Building the Science of Falls‐Prevention Research

Despite myriad studies of falls and their related risks in older adults, researchers and clinicians across disciplines continue to grapple with this complex issue. Part of the dilemma in determining the best management approaches to this geriatric syndrome is its multifactorial etiology and the need for multidisciplinary interventions. Coordination of fall-risk management, like interventions in incontinence and functional dependency, rely on interdisciplinary dialogue and action to derive a fuller understanding of its meaning and potential resolution. Thus, comprehensive assessment and coordinated care management among all involved parties is not only critical to a discussion of falls, but has also been shown to be the most effective means of providing quality care to the elderly. Despite this evidence, most elder care remains fragmented, even in settings such as nursing homes, with predominately older populations. Given what we know we should do empirically to best meet the needs of older adults, it is not surprising that previous fall-intervention programs have focused on and been effective with a coordinated care approach to fall-risk assessment and management. Most of these studies have been conducted in nursing homes; few have examined hospitalized elders in acute or rehabilitative stages of convalescence. Rehabilitation connotes that individuals’ acute medical illnesses have been stabilized and that they are advancing toward improvement of mobility skills for eventual discharge. During this vital transition from acute illness to health restoration, patients may struggle with weakness, unsteady gait, and transient confusion that put them at greater risk for falls and related injuries. Thus, the work by Vassello et al. in this issue of the Journal of the American Geriatrics Society not only represents a timely and important addition to falls research literature, but also incorporates expert interdisciplinary risk assessment and reduction of modifiable fall-risk factors in this high-risk rehabilitation population. Before evaluating any clinical intervention, it is imperative that researchers designate which population is most likely to achieve its benefit. Although Vassello et al.’s research holds promise in fall-risk intervention in a previously neglected rehabilitation population, their use of a fall-risk screening tool with low predictability cannot accurately distinguish high-risk participants, those who would most benefit from their intervention, from low-risk participants, those who derive limited benefit from a concerted (and expensive) intervention to prevent falls. Further research is needed to develop valid, reliable instruments to differentiate levels of fall risk. This is crucial to employing cost-effective, multifactorial interventions, because researchers’ abilities to accurately select participants most likely to respond to the intervention greatly affect these often time-consuming models. The relationship between psychological factors and fall outcomes is also a key ingredient in evaluating any fall intervention. In Vassello et al.’s study, it is difficult to glean the significance of increased antidepressant drug use by some participants in the study and their associated fall risk. Does this finding indicate greater incidence of depression or better treatment of depression in the control units? Therefore, the lack of clear stratification between groups and the analytic exclusion of variables known to increase fall risk muddies the water when considering the overall effectiveness of the intervention and its cost/risk profile. More meaningful findings would be achieved with attention to clinical parameters (e.g., depression and cognition measured using valid instruments) known to influence an individual’s level of fall risk. The correlation between depression and medical comorbidity, including functional impairment, is well documented. A significant association has also been demonstrated between low bone mineral density and depressive symptoms such that individuals may be at greater risk for fall-related injuries. Thus, increased incidence of depression may not only represent an explanatory difference in fall outcomes between the experimental and control groups in Vassello et al.’s study, but may also clarify differences regarding individuals’ length of stay. Depression is clearly associated with increased length of stay and other indicators of healthcare utilization by hospitalized medical patients. Finally, this intervention may not be realistic for acutecare patients, given that the interdisciplinary assessment/ plan was initiated up to 3 days after admission and changes were based on weekly evaluations and case conferences. Thus, the timing of the assessment and evaluation of the intervention effectiveness needs to be adjusted to fit the short length of stay typical in hospitals, but like other comprehensive assessment and individualized intervention plans targeting identified fall-risk factors, it may be more applicable to nursing home settings. Most of these studies used a consultation model that did not always result in a high adherence to their expert recommendations. The critical question remains; knowing that administrative buyin is a major factor influencing whether research-generated information is put into everyday clinical practice, how do we incorporate multidisciplinary/multifactorial interventions in care settings for elders that are simple, costeffective, and supported by administration and reflect best-practice ideals?