Icahn School of Medicine at Mount Sinai
The recent AAMC/Hartford Foundation Minimum Geriatrics Competencies for medical students (MSs) recommended that all graduating students ask about falls and conduct a brief fall risk assessment on a patient. The goal of this resource is to improve MSs´ understanding of the impact of falls on the lives of older adults, fall risk factors, and evidence based interventions to reduce fall risk, by performing a Fall Risk Assessment on an older adult patient. At Mount Sinai School of Medicine, the Fall Risk Assessment occurs during the third year Integrated Internal Medicine-Geriatrics Clerkship.
- To be able to recognize the impact of falls on the lives of older adults.
- To be able to identify risk factors for falls in the elderly.
- To be able to perform the 3 Chair Rise and Timed Up and Go tests to assess functional status.
- To be able to describe interventions to reduce an older patient's risk of falling.
The Fall Risk Assessment Experience Student Guide provides background information about falls, fall risk factors, interventions to prevent falls, and patient education material. The Guide directs the student to read a comprehensive fall assessment and management article, obtain relevant information from the patient´s medical record (documented fall risk factors, medications, etc.) and then conduct a fall risk assessment (including questions about fall risk factors, orthostatic vital signs, observed gait and balance, 3 chair rise and the timed up and go test) on their patient. Findings are then reviewed with the patient´s doctor and recommendations offered to the patient. This hands-on student directed approach activates learning, as the student plays a primary role in the patient's care by identifying risk factors, recommending treatment, and providing counseling.
Falls are common in older adults and result in significant morbidity, including injury, pain, disability, and even death. Risk factors for falling have been identified and interventions to improve these risk factors have been found to reduce fall rates by more than 30%. However, medical students (MSs) are frequently not instructed on fall risk assessment and management.
During the 2007-2008 academic year third year MSs performed the Fall Risk Assessment Experience with 19 of 27 (70%) of eligible senior mentors. Falls were common even among this highly functional community dwelling population as 79% of the mentors reported previously falls on the Fall Risk Assessment Questionnaire. In spite of this, at the start of the assessment, 11/19 (61%) did not think they were at risk of having another fall. Patients reported low rates of being asked about falls and of feeling they were at risk of falling. 36% of senior mentors said they were "almost never" asked about falls by their doctor while only 29% noted that their physician "almost always" asked them about falls.
The student-directed fall risk assessment module identified multiple fall risk factors and students were able to make important recommendations to reduce their senior mentors´ risk of future falls. All mentors had at least one risk factor for falling in addition to age. The mean number of fall risk reduction strategies recommended was 3.3 (range 0-8).
73% of the older adults found the intervention to be helpful in recognizing their own fall risks. The assessment changed the mentors' perceptions of their own risk of having a fall from 39% thinking they were at risk to 50% thinking they were at risk afterwards. 53% said there are things that they are going to do differently after the assessment to reduce their risk of falling. These included "being more careful", doing exercises, taking tai chi, taking their time when first getting up, and using a walker.
Our resource is student driven and this makes it very easy to incorporate into any clerkship or rotation. In addition, highlighting the importance of chart review as a method for health care providers to evaluate the quality of their care and make important practice changes is helpful when incorporating this resource into a curriculum. This cueing facilitates an appreciation for reflection and self assessment in the student.
Scheduling time for the assessment is imperative as the actual assessment takes between 20 to 30 minutes to complete. Informing the patient about the assessment before the visit is also very useful. Patients can then bring questions they have to the assesment and many misconceptions can be clarified during the visit.