The older adult (age 65+) population is expected to increase to almost 88 million by 2050.¹ Older adults are also living longer; many are living with multiple chronic diseases and using a high number of daily medications.^{2, 3} These factors increase their risk for falls.^{2, 3} Each year, 29% of older adults report falling, resulting in approximately 30 million falls.⁴ While not all falls result in an injury, injurious falls result in about 3 million emergency department visits and over 800,000 hospitalizations each year.⁵

In parallel with the increased number of older adults, there is expected to be an increased need for health professionals with expertise in geriatric medicine to address falls and other geriatric syndromes.⁶ Previous research reports barriers to improving geriatric training at the student level across health profession disciplines.^{6, 7} These include lack of geriatrics-trained educators, limited financial incentives to pursue a career in geriatrics, and packed curricula with limited opportunities for expansion.⁶

Post training, a limited number of primary care practices report routinely assessing and addressing fall risk factors in their older adult patients.⁸ Reported barriers to managing fall risk include limited awareness about significant health impact of falls, limited knowledge about what can be done to prevent falls, lack of reimbursement for fall prevention activities, and competing health priorities.^9-14

This study describes the circumstances in which primary care providers (PCP) screen for fall risk and assess for gait and balance (GB) impairments in older adults and assesses any differences between nurse practitioners (NP) and other PCPs. In addition, the clinical resources used to review and manage medications for fall prevention is reported. This paper focuses on the specific practices of nurse practitioners (NP), as a growing workforce in primary care,^{15, 16} as well as family practitioners (FP) and internal medicine providers (IM).

Table 1 describes provider demographics and practice characteristics by PCP type. There were significant differences across provider types for gender, race/ethnicity, years in practice, average number of patients per week, practice setting, percentage of patients over 65 seen each week, patient SES, and regions. More than 87% of NPs were female compared to a smaller percentage of FPs (34.3%) and IMs (21.7%). Overall, NPs saw fewer patients per week compared to other PCP types. Among NPs, 73.7% saw fewer than 100 patients per week, while 32.2% of FPs and 40.8% of IMs providers saw fewer than 100 patient per week. NPs saw a greater percentage of older adults (18.4%) compared to FPs (2.5%) and IMs (6.7%).

Among all PCP types, 56.4% stated they would screen for fall risk during each wellness visit, 52.9% said they would screen when an older patient presents with a fall injury, and 51.9% stated they would screen if their older patient was concerned about falling (Table 2). More NPs and FPs reported screening older adult patients for falls during each wellness visit compared to IMs (64.0%, 62.3%, and 47.7% respectively). Most PCPs did not use a standardized test to assess GB. Among NPs, 64.9% stated they observed the patient walking compared to 48.5% of FPs and 44.6% of IMs. The most common standardized assessment used was the TUG. The TUG was used by 31.4% of FPs, compared to 28.6% of IMs and 13.2% of NPs.

Clinical compendia (47.0%) was most frequently used to evaluate the safety profile of a medication followed by embedded resources in EHR systems (20.2%; Table 2). NPs were the highest reported users of clinical compendia (53.9%), but lowest users of EHR (15.8%) compared to other PCPs. The Beers Criteria was used by 13.5% of all PCP types.

After adjusting for provider and practice characteristics, IMs had lower odds of reporting that they screen for fall risk at each wellness visit (aOR=0.5; CI=0.3-0.8) compared to NPs (Table 3). There was no significant difference between FPs and NPs. IMs and FPs had higher odds than NPs of reporting that they screen for fall risk when the patient presents with a fall injury. IMs and FPs also report higher odds of using a standardized GB test compared to NPs. Independent of PCP type, PCPs who see a larger proportion of older adults (more than 25% of their patients are 65 and older) were more likely to screen for fall risk during each wellness visit and to use a standardized GB assessment than PCPs whose patient population was younger (fewer than 25% of patients are 65 and older) (data not shown).

Around half of all PCPs in this sample indicated routinely screening for fall risk at each wellness visit. After adjusting for demographic and practice characteristics, IMs had lower odds of screening at each wellness visit compared to NPs. NPs may be more likely to screen during wellness visits because their training emphasizes a holistic approach, including the protection and promotion of health.^19-21 Previous studies have reported that the majority of older adults who experience a fall do not seek medical care or talk to a healthcare provider about their fall.²² These results suggests that there is an unmet need for fall screening among older adult patients at all healthcare encounters. The American and British Geriatric Society (AGS/BGS) guideline recommends annual screening for fall risk for all adults age 65 and older²³ and falls screening is a reimbursable component of the Medicare Annual Wellness Visit.²⁴

AGS/BGS guidelines recommend patients that screen at risk for a fall be further assessed for modifiable risk factors including GB limitations.²³ The guideline suggest using a standardized assessment like the TUG or Berg Balance Scale. NPs were least likely to report using a standardized GB assessment. This difference persisted after adjusting for demographic and practice characteristics. Standardized GB assessment tests may help PCPs identify specific underlying mobility deficits contributing to the individual’s fall risk and select appropriate interventions.^{23, 25, 26} Examples of standardized GB tests include the TUG, the 30-SCST, and the 4-SBT. These GB assessments are validated, have high test retest reliability, and may be administered in primary care settings.^27-30 Using a standardized test allows PCPs to evaluate changes in gait or balance for those patients who participated in fall prevention activities and to compare repeated test results over time and between providers.^31-34 Of the standardized approaches to assess GB, the TUG had the highest reported use but was used by fewer than 30% of all PCPs and only 13% of NPs. This may be due to a lack of knowledge about GB tests. Evidence suggest that few NPs received adequate geriatric training due to the lack of didactic geriatric coursework being required or offered in nursing curriculums.^{6, 35-37}

Most PCPs, including NPs, reported using clinical compendia to guide clinical judgement around medication use in older adults. However, less than a fifth of PCPs, including less than 16% of NPs, reported using the AGS’s Beers Criteria which highlights medication classes deemed inappropriate for use in older adults and contains information relevant to older adult prescribing that may not be found in standard clinical compendia.³⁸ Previous research found that PCPs have either not heard of or used the Beers Criteria when prescribing medications for older adults.^{39, 40} One barrier to appropriate prescribing in older adults is a lack of formal education on older adult prescribing.⁴⁰ The Beers Criteria is an important resource for NPs that emphasizes the benefit of limiting inappropriate medication prescribing in older adults and aims to reduce polypharmacy. NPs can use these criteria to identify medication that place older adults at high risk of adverse drug events and initiate regimen change.

Referral to a consultant pharmacist to manage medications was the least reported medication resource. Pharmacist directed patient care may increase medication adherence, improve patient awareness of medications they are taking, and reduce adverse medication events.⁴¹ Collaborative practice agreements between PCP and pharmacists are one way to incorporate pharmacists in the healthcare delivery system to improve the overall health of older adults.⁴²

NPs in our sample reported serving a larger proportion of older adults compared to other PCPs and are more likely to routinely screen for fall risk during annual wellness visits. This makes NPs well positioned to address older adult fall prevention in the primary care setting. Additional training on the value of using standardized GB tests may help NPs ensure they are appropriately identifying and managing their patient’s fall risk over time. CDC’s fall prevention initiative, Stopping Elderly Accidents Deaths and Injury (STEADI) and the AGS’s Beers Criteria are free resources available to NPs to assist them in their older adult fall prevention and safe medication prescribing efforts.