The Holy Grail, the Fountain of Youth, the Philosopher’s Stone, Botox. Humankind has always searched for those elusive, transformative objects that would somehow protect, heal, or rejuvenate a person.
For physical therapists in geriatric settings, that mythical quest is for the singular test that will, with 100% accuracy, predict who will fall. Spoiler alert: Be prepared for disappointment.
As with all myths, there are elements of truth. Mobility and balance are crucial to keeping older adults on their feet. However, they are only a part, and often a small part, of the story. An older adult can be a marathon runner, but if he starts taking Percocet to manage his post-race pain, he will probably experience a fall. The geriatric population reflects a wide range of ages and abilities. Thus, a “one-size-fits-all” approach to assessing fall risk can easily miss the mark.
Assessing the Assessment Tools
In a June 2014 study [Epub ahead of print], Chitra Lakshmi K. Balasubramanian, PT, PhD, pointed out that many commonly used assessments, such as the Berg Balance Scale, Timed Up & Go test, and Dynamic Gait Index, among others, have ceiling effects that make them inadequate for community-dwelling adults aged 65 and older who are “active and ambulatory.” She examined the validity and reliability of the Community Balance and Mobility (CB&M) Scale, and whether it might be more accurate in detecting gait, balance, and mobility deficits and predicting falls in this mobile geriatric population.
While Balasubramanian found that the CB&M scale is reliable and valid, and does not demonstrate any ceiling effects, her results did NOT conclude whether it is an accurate predictor of fall risk. However, she makes an excellent broader point: If the selected assessment is not matched for the patient’s ability, we may be missing problems that can be addressed by physical therapy. We need a wide selection of tools tailored to our client on all levels of the ICF model: impairments of body structure/function, daily tasks activities, and life roles.
A Patient-Specific Approach
The take-home message: For physical therapists to be effective fall risk managers, we have to perform a fall risk screen on ALL of our clients. Those that screen positive need to have all positive risk factors (balance, polypharmacy, cognition, etc) assessed using appropriate tools. These tools should be objective, able to capture change over time, and relevant to the patient’s movements and abilities. [Thankfully, there are excellent tools and resources to support integration of screening and assessment into PT practice—including the Centers for Disease Control & Prevention's Stopping Elderly Accidents, Deaths & Injuries toolkit (CDC STEADI) and the Fall Risk Assessment and Screening Tool (FRAST).
In other words, no single tool or measure can be the Holy Grail for predicting fall risk because people are too variable. The CB&M scale assesses many different movement patterns, but what if the patterns are not common or useful to your patient? Asking someone to perform an unfamiliar activity can pose an appropriate challenge, but it may not elicit the information we need. Another validated tool may be more appropriate given the characteristics of this individual in his or her environment. Once we have identified a patient’s risk factors, assessed the interaction of the risk factors with his or her environment, and then selected the appropriate assessment tool, we are strategically positioned to prescribe the most appropriate evidence-based interventions.
The Magic Elixir
Wait—maybe we have found our own magic elixir for fall prevention: Validated assessments (matched to our patient or client's abilities) + Clinical judgment + Patient-specific picture provided by the ICF model. These 3 elements are required to truly evaluate and develop effective interventions to achieve the ultimate goal: helping an individual avoid falls.
What do YOU think? Give us your feedback in the comments, or on social media (hashtag #PTNow).
Thanks to Tiffany E. Shubert, PT, PhD, clinical architect at Shubert Consulting and author of the PTNow clinical summary, “Fall Risk in Community-Dwelling Elders,” for contributing this week’s post!