Shan Liu, MD
Emergency Physician
Harvard University
Boston, Massachusetts

Teresita Hogan, MD, GEDC Core Faculty
Emergency Physician
University of Chicago
Chicago, Illinois

Jessica Babbitt, PT, DPT, CEEAA
Inpatient Physical therapist
Indianapolis, Indiana

Elizabeth Goldberg, MD
Emergency Physician
Brown University
Providence, Rhode Island

Dr. Liu, an emergency physician and researcher at Harvard, reviewed the literature about older people and falls and specifically as it relates to the ED. Her reading of the evidence suggests that falls are common in the older population – one in every three older people fall every year. They are complex because they represent a syndrome not just an event. The presentation of an older person with a fall often represents a sentinel event – the first stage of a decline in function and health that perhaps can be reversed or slowed with the right approach. EDs and the staff in them can make a difference in that decline. However, the main barriers to effective intervention are both time (time available and time taken) and knowledge on the part of the ED staff.

Dr. Goldberg, an emergency physician at Brown University, described a grant-supported falls assessment that she led in her ED and its outcomes. Called GAPCare, it involved a standardized assessment. First a pharmacist, spent 20 minutes with the patients, preformed a review of their medications, and used open-ended questions to clarify the patient’s attitudes about and use of their meds. The pharmacist made recommendations back to the person’s primary care provider. Next, a physical therapist performed a Timed Up and Go test, as well as a gait assessment and observing the patient’s use of their gait aid. Depending on their assessment, the patient could be referred to acute rehabilitation, or to community services. Key findings from the intervention were that it did NOT increase length of stay and succeeded in reducing subsequent falls-related and all-cause ED re-visits. Having the PT assessment helped patients and families understand their care needs after a fall. And significantly the brief motivational interview by an ED pharmacist had a big impact on reducing fall-risk medications. An essential part of both interventions was ensuring that the transition of care and communication back to the patient’s primary care physicians was thorough and complete. Without that communication, only about 28% of older people going to an ED with a fall every report that fall to the PCP.

Dr. Babbitt, a physical therapist in hospital practice in Cleveland, frequently sees older patients in the ED. She described what she thinks of as key components of a falls assessment which all ED clinicians could add to their practice. First, she thinks it’s essential to ask for additional details about the fall itself, not just “oh, you fell.” What happens when you fall? Did your legs give out? Did you feel dizzy (room spinning or light-headed)? Are you tripping over things? How frequently? When did the falls start? Where did it happen? What time of day? What was the physical environment at the time? What was the person wearing? Who or what were around? Her approach to her exam is to observe bed mobility; transfers; and gait. She says that a gait assessment is essential to determine diagnosis and to see if the person needs an assistive device. Three things that she assesses are: is the person reaching for things when he walks (furniture cruising); how wide are his feet compared to his shoulders? Are they shuffling? Finally, she described the importance of considering and addressing the fear of falling that comes with an initial or multiple falls. Clinicians need to be cautious in order to gain the trust and confidence of the patient