Understanding falling incidents in older adults - Essay Example

? Understanding Falling Incidents in Older Adults: A Critical Appraisal Teacher Table of Contents Part I: Introduction 2 Part II: Methodology 3 Table 1: Internet Research, Search Terms and Papers 3 Part III: Critical Summaries 4 3.1 Robitaille et al. (2005) 4 3.1.a Inclusion Criteria 5 3.1.b Selection Process 5 3.1.c Terms of Session 6 3.1.d Analysis 6 3.1.e Results 6 3.2 Russell et al. (2010) Second Study 7 3.2.a Inclusion Criteria 7 3.2.b Selection Process 8 3.2.c Terms of Session 8 3.2.d Analysis 9 3.2.e Results 9 Part IV: Discussion of Findings 10 Part V: Personal Reflections on Practice Related to the Research 11 Appendix A: RCT CASP for Robitaille et al. (2005) 12 Appendix B: RCT CASP for Russell et al. (2010) 14 Resources 17 Part I: Introduction This is a critical appraisal of two research papers which reflect studies in the problems of falling as issues for older adults. The two papers to be critically appraised are ‘Moving Forward in Fall Prevention: An Intervention to Improve Balance Among Older Adults in Real-World Settings’ (Robitaille et al. 2005) and ‘A Randomized Controlled Trial of a Multifactorial Falls Prevention Intervention for Older Fallers Presenting to Emergency Departments’ by Russell et al. (2010). These papers were chosen because they represent an aspect of my field of practice – working with older adults. The paper is divided into five sections: Part I: the Introduction; Part II: Methodology of Selection for the papers chosen for this study; Part III: Critical Summaries which outlines the purpose, structure and results of the studies; Part IV: Discussion of Findings which provides the results and the why of the results; and Part V: Personal Reflection which provides information on how this paper and the studies relate to my field of practice. When mature adults move into the senior years, there are a number of functions that begin to slow down and one of these is the ability to recover from a stumble, or tripping over an object. Regaining one’s balance is harder because reaction time in physical recovery is slower (Sollitto 2013). Loss of muscle structure is also a key component which is obviously evident when older adults exercise less because they tire more often or may have some underlying illness. As vision deteriorates with age, perception of distance and depth may also cause problems, particularly when using bifocal or trifocal where looking quickly over the glass lens can change the focus of depth to something that it is not (Sollitto 2013). Falling down can also cause fractured or broken bones because older bones are more brittle. They also will not heal as easily, and it is important to provide nutritional information and appropriate medical intervention to keep the elder adult healthy with quality of life (Sollitto 2013). Part II: Methodology of Selection The selection for determining the papers used in this research required that the studies had to have been done within the past decade, 2003-2013. This would provide more information that utilized the latest in research skills, study design and data analysis of the study results. Several medical websites such as COCHRANE, PubMed and other journal repositories, were used in the search process along with specific search terms in order to pull studies that reflected the subject matter of senior adults and falling issues. Internet Research, Search Terms and Papers Website Search Terms Used Papers Reviewed – Not Used COCHRANE Library ‘old people falling ratios,’ ‘research studies on falls by the elderly’ ‘Population-based interventions for the prevention of fall-related injuries in older people’, McClure et al. (2008). PubMed ‘falling down statistics in elderly’, ‘balance research in falls’ ‘Peculiarities of postural balance among elderly men with fear of falling syndrome’, Gerontol (2012). Amedeo - Medical Literature Guide ‘elderly falling ratios’, ‘balance problems in elderly’ ‘Reliability and validity of the Persian lower extremity functional scale (LEFS) in a heterogeneous sample of outpatients with lower limb musculoskeletal disorders’, Negahban et al. (2013). National Library of Medicine (NLM) ‘interventions for falling elderly’, Refined by ‘cure/prevention’, ‘falling elderly ratios’ ‘CER-HTA-PCOR: Converging on What Works for Patients Transcript’, US NLM (2011). Table 1(author created) CASP tools were used on a final selection of two research studies to determine viability for this research paper in order to help find focal points for appropriate review. The RCT CASP was used for both the Russell et al. (2010) study and the Robitaille et al. (2005) study in final review. The criteria for respondent selection was to find research studies that specifically provided monitored exercise programs to elderly adults who were concerned about their tendency towards falling. Minimum age was 60 + and each was evaluated through face-to-face questionnaire as to their physical capability, with only one being disqualified out of the total of 213 (n=200) initially interviewed for the Robetaille et al. (2005) study and for the Russell et al. (2010) study. The studies had to also provide selection of respondent criteria and data analysis for reviewing the success of the study, both in design and in results. Part III: Critical Summaries In preparation for critical analysis of these two studies, other information was studied for a more rounded view of what older adults experienced in different circumstances and some of this had to do with circumstances found in hospitals and even nursing homes where injuries from falls could be avoided by changing different things such as providing less hard flooring surfaces (Fonda et al. 2006; Press Association 2010). Certainly, keeping pathways free of floor obstacles is a given in any home or community where elderly adults reside for any length of time. The severity of injury is also proportional to the agility of any given senior adult to react quickly enough to stop a fall or not have knees and ankles give way because of lack of strength (Stevens & Sogolow 2005; Sollitto 2013). First Study 3.1 Robitaille et al. (2005) In the first study reviewed for this project, Robitaille et al. (2005) conducted research utilizing community organizations (17) that offered exercise or mobility programs designed to help senior citizens with developing more agility in their everyday routines. The first 10 groups selected offered a specific program called “Stand Up!” which had a more designed structure for independent senior adults in its offerings of exercise routines. These 10 community groups were called the ‘experimental’ groups, while the other seven groups offered a fairly standard arrangement of exercise and were known as the ‘control’ groups (Robitaille et al. 2005). 3.1.aInclusion Criteria: The criteria for inclusion in the study was that a senior had to be 60+, live independently without assistance, and have a certain amount of mobility level in order to handle the various exercises. Of 213 initial respondents interviewed, one was rejected for mobility and health issues, 12 were eliminated because they did not attend the baseline evaluation, leaving a final total of 200 for the respondent sampling. This would provide an 80% observance that would detect a 15% difference in balance improvement. A capacity-to-exercise was given along with data collection of demographics, health status and vitality measures, and educational level (Robitaille et al. 2005). 3.1.b Selection Process: A central contact point person from each community group was interviewed about the selection process and each participant was assessed by the same physiotherapist who was blinded to group membership (experimental or control) and participant assessments were conducted at each community group for the respective area to retain a high participation rate for the study. In the physical performance measures, three dimensions of balance were recorded: once before the study began and then again after the study was completed. These measures consisted of : 1) the ‘static balance’ with one leg and eyes open, then closed, along with a tandem stance test; 2) a stability limits which incorporated functional reach and lateral reach tests; and 3) mobility test with tandem walk test. A lower extremity motor strength test was conducted along with a vitality test. The baseline mean age of participants was 73.9 years of whom 84% were women. Over half of participants lived alone and nearly 40% had fallen within the previous year (Robitaille et al. 2005). 3.1.c Terms of Session: The program was conducted over a 12-week span with bi-weekly sessions, coupled with at-home exercise sessions utilizing a poster which showed the movements to be done. The exercise program was designed to enhance leg strength, ankle mobility and proprioception (sense of relativity to other parts of the body). The cost of the 12-week session was US $1,400 which in some areas, receives financial assistance from health authorities (Robitaille et al. 2005). 3.1.d Analysis: In statistical analysis, once the results were all in, linear regression analyses was done with each outcome variable in three inclusion steps: 1) the effects of group membership with control for baseline scores; 2) control in series of covariates, based on demographic variables (age, gender, health, etc.); and 3) testing modifier effects of covariates through interaction terms. Alternative analysis was also done but, as there were very little differences in the results, only the linear regression analysis was provided within final discussion of analysis. 3.1.e Results: In general results, it was deemed likely that the “Stand Up!” program was quite suitable to be offered to a majority of senior adults and that there was significant improvement in mobility factors for those in this program. It was also determined that success in such programs required the following factors: focus on the various systems geared towards balance enhancement; monitoring of intensity training, overload and progression; obtain high continued attendance rates; and adapt to the reality of the local community (Robitaille et al. 2005). Notably lacking in the study was a consent notice to the respondents and mention of approval from a suitable medical authority to conduct such research (See Appendix A for the RCT CASP review). Second Study 3.2 Russell et al. (2010) In this study, the purpose was to investigate the effect of a referral-based targeted multifactorial falls prevention intervention on the occurrence of recurrent falls and possible subsequent injuries incurred by older seniors who had presented themselves to an emergency department (ED) and then were discharged home (Russell et al. 2010). The intervention was to send patients to existing community services where they were referred to other services and health promotion recommendations, based on the falls risk factors within a baseline assessment. After a year of the study it was determined that there was no significant difference in amount of falls or in improvement between the two groups, indicating that different measures should be provided to those discharged (Russell et al. 2010). As we have shown in the first paper review, exercise which is geared to specific movement strengthening and development, is one of the best processes for recovery (Robitaille et al. 2005). 3.2.a Inclusion Criteria There were 361 participants randomly selected for the standard care group of simply being discharged to home after the ED visit. There were 351 randomly selected to the intervention group whereby they were sent to community groups for referrals to other extended services and to health promotion programs. Those unable to follow instructions or to walk independently were excluded although later, those who fit this exclusion, were admitted if they had a care giver who could help with sustaining the patient with the program (Russell et al. 2010). The intervention group received standard care like the control group but also received recommendations from the baseline assessor to meet with a physiotherapist, occupational therapist, the family physician, or medical personnel in podiatry and/or dietetics. Health promotions consisted of hip protector suggestions, types of improved safety footwear and making various adjustments in the home to accommodate personalized and specific issues (Russell et al. 2010). 3.2.b Selection Process Participants were randomly selected from seven EDs in Melbourne, Australia, and ED staff were ask to inform potential candidates about the study and to gain informed patient consent for the study researchers to contact them about the study (Russell et al. 2010). In five of the hospitals with participating EDs, a designated staff member sifted through the cases each week to find suitable candidates for the study and then made initial contact through a phone call or by mail. Some advertisements were also put out in Australian war veterans magazines as well and these responses were also collected and sifted through. 3.2.c Terms of Session This was a year-long process and a physiotherapist, occupational therapist and a doctor or research fellow, conducted a baseline assessment at the participant’s home utilizing structured protocol. This included demographics, age, listing of falls and surrounding circumstances, indexing of falls, circumstances and injuries sustained, and any other relevant variables criteria. A Falls Risk for Older People in the Community (FROP-Com) was the primary tool to guide assessors in referrals in conjunction with other assessments of variables (Russell et al. 2010). Those in the standard care program were advised simply to consult with their physician about their risks of falling once discharged from the ED. Those in the intervention group received more detail with community referrals and health promotional programs after their discharge from the ED as noted in the Inclusion section. 3.2. d Analysis In a random check of the records, there was a 1.3% data entry error overall. All data were analyzed on the basis of intent to treat analysis principle and the Fisher exact test was used to analyze the effects of the intervention on primary outcome variables such as number of those who fell and number of those who fell and sustained an injury. Covariates were only used if they showed more than a 5% difference of the magnitude of an intervention. In analyzing the effect of outliers, after the primary investigation was done, a sensitivity analysis was conducted on the effects of the intervention, with the top 5% of fallers removed from the data analysis. These were compared and analyzed with the initial assessment data to come up with final results (Russell et al. 2010). 3.2.e Results The final results showed that the intervention, based on a single multifactorial falls risk assessment and referrals to community services did not have any effect on the amount of falls between the two groups. It was determined that results were lessened when there had to be a separate consent for each referral obtained and once the referral was made, researchers had no control over the nature or scope of the implemented service. Finally, it was shown that interventions that actively provide treatment were more effective than simple referrals and education. Interventions must encompass the medical, physical and environmental aspects of falls (Russell et al. 2010). (See Appendix B for RCT CASP) Part IV: Discussion of Findings In the Robitaille et al. (2005) study, the results showed that those who had issues with balance fared very well under those programs providing specialized exercise or movement patterns that enhanced balance skills. While this was hard to monitor statistically, it was noted that the experimental groups had 40% less falls than did the control groups, attributed to the types of exercises provided that either enhanced balance skills, or not (Robitaille et al. 2005). What were considered for potential further research were the long-term effects of such exercise programs in respondents maintaining these skills over time as well. As with all exercise, the more it becomes a regular routine, the more the benefits of becoming physically fit were shown in the results (Robitaille et al. 2005). The Russell et al. (2010) showed that simply referring patients to community groups for extended service and health education programs did not provide enough benefits to sustain such interventions and provided no value to the patients. Ultimately, comparison between the two papers and results show that physical programs such as the “Stand Up!” one used in the first case, are the most satisfactory in providing beneficial lifestyle and wellness to the patients (Robitaille et al. 2005). The design for the research study in the Russell et al. (2010) paper was also poor as it appeared to merely skim the surface of a much deeper issue, one that requires providing more individualized structure to an intervention regime. Part V: Personal Reflection on Practice Related to the Research The findings are related to each other because each offers an intervention but they are two different types of intervention. One is an active-based intervention whereby participants physically move around in methods that are intended to help strengthen body structure. In the other intervention, this is just a simple method of palming a participant off to another assessor with an almost non-existent method of intervention other than an educational program. This would seem more depersonalized than in the first study intervention that is somewhat tailored to provide exercise, which is always healthy in moderate doses. Subsequently, while both papers have interventions, they are both at opposite ends of the bar from each other, certainly in the resulting benefits that they provide. In my practice, this research is beneficial because it shows that each patient must be treated individually and that the surrounding environment of that patient must also be addressed when designing a suitable intervention program that is to return health and wellness to a human life. It also reminds me that in practice, the review of research studies is always an important aspect of developing my practice in the information that these studies provide and how results can also provide me with a framework of developing solutions for my patients. Appendix A: RCT CASP Robitaille et al. (2005) Robitaille, Y, Laforest, S, Fournier, M, Gauvin, L, Parisien, M, Corriveau, H, Trickey, F and Damestoy, N 2005, ‘Moving Forward in Fall Prevention: An Intervention to Improve Balance Among Older Adults in Real-World Settings’, American Journal of Public Health, vol. 95, pp. 2049-2056. Paper Design RCT Appraisal Tool CASP for RCT 1.-Did the trial address a clearly focused issue? The purpose of the study was to determine the efficiency of a group-based exercise intervention, designed to improve balance among older adults. The intervention was called “Stand Up!” 2.-Was the assignment of patients to treatments randomized? There were two sets of community organizations: experimental (10) and control (7). The programs were offered consecutively rather than at the same time. 3.-Were all of the patients who entered the trial properly accounted for at its conclusion? Yes, they were all accounted for through final measurement assessments. Each data account was analysed through linear regression for each outcome variable using forward inclusion as noted in the study. 4.-Were patients, health workers and study personnel ‘blind’ to treatment? Each participant was assessed by the same trained physiotherapist who was blinded to group membership. Time trails were limited to a maximum of 60 seconds and two trials were carried out for each test with the better score used in analysis. Participant assessments were conducted at a location in each group’s neighbourhood to promote retention levels. 5.-Were the groups similar at the start of the trial? Yes, the minimum age was 65 years old to participate in the study and each person had either already had a fall or had concerns about falling. 6.-Aside from the experimental intervention, were the groups treated equally? Each group was treated the same in participant assessment and in collecting demographic data through face-to-face interviews covering physical health, health problems, medications, health and vitality, number of falls experienced in previous year, balance confidence and amount and variety of exercise typically done within the previous month. 7.-How large was the treatment effect? There were 200 participants recruited by all 17 groups and the cluster groupings were done with 5 to 17 at a time. Experimental groups offered the “Stand Up!” program while the control groups did not. 8.-How precise was the estimate of the treatment effect? All data was analysed with the same criteria and final results in the study showed the linear regression analysis. All data was put through the IBM SPSS analysis software program v.11. 9.-Can the results be applied to the local population? Community organizations participated in the program that, normally, offer similar exercise programs to the elderly and therefore, the purpose of the study was to determine if this could be applied to all elderly people. 10.-Were all clinically important outcomes considered? The main outcome of this study was to determine the measure of balance improvement (if any) in those in the intervention program as compared to the control group. The mean age for the total respondent population was 73.9 years with 84% females. Over half lived alone and 40% reported having fallen within the year before the intervention. 11.-Are the benefits worth the harm and risks? Only 1 person was eliminated from the initial trials during the capacity-to-exercise questionnaire because of obvious inability to do the proposed exercises. As shown, medical determination is essential to whether elderly adults can do the exercises in the program. Of the 213 initially interviewed, the final 200 were determined capable of doing the program. Results show that the benefits far outweigh the risks as most were capable of following the exercise regime set out for them. When conducted properly, there was very little risk for injury. Appendix B: RCT CASP Russell et al. (2010) Russell, MA, Hill, KD, Day, LM, Blackberry, I, Schwartz, J, Giummarram, MJ, Dorevitch, M, Ibrahim, JE, Dalton, AC, Econ, M & Dharmage, SC 2010, ‘A Randomized Controlled Trial of a Multifactorial Falls Prevention Intervention for Older Fallers Presenting to Emergency Departments’, Journal of the American Geriatrics Society, vol. 58, pp. 2265-2274. Paper Design RCT Appraisal Tool CASP for RCT 1.-Did the trial address a clearly focused issue? The objective was to investigate the effect of a referral-based targeted multifactorial falls prevention intervention on occurrence of recurrent falls and injuries in older seniors presented to an emergency department (ED) after a fall and discharged directly home from the ED. 2.-Was the assignment of patients to treatments randomized? Yes, this was a randomized control process and assessors of outcomes were blinded to group allocations. Definition of a fall was based on the Kellogg International Working Group (KIWG) definition. The FROP-Com assessment tool was primary in guiding referrals by measuring number of falls risk factors through previous falls, balance, independence in activities of daily living, scoring from 0-60. Final criteria for inclusion were English-speaking status and cognitive status. Research officers were unaware of randomization status. 3.-Were all of the patients who entered the trial properly accounted for at its conclusion? Yes, each was accounted for through the results analysis process. 4.-Were patients, health workers and study personnel ‘blind’ to treatment? Yes, health assessors were blinded to group allocations. Seven EDs in metropolitan Melbourne provided the settings. 5.-Were the groups similar at the start of the trial? Criteria inclusion to groups consisted of community dwellers aged 60 +, who had a fall and went to the ED and were discharged home. Those who were excluded were not able to follow instructions or walk independently. The intervention group had the addition of referral to a community group for further services in occupational therapy, physiotherapy and podiatry referrals. 6.-Aside from the experimental intervention, were the groups treated equally? Each respondent in one group was 60+, lived in community dwellings, suffered a fall and went to the ED for help and treatment and then was discharged home. The difference made was what happened after the ED discharge. 7.-How large was the treatment effect? There were 361 participants who were randomly chosen for standard care from the ED for inclusion in statistical review. The intervention group was 351 respondents, making a total of 712. 8.-How precise was the estimate of the treatment effect? The Fisher exact test was used to analyse the effects of the intervention on primary outcome variables. Effect of intervention on primary outcome variables of injury rates and fall rates was analysed using the negative binomial model. 9.-Can the results be applied to the local population? Results could certainly be made to the general public although recommendations would obviously be made on an individual basis after review. 10.-Were all clinically important outcomes considered? Yes, they were but there were little differences seen between the intervention and control groups and it was determined that further research was needed, perhaps a differently designed study too. 11.-Are the benefits worth the harm and risks? Any type of educational and/or physical program could only be beneficial in some manner although this study showed very little differences between the groups. Resources Fonda, D, Cook, F, Sandler, V & Bailey, M 2006, ‘Sustained reduction in serious fall-related injuries in older people in hospital’, Medical Journal of Australia, 17 April 2006, vol. 184, no. 8, pp. 379-382. Press Association 2010, ‘Soft flooring in hospitals could cut injuries from falls’, Nursing Times.net Online, 11 November 2010, available from accessed 18 April 2013. Robitaille, Y, Laforest, S, Fournier, M, Gauvin, L, Parisien, M, Corriveau, H, Trickey, F and Damestoy, N 2005, ‘Moving Forward in Fall Prevention: An Intervention to Improve Balance Among Older Adults in Real-World Settings’, American Journal of Public Health, vol. 95, pp. 2049-2056. Russell, MA, Hill, KD, Day, LM, Blackberry, I, Schwartz, J, Giummarram, MJ, Dorevitch, M, Ibrahim, JE, Dalton, AC, Econ, M & Dharmage, SC 2010, ‘A Randomized Controlled Trial of a Multifactorial Falls Prevention Intervention for Older Fallers Presenting to Emergency Departments’, Journal of the American Geriatrics Society, vol. 58, pp. 2265-2274. Sollitto, M 2013, ‘Why Do Elderly People Fall More Easily?’, AgingCare.com Online, Elder Care, Available from accessed 17 April 2013. Stevens, JA & Sogolow, ED 2005, ‘Gender differences for non-fatal unintentional fall related injuries among older adults’, Injury Prevention, vol. 11, pp.115-119. Read More