Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury

PURPOSE

This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition.

METHOD

Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines.

RESULTS

64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %).

CONCLUSION

Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.

Development and External Validation of a Machine Learning-based Fall Prediction Model for Nursing Home Residents: A Prospective Cohort Study

OBJECTIVES

To develop and externally validate a machine learning-based fall prediction model for ambulatory nursing home residents. The focus is on predicting fall occurrences within 6 months after baseline assessment through a binary classification task, aiming to provide staff with an effective and user-friendly fall-risk assessment tool.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

A total of 864 older residents living in 4 nursing homes between May 2022 and March 2023 in China.

METHODS

Potential fall-risk predictors were collected through in-person interviews and assessments of anthropometric and physical function. Participants were followed for 6 months, with falls recorded by trained nurses. Seven machine learning algorithms, including Logistic Regression (LR), Gradient Boosting Machine (GBM), eXtreme Gradient Boosting (XGBoost), Random Forest (RF), Support Vector Machine (SVM), Neural Networks (NN), and Decision Tree (DT), were used to develop prediction models. Performance was evaluated using the area under the receiver operating characteristic curve (ROC-AUC) and Precision-Recall curve (PR-AUC), with calibration assessed via a calibration curve. Feature importance was visualized using SHapley Additive exPlanations (SHAP).

RESULTS

The 6 selected predictors were balance, grip strength, fatigue, fall history, age, and comorbidity. The ROC-AUC for the models ranged from 0.710 to 0.750, PR-AUC from 0.415 to 0.473, sensitivity from 0.704 to 0.914, and specificity from 0.511 to 0.687 in the validation cohort. The LR model was converted into a nomogram.

CONCLUSIONS AND IMPLICATIONS

The machine learning-based fall-prediction models effectively identified nursing home residents at high risk of falls. The developed nomogram can be integrated into clinical practice to enhance fall risk assessment protocols, ultimately improving patient safety and care in nursing homes.

Association between Polypharmacy and Hospitalization among Older Adults Admitted to Emergency Departments for Falls in Guadeloupe: A Retrospective Cohort Study

Introduction: Falls are a common geriatric syndrome in older people. Falls are associated with adverse health events such as dependency, unplanned emergency admissions and death. This study aimed to identify the factors associated with fall severity, such as diabetes, hypertension, heart disease, cognitive decline and polypharmacy, as well as sociodemographic characteristics in patients aged 70 years and over admitted to the emergency department in Guadeloupe. Method: A single-center, observational, retrospective study of patients aged 70 years and over admitted to the emergency department (ED) of the University Hospital of Guadeloupe for a fall between 1 May 2018 and 30 April 2019 was conducted. Fall severity was defined as the need for hospitalization. Bivariate analysis was used to determine the associations between fall severity and sociodemographic characteristics, comorbidities, history of falls and polypharmacy (defined as the daily use of at least five drugs). Polypharmacy was analyzed as a binary variable (>5 drugs daily; yes or no) in categories (0-3 (ref.), 4-6, 7-9 and ≥10 drugs). Results: During the study period, 625 patients who attended the ED for a fall were included. The mean age was 82.6 ± 7.6 years, and 51.2% were women. Of these, 277 patients (44.3%) were admitted to the hospital, and 3 patients (0.5%) died. In the bivariate analysis, only polypharmacy was associated with hospitalization for a fall (OR: 1.63 [95% CI: 1.33-2.02]). The odds ratios for the polypharmacy categories were 1.46 [95% CI 0.99-2.14], 1.65 [1.09-2.50] and 1.48 [0.76-2.85] for 4-6, 7-9 and ≥10 drugs, respectively. Conclusions: Polypharmacy was associated with hospitalization as a proxy for fall severity. A regular review of drug prescriptions is essential to reduce polypharmacy in older adults.

Exploring the Effectiveness of Emergency Medical Services Becoming Active in Fall Prevention: A Literature Review

Falls, particularly among the elderly, are a prevalent and growing healthcare issue in the United States. Individuals who experience falls face heightened morbidity and mortality risks, along with substantial expenses associated with managing any resulting injuries. First responders frequently respond to 911 calls related to falls, with a significant portion of these cases not resulting in hospital or healthcare facility transfers. As such, many fall victims receive treatment without any preventive measures being implemented. The purpose of this review is to explore the current studies that examine whether Emergency Medical Service personnel can effectively act in fall prevention. While earlier studies present conflicting findings, recent research indicates the potential for preventive strategies that go beyond mere referrals.

Nurse-led physical activity interventions for people with dementia in nursing homes: A systematic review on intervention characteristics and implementation facilitators/barriers

BACKGROUND

Physical activities are important to maintain and promote physical functioning and activities of daily living in people with dementia. Nurses are in a key position to deliver physical activity interventions in nursing homes. However, synthesized strategies for sustainable implementation of physical activity interventions in nursing homes for people with dementia are lacking.

OBJECTIVE

We aimed at synthesizing the evidence on nurse-led physical activity interventions and at identifying facilitators and barriers to sustainable implementation of physical activity interventions for people with dementia.

DESIGN

Systematic review.

REVIEW METHODS

We performed a comprehensive literature search combining database searches (MEDLINE, CINAHL, CENTRAL, Web of Science Core Collection; last search: September 27, 2023) and supplementary search methods (citation tracking, web searching, clinical guideline database searching). We considered studies on nurse-led physical activity interventions for people with dementia living in nursing homes for eligibility; published as journal articles and related material in English, French, German language, without restrictions on primary study design and publication year. Independently and in duplicate, we assessed the references' eligibility and the quality of the included studies. We used the Mixed Methods Appraisal Tool to appraise quality of included studies. We piloted and double-checked data extractions, and summarized the results narratively and graphically (harvest plot). We prospectively registered our review (PROSPERO CRD42021271833).

RESULTS

We identified 24 studies (of which eleven were randomized trials) assessing various interventions that we categorized into physical exercise (n = 8), care-integrated physical activity (n = 6), outdoor or walking activity (n = 5), technology-supported physical exercise (n = 3), and dancing (n = 2). Types of outcomes and length of follow-up varied widely. Effects were inconclusive, except for outdoor or walking activities showing an overall positive impact on physical outcomes. For eight interventions, we identified evidence on implementation barriers (b) and facilitators (f), including staff shortage (b), staff time resources (b), or ease of implementation for staff (f) and adaptability of interventions (f) or refusal to participate of people with dementia (b).

CONCLUSIONS

The results of our review provide a comprehensive overview on types, characteristics and effects of nurse-led physical activity interventions for people with dementia in nursing homes. Based on evidence from a range of study designs and sources, we came to the conclusion that all stakeholders involved considered physical activity interventions for people with dementia as useful and relevant. Outcome measures varied widely and a clear conclusion on effectiveness remains open.

Characteristics and Consequences of Falls in People Who Use Wheelchairs in Long-Term Care Settings

OBJECTIVES

The purpose of this study was to understand the characteristics and consequences of falls in individuals using wheelchairs in long-term care settings.

DESIGN

Observational analysis of real-world falls in long-term care.

SETTING AND PARTICIPANTS

Residents using wheelchairs from 2 long-term care facilities in British Columbia, Canada (n = 32 participants, mean age = 84.7 years, 12 women).

METHODS

Two raters used the validated Falls Video Analysis Questionnaire, adapted from the original version, to assess the causal, behavioral, and environmental aspects of falls from wheelchairs.

RESULTS

A total of 58 wheelchair fall videos were identified out of 300 total videos that were collected from 2007 to 2014. Wheelchair falls were most often caused by incorrect transfer or shift of body weight (70.7%). Participants most often fell backward with 89.7% striking their pelvis. Individuals using wheelchairs had limited protective response, with only 10.3% demonstrating a step response. Improper brake position contributed to 67.2% of falls. No serious fall-related injuries were reported.

CONCLUSIONS AND IMPLICATIONS

The findings highlight the unique nature of falls in older adults who use wheelchairs in long-term care settings. Overall, the results of this study support clinical practice and the critical need for developing specialized fall prevention and fall detection interventions for individuals who use wheelchairs in long-term care.

Exploring Early, Middle, and Late Loss in Basic Activities of Daily Living among Nursing Home Residents: A Multicenter Observational Study

Nursing home (NH) residents commonly face limitations in basic activities of daily living (BADLs), following a hierarchical decline. Understanding this hierarchy is crucial for personalized care. This study explores factors associated with early, middle, and late loss in BADLs among NH residents. A multicenter cross-sectional study was conducted in 30 NHs in Catalonia, Spain. Dependent variables were related to limitations in BADLs: early loss (self-care-related BADLs: personal hygiene, dressing, or bathing), middle loss (mobility-related BADLs: walking or wheelchair handling, toileting, and transferring), and late loss (eating). Independent variables were based on a comprehensive geriatric assessment and institutional factors. Logistic regression was used for the multivariate analyses. The study included 671 older adults. Early loss in BADLs was significantly associated with urinary incontinence, cognitive impairment, and falls. Middle loss in BADLs was linked to fecal incontinence, urinary incontinence, ulcers, and cognitive impairment. Late loss in BADLs was associated with fecal incontinence, the NH not owning a kitchen, neurological disease, cognitive impairment, dysphagia, polypharmacy, and weight loss. These findings highlight the need to address geriatric syndromes, especially cognitive impairment and bladder/bowel incontinence. Monitoring these syndromes could effectively anticipate care dependency. The presence of kitchens in NHs may help to address limitations to eating, allowing for potential personalized meal adaptation.

The Association of Organizational, Environmental, and Staffing Characteristics of Residential Care Facilities and the Risk Rating of Statutory Notifications: A Cross-Sectional Study in Ireland

OBJECTIVES

Safety incidents (SIs) are an indicator of quality in health and social care services. Safety incident research has largely focused on acute health care settings. We aimed to examine the association of organizational, environmental, and staffing characteristics of residential care facilities (RCFs) and severity of regulatory SI notifications.

METHODS

This was a retrospective analysis of SI notifications to the regulator for social care in Ireland received in 2018 and 2019. The mean risk rating of SI notifications for each RCF was used as the outcome. Regression analysis was conducted for the association of RCF characteristics (beds, staff to bed ratio, staff full-time equivalent (FTE), nurse to bed ratio, nurse FTE, number of RCF operated by the service provider, non-statutory or statutory provider) and the outcome, separately for nursing homes and residential disability services.

RESULTS

A total of 53,268 SI notifications were received. One thousand nine hundred RCFs were operational during the period: 594 (31.3%) for RCF-Nursing home and 1304 (68.7%) for RCF-Disability. For nursing homes, in the most adjusted model, the number of RCF operated by a provider ( β coefficient [95% confidence interval] = 0.508 [0.223-0.793]) was positively associated with mean risk rating of SI. For disability services, the following characteristics were positively associated in the most adjusted model: beds (0.081; 0.060-0.101), staff to bed ratio (0.068; 0.017-0.120), nurse to bed ratio (0.356; 0.044-0.667), staff FTE (0.029; 0.015-0.042), and number of RCF operated by a provider (0.067; 0.050-0.084).

CONCLUSIONS

Various modifiable organizational, environmental, and staffing characteristics and severity of SI notifications were associated in this study, most of which were related to RCF-Disability. Policymakers and providers of social care services should be cognizant of the relationship of these characteristics and severity of SI, when designing and planning residential care.

Rasch analysis of Morse Fall Scale among the older adults with cognitive impairment in nursing homes

This is a cross-sectional study to investigate the efficacy of Morse Fall Scale (MFS) in nursing homes for older adults with cognitive impairment. According to Rasch analysis, the person separation index was 0.95 (person reliability 0.48), and the item separation index was 9.23 (item reliability 0.99). Wright map showed all items can be considered appropriately directed to the older adults, but the items mainly located at both ends with the center missing. Each item was accepted with good infit and outfit statistics with positive PTMEA CORR. values from 0.49 to 0.68. Two items could be significant differential item functioning (DIF) between the two groups of different fall experience in the past year (item 1 and item 3). In conclusion, nursing assistant could adopt MFS to evaluate fall risk of older adults with cognitive impairment, but the risk grades are still not precise enough. In the future, MFS should be explored and refined further.

Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes

INTRODUCTION

Falls in nursing homes are a major cause for decreases in residents' quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls Programme, an evidence-based quality improvement intervention. The LOCK Falls Programme involves the entire front-line care team in (1) focusing on evidence of positive change, (2) collecting data through systematic observation and (3) facilitating communication and coordination of care through the practice of front-line staff huddles.

METHODS AND ANALYSIS

The study protocol describes a mixed-methods, 4-year hybrid (type 2) effectiveness-implementation study in State Veterans Homes in the USA. The study uses a pragmatic stepped-wedge randomised trial design and employs relational coordination theory and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to guide implementation and evaluation. A total of eight State Veterans Homes will participate and data will be collected over an 18-month period. Administrative data inclusive of all clinical assessments and Minimum Data Set assessments for Veterans with a State Veterans Home admission or stay during the study period will be collected (8480 residents total). The primary outcome is a resident having any fall. The primary analysis will be a partial intention-to-treat analysis using the rate of participants experiencing any fall. A staff survey (n=1200) and qualitative interviews with residents (n=80) and staff (n=400) will also be conducted. This research seeks to systematically address known barriers to nursing home quality improvement efforts associated with reducing falls.

ETHICS AND DISSEMINATION

This study is approved by the Central Institutional Review Board (#167059-11). All participants will be recruited voluntarily and will sign informed consent as required. Collection, assessment and managing of solicited and spontaneously reported adverse events, including required protocol alterations, will be communicated and approved directly with the Central Institutional Review Board, the data safety monitoring board and the Office of Research and Development. Study results will be disseminated through peer-reviewed publications and conference presentations at the Academy Health Annual Research Meeting, the Gerontological Society of America Annual Scientific Meeting and the American Geriatrics Society Annual Meeting. Key stakeholders will also help disseminate lessons learnt.

TRIAL REGISTRATION NUMBER

NCT05906095.

Effectiveness of fall prevention interventions in residential aged care and community settings: an umbrella review

INTRODUCTION

Preventing falls is a priority for aged care providers. Research to date has focused on fall prevention strategies in single settings (e.g., residential aged care (RAC) or community settings). However, some aged care providers deliver care, including fall prevention interventions, across RAC and community settings. We conducted an umbrella review to identify what type of fall prevention interventions had the greatest impact on falls outcomes in RAC and community settings.

METHODS

Five databases were searched for systematic reviews of falls prevention randomised control trials in older adults living in the community or RAC. Data extracted included systematic review methods, population characteristics, intervention characteristics, setting details (RAC or community), and fall-related outcomes (falls, people who have had a fall, fall-related hospitalisations, and fall-related fractures). Review quality was appraised using the Assessment of Multiple Systematic Reviews-2 tool.

RESULTS

One-hundred and six systematic reviews were included; 63 and 19 of these stratified results by community and RAC settings respectively, the remainder looked at both settings. The most common intervention types discussed in reviews included 'exercise' (61%, n = 65), 'multifactorial' (two or more intervention types delivered together) (26%, n = 28), and 'vitamin D' (18%, n = 19). In RAC and community settings, 'exercise' interventions demonstrated the most consistent reduction in falls and people who have had a fall compared to other intervention types. 'Multifactorial' interventions were also beneficial in both settings however demonstrated more consistent reduction in falls and people who fall in RAC settings compared to community settings. 'Vitamin D' interventions may be beneficial in community-dwelling populations but not in RAC settings. It was not possible to stratify fall-related hospitalisation and fall-related fracture outcomes by setting due to limited number of RAC-specific reviews (n = 3 and 0 respectively).

CONCLUSION

'Exercise' interventions may be the most appropriate falls prevention intervention for older adults in RAC and community settings as it is beneficial for multiple fall-related outcomes (falls, fall-related fractures, and people who have had a fall). Augmenting 'exercise' interventions to become 'multifactorial' interventions may also improve the incidence of falls in both settings.

Staff's insights into fall prevention solutions in long-term care facilities: a cross-sectional study

BACKGROUND

Falls are one of the most common and serious health issues in long-term care facilities (LTCFs), impacting not just residents, but staff and the healthcare system. This study aimed to explore LTCF staff's current practices around falls prevention, and their suggested solutions for better falls prevention.

METHODS

In the southwest of Ireland, a descriptive cross-sectional study was conducted in 13 LTCF sites, across a range of provider types and facility sizes. A survey, measuring staff knowledge, skills and attitudes, was distributed in physical and online formats. Staff suggestions for prioritising fall and fall-related injury prevention activities, and current staff practices regarding fall incidents were also sought. Content analysis was used to analyse responses, mapping categories and subcategories to the refined theoretical domains framework (TDF) and to an existing fall prevention guideline.

RESULTS

There were 155 respondents (15% response rate), from staff of the LTCFs. Environmental reviews and modifications (aligned to the TDF environmental context and resource domain) were the most common suggestions for preventing both falls and fall-related injuries. Other common suggestions for preventing falls were staff education, monitoring of residents, and using alarm/calling systems, while few staff members, across all roles, reported assessing residents, exercises, reviewing medications, and vitamin D supplements. For preventing fall-related injuries, suggestions included protective equipment, hip protectors and alarm/calling systems. Staff used a standardised approach when responding to a fall incident, with intensive and holistic post-fall control measures. HCAs focussed on transferring residents safely, while nurses of all grades focused more on post-fall assessment. Respondents believed that staff education, communication, increasing staffing levels and enhancing specialist care could support their practice.

CONCLUSION

Noting the low response rate, the results suggest an awareness gap regarding some evidence-based, resident-focussed falls prevention solutions, such as pro-active fall-risk assessment, exercise, medication review, and Vitamin D supplements. These aspects should be included in future fall prevention education programmes in LTCFs.

Staff Experiences in Managing Incidents in Nursing Homes: A Descriptive Qualitative Study

Introduction

Adverse incidents in nursing home (NH) may occur as the result of inadequate monitoring for signs of unobservable initial complications, medical errors, improper nursing interventions, lack of communication, and inadequate reporting.

Purpose

This study explores incident types, causes, handling, and documentation in Indonesian NHs through a qualitative approach.

Patients and Methods

In-depth interviews were conducted with 23 NH staff members, including managers, nurses, and support staff.

Results

Five themes and 17 sub-themes emerged, with falls and resident-to-resident abuse as common adverse incidents. Causes included older adults' conditions, environment, and misunderstanding. Follow-up action included first aid, hospital referrals, and assertive communication. Adverse incidents were actively reported through verbal and written reports or WhatsApp groups. Reports and documentation remain unstructured, however, as there were no standard operating procedures regarding incident reporting, documentation, and the types of adverse incidents that staff should report.

Conclusion

Improvements in management, documentation, and reporting adverse incidents are highlighted in this research. Practitioners, nurses, and social workers should develop guidelines for handling, reporting, and documenting adverse incidents in NHs.

Geospatial Mapping to Target Injury Prevention for Older Adult Ground-Level Falls: A Feasibility Study

BACKGROUND

Trauma centers target injury prevention efforts based on trauma registry and local epidemiological data. Identifying geographic patterns of injury through geospatial mapping has emerged as a technology to help identify at-risk individuals. Yet, the feasibility of using spatial analysis to target injury prevention efforts remains unknown.

OBJECTIVE

This study aims to demonstrate the use of geospatial mapping of older adult ground-level falls to target injury prevention efforts.

METHODS

This retrospective cohort analysis of ground-level falls among older adults was conducted from 2017 to 2020 at a Level I trauma center and safety net hospital. Trauma admissions, U.S. census median income, Hispanic percentage, and population density by zip codes were combined to create choropleth and heat maps to identify injury hot spots to target fall prevention classes.

RESULTS

A total of 5,629 patients were reviewed, of which 3,002 (53%) were fall cases. Low-level falls (<10 ft) accounted for 2,224 cases; 1,449 were among older adults centered around the study hospital. Ground-level falls accounted for 1,663 patients, of whom 1,182 were older adults clustering around senior housing, assisted living facilities, nursing homes, and rehabilitation centers. As a result, our fall prevention classes are now targeted at these newly identified locations.

CONCLUSION

Geospatial analysis provided powerful visualization of fall injury locations to target our fall prevention efforts. Geospatial analysis is a feasible tool for trauma centers to guide injury prevention strategies that effectively target the populations most in need.

Relationship Between Depression and Falls Among Nursing Home Residents: Protocol for an Integrative Review

BACKGROUND

Aging exposes individuals to new health disorders and debilitating chronic diseases, yet most older adults, even in functional decline, do not want to leave their homes. Nevertheless, for many, institutionalization in a nursing home (NH) may become essential to ensure their continued safety and health. Depression is one of the most common psychiatric disorders among older adults, especially among those who are institutionalized. Depressed NH residents face a high risk of future functional decline and falls, decreasing their quality of life. The relationship between depression and falls is complex and bidirectional. Previous reviews have focused on home-dwelling older adults or explored the relationship between antidepressant drugs and falls. To the best of our knowledge, no integrative literature reviews have explored the relationship between depression and falls among NH residents.

OBJECTIVE

Analyze studies on the relationship between depression and falls among NH residents.

METHODS

We will conduct an integrative literature review of published articles in relevant scientific journals on the relationship between depression and depressive symptomatology and falls among NH residents. As usually defined, we will consider NH residents to be people aged 65 years and older who can no longer live safely and independently in their homes. We will also consider older adults on short-term stays in an NH for rehabilitation after hospital discharge. Retrieved articles will be screened for eligibility and analyzed following previously reported steps. The most pertinent bibliographical databases will be examined for qualitative, quantitative, and mixed methods studies, from inception until August 31, 2023, thus ensuring that all relevant literature is included. We will also hand-search the bibliographies of all the relevant articles found and search for unpublished studies in any language. If appropriate, we will consider conducting a meta-analysis of the studies retrieved.

RESULTS

A first round of data collection was completed in March 2023. We retrieved a total of 2276 references. A supplementary literature search to ensure the most up-to-date evidence is ongoing. We anticipate that the review will be completed in late September 2023, and we expect to publish results at the end of December 2023.

CONCLUSIONS

This integrative review will increase knowledge and understanding of the complex relationship between depression and falls in NH environments. Its findings will be important for developing integrated, multidisciplinary models and care recommendations, adaptable to each NH resident's situation and health status, and for creating preventive interventions to help them maintain or recover optimal health stability.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46995.

Staff knowledge, attitudes and confidence levels for fall preventions in older person long-term care facilities: a cross-sectional study

BACKGROUND

Falls are the most common health problem affecting older people in long-term care facilities (LTCFs), with well-recognised adverse psychological and physical resident outcomes, and high staff burden and financial cost. LTCF staff knowledge and skills can play a vital role in providing and promoting fall prevention care.

METHODS

A descriptive cross-sectional survey study was conducted across 13 LTCF sites in the Southwest of Ireland; a sampling frame facilitated inclusion of a range of provider types and facility sizes. An existing questionnaire, based on fall prevention guidance, and examining staff knowledge, skills and attitudes, was distributed in physical and online formats.

RESULT

The response rate was 15% (n = 155), predominantly healthcare assistants, staff nurses and senior nurses. Almost 90% expressed high confidence levels for delivering fall prevention interventions and being aware of how falls affect LTCFs. However, over half underestimated the fall rate in LTCFs, and only 60% had adequate knowledge. Longer experience in working with older people in healthcare services was associated with greater knowledge (p = .001) and confidence in fall prevention interventions (p = .01), while senior nurses had more knowledge than others (p = .01). LTCF staff had lowest knowledge about "identification systems for residents at high risk of falling", "keeping confused residents near nursing stations", "the effect of using antipsychotic medicine on falls", "using a toileting regimen" and "staff responsibility regarding fall prevention efforts". Despite their knowledge gaps, nearly 50% thought they had enough fall prevention training; their main preference for any further fall education training was face-to-face education.

CONCLUSION

The results, with the caveat of a low response rate, show the need for interdisciplinary fall prevention training that is tailored to both the perceived learning needs and actual knowledge gap of LTCF staff and their preferences for learning delivery, as part of an overall approach to reducing fall-related adverse outcomes.

Effects of Physical Activity on Physical and Mental Health of Older Adults Living in Care Settings: A Systematic Review of Meta-Analyses

Previous studies included in meta-analyses have highlighted the effects of physical activity on the physical and psychological health of older adults living in care settings. We conducted a systematic review of meta-analyses, of institutionalized older adults, to evaluate and conduct a narrative synthesis of the results of these meta-analyses. A literature search was conducted in three databases (PubMed, Web of Science, and Cochrane Library) until 22 March 2023. After screening the identified articles with the PRISMA criteria filters, we included 11 meta-analyses in this systematic review. Higgins' (2013) assessment tool of the meta-analyses demonstrates that the studies were of good quality although future meta-analyses need to provide more information on the treatment of missing data. A summary of the results of these meta-analyses shows that physical activity reduces the rate of falls, mobility issues, functional dependence, and depression, and improves health status. Future studies need to focus on new ways to promote and adapt physical activities to increase the participation of older adults in care settings.

The Effect of a Standing Intervention on Falls in Long Term Care: a Secondary Analysis of a Randomized Controlled Trial

Background

Older adults in long term care (LTC) spend over 90% of their day engaging in sedentary behaviour. Sedentary behaviour may exacerbate functional decline and frailty, increasing the risk for falls. The purpose of this study is to explore the impact of a 22-week standing intervention on falls among LTC residents at 12-month follow-up.

Methods

This was a planned secondary analysis of the Stand if You Can randomized controlled trial. The original trial randomized 95 participants (n = 47 control; n = 48 intervention) to either a sitting control or a supervised standing intervention group (100 minutes/week) for 22 weeks. Falls data were available to be collected over 12 months post-intervention for 89 participants. The primary outcome was a hazard of fall (Yes/No) during the 12-month follow-up period.

Results

A total of 89 participants (average age 86 years ± 8.05; 71.9% female) were followed for 12-months post-intervention. Participants in the intervention group (n=44) had a significantly greater hazard ratio of falls (2.01; 95% CI = 1.11 to 3.63) than the control group (n=45) when accounting for the history of falls, frailty status, cognition level, and sex.

Conclusion

Participants who received a standing intervention over 22 weeks were twice as likely to fall 12 months after the intervention compared with the control group. However, the prevalence of falls did not surpass what would be typically observed in LTC facilities. It is imperative that future studies describe in detail the context in which falls happen and collect more characteristics of participants in the follow-up period to truly understand the association between standing more and the risk of falls.

Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool

BACKGROUND

Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents.

METHODS

Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample.

RESULTS

Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample.

CONCLUSIONS

We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.

Exercise for Preventing Falls in People with Dementia: Time to Work Together

Since the last two decades, many systematic reviews and meta-analyses found contradicting results on the effect of exercise in reducing falls in people with dementia. The recently published systematic review in the Journal of Alzheimer's Disease found positive results in reducing falls in only two studies. The authors conclude that insufficient data remains in reducing the number of falls by exercise interventions. This commentary focuses on interdisciplinary approaches that could reduce the number of falls in this vulnerable population.

Association between mild cognitive impairment and falls among Chinese older adults: the mediating roles of balance capacity and depressive symptoms

BACKGROUND

This study aimed to examine the association between mild cognitive impairment (MCI) and the follow-up risk of falls among Chinese older adults, exploring the mediating roles of balance capacity and depressive symptoms in the association between MCI and falls.

METHODS

A total of 5482 adults aged 60 years and above from waves 2015 and 2018 of the China Health and Retirement Longitudinal Study were included for analysis. Cognition was assessed by a global cognition score, which included three tests: episodic memory, figure drawing and Telephone Interview of Cognitive Status. Depressive symptoms were assessed with the Centre for Epidemiological Studies Depression Scale. Logistic regression models were used to estimate the association between MCI and falls. Mediation analysis was employed to explore the potential mediating roles of balance capacity and depressive symptoms in the association between MCI and falls.

RESULTS

MCI was significantly associated with the risk of falls (OR 1.259, 95% CI 1.080 to 1.467). Balance capacity and depressive symptoms played parallel mediating roles in the association between MCI and falls, and the mediating effects were 0.004 (95% CI 0.003 to 0.024) and 0.010 (95% CI 0.004 to 0.016), respectively.

CONCLUSIONS

It is necessary to screen for and recognise MCI in order to prevent falls among older adults. More efforts should be made to improve balance capacity and relieve depressive symptoms to reduce the risk of falls among older adults with MCI.

The Impact of Living Arrangements on the Prevalence of Falls after Total Joint Arthroplasty: A Comparison between Institutionalized and General Geriatric Population

Due to population aging, there is an increasing need for orthopedic surgery, especially total knee arthroplasty (TKA) and total hip arthroplasty (THA). In geriatric patients, postoperative falls are common events which can compromise the success of these expensive procedures. The aim of our study was to assess the influence of living arrangements on the prevalence of postoperative falls following joint replacement. We included 441 patients after TKA or THA, living in nursing homes, alone or with family. The prevalence of falls in the first 2 years (15.2%) was significantly influenced by living arrangements: patients with TKA or THA living alone had three times higher odds of falling compared to those living with family, and institutionalized patients with THA had four times higher odds of falling compared to those living with family. Of 67 patients who fell, 6 (8.9%) needed reintervention. For TKA patients, the fall rates were not significantly different between institutions and family, indicating the interest of nursing homes in offering proper care. However, for the THA group, the results were poorer, emphasizing the need for improvement in postoperative rehabilitation. Further multi-centric studies are required for generalizing the impact of living arrangements on fall prevalence after joint replacement.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias

BACKGROUND

Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL.

METHODS

Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits.

RESULTS

The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL.

CONCLUSIONS

Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review

BACKGROUND

Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies.

METHODS

A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results.

RESULTS

Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8).

CONCLUSION

This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined.

TRIAL REGISTRATION

This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.

"It's all about the money": an interpretive description of embedding physical therapy-led falls prevention group exercise in long-term care

BACKGROUND

Falls prevention interventions are effective for community dwelling older adults however, the same cannot be said for older adults living in long-term care (LTC). The Staying UpRight (SUp) randomized controlled trial was designed to test the effectiveness of a progressive strength and balance group exercise program delivered to LTC residents. This paper explores the factors impacting LTC providers' decisions to continue the program on completion of the funded trial period.

METHODS

A qualitative study using an Interpretive Description approach. Semi-structured interviews and focus groups were conducted with 15 LTC staff involved in the randomized controlled trial. Data were analysed using conventional content analysis.

RESULTS

Practice change occurred following participation in the trial with some facilities starting exercise groups, some increasing the number of exercise groups offered and physical therapists selecting elements of the program to adopt into their practice. Decisions about continuing with SUp as designed were constrained by organizational decisions regarding funding and resources. Three factors were identified which informed decision-making: business models and philosophies, requirements for evidence, and valuing physical therapy.

CONCLUSIONS

Managers and facilitators adapted SUp by selecting and delivering components of the program in response to the changes they had observed in participating residents. However, our findings highlight that while SUp was valued, the tight financial environment created by the current funding model in New Zealand did not support funding physical therapist delivered falls prevention exercise programs in LTC. This study may provide policy makers with important information on changes needed to support falls prevention service delivery in LTC.

TRIAL REGISTRATION

This study is a sub-study of a randomized controlled trial which was registered to the Australian New Zealand Clinical Trials Registry ACTRN12618001827224 on 09/11/2018. Universal trial number U1111-1217-7148.

The Effect of Exercise on Falls in People Living with Dementia: A Systematic Review

BACKGROUND

People living with dementia (PWD) are at a heightened risk for falls. However, the effects of exercise on falls in PWD are unclear.

OBJECTIVE

To conduct a systematic review of randomized controlled trials (RCTs) examining the efficacy of exercise to reduce falls, recurrent falls, and injurious falls relative to usual care among PWD.

METHODS

We included peer-reviewed RCTs evaluating any exercise mode on falls and related injuries among medically diagnosed PWD aged ≥55years (international prospective register of systematic reviews (PROSPERO) ID:CRD42021254637). We excluded studies that did not solely involve PWD and were not the primary publication examining falls. We searched the Cochrane Dementia and Cognitive Improvement Group's Specialized Register and grey literature on 08/19/2020 and 04/11/2022; topical categories included dementia, exercise, RCTs, and falls. We evaluated the risk of bias (ROB) using the Cochrane ROB Tool-2 and study quality using the Consolidated Standards of Reporting Trials.

RESULTS

Twelve studies were included (n = 1,827; age = 81.3±7.0 years; female = 59.3%; Mini-Mental State Examination = 20.1±4.3 points; intervention duration = 27.8±18.5 weeks; adherence = 75.5±16.2%; attrition = 21.0±12.4%). Exercise reduced falls in two studies [Incidence Rate Ratio (IRR) range = 0.16 to 0.66; fall rate range: intervention = 1.35-3.76 falls/year, control = 3.07-12.21 falls/year]; all other studies (n = 10) reported null findings. Exercise did not reduce recurrent falls (n = 0/2) or injurious falls (n = 0/5). The RoB assessment ranged from some concerns (n = 9) to high RoB (n = 3); no studies were powered for falls. The quality of reporting was good (78.8±11.4%).

CONCLUSION

There was insufficient evidence to suggest that exercise reduces falls, recurrent falls, or injurious falls among PWD. Well-designed studies powered for falls are needed.

Effectiveness of physical rehabilitation in improving physical functioning and quality of life for long-term-care residents with dementia: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of physical rehabilitation versus non-rehabilitation control in improving physical functioning and quality of life in long-term care residents with dementia.

INTRODUCTION

Many long-term-care residents live with dementia and have impaired physical function and poor quality of life. Physical rehabilitation can improve physical function and quality of life for people living with dementia, yet many long-term-care residents with dementia do not receive this intervention, and health care providers are unsure of which rehabilitation interventions are effective. Studies synthesizing effective rehabilitation programs are needed to guide practice in the long-term-care sector where many residents live with dementia. Previous studies have focused broadly on long-term care, specific professions, interventions or outcomes, or people with dementia in the community. Our review will focus on long-term-care residents living with dementia and a broader definition of physical rehabilitation.

INCLUSION CRITERIA

This review will include studies that evaluate physical rehabilitation in comparison with non-rehabilitation controls among long-term-care residents with any severity of dementia. We will include studies that measure the effect on performance-based physical functioning and self- or proxy-reported quality of life.

METHODS

Searches will be conducted in APA PsycINFO (EBSCO), CINAHL (EBSCO), MEDLINE (Ovid), Embase, Scopus, and the Cochrane CENTRAL database with no date or language limitations. Two independent reviewers will conduct a critical appraisal of eligible studies, assess methodological quality, and extract the data. Where possible, studies will be pooled in a statistical meta-analysis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022308444.

Controversies in Osteoporosis Treatment of Nursing Home Residents

Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment.

Factors Associated with Falls in Canadian Long Term Care Homes: a Retrospective Cohort Study

Background

Half of Canadians living in long-term care (LTC) homes will fall each year resulting in consequences to independence, quality of life, and health. The objective in this study was to analyze factors that contribute to, or are protective against, falls in Canadian LTC homes.

Methods

We analyzed of a retrospective cohort of a stratified random sample of Canadian LTC homes in Western Canada from 2011-2017. We accessed variables from the RAI-MDS 2.0 to assess the association of the dependent variable "fall within the last 31-180 days" with multiple independent factors, using generalized estimating equation models.

Results

A total of 28,878 LTC residents were analyzed. Factors found to increase the odds of falling were other fractures (OR 3.64 [95% confidence interval; CI 3.27, 4.05]), hip fractures (OR 3.58 [3.27, 3.93]), moderately impaired cognitive skills (OR 2.45 [2.28, 2.64]), partial support to balance standing (OR 2.44 [2.30, 2.57]), wandering (OR 2.31 [2.18, 2.44]).

Conclusion

A range of factors identified were associated with falls for people living in LTC homes. Individual physical ability represented the largest group of independent factors contributing to falls. Residents who experience any fracture or an acute change in behaviour, mobility, or activities of daily living (ADL) should be considered at increased risk of falls.

Falls prediction using the nursing home minimum dataset

OBJECTIVE

The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.

MATERIALS AND METHODS

The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.

RESULTS

The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.

DISCUSSION

Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.

CONCLUSION

The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

Implementation strategies supporting fall prevention interventions in a long-term care facility for older persons: a systematic review protocol

INTRODUCTION

Falls are common among older people in long-term care facilities (LCFs). Falls lead to significant morbidity, mortality and reduced quality of life among residents. Fall prevention interventions have been shown to reduce falls in LCFs. However, this may not always translate to effectiveness in real-world situations. We will conduct a systematic review (SR) to identify the implementation strategies used in fall prevention interventions in LCF, describing the effectiveness of strategies in terms of key implementation outcomes and fall reduction.

METHODS AND ANALYSIS

The search will include scientific papers in electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Scopus and Web of Science, and published theses. The SR will consider all original research that empirically evaluated or tested implementation strategies to support fall prevention interventions in LCF, published in English or Arabic between 1 January 2001 and 31 December 2021, where data are presented on the implementation strategy (eg, audit and feedback, champions) and/or implementation outcome (eg, fidelity). Clinical trials, quasi-experimental studies and quality improvement studies will be eligible for inclusion. Two researchers will complete abstract screening, data abstraction and quality assessments independently. The screening process will be presented using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Data will be extracted into a standardised table, including the country, year, authors, type of study, primary clinical outcome (falls rate and/or risk reduction as available), implementation strategy and implementation outcomes. Implementation strategies will be defined and categorised using the Expert Recommendation for Implementing Change Taxonomy. Implementation outcomes will be defined and categorised using the Implementation Outcomes Taxonomy, and clinical outcomes of the intervention effectiveness for falls preventions will be reported as formulated in each study, with a final narrative synthesis of data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study, and the results will be disseminated via peer-reviewed journals and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021239604.

A Methodological Quality Evaluation of Meta-Analyses on Nursing Home Research: Overview and Suggestions for Future Directions

(1) Background: The nursing home (NH) research field lacks quality reporting about meta-analyses (MAs), and most gradings of MA evidence are biased on analyzing the effectiveness of independent variables in randomized control trials. (2) Objectives: This study aimed to perform a critical methodological review of MAs in the NH research field. (3) Methods: We searched the articles from four databases (PubMed, MEDLINE, CINAHL, and PsycINFO) until 15th January 2021. We reviewed a total of 41 published review articles in the NH research field. (4) Results: The studies primarily fell into the following categories: medicine (17/41), nursing (7/41), and psychiatry or psychology (6/41); 36.6% of the reviewed studies did not use any validated MA guidelines. The lowest correctly reported PRISMA 2000 guideline item was protocol and registration (14.6%), and more than 50% of articles did not report risk of bias. Moreover, 78.0% of studies did not describe missing reports of effect size formula. (5) Discussion: NH researchers must follow appropriate and updated guidelines for their MAs in order to provide validated reviews, as well as consider statistical issues such as the complexity of interventions, proper grouping, and scientific effect-size calculations to improve the quality of their study. Future quality review studies should investigate more diverse studies.

Facilitators and barriers to implement nurse-led physical activities for people with dementia in nursing homes: a protocol for a mixed-methods systematic review

Introduction

Dementia is a major neurocognitive disorder and accounts for a great proportion of nursing home residents. Bodily symptoms such as gait, balance difficulties and muscle weakness are common in people with dementia. Physical activities are important to maintain and promote physical functioning and activities of daily living.

Nurses are a prone stakeholder to deliver physical activity interventions in nursing homes. However, several barriers have been reported for implementing nurse-led physical activity programmes. Also synthesised strategies for sustainable implementation in nursing homes are lacking. We, therefore, aim to synthesise the evidence on physical activity interventions which can be led by nurses and to identify facilitators and barriers of sustainable implementation of physical activity for people with dementia.

Methods and analysis

We will conduct a mixed-methods systematic review to (1) describe the characteristics of nurse-led physical activities for people with dementia living in nursing homes and to (2) determine facilitators and barriers for sustainable implementation of nurse-led physical activities for people with dementia in nursing homes. We will search four different electronic databases, do forward and backward citation tracking and will web-search additionally. We will also search through guideline databases. Two reviewers will independently screen the identified studies for their eligibility. Data extraction and critical appraisal of included studies will be performed by one reviewer and double-checked by another reviewer. We will analyse the data using an integrative mixed-method synthesis and we will summarise the findings narratively.

Ethics and dissemination

No ethics approval is needed to perform this systematic review. We will publish our review results as scientific and non-scientific journal articles and we will hold an oral or a poster conference presentation. The review results will inform the development of structured and easy to understand guidance for nurses to initiate tailored physical activities for people with dementia in nursing homes.

The Effect of Exercise Intervention on Reducing the Fall Risk in Older Adults: A Meta-Analysis of Randomized Controlled Trials

Exercise intervention has a positive effect on reducing the fall risk in older adults. To investigate the effect of different factors of exercise intervention (type, duration, and frequency) on reducing the fall risk in older adults, a meta-analysis was performed in this study. According to the PRISMA^®, two researchers independently searched PubMed, Web of Science, and the China National Knowledge Infrastructure databases to assess the quality of the studies using the PEDro scale. A total of 648 subjects in 10 randomized controlled trials were included in this study, and the exercise interventions included integrated training (resistance training, core training, and balance training), balance training, core training, Pilates, Ba Duan Jin, and Tai Chi. These studies show that exercise intervention has a huge and significant impact on reducing the risk of falls of the elderly. In conclusion, an integrated intervention with a frequency of more than five times a week and a duration of more than 32 weeks are more effective in reducing the fall risk.

Efficacy of exercise-based interventions in preventing falls among community-dwelling older persons with cognitive impairment: is there enough evidence? An updated systematic review and meta-analysis

Objective

Exercise prevents falls in the general older population, but evidence is inconclusive for older adults living with cognitive impairment. We performed an updated systematic review and meta-analysis to assess the potential effectiveness of interventions for reducing falls in older persons with cognitive impairment.

Methods

PubMed, EMBASE, CINAHL, Scopus, CENTRAL and PEDro were searched from inception to 10 November 2020. We included randomised controlled trials (RCTs) that evaluated the effects of physical training compared to a control condition (usual care, waitlist, education, placebo control) on reducing falls among community-dwelling older adults with cognitive impairment (i.e. any stage of Alzheimer’s disease and related dementias, mild cognitive impairment).

Results

We identified and meta-analysed nine studies, published between 2013 and 2020, that included 12 comparisons (N = 1,411; mean age = 78 years; 56% women). Overall, in comparison to control, interventions produced a statistically significant reduction of approximately 30% in the rate of falls (incidence rate ratio = 0.70; 95% CI, 0.52-0.95). There was significant between-trial heterogeneity (I² = 74%), with most trials (n = 6 studies [eight comparisons]) showing no reductions on fall rates. Subgroup analyses showed no differences in the fall rates by trial-level characteristics. Exercise-based interventions had no impact on reducing the number of fallers (relative risk = 1.01; 95% CI, 0.90–1.14). Concerns about risk of bias in these RCTs were noted, and the quality of evidence was rated as low.

Conclusions

The positive statistical findings on reducing fall rate in this meta-analysis were driven by a few studies. Therefore, current evidence is insufficient to inform evidence-based recommendations or treatment decisions for clinical practice.

PROSPERO Registration number: CRD42020202094.

Injury-Related Emergency Department Presentations Among Residential Aged Care Residents in Victoria, Australia

OBJECTIVE

This study aimed to quantify and describe the characteristics of emergency department (ED) injury presentations and subsequent hospital admissions among residents of residential aged-care facilities (RACFs) in Victoria, Australia between 2008 and 2018.

METHODS

This study comprised a single jurisdiction population-based study of consecutive injury-related ED presentations of RACFs residents using the Victorian Emergency Minimum Dataset (VEMD).

RESULTS

The rate of ED injury presentations per 100,000 population decreased by .8% per year over 10 years (P = .03); however, the rate per 100,000 RACF bed days increased by .6% per year (P = .05). The proportion of presentations subsequently admitted to hospital increased 4.0% per year (P<.0001). The majority of presentations were due to falls (82.5%), with fracture(s) being the most common injury type (34.0%).

DISCUSSION

The increased rate of ED visits and hospital admissions in RACFs residents highlights the need to design specialized emergency care services and/or provide better direct access to hospital care for this vulnerable population.

Nursing home performance in a trial to reduce hospitalizations: Implications for future trials

BACKGROUND

Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care.

DESIGN

Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers.

PARTICIPANTS

Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support.

MEASUREMENTS

Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes.

RESULTS

The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings.

CONCLUSION

Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.

Trends of Nursing Research on Accidental Falls: A Topic Modeling Analysis

This descriptive study analyzed 1849 international and 212 Korean studies to explore the main topics of nursing research on accidental falls. We extracted only nouns from each abstract, and four topics were identified through topic modeling, which were divided into aspects of fall prevention and its consequences. "Fall prevention program and scale" is popular among studies on the validity of fall risk assessment tools and the development of exercise and education programs. "Nursing strategy for fall prevention" is common in studies on nurse education programs and practice guidelines to improve the quality of patient safety care. "Hospitalization by fall injury" is used in studies about delayed discharge, increased costs, and deaths of subjects with fall risk factors hospitalized at medical institutions due to fall-related injuries. "Long-term care facility falls" is popular in studies about interventions to prevent fall injuries that occur in conjunction with dementia in long-term care facilities. It is necessary to establish a system and policy for fall prevention in Korean medical institutions. This study confirms the trends in domestic and international fall-related research, suggesting the need for studies to address insufficient fall-related policies and systems and translational research to be applied in clinical trials.

Predicting Short-Term Risk of Falls in a High-Risk Group With Dementia

OBJECTIVES

To develop a prognostic model to predict the probability of a short-term fall (within the next 7 to 30 days) in older adults with dementia.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

Fifty-one individuals with dementia at high risk of falls from a specialized dementia inpatient unit.

METHODS

Clinical and demographic measures were collected and a vision-based markerless motion capture was used to record the natural gait of participants over a 2-week baseline. Falls were tracked throughout the length of stay. Cox proportional hazard regression analysis was used to build a prognostic model to determine fall-free survival probabilities at 7 days and at 30 days. The model's discriminative ability was also internally validated.

RESULTS

Fall history and gait stability (estimated margin of stability) were statistically significant predictors of time to fall and included in the final prognostic model. The model's predicted survival probabilities were close to observed values at both 7 and 30 days. The area under the receiver operating curve was 0.80 at 7 days, and 0.67 at 30 days and the model had a discrimination performance (the Harrel concordance index) of 0.71.

CONCLUSIONS AND IMPLICATIONS

Our short-term falls risk model had fair to good predictive and discrimination ability. Gait stability and recent fall history predicted an imminent fall in our population. This provides some preliminary evidence that the degree of gait instability may be measureable in natural everyday gait to allow dynamic falls risk monitoring. External validation of the model using a separate data set is needed to evaluate model's predictive performance.