'They will tell me if there is a problem': limited discussion between health professionals, older adults and their caregivers on falls prevention during and after hospitalization

Preventing hospital falls: feasibility of care workforce redesign to optimise patient falls education

OBJECTIVE

To examine the feasibility of using allied health assistants to deliver patient falls prevention education within 48 h after hospital admission.

DESIGN AND SETTING

Feasibility study with hospital patients randomly allocated to usual care or usual care plus additional patient falls prevention education delivered by supervised allied health assistants using an evidence-based scripted conversation and educational pamphlet.

PARTICIPANTS

(i) allied health assistants and (ii) patients admitted to participating hospital wards over a 20-week period.

OUTCOMES

(i) feasibility of allied health assistant delivery of patient education; (ii) hospital falls per 1,000 bed days; (iii) injurious falls; (iv) number of falls requiring transfer to an acute medical facility.

RESULTS

541 patients participated (median age 81 years); 270 control group and 271 experimental group. Allied health assistants (n = 12) delivered scripted education sessions to 254 patients in the experimental group, 97% within 24 h after admission. There were 32 falls in the control group and 22 in the experimental group. The falls rate was 8.07 falls per 1,000 bed days in the control group and 5.69 falls per 1,000 bed days for the experimental group (incidence rate ratio = 0.66 (95% CI 0.32, 1.36; P = 0.26)). There were 2.02 injurious falls per 1,000 bed days for the control group and 1.03 for the experimental group. Nine falls (7 control, 2 experimental) required transfer to an acute facility. No adverse events were attributable to the experimental group intervention.

CONCLUSIONS

It is feasible and of benefit to supplement usual care with patient education delivered by allied health assistants.

Clinical Characteristics and Outcomes of Inpatient Falls During Inpatient Rehabilitation: A Case-Control Study

ABSTRACT

Inpatient falls have a significant impact on the outcomes of older patients during inpatient rehabilitation. A retrospective case-control study was conducted using data of 7066 adults aged 55 yrs or older to evaluate significant predictors of inpatient falls during inpatient rehabilitation and the association of inpatient falls with discharge destination and length of stay. A stepwise logistic regression was used to model odds of inpatient falls and home discharge with demographic and clinical characteristic variables and a multivariate linear regression to evaluate the association between inpatient falls and length of stay.Nine hundred thirty-one of 7066 patients (13.18%) had inpatient falls during inpatient rehabilitation. The group with inpatient falls had longer length of stay (14.22 ± 7.82 vs. 11.85 ± 5.33 days, P < 0.0001) and a decreased proportion of home discharges when compared with the group without inpatient falls. There were increased odds of inpatient falls among patients with diagnoses of head injury, other injuries, a history of falls, dementia, a divorced marital status, and a use of laxatives or anticonvulsants. Inpatient falls were associated with an increased length of stay (coefficient = 1.62, confidence interval = 1.19-2.06) and decreased odds of home discharge (odds ratio = 0.79, confidence interval = 0.65-0.96) after inpatient rehabilitation. This knowledge may be incorporated into strategies for reducing inpatient falls during inpatient rehabilitation.

Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study

BACKGROUND

When there are safety concerns, healthcare professionals (HCPs) may disregard older adults' wishes to return or remain at home. A paradigm shift is needed for HCPs to move from labelling older adults as living at risk to helping them live with risk. The Living with Risk: Decision Support Tool (LwR:DST) was developed to support older adults and HCPs with difficult decision-making regarding living with risk. The study objectives were to: (1) validate, and (2) pilot-test the LwR:DST in hospital and community settings.

METHODS

The study was conducted across Canada during the pandemic. The LwR:DST's content was validated with quantitative and qualitative data by: (1) 71 HCPs from hospital and community settings using the Delphi method, and (2) 17 older adults and caregivers using focus groups. HCPs provided feedback on the LwR:DST's content, format and instruction manual while older adults provided feedback on the LwR:DST's communication step. The revised LwR:DST was pilot-tested by 14 HCPs in one hospital and one community setting, and 17 older adults and caregivers described their experience of HCPs using this approach with them. Descriptive and thematic analysis were performed.

RESULTS

The LwR:DST underwent two iterations incorporating qualitative and quantitative data provided by HCPs, older adults and caregivers. The quantitative Delphi method data validated the content and the process of the LwR:DST, while the qualitative data provided practical improvements. The pilot-testing results suggest that using the LwR:DST broadens HCPs' clinical thinking, structures their decision-making, improves their communication and increases their competence and comfort with risk assessment and management. Our findings also suggest that the LwR:DST improves older adults' healthcare experience by feeling heard, understood and involved.

CONCLUSIONS

This revised LwR:DST should help HCPs systematically identify frail older adults' risks when they remain at or return home and find acceptable ways to mitigate these risks. The LwR:DST induces a paradigm shift by acknowledging that risks are inherent in everyday living and that risk-taking has positive and negative consequences. The challenges involved in integrating the LwR:DST into practice, i.e., when, how and with whom to use it, will be addressed in future research.

Patients' experience with a community pharmacy fall prevention service

Background

Pharmacists can contribute to fall prevention, by offering services such as fall risk screenings, counselling, and medication reviews. Patient acceptance of the role of pharmacists in fall prevention is crucial.

Objectives

The aim of this study was to explore patients' experience with a community pharmacy fall prevention service.

Methods

Interviews were conducted with patients one month after they participated in a pharmacy fall prevention service, in the Netherlands. Patient inclusion criteria for the service were: age ≥ 70 years, use of ≥5 drugs including ≥1 fall risk-increasing drug. The service included a fall risk screening followed by counselling and a medication review. The semi-structured interview guide was based on the consolidated framework for implementation research and included the following topics: outcomes, patient's motivation, and contact with the pharmacy technician.

Results

Of the 91 participants of the fall prevention service, 87 patients were interviewed with a median age of 78.0 years (first quartile [Q1] - third quartile [Q3]: 74.0-84.75) and 46.3% were female. Many patients expressed positive feedback about receiving a medication review. Most patients whose medication was deprescribed expressed to be positive about this. Others were reassured about the appropriateness of their medication use. Patients reported that the service enhanced their awareness about fall prevention. Only a few patients were motivated to adapt their lifestyle. Patients appreciated the attention and contact.

Conclusions

Patients see a potential benefit for a community pharmacy falls prevention service, including a medication review. Patient education appeared to enhance their fall risk awareness.

Pharmacy fall prevention services for the community-dwelling elderly: Patient engagement and expectations

Medication use is an important risk factor for falls. Community pharmacists should therefore organise fall prevention care; however, little is known about patients' expectations of such services. This qualitative study aims to explore the expectations of community-dwelling older patients regarding fall prevention services provided by community pharmacies. Telephone intakes, followed by three focus groups, were conducted with 17 patients, who were aged ≥75 years, used at least one fall risk-increasing drug (FRID) and were registered at a community pharmacy in Amsterdam, the Netherlands. Some time of the focus groups was spent on playing a game involving knowledge questions and activities to stimulate discussion of topics related to falling. Data were collected between January 2020 and April 2020, and all focus groups were audiotaped and transcribed verbatim. The precaution adoption process model (PAPM) was applied during data analysis. Patients who had already experienced a fall more often mentioned that they took precautions to prevent falling. In general, patients were unaware that their medication use could increase their fall risk. Therefore, they did not expect pharmacists to play a role in fall prevention. However, many patients were interested in deprescribing. Patients also wanted to be informed about which medication could increase fall risk. In conclusion, although patients initially did not see a role for pharmacists in fall prevention, their perception changed when they were informed about the potential fall risk-increasing effects of some medications. Patients expected pharmacists to focus on drug-related interventions to reduce fall risk, such as deprescribing.

The use of control - the actions of informal carers on those at risk from falling at home. A qualitative study

To explore the experiences of informal carers who provide care for frail, older adults who are at risk from falling in their own home. Frail, older adults who fall present a significant challenge for their careers and the health and social care services that support them. Falls can often mean long stays in acute hospital facilities or admission to care homes. Research studies have often investigated the cause and effect of falls in relation to risk, but there has been a limited amount of insight into how informal carers manage those who are at risk from falling in their own home. A qualitative study that used thematic analysis was adopted. Ten informal carers participated in the study. Data were collected via one to one, semi structured interviews in the care recipient's home from February to May 2019. The study applied the COREQ research checklist. Findings highlight that informal carers believed that once a fall had occurred, further falls were inevitable and that falls prevention interventions were of little value. To prevent falls, informal carers would restrict the activity of the care recipient as well as controlling both the environment and the care recipient's movements. A better understanding of the use of control and monitoring of care recipients by informal carers is important. This knowledge will enable the delivery of falls prevention interventions for the frail, adult population that are effective, appropriate and promote the delivery of evidence-based care.

Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study

In hospitals, patient falls prevention education is frequently delivered by nurses and allied health professionals. Hospital falls rates remain high globally, despite the many systems and approaches that attempt to mitigate falling. The aim of this study was to investigate health professional views on the enablers and barriers to providing patient falls education in hospitals. Four focus groups with 23 nursing and allied health professionals were conducted at 3 hospitals. Three researchers independently coded the data and findings were analysed thematically with a descriptive qualitative approach to identify and develop themes according to barriers and enablers. Barriers included (i) limited interprofessional communication about patient falls; (ii) sub-optimal systems for falls education for patients and health professionals, and (iii) perceived patient-related barriers to falls education. Enablers to providing patient falls education included: (i) implementing strategies to increase patient empowerment; (ii) ensuring that health professionals had access to effective modes of patient education; and (iii) facilitating interprofessional collaboration. Health professionals identified the need to overcome organisational, patient and clinician-related barriers to falls education. Fostering collective responsibility amongst health professionals for evidence-based falls prevention was also highlighted.

Designing and evaluating falls prevention education with residents and staff in aged care homes: a feasibility study

Purpose

The purpose of this study was to co-design a falls prevention education programme with aged care home residents and staff and evaluate its feasibility. The intention of providing the education programme was to assist residents to stay safe and mobile whilst reducing their risk of falling.

Design/methodology/approach

A two-phase mixed methods participatory design using a resident (n = 6) and care staff (n = 5) consumer engagement panel, pre- and post-programme resident (n = 35) survey and semi-structured care staff interviews (n = 8) was undertaken in two countries.

Findings

A poster, brochure, video and staff education guide featuring 12 safety messages depicting fall prevention behaviours were co-designed. Residents, supported by staff, perceived the falls prevention education programme as enjoyable and informative, but there were no significant differences in capability, opportunity or motivation. However, several residents were observed enacting fall prevention behaviours such as “If I feel unwell, I'll ring the bell” and waiting for staff assistance. Challenges to programme demand, acceptability and implementation which may have impacted residents' exposure and engagement with the programme were identified, along with recommendations to improve feasibility.

Practical implications

When developing falls prevention education programmes partnering with residents and staff, providing choices to meet personal and aesthetic preferences along with frequent, shorter duration learning opportunities are important for translating education messages into actions.

Originality/value

The use of bespoke resources, novel rhymes, positive messages emphasising safety and co-designing with residents themselves was a welcomed point of programme difference.

A survey of nurses, physiotherapists and occupational therapists in mobility care and gait aid use for hospital patients with dementia

This study described mobility care practice of nurses, physiotherapists and occupational therapists and gait aid use for hospital patients with dementia. Two surveys, tailored to staff mobility care roles were distributed in Australian hospitals. Physiotherapists and occupational therapists were asked additional questions regarding assessments and factors for prescribing gait aids to patients with dementia. Descriptive statistics for closed-ended and summative content analyses for open-ended questions were undertaken. Nurses (n=56), physiotherapists (n=11) and occupational therapists (n=23) used various practices to ensure ambulation safety for patients with dementia. Nurses and occupational therapists commonly referred patients with dementia to physiotherapists for mobility and gait aid assessments. Therapists predominantly considered the severity of dementia, the person's learning ability and mobility history in deciding about gait aid use. Exploring ways to strengthen nursing and health professional education, and inter-professional practice for safe mobility in patients with dementia, with and without gait aids, could be helpful.

Exploring the relationship between perceived susceptibility and severity of falling among older adults in Singapore

Introduction

Despite extensive research about improving the effectiveness of falls prevention interventions, at-risk individuals are not always willing recipients. Reasons for rejecting treatments are still poorly understood. Applying the health belief model (HBM), if perceived severity and susceptibility can be understood in the context of falling, this might better inform intervention designs.

Method

Sixty-two participants were recruited from inpatient wards at a local acute hospital. Participants completed two self-report questionnaires, the Staying Independent Checklist (SIC) and the Falls Efficacy Scale – International (FES-I), measuring perceived susceptibility and severity respectively.

Results

One-way ANOVA analysis revealed a significant association between FES-I total scores and SIC score categories [ F (1,60) = 6.277, p = .015].Stepwise regression with backward elimination also found that falls history (β = .292, p = .033), sex (β = .269, p = .042), and FIM lower body dressing (β = − .286, p = .035) had significant associations with FES-I scores.

Conclusion

Level of perceived susceptibility and severity of falling should be considered when determining if falls prevention interventions are relevant, regardless of functional ability and physical health status. Future research to determine the underlying mechanisms which drives health behaviours related to falls prevention should be conducted.

Tailored Education Increased Capability and Motivation for Fall Prevention in Older People After Hospitalization

Recently hospitalized older people are at risk of falls and face barriers to undertaking fall prevention strategies after they return home from hospital. The authors examined the effects of tailored education delivered by physiotherapists on the knowledge (capability) and the motivation of older people to engage in fall prevention after hospital discharge. Utilizing data gathered from a recent trial, data was analyzed from 390 people who were 60 years and over without impaired cognition (>7/10 abbreviated mental test score) and discharged from three Australian hospitals. Motivation and capability were measured at baseline in the hospital and at 6-months after hospital discharge by blinded assistants using structured surveys. Bivariate analysis using generalized linear modeling explored the impact of education on the capability and motivation. Engagement in fall prevention strategies was entered as an independent variable during analysis to determine associations with capability and motivation. The education significantly improved capability [-0.4, 95% CI (-0.7, -0.2), p < 0.01] and motivation [-0.8, 95% CI (-1.1, -0.5), p < 0.01] compared with social-control at the time of hospital discharge. In contrast, social-control participants gained capability and motivation over the 6-months, and no significant differences were found between groups in capability [0.001, 95% CI (-0.2, 0.2), p = 0.9] and motivation [-0.01, 95% CI (-0.3, 0.3), p = 0.9] at follow-up. Tailored fall prevention education is recommended around hospital discharge. Participants still needed to overcome barriers to falls prevention engagement post hospitalization. Thus, tailored education along with direct clinical services such as physiotherapy and social supports is warranted for older people to avoid falls and regain function following hospitalization.

Therapists' perspectives on fall prevention in spinal cord injury rehabilitation: a qualitative study

PURPOSE

Therapists play a key role in delivering fall prevention/management education to individuals with spinal cord injury/disease, yet their perspectives on this topic remain understudied. Here, we described the perspectives of physical and occupational therapists who routinely provided rehabilitation to patients with spinal cord injury/disease on: (1) how fall risk was assessed, (2) what fall prevention education, interventions or strategies were provided, and (3) opportunities to improve fall risk assessment and the delivery of fall prevention education, strategies and interventions.

MATERIALS AND METHODS

Twenty-one therapists completed an individual interview or focus group that was analyzed using an inductive thematic analysis.

RESULTS

Four main themes were identified: (1) policy and procedures impact practice (i.e., policy and procedures positively and negatively impact practice), (2) assessing and managing fall risk/falls in patients with spinal cord injury/disease (i.e., discipline-specific roles in fall risk assessments and fall management processes in rehabilitation), (3) fall prevention and management education (i.e., helicopter therapists and challenges with fall prevention and management education), (4) building insight into fall risk and management (e.g., building insight into fall risk for patients and therapists).

CONCLUSIONS

This study revealed opportunities to improve the delivery of fall prevention education and training to individuals with spinal cord injury/disease.IMPLICATIONS FOR REHABILITATIONFall prevention education should be initiated in spinal cord injury rehabilitation and then reinforced in community rehabilitation.Barriers and challenges faced by therapists when delivering fall prevention and management education/training in spinal cord injury rehabilitation include their perceptions of a patient's readiness to receive fall prevention education, short length of stay in rehabilitation, organization's expectations of zero falls and a lack of spinal cord injury-specific fall prevention resources.Therapists who work in spinal cord injury rehabilitation may benefit from information about fall risk factors encountered by individuals with spinal cord injury/disease in the community.

Patient Perspectives on Hospital Falls Prevention Education

Hospital falls remain an intractable problem worldwide and patient education is one approach to falls mitigation. Although educating patients can help their understanding of risks and empower them with prevention strategies, patient experiences of hospital falls education are poorly understood. This study aimed to understand the perspectives and preferences of hospitalized patients about falls prevention education. Three focus groups were conducted in Australian hospitals. A phenomenological approach was used to explore patient perspectives and data were analyzed thematically. The focus groups revealed that most people did not realize their own risk of falling whilst an inpatient. Experiences of falls prevention education were inconsistent and sometimes linked to beliefs that falls were not relevant to them because they were being cared for in hospital. Other barriers to falls mitigation included poor patient knowledge about hospital falls risk and inconsistencies in the delivery of falls prevention education. A strong theme was that individualized, consistent education, and small interactive groups were helpful.

Managing and keeping control: A qualitative synthesis of nursing and care staff strategies to prevent older people from falling

AIM

To better understand formal care providers' role in fall prevention.

DESIGN

Qualitative synthesis as part of an integrative review.

DATA SOURCES

Fifteen electronic databases were consulted with the time limit being December 2017. Studies included were qualitative primary studies on formal care providers and fall prevention of people over 65 years of age in health care facilities. 17 studies were included.

REVIEW METHODS

Qualitative researchers carried out a critical appraisal and abstraction of the studies retained. Primary studies were imported into Nvivo 12 software; grounded theory procedures of constant comparison, microanalysis, coding, development of memos and diagrams were completed concurrently in a continuous growing process of data conceptualization. Analysis was iterative; it started with open coding and ended with the development of an integrative memo.

FINDINGS

Primary studies were synthesized with the emerging core category of "Managing and keeping control" and described by the emerging strategies of risk management, risk control and articulation work. These three categories account for the formal care providers' role in fall prevention in health care facilities.

CONCLUSION

Fall prevention is not given by a series of means and instruments; it is rather built in the interactions between formal care providers and the material and social world. The interactive character of prevention implies that outcomes cannot always be anticipated.

IMPACT

Although falls are one of the most researched clinical problems in nursing, the role played by nursing and care staff is dispersed and scantily documented. Formal care providers alternate risk management with risk control strategies to prevent older people from falling in health care facilities, they also resort to the articulation of the health care team as a complementary strategy. This review shows the dynamic character of fall prevention, which is something that has tended to go unnoticed in the literature and in policy.

Older adults' views on barriers and facilitators to participate in a multifactorial falls prevention program: Results from Prevquedas Brasil

OBJECTIVES

To understand the reasons older people engage in a multifactorial fall prevention program and, to identify the barriers and facilitators for adherence.

METHODS

Cross-sectional study, with 218 older adults from the intervention group of a 12-week multifactorial fall prevention program (Prevquedas Brazil). We interviewed participants using a semi-structured questionnaire concerning reasons to engage in, barriers, and facilitators to participating in the program. We compared participants with low (0-5 sessions) and moderate/high (6-12 sessions) adherence regarding barriers and facilitators.

RESULTS

Physical and mental health problems (55 %), and competing demands (45.2 %) were the most frequent barriers reported. Pleasant environment (97.7 %), a sense of receiving proper care (96.7 %), and empathy with the team (96.7 %) were the main facilitators. Seven out of the twelve facilitators distinguished participants with high adherence from those with low adherence. Only the barriers related to the program characteristics and the lack of social support were able to identify participants with low adherence. Open-ended questions revealed that self-determination, commitment, and the desire of being physically active and fit promoted participation. Anticipated health benefits and functional gains, a need to take action due to fall consequences, and encouragement from others were among the reasons to engage in the program.

CONCLUSION

Although barriers should not be neglected, facilitators are critically important for adherence. Health professionals may develop skills to facilitate uptake and optimize older adults' participation. Implementing sustainable fall prevention programs in low and middle-income countries requires overcoming the fragmentation and inflexibility of healthcare services.

Hospitalist Perceptions of Fall Prevention: A Comparison of Two Health Care Systems

Inpatient falls are common, but little is known about hospitalist perceptions regarding their exact role in fall prevention. The authors conducted a cross-sectional analysis of hospitalists' attitudes and perceived barriers to fall prevention practices in 2 different hospital systems in Portland, Oregon. A total of 42 responses were collected. Although hospitalists in both groups agreed that all patients admitted should undergo fall risk assessments (FRAs), both groups disagreed that hospitalists should be responsible for performing them. Neither group felt that they had the time to complete FRAs and were either neutral or felt the lack of expertise to conduct them. These findings suggest that the hospitalist role in inpatient fall prevention multidisciplinary teams may be unclear to physician providers and that health care systems may benefit from examining this further.

Modification of Potentially Inappropriate Prescribing Following Fall-Related Hospitalizations in Older Adults

BACKGROUND

There is strong evidence that potentially inappropriate prescribing is associated with falls in older adults. Fall-related hospitalizations should trigger medication review.

OBJECTIVES

The aim of this before-and-after cohort study was to explore patterns of relevant potentially inappropriate prescribing in older people with fall-related hospitalizations.

METHODS

Data on older adults with hospitalizations for falls, fractures and syncope between 2012 and 2016 were collected from 44 general practices in Ireland. Fall-related prescribing was defined from the Screening Tool for Older Persons' Prescriptions (sedatives and vasodilators) and the Screening Tool to Alert doctors to Right Treatment (vitamin D). Prevalence of prescriptions were estimated from general practice and hospital discharge records. Mixed-effects logistic regression was conducted to compare the 12-month pre- and post-hospitalization periods.

RESULTS

Overall, 927 individuals (68% female, average age 81.2 years; standard deviation 8.6) were included, 45% of whom had a diagnosis of fracture, 28% had syncope, and 27% had a fall without fracture/syncope. After adjustment for covariates and practice clustering effects, both vitamin D and sedatives had higher odds of prescription post-hospitalization (adjusted odds ratio [aOR] 4.47, 95% confidence interval [CI] 2.09-9.54, and aOR 1.75, 95% CI 1.29-2.39, respectively). With adjustments for age and sex, having a fracture was associated with new initiation of vitamin D (aOR 2.81, 95% CI 1.76-4.46) and having syncope was associated with continuing on vasodilators (aOR 1.99, 95% CI 1.06-3.74). No factors were associated with new sedative initiation.

CONCLUSION

Fall-related potentially inappropriate prescribing is prevalent in older adults who have a history of falls, and continues after discharge from hospital. Future studies should investigate why such prescribing is initiated after a fall-related hospitalization, and explore interventions that could reduce such hazardous prescribing.

[Evaluation of a simple screening tool for ambulant fall prevention]

BACKGROUND

An individual's risk of falling is generally difficult to detect and it is likely to be underestimated. Thus, preventive measures are challenging and they demand sufficient integration and implementation into aftercare and outpatient management. The Aachen Falls Prevention Scale (AFPS) is a quick and easy tool for patient-driven fall risk assessment. Older adults' risk of falling is identified in a suitable manner and they then have the opportunity to independently assess and monitor their risk of falling.

OBJECTIVES

The aim of the current study was to evaluate the AFPS as a simple screening tool in geriatric trauma patients via the identification of influencing factors, e.g. objective or subjective fall risk, fear of falling (FOF) and demographic data. In this context, we investigated older adults' willingness to take part in special activities concerning fall prevention.

METHODS

Retrospectively, all patients over 70 years of age who received in-hospital fracture treatment between July 2014 and April 2016 were analyzed at a level I trauma center. After identification of 884 patients, participants completed a short questionnaire (47 questions, yes/no, Likert scale) comprising the AFPS. A history of falls in the past year was considered an indicator of a balance disorder. In addition, ambulant patients were invited to participate between July and August 2016.

RESULTS

In total, 201 patients (mean 80.4 years, range 63-97 years) performed a self-assessment based on the AFPS. After steps 1 and 2 of the AFPS had been completed, 95 (47%) participants rated their subjective risk of falling as high (more than 5 points). Of the participants 84 (42%) were objectively classified as "fallers" with significant effects on their AFPS evaluation and rating of their subjective risk of falling. Furthermore, 67% of the participants identified a general practitioner as their main contact person, and 43% of the respondents viewed the AFPS as a beneficial screening tool in fall risk evaluation (8% negative attitudes). Only 12% of the participants could imagine using the AFPS app version as a feasible option.

CONCLUSION

It would be advantageous to pretest at-risk individuals in their environment using a simple self-assessment approach, with the main purpose of identifying potential balance problems. With this approach, cost savings in the healthcare system are possible, combined with a higher health-related quality of life in the geriatric population.

Falls After Hospital Discharge: A Randomized Clinical Trial of Individualized Multimodal Falls Prevention Education

BACKGROUND

Older people are at high risk of falls after hospital discharge. The study aimed to evaluate the effect of providing individualized falls prevention education in addition to usual care on falls rates in older people after hospital discharge compared to providing a social intervention in addition to usual care.

METHODS

A randomized clinical trial at three hospitals in Western Australia: participants followed for 6 months after discharge. Baseline and outcomes measured by assessors masked to group allocation. Participants: aged 60 years and over, admitted for rehabilitation. Eligibility included: cognitively able to undertake education (Abbreviated mental test score >7/10). Intervention: tailored education comprising patient video and workbook, structured discussion and goal setting led by trained therapist. Main outcomes: falls in the 6 months after discharge; proportion of participants sustaining one or more falls.

RESULTS

There were 382 (194 intervention; 188 control) participants (mean age 77.7 [SD 8.7] years). There were 378 falls (fall rate per 1,000 patient-days, 5.9 intervention; 5.9 control) reported by 164 (42.9%) participants in the 6 months following hospital discharge; 188 (49.7%) of these falls were injurious. There were no significant differences in falls rates between intervention and control groups: (adjusted IRR, 1.09; 95% CI [0.78 to 1.52]) or the proportion of participants who fell once or more (adjusted OR, 1.37; 95% CI [0.90 to 2.07]).

CONCLUSIONS

Providing individualized falls prevention education prior to discharge did not reduce falls at home after discharge. Further research is warranted to investigate how to reduce falls during this high-risk transition period.

Exploring purpose-designed audio-visual falls prevention messages on older people's capability and motivation to prevent falls

The number of falls and fall-associated injury rates among older people continues to rise worldwide. Increased efforts to influence older people's falls prevention behaviour are needed. A two-phase exploratory community-based participatory study was conducted in Western Australia. First, three prototype audio-visual (AV) falls prevention messages were designed collaboratively with six older people. Second, the messages' effect on community-dwelling older people's knowledge, awareness and motivation to take action regarding falls prevention was explored using focus groups. Data were analysed using thematic analysis to explore participants' responses to the messages. The participants' (n = 54) perspectives on the AV messages varied widely and stereotypes of ageing appeared to influence these. The presented falls facts (including falls epidemiology statistics) increased some participants' falls risk awareness and falls prevention knowledge. Other participants felt ready-to-use falls prevention information was lacking. Some expressed positive emotions or a personal connection to the messages and suggested the messages helped reduce ageing-related stigma. Strongly opposing viewpoints suggested that other participants identified implicit negative messages about ageing, which reduced their motivation with the messages. Suggestions to improve the message persuasiveness included adding more drama and tailoring messages to appeal to multiple age groups. Overall, the AV falls prevention messages designed in collaboration with older people elicited a divergent range of positive and negative perspectives from their peers, which was conceptualised by the overarching theme 'we all look at things different ways'. Opinions differed regarding whether the messages would appeal to older people. Public campaigns targeting falls prevention should be designed and tailored towards older peoples' differing perspectives about ageing.

The relationship between discharge medications and falls in post-hospitalised older adults: A 6-month follow-up

OBJECTIVE

To identify discharge medications, especially psychotropic medications that are associated with falls, amongst older adults within 6 months following hospitalisation.

METHODS

Negative binomial regression was used to examine relationships between discharge medications and falls in older post-hospitalised adults. Multiple regression that considered falls risk factors at discharge was performed.

RESULTS

Data for 267 participants showed that discharge medications were not independently associated with falls postdischarge after adjustment for other falls risk factors. Male gender (adjusted incidence rate ratio [95% confidence interval, CI]) 2.15 [1.36-3.40]), higher depression scores (1.14 [1.05-1.25]) and co-morbidity of neurological disease other than stroke (5.98 [3.08-11.60]) were independently associated with an increased rate of falls. Higher depression scores (1.20 [1.11-1.31]) and co-morbidity of cancer (1.97 [1.20-3.25]) were independently associated with an increased rate of injurious falls in the 6 months postdischarge.

CONCLUSION

Falls prevention strategies, other than hospital discharge medication management in the postdischarge older adults, warrant investigation.

To manage a complex dependency: The experience of caregiving after a fall

AIM

To understand the experience of family members of an older relative who has had a fall which required medical attention.

BACKGROUND

There is abundant bibliography in caregiving, but little is known about the problems faced by caregivers and how family members cope when their older relative has a fall.

DESIGN

Qualitative study that used a symbolic interactionism perspective.

METHODS

Twenty-two people with older relatives, who had had a fall and contacted health services in Spain, participated in the study. Data were obtained via written accounts, focus groups, and semi-structured interviews between February 2014 - December 2015. Analysis was guided by grounded theory procedures.

RESULTS

With the fall, dependency becomes a complex issue for the family. To manage a complex dependency is the core issue that emerges from the data analysis. It depicts family efforts to assist their relative in gaining autonomy after a fall, in the best conditions they can provide. They do this with little guidance and support from healthcare professionals.

CONCLUSIONS

Guides and protocols for the care of a fragile older person, particularly after a fall, should not only include care but also support to caregivers. Health professionals and especially nurses need to be aware and respond to the family caregivers needs after a fall. To the fall prevention initiatives already in place, it must be added that those who support family members to cope with the care of an older person who has had a fall.

Hospital readmission risks in older adults following inpatient subacute care: A six-month follow-up study

BACKGROUND

High rates of unplanned hospital readmissions are a burden on healthcare systems and individuals. This study examined factors at, and after initial hospital discharge and their associations with unplanned hospital readmission for older adults up to six months post-discharge from subacute care.

METHODS

Older subacute care patients were surveyed prior to discharge, and assessed monthly post-discharge for six months. Data included the Geriatric Depression Scale, Phone-Fitt sub-scales, Friendship Scale, modified Lubben Social Network Scale, unplanned hospital readmission, self-reported physical capacity and falls in the last month were collected. Regression analyses were used to examine relationships between unplanned hospital readmission and variables that may predispose this outcome.

RESULTS

Participants (n = 311) completed the baseline assessment. N = 218 (70%) completed all at six-month post-discharge. Eighty-nine (29%) participants shared 143 readmissions. Those with cancer history (adjusted OR [95% CI]) (1.97 [1.15, 3.39]), neurological disease other than stroke (2.95 [1.32, 6.57]) and dependence on others to assist in bending tasks (1.94 [1.14, 3.29]) at initial discharge were associated with readmission within six months post-discharge. Those who fell in the last month (adjusted OR [robust 95% CI]) (2.28 [1.43, 3.64]), being less physical active (0.98 [0.96, 0.99]), and dependence on others in moving around residence (2.63 [1.37, 5.06]) after initial discharge were associated with a readmission in the next month within six months post-discharge.

CONCLUSION

Trials investigating the effectiveness of strategies to reduce falls, build physical capacity, increase physical activity level, and connection with health care services after discharge to prevent readmission are warranted.

Conceptual definitions of indicators for the nursing outcome "Knowledge: Fall Prevention"

ABSTRACT Objective: to construct conceptual definitions for indicators of nursing outcome Knowledge: Fall Prevention, selected for evaluation of hospitalized patients with the nursing diagnosis Risk for falls. Method: integrative literature review performed in the LILACS, MEDLINE and Web of Science databases, comprising articles published in English, Spanish and Portuguese languages from 2005 to 2015. Results: the final sample of the study was composed of 17 articles. The conceptualizations were constructed for 14 indicators of nursing outcome Knowledge: Fall Prevention focused on hospitalized patients. Conclusion: the theoretical support of the Nursing Outcomes Classification (NOC), through the process of constructing the conceptual definitions of the indicators of its results, allows nurses to accurately implement this classification in clinical practice and to evaluate the effectiveness of their interventions through the change of the patients' status over time.

Crossing a Line: A narrative of risk-taking by older women serving as caregivers

BACKGROUND

Caregiving carried out by adults for other adults is increasing around the world as the demographics of many industrialized countries shift toward an older population with escalating care needs toward the end of life. Although much has been written about caregiving, few studies document the experiences of providing care as narrated by the caregivers.

AIM

To explore the everyday experiences of older adults serving as primary informal caregivers to significant others.

METHODS

A process of narrative inquiry was used via repeated interviews with three older women caregivers providing care to family members or friends. The data were analyzed using storyboarding techniques and identifying critical turning points, culminating in a poetic transcription of the resulting narrative.

RESULTS

These caregivers describe a tension that exists across their experiences and communication with authorities on whom they rely for guidance and collaboration. Situations in which this tension pushes the caregivers to act in ways that represent risk to themselves or their care recipients are central to the collective narrative.

CONCLUSION AND SIGNIFICANCE

The everyday experiences of older adult caregivers include not only familiar care routines, but also advocacy on behalf of care recipients and negotiations with external authorities, resulting at times in unwelcome risk-taking. Their narrative warrants attention due to the lack of power described by caregivers when acting on behalf of their care recipients and the need for those in authority to recognize their dilemma.

Barriers and enablers to the implementation of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomised controlled trial

Evidence for effective falls prevention interventions in acute wards is limited. One reason for this may be suboptimal program implementation. This study aimed to identify perceived barriers and enablers of the implementation of the 6-PACK falls prevention program to inform the implementation in a randomised controlled trial. Strategies to optimise successful implementation of 6-PACK were also sought. A mixed-methods approach was applied in 24 acute wards from 6 Australian hospitals. Participants were nurses working on participating wards and senior hospital staff including Nurse Unit Managers; senior physicians; Directors of Nursing; and senior personnel involved in quality and safety or falls prevention. Information on barriers and enablers of 6-PACK implementation was obtained through surveys, focus groups and interviews. Questions reflected the COM-B framework that includes three behaviour change constructs of: capability, opportunity and motivation. Focus group and interview data were analysed thematically, and survey data descriptively. The survey response rate was 60% (420/702), and 12 focus groups (n = 96 nurses) and 24 interviews with senior staff were conducted. Capability barriers included beliefs that falls could not be prevented; and limited knowledge on falls prevention in patients with complex care needs (e.g. cognitive impairment). Capability enablers included education and training, particularly face to face case study based approaches. Lack of resources was identified as an opportunity barrier. Leadership, champions and using data to drive practice change were recognised as opportunity enablers. Motivation barriers included complacency and lack of ownership in falls prevention efforts. Motivation enablers included senior staff articulating clear goals and a commitment to falls prevention; and use of reminders, audits and feedback. The information gained from this study suggests that regular practical face-to-face education and training for nurses; provision of equipment; audit, reminders and feedback; leadership and champions; and the provision of falls data is key to successful falls prevention program implementation in acute hospitals.

Reducing falls after hospital discharge: a protocol for a randomised controlled trial evaluating an individualised multimodal falls education programme for older adults

INTRODUCTION

Older adults frequently fall after discharge from hospital. Older people may have low self-perceived risk of falls and poor knowledge about falls prevention. The primary aim of the study is to evaluate the effect of providing tailored falls prevention education in addition to usual care on falls rates in older people after discharge from hospital compared to providing a social intervention in addition to usual care.

METHODS AND ANALYSES

The 'Back to My Best' study is a multisite, single blind, parallel-group randomised controlled trial with blinded outcome assessment and intention-to-treat analysis, adhering to CONSORT guidelines. Patients (n=390) (aged 60 years or older; score more than 7/10 on the Abbreviated Mental Test Score; discharged to community settings) from aged care rehabilitation wards in three hospitals will be recruited and randomly assigned to one of two groups. Participants allocated to the control group shall receive usual care plus a social visit. Participants allocated to the experimental group shall receive usual care and a falls prevention programme incorporating a video, workbook and individualised follow-up from an expert health professional to foster capability and motivation to engage in falls prevention strategies. The primary outcome is falls rates in the first 6 months after discharge, analysed using negative binomial regression with adjustment for participant's length of observation in the study. Secondary outcomes are injurious falls rates, the proportion of people who become fallers, functional status and health-related quality of life. Healthcare resource use will be captured from four sources for 6 months after discharge. The study is powered to detect a 30% relative reduction in the rate of falls (negative binomial incidence ratio 0.70) for a control rate of 0.80 falls per person over 6 months.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and at conferences worldwide. This study is approved by hospital and university Human Research Ethics Committees.

TRIAL REGISTRATION NUMBER

ACTRN12615000784516.

'It promoted a positive culture around falls prevention': staff response to a patient education programme-a qualitative evaluation

OBJECTIVES

The purpose of this study was to understand how staff responded to individualised patient falls prevention education delivered as part of a cluster randomised trial, including how they perceived the education contributed to falls prevention on their wards.

DESIGN

A qualitative explanatory study.

METHODS

5 focus groups were conducted at participatory hospital sites. The purposive sample of clinical staff (including nurses, physiotherapists and quality improvement staff) worked on aged care rehabilitation wards when a cluster randomised trial evaluating a patient education programme was conducted. During the intervention period, an educator, who was a trained health professional and not a member of staff, provided individualised falls prevention education to patients with good levels of cognition (Mini-Mental State Examination >23/30). Clinical staff were provided with training to support the programme and their feedback was sought after the trial concluded, to understand how they perceived the programme impacted on falls prevention. Data were thematically analysed using NVivo qualitative data analysis software.

RESULTS

5 focus groups were conducted at different hospitals (n=30 participants). Staff perceived that the education created a positive culture around falls prevention and further, facilitated teamwork, whereby patients and staff worked together to address falls prevention. The educator was perceived to be a valuable member of the team. Staff reported that they developed increased knowledge and awareness about creating a safe ward environment. Patients being proactive and empowered to engage in falls prevention strategies, such as ringing the bell for assistance, was viewed as supporting staff falls prevention efforts and motivating staff to change practice.

CONCLUSIONS

Staff responded positively to patient falls prevention education being delivered on their wards. Providing individualised patient education to older patients with good levels of cognition can empower staff and patients to work as a team to address falls prevention on hospital rehabilitation wards.

'My independent streak may get in the way': how older adults respond to falls prevention education in hospital

OBJECTIVES

The aim of the study was to determine how providing individualised falls prevention education facilitated behaviour change from the perspective of older hospital patients on rehabilitation wards and what barriers they identified to engaging in preventive strategies.

DESIGN

A prospective qualitative survey.

METHODS

Older patients (n=757) who were eligible (mini-mental state examination score>23/30) received falls prevention education while admitted to eight rehabilitation hospital wards in Western Australia. Subsequently, 610 participants were surveyed using a semistructured questionnaire to gain their response to the in-hospital education and their identified barriers to engaging in falls prevention strategies. Deductive content analysis was used to map responses against conceptual frameworks of health behaviour change and risk taking.

RESULTS

Participants who responded (n=473) stated that the education raised their awareness, knowledge and confidence to actively engage in falls prevention strategies, such as asking for assistance prior to mobilising. Participants' thoughts and feelings about their recovery were the main barriers they identified to engaging in safe strategies, including feeling overconfident or desiring to be independent and thinking that staff would be delayed in providing assistance. The most common task identified as potentially leading to risk-taking behaviour was needing to use the toilet.

CONCLUSIONS

Individualised education assists older hospital rehabilitation patients with good levels of cognition to engage in suitable falls prevention strategies while on the ward. Staff should engage with patients to understand their perceptions about their recovery and support patients to take an active role in planning their rehabilitation.

Development and Evaluation of an Online Fall-Risk Questionnaire for Nonfrail Community-Dwelling Elderly Persons: A Pilot Study

Introduction. Falls are frequent in older adults and may have serious consequences but awareness of fall-risk is often low. A questionnaire might raise awareness of fall-risk; therefore we set out to construct and test such a questionnaire. Methods. Fall-risk factors and their odds ratios were extracted from meta-analyses and a questionnaire was devised to cover these risk factors. A formula to estimate the probability of future falls was set up using the extracted odds ratios. The understandability of the questionnaire and discrimination and calibration of the prediction formula were tested in a cohort study with a six-month follow-up. Community-dwelling persons over 60 years were recruited by an e-mail snowball-sampling method. Results and Discussion. We included 134 persons. Response rates for the monthly fall-related follow-up varied between the months and ranged from low 38% to high 90%. The proportion of present risk factors was low. Twenty-five participants reported falls. Discrimination was moderate (AUC: 0.67, 95% CI 0.54 to 0.81). The understandability, with the exception of five questions, was good. The wording of the questions needs to be improved and measures to increase the monthly response rates are needed before test-retest reliability and final predictive value can be assessed.

How older adults would like falls prevention information delivered: fresh insights from a World Café forum

Translation of falls prevention evidence into practice is problematic. Understanding older adults’ views about falls prevention information could enhance delivery of falls prevention, resulting in better engagement and uptake of recommended activities. The aim of this study was to examine the views and preferences of community-dwelling older adults about seeking and receiving falls prevention information. A community forum using a modified World Café approach was conducted. Participants discussed five topic areas in small groups, under the guidance of table facilitators. Perspectives were captured on paper. Thematic analysis was conducted to identify factors that influence participants’ engagement and uptake of information. Seventy-three older adults participated in the forum covering wide-ranging preferences around falls prevention information. Personal experience was considered the key influence on an older adult's decision to initiate seeking information. While health professionals were often approached, alternative sources such as public libraries, peer educators and seniors’ organisations were also favoured as credible sources of information. Older adults proposed falls prevention information should be delivered with a positive tone, coupled with highly valued qualities of respect, empathy and time to listen to foster motivation to engage in recommended activities. Consumer-focused practical strategies were proposed to potentially improve future design, communication and dissemination of falls prevention information. This improvement could enhance engagement of messages and subsequent uptake of falls prevention recommended strategies.

Educators' perspectives about how older hospital patients can engage in a falls prevention education programme: a qualitative process evaluation

OBJECTIVES

Falls are the most frequent adverse event reported in hospitals. Patient and staff education delivered by trained educators significantly reduced falls and injurious falls in an older rehabilitation population. The purpose of the study was to explore the educators' perspectives of delivering the education and to conceptualise how the programme worked to prevent falls among older patients who received the education.

DESIGN

A qualitative exploratory study.

METHODS

Data were gathered from three sources: conducting a focus group and an interview (n=10 educators), written educator notes and reflective researcher field notes based on interactions with the educators during the primary study. The educators delivered the programme on eight rehabilitation wards for periods of between 10 and 40 weeks. They provided older patients with individualised education to engage in falls prevention and provided staff with education to support patient actions. Data were thematically analysed and presented using a conceptual framework.

RESULTS

Falls prevention education led to mutual understanding between staff and patients which assisted patients to engage in falls prevention behaviours. Mutual understanding was derived from the following observations: the educators perceived that they could facilitate an effective three-way interaction between staff actions, patient actions and the ward environment which led to behaviour change on the wards. This included engaging with staff and patients, and assisting them to reconcile differing perspectives about falls prevention behaviours.

CONCLUSIONS

Individualised falls prevention education effectively provides patients who receive it with the capability and motivation to develop and undertake behavioural strategies that reduce their falls, if supported by staff and the ward environment.

Development of an Automated Self-assessment of Fall Risk Questionnaire for Hospitalized Patients

Falls in hospital settings continue to challenge health care providers. Multifactorial interventions aim to reduce falls but rarely involve the patient as an active participant. A patient self-assessment of fall risk questionnaire was customized in the hospital's computer-based, television-equipped, interactive patient care system. Designed to engage patients in determining their risk for falling, the questionnaire is a reliable and valid means for patients and nurses to assess risk of falls.

Elder and caregiver solutions to improve medication adherence

Medication mismanagement is a growing public health concern, especially among elders. Annually, it is a major contributor to emergency hospitalization and nursing home placement. Elders and their caregivers, as healthcare consumers and stakeholders in this issue, are uniquely qualified to inform strategies to improve medication adherence. We conducted a qualitative study to ascertain caregiver and elder perceptions of barriers to medication management and to identify community-derived solutions to improve medication management. Nine focus groups (N = 65, mean age = 71) were conducted with caregivers or elders from five communities. Participants were recruited by key informants utilizing snowball sampling methodology. The following themes were identified in the participant-recommended proposed solutions improving medication adherence: (i) use of personal systems to overcome barriers to medication adherence, (ii) various solutions to address cost concerns, (iii) the need for regular review of medications by doctors or pharmacists to eliminate unnecessary medications, (iv) desire for community-driven support systems, and (v) using medical advocates. Elders and caregivers recognized medication non-adherence as a community-wide issue and were eager to offer solutions they thought would work in their communities. These solutions can lend credibility to strategies currently being developed/utilized and offer innovative recommendations for future interventions.

What factors influence community-dwelling older people's intent to undertake multifactorial fall prevention programs?

Purpose

To investigate previous, current, or planned participation in, and perceptions toward, multifactorial fall prevention programs such as those delivered through a falls clinic in the community setting, and to identify factors influencing older people’s intent to undertake these interventions.

Design and methods

Community-dwelling people aged >70 years completed a telephone survey. Participants were randomly selected from an electronic residential telephone listing, but purposeful sampling was used to include equal numbers with and without common chronic health conditions associated with fall-related hospitalization. The survey included scenarios for fall prevention interventions, including assessment/multifactorial interventions, such as those delivered through a falls clinic. Participants were asked about previous exposure to, or intent to participate in, the interventions. A path model analysis was used to identify factors associated with intent to participate in assessment/multifactorial interventions.

Results

Thirty of 376 participants (8.0%) reported exposure to a multifactorial falls clinic-type intervention in the past 5 years, and 16.0% expressed intention to undertake this intervention. Of the 132 participants who reported one or more falls in the past 12 months, over one-third were undecided or disagreed that a falls clinic type of intervention would be of benefit to them. Four elements from the theoretical model positively influenced intention to participate in the intervention: personal perception of intervention effectiveness, self-perceived risk of falls, self-perceived risk of injury, and inability to walk up/down steps without a handrail (P<0.05).

Conclusion

Multifactorial falls clinic-type interventions are not commonly accessed or considered as intended fall prevention approaches among community-dwelling older people, even among those with falls in the past 12 months. Factors identified as influencing intention to undertake these interventions may be useful in promoting or targeting these interventions.

Depressive symptoms and adverse outcomes from hospitalization in older adults: secondary outcomes of a trial of falls prevention education

Depression is common in older people and symptoms of depression are known to substantially increase during hospitalization. There is little known about predictors of depressive symptoms in older adults or impact of common interventions during hospitalization. This study aimed to describe the magnitude of depressive symptoms, shift of depressive symptoms and the impact of the symptoms of depression among older hospital patients during hospital admission and identify whether exposure to falls prevention education affected symptoms of depression. Participants (n=1206) were older adults admitted within two Australian hospitals, the majority of participants completed the Geriatric Depression Scale - Short Form (GDS) at admission (n=1168). Participants' mean age was 74.7 (±SD 11) years and 47% (n=551) were male. At admission 53% (619 out of 1168) of participants had symptoms of clinical depression and symptoms remained at the same level at discharge for 55% (543 out of 987). Those exposed to the low intensity education program had higher GDS scores at discharge than those in the control group (low intensity vs control n=652, adjusted regression coefficient (95% CI)=0.24 (0.02, 0.45), p=0.03). The only factor other than admission level of depression that affected depressive symptoms change was if the participant was worried about falling. Older patients frequently present with symptoms of clinical depression on admission to hospital. Future research should consider these factors, whether these are modifiable and whether treatment may influence outcomes.