by Nic Colombo
When preparing for your physio interview, there are a few key areas you need to know inside out, and falls in older people is definitely one of them.
We know that people over 65 have the highest risk of falling (with 30% of those over 65, and 50% of those over 80 falling at least once a year (Todd and Skelton, 2004)). The issue is not just the high incidence of falls in older people (kids and athletes also fall a lot) but rather the combination of a high incidence of falls and a high susceptibility to injury (Rubenstein, 2001). In fact, falls are the commonest cause of death from injury in that population with many of them resulting in fractures and/or head injuries. The infamous FNOF being a prime example (as well as hip fractures in general, accounting for 25% of fractures resulting from falls in the community).
Falls thus cost the NHS a lot of money, both during and after hospital admission, in the acute, community and social care settings (B). More than £2 billion a year actually (Yang Tian et al., 2013). With our population ageing faster than ever (B) and the number of people aged 65 and over predicted to increase by 2 million by 2021, costs are set to rise even further (Yang Tian et al., 2013). Check this Kings Fund paper if you're interested to know more about what falls cost the NHS. It goes in really great details about the different costs using the example of fallers in Torbay, Devon.
Generic picture of cute elderly couple to spark your interest. (source)
What do interview questions on falls look like
Falls in older people are thus a major issue and you, as a qualified physiotherapist, are one of the key professionals involved in their prevention and management. There's 99% chances it will come up in some shape or form in your interview.
Interview questions on falls revolve around a few recurrent themes:
- Falls pathway (ie NICE Pathway)
- Falls assessment (your assessment, part of the MDT assessment)
- Falls intervention (your intervention, part of the MDT intervention)
- Local Falls policy (what the hospital has put in place locally to deal with falls)
If you know this, you're basically all set to nail your question on falls. We'll talk about the first two points in this article, and the next two in Part II.
But first here's some examples of interview questions. Check out how they revolve around the four themes described above.
Key reference: NICE Guidelines for falls in older people
The NICE (National Institute for Health and Care Excellence) Guidelines for falls in older people (B) is something you'll have to bring up in your interview. One of those key references you need to cite. NICE have also produced a care pathway for the management of falls in older people (B) which gives us a really good overview of the guidelines and of what is expected from healthcare professionals to manage their fallers from beginning to end. It also helps you structure your answers.
The next part of this article will be based on what the NICE Guidelines suggest. Other guidelines and pathways relevant to the topic include the NICE Pathway for the management of hip fractures and the NICE Pathway for Osteoporosis.
Your assessment: part of a multi-factorial one
The NICE Guidelines stipulate that all people aged 65+ admitted to hospital should be considered for a multi-factorial assessment for their risk of falling in hospital and in the community. This is also the case for patients aged 50-64 with co-morbidities placing them at higher risk of falling (more on this below).
If you get asked in your interview to describe your assessment for one of these patients, one of the first things to say is that your assessment will be part of a bigger, interdisciplinary, multi-factorial assessment (B).
Let me stress how important this is:
If you get asked in your interview to describe your assessment for an older patient with a history of falls, the first thing to say is that your assessment will be part of a bigger, interdisciplinary, multi-factorial assessment - as stipulated by the NICE Guidelines for falls in older people.
Then, keep in mind that patient's safety (and yours) come first - so ultimately what your interviewer wants, is that you demonstrate in your answer how you can consistently risk-assess, document and seek help to the appropriate people if required (know your scope of practice). (B)
Okay. So what does a multi-factorial assessment actually consist of?
Really important however often overlooked. A detailed falls history (B) is key to determine the cause of the falls. You'll find that you (as a therapist) are often the first one to get a proper, detailed history. Make sure you know when the patient has fallen, how exactly it has happened, was the patient able to get off the floor independently, was the patient able to call for help, was an ambulance called straight away? Is this the first time the patient has fallen, how many falls has the patient had in the last year? And so on... Always dig further in your questioning, you'll never have too many details. Document everything so other professionals can benefit from your amazing questioning skills
More often than not, you won't be able to get that many details from the patient because of a number of reasons including cognition, memory, language barrier, or sometimes them just not wanting to tell you... Make sure to extend your questioning to other relevant people, such as family, carers, and other healthcare professionals (B) previously involved in the patient's care.
Cognitive assessments allow you to better estimate your patient's functional ability and is often used to predict mortality during hospital admissions (Woodford and George, 2007). This will obviously guide your assessment and your intervention. Familiarise yourself with results from cognitive assessment tools frequently used such as the MMSE, the MoCA or the Abbreviated Mental State (AMS) tools; and liaise with Doctors, Psychologists and OTs, who will be the ones leading on this.
Your typical geriatric patient commonly present with multiple co-morbidities in addition to their admitting diagnosis. (B) (Patrick et al. 2001) Co-morbidities often result in increase disability and mortality and you'll often find these patients being "frequent flyers", with recurrent hospital admissions throughout the year. They will typically be harder to rehabilitate, with less functional gains (Patrick et al. 2001) and longer hospital stays (Weber et al. 1995).
Frequent co-morbidites which can have an impact on your rehab include (in no particular order) UTIs (and other infections causing delirium), postural hypotension, osteoporosis, dementia, visual impairement, diabetes and peripheral neuropathies, chronic heart failure, amongst many others.
Drug use if one of the most common factors leading to falls, but it is also the most modifiable. Fall-risk increasing drugs (FRIDs) are numerous and include antihypertensives which can cause hypotension, antidepressants which can sedate your patient, diuretics and analgesics, amongst others. Another factor is the amount of drugs they are taking: 4 or more drugs is known to increase an elderly's risk of falling (B) (Hartikainen et al., 2006). As a physio, it's a good habit to ask for your patient's up-to-date medication list, as well as the times of the day they are supposed to take them, so you can best time and tailor your intervention.
Posture, mobility, gait, balance, ROM and muscle weakness
This is your part, your time to shine, what you've been training for. Every other member of the MDT is waiting on your assessment, usually within 24 to 48 hours of admission if you're working on the ward (B) (nurses will perform a basic mobility assessment on admission). This is also the case in the community, where you'll be the one leading on this and reporting to other professionals in your team. I won't go into too much details here as you should have seen this in depth over the last 3 years. Make sure you familiarise yourself with evidence-based outcome measures (B). If possible get a falls assessment form from the hospital you're applying to and see which ones they use. Berg, 5 times STS, TUAG, BEST test, Dual task TUAG, Pastors test, modified CTSIB, Functional Reach Test... These guys will become your best friends over the next couple of years. If you're able to explain how you'll interpret the results, you'll definitely impress your interviewer (it's good habit to keep flash cards with each test's instructions and normal values).
When carring out your assessment, you may find that your patient presents with vestibular symptoms. Your main role as a newly qualified physio is to recognise them, document and report them quickly to the team so it can be appropriately managed. To help you do this, many falls assessment forms include a vestibular screen. Reported symptoms to look out for include light-headedness/dizziness/nausea especially following change in body or head position; ataxic, shuffling gait; visual changes with head movement, recent hearing changes, history of loss of consciousness amongst others.
As Menant et al. (2008) put it beautifully: "footwear influences balance and the subsequent risk of slips, trips, and falls by altering somatosensory feedback to the foot and ankle and modifying frictional conditions at the shoe/floor interface". In reality, you'll often see patients wearing the oddest things on their feet, ranging from completely knackered 12-year-old shoes to DVT stockings given out during an admission a few years ago, or cast boots their neighbours gave them. I saw an elderly care ward patient once getting brought in with two left shoes... To my knowledge, there is no strong evidence showing which type of specific shoes help reduce falls, but sometimes common sense is your answer. If in doubt, always go for closed slippers.
There has been a lot of interest lately linking continence problems to falls. Incontinence can impact on an older person's ability to stay healthy and active, and thus incontinence management is key in preventing recurrent falls in the older population. Make sure your patient is supported in this and go and help that patient on the ward who needs assistance to go to the loo, before they try to get out of bed on their own and fracture their hip.
Vision and hearing changes are often associated with falls and fear of falling. Make sure you are aware of any visual or hearing problems so you can best tailor your intervention. Look out for cataract, macular degeneration, glaucoma and co. Extra points if you know which of these are the most prevalent in your hospital's demographics.
What you'll often find is that many elderly people believe sensory problems are "part of ageing" and avoid assessment and help. Many healthcare professionals overlook them too. Ask your patient when their last hearing and vision check was, if it's older than 6 month to a year, they need a new one!
Most factors describe above are what we call intrinsic factors. But extrinsic factors (B) (such as the patient's environment and social setting) need to be assessed too. For a full comprehensive assessment (and a safe discharge) your patient's home environment needs to be looked at, as that's where most falls occur. Make sure you mention this in your interview, and that you will liaise and work alongside other professionals like the OT for a complete assessment. It shows that you're aware of the bigger picture, and not just considering the patient as someone in hospital.
Social setting and environmental factors are key.
Remember, as always your assessment (and following treatment) should be patient-centred (B) and take into account the individualised needs and preferences of your patient. Need an advocate? Book one. Your patient requires a female therapist? Provide one. Be pro-active. “A one size fits all approach will not work” as Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, once said.
So that's it for the first part of our "Physio interview preparation" blog on Falls in older people. I hope it has given you some insight into what's expected from you in your interview if you do get a question on falls. In Part II, we'll go over the intervention (treatment, monitoring, etc) and the importance of hospitals' local falls policies.
And remember, as a newly qualified physio, "SDS" is what an interviewer needs to know after interviewing you. That you're safe, you document everything and seek help when required.
Interview buzzwords (B)
In every blog post from the Physio interview series, you'll see (B) next to some words. These are buzzwords and buzzphrases - stuff that interviewers are waiting for you to say in your interview, as they help demonstrate your understanding of the topic.
Here's the list of buzzwords and phrases in this article:
- NICE guidelines for preventing falls in older people
- during and after hospital admission - in the acute, community and social care setting
- ageing population
- NICE Pathway for the management of falls in older people
- multi-factorial assessment
- risk assessment
- detailed falls history
- question relevant people, such as family, carers, and other healthcare professionals
- geriatric patient commonly present with multiple co-morbidities
- 4 or more drugs is known to increase an elderly's risk of falling
- falls assessment within 24 to 48 hours of admission
- evidence-based outcome measures
- extrinsic factors
- patient centred-care
Hairtikainen S. et al. (2007) Medication as a Risk Factor for Falls: Critical Systematic Review. http://biomedgerontology.oxfordjournals.org/content/62/10/1172.full
Menant JC et al. (2008) Optimizing footwear for older people at risk of falls. http://www.ncbi.nlm.nih.gov/pubmed/19235118
Rubenstein LZ, Powers CM, MacLean CH (2001). Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders. Ann Intern Medicine;135:686-693
Tian Y et al. (2013) Exploring the system-wide costs of falls in older people in Torbay. http://www.kingsfund.org.uk/publications/exploring-system-wide-costs-falls-older-people-torbay
Todd C, Skelton D. (2004) What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls?
Woodford HJ, George J (2007) Cognitive assessment in the elderly: a review of clinical methods. http://qjmed.oxfordjournals.org/content/100/8/469
About the author
Nic works as a Senior Physiotherapist both in a busy NHS hospital in East London and privately. Since he qualified, he has gained a large amount of experience assessing and treating various conditions, but also meeting and working alongside all sorts of healthcare professionals. He set up QualifiedPhysio with the idea of making available to future and new physios all the advice, guidance and resources he got along the way, to bridge that gap between Uni and their first job.