Case Study

A 73-year-old woman comes to your office for routine follow-up for hypertension. She lives alone in an apartment and walks slowly, requiring the use of a cane. She is otherwise healthy and alert. Her most recent eye examination was three years ago.

Case Study Questions

1. According to the U.S. Preventive Services Task Force (USPSTF), which one or more of the following statements are correct?

   A. Older age is an important risk factor for falls.

   B. The average healthy adult older than 60 years can perform the timed Get-Up-and-Go test in 20 to 30 seconds.

   C. A pragmatic approach to identifying persons at high risk of falls involves a brief assessment of history of previous falls, mobility problems, and the results of a timed Get-Up-and-Go test.

   D. There is good evidence that a falls risk assessment should be performed every six to 12 months in older adults.

2. Which one of the following statements about multifactorial falls risk assessment with comprehensive management of identified risks is correct?

   A. It should be performed for all older adults.

   B. It entails assessing the risk factors for falls and providing medical and social care to address factors identified during the assessment.

   C. It is associated with a large possibility of harm.

   D. There are several evidence-based instruments available that reliably and accurately identify older adults at increased risk of falling.

3. You determine that this patient is at an increased risk of falls. Which one of the following interventions should you offer, given the evidence of its benefit?

   A. Discontinue her hypertension medication.

   B. Add protein supplementation to her diet.

   C. Start a physical therapy/exercise regimen, along with vitamin D supplementation.

   D. Address home hazard modifications.

   E. Provide a comprehensive eye examination with vision correction.

Answers

1. The correct answers are A and C. Older age is strongly related to the risk of falls. Although no single recommended tool or brief approach can reliably identify older adults at increased risk of falls, one approach is to use a history of falls and mobility problems and the results of a timed Get-Up-and-Go test. This test is performed by observing the time it takes a person to rise from an armchair, walk 3 m (10 ft), turn, walk back, and sit down again. It can be done in less than 10 seconds by the average healthy adult older than 60 years. The USPSTF did not find evidence to recommend a frequency for performing a brief falls risk assessment, although some organizations recommend asking patients about falls and balance or gait problems on a yearly basis.

2. The correct answer is B. Comprehensive multi-factorial assessment and management interventions include assessment of multiple risk factors for falls, and providing medical and social care to address factors identified during the assessment. The USPSTF does not recommend automatically performing an in-depth mul-tifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in all community-dwelling adults 65 years and older, because the likelihood of benefit is small. However, there may be reasons for providing this service to certain individuals; important considerations include the circumstances of prior falls, comorbid medical conditions, and the patient's values. The USPSTF found convincing evidence that the harms of multifactorial assessment with comprehensive management of identified risks are no greater than small. There is no single evidence-based instrument that can reliably or accurately identify older adults at increased risk of falls.

3. The correct answer is C. There is convincing evidence that exercise or physical therapy regimens are of moderate net benefit in preventing falls in older adults, and adequate evidence that vitamin D supplementation is of moderate net benefit in preventing falls. The USPSTF therefore recommends these interventions for all community-dwelling adults 65 years or older who are at increased risk of falls. There is not enough evidence to recommend vision correction, medication discontinuation, protein supplementation, education or counseling, or home hazard modification.