Effectiveness of preventive home visits in reducing the risk of falls in old age: a randomized controlled trial

Preventive Home Visits Among Frail Community-Dwelling Older Adults. The Added Value of Follow-Up Telephone Calls

People in need of care and support do not always find appropriate services. This paper aims to explore the content and added value of monthly follow-up telephone calls after preventive home visits. We used both monitoring data and qualitative semi-structured interviews (with older adults, formal and informal caregivers). Results indicate that a majority of older adults (N = 95) received a regular follow-up of four telephone calls. Social connection and involvement were mentioned by all three groups as positive aspects of the program. Although time-consuming, this paper draws attention to the added value of follow-up telephone calls after preventive home visits.

The development, incidence and treatment trends of trochanteric fractures in Germany: a cohort study

BACKGROUND

Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments.

METHODS

Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences.

RESULTS

985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures.

CONCLUSIONS

We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.

Environmental interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention.

OBJECTIVES

To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.

MAIN RESULTS

We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency.  Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter).  Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts.  Education  We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence).  Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence.  Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.

Impact of Geriatric Events on Clinical Outcomes and Resource Utilization of Acute Coronary Syndrome Hospitalizations

Background The effect of geriatric events (GEs) on outcomes of acute coronary syndrome (ACS) admissions is poorly understood. We evaluated the prevalence and impact of GEs on clinical outcomes and resource utilization of older patients admitted with ACS. Methods Using the 2018 National (Nationwide) Inpatient Sample, we analyzed all elective hospitalizations for ACS in older adults (age ≥ 65 years) and a younger reference group (age 55-64). Nationally-weighted descriptive statistics were generated for GEs based on ACS subtypes. Multivariate logistic regression models controlling for comorbidities, frailty, patient procedure, and hospital-level variables were used to estimate the association of age with GEs and GEs with outcomes. Results Out of 403,760 admissions analyzed, 71.9% occurred in older adults (≥65 years). The overall rate of any GE in older adults with ACS was 3.4%. With advancing age, the number of GEs was found to significantly increase (p<0.001). After adjustments, having any GE was found to have a significant impact on mortality (adjusted OR (AOR): 1.32; 95%CI: 1.15-1.54; p < 0.001), post-myocardial infarction (MI) complications (AOR: 1.53; 95%CI: 1.36-1.71; p < 0.001), prolonged hospital stays (AOR: 2.97; 95%CI: 2.56-3.30; p < 0.001), and non-home (acute care and skilled nursing home) discharge (AOR: 1.68; 95%CI: 1.53-1.85; p < 0.001). The occurrence of GEs was also associated with a substantial increase in total hospitalization costs with a mean increase of $48,325.22 ± $5,539 (p < 0.001). A dose-response relationship was established between GEs and all outcomes. Limitations of the study included the use of retrospective data and an administrative database. Conclusion Geriatric events were found to significantly worsen outcomes for older adults with ACS. There is, therefore, a need for increased awareness and effective management of GEs in older adults to improve their health outcomes and reduce the burden on the healthcare system.

Promouvoir la santé mentale des personnes âgées avec des incapacités physiques : revue systématique des interventions proposées à domicile et en établissement

Introduction&#160;: Promoting the mental health of vulnerable elderly patients is a public health priority.Context&#160;: In many cases, mental health interventions for elderly people are not appropriate for those with multiple physical disabilities.Objectives&#160;: This article aims to provide gerontology professionals with an overview of the types of interventions available based on their practice setting (home or long-term care facility) and the characteristics of the people who use them (over 75 years old with physical disabilities).Method&#160;: A systematic literature review was conducted using the PsycInfo, PubMed, and Cochrane databases, using data ranging from 2001-2022. All interventions aimed at addressing mental health issues were included, regardless of their research methodology.Results&#160;: A total of 18 studies were included in this systematic review. The methodological limitations of these studies had a negative impact on our ability to draw conclusions and generalizations about the results of this review. However, the social and psychological support interventions studied seem to hold much promise.Discussion&#160;: The provision of personalized support seems to be an important factor in determining the success of an intervention, whether at home or in a long-stay facility.Conclusion&#160;: Further studies are needed to provide evidence of the effectiveness of these interventions.

Effect of Home Visits by Nurses on the Physical and Psychosocial Health of Older Adults: A Systematic Review and Meta-Analysis

Background

One of the best ways to maintain and develop physical and psychosocial health is to make regular home visits. This meta-analysis aimed to determine (by subgroups) the effects of interventions based on nurses' home visits on physical and psychological health outcomes of older people.

Methods

This search was carried out using the The CINAHL, Cochrane, MEDLINE, PubMed, Science Direct, Web of Science, and Turkish databases. Experimental and observational studies were included.

Results

The meta-analysis included 26 (with subgroups 50) out of 13110 studies. The minimum and maximum values of the effect size (Hedges g) were g = -0.708 and g = 0.525, respectively. The average effect size was g = 0.084 (SD = 0.21).

Conclusion

Home visit interventions are effective in reducing the frequency of hospitalization in the older adults, and improving physical and psychosocial health. They are negatively effective on falls and have no significant effect on the quality of life.

The Effect of Individualized Fall Prevention Programs on Community-Dwelling Older Adults: A Scoping Review

An alarming rate of injurious falls among older adults warrants proactive measures to reduce falls and fall risk. The purpose of this article was to examine and synthesize the literature as it relates to programmatic components and clinical outcomes of individualized fall prevention programs on community-dwelling older adults. A literature search of four databases was performed using search strategies and terms unique to each database. Title, abstract, and full article reviews were performed to assure inclusion and exclusion criteria were met. Data were analyzed for type of study, program providers, interventions and strategies used to deliver the program, assessments used, and statistically significant outcomes. Queries resulted in 410 articles and 32 met all inclusion criteria (19 controlled trials and 13 quasi-experimental). Physical therapists were part of the provider team in 23 (72%) studies and the only provider in 10 (31%). There was substantial heterogeneity in procedures and outcome measures. Most common procedures were balance assessments (n=30), individualized balance exercises (n=29), cognition (n=21), home and vision assessments (n=16), specific educational modules (n=15), referrals to other providers/community programs (n=8), and motivational interviewing (n=7). Frequency of falls improved for eight of 13 (61.5%) controlled trials and four of five (80%) quasi-experimental studies. Balance and function improved in six of 11 (54.5%) controlled trials and in each of the six (100%) quasi-experimental studies. Strength improved in three of seven (43%) controlled trials and four of five (75%) quasi-experimental studies. While many programs improved falls and balance of older adults, there was no conclusive evidence as to which assessments and interventions were optimal to deliver as individualized fall prevention programming. The skill of a physical therapist and measures of fall frequency, balance, and function were common among the majority of studies reviewed. Despite the variability among programs, there is emerging evidence that individualized, multimodal fall prevention programs may improve fall risk of community-dwelling older adults and convenient access to these programs should be emphasized.

Older people living at home: experiences of healthy ageing

AIM

The purpose of this study was to investigate how old persons perceived their life to be, how they viewed the ageing process and their need of health care and societal support.

BACKGROUND

The purpose of WHO's Healthy Ageing strategy and development of age-friendly environments is to support physiological and psychosocial changes in old persons by facilitating basic needs. Interventions to operationalize these needs in older people living at home are often developed from a professional perspective and to a small extent involves the perceptions, experience and expectations of the older persons.

METHOD

This qualitative study has an explorative design using focus group discussions to collect data. In all, 34 persons between 69 and 93 years of age participated in seven group discussions. The interviews were analyzed using inductive manifest content analysis.

FINDINGS

The main results suggest that most old persons enjoyed life and wished it to continue for as long as possible. Important was to sustain networks and to feel useful. Unexpected changes were described as threats and the need to use health care services was associated with illness and being dependent. The result is presented in three categories with sub-categories: 'Embracing life', 'Dealing with challenges' and 'Considering the future'.

Practices of caregivers when evaluating the risk of falls in the admission of older adults to nursing homes

Falls are a complex problem for the older population residing in nursing homes. Despite recommendations, many difficulties remain in the evaluation of and systematic information on fall risk factors.

Evaluating a Novel Multifactorial Falls Prevention Activity Programme for Community-Dwelling Older People After Stroke: A Mixed-Method Feasibility Study

Purpose

The overall purpose of this study was to explore participants’ and physiotherapists’ experiences regarding the acceptability, implementation, and practicality of a novel group-based multifactorial falls prevention activity programme for community-dwelling older people after stroke. Specifically, the purpose was to explore if and how participating could impact on the participants’ health-related quality of life (HRQoL) in terms of their daily lived experience regarding physical, mental, emotional and social well-being. A secondary purpose was to explore whether participating in the programme could positively influence participants’ balance, strength, falls efficacy, mobility and motor impairment of the trunk.

Materials and Methods

This was an exploratory mixed-method Phase I feasibility study. A convenience sample of five older community-dwelling people after stroke participated in a novel eight-week multifactorial activity programme which included falls education, a mix of individually tailored and group-based strength and balance exercises, exploring limits of stability and safe landing techniques and a social element. Qualitative data from post-intervention interview transcripts with the participants and the physiotherapists who delivered the programme were thematically analysed using both deductive and inductive approaches to explore the participants’ and therapists’ experiences with the programme. Quantitative outcomes included balance, strength, falls efficacy, mobility and motor impairment of the trunk.

Results

The programme was deemed feasible in terms of acceptability, implementation and practicality by the participants as well as the physiotherapists delivering the programme. The overarching theme regarding HRQoL identified that participating in the programme was perceived to empower the participants living with stroke and positively influenced their daily physical, mental, emotional and social well-being. Participant outcomes showed a change in the direction of improvements in balance, strength, mobility, motor impairment of the trunk and reduced concerns about falling. Subjectively, participants only reported perceived improvements in balance and strength.

Conclusion

Running a novel multifactorial falls prevention activity programme for older community-dwelling people after stroke was feasible. Participating in the programme helped participants to perceive improved balance, strength and empower them to make meaningful changes, improving their daily lived experiences. A future fully powered study could build on these results to investigate physical improvements, prevention of falls and improvements to domains of HRQoOL.

Geriatric Events among Older Adults Undergoing Nonelective Surgery are Associated with Poor Outcomes

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55–64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose–response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.

Effectiveness of multifactorial interventions in preventing falls among older adults in the community: A systematic review and meta-analysis

BACKGROUND

Falls often cause unexpected injuries that older adults find difficult to recover from (e.g., hip and other major fractures, intracranial bleeding); therefore, fall prevention and interventions are of particular significance.

OBJECTIVES

This study aimed to examine the effectiveness of multifactorial fall prevention interventions among community-dwelling older adults and compare subgroups that differed in terms of their degree of fall risk and the intensity and components of interventions.

METHODS

An exhaustive systematic literature search was undertaken using the following databases: Ovid-Medline, Ovid-Embase, and the Cochrane Central Register of Controlled Trials (Central). Two investigators independently extracted data and assessed the quality of the studies by examining the risk of bias. We conducted a meta-analysis of randomized controlled trials that had been published up to March 31st, 2019, using Review Manager.

RESULTS

Of 1,328 studies, 45 articles were relevant to this study. In total, 29 studies included participants in the high-risk group, 3 in the frail group, and 13 in the healthy older adult group. Additionally, 28 and 17 studies used active and referral multifactorial interventions, respectively. Multifactorial interventions included the following components: exercise, education, environmental modification, medication, mobility aids, and vision and psychological management. Multifactorial interventions significantly reduced fall rates in the high-risk (risk ratio 0.66; 95% confidence interval 0.52-0.84) and healthy groups (risk ratio 0.72; 95% confidence interval 0.58-0.89), when compared to the control group. Active multifactorial interventions (risk ratio 0.64; 95% confidence interval 0.51-0.80) and those featuring exercise (risk ratio 0.66; 95% confidence interval 0.54-0.80) and environmental modification also showed significantly reduced fall rates (risk ratio 0.65; 95% confidence interval 0.54-0.79) compared to usual care. Multifactorial interventions had a significantly lower number of people who experienced falls during the study period compared to usual care in the healthy group (risk ratio 0.77; 95% confidence interval 0.62-0.95). Active multifactorial interventions (risk ratio 0.73; 95% confidence interval 0.60-0.89) and those featuring exercise (risk ratio 0.79; 95% confidence interval 0.66-0.95) and environmental modification (risk ratio 0.80; 95% confidence interval 0.68-0.95) had a significantly lower number of people who experienced falls compared to those receiving usual care.

CONCLUSIONS

Active multifactorial interventions had positive effects on fall rates and the number of people experiencing falls. Thus, healthcare workers, including nurses, should be involved in planning fall prevention programs so that older adults can be provided with optimal care; multifactorial interventions that include exercise and environmental modification are particularly effective in reducing falls.

Geriatric Events Among Older Adults Undergoing Nonelective Surgery Are Associated with Poor Outcomes

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure (P < 0.001). After adjustment, the probability of any GE increased with age category (P < 0.001); having any GE was associated with higher probability of all outcomes (P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.

Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants

Objective

To assess the longer term effects of multifactorial interventions for preventing falls in older people living in the community, and to explore whether prespecific trial-level characteristics are associated with greater fall prevention effects.

Design

Systematic review with meta-analysis and meta-regression.

Data sources

MEDLINE, EMBASE, CINHAL, CENTRAL and trial registries were searched up to 25 July 2018.

Study selection

We included randomised controlled trials (≥12 months’ follow-up) evaluating the effects of multifactorial interventions on falls in older people aged 65 years and over, living in the community, compared with either usual care or usual care plus advice.

Review methods

Two authors independently verified studies for inclusion, assessed risk of bias and extracted data. Rate ratios (RaR) with 95% CIs were calculated for rate of falls, risk ratios (RR) for dichotomous outcomes and standardised mean difference for continuous outcomes. Data were pooled using a random effects model. The Grading of Recommendations, Assessment, Development and Evaluation was used to assess the quality of the evidence.

Results

We included 41 trials totalling 19 369 participants; mean age 72–85 years. Exercise was the most common prespecified component of the multifactorial interventions (85%; n=35/41). Most trials were judged at unclear or high risk of bias in ≥1 domain. Twenty trials provided data on rate of falls and showed multifactorial interventions may reduce the rate at which people fall compared with the comparator (RaR 0.79, 95% CI 0.70 to 0.88; 20 trials; 10 116 participants; I²=90%; low-quality evidence). Multifactorial interventions may also slightly lower the risk of people sustaining one or more falls (RR 0.95, 95% CI 0.90 to 1.00; 30 trials; 13 817 participants; I²=56%; moderate-quality evidence) and recurrent falls (RR 0.88, 95% CI 0.78 to 1.00; 15 trials; 7277 participants; I²=46%; moderate-quality evidence). However, there may be little or no difference in other fall-related outcomes, such as fall-related fractures, falls requiring hospital admission or medical attention and health-related quality of life. Very few trials (n=3) reported on adverse events related to the intervention. Prespecified subgroup analyses showed that the effect on rate of falls may be smaller when compared with usual care plus advice as opposed to usual care only. Overall, heterogeneity remained high and was not explained by the prespecified characteristics included in the meta-regression.

Conclusion

Multifactorial interventions (most of which include exercise prescription) may reduce the rate of falls and slightly reduce risk of older people sustaining one or more falls and recurrent falls (defined as two or more falls within a specified time period).

Trial registration number

CRD42018102549.

Occupational Therapy Fall Prevention Interventions for Community-Dwelling Older Adults: A Systematic Review

OBJECTIVE

Accidental falls among community-dwelling older adults are preventable and increase the risk of morbidity, hospitalization, and institutionalization. We updated and broadened a 2008 systematic review examining the evidence for the effectiveness of fall prevention interventions in improving fall-related outcomes, occupational performance, quality of life, and health care facility readmissions for community-dwelling older adults.

METHOD

We searched and analyzed literature published from 2008 to 2015 from five electronic databases.

RESULTS

Fifty articles met the inclusion criteria and were critically appraised and synthesized-37 provided Level I; 5, Level II; and 8, Level III evidence. Analysis was organized into four intervention themes: single component, multicomponent, multifactorial, and population based. Mixed evidence was found for single-component and multifactorial interventions, strong evidence was found for multicomponent interventions, and moderate evidence was found for population-based interventions.

CONCLUSION

These findings can inform the delivery and integration of fall prevention interventions from acute care to community discharge.

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT

BACKGROUND

Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression.

OBJECTIVES

(1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT).

DESIGN

Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation.

INTERVENTION DEVELOPMENT

Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation.

FEASIBILITY RCT

Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU).

SETTING

Community settings in London and Hertfordshire, UK.

PARTICIPANTS

A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty.

MAIN OUTCOME MEASURES

Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs.

RESULTS

We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding.

CONCLUSIONS

Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible.

FUTURE WORK

A large, definitive RCT of the HomeHealth service is warranted.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.

Multifactorial and multiple component interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common, particularly in those aged over 65, with around one-third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.

OBJECTIVES

To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017.

SELECTION CRITERIA

Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random-effects model. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow-up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.Forty-four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I² not reported if = 0%).Multifactorial interventions versus usual care or attention controlThis comparison was made in 43 trials. Commonly-applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I² = 88%; low-quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low-quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I² = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I² = 53%); fall-related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low-quality evidence that multifactorial interventions may reduce the risk of fall-related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health-related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I² = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self-limiting musculoskeletal symptoms in total.Multifactorial interventions versus exerciseVery low-quality evidence from one small trial of 51 recently-discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall-related outcomes were not assessed.Multiple component interventions versus usual care or attention controlThe 17 trials that make this comparison usually included exercise and another component, commonly education or home-hazard assessment. There is moderate-quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I² = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low-quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low-quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall-related fractures (2 trials) or fall-related hospital admission (1 trial). There is low-quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health-related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I² = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.Multiple component interventions versus exerciseThis comparison was tested in five trials. There is low-quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low-quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.

AUTHORS' CONCLUSIONS

Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall-related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.

[The occupational therapist and the assessment of the elderly person's home]

The falls of elderly people in their home are frequently related to the environment. Plans and photographs of the home provided by the patient's relatives are useful and constitute relevant assessment tools. The home visit is even more effective as it helps to identify areas which pose a high risk of falling which cannot be picked up by the other tools.

Specifying the content of home-based health behaviour change interventions for older people with frailty or at risk of frailty: an exploratory systematic review

OBJECTIVES

To identify trials of home-based health behaviour change interventions for frail older people, describe intervention content and explore its potential contribution to intervention effects.

DESIGN

15 bibliographic databases, and reference lists and citations of key papers, were searched for randomised controlled trials of home-based behavioural interventions reporting behavioural or health outcomes.

SETTING

Participants' homes.

PARTICIPANTS

Community-dwelling adults aged ≥65 years with frailty or at risk of frailty.

PRIMARY AND SECONDARY OUTCOME MEASURES

Trials were coded for effects on thematically clustered behavioural, health and well-being outcomes. Intervention content was described using 96 behaviour change techniques, and 9 functions (eg, education, environmental restructuring).

RESULTS

19 eligible trials reported 22 interventions. Physical functioning was most commonly assessed (19 interventions). Behavioural outcomes were assessed for only 4 interventions. Effectiveness on most outcomes was limited, with at most 50% of interventions showing potential positive effects on behaviour, and 42% on physical functioning. 3 techniques (instruction on how to perform behaviour, adding objects to environment, restructuring physical environment) and 2 functions (education and enablement) were more commonly found in interventions showing potential than those showing no potential to improve physical function. Intervention content was not linked to effectiveness on other outcomes.

CONCLUSIONS

Interventions appeared to have greatest impact on physical function where they included behavioural instructions, environmental modification and practical social support. Yet, mechanisms of effects are unclear, because impact on behavioural outcomes has rarely been considered. Moreover, the robustness of our findings is also unclear, because interventions have been poorly reported. Greater engagement with behavioural science is needed when developing and evaluating home-based health interventions.

PROSPERO REGISTRATION NUMBER

ID=CRD42014010370.

Potential analysis for research on occupational therapy-led physical exercise programmes and home environment adaptation programmes to prevent falls for elderly people living at home / Potenzialanalyse zu ergotherapeutischen körperlichen Trainingsprogrammen und Wohnraumanpassungen zur Vermeidung von Stürzen bei zu Hause lebenden älteren Menschen

Background

In Germany, four to five million community-dwelling people aged 65 years or older fall every year. The presented potential analysis evaluates the potential of occupational therapy-led physical exercise programs and home environment adaptations to reduce the frequency of falling and as well as intrinsic and extrinsic risk factors for falling of older people living at home.

Methods

The potential analysis was compiled according to a method guideline (p.11-22) available as follows: http://www.cochrane. de/news/leitfaden-f%C3%BCr-gesundheitsfachberufe-mai-2013. The research question of fall prevention was considered as very relevant for health care and specified according to the PICOS-system. A Cochrane review was systematically searched and the body of evidence was assessed using the GRADE-system. In addition, studies after the search period of the Cochrane review were identified using the search strategy of this review. Both the studies within and after the review were assessed regarding their transferability to the German health care context.

Corpus of evidence

A Cochrane review from 2012 revealed that occupational therapy-led physical exercise programs reduced the frequency of falling of older people living at home (7 studies, 951 participants, 0.68 RaR; 95%-KI [0.58-0.80]), the number of fallers (6 studies, 714 participants, 0.78 RaR, 95%-KI [0.64-0.94]) and the fractures (6 studies, 810 participants, 0.34 RaR, 95%-KI [0.18-0.63]). Further studies showed that home environment adaptation programs significantly reduced the number of falls (4 studies, 1443 participants, 0.69 RaR, 95%-KI [0.55-0.86]) and the number of fallers (5 studies, 1153 participants, 0.79 RaR, 95%-KI [0.70-0.91]). However, direct implementation into the German healthcare context is not recommendable.

Implication for research

It is recommended (1) to manualise identified home environment adaptation programmes for the German healthcare context and (2) to pilot-test the physical exercise programmes ‘LiFE’ with regard to theoretical framework, acceptance, applicability and feasibility and to examine both interventions as part of a feasibility study. If this trial results in a feasible treatment programme well accepted by patients and their treating occupational therapists, a large-scaled randomized clinical trial in terms of comparative effectiveness research may follow.

Views and experiences of Malaysian older persons about falls and their prevention-A qualitative study

Background

Few studies on falls interventions have been conducted in South East Asia. Despite its population ageing rapidly, the acceptability of interventions among the older population in this region remains variable. This study aims to explore views and experiences regarding falls and their prevention among older persons at high risk of falls.

Method

Sixteen individuals aged 60 years and over with at least one fall in the preceding 12 months were recruited from our Primary Care clinics. A qualitative study using semi-structured interviews among individuals and focus-groups was conducted. Thematic analyses were conducted on transcriptions of audio-taped interviews using the WeftQDA software. The interviews ceased when data saturation was achieved.

Results

The three themes included older persons’ views on falls, help-seeking behaviour and views on falls interventions. Many older persons interviewed did not perceive falls as a serious problem, some reported a stigma surrounding falls, while others felt they had not sustained more serious injuries due to God’s grace. Older persons sought traditional medicine and other alternative treatments for pain relief and other fall-related symptoms. Accessibility of healthcare facilities often prevented older persons from receiving physiotherapy or eye tests.

Conclusion

The delivery of complex interventions for a multifactorial condition such as falls in the older persons in our setting is inhibited by various cultural barriers, falls perceptions as well as logistic difficulties. Efforts to establish a multi-disciplinary intervention among our older population will need to include strategies to overcome these issues.

Association between age, gender and multimorbidity level and receiving home health care: a population-based Swedish study

Background

Home health care is an important part of primary health care. How delivery of home health care is organised is probably important for sustainability of the healthcare system as a whole. More than 50 % of individuals over 65 years old have multimorbidity, which increases with higher age, also influencing the needs of home health care. Our aim was to study the proportion of the population above 65 years receiving home health care according to age, gender and multimorbidity level.

Methods

The study population comprised 32,130 people aged 65 or more, living in Blekinge County in southern Sweden. We analysed data from patient electronic medical records for patients receiving home health care delivered in patients’ own homes by nurses, physiotherapists and occupational therapists. We used the Adjusted Clinical Groups Case-Mix System in order to group individuals according to diagnoses into six levels of multimorbidity. In order to analyse the differences between individuals receiving home health care and those who did not, we used Chi squared test. Logistic regression analysis was conducted in order to study how the dependent variable was influenced by the independent variables.

Results

A total of 7860 (28 %) of the studied population received home health care in 2011. Logistic regression analysis showed that men had 26 % lower odds of receiving home care compared to women (OR = 0.74, 95 % CI 0.69–0.78). There was also a substantial group (22 %) with low multimorbidity level among people receiving home health care. Adjusting for gender and age showed no differences in odds of receiving home health care for patients with lower levels of multimorbidity. However, for patients with higher levels of morbidity the odds increased dramatically for both genders.

Conclusion

The question of to whom and to what extent home health care should be provided is an important challenge for policy makers. Our results show that there are differences in the use of home health care dependent on gender, age and multimorbidity level, but also that home health care is provided to individuals with low morbidity. Further studies could explain the factors influencing home health care use.

Comparative analysis of the expected demands for nursing care services among older people from urban, rural, and institutional environments

Background

Demand for nursing and social services may vary depending on the socio-demographic variables, health status, receipt of formal and informal care provided, and place of residence.

Objectives

To conduct a comparative analysis of the expectations of older people from urban, rural, and institutional environments concerning nursing care with respect to the care provided and elements of a comprehensive geriatric assessment.

Material and methods

The study comprised 2,627 individuals above the age of 65 years living in urban (n=935) and rural (n=812) areas as well as nursing homes (n=880).

Results

Family care was most often expected both in urban (56.6%) and rural (54.7%) environments, followed by care provided simultaneously by a family and nurse (urban – 18.8%; rural – 26.1%) and realized only by a nurse (urban – 24.6%; rural – 19.2%). Not surprisingly, nursing home residents most commonly expected nursing care (57.5%) but 33.1% preferred care provided by family or friends and neighbors. In the whole cohort of people living in the home environment (n=1,718), those living with family demonstrated willingness to use primarily care implemented by the family (62.0%), while respondents living alone more often expected nursing services (30.3%). In the logistic regression model, among the respondents living in the city, only the form of care already received determined the expectations for nursing care. Among the respondents living in the county, the presence of musculoskeletal disorders, better nutritional status, and current care provided by family decreased expectations for nursing care. Higher cognitive functioning, symptoms of depression, and living alone increased the willingness to obtain nursing care.

Conclusion

Older inhabitants of urban areas, rural areas, and those residing in institutions have different expectations for individual nursing care. Nearly 45% of seniors living in the community expect to obtain nursing care, while only 1.6% do not expect any social or nursing help. While the expectations for the provision of nursing care are significantly increased by living alone, they are decreased by having access to care provided by family. Support for families to take care of elderly relatives would appear to be essential for an effective nursing and social care system.