Yes
  4. Was their protocol pre-published and the study registered? No
  5. Characteristics of the sources of evidence used as eligibility criteria was specified? Yes
  6. All information sources in the search were described? Yes
  7. The presented the full electronic search strategy for at least one database, including any limits used, such that it could be repeated. Yes
  8. The process for selecting sources of evidence (i.e., screening and eligibility) was included in the scoping review. Yes
  9. Methods of charting data from the included sources of evidence was described. Yes
  10. There was a list of all variables and definitions for which data were sought and any assumptions and simplifications made. Yes
  11. If done, a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate) was provided. No
  12. The methods of handling and summarizing the data that were charted was described. Yes
  13. Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram. Yes
  14. For each source of evidence, present characteristics for which data were charted and provide the citations. Yes
  15. If done, present data on critical appraisal of included sources of evidence (see item 12). No
  16. For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives. Yes
  17. The authors summarized and/or present the charting results as they relate to the review questions and objectives. Yes
  18. The authors summarized the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups. Yes
  19. They discuseds the limitations of the scoping review process. Yes
  20. The provided a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps. Yes
  21. The described sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review. Yes

Results: 32 studies were included (3 meta-analyses and 23 RCTs) with a total of 571,071 patients to try to answer the first PICO question about falls prevention. Studies were from 11 countries, 1999-2019, with follow-up from 1 to 18 months. Interventions included falls risk assessment, physical rehabilitation sessions, preventive education, educational guidelines, follow-up with NP or PT, and alert devices. Most used recurrent falls as the outcome although anxiety over falls, functional ability and QALYs also featured.

17 studies were included (4 meta-analyses and 8 RCTs) with a total of at least 17,232 patients to address the second PICO question about risk stratification. Studies were from 9 countries, 2011-18, with follow-up from 6 to 12 months. 11 screening instruments were identified with interventions including educational, physical therapy, follow-up calls, discharge planning and home visits. Most used recurrent falls as the outcome.

Key Result: The GEAR-Falls group identified five research priorities.

  1. EMS role in improving fall-related outcomes
  2. Identifying optimal ED fall assessment tools
  3. Clarifying patient-prioritized fall interventions and outcomes
  4. Standardizing uniform fall ascertainment and measured outcomes
  5. Exploring ideal intervention components

We asked Liz five nerdy questions about her study.  Listen to the SGEM podcast to hear her responses.

1. Question Selection: Your group original had three PICO questions (the third was about specific risk factors for falls e.g. polypharmacy). How and why did you decide to address the two that you did?

2. Consensus Conference: You held a consensus conference of your multidisciplinary group with the initial findings of the scoping review to generate and vote on research priorities. How do you manage an event like this to reduce the risk of one or two influential (or loud) people dominating discussions?

3. Disagreements: For your second PICO question, your reviewers disagreed with each other quite a lot about what should be included (Cohen’s Kappa 0.12) – can you tell us a bit more about that and how you handled it?

4. Definitions:  You talked in your discussion about how many definitions vary across research groups, even including what actually constitutes a “fall” – can you expand on that, and what do YOU consider to be a fall?

5. Patient Advocates: You had the review and the consensus recommendations reviewed and commented on by patient advocates before final write-up. What did the patient advocates change, and if you did it again would you include them earlier? 

Comment on Authors’ Conclusion Compared to SGEM Conclusion: The literature on falls in the older adult is difficult to synthesize due to differing definitions. There is plenty of room for good quality research on the identification of and interventions for older patients who fall.

SGEM Bottom Line: Patients may (or may not) benefit from falls screening and interventions. There is inadequate evidence to support a specific tool or intervention across the board, but it is likely that multifactorial interventions are most effective.

Case Resolution: You refer your patient to the Frailty outreach service, where she will undergo a comprehensive geriatric assessment.

Dr. Kirsty Challen

Clinical Application: Many centers have falls screening or prevention program; encourage yours to get involved in the GEAR-Falls priority research areas (or the equivalent in your locality).

What Do I Tell My Patient?  Previous falls are a predictor of future falls – we don’t know the best way to support you to reduce this risk, but we think the most useful approach is looking at all those different factors that might contribute, so we have a team that can do this.

Keener Kontest: Another week without a winner. The term Code Blue originate at the Bethany Medical Center in Kansas City, Kansas.

Listen to the SGEM podcast for this weeks’ question. If you know, then send an email to thesgem@gmail.com with keener in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn, SGEMers. What do you think of this episode on fall risk stratification and prevention in older adults? Tweet your comments using #SGEMHOP.  What questions do you have for Liz and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. Stalenhoef PA, Crebolder HF, Knottnerus JA, Van der Horst FG. Incidence, risk factors, and consequences of falls among elderly subjects living in the community: a criteria-based analysis. Eur J Public Health1997;7:328–34.
  2. Albert A, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS Data Brief 2013;130:1–8.
  3. Masud T, Morris RO. Epidemiology of falls. Age Ageing 2001;30:3–7.
  4. Yildiz M, Bozdemir MN, Kilicaslan I, et al. Elderly trauma: the two years experience of a university-affiliated emergency department. Eur Rev Med Pharmacol Sci 2012;16(Suppl 1):62–7.
  5. Centers for Disease Control and Prevention. Fatalities and injuries from falls among older adults–United States, 1993–2003 and 2001–2005. MMWR Morb Mortal Wkly Rep 2006;55:1221–4.