Multifaceted Interventions: Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques)

Tinetti, et al.

This study used a tailored combination of intervention strategies based on an assessment of each participant’s fall risk factors. Participants were about 30 percent less likely to fall compared with people who did not receive the intervention.

Population

Participants were members of a health maintenance organization. All were 70 or older and lived in the community. Most participants were female.

Geographic Locale

Farmington, Connecticut, United States

Focus

Identify and modify each participant’s risk factors.

Program Setting

The intervention was delivered to participants in their homes.

Content

This program provided an individualized intervention for each participant. The content varied based on the fall risk factors identified. Possible intervention components included medication adjustment, recommendations for behavioral change, education and training, home-based physical therapy, and a home-based progressive balance and strengthening exercise program. The selection of interventions was guided by decision rules and priorities. No participant received more than 3 balance and strength training programs.

Risk Factor	Intervention
Assessed by a nurse practitioner:
Postural hypotension	Behavioral recommendations such as elevating the head of the bed and using ankle pumps; made changes in medications
Use of sedative-hypnotic medication	Education; discontinued medication; non-pharmacological alternatives
Use of 4+ prescription medications	Reviewed medications with primary physician; the final decision on medication changes was made by the primary physician
Inability to transfer safely to bathtub or toilet	Training in transfer skills; home modifications (e.g., installing grab bars and a raised toilet seat)
Environmental hazards	Home modifications (e.g., removing rugs and installing railings)
Assessed by a physical therapist:
Gait impairments	Gait training; use of assistive devices; balance and/ or strengthening exercises
Impairments in transfer skills or balance	Training in transfer skills; home modifications; balance exercises (progressing through 4 levels of difficulty)
Impairment in leg or arm strength or in range of motion	Progressive strengthening exercises with resistance bands and putty, increasing resistance after participant could complete 10 repetitions; exercises were performed for 15-20 minutes twice a day

Duration

The intervention was conducted over a 3-month period. The amount and duration of contacts varied by the type of interventions received.

Delivered by

A nurse practitioner and physical therapist (PT) conducted the risk factor assessments. Medication adjustments were undertaken in cooperation with the participant’s primary physician who made the final decision on medication changes. The PT conducted all physical therapy and supervised exercise sessions.

Minimum Level of Training Needed

The assessment requires at least a well trained paraprofessional such as a PT assistant or licensed practical nurse (LPN). The intervention needs at least a BA-level nurse. The physical therapy portion requires a physical or occupational therapist, or a physical or occupational therapy assistant with supervision by a physical or occupational therapist.

Key Elements

The assessments need to be clearly linked to the intervention components. The minimum risk factor interventions include (1) postural blood pressure and behavioral recommendations; (2) medication review and reduction (especially psychoactive medications); (3) balance, strength, and gait assessments and interventions; and (4) environmental assessment and modification.

It is essential that the progressive balance and strength exercise program includes both supervised and at-home (unsupervised) components.

Available Materials

Intervention materials including risk factor assessments and treatment worksheets, medication reduction strategies, balance exercises, home safety checklists, and information sheets can be requested through the intervention web site www.fallprevention.org.

Study Citation

Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, Koch ML, Trainor K, Horwitz RI. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine. 1994 Sept 29;331(13):821-7.

Supplemental articles

Koch M, Gottschalk M, Baker DI, Palumbo S, Tinetti ME. An impairment and disability assessment and treatment protocol for community-living elderly persons. Physical Therapy. 1994 Apr;74(4):286-94.

Tinetti ME, Baker DI, Garrett PA, Gottschalk M, Koch ML, Horwitz RI. Yale FICSIT: Risk factor abatement strategy for fall prevention. Journal of the American Geriatrics Society. 1993 Mar;41(3):315-320.

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