Are triage questions sufficient to assign fall risk precautions in the ED?

OBJECTIVES

The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls.

METHODS

Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered.

RESULTS

The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses).

CONCLUSIONS

Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls.

Rethinking energy in parkinsonian motor symptoms: a potential role for neural metabolic deficits

Parkinson’s disease (PD) is characterized as a chronic and progressive neurodegenerative disorder that results in a variety of debilitating symptoms, including bradykinesia, resting tremor, rigidity, and postural instability. Research spanning several decades has emphasized basal ganglia dysfunction, predominantly resulting from dopaminergic (DA) cell loss, as the primarily cause of the aforementioned parkinsonian features. But, why those particular features manifest themselves remains an enigma. The goal of this paper is to develop a theoretical framework that parkinsonian motor features are behavioral consequence of a long-term adaptation to their inability (inflexibility or lack of capacity) to meet energetic demands, due to neural metabolic deficits arising from mitochondrial dysfunction associated with PD. Here, we discuss neurophysiological changes that are generally associated with PD, such as selective degeneration of DA neurons in the substantia nigra pars compacta (SNc), in conjunction with metabolic and mitochondrial dysfunction. We then characterize the cardinal motor symptoms of PD, bradykinesia, resting tremor, rigidity and gait disturbance, reviewing literature to demonstrate how these motor patterns are actually energy efficient from a metabolic perspective. We will also develop three testable hypotheses: (1) neural metabolic deficits precede the increased rate of neurodegeneration and onset of behavioral symptoms in PD; (2) motor behavior of persons with PD are more sensitive to changes in metabolic/bioenergetic state; and (3) improvement of metabolic function could lead to better motor performance in persons with PD. These hypotheses are designed to introduce a novel viewpoint that can elucidate the connections between metabolic, neural and motor function in PD.

Interdisciplinary allied health education in treating older adults with low vision

In 2000, the number of elderly citizens in the United States was 35 million, an increase of 3.7 million (11%) since 1990. Of these older adults, approximately 1.3 million (4%) have a low vision impairment. Older adults make up two-thirds of those diagnosed with a visual impairment. Low vision impairment, which is different from the typical vision changes associated with aging, occurs because of a chronic visual disorder that cannot be corrected medically, surgically, or with conventional eyeglasses, most often resulting in disability. The leading causes of low vision impairment are diabetic retinopathy, cataract, glaucoma, and age-related macular degeneration. Combined with the other physical changes associated with aging, the development of a low vision impairment further challenges the functional performance and safety of those 65 and older. Furthermore, the psychological impact from the physical changes accompanying aging is compounded for those with a low vision impairment. In response to the health needs of all age groups, Healthy People 2010 has established overarching goals to increase quality and years of healthy life and eliminate health disparities. An interdisciplinary course for allied health students was developed to support future health care providers in improving quality of life for older adults with low vision and help decrease health disparities in this population. This paper reports on the pilot experience with this course.