1. American Academy of Neurology © 2008 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

2. 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 guidelines@aan.com to learn about options for sharing this content beyond your personal use.guidelines@aan.com American Academy of Neurology © 2008

3. 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.

4. American Academy of Neurology © 2008 Overview Background Gaps in care AAN guideline process Analysis of evidence Summary Recommendations for future research

5. 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.]

6. 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.

7. 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.

8. American Academy of Neurology © 2008 AAN Guideline Process Clinical Question Evidence Conclusions Recommendations

9. 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

10. American Academy of Neurology © 2008 Literature Search/Review: Rigorous, Comprehensive, Transparent Complete Relevant Search Review abstracts Review full text Select articles

11. 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

12. 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

13. 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

14. 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?

15. 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)

16. American Academy of Neurology © 2008 Literature Search/Review 86 articles 193 articles 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

17. American Academy of Neurology © 2008 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.

18. American Academy of Neurology © 2008 Clinical Question 1. Which neurologic conditions are associated with an increased risk of falling?

19. 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%

20. 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).

21. 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.

22. 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.

23. 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, 3 rd 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 community- dwelling and institutionalized older populations, indicated increased risk of falls in the presence of dementia or cognitive impairment.

24. 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.

25. 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

26. 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%.

27. 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.

28. 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.

29. 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).

30. 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.

31. 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.

32. 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?

33. 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 Get- Up-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] 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.

34. 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.

35. 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%.

36. 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-and- Go 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.

37. 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 Get- Up-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).

38. 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.

39. 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.

40. 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.

41. To access the full guideline please visit: AAN.com/Guidelines Published in Neurology February 5, 2008 70:473-479 American Academy of Neurology © 2008

42. Questions or Comments?

43. American Academy of Neurology © 2008 Thank you for your participation!