The physicians interviewed articulated a set of physician, logistical, and patient factors that intersect to either facilitate or impede the incorporation of fall risk evaluation and management into the primary care of elderly patients. The results of this study suggest several obstacles to identifying elderly patients at high risk of falls and directing treatment toward this group. First, clinicians must appreciate the significant morbidity that results from falls among elderly patients. Second, clinicians need to have sufficient awareness of the importance of falls to consider addressing it during clinical encounters. Third, clinicians who are willing to address falls should be ready to maneuver the logistics of fall risk evaluation and management. Finally, patients and their family members require motivation to request fall-related services and to participate in the management process.
Many of the hurdles cited by respondents are not unique to fall risk evaluation and management. Any new intervention considered preventive must overcome reimbursement and time constraints.17
Transportation, family involvement, and medical training themes could be applied to the entire spectrum of geriatric health issues. Physicians have cited patient adherence as a barrier to adoption in several settings.18, 19
Because these themes are not unique to fall risk management, they invite strategies that cannot only improve management of falls, but management of elderly patients in general.
One challenging set of physician strategies requires an understanding of the motivators of patient behavior and the willingness to use this understanding to pursue fall risk reduction. Physicians who recognize the shame and denial that elderly patients associate with a fall may be less likely to wait for patients to report falls spontaneously. Physicians can improve their identification of patients at high risk for falls by directly asking the patient or family whether they have fallen in the last year. As recommended by the AGS, routinely asking this simple question to all elderly patients would identify a group that would most benefit from intervention. Furthermore, physicians who recognize patients' concerns over the costs and appropriateness of multiple medications can use these concerns to motivate patients to accept medication reductions.
A different set of physician strategies requires modifications to their approach to familiar clinical problems. For example, the goal of osteoporosis management is the same as fall prevention-injury reduction. By tying fall risk directly into osteoporosis management, physicians increase their awareness of falls and the likelihood of addressing fall risk on a regular basis. An additional physician strategy is to use fall risk evaluation and management as a tool for approaching a common problem, such as dizziness. Linking fall risk evaluation and management to a complaint of dizziness gives physicians a series of helpful interventions in response to a common (prevalence 18% to 30%)20, 21
Another group of strategies focuses on logistical preparation. Physicians' offices could contact the families of elderly patients and encourage them to attend visits regularly. Family members can play a significant role in obtaining an accurate history of falls, investigating medication effects, and participating in treatment decisions. Patients could be alerted before a visit that they should bring their medications to office visits for review. Physicians could prepare their office staff and organize visit flow so that postural blood pressure checks and review of medication effects occur regularly with elderly patients at risk for falls. Finally, knowledge of public transportation options for the elderly, familiarity with physical therapists versed in gait and balance treatment, and understanding of eligibility requirements for home safety assessments and outpatient rehabilitation services are all essential components of successful treatment plans. Accumulating this knowledge requires an up-front investment of time by busy physicians, nurses, and social workers. The physician's commitment and leadership in investing this time could result in more efficient and effective care of elderly patients that would address many of their unmet needs.
Several systemic responses could increase implementation of fall risk evaluation and management. The available International classification of Diseases, 10th revision (ICD-10) codes are cumbersome for fall risk assessment; providers must use various codes pertaining to the individual conditions that increase the risk of falls. A single ICD-10 code for a high risk of falls could enhance the likelihood that providers would perform fall risk evaluation and management and that these services would be covered. Development of fall risk management-specific current procedural terminology (CPT) codes could further improve the chances of fall evaluation. Increased state and local funding of transportation programs for elderly citizens will enhance all aspects of their medical care. Although the current cost environment makes any increase in expenditures difficult to achieve, thoughtful systemic actions should reflect the unique medical and social requirements of elderly patients.
Medical schools and residency programs shape how physicians weigh the harms and benefits of treatments for patients with multiple morbidities. This study was not designed to determine the relative importance of different exposures to geriatrics. Nonetheless, our results suggest that an increased focus on multifactorial geriatric health conditions could influence how physicians balance the risk of falls against the risk of other illnesses.
Finally, patients and families should be educated about the importance of fall prevention, and empowered to report falls and fall-related symptoms to their physicians. The challenge for fall prevention advocates lies in effectively communicating the message to patients and increasing their involvement in decision making.22
Toward this end, CCFP has used posters, the internet, newspapers, television, billboards, public service announcements, and personal outreach at senior centers to motivate patients and families to discuss falls with their physicians.
The qualitative design of this study limits our ability to make conclusions about the relative importance of the themes. However, our primary goal was not to quantify the relative importance of factors, but to identify key themes. Another limitation of our study was a low response rate in a sample of physicians who had participated in outreach sessions on fall risk evaluation and management. Our results may not be applicable to physicians who have not had a similar outreach session. Although our sample is narrow, we suspect that the content of our conclusions reflects the experience of most primary care providers. Furthermore, the goal of this study was to determine the facilitators and barriers to fall risk evaluation and management in a best-case scenario—a physician informed of the existing research and willing to be interviewed. Insights gained from this study will improve future efforts to promote fall risk evaluation and management to less informed audiences. Finally, physicians' perceptions of patient wishes may not correlate well with actual patient wishes.22
Further research should investigate whether physicians' perceptions accurately reflect patient attitudes toward falls.
Fall risk evaluation and management in elderly patients requires the integration of multiple complex factors. With many potential barriers to successful adoption, falls are often omitted from a clinical encounter. The actions discussed above offer strategies for enhancing the incorporation of fall risk evaluation and management into the clinical care of elderly patients. Modifications in physician, systemic, and patient activities will result in primary care that is more responsive to the needs of older patients.