Detection and management of falls and instability in vulnerable elders by community physicians.
OBJECTIVE
To investigate quality of care for falls and instability provided to vulnerable elders.


METHODS
Six process of care quality indicators (QIs) for falls and instability were developed and applied to community-living persons aged 65 and older who were at increased risk of death or decline. QIs were implemented using medical records and patient interviews.


METHODS
Northeastern and southwestern United States.


METHODS
Three hundred seventy-two vulnerable elders enrolled in two senior managed care plans.


METHODS
Percentage of QIs satisfied concerning falls or mobility disorders.


RESULTS
Of the 372 consenting vulnerable elders with complete medical records, 57 had documentation of 69 episodes of two or more falls or fall with injury during the 13-month study period (14% of patients fell per year, 18% incidence). Double this frequency was reported at interview. An additional 22 patients had documented mobility problems. Clinical history of fall circumstances, comorbidity, medications, and mobility was documented from 47% of fallers and two or more of these four elements from 85%. Documented physical examination was less complete, with only 6% of fallers examined for orthostatic blood pressure, 7% for gait or balance, 25% for vision, and 28% for neurological findings. The evaluation led to specific recommendations in only 26% of cases, but when present they usually led to appropriate treatment modalities. Mobility problems without falls were evaluated with gait or balance examination in 23% of cases and neurological examination in 55%.


CONCLUSIONS
Community physicians appear to underdetect falls and gait disorders. Detected falls often receive inadequate evaluation, leading to a paucity of recommendations and treatments. Adhering to guidelines may improve outcomes in community-dwelling older adults.
Rubenstein
Laurence Z
LZ
UCLA School of Medicine, Los Angeles, California, USA. Lzrubens@ucla.edu
Solomon
David H
DH
Roth
Carol P
CP
Young
Roy T
RT
Shekelle
Paul G
PG
Chang
John T
JT
MacLean
Catherine H
CH
Kamberg
Caren J
CJ
Saliba
Debra
D
Wenger
Neil S
NS
D000058:Accidental Falls / Q000517:prevention & control* / Q000706:statistics & numerical data; D000203:Activities of Daily Living; D000368:Aged; D003154:Community Medicine / Q000592:standards*; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment / Q000379:methods; D019983:Guideline Adherence / Q000592:standards; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000592:standards; D008403:Mass Screening / Q000592:standards; D008485:Medical Audit; D009511:New England / Q000453:epidemiology; D010043:Outcome and Process Assessment, Health Care; D010808:Physical Examination / Q000592:standards; D004856:Postural Balance; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D018570:Risk Assessment / Q000592:standards; D012678:Sensation Disorders / Q000175:diagnosis / Q000517:prevention & control; D015206:Southwestern United States / Q000453:epidemiology; D011795:Surveys and Questionnaires; D035862:Vulnerable Populations