A couple of my patients had a rough summer. In the past month, two of my elderly patients have fallen and broken their hips. Approximately 30% of community-dwelling people aged 65 years and older experience at least one fall per year, and falls are the leading cause of home injury deaths among adults aged 80 years or older.
Although I have been diligent about assessing bone mineral densities and addressing gait abnormalities, these two accidents happened. While reading through the emergency department and surgical notes to monitor my patients’ progress, I felt some despair and resorted to musings about what else could have been done to prevent these outcomes.
The medical literature suggests that multimodality approaches to the assessment and reduction of risk factors can reduce the rates of falls. Home visits provide a unique "inside" view of potential risk factors for falls that can be addressed prior to a patient breaking a hip. Should I have gone to their homes to prevent this?
Tobias Luck of the University of Leipzig and his colleagues conducted a multicenter, randomized clinical trial assessing the efficacy of a home visit intervention in a sample of community-dwelling individuals aged 80 years and older in Germany. Individuals who met the age criteria, were living at home, and had functional impairment of three or more activities of daily living were eligible for enrollment. All participants received baseline interviews in their homes (Clin. Interv. Aging 2013;8:697-702).
Participants in the intervention group underwent an analysis by multidisciplinary teams, individualized interventions were developed, and home counseling was conducted. A booster session was provided to the intervention group. The primary outcome was the incidence of institutionalization over the study period of 18 months.
Analyses were based upon 230 participants who remained in the study (112 control patients, 118 intervention patients). A significant decrease in the number of falls from baseline to follow-up was observed in the intervention group (incidence rate ratio, 0.63) and a significant increase was observed in the control group (incidence rate ratio, 1.96).
Data suggest that multifactorial interventions to prevent falls work. The challenge for us is to see how we can channel the resources dedicated to office practice toward conducting home visits. In a capitated environment, this may become increasingly easy to justify.
Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no relevant financial conflicts. The opinions expressed are those of the author.