Falls prevention interventions for community-dwelling older people living in mainland China: a narrative systematic review

Using a participatory design to develop an implementation framework for integrating falls prevention for older people within the Chinese primary health care system

BACKGROUND

Chinese National Essential Public Health Service Package (NEPHSP) has mandated primary health care providers to provide falls prevention for community-dwelling older people. But no implementation framework is available to guide better integration of falls prevention for older people within the primary health care system.

METHODS

This is a two-stage online participatory design study consisting of eight workshops with stakeholders from three purposively selected cities. First, two workshops were organised at each study site to jointly develop the framework prototype. Second, to refine, optimise and finalise the prototype via two workshops with all study participants. Data analysis and synthesis occurred concurrently with data collection, supported by Tencent Cloud Meeting software.

RESULTS

All participants confirmed that the integration of falls prevention for older people within the NEPHSP was weak and reached a consensus on five opportunities to better integrate falls prevention, including workforce training, community health promotion, health check-ups, health education and scheduled follow-up, during the delivery of NEPHSP. Three regional-tailored prototypes were then jointly developed and further synthesised into a generic implementation framework by researchers and end-users. Guided by this framework, 11 implementation strategies were co-developed under five themes.

CONCLUSIONS

The current integration of falls prevention in the NEPHSP is weak. Five opportunities for integrating falls prevention in the NEPHSP and a five-themed implementation framework with strategies are co-identified and developed, using a participatory design approach. These findings may also provide other regions or countries, facing similar challenges, with insights for promoting falls prevention for older people.

The direct and mediating effects of cognitive impairment on the occurrence of falls: a cohort study based on community-dwelling old adults

Background

Cognitive impairment has been reported to be associated with falls in older adults. However, the complex relationship among falls, cognitive impairment and its associated factors, which could be targeted with specific interventions, remains to be elucidated. This study aimed to examine the direct effects of cognitive impairment on falls, to identify the factors associated with cognitive impairment and to explore the mediation role of cognitive impairment in the association of fall with cognition related factors.

Methods

This 1-year follow-up cohort study enrolled old adults aged 60  years or over. Information about demographic and anthropometric characteristics, fall outcomes, function and nutritional status were collected through face-to-face interview. Cognitive function was evaluated by the Montreal Cognitive Assessment (MoCA). Multivariable regression analyses were used to test the association between cognitive impairment and falls and to identify the factors related to cognitive impairment. Additionally, we conduct causal mediation analyses to estimate the mediation effects of cognitive impairment in the pathways of fall occurrence.

Results

Of the 569 participants included in this study, 366 (64.32%) had cognitive impairment, 96 (16.87%) had fall history in the past 1  year, 81 (14.24%) experienced fall and 47 (8.26%) received treatment because of falling during the 1-year follow-up. The association between cognitive impairment and 1-year fall risk was confirmed after adjusting for multiple covariates [odds ratio (OR):2.03, 95% confidence interval (CI): 1.13-3.80]. IADL disability, depression and low grip strength were associated with a higher prevalence of cognitive impairment. While overweight, higher education and higher income level were found to be related to a lower risk of cognitive impairment. Among these associated factors, cognitive impairment mediated the positive association of falling with IADL ability and depression, and a negative relationship with education and income level.

Conclusion

Our study not only confirmed the direct influence of cognitive impairment on fall risk in older adults, but also suggested a mediating role that cognitive impairment played in the pathways of fall occurrence. Our finding could help develop more specific interventions for fall prevention.

Characteristics of falls among older hip fracture patients from six Chinese hospitals: a post-hoc descriptive analysis

BACKGROUND

There is well-established evidence to understand the characteristics of falls among the older patients with hip fracture in many countries, but very little knowledge existed in China. This study described the characteristics of falls in older patients with hip fractures from six Chinese hospitals.

METHODS

This cross-sectional study is a post-hoc descriptive analysis of a recently completed trial. Eligible patients were aged 65 years and older, with confirmed hip fractures due to falls, and were admitted to the hospital within 21 days of the fracture. All patients were consecutively enrolled and screened within one year (November 15, 2018, to November 14, 2019). The collected data included patient demographics and fall-related information.

RESULTS

A total of 1,892 patients' fall-related information were described. Most patients with hip fractures caused by falls were in the oldest old age group (60.4% in age group ≥ 80), with an overall average age of 80.7 (7.6) years. There were more females (n = 1,325, 70.0%) than males (n = 567, 30.0%). The majority lived in urban (n = 1,409, 74.5%). Most falls (n = 1,237, 67.3%) occurred during the daytime (6:01-18:00). There were 1,451 patients had their falls occurring at home (76.7%). Lost balance (n = 1,031, 54.5%) was reported as the primary reason to cause falls. The most common activity during a fall was walking (n = 1,079, 57.0%).

CONCLUSIONS

Although the incidence of fall-related hip fractures in China is unclear, preventing falls and fall-related hip fractures in older people remains an urgent health concern as the ageing society increases. Studies with larger sample size and diverse population are needed to robustly understand this growing epidemic.

Cross-sectional study on prevalence and risk factors for falls among the elderly in communities of Guangdong province, China

OBJECTIVE

This study aims to investigate the prevalence and risk factors of falls among the elderly in Guangdong, China.

METHODS

A cross-sectional study was conducted in six communities of Guangdong province. People over 60 years old were selected with multistage random-cluster sampling. Data on falls within the previous 12 months and fall-related risk factors were collected through a face-to-face interview.

RESULTS

The prevalence of falls among older adults was 11.9% (95% CI: 11.0% to 12.8%) among 5374 interviewees. The common injuries caused by falls were bruises/scrapes (40.0%) and fractures (15.5%), and most people fall while doing housework (35.0%). Univariate analysis showed that 14 factors were associated with falls among older adults, including gender, age, residence, occupation, education level, balance ability, situation of cognition, disease, depression, living arrangement, marital status, the behaviour of exercise, drinking and drug use (p<0.05). Multivariate analysis showed that the associated factors of falls among older adults included woman (OR=1.68, 95% CI: 1.40 to 2.02), age from 70 to 79 years (OR=1.31, 95% CI: 1.09 to 1.58), age over 80 (OR=1.63, 95% CI: 1.25 to 2.13), impaired balance ability (OR=1.45, 95% CI: 1.20 to 1.75), exercise several times per month (OR=1.69, 95% CI: 1.13 to 2.53), polypharmacy (OR=1.54, 95% CI: 1.19 to 2.00), cognition impairment (OR=1.35, 95% CI: 1.08 to 1.69), mild depression (OR=1.89, 95% CI: 1.47 to 2.45) and moderate depression (OR=3.07, 95% CI: 1.99 to 4.73).

CONCLUSIONS

The hazards caused by falls to the elderly in China cannot be ignored. A multidimensional customised fall prevention programme should be considered to reduce the risk of falls among the elderly based on the results above.

Perceptions of Facilitators and Barriers to Implementation of Falls Prevention Programs in Primary Health Care Settings in China

IMPORTANCE

Falls have become a major public health issue in China with population aging. Although falls prevention for older community-dwelling people has been included in the National Essential Public Health Service Package since 2009, there is limited understanding of the implementation of this program.

OBJECTIVE

To identify the associated factors and provide recommendations to inform the better implementation of falls prevention in the Chinese primary health care system.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted in 3 purposively selected cities in China from March 1 to June 7, 2021. Health administrators from the local health commission or bureau, staff members from local Centers for Disease Control and Prevention and primary health care facilities and community-dwelling older people were recruited, using a combination of purposive sampling and snowball sampling.

MAIN OUTCOMES AND MEASURES

In-depth interviews were conducted with health administrators and focus groups with other participants. Data analysis followed the guidance of the Consolidated Framework for Implementation Research. Study outcomes included facilitators and barriers of implementing falls prevention for older people in the Chinese primary health care settings. A framework with recommendations was developed to inform the future intervention implementation.

RESULTS

Among a total of 130 participants interviewed, 77 (59.2%) were female and the mean (SD) age was 47.4 (16.7) years. Clear recognition of the challenges and benefits of falls prevention, adaptive regionally tailored guidance plans, and continuous governmental policy and financial support were the major facilitators, whereas the major barriers consisted of insufficient confidence in delivering interventions and poor understanding of the falls burden, low recognition of the importance of falls prevention, limited multisectoral collaboration, and weak financial incentives. A 7-strategy embedded framework-including data-driven surveillance, audit and feedback, implementation strategy, workforce strengthening, community empowerment, internal services integration, and external enabling environment-was developed to foster successful implementation.

CONCLUSIONS AND RELEVANCE

This qualitative study identified major facilitators and barriers to the implementation of falls prevention for older people at the primary care level, which have the potential to contribute to better implementation of falls prevention for older people in the Chinese primary health care system.

Effects of Nurse-Led Fall Prevention Programs for Older Adults: A Systematic Review

Falls among older adults are preventable events and fall prevention programs led by nursing staff are promising and viable programs for preventing falls. This systematic review aimed to gain insight into the effects of nurse-led fall prevention programs for older adults. The Preferred Reporting Items for Systemic Reviews and Meta-Analysis was used as a guideline in reporting this literature search conducted through CINAHL, MEDLINE, Eric, Science Direct, and Google Scholar databases. The Johns Hopkins Nursing Evidence-Based Practice was used to determine the level of evidence and quality rating of the articles, while data extraction was done by a matrix review method. The review included six randomized controlled trials, two non-randomized controlled trials, and three quasi-experimental designs. Six studies directed their education component of the intervention on the nursing staff, while three focused on the older participants. Nurses' roles were patient assessment, patient education, administration of exercise programs, and follow-up post interventions. Fall rates and fall incidents were reduced in five studies, while three studies changed patients' behavior. Fall prevention programs with education components specific for older adults and nursing staff resulted in positive outcomes. Nursing staff make a significant contribution to improving patients' outcomes, and a fall prevention program that focuses on reducing injurious fall rates and enhancing participants' behavior could maximize its effects.

Burden of falls among people aged 60 years and older in mainland China, 1990-2019: findings from the Global Burden of Disease Study 2019

BACKGROUND

Falls in older people have become a major public health concern worldwide, but a comprehensive assessment of the burden of falls for older people in mainland China has not been done. We aimed to investigate the burden of falls among older people at the national and subnational level in mainland China, and explore the trends from 1990 to 2019, using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHOD

Using data from GBD 2019, we estimated the burden of falls among people aged 60 years and older by sex and age group in terms of incidence, mortality, and disability-adjusted life-year (DALY) rates and assessed these indicators at the subnational level in 31 geographical units (hereafter called provinces). We investigated the overall trend in the burden of falls across these 31 provinces from 1990 to 2019, and assessed the change in the burden of falls by sex, age group (60-64, 65-69, 70-74, 75-79, and ≥80 years), and province between 1990 and 2019.

FINDINGS

In 2019, in mainland China, the incidence rate of falls among people aged 60 years and older was 3799·4 (95% uncertainty interval [UI] 3062·4-4645·0) new falls per 100 000 population, and 39·2 deaths (21·8-48·8) per 100 000 population and 1238·9 DALYs (920·5-1553·2) per 100 000 population were due to falls. We found no significant difference in the burden of falls between males and females. The incidence, mortality, and DALY rates of falls for people aged 80 years and older were significantly higher than those in the other age groups, except for incidence rate, which was non-significantly different between the age 75-79 years group and the oldest age group. Large variations in the incidence and DALY rates of falls were observed across 31 provinces. Although between 1990 and 2019 we found no significant changes in overall mortality due to falls in all provinces and in DALY rates for 23 provinces (DALY rates significantly decreased in two provinces and increased in six provinces), we found large increases in the incidence rate of falls in both males (percentage change between 1990 and 2019: 82·9% [67·4-100]) and females (77·0% [63·3-91·8]). The percentage change in incidence rate of falls between 1990 and 2019 varied from 50·0% (42·2-59·5) for people aged 60-64 years to 123·8% (105·4-141·9) for people aged 80 years and older. All provinces had significant increases in the incidence rate of falls between 1990 and 2019, with Sichuan having the greatest increase (148·5% [125·5-171·4]) and Jilin the smallest increase (14·7% [3·6-26·1]).

INTERPRETATION

Between 1990 and 2019, the incidence rate of falls increased substantially in older adults across mainland China, whereas the rates of mortality and DALY of falls among older people remained relatively stable, suggesting improvements in outcomes of falls. Nevertheless, falls remain an ongoing health burden for older people in mainland China, and there is an urgent need to introduce system-wide, integrated, and cost-effective measures to protect and support older people to minimise their risks and combat an increasing absolute burden as the population continues ageing.

FUNDING

Bill & Melinda Gates Foundation.

Cognitive Frailty and Falls in a National Cohort of Older Chinese Inpatients

Previous studies have investigated the association between cognitive frailty and falls among older adults in community; however, no study investigated this relationship among older patients living in hospital. This study aimed to examine the relationship of cognitive frailty with falls among older inpatients in Chinese hospital.

METHODS

This analysis consisted of 9192 older inpatients aged 65 years or over from six hospitals in China. We used FRAIL scale and Mini-Cog to assess frailty and cognitive impairment, respectively. A generalized estimating equation was used to examine the relationship between cognitive frailty and falls at 30-day follow-up.

RESULTS

Among 9192 older inpatients enrolled in this present study, the mean (SD) age was 72.40(5.72) years, with 3850(41.88%) women. The cross-sectional analysis found that after controlling for variables (age, gender, education, depression, and hospital ward cluster effect), hospitalized patients with cognitive frailty, frailty only, or cognitive impairment only at baseline were all associated with history of falls (P<0.05). At 30-day follow-up, generalized estimating equation with full-adjustment showed that inpatients with cognitive frailty were at greater risk of falls than those of non-frail and cognitive intact (OR=3.0,95%CI:1.32-6.83). This association was also observed in individuals with frailty only (OR=2.11,95%CI:1.04-4.27) but not for patients with cognitive impairment only((OR=1.11,95%CI:0.43-2.85).

CONCLUSION

Our study suggested that hospitalized Chinese older adults with cognitive frailty were independently associated with falls. Early screening frailty and cognitive impairment were significant for older patients by clinicians, and corresponding interventions, exercise training and nutritional programs, should be implemented to prevent falls.

Mild cognitive impairment is associated with fall-related injury among adults aged ≥65 years in low- and middle-income countries

OBJECTIVES

There is a scarcity of data on the association between mild cognitive impairment (MCI) and falls, especially from low- and middle-income countries (LMICs) where 70% of all older adults reside. Thus, we investigated the association between MCI and fall-related injury among older adults residing in six LMICs (China, Ghana, India, Mexico, Russia, South Africa).

DESIGN

Cross-sectional, community-based data from the WHO Study on global AGEing and adult health (SAGE) were analyzed.

METHODS

The definition of MCI was based on the National Institute on Ageing-Alzheimer's Association criteria, and information on past 12-month fall-related injury was also collected. Multivariable logistic regression analysis was conducted to assess associations.

RESULTS

The analytical sample consisted of 13,623 individuals aged ≥65 years [mean (SD) age 72.3 (10.9) years; 45.6% males]. The prevalence of fall-related injury was higher among those with MCI (6.3%) vs. no MCI (4.1%). After adjustment for potential confounders, MCI was associated with a 1.53 (95%CI = 1.12-2.07) times higher odds for fall-related injury.

CONCLUSIONS

MCI was associated with higher odds for fall-related injury among older adults in LMICs. Future studies are warranted to investigate the mechanisms underlying this association and to elucidate whether targeting those with MCI can lead to reduced risk for falls among older adults.