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How to identify balance disorders and reduce fall risk

The Journal of Family Practice. 2022 January;71(1):20-30 | doi: 10.12788/jfp.0332
January 20, 2022|Family Medicine
Daniel Newsted, PhD;Dougal Bale, Bphty;Maxine Armstrong, MSc, CASLPO;Michael M. Beyea, MD, PhD, FRCPC;Matthew T.W. Simpson, MD, MSc, CD, CCFP;Sudeep S. Gill, MD, MSc, FRCPC;Jason A. Beyea, MD, PhD, FRCSC
Author and Disclosure Information

Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Queen’s University School of Medicine, Kingston, (Drs. Newsted and Jason A. Beyea); Physiotherapy Outpatient Services, Providence Care Hospital, West Kingston (Mr. Bale); Quinte Hearing Centre, Belleville/Picton (Ms. Armstrong); Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, and Department of Critical Care, William Osler Health System, Brampton (Dr. Michael M. Beyea); Department of Family Medicine, Queen’s University School of Medicine, Kingston (Dr. Simpson); Division of Geriatric Medicine, Department of Medicine, Queen’s University School of Medicine, Kingston (Dr. Gill); ICES Queen’s, Queen’s University, Kingston (Drs. Gill and Jason A. Beyea), Ontario, Canada
jason.beyea@queensu.ca

Dr. J.A. Beyea discloses that he has a proprietary interest in Kingston Ear Institute Inc., which is a multidisciplinary clinic that provides diagnostic and therapeutic services for hearing, balance, and vestibular loss. Ms. Armstrong discloses a proprietary interest in Quinte Hearing Centre, which is a clinic that provides diagnostic and therapeutic services for hearing loss.

The other authors reported no potential conflict of interest relevant to this article.

A multifactorial risk assessment, correction of hearing impairment, exercise, and an optimized home environment can help prevent imbalance-related falls.

PRACTICE RECOMMENDATIONS

› Utilize a falls-prevention program for older patients that focuses on balance and functional exercises. A

› Perform a multifactorial assessment of the risk of falls in older patients that includes optimizing medications, managing comorbidities, and addressing environmental hazards. B

› Use a systems-based approach to presentations of imbalance to direct your clinical judgment and highlight the need for referral to specialists for management and rehabilitation. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

In our experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system.

Research abounds into the validity of commonly used FRATs across institutions, patient populations, and clinical environments:

The Johns Hopkins FRATa determines risk using metrics such as age, fall history, incontinence, cognition, mobility, and medications75; it is predominantly used for assessment in hospital inpatient units. This tool has been validated repeatedly.76,77

Peninsula Health FRATb stratifies patients in subacute and residential aged-care settings, based on risk factors that include recent falls, medications, psychological status, and cognition.78

FRAT-upc is a web-based tool that generates falls risk using risk factors that users input. This tool has been studied in the context of patients older than 65 years living in the community.79

Although FRATs are reasonably useful for predicting falls, their utility varies by patient population and clinical context. Moreover, it has been suggested that FRATs neglect environmental and personal factors when assessing risk by focusing primarily on bodily factors.80 Implementing a FRAT requires extensive consideration of the target population and should be accompanied by clinical judgment that is grounded in an individual patient’s circumstances.81

Continue to: Preventing falls in primary care

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