Patient Safety: Assessing Fall Risk

From the AANEM Quality and Patient Safety Committee

Falls are a major cause of injury-related morbidity and disability leading to significant healthcare cost and impaired health. In addition to falls associated with activities of daily living (ADLs), the patients may also fall during outpatient diagnostic testing (e.g. radiology, electrodiagnostic (EDX)). The EDX evaluation is a clinical assessment tool that, in concert with a thorough history and physical exam, can be important for making a diagnosis. In this case symptoms, exam findings and the EDX results indicate a mild polyneuropathy. Is that diagnosis sufficient to explain the tendency for falls? Significant literature on factors contributing to falls exists. The factors are broadly classified into intrinsic and extrinsic. Intrinsic factors include: age, cognitive dysfunction, general impairment with ADLs, impaired visual acuity, imbalance, and lower limb strength. Extrinsic factors include: medications (particularly psychoactive ones like benzodiazepines) and obstructions to walking (like improperly placed furniture, slippery floors, and loose carpets). The risk of falling in an outpatient- based diagnostic setting like radiology suite has also been studied. Patients who require walkers or wheelchairs coming for EDX studies share similar risks to those identified in the radiology study.

The STEADI algorithm from the Centers for Disease Control provides a framework for assessing fall risk but begins by asking three key questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? Physical exam findings of slowness in the Timed Up and Go (TUG) test, the need to push with the hands to arise from a chair, and inability to stand on one foot for 5 seconds unaided are predictors of falls.

Assessment of the potential for a fall during outpatient testing like EDX and radiology procedures should include identification of risk factors, education of staff, and a decision tree of how to perform a challenging transfer must all be taking place.

Scenario: A 75-year-old man is referred to the EDX Lab for assessment of a potential neuromuscular disorder as a cause of several falls he has experienced over the last 6 months. He reports numbness in the feet and feeling slightly unsteady when standing. Treatment for hypertension was also begun about 6 months ago. Evaluation reveals normal limb strength, absent ankle reflexes and decreased light touch, and vibratory sensations in the feet. He requires a mild push from his hands to rise from the chair. He does not use a walking aid, but his gait is mildly slow and broad-based.

His limbs were too cool for reliable conduction studies and had to be warmed before testing. This required a transfer from his chair to a foot warming sink and then to the exam bed. The EDX testing showed a mild axonal polyneuropathy.

Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015;99(2):281-293. doi:10.1016/j.mcna.2014.11.004

Algorithm for Fall Risk Screening Assessment and Intervention. www.cdc.gov/steadi

Abujudeh HH, Aran S, Daftari Besheli L, Miguel K, Halpern E, Thrall JH. Outpatient falls prevention program outcome: an increase, a plateau, and a decrease in incident reports. AJR Am J Roentgenol. 2014;203(3):620-626. doi:10.2214/AJR.13.11982

Answer: B - The difficulty arising from the chair

Authors: Rebecca O'Bryan, MD, PM&R Cleveland Clinic Foundation Martin Health & John Kincaid, MD