James Frith is a Consultant Geriatrician in Newcastle and Chair of the BGS Falls and Bone Health Special Interest Group. He will be speaking at the upcoming 21st International Conference on Falls and Postural Stability on 25 September 2020. He tweets @jamesfrith1981
Love it or loathe it, the virtual consultation is likely to be around for a good while longer. For various reasons these may be more challenging for older people and their clinicians. I was not a fan to begin with and I still miss the clinical information gained by watching the patient stand up and walk to the consultation room. However, I am slowly getting to used it and do recognise that there are some advantages to remote consulting for patients. To help me (and hopefully you) adapt to this rapidly changing practice, I have collated some useful advice from experts in their field into this two-part blog.
Falls History
Fiona Shaw, Geriatrician Newcastle Falls and Syncope Service, Chair of Northern Regional Falls Task Group
Do you have any tips for taking a falls history over the phone?
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Gather as much information as possible from existing records e.g. GP records often have BP and ECG; discharge summaries may contain history and examination and maybe even a postural BP.
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Introduce yourself and make sure the patient knows who you are and why you are calling; there are a lot of people doing telephone consultations at present.
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Take the history as normal. You may have to rely on subjective assessments (e.g. balance, oedema, vision)
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Cognitive, hearing and language barriers are common. Getting the patient’s consent for someone else to speak on their behalf has solved these for me so far. The loudspeaker function on the patient’s phone has also been helpful.
Who needs a face to face (F2F) assessment?
I decide on the basis of whether or not I have enough information to confidently make a diagnosis and management plan. I have listed very few people for F2F assessment, but have brought patients in for:
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Examination e.g. Dix-Hallpike.
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Physiotherapy assessment and intervention for suspected gait and balance issue.
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Investigations e.g. postural BP or tilt test.
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Complex management discussions e.g. weighing up risk and benefit of alternative treatments.
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I have also requested F2F assessments in the community e.g. with the optician.
Gait & Balance
Grzegorz Drozdz MSc, Trust Falls Lead Practitioner, UCLH, Senior Specialist Physiotherapist
Is it safe to perform a gait and balance assessment over the phone?
It is important to identify any factors which may increase risks, such as visual and cognitive impairment, the environment, physical disability and dizziness. Having a carer or family member present may help reduce the risk, but for high risk individuals a F2F assessment may be preferable.
Is it possible to screen for gait and balance problems over the telephone?
An individualized approach is required, and this may require information from a carer or relative. If safe and practical, options include the Timed Up and Go, The Timed 180 Turn Test and the Sit to Stand Test, accepting that there will be some reduction in accuracy and limitations to each test. Other pragmatic approaches include simply asking people questions about their gait and balance or administering tools such as the Falls Risk Assessment Tool (FRAT). Using video may help but brings its own difficulties too.
Can gait and balance interventions be delivered virtually?
For some, providing adequate education and advice will be adequate. The Get Up & Go Guide To Staying Steady published by the CSP and SAGA is useful written information to send patients. It includes advice to reduce the risk of falls, how to get up from a fall, and exercises to improve balance, proprioception and strength. Others may require more tailored interventions which can be delivered over the phone with written information sent out, while others may need F2F intervention.
Footwear
Brian O’Rourke, Physiotherapist, The Royal College of Surgeons in Ireland (Brian is running a footwear workshop at the BGS’s 21st International Conference on Falls and Postural Stability on 25th September)
Can a footwear assessment be performed over the telephone?
Keep it simple and focus on education. Ask the client to have their most commonly used indoor and outdoor footwear ready before the session. Lead them through a footwear review discussing the key features of a safe shoe e.g. fixation, heel height, a firm mid-sole and sole threading. Advise on the risks of wearing slippers. Having a family member present may be beneficial. In terms of shoe-fit ask about comfort of the shoe and if there is a small gap in front of the toes (as specific shoe/foot measuring is not available). Follow up with an email/letter with key points from the session.
Home Hazards
Chris Elliott PhD, Advanced Independent Occupational Therapist
Is it possible to assess home hazards over the phone, or by video?
Yes, this can be done remotely using a home hazard checklist. This can be a great prompt when talking to the client about their environment, helping to identify potential falls risks and offering the opportunity to give advice on preventative measures. Using video does provide more information as it enables more objective functional assessments of mobility. A video can also show potential falls risks, that might not be described or identified by the client e.g. pulling on basins to stand from the toilet, double handed use of a handrail etc.
Of course, there are limits to using video, so having a friend or family member at hand to hold the camera is hugely helpful. Other important considerations before undertaking a remote assessment are capacity, cognition, mental health, and sensory needs. Where there is any doubt that a virtual assessment will not satisfactorily capture a client’s abilities or function, a home visit would always be preferable. More resources about home hazards and ‘digital OT’ can be found on the
Royal College of Occupational Therapy website. Age UK also produce a
self-complete checklist for individuals and their carers.
Register now for the 21st International Conference on Falls and Postural Stability on Friday 25 September 2020. You can follow the conference live on Twitter via #BGSconf
