Preventing falls in assisted living: Results of a quality improvement pilot study

Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: Do settings respond differently during public health crises?

BACKGROUND

COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to historical periods.

METHODS

This was a population-based, repeated cross-sectional study using linked clinical and health administrative databases (January 2018 to December 2021) for residents of all publicly subsidized AL and NH settings in Alberta, Canada. Setting-specific monthly cohorts were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. Monthly rates (per 100 person-days) of all-cause hospitalization, hospitalization with delayed discharge, and hospitalization with death were plotted and rate ratios (RR) estimated for period (pandemic wave vs historical comparison), setting (AL vs NH) and period-setting interactions, using Poisson regression with generalized estimating equations, adjusting for resident and home characteristics.

RESULTS

On March 1, 2020, there were 9,485 AL and 14,319 NH residents, comparable in age (mean 81 years), sex (>60% female) and dementia prevalence (58-62%). All-cause hospitalization rates declined in both settings during waves 1 (AL: adjusted RR 0.60, 95%CI 0.51-0.71; NH: 0.74, 0.64-0.85) and 4 (AL: 0.76, 0.66-0.88; NH: 0.65, 0.56-0.75) but unlike NHs, AL rates were not significantly lower during wave 2 (and increased 27% vs NH, January 2021). Hospitalization with delayed discharge increased in NHs only (during and immediately after wave 1). Both settings showed a significant increase in hospitalization with death in wave 2, this increase was larger and persisted longer for AL.

CONCLUSIONS

Pandemic-related changes in hospitalization events differed for AL and NH residents and by wave, suggesting unique system and setting factors driving healthcare use and outcomes in these settings in response to this external stress.

Strategies to implement multifactorial falls prevention interventions in community-dwelling older persons: a systematic review

BACKGROUND

One-third of the community-dwelling older persons fall annually. Guidelines recommend the use of multifactorial falls prevention interventions. However, these interventions are difficult to implement into the community. This systematic review aimed to explore strategies used to implement multifactorial falls prevention interventions into the community.

METHODS

A systematic search in PubMed (including MEDLINE), CINAHL (EBSCO), Embase, Web of Science (core collection), and Cochrane Library was performed and updated on the 25th of August, 2022. Studies reporting on the evaluation of implementation strategies for multifactorial falls prevention interventions in the community setting were included. Two reviewers independently performed the search, screening, data extraction, and synthesis process (PRISMA flow diagram). The quality of the included reports was appraised by means of a sensitivity analysis, assessing the relevance to the research question and the methodological quality (Mixed Method Appraisal Tool). Implementation strategies were reported according to Proctor et al.'s (2013) guideline for specifying and reporting implementation strategies and the Taxonomy of Behavioral Change Methods of Kok et al. (2016).

RESULTS

Twenty-three reports (eighteen studies) met the inclusion criteria, of which fourteen reports scored high and nine moderate on the sensitivity analysis. All studies combined implementation strategies, addressing different determinants. The most frequently used implementation strategies at individual level were "tailoring," "active learning," "personalize risk," "individualization," "consciousness raising," and "participation." At environmental level, the most often described strategies were "technical assistance," "use of lay health workers, peer education," "increasing stakeholder influence," and "forming coalitions." The included studies did not describe the implementation strategies in detail, and a variety of labels for implementation strategies were used. Twelve studies used implementation theories, models, and frameworks; no studies described neither the use of a determinant framework nor how the implementation strategy targeted influencing factors.

CONCLUSIONS

This review highlights gaps in the detailed description of implementation strategies and the effective use of implementation frameworks, models, and theories. The review found that studies mainly focused on implementation strategies at the level of the older person and healthcare professional, emphasizing the importance of "tailoring," "consciousness raising," and "participation" in the implementation process. Studies describing implementation strategies at the level of the organization, community, and policy/society show that "technical assistance," "actively involving stakeholders," and "forming coalitions" are important strategies.

TRIAL REGISTRATION

PROSPERO CRD42020187450.

The Impact of a Randomized Controlled Trial Testing the Implementation of Function-Focused Care in Assisted Living on Resident Falls, Hospitalizations, and Nursing Home Transfers

The purpose of this study was to test the impact of function-focused care on adverse outcomes in assisted living. This was a randomized trial including 85 settings. The age of the 794 recruited participants was 89.48 (SD = 7.43) years, the majority was female (n = 561, 71%) and White (n = 771, 97%). The percentage of residents in the treatment group experiencing a fall decreased at 12 months from 26% to 20% and the control group increased from 24% to 25%, p = .02. A greater percentage of residents in the treatment group transferred to nursing facilities at 4 months (4-1% in control vs. 4-5% in treatment, p = .02) and 12 months (4-2% in control and 4-7% in treatment, p = .01). There was no treatment effect on emergency room or hospital transfers. The findings support the safety of function-focused care related to falls and need for hospital transfers.

Documented, Systematic and Individualized Communication With the Attending Physician for Fall Risk Reduction/Injury Mitigation Care Planning

Falls are common in nursing homes (NHs) and may result in serious injury to the resident as well as legal and regulatory liability for the NH. Some of these falls and injuries might be avoided if attending physicians were involved in risk reduction. I developed a communication tool to solicit from attending physicians specific risks for patients most likely to experience a fall and injury, and to consider strategies to reduce those risks. The communication tool addresses medications, osteopenia, vitamin D deficiency, vision, hearing, gait/balance/peripheral sensation, injury mitigation, altered mental status, restraints, and philosophy of treatment. An important component of implementation is to ensure full participation by the attending physician. Suggestions for implementation and evaluation are discussed, as well as potential application to clinical problems other than falls.

Physical Function, Relocation, and Mortality Outcomes in Residential Care and Assisted Living Residents

Objective: This study aimed to identify predictors of 6-month physical function and 12-month relocation or death in 272 residents of 34 residential care/assisted communities. Method: Measures collected at baseline, 6, and 12 months included health and demographic characteristics; self-reported pain, fatigue, and depressive symptoms; exercise self-efficacy, barriers, and expectations; attitudes on aging; performance-based physical function and physical activity; and community demographics, programs, and policies. GLIMMIX procedures for regression analyses with community as a random effect were run. Results: Better baseline physical function and grip strength, female sex, and residential care community predicted better 6-month physical function. At 12 months, 25.6% had relocated or died. The odds of 12-month relocation or death for 1-point increase in physical function score was 0.84 and for 1-point increase in depression score was 1.16. Discussion: Targets to promote longer tenure in residential care/assisted living include programs to ameliorate functional decline and depression screening and treatment.

Impact of Function Focused Care and Physical Activity on Falls in Assisted Living Residents

Background

There continues to be a belief among nurses, patients, and families that physical activity increases the risk of falling.

Purpose

The purpose of this study was to test the hypothesis that controlling for age, function, cognition, medication use, gender, comorbidities, and cognition, residents who are exposed to Function Focused Care for Assisted Living (FFC-AL-EIT) and engage in moderate levels of physical activity would not be more likely to fall.

Methods

This was a secondary data analysis using data from the first two cohorts of a randomized trial testing FFC-AL-EIT in the United States.

Results

The study included 381 residents, the majority of whom were female (70%), white (97%), with a mean age of 87.72 (standard deviation = 7.47). Those who engaged in more moderate-intensity physical activity were 1% less likely to fall (odds ratio = .99, p = .03). There was no significant association between exposure to function focused care and falling (odds ratio = 1.58, p = .09).

Conclusion

There was no indication that those who were exposed to function focused care or those who engaged in moderate-level physical activity were more likely to fall. In fact, engaging in moderate-level physical activity was noted to be slightly protective of falling.