Transcript Assessing Patients In A Neurology Practice For Risk Of Falls

Practice Parameter: Assessing Patients in
a Neurology Practice for Risk of Falls
(An Evidence-Based Review)
American Academy of Neurology (AAN)
Quality Standards Subcommittee
D.J. Thurman, MD, MPH; J.A. Stevens, PhD;
J.K. Rao, MD, MHS
American Academy of Neurology © 2008
The AAN develops these presentation slides
as educational tools for neurologists and
other health care practitioners. You may
download and retain a single copy for your
personal use.
Please contact [email protected] to learn
about options for sharing this content
beyond your personal use.
American Academy of Neurology © 2008
Presentation Objectives
• To review the practice parameter for
screening methods and assessments
of risk for falls pertaining to patients
likely to be seen in neurology
practices.
• To make evidence-based
recommendations.
American Academy of Neurology © 2008
Overview
•
•
•
•
•
•
Background
Gaps in care
AAN guideline process
Analysis of evidence
Summary
Recommendations for future research
American Academy of Neurology © 2008
Background
• Public Health Burden of Unintentional Falls:
– Each year, unintentional falls in the United States account for
more than 16,000 deaths, of which three quarters occur among
persons over 64 years of age. [Ref. 1, Centers for Disease
Control and Prevention.]
– Each year, approximately 500,000 U.S. seniors are hospitalized
for fall-related injuries. [Ref. 2, Alexander et al.]
American Academy of Neurology © 2008
Background
• General Risk Factors:
(Previously recognized in systematic reviews)
–
–
–
–
–
–
–
–
–
Muscle weakness
Deficits in gait or balance
Visual deficits
Arthritis
Impairments in activities of daily living
Depression
Cognitive impairment
Use of sedatives, antidepressants, and neuroleptics
Age >65 years
Multiple risk factors in a single patient have additive effects.
American Academy of Neurology © 2008
Gaps in Care
• Clinical practice guidelines exist on reducing fall
risk in elders showing effective interventions to
decrease falls
• Many patients at risk of falling seek neurological
consultation
• Neurologists can play a role in screening for fall
risk
• This clinical practice guideline seeks to evaluate
screening methods and identify those patients at
the greatest risk of falling.
American Academy of Neurology © 2008
AAN Guideline Process
Clinical Question
Evidence
Conclusions
Recommendations
American Academy of Neurology © 2008
Clinical Question
• Question should address an area of
quality concern, controversy, confusion, or
variation in practice
• Question must be answerable with
sufficient scientific data
– Potential to improve clinical care and patient
outcomes
American Academy of Neurology © 2008
Literature Search/Review:
Rigorous, Comprehensive, Transparent
Complete
Search
Review abstracts
Review full text
Select articles
Relevant
American Academy of Neurology © 2008
AAN Classification for
Evidence
• All studies rated Class I, II, III, or IV
• Therapeutic Studies
– Randomization, control, blinding
– Not used in this parameter
• Diagnostic Studies
– Comparison to gold standard
– Not used in this parameter
• Prognostic Studies
– Measure risk, predictive values, in representative patient
populations
– Applied in this parameter
American Academy of Neurology © 2008
AAN Level of
Recommendations
A = Established as effective (or useful), ineffective,
or harmful for the given condition in the specified
population
B = Probably effective (or useful), ineffective, or
harmful for the given condition in the specified
population
C = Possibly effective (or useful), ineffective, or
harmful for the given condition in the specified
population
U = Data is inadequate or conflicting; given current
knowledge, intervention is unproven
American Academy of Neurology © 2008
AAN Level of
Recommendations
A = Requires two consistent Class I studies
B = Requires one Class I study or two
consistent Class II studies
C = Requires one Class II study or two
consistent Class III studies
U = Studies not meeting criteria for Class I
through Class III
American Academy of Neurology © 2008
Clinical Questions
• Which neurologic conditions are
associated with an increased risk of
falling?
• Are there practical clinical screening
methods for neurologists that can
accurately identify older patients and those
with chronic neurologic conditions who are
at high risk of falling?
American Academy of Neurology © 2008
Methods
• Literature Search
– National Library of Medicine MEDLINE, and Cochrane Library
• Search limited to English-language articles published
January 1980 - January 2005
• At least two authors reviewed each full article
• Any disagreements were resolved by consensus after
discussions between reviewers
• Risk of bias determined using the AAN Classification of
Prognostic Evidence for each study (Class I – IV)
• Strength of practice recommendations linked directly to
level of evidence (Level A – U)
American Academy of Neurology © 2008
Literature Search/Review
193 articles
86 articles
American Academy of Neurology © 2008
Exclusion criteria:
-Falls resulting from
environmental
hazards (e.g., icy
walkways)
-Falls associated with
unusual high-risk
activities or events
(e.g., sports or
shoving)
-Falls following loss of
consciousness due to
seizures or syncope
Literature Search/Review
• Studies were divided into two areas:
– Measurement of non-syncopal falls
– Addressing specific neurologic risk factors or screening tools that
could be easily applied in a clinical setting without special
equipment.
• Majority of articles described the experience of seniors
living in the community.
• Articles described prospective cohort studies of incident
falls
• Graded as Class I – IV using the AAN Classification of
Evidence for prognostic Intervention
• At least two Class III and one or more Class I or II
articles pertained to a single risk factor or screening test.
American Academy of Neurology © 2008
Clinical Question 1.
• Which neurologic conditions are
associated with an increased risk of
falling?
American Academy of Neurology © 2008
Analysis of Evidence
• Risk of future falls determined from history
of falls
– Period for the history of falls was 1 year
(range: 3 months to 2 years)
– Five Class I studies examined the risk of
future falls among older adults with a history
of recent falls; follow-up period usually 1 year
– With history of falls, pooled absolute risk of
falling was 55%
American Academy of Neurology © 2008
Analysis of Evidence
• Risk of falls due to neurologic conditions
determined from history and examination
– Strong evidence supports diagnoses of
stroke, dementia, and disorders of gait and
balance, including people who use assistive
devices to ambulate (Level A).
– Good evidence supports Parkinson disease,
peripheral neuropathy, lower extremity
weakness or sensory loss, and substantial
loss of vision (Level B).
American Academy of Neurology © 2008
Analysis of Evidence
• Stroke
– Three Class I studies found significantly greater risk
of falling among persons with a past history of stroke.
– Absolute risk of falling during follow-up was 34%,
using data pooled from three studies.
– Class III study demonstrated that stroke patients have
an increased risk of falls among persons undergoing
rehabilitation.
– Class III studies identified cognitive impairment,
confusion, and impairment in activities of daily living
as factors increasing risk of falls among stroke
patients.
American Academy of Neurology © 2008
Analysis of Evidence
• Parkinson disease
– Class I study estimated an increased risk of
falls among seniors with this disease.
– Class II study reported the absolute risk of
falls among persons with this condition as
68% during the follow-up period.
– Other Class II or III studies revealed those
with postural instability and absent arm
swinging during walking were at much greater
risk of falls than those without instability.
American Academy of Neurology © 2008
Analysis of Evidence
• Dementias and cognitive impairment
– Twelve studies were based on findings from the
standardized Mini-Mental State Examination (MMSE)
or criteria of the American Psychiatric Association’s
Diagnostic and Statistical Manual, 3rd Ed.
– Two Class I studies of community-dwelling seniors
found an increased risk of falls among those with
cognitive impairment.
– Six Class II studies representing both communitydwelling and institutionalized older populations,
indicated increased risk of falls in the presence of
dementia or cognitive impairment.
American Academy of Neurology © 2008
Analysis of Evidence
• Dementias and cognitive impairment (cont.)
– One Class II study found a higher risk of falls among
moderately demented persons than in those who
were mildly demented.
– Four Class III studies provided evidence that
dementia or cognitive impairment increase the risk of
falling among institutionalized seniors.
– Pooled data from five of these studies indicates an
absolute risk of falling of 47% among patients with
dementia during study follow-up.
American Academy of Neurology © 2008
Analysis of Evidence
• Peripheral neuropathy
– One Class I study yielded an absolute risk of
falling of 55% during an average follow-up
time of nearly 6 months.
– Two Class III studies found an increased risk
of falls among persons with peripheral
neuropathy
American Academy of Neurology © 2008
Analysis of Evidence
• Disorders of gait and balance
– Ten studies (including 2 Class I) associated various
signs or symptoms of gait or balance abnormalities
with increased risks of falling.
– Populations included older adults residing in a variety
of settings – communities, housing for seniors, or
nursing homes.
• Use of assistive devices
– Class I study reported an RR for falls of 2.5 among
seniors who used a walker or cane.
– Two Class III studies reported sensitivities of 59%
and 23%.
American Academy of Neurology © 2008
Analysis of Evidence
• Lower extremity weakness or sensory loss
– Class I study reported an RR falls of 2.4 among
seniors with lower extremity disability manifest by
“problems with strength, sensation, or balance.”
– Class II study reported ORs of 2.2 among stroke
survivors with LE motor impairment and 3.1 among
those with combined LE motor and sensory
impairments.
– Class III study reported an OR of 1.8 for seniors with
lower extremity sensory loss and an OR of 4.1 for
those with hip flexion weakness.
American Academy of Neurology © 2008
Analysis of Evidence
• Vision loss
– Class I study reported an RR for falls of 1.7 among
seniors with vision loss.
– Class III studies of persons with corrected visual
acuity less than 20/30 indicated an RR for falling of
2.1.
– Class III study reported an OR of 1.8 for the risk of
falling among seniors with impaired vision.
– Class III studies yielded ORs of 2.9 for adults with
nuclear cataracts and 3.2 for seniors who were blind.
– Class II self-reported impaired eyesight found an OR
of 2.6.
American Academy of Neurology © 2008
Conclusions
• An increased risk of falls is established among persons
with diagnoses of stroke, dementia, and disorders of gait
and balance, including those who use assistive devices
to ambulate (Level A).
• An increased risk of falls is also probable among patients
with Parkinson disease, peripheral neuropathy, lower
extremity weakness or sensory loss, and substantial loss
of vision (Level B).
American Academy of Neurology © 2008
Conclusions (cont.)
• As for screening measures that may predict or further
assess fall risk, a history of falling in the past year
strongly predicts the likelihood of future falls (Level A).
• Other systematic, evidence-based reviews (not rated) of
numerous studies have identified general risk factors for
falls, including advanced age, age-associated frailty,
arthritis, impairments in activities of daily living,
depression, and the use of psychoactive medications
including sedatives, antidepressants, and neuroleptics.
American Academy of Neurology © 2008
Recommendation
• Patients with any of the fall risk factors
identified above should be asked about
falls during the past year (Level A) and
further evaluated where indicated.
American Academy of Neurology © 2008
Clinical Question 2.
• Are there practical clinical screening
methods for neurologists that can
accurately identify older patients and
those with chronic neurologic
conditions who are at high risk of
falling?
American Academy of Neurology © 2008
Analysis of Evidence
Prediction of risk of falling using other screening
assessments
• Get-Up-and-Go Test (GUGT) and Timed GetUp-and-Go Test (TUG)
– Measure ability to rise independently from a sitting
position, walk a short distance, turn around, then walk
back and sit down. [Details in e-Appendix of parameter at
http://www.neurology.org/content/70/6/473/suppl/DC1]
– Two Class II and three Class III suggest these
measures are useful in assessing risk of falling.
American Academy of Neurology © 2008
Analysis of Evidence
• Standing unassisted from sitting position
– Measures people’s ability to rise from sitting in
a chair without using their arms.
– Class II study reported an adjusted OR for
falling of 3.3 for those who failed.
– Class I study timed the performance of this
test, finding that the OR for falls among
persons either unable to stand or requiring 2
seconds or more to do so was 3.0.
American Academy of Neurology © 2008
Analysis of Evidence
• Tinetti Mobility Scale (TMS)
– Measure of dynamic stability while carrying
out 14 tasks. [Details in e-Appendix of parameter at
www.aan.com/go/practice/guidelines]
– Four Class II studies yielded sensitivities of
96%, 76%, 93%, and 62%.
– Specificities of 96%, 83%, 11%, and 70%.
American Academy of Neurology © 2008
Conclusions (cont.)
• As for screening measures that may predict or further
assess risks of falls, a history of recent falls is an
established predictor of future falls (Level A).
• Additional screening instruments of probable value
include additional screening instruments of probable
value include the Get-Up-and-Go Test or Timed Up-andGo Test, an assessment of ability to stand from a sitting
position, and the Tinetti Mobility Scale (Level B).
– These functional screening instruments overlap in their
assessments of gait, mobility, balance; evidence is lacking as to
whether they have predictive value exceeding that of a standard
comprehensive neurological examination.
American Academy of Neurology © 2008
Recommendations
• All patients with any of the fall risk factors should be
asked about falls during the past year (Level A).
• After a comprehensive standard neurologic examination,
including an evaluation of cognition and vision, if further
assessment of the extent of fall risk as needed, other
screening measures to be considered include the GetUp-and-Go Test or Timed Up-and-Go Test, an
assessment of ability to stand unassisted from a sitting
position, and the Tinetti Mobility Scale (Level B).
• Other screening measures described in Appendix e-4, of
paramenter at aan.com/go/practice/guidelines, (Level
C).
• Other screening instruments of possible utility are
described in appendix e-4 (which is available at
aan.com/go/practice/guidelines( (Level C).
American Academy of Neurology © 2008
Clinical Context
• Other evidence-based guidelines for the
management of these risks have been
developed that may be consulted.
• As well as other guidelines for the
treatment of underlying disorders where
possible.
American Academy of Neurology © 2008
Future Research
Recommendations
• Additional prospective studies are
needed to assess predictors of fall
risk among a broader spectrum of
patients.
• Further assessment is required for fall
risks associated with other specific
neurologic conditions that may affect
gait, mobility, or balance.
American Academy of Neurology © 2008
Future Research
Recommendations
• Analyses should include evaluations of the inter-rater
reliability of predictors, comparative risk, sensitivity and
specificity. These studies should:
– Systemically assess predictive characteristics of
individual and combined elements of a standard
neurological examination
– Compare the relative utility of the gait, mobility, and
balance tests
– Emphasize practical screening tools that may be
performed quickly and easily in the office or at the
bedside.
American Academy of Neurology © 2008
To access the full guideline please visit:
AAN.com/Guidelines
Published in Neurology February 5, 2008 70:473-479
American Academy of Neurology © 2008
Questions or
Comments?
American Academy of Neurology © 2008
Thank you for your
participation!
American Academy of Neurology © 2008