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.
David Elliott, Professor of Clinical Vision Science, University of Bradford
Are there any useful ways that clinicians can screen for visual problems over the phone?
This is fairly simple using a standard question such as “How is your vision? Is it good enough to see the TV, when driving, seeing faces across the street, reading newspapers and bus numbers?”
“When is the last time you had a sight test?” and "Do you wear bifocals or varifocals when you are walking outside the home?" are also useful questions, but note that vulnerable patients should not attend for a sight test under the current situation unless the potential benefits outweigh the risks.
Fear of falling (FoF)
Steve Parry, Geriatrician, Newcastle Falls and Syncope Service, Chief Investigator of the STRIDE study (Strategies for Increasing Independence, Confidence and Energy)
Are there any useful screening tools for FoF which can be performed over the telephone?
I find patients volunteer this information frequently (e.g. "I have to link arms when I go out"), but I ask specifically "are you worried about falling?" and "does this make you do less activity than you would otherwise?” In the STRIDE Study, an assessment of FoF on a 0-10 scale (where 10 is most severe) had reasonably good correlation with validated tools such as the FoF Efficacy Scale International.
With reduced face to face clinical time, is there anything that people with FoF can do to help themselves at home?
Exercise and strength and balance training first and foremost. CBT is also of benefit if available.
When doing a falls assessment over the phone, what are the key questions to distinguish falls from syncope?
Clinically, the most useful are “do you recall the moment you hit the ground?” and “which part of your body did you injure when you fell?” Being unable to recall the moment of impact could indicate a loss of consciousness, as could head and facial injuries, as opposed to hand/wrist injuries which suggest consciousness was intact. A good history is usually more valuable than most investigations, and if at all possible, try to get a witness history as this may be key in determining the diagnosis. The past medical history and the drug history will also reveal important risks for syncope. A recent ECG may be available in clinical records, but if not, those with suspected syncope will usually need an examination of heart sounds, an ECG and a postural BP before further decisions are made. If syncope is suspected, don’t forget to give advice on driving.
Michael Vassallo, Consultant Geriatrician at the Royal Bournemouth Hospital and Visiting Professor at Bournemouth University
When assessing falls risk factors, are there any useful ways to assess cognition over the telephone?
Firstly, I would say that it is important to make sure the environment is suitable, for example is the phone line of good quality and can the patient hear you well (hearing aid, background noise etc)? Another pitfall is the patient taking notes during the test so that he/she can give a false impression of ability to recall.
There are several validated tools available for use over the telephone which can be found in Castanho’s 2014 review
. Pragmatically, I use the Six Item Cognitive Impairment Test (6CIT) which can be done over the phone, but also would consider the AMTS as it is familiar and easy to administer. One must emphasise that these are only screening tools and are not diagnostic of dementia. This is stating the obvious, but I think it needs to be emphasised that one cannot diagnose dementia over the phone alone.
Claire McDonald, Consultant Geriatrician Gateshead, Chief Investigator of the ImPROve study (Improving Parkinson’s Related Overactive bladder)
Do you have any advice for assessing incontinence as a falls risk factor over the phone?
This is relatively simple as the information can easily be gathered by asking patients if they experience incontinence and if they do, taking a history as usual to explore whether it could be urge, stress or mixed urinary incontinence. I suspect it is easier for some patients to talk about this in a face to face consultation, but perhaps others will find it easier over the phone. Either way, building a rapport and putting the patient at ease will help explore this risk factor.
Julia Newton, Professor of Ageing & Medicine, Newcastle Falls and Syncope Service
How have you found virtual falls assessments?
I was initially concerned that telephone falls assessments would miss lots of valuable clinical information, but I have been pleasantly surprised and now I am a complete convert. Not needing to take time off work, pay for parking and arrange travel are very much felt by patients as being significant benefits. The problem seems to me to be related to the paternalistic views of clinicians – just because we have always done it like this doesn’t mean we should. How confident are we that eyeballing a patient and laying on of our healing hands leads to better care?
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