Uptake and adherence with soft- and hard-shelled hip protectors in Norwegian nursing homes: a cluster randomised trial

Compliant flooring to prevent fall-related injuries: a scoping review protocol

INTRODUCTION

Fall-related injuries can have serious consequences for older adults, including increased risk of dependence in daily activities and mortality. Compliant flooring is a passive intervention that may reduce the incidence and severity of fall-related injuries in healthcare settings, including acute and long-term care, but few sites have implemented compliant flooring, in part because synthesised evidence about key performance aspects has not been available.

METHODS AND ANALYSIS

We will conduct a scoping review to address the question: what is presented about the biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety associated with compliant flooring systems that aim to prevent fall-related injuries? We will conduct a comprehensive and systematic literature search of academic databases (AgeLine, CINAHL, EBM Reviews, MEDLINE (Ovid), SportDiscus and Web of Science) and grey literature (clinical trial registries, theses/dissertations, abstracts/conference proceedings and relevant websites). 2 team members will independently screen records (first titles and abstracts, then full text) and extract data from included records. Numerical and narrative analyses will be presented by theme (biomechanical efficacy, clinical effectiveness, cost-effectiveness, workplace safety).

ETHICS AND DISSEMINATION

This scoping review responds to the information needs of healthcare decision-makers tasked with preventing fall-related injuries. This review will summarise evidence about compliant flooring as a potential intervention for preventing fall-related injuries in older adults and identify gaps in evidence and new avenues for research. Results will be especially useful in long-term care, but also applicable in acute care, assisted living and home care. We will disseminate the review's findings via open-access publications, conference presentations, a webinar, a Stakeholder Symposium and a Knowledge-to-Action Report.

Facilitators of and barriers to hip protector acceptance and adherence in long-term care facilities: a systematic review

BACKGROUND

Hip protectors represent an attractive strategy for reducing hip fractures among high-risk fallers in long-term care facilities. However, clinical studies yield conflicting results regarding their clinical value. This is mainly due to poor acceptance and adherence among users in wearing these devices. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with hip protector use.

PURPOSE

The objective of this systematic review is to synthesize available research evidence to identify factors that influence acceptance and adherence among older adults living in long-term care facilities.

METHODS

A key word search was conducted for studies published in English between 2000 and 2013 that employed quantitative, qualitative, or mixed-methods research designs. Two independent reviewers evaluated each article for inclusion, with a third reviewer when needed to resolve discrepancies.

RESULTS

Twenty-eight articles met our inclusion criteria, and facilitators and barriers were clustered into 4 socio-ecological levels: system (eg, facility commitment, staff shortages), caregiver (eg, belief in the efficacy of protectors, negative perceptions), resident (eg, clinical risk factors for falls and related fractures, acute illness), and product (eg, soft shell, discomfort).

DISCUSSION

The outcomes provide decision makers, health professionals, and caregivers with a greater awareness of strategies to improve compliance with the use of hip protectors. Furthermore, researchers can use this information to design clinical trials that yield high acceptance and adherence.

Hip Protectors: Are They Worth it?

Hip fractures are one of the most serious conditions in frail elderly subjects, greatly increasing morbidity and mortality, and decreasing healthy life years. Since their first introduction on the market, hip protectors have been revealed to be a potential preventive measure for hip fractures, in addition to other well-known recognized medical interventions and rehabilitation procedures. However, randomized controlled trials have given contradictory results regarding their efficacy. Moreover, little data are available on the cost effectiveness of hip protectors. Adherence is a major problem in assessing the effectiveness of hip protectors in preventing fractures. Indeed, there is a lack of general consensus on a standard definition and quantitative objective estimation of adherence to hip protectors, along with still scarce evidence on specific interventions on how to ameliorate it. From what is known so far, it seems reasonable to advise the use of hip protectors in aged care facilities, since recent pooled analyses have suggested their efficacy in this setting. The introduction of sensors combined with hip protectors will probably address this issue, both for monitoring and optimizing compliance, especially in elderly people. In the meantime, new, well-designed studies following specific guidelines are strongly encouraged and needed. In particular, studies in community-dwelling elderly individuals at high risk of first or further fragility fractures are required. The optimization of the tested devices in a preclinical setting according to international standard biomechanical testing is necessary.

Hip protectors for preventing hip fractures in older people

BACKGROUND

Older people living in nursing care facilities or older adults living at home are at high risk of falling and a hip fracture may occur after a fall. Hip protectors have been advocated as a means to reduce the risk of hip fracture. Hip protectors are plastic shields (hard) or foam pads (soft), usually fitted in pockets in specially designed underwear.This is an update of a Cochrane review first published in 1999, and updated several times, most recently in 2010.

OBJECTIVES

To determine if the provision of external hip protectors (sometimes referred to as hip pads or hip protector pads) reduces the risk of fracturing the hip in older people.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE (1950 to week 3 November 2012), MEDLINE In-Process (18 December 2012), EMBASE (1988 to 2012 Week 50), CINAHL (1982 to December 2012), BioMed Central (January 2010), trial registers and reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing an intervention group provided with hip protectors with a control group not provided with hip protectors.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We sought additional information from trialists. Data were pooled using fixed-effect or random-effects models as appropriate.

MAIN RESULTS

This review includes 19 studies, nine of which were cluster randomised. These included approximately 17,000 people (mean age range 78 to 86 years). Most studies were overall at low risk of bias for fracture outcomes. Trials tested hard or soft hip protectors enclosed in special underwear in 18 studies.Pooling of data from 14 studies (11,808 participants) conducted in nursing or residential care settings found moderate quality evidence for a small reduction in hip fracture risk (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.67 to 1.00); the absolute effect is 11 fewer people (95% CI, from 20 fewer to 0) per 1000 having a hip fracture when provided with hip protectors.There is moderate quality evidence when pooling data from five trials in the community (5614 participants) that shows little or no effect in hip fracture risk (RR 1.15, 95% CI 0.84 to 1.58); the absolute effect is two more people (95% CI 2 fewer to 6 more) per 1000 people having a hip fracture when provided with hip protectors.There is probably little to no effect on falls (rate ratio 1.02, 95% CI 0.9 to 1.16) or fractures other than of the hip or pelvis (rate ratio 0.87, 95% CI 0.71 to 1.07). However, the risk ratio for pelvic fractures is RR 1.27 (95% CI 0.78 to 2.08); this is an absolute effect of one more person (95% CI 1 fewer to 5 more) per 1000 having a pelvic fracture when provided with hip protectors.The incidence of adverse events while wearing hip protectors, including skin irritation, ranged from 0% to 5%. Adherence, particularly in the long term, was poor.

AUTHORS' CONCLUSIONS

Hip protectors probably reduce the risk of hip fractures if made available to older people in nursing care or residential care settings, without increasing the frequency of falls. However, hip protectors may slightly increase the small risk of pelvic fractures. Poor acceptance and adherence by older people offered hip protectors is a barrier to their use. Better understanding is needed of the personal and design factors that may influence acceptance and adherence.

Autonomy, choice, patient-centered care, and hip protectors: the experience of residents and staff in long-term care

The purpose of this study was to examine long-term care (LTC) resident and staff perceptions on the decision to use hip protectors and identify the factors that influence attitudes toward hip protector use. Staff (N = 39) and residents (N = 27) at two residential care facilities in British Columbia, Canada were invited to participate in focus groups on fall prevention and hip protector use. A total of 11 focus groups were conducted. Using framework analysis results show that residents and staff shared concerns on aesthetic and comfort issues with hip protectors. Residents also generally felt they did not need, or want to use, hip protectors. However, they also had desire to be cooperative within the LTC environment. Staff underscored their role in advocating for hip protector use and their desire to protect residents from harm. Practice considerations for facilities wishing to promote hip protectors within a patient centered framework are highlighted.

When and where do hip fractures occur? A population-based study

We investigated the effects of socio-demographic and health factors on timing and location of hip fracture among 484 subjects. Time of fracture varied between community dwellers and residential care facility dwellers, and in relation to subjects' psychotropic drug status. Indoor hip fracture incidence increased on snow-covered days.

INTRODUCTION

This paper aims to describe the timing and whereabouts of hip fracture cases in a population-based setting and to relate these factors with residential and health status, seasonal variation, and snow-covered ground.

METHODS

We consecutively included 484 incident hip fracture events (age ≥50 years) admitted to a Swedish orthopedic department during a 1-year period. Data concerning socio-demographic details, fall location, time of fracture, comorbidity, and medications were collected from in-patient medical records and through patient or caregiver interviews.

RESULTS

The expected peak in fracture occurrence during daytime was observed among community dwellers but not among subjects living in residential care. Hip fracture was twice as likely to occur during nighttime hours among psychotropic drug users (adjusted odds ratio (Adj. OR), 2.20; 95% confidence interval (CI), 1.12-4.30) compared to those not receiving these medications. Subjects without dementia, taking psychotropic drugs, were also more likely to fracture during nighttime hours (Adj. OR, 2.91; 95% CI, 1.40-6.0). We observed an increase in indoor hip fracture incidence on snow-covered days among community dwellers (incidence rate ratio, 1.34; 95% CI, 1.02-1.74). We observed only a weak seasonal trend in hip fracture incidence, based on month, among community dwellers who fractured indoors.

CONCLUSIONS

Special attention and possibly fall-preventive efforts should be directed not only toward those living in residential care facilities but also toward community-dwelling subjects taking psychotropic drugs since these groups have a higher incidence of nighttime hip fracture. Further research aiming to explain the seasonal variation of indoor fracture incidence among community dwellers is warranted.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Diagnostic accuracy of three types of fall risk methods for predicting falls in nursing homes

AIMS

To determine the diagnostic accuracy of three different methods for identifying individuals at high risk of falling. The St- Thomas Risk Assessment tool (STRATIFY- modified for nursing homes), staff judgment of fall risk, and previous falls remembered by the staff were evaluated. We also examined whether a combination of two of the methods would increase accuracy.

MATERIALS AND METHODS

A prospective observational cohort study was carried out for 18 months. One thousand one hundred and forty-eight participants were included and assessed for fall risk. Falls among these residents were recorded from the date of inclusion to the date of death, transfer, or end of observation time. Diagnostic accuracy was evaluated in terms of sensitivity, specificity, predictive values and likelihood ratios, as well as Kaplan-Meier estimates and the Cox proportional hazard model, with time to the first fall as the dependent variable. Sensitivity, specificity, predictive value and likelihood ratios were calculated for falls within 30, 90 and 180 days of assessment for fall risk.

RESULTS

Five hundred and seventy (49.6%) of the 1148 residents had one or more falls during the observation period. One thousand one hundred had more than 30 days of observation, 987 more than 90 days, and 867 more than 180 days. For falls within 30 days of assessment for fall risk, sensitivity varied from 65% to 72%, specificity from 69% to 75%, positive predictive value from 31% to 35% and negative predictive value from 91% to 92%. Sensitivity and negative predictive value decreased for falls within 90 days and decreased further for falls within 180 days, whereas specificity and positive predictive value increased for all three assessment methods. Staff judgment of fall risk was the single method having the highest sensitivity but the lowest specificity. A combination of either two of them increased sensitivity to more than 80%, but decreased specificity. The positive Likelihood ratio varied from 2.24 to 2.70 and the negative Likelihood ratio from 0.41 to 0.49 for falls within 30 days. The relative risk of sustaining a fall was 2.4, 2.9 and 3.0 times higher for those assessed to be at high risk of falls compared with those assessed to be at low risk, according to STRATIFY, staff judgment of fall risk and previous falls remembered by the staff, respectively.

CONCLUSIONS

The diagnostic accuracy of the three methods did not differ markedly. However, staff judgment had the highest sensitivity and the lowest specificity after 30, 90 and 180 days. A combination of either two of the methods showed the highest sensitivity but the lowest specificity.

Hip protectors for preventing hip fractures in older people

BACKGROUND

Hip fracture in older people usually results from a fall on the hip. Hip protectors have been advocated as a means to reduce the risk of hip fracture.

OBJECTIVES

To determine if external hip protectors reduce the incidence of hip fractures in older people following a fall.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2010), The Cochrane Library 2010, Issue 2, MEDLINE (1950 to November 2009), MEDLINE in-process (30 December 2009), EMBASE (1988 to 2009 week 52), CINAHL (1982 to February 2009), BioMed Central (January 2010) and reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing the use of hip protectors with an unprotected control group.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed risk of bias and extracted data. We sought additional information from trialists. Data were pooled using fixed-effect or random-effects models as appropriate.

MAIN RESULTS

Pooling of data from 13 studies (11,573 participants) conducted in nursing or residential care settings found a marginally significant reduction in hip fracture risk (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.66 to 0.99); statistical significance was lost following exclusion of five studies (3757 participants) assessed at high risk of bias (RR 0.93, 95% CI 0.74 to 1.18).Pooling of data from three trials (5135 community-dwelling participants) showed no evidence of reduction in hip fracture risk (RR 1.14, 95% CI 0.83 to 1.57).There was no evidence of a statistically significant effect on incidence of pelvic or other fractures, or on rate of falls. No important adverse effects of the hip protectors were reported but adherence, particularly in the long term, was poor.

AUTHORS' CONCLUSIONS

The effectiveness of the provision of hip protectors in reducing the incidence of hip fracture in older people is still not clearly established, although they may reduce the rate of hip fractures if made available to frail older people in nursing care. It remains unknown from studies identified to date if these findings apply to all types of hip protectors. Some cluster-randomised trials have been associated with high risk of bias. Poor acceptance and adherence by older people offered hip protectors have been key factors contributing to the continuing uncertainty.

Hip protectors: recommendations for conducting clinical trials--an international consensus statement (part II)

INTRODUCTION

While hip protectors are effective in some clinical trials, many, including all in community settings, have been unable to demonstrate effectiveness. This is due partly to differences in the design and analysis. The aim of this report is to develop recommendations for subsequent clinical research.

METHODS

In November of 2007, the International Hip Protector Research Group met to address barriers to the clinical effectiveness of hip protectors. This paper represents a consensus statement from the group on recommended methods for conducting future clinical trials of hip protectors.

RESULTS AND CONCLUSIONS

Consensus recommendations include the following: the use of a hip protector that has undergone adequate biomechanical testing, the use of sham hip protectors, the conduct of clinical trials in populations with annual hip fracture incidence of at least 3%, a run-in period with demonstration of adequate adherence, surveillance of falls and adherence, and the inclusion of economic analyses. Larger and more costly clinical trials are required to definitively investigate effectiveness of hip protectors.

Hip protectors: recommendations for biomechanical testing--an international consensus statement (part I)

INTRODUCTION

Hip protectors represent a promising strategy for preventing fall-related hip fractures. However, clinical trials have yielded conflicting results due, in part, to lack of agreement on techniques for measuring and optimizing the biomechanical performance of hip protectors as a prerequisite to clinical trials.

METHODS

In November 2007, the International Hip Protector Research Group met in Copenhagen to address barriers to the clinical effectiveness of hip protectors. This paper represents an evidence-based consensus statement from the group on recommended methods for evaluating the biomechanical performance of hip protectors.

RESULTS AND CONCLUSIONS

The primary outcome of testing should be the percent reduction (compared with the unpadded condition) in peak value of the axial compressive force applied to the femoral neck during a simulated fall on the greater trochanter. To provide reasonable results, the test system should accurately simulate the pelvic anatomy, and the impact velocity (3.4 m/s), pelvic stiffness (acceptable range: 39-55 kN/m), and effective mass of the body (acceptable range: 22-33 kg) during impact. Given the current lack of clear evidence regarding the clinical efficacy of specific hip protectors, the primary value of biomechanical testing at present is to compare the protective value of different products, as opposed to rejecting or accepting specific devices for market use.

Hip protectors for preventing hip fractures among elderly adults

Prevention of fractures in the elderly consists of prevention and treatment of osteoporosis, prevention of falling and prevention of fractures using injury-site protection. Since the majority of hip fractures in elderly people are caused by a sideways fall with direct impact on the greater trochanter of the proximal femur, one option to prevent the fracture is a biomechanically effective external hip protector. The biomechanical test results of an energy-shunting and energy-absorbing hip protector have demonstrated that this type of hip protector can provide an effective impact force attenuation in typical falling conditions of older adults by reducing the initial force down to the seventh part. Recent meta-analyses and systematic reviews combining findings of all different types of hip protectors suggest that in care homes and institutions with high rates of hip fracture, the use of hip protectors might help to reduce the risk of fracture to 20–60%, but there is no evidence of a public health level benefit from hip protectors for lower-risk (usually home-dwelling) elderly people.

A Nordic multi-center study on physical and daily activities for residents in nursing home settings: design of a randomized, controlled trial

BACKGROUND AND AIMS

Nursing home residents constitute a frail, multi-diseased and heterogeneous group. As physical activity is essential for the preservation of function, personalized training and activities are of great importance. The main objective of this study was to describe the influence of an individually tailored intervention program, in a nursing home setting, on physical capacity, degree of dependence in Activities of Daily Living (ADL), long-term participation in physical and/or daily activities, and self-rated wellbeing. The aim of the present work is to describe the overall design of the study.

METHODS

Nursing homes in Sweden, Norway and Denmark were involved, and 322 residents were randomized to either Intervention or Control groups. The intervention lasted for three months and consisted of physical and daily activities, led by physiotherapists and occupational therapists, and was built on their evaluations and on the goals expressed by each resident. Tests of muscle strength, mobility, balance function and confidence, ADL, level of physical activity, wellbeing and cognitive function were performed at baseline, directly after the intervention period and three months later.

RESULTS

They will be presented in articles to follow.

CONCLUSIONS

Although it is a great challenge to carry out an intervention study directed toward such a frail population, it is of great interest to find out whether individually tailored and enhanced activities can lead to decreased dependence in ADL and increased wellbeing.

Predictors of uptake and adherence to the use of hip protectors among nursing-home residents

The aim of the present study was to identify predictors for initial uptake and adherence with the use of hip protectors when offering hip protectors free of charge to nursing-home residents. An 18 months prospective follow up study was carried out in 18 Norwegian nursing homes. One thousand two hundred and thirty-six residents were included in the study of which 604 started to use a hip protector. A multivariate logistic regression model was used to identify predictors for the initial uptake. A Cox proportional hazard model was used to identify predictors for adherence. A stepwise backward strategy was used in both the logistic and in the Cox regression. The effect of nursing homes as clusters was adjusted for in the analysis. The uptake rate among all residents was 46% and the adherence was approximately 75% after 3 months, and approximately 60% after 18 months. Female gender [odds ratio (OR): 1.54, 95% CI: 1.06-2.24, P = 0.022], previous fractures (OR: 1.67, 95% CI: 1.02-2.75, P = 0.043), previous falls (OR: 2.08, 95% CI: 1.35-3.19, P < 0.001) and memory (not able to memorise: OR: 3.71, 95% CI: 2.09-6.59, P < 0.001, large problems with memorising: OR: 2.85, 95% CI: 1.81-4.49, P < 0.001, medium problems with memorising: OR: 2.45, 95% CI: 1.39-4.33, P = 0.002, some problems with memorising: OR: 1.99, 95% CI: 1.14-3.48, P = 0.016) seemed to be important predictors for uptake. Among those who took up the offer male gender (HR: 1.71, 95% CI: 1.00-2.91, P = 0.049), memory (not able to memorise: HR: 0.26, 95% CI: 0.14-0.50, P < 0.001, large problems with memorising: HR: 0.32, 95% CI: 0.22-0.45, P < 0.001, medium problems with memorising: HR: 0.46, 95% CI: 0.30-0.73, P < 0.001, some problems with memorising: HR: 0.49, 95% CI: 0.32-0.73, P = 0.001) and bowel incontinence (HR: 0.41, 95% CI: 0.25-0.66, P < 0.001) were predictors for a lower probability of ending hip protector use. Factors related to a high risk of falling were important predictors for both uptake and adherence. The fact that neither memory impairments nor incontinence (bowel) seemed to be barriers to hip protector use is important since these characteristics are common among nursing-home residents and tertiary prevention such as the use of hip protectors is probably the most feasible intervention to prevent hip fractures in this group.