Developing an ICF code set for health care practitioners to identify fall risk factors in older adults

Abstract

Falls in adults older than 65 years of age constitute a global health concern and are the main cause of injury-related mortality in older adults. The falls death rate increased by 30% from 2009 to 2018, mainly due to the age of older adults increasing. Globally, it is estimated that as many as a third of community-dwelling older adults may experience a fall accident every year, of whom 35.5% may experience recurrent falls. This results in escalating health care cost due to falls in older adults. However, evidence shows that falls can be reduced and even prevented by early identification of fall risk factors and providing early intervention for those individuals who are at increased risk of future falls. If preventive health care services (which would include the identification of fall risk factors and screening for falls) are more readily available to older adults, the rising cost of health care could be offset and the health-related quality of life of these older adults could be enhanced. One way of identifying fall risk factors in older adults is by using the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). However, this framework contains more than 1400 codes, which impedes its clinical usability. The main aim of this study was to develop an ICF code set for fall risk factors in older adults so as to guide health care practitioners in the identification of fall risk factors as the first step in assessing and managing fall risk in a multidisciplinary health context. Information about the numerous multidisciplinary factors that influence fall risk was obtained and integrated from different data sources. The universal fall risk code set that was subsequently created for this population contains the minimum amount of information needed to meet the three objectives of an ICF code set, namely to guide health care practitioners in (i) identifying fall risk factors in older adults; (ii) determining which fall risk factors would justify further diagnostic assessment or intervention; and (iii) determining areas in which further functional assessment and/or intervention might be warranted which falls outside of the health care practitioner’s scope of practice, thereby necessitating further referral. This study followed a three-phase exploratory, sequential, mixed method research design. It also incorporated the suggested principles outlined by the ICF Research Branch for developing an ICF core set. Phase 1 focused on the qualitative data obtained from a systematic review and three different focus groups of older adults, as well two focus groups of diverse health care practitioners. The main aim of Phase 1 was to develop a list of relevant fall risk factors in older adults (65 years old and older). Phase 2 used a modified Delphi process to distil the list of relevant factors to those critical to fall risk in older adults. First, experts in the ICF were consulted to review the code set factors to be used in Round 1 of the Delphi process. Thereafter, based on their recommended changes, a three-round Delphi process commenced with experts in fall risk assessment, so as to determine the codes most critical to the identification of fall risk factors in older adults. Round 1 started with 87 codes, which were eventually reduced to 53 codes after Round 3. In Phase 3, the developed ICF code set was administered to audiologists, a group of health care practitioners who are routinely involved in screening for fall risk in this population. The aim of this phase of the study was to determine the clinical utility of the code set in terms of its appropriateness, accessibility, practicability, acceptability and professional utility. The findings from this research study not only indicated that the ICF code set for fall risk factors in older adults has high clinical utility with regard to its acceptability, appropriateness and the professional utility, but also revealed that it could potentially be used by health care practitioners from different disciplinary backgrounds. The findings further provided recommendations on how future studies could expand on this research and add to the existing body of knowledge on fall risk factors and preventive health care in older adults by emphasising healthrelated quality of life in this population. These recommendations included the need for situational awareness and appropriate referral strategies by health care practitioners; providing health care practitioners with a measure to document fall risk factors in line with the domains of the ICF; guiding health care practitioners to determine areas in need of assessment and intervention; and determining the training needs of audiologists as well as their lack of initiative in expanding their own skills and knowledge.