Preventing falls and fractures in long-term care

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.

Psychological Effects of Whole-Body Vibration Training in Frail Older Adults: An Open, Randomized Control Trial

The aim of this study was to identify the psychological effects of whole-body vibration (WBV) exercise in frail older adults. About 117 male and female volunteers (82.5 ± 7.9 years) from residential care facilities were randomized and assigned to control, simulated exercise (SIM), or WBV exercise (WBV) groups. All received regular care, while exercise groups also underwent 16 weeks of training (3 × 20 min/week). WBV exercise began with 5 × 1 min bouts (6 Hz/2 mm, 1:1 min exercise:rest), self-progressing to 10 × 1 min (up to 26 Hz/4 mm), and maintaining knee flexion. SIM training mimicked exercise stance and duration. Pre- and post-measures of falls-confidence, quality of life, and functional independence were completed using validated questionnaires. Functional independence and falls-confidence scores increased by 5.8% and 17.4% respectively with WBV exercise, compared with declines in SIM (p = .074/p = .035, respectively) and control (p = .000/p = .000, respectively) participants. Beneficial effects remained for at least 6-month post-intervention. Further WBV benefits were observed in activity, mobility, and self-care elements of quality of life. Sixteen weeks of low-level WBV exercise is sufficient to enhance frail older adults' falls-related confidence, quality of life, and functional independence.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Specific item patterns in comparison to generalized sum score-the Care Dependency Scale (CDS) as a screening tool for specific care problems

AIMS

The aim of this study is to identify items of the Care Dependency Scale (CDS) with overriding importance for the specific nursing care problems of pressure ulcers, falls, and malnutrition.

METHOD

Secondary data analysis of 5 multicentre consecutive annual cross-sectional surveys from 2008 to 2012. For the study, data were analysed from 19 787 individuals in 262 long-term care facilities throughout Germany. Based on a standardized study protocol and international definitions, data regarding care dependency and care problems were gathered by direct examination. To identify the most relevant items of the CDS regarding pressure ulcers, falls, and malnutrition, classification trees (Classification and Regression Trees) were calculated. The validity of the identified items was then confirmed by applying "area under the receiver operating characteristic curve (AUC)" statistics.

RESULTS

The Classification and Regression Tree analysis showed a total of 6 nodes for pressure ulcer prevalence on 2 levels. Both levels provided the CDS item mobility as the most important predictor for the prevalence of pressure ulcers with a prevalence of 9.0% for these being completely dependent. The most important CDS item to determine malnutrition is completely dependent on eat and drink with a malnutrition prevalence of 25.2%. Of all CDS items that have been entered into the model, the item mobility showed the strongest association with falls. For pressure ulcers, the CDS items mobility (0.72) and body posture (0.71) provided a higher AUC than the total CDS sum score. Furthermore, for malnutrition, we measured an AUC of 0.63 for item eat and drink while the total CDS provided an AUC of 0.62.

CONCLUSIONS

The results of our study suggest that the CDS may be a useful tool for screening patients regarding the risk of pressure ulcers and/or malnutrition. According to our study, the CDS can be used as an assessment for many different care problems.

Fall risk assessment tools for use among older adults in long-term care settings: A systematic review of the literature

OBJECTIVE

To conduct a systematic review of published fall risk assessment tools (FRATs) tested for predictive validity among older adults in long-term care (LTC).

METHODS

A systematic search was conducted using five databases. Only studies reporting on sensitivity and specificity values, conducted in LTC on populations primarily aged over 60 years, were considered.

RESULTS

Fifteen papers were included and three different categories of FRATs emerged: multifactorial assessment tools, functional mobility assessments and algorithms. Several FRATs showed moderate-to-good predictive validity and reliability, with the Modified Fall Assessment Tool and the Peninsula Health Falls Risk Assessment Tool (PHFRAT) also demonstrating good feasibility.

CONCLUSION

Evidence for the best choice of FRAT for use in LTC remains limited. Further research is warranted for the PHFRAT, recommended for use in LTC by best practice guidelines, before its establishment as the tool of choice for these clinical settings.

Effectiveness of Non-Pharmacological Interventions to Prevent Falls in Older People: A Systematic Overview. The SENATOR Project ONTOP Series

BACKGROUND

Falls are common events in older people, which cause considerable morbidity and mortality. Non-pharmacological interventions are an important approach to prevent falls. There are a large number of systematic reviews of non-pharmacological interventions, whose evidence needs to be synthesized in order to facilitate evidence-based clinical decision making.

OBJECTIVES

To systematically examine reviews and meta-analyses that evaluated non-pharmacological interventions to prevent falls in older adults in the community, care facilities and hospitals.

METHODS

We searched the electronic databases Pubmed, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, PsycINFO, PEDRO and TRIP from January 2009 to March 2015, for systematic reviews that included at least one comparative study, evaluating any non-pharmacological intervention, to prevent falls amongst older adults. The quality of the reviews was assessed using AMSTAR and ProFaNE taxonomy was used to organize the interventions.

RESULTS

Fifty-nine systematic reviews were identified which consisted of single, multiple and multifactorial non-pharmacological interventions to prevent falls in older people. The most frequent ProFaNE defined interventions were exercises either alone or combined with other interventions, followed by environment/assistive technology interventions comprising environmental modifications, assistive and protective aids, staff education and vision assessment/correction. Knowledge was the third principle class of interventions as patient education. Exercise and multifactorial interventions were the most effective treatments to reduce falls in older adults, although not all types of exercise were equally effective in all subjects and in all settings. Effective exercise programs combined balance and strength training. Reviews with a higher AMSTAR score were more likely to contain more primary studies, to be updated and to perform meta-analysis.

CONCLUSIONS

The aim of this overview of reviews of non-pharmacological interventions to prevent falls in older people in different settings, is to support clinicians and other healthcare workers with clinical decision-making by providing a comprehensive perspective of findings.

Older Persons' Transitions in Care (OPTIC): a study protocol

BACKGROUND

Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions.

METHODS/DESIGN

This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).

DISCUSSION

Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.