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Detection and Management of Falls and Instability in Vulnerable Elders by Community Physicians

Authors

  • Laurence Z. Rubenstein MD, MPH,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • David H. Solomon MD,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Carol P. Roth RN, MPH,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Roy T. Young MD,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Paul G. Shekelle MD, PhD,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • John T. Chang MD, MPH,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Catherine H. MacLean MD, PhD,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Caren J. Kamberg MSPH,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Debra Saliba MD, MPH,

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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  • Neil S. Wenger MD, MPH

    1. From the *UCLA School of Medicine, Los Angeles, CaliforniaRAND Corporation, Santa Monica, CaliforniaGreater Los Angeles VA Medical Center, Los Angeles, California
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Address correspondence to Laurence Z. Rubenstein, MD, MPH, Geriatric Research Education and Clinical Center, Greater Los Angeles VA Medical Center (11E), 16111 Plummer Street, Sepulveda, CA 91343. E-mail: Lzrubens@ucla.edu

Abstract

Objectives: To investigate quality of care for falls and instability provided to vulnerable elders.

Design: Six process of care quality indicators (QIs) for falls and instability were developed and applied to community-living persons aged 65 and older who were at increased risk of death or decline. QIs were implemented using medical records and patient interviews.

Setting: Northeastern and southwestern United States.

Participants: Three hundred seventy-two vulnerable elders enrolled in two senior managed care plans.

Measurements: Percentage of QIs satisfied concerning falls or mobility disorders.

Results: Of the 372 consenting vulnerable elders with complete medical records, 57 had documentation of 69 episodes of two or more falls or fall with injury during the 13-month study period (14% of patients fell per year, 18% incidence). Double this frequency was reported at interview. An additional 22 patients had documented mobility problems. Clinical history of fall circumstances, comorbidity, medications, and mobility was documented from 47% of fallers and two or more of these four elements from 85%. Documented physical examination was less complete, with only 6% of fallers examined for orthostatic blood pressure, 7% for gait or balance, 25% for vision, and 28% for neurological findings. The evaluation led to specific recommendations in only 26% of cases, but when present they usually led to appropriate treatment modalities. Mobility problems without falls were evaluated with gait or balance examination in 23% of cases and neurological examination in 55%.

Conclusion: Community physicians appear to underdetect falls and gait disorders. Detected falls often receive inadequate evaluation, leading to a paucity of recommendations and treatments. Adhering to guidelines may improve outcomes in community-dwelling older adults.

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