Accidental Fall Rates in Community-Dwelling Adults Compared to Cancer Survivors During and Post-Treatment: A Systematic Review With Meta-Analysis

Remotely delivered exercise to older rural cancer survivors: a randomized controlled pilot trial

PURPOSE

The study aimed to determine the feasibility of remotely delivered exercise (tele-exercise) for older, rural cancer survivors and to explore the effects of tele-exercise on physical function, physical activity, and patient-reported outcomes.

METHODS

Participants were rural cancer survivors age ≥ 60 years (79% female; mean age 70.4 ± 5.7) randomly assigned to the remotely delivered EnhanceFitness (tele-EF) exercise program, inclusive of aerobic, strength, and balance training and led by American Council on Exercise certified instructors for 1 h, 3 days/week for 16 weeks (n = 20) or to a waitlist control group (n = 19). We assessed feasibility, physical function, accelerometer-measured physical activity, and patient-reported outcomes at baseline and post intervention.

RESULTS

Among those screened as eligible, 44 (64%) consented to participate with 39 randomized after completing baseline measures. Attrition was equivalent between groups (n = 1, each) with 95% completing the study. The median class attendance rate was 86.9% (interquartile range: 79-94%). Compared to controls, tele-EF participants had statistically significant improvement in the five-time sit-to-stand test (- 3.4 vs. - 1.1 s, p = 0.03, effect size = 0.44), mean daily light physical activity (+ 38.5 vs 0.5 min, p = 0.03, effect size = 0.72) and step counts (+ 1977 vs. 33, p = 0.01, effect size = 0.96). There were no changes in self-efficacy for exercise, fatigue, or sleep disturbance between groups.

CONCLUSIONS

Findings indicate that tele-EF is feasible in older, rural cancer survivors and results in positive changes in physical function and physical activity.

IMPLICATIONS FOR CANCER SURVIVORS

Tele-EF addresses common barriers to exercise for older, rural cancer survivors, including limited accessible opportunities for professional instruction and supervision.

Frailty in older Turkish cancer patients undergoing post-surgical adjuvant chemotherapy

Background:

Understanding the frailty levels of older patients undergoing surgery and chemotherapy will contribute to timely and reliable care practices and improve care outcomes.

Aims:

To determine the frailty of cancer patients who received chemotherapy treatment after surgery.

Methods:

This descriptive study included 192 Turkish patients aged over 60 years who received chemotherapy after surgery for cancer. Data were collected using a patient survey and the Edmonton Frailty Scale.

Results:

The average age of the participants was 66.3±5.3 years. Around 40% (40.6%) of the sample were diagnosed with breast cancer. The Edmonton Frailty Scale score of the group was 6.6 (SD±3.7). A quarter of the sample (22.9%) were at risk of frailty. Frailty levels were higher in older individuals with gastrointestinal cancers and other cancer groups compared with patients with breast cancer (p<0.001); patients with additional chronic diseases other than cancer (p=0.004); and in those with a history of falling and hospitalisation in the past year (p<0.001).

Conclusions:

Older patients with gastrointestinal cancer, additional chronic disease and a history of falling and hospitalisation within the past year should be evaluated closely for frailty before and during chemotherapy. It is crucial to consider the patient's vulnerability when making care and treatment decisions for older patients with cancer. Understanding the frailty levels of older patients who undergo surgery and receive chemotherapy can help health professionals to decide on timely and reliable care practices and improve care outcomes.

Falls in older ambulatory care patients with cancer in Iran: Implications for clinical practice

RATIONALE/AIM

Falls can have severe consequences particularly for older patients with cancer undergoing ambulatory care. The aim of the study is to identify the predictors of falls in older patients receiving cancer ambulatory care and evaluate the accuracy of the final multivariable model in detecting older patients with falls.

METHOD

A retrospective study was conducted on 300 older patients aged 60 years and above that were referred for ambulatory care in three oncology clinics based at hospitals in Tehran, Iran. Participants completed a questionnaire comprising demographic, history of falls, and cancer-related factors. Logistic regression was used to determine risk factors associated with falls.

RESULTS

A total of 35.3% of the older patients with cancer had experienced a fall in the 6 months following the start of their ambulatory care. The most important predictors of falls include the fourth stage of cancer (odds ratio [OR]: 6.47, 95% confidence interval [CI]: 3.20-13.08, p < 0.001), fear of falling (OR: 5.64, 95% CI: 2.58-12.33, p < 0.001), use of hearing (OR: 2.38, 95% CI: 1.07-5.29, p = 0.033) and visual aids (OR: 2.36, 95% CI: 1.12-5.01, p = 0.025), and the number of visits to the doctor (OR: 1.10, 95% CI: 1.01-1.21, p = 0.035).

CONCLUSIONS

The results indicate that a reduction in falls is possible by introducing strategies to improve care for older patients in the advanced stage of cancer, eliminating the causes of fear of falling, examining and improving vision and hearing, and identifying and addressing the underlying causes of visits to the doctor.

Screening recall in older cancer survivors detects differences in balance and mobility

PURPOSE

Cognitive impairments have been reported by up to two-thirds of cancer survivors whose primary cancer did not occur in the central nervous system. Physical impairments as sequelae of cancer-related cognitive impairment (CRCI) have not been well described in previous studies. Furthermore, there is scarcity of literature describing differences among physical performance in those with and without CRCI. The purpose of this study is to examine the differences in physical function of older cancer survivors based on cognitive ability to determine if physical performance differs when different cognitive screening measures are employed.

METHODS

Adults age 65 + with a history of cancer from the 2010 Health and Retirement Study (n = 1,953) were assigned to groups according to their cognitive ability. Between-group demographic, mobility, and cognitive differences were analyzed using chi-squared and t tests. Recall and orientation were used as cognitive variables, and physical performance outcomes included gait speed, balance, and grip strength.

RESULTS

Respondents with Low Recall had more impaired balance (semi-tandem, tandem) (p < .05) and slower gait speeds (p < .05). Respondents that were Not-Oriented had slower gait speed (p < .05). Between-group differences in demographics were found by recall and orientation groups.

CONCLUSIONS

Impairments in balance and gait speed are able to be detected when recall is screened in a population of older cancer survivors. When assessing how physical mobility is related to fall risk, a screen of cognition should go beyond just orientation.

Feasibility of a Remotely Delivered Strength and Balance Training Program for Older Adults with Cancer

Falls are a major issue among older adults with cancer and lead to interruptions in cancer treatment. Resistance and balance training can prevent falls in older adults, but minimal evidence is available regarding the older cancer population, who often have unique risk factors. We used a pre-post design to assess the feasibility of a remotely delivered exercise program that progressed in difficulty and its efficacy on lower body strength, balance, and falls in older adults with cancer who had prior in-person exercise experience. Twenty-six older adults with cancer completed the intervention. Attendance rate for the virtual component was 97.6% and for the independent component was 84.7%. Participants perceived the program as rewarding and enjoyable (100%), felt this program prepared them to exercise on their own (92%), were confident to continue exercising on their own (81%), and would recommend the program to other patients (100%). The median balance score at baseline and end-of-study was 4 (IQR = 0). The median chair-stand time decreased from 9.2 s (IQR = 3.13) to 7.7 s (IQR = 4.6). A statistically significant difference in lower body strength (r = 0.68, p = 0.001) was detected post-intervention. The findings from this study can inform the design of a larger randomized trial.

Exploring the Environment behind In-Patient Falls and Their Relation to Hospital Overcrowdedness-A Register-Based Observational Study

(1) Background: Inpatient falls are a serious threat to patients' safety and their extrinsic factors are, at present, insufficiently described. Additionally, hospital overcrowdedness is known for its malicious effects but its relation to the inpatient falls is currently underexplored. The aim of this study was to explore the distribution of falls and their extrinsic characteristics amongst a range of different clinics, and to explore the correlation and predictive ability of hospital overcrowding in relation to inpatient falls. (2) Methods: An observational, cross-sectional, registry-based study was conducted using retrospective data from an incidence registry of a hospital organization in Sweden during 2018. The registry provided data regarding the extrinsic factors of inpatient falls, including the clinics' overcrowdedness. Simple descriptive statistics, correlation analysis and simple linear regression analysis were used. (3) Results: Twelve clinics were included. A total of 870 inpatient falls were registered during 2018. Overcrowdedness and total amount of falls were positively and very strongly correlated (r = 0.875, p < 0.001). Overcrowdedness was a significant predictor of the total amount of inpatient falls (p < 0.001, α = 0.05). (4) Conclusions: The characteristics regarding inpatient falls vary among the clinics. Inpatient overcrowding might have a significant role in the prevalence of inpatient falls, but further high-evidence-level studies are required.

Patient-Reported Continuity of Care and Functional Safety Concerns After Inpatient Cancer Rehabilitation

BACKGROUND

Patients with cancer have been noted to have inadequate continuity of care after discharge from hospital. We sought to assess patient-reported continuity of care and functional safety concerns after acute inpatient rehabilitation.

METHODS

This was a prospective study that used cross-sectional surveys at a National Cancer Institute Comprehensive Cancer Center. All patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, met the inclusion criteria, and completed two surveys (assessing continuity of care and functional safety concerns) upon discharge and 1 month after discharge were included in the study.

RESULTS

A total of 198 patients completed the study, and no major concerns were reported by the patients. The greatest concern was a lack of adequate communication management among different providers, reported by only 10 (5.0%) patients. The combined fall and near-fall rate within 1 month after discharge was (25/198) 13%. Brain metastasis, a comorbidity of depression, and a history of falls were significantly associated with a higher risk of falls or near falls within 1 month after discharge.

CONCLUSION

Although overall patients with cancer reported adequate continuity of care and feeling safe to function at home after acute inpatient rehabilitation, it is important to be aware that fall or near-fall events within 1 month after acute inpatient rehabilitation are associated with brain metastasis, comorbidity of depression, and a history of falls. Thus, patients with these risk factors may benefit from including more focused fall prevention education and interventions.

IMPLICATIONS FOR PRACTICE

Patients with cancer often have extensive problems that require care from multiple health care providers simultaneously, and a high level of coordination is needed for adequate transition of care from the inpatient to the outpatient setting. This transition of care period is prone to inadequate continuity of care and, for older adults, a particular risk for falls. Assessment for risk of fall is also an important factor to consider when evaluating patients to continue oncology treatments. There is a gap in knowledge regarding patient-reported continuity of care and functional safety concerns after acute inpatient cancer rehabilitation.

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

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

Physical exercise for bone health in men with prostate cancer receiving androgen deprivation therapy: a systematic review

PURPOSE

Androgen deprivation therapy (ADT) is a treatment used in men with prostate cancer (PCa); however it is responsible for many adverse effects, with negative impact on quality of life. ADT causes loss of bone mineral density (BMD) and skeletal muscle mass, alteration of body composition, and cognitive function, which altogether lead to increased risk of accidental falls and fractures. This systematic review analyses the effectiveness of physical exercise (PE) in preventing accidental falls and fractures and reducing the loss of BMD in men with PCa receiving ADT.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library for articles between database inception and September 2, 2020. Eligible studies included randomized controlled trials (RCTs) investigating the effects of exercise on bone health in men with PCa receiving ADT.

RESULTS

Nine RCTs were included. Experimental PE consisted in multicomponent programmes that involved aerobic, resistance, impact-loading exercise, and football training. None of the RCTs investigated the risk of accidental falls and fractures, while two trials reported beneficial effects of PE on lumbar spine, hip, and femoral shaft BMD. No further significant difference was detected in the outcomes investigated.

CONCLUSION

Evidence of the effectiveness of PE to prevent the risk of accidental falls and fractures and BMD loss is lacking. Nevertheless, clinical guidelines recommend PE as a part of the clinical management of men with PCa receiving ADT due to its known numerous health benefits. Research should focus on PE strategies to prevent accidental falls, a clinically relevant outcome in this vulnerable population.

TRIAL REGISTRATION

The study protocol was registered with International Prospective Register of Systematic Reviews (PROSPERO, number CRD 42020158444 ) on 04/28/2020.

Direct care nurses and support staff thoughts and feelings about the reasons patients fall at a cancer center

Extensive research addresses the prevalence and high fall risk for cancer patients related to age, diagnosis, treatment side effects, pharmacological side effects, and cognitive and/or motor deficits. The purpose of the study was to explore the thoughts and feelings that inpatient and outpatient oncology direct care nurses (registered nurses) and support staffs have about reasons patients fall; as well as their thoughts on what might be done to prevent falls. This descriptive qualitative study used focus groups as the method for discovery. Six themes were identified: Effect on Me, Guilt, Noncompliance, Poor Choices, Inconsistency, and No Authority. This study is significant and relevant because there is little previous research addressing staff thoughts and feelings about why patients fall and what additional interventions they think can be implemented to prevent falls. Findings from this study may be helpful in developing and/or refining current fall policies. Existing research suggests unlicensed patient care providers often have minimal participation in postfall reviews. This study suggests they can provide insight into why patients fall. Additionally, both registered nurses and unlicensed providers describe barriers that often impede their ability to work as a team to prevent patient falls. Findings from this study identified the need for the patient care team to strengthen collaborative work to create safer patient environments.

Addressing Falls Among Older Oncology Patients Through Complexity Science

Traditional quality assurance processes provide significant opportunities for positive disruption. Doctor of Nursing Practice (DNP) students are well positioned to apply program learning to large-scale change in complex organizations. This article presents an innovative approach for creating a point-of-care interdisciplinary approach to address high fall risk frequencies in ambulatory oncology clinics using complexity leadership principles. Processes for nurse executives to consider for replication of this approach for other challenging clinical situations are suggested using the emerging competence of DNP educated nurses. Adults with cancer who are older than 65 years are at a higher risk for falls than older adults without cancer. Oncology providers and nurses are not routinely screening, documenting, and preventing falls. A fall injury in an older adult with cancer may not only delay or impact cancer treatment but also result in hospitalization, loss of function, and/or death. Increasing awareness of the impact of falls and implementing change within a large ambulatory health care organization requires an interdisciplinary team approach. Complexity theory supports nonlinear change initiated at the grassroots level to create a dynamic movement to bring forth emergence and adaptation. The use of the Centers for Disease Control and Prevention STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative will enable oncology professionals to screen, assess, and intervene by collaborating, communicating, and coordinating with other health care specialists to introduce a fall prevention quality improvement system process. Nurse executives need to know about STEADI.

Safety of Care by Caregivers of Cancer Patients

OBJECTIVES

To describe common areas of threats to patient safety and quality of care when caregivers provide care. Recommendations for caregivers to enable them to provide safe care are included.

DATA SOURCES

Research-based articles and reports.

CONCLUSION

The literature is limited in discussion on home safety issues for caregivers. Non cancer-specific literature provides some direction for recommendations for nurses to guide caregivers.

IMPLICATIONS FOR NURSING PRACTICE

The home environment is an unregulated and uncontrolled site, and the safety risks families take are unknown. Professionals should assess the caregiver's knowledge and ability when providing caregiving guidance to ensure the patient is receiving safe and quality care. Nurses need to stress the importance of providing safe quality care and provide education and community resources.

A Practical Guide to Geriatric Syndromes in Older Adults With Cancer: A Focus on Falls, Cognition, Polypharmacy, and Depression

Geriatric syndromes are multifactorial conditions that are prevalent in older adults. Geriatric syndromes are believed to develop when an individual experiences accumulated impairments in multiple systems that compromise their compensatory ability. In older adults with cancer, the presence of a geriatric syndrome is common and may increase the complexity of cancer treatment. In addition, the physiologic stress of cancer and cancer treatment may precipitate or exacerbate geriatric syndromes. Common geriatric syndromes include falls, cognitive syndromes and delirium, depression, and polypharmacy. In the oncology setting, the presence of geriatric syndromes is relevant; falls and cognitive problems have been shown to be predictive of chemotherapy toxicity and overall survival. Polypharmacy and depression are more common in older adults with cancer compared with the general geriatric population. Multiple screening tools exist to identify falls, cognitive problems, polypharmacy, and depression in older adults and can be applied to the oncology setting to identify patients at risk. When recognized, several interventions exist that could be considered for this vulnerable population. We review the available evidence of four geriatric syndromes in the oncology setting, including clinical implications, validated screening tools, potential supportive care, and therapeutic interventions.

Exercise for reducing falls in people living with and beyond cancer

BACKGROUND

Current treatment modalities for cancer have been successful in achieving improved survivorship; however, they come with a number of long-term adverse effects. Accidental falls are a common and clinically significant adverse event in people living with and beyond cancer and rates are higher than in the rest of the population.

OBJECTIVES

To assess the effects of prescribed or provided exercise for reducing accidental falls, and falls risk factors of strength, flexibility and balance, in people living with and beyond cancer.

SEARCH METHODS

We searched the following electronic databases from inception to 10 July 2018, with no restrictions: CENTRAL, MEDLINE, Embase, and seven other databases. We searched clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP) for ongoing trials, and reference lists of reviews and retrieved articles for additional studies.

SELECTION CRITERIA

We included all randomised controlled trials investigating exercise interventions versus no treatment, usual care or non-exercise interventions on falls incidence or falls risk factors in adults living with and beyond cancer (18 years of age or older at diagnosis). We excluded cross-over studies and studies in acute or inpatient hospice care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently completed data extraction for included papers. We used Covidence software to manage screening, data collection and extraction. We assessed evidence using GRADE and presented results in a 'Summary of findings' table.

MAIN RESULTS

Eleven studies (835 participants) compared exercise to usual care. No studies compared exercise with no treatment or non-exercise interventions. The quality of the evidence was very low for the primary outcome rates of falls, and very low to low for the secondary outcomes. We downgraded the evidence due to study limitations (risk of bias), and issues of imprecision due to small sample sizes, inconsistency and indirectness. All studies were at high risk of bias for blinding of participants and personnel due to inability to blind participants to an exercise intervention. Risk of bias was generally low or unclear for other categories.There was generally little information on the important outcomes comparing exercise to usual care.Rates of falls and number of fallers: one study (223 participants) measured accidental falls, but reported neither the rate of falls or the number of fallers; there was no difference in the number of falls between exercise and usual care (very low-quality evidence).Strength: 10 studies (813 participants) reported on strength outcomes. Two analyses favoured exercise over usual care: quadriceps strength (2 studies, 72 participants; mean difference (MD) 8.99 kg, 95% confidence interval (CI) 1.29 to 16.70; low-quality evidence), and leg press (4 studies, 388 participants; MD 21.1 kg, 95% CI 8.47 to 33.74; low-quality evidence). In one analysis of the Sit-to-Stand Test, there was no difference between exercise and usual care (4 studies, 214 participants; standardised mean difference (SMD) -0.45, 95% CI -1.05 to 0.14; very low-quality evidence).Flexibility: one study (21 participants) reported on flexibility for Sit-and-Reach Distance (MD 2.05 cm, 95% CI 0.59 to 3.51; very low-quality evidence).Balance: five studies (350 participants) measured three different balance outcomes. Two analyses favoured exercise over usual care: postural balance (4 studies, 127 participants; standardised mean difference (SMD) 0.44, 95% CI 0.08 to 0.79; very low-quality evidence), and Backward Walk Test (2 studies, 280 participants; SMD -0.24, 95% CI -0.48 to -0.01; low-quality evidence). There was no difference between exercise and usual care for the Timed Up-and-Go Test (1 study, 15 participants; MD -0.35 seconds, 95% CI -1.47 to 0.77; low-quality evidence).Number of people sustaining a fall-related fracture: the quality of the evidence for exercise reducing fall-related fractures was very low.Adverse events: a single study (223 participants) noted some temporary muscle soreness on initiation of exercise or when there was an increase in the weight lifted. As no occurrence data were reported, we could not assess this variable further. No studies reported musculoskeletal injury. Analysis indicated that there was very low-quality evidence that exercise did not increase fatigue.

AUTHORS' CONCLUSIONS

There is a paucity of evidence for exercise training to reduce fall rates in people living with and beyond cancer. Exercise training may improve strength, flexibility and balance for people in this population, but the evidence is very low quality.