Fall Prevention – Examination – Part III

Why is there so much disagreement regarding the best way to minimize the risk of falling? 

                                                  A review of several recent studies regarding the cause of falling reveals different assessments, different treatments, and different health care specialists involved. This makes it very difficult to effectively compare or reproduce findings. For example, in one study vestibular function was evaluated through comprehensive evaluation using VNG with calorics, Rotational Chair and Computerized Dynamic Posturography (Alvord, Benniger, & Stach, 2008). In another, only Dynamic Visual Acuity was used to assess vestibular function (Vind, et al 2009). Many studies do not incorporate any vestibular tests, but identify “Balance dysfunction” using Romberg and “Timed Get Up and Go” tests, or some other screening procedure (Hendricks, et al., 2008).

The bigger variable in determining the effectiveness of any fall prevention program is patient behavior.  Patients that have had a fall, therefore more likely to be enrolled in an fall prevention program, often develop a “post-fall anxiety syndrome.”  In the short term, this may reduce their risk of falling as a result of reduced activity and overly cautious behavior.  In the long term, this behavior can lead to deconditioning, weakness and unstable gait, ultimately increasing fall risk (Rubenstein, 2006). Patients undergoing exercise based balance training may become more confident, therefore more active and likely to engage in risky behaviors.  These variables are generally not considered in Fall Prevention studies.

Should vestibular evaluation be part of a fall prevention assessment?

 Despite the fact that there have been many studies exploring the risk factors associated with falling, very few directly address vestibular function. Most fall risk assessments use informal screening procedures or limited vestibular examinations, which often fail to identify vestibular dysfunction.  In two recent studies incorporating comprehensive vestibular evaluation, 67 to 73% of subjects undergoing fall risk assessment had evidence of vestibular dysfunction (Alvord, et al., 2008; Jacobson, McCaslin, Grantham, & Piker, 2008).  Again, a critical element in identifying vestibular dysfunction rests in the evaluation technique.  Many labs rely entirely on Electronystagmography, and fail to perform rotary chair or posturography tests.  In a “Risk of Falls” study by Jacobson et al (2008), approximately 40% of vestibular dysfunction patients would have been missed if the evaluation was limited to caloric testing.

Is there a way to quickly screen someone for potential risk factors for falling? Is there a tool available so that a patient can do a preliminary self- assessment?

Yes. Maybe. I think so. I am working on it.  Tune in next week and see what you think.

References:

Alvord, L., Benniger, M., & Stach, B. (2008). A preliminary study of the effectiveness of an otolaryngology-based multidisciplinary falls prevention clinic. Ear Nose Throat Journal, 87(9), 510-513.

 Jacobson, G., McCaslin, D., Grantham, S., & Piker, E. (2008). Significant vestibular system impairment is common in a cohort of elderly patients referred for assessment of falls risk, J Am Acad Audiol, 19, 799-807.

 Hendricks, M., Bleijlevens, M., van Haastregt, J., Crebolder, H., Diederiks, J., Evers, S., et al. (2008). Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: a randomized, controlled trial. JAGS, 56, 1390-1397.

 Rubenstein, L. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Aging, 35(S2), 37-41.

Vind, A., Andersen, H., Pedersen, K., Jorgensen, T., & Schwarz, P. (2009). An outpatient myltifactorial falls prevention intervention does not reduce falls in high-risk elderly Danes. JAGS, 57, 971-977.

 

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.