Preventing Falls In The Elderly: Where DPMs Can Have An Impact

Douglas H. Richie, DPM, FACFAS

   In 2008, Menant and co-workers published a systematic review of the literature to provide a comprehensive understanding of the role of footwear and traumatic falls.24 This review again concluded that elderly people should wear properly fitted shoes inside the home. Wearing slippers, socks or being barefoot has consistently been associated with an increased risk of falling indoors. The authors recommended shoes with firm, thin soles, citing evidence that softer shoes have been associated with balance problems. Finally, the authors recommended a tread sole with beveled heels to prevent slip-induced falls.

What You Should Know About Testing To Assess Fall Risk

Combining the current knowledge from the general scientific literature as well as the large number of papers published by podiatric researchers, there are key risk factors that are most relevant to the patient presenting to the podiatric physician. These risk factors include: history of a previous fall, diabetes, gait impairment, arthritis, reduced ankle joint range of motion, weakness of toe flexors, reduced plantar sensation, hallux valgus, claw toe, plantar calluses and foot pain. Recognizing any or all of these findings in the history or examination of any patient in podiatric practice should be a tip-off that intervention(s) may be necessary, much of which the podiatric physician can implement.

   For those podiatric physicians who want to get more involved with the screening of all of their patients for a fall risk assessment, many clinical tests are available. Often, these tests are time consuming and one could question whether they actually fall within the scope of podiatric practice.

   There is one protocol developed by our Australian colleagues as a screening for fall risk in primary care. One may modify this protocol and apply it to podiatric practice. Tiedemann and co-workers have developed a fall risk assessment tool, which an external study validated and proved reliable.2 This tool can provide a feasible fall risk assessment that can accurately predict multiple falls and assist with guiding interventions in community-living older people. This assessment discriminates between those who have had multiple falls and those who have not had multiple falls with an accuracy of 72 percent. This compares well with other similar assessments for identifying those with multiple falls and exceeds the predictive ability of other popular tests including the Timed Up and Go test and the Functional Reach test. The QuickScreen® Clinical Assessment Form illustrates the test. Here are the key points of the assessment.
1. There is a test of low (10 percent) contrast visual acuity measured at a distance of 3 m.8
2. The assessment has a tactile sensitivity test at the ankle using a single Semmes–Weinstein-type pressure monofilament.
3. For the near tandem stand test, the participant stands with his or her eyes closed and with bare feet in a near tandem position. The feet are parallel and separated laterally by 2.5 cm. The heel of the front foot is 2.5 cm anterior to the great toe of the back foot.
4. In the sit-to-stand test, participants rise from a standard height (43 cm) chair five times as fast as possible with their arms folded.
5. The alternate step test involves placing the whole foot (shoes removed) onto a step that is 18 cm high and 40 cm deep. Patients alternate with the right and left feet for a total of eight repetitions as quickly as possible.

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