A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes

OBJECTIVES: to evaluate the effectiveness of a policy of making hip protectors available to residents of nursing homes. DESIGN: a cluster randomised controlled trial of the policy in nursing and residential homes, with the home as the unit of randomisation. SETTING: 127 nursing and residential homes in the greater Belfast area of Northern Ireland. PARTICIPANTS: 40 homes in the intervention group (representing 1,366 occupied beds) and 87 homes in the control group (representing 2,751 occupied beds). INTERVENTIONS: a policy of making hip protectors available free of charge to residents of nursing homes and supporting the implementation process by employing a nurse facilitator to encourage staff in the homes to promote their use, over a 72-week period. MAIN OUTCOME MEASURES: the rate of hip fractures in intervention and control homes, and the level of adherence to use of hip protectors. RESULTS: there were 85 hip fractures in the intervention homes and 163 in the control homes. The mean fracture rate per 100 residents was 6.22 in the intervention homes and 5.92 in the control homes, giving an adjusted rate ratio for the intervention group compared to the control group of 1.05 (95% CI 0.77, 1.43, P = 0.76). Initial acceptance of the hip protectors was 37.2% (508/1,366) with adherence falling to 19.9% (272/1,366) at 72 weeks. CONCLUSIONS: making hip protectors available to residents of nursing and residential homes did not reduce the rate of hip fracture. This research does not support the introduction of a policy of providing hip protectors to residents of nursing homes.     

Effectiveness and acceptability of a newly designed hip protector: a pilot study

Hip fracture has a significant economic and personal cost, involving hospital admission and functional impairment for elderly people. To assess the benefit of using a newly designed hip protector (new material and new design) to prevent fracture in a realistic setting, a randomised intervention-control design was used to trial the effectiveness of pads worn by high falls risk residents (n=71) in nursing home for 9 months. 40 residents were in the intervention group and 31 were in the control group. A profile of falls, including time of day, and orientation was obtained to demonstrate the potential effectiveness of the protectors for injury prevention. Acceptance of the hip protector was also surveyed amongst nursing home staff and residents. One hundred and one falls and six fractures occurred in the control group. In contrast, one hundred and ninety one falls and three fractures occurred in the hip protector (pads) group. The three fractures in the protector wearing group occurred when pads were not in place. This was extrapolated as 1 in every 16.8 falls and 1 in every 63.7 falls resulting in fracture in the two groups, respectively. The relative risk of fracture was 0.264 (95% CI=0.073-0.959) when the fracture incidence rate in the intervention group (three fractures per 191 falls) was compared to the control group (six fractures per 101 falls). This is a statistically significant result and implies that this newly designed hip protector is effective in preventing hip fracture. The majority of falls occurred during the day, which was when protectors were worn in this study, but the data on orientation was incomplete, with direction unknown in 74% of falls. Compliance was an issue, which was interpreted as only 50.3% of falls recorded with protectors in place. Dementia was identified as the explanation for this as the pads were often removed by these residents who comprised the majority of participants. Perception of low risk was the primary barrier to residents accepting the intervention. Comfort of protectors was not a significant concern for staff or residents, and only staff described appearance as an issue. In conclusion, the newly designed hip protector is protective against fractures in a realistic setting. Compliance and acceptance of the protectors will ultimately determine the viability of this prophylaxis.     

Predictors of adherence with the recommended use of hip protectors

BACKGROUND: Hip protectors can prevent many hip fractures in older persons at high risk for falling. Few published studies have investigated the use of hip protectors in community-dwelling older persons, and the level of adherence with their use, and predictors of adherence in this setting, are not clear. The aim of this study was to report the predictors of adherence and the level of adherence with the use of hip protectors in frail community-dwelling older women. METHODS: This cohort study of the intervention group of a randomized, controlled trial recruited participants from aged care health services in urban areas of northern Sydney, Australia. Participants were 302 women who were 74 years or older (mean age, 83 years) and who had 2 or more falls or 1 fall requiring hospital admission in the previous year and who lived in their own homes. The main outcome measure was adherence with the use of hip protectors. RESULTS: Adherence was approximately 53% during the 2 years of the study, and hip protectors were worn at the time of 51% of falls. The significant independent predictors of nonadherence with hip protector use were lower self-efficacy for hip protector use (odds ratio [OR], 0.51; 95% confidence interval [CI],.33 to.79), higher number of perceived barriers to hip protector use (OR, 0.52; 95% CI, .38 to.72), and lower self-rated health (OR, 0.71; 95% CI, .55 to.93). CONCLUSIONS: Three easily measured factors independently predicted subsequent adherence with hip protector use. These findings may form the basis for strategies to improve adherence with the use of hip protectors and with other types of treatment or preventive strategies in older persons.     

Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial

OBJECTIVES: To evaluate the effectiveness of a multifactorial fall prevention program in prespecified subgroups of nursing home residents.
DESIGN: Secondary analysis of a cluster-randomized, controlled trial.
SETTING: Six nursing homes in Germany.
PARTICIPANTS: Seven hundred twenty-five long-stay residents; median age 86; 80% female.
INTERVENTION: Staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training.
MEASUREMENTS: Time to first fall and the number of falls. Falls were assessed during the 12-month intervention period. Univariate regression analyses were performed, including a confirmatory test of interaction.
RESULTS: The intervention was more effective in people with cognitive impairment (hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35–0.69) than in those who were cognitively intact (HR=0.91, 95% CI=0.68–1.22), in people with a prior history of falls (HR=0.47, 95% CI=0.33–0.67) than in those with no prior fall history (HR=0.77, 95% CI=0.58–1.01), in people with urinary incontinence (HR=0.59, 95% CI=0.45–0.77) than in those with no urinary incontinence (HR=0.98, 95% CI=0.68–1.42), and in people with no mood problems (incidence rate ratio (IRR)=0.41, 95% CI=0.27–0.61) than in those with mood problems (IRR=0.74, 95% CI=0.51–1.09).
CONCLUSION: The effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, a history of falls, urinary incontinence, and depressed mood were important in determining response.     

Predictors of uptake and adherence to the use of hip protectors among nursing-home residents

The aim of the present study was to identify predictors for initial uptake and adherence with the use of hip protectors when offering hip protectors free of charge to nursing-home residents. An 18 months prospective follow up study was carried out in 18 Norwegian nursing homes. One thousand two hundred and thirty-six residents were included in the study of which 604 started to use a hip protector. A multivariate logistic regression model was used to identify predictors for the initial uptake. A Cox proportional hazard model was used to identify predictors for adherence. A stepwise backward strategy was used in both the logistic and in the Cox regression. The effect of nursing homes as clusters was adjusted for in the analysis. The uptake rate among all residents was 46% and the adherence was approximately 75% after 3 months, and approximately 60% after 18 months. Female gender [odds ratio (OR): 1.54, 95% CI: 1.06–2.24, P = 0.022], previous fractures (OR: 1.67, 95% CI: 1.02–2.75, P = 0.043), previous falls (OR: 2.08, 95% CI: 1.35–3.19, P < 0.001) and memory (not able to memorise: OR: 3.71, 95% CI: 2.09–6.59, P < 0.001, large problems with memorising: OR: 2.85, 95% CI: 1.81–4.49, P < 0.001, medium problems with memorising: OR: 2.45, 95% CI: 1.39–4.33, P = 0.002, some problems with memorising: OR: 1.99, 95% CI: 1.14–3.48, P = 0.016) seemed to be important predictors for uptake. Among those who took up the offer male gender (HR: 1.71, 95% CI: 1.00–2.91, P = 0.049), memory (not able to memorise: HR: 0.26, 95% CI: 0.14–0.50, P < 0.001, large problems with memorising: HR: 0.32, 95% CI: 0.22–0.45, P < 0.001, medium problems with memorising: HR: 0.46, 95% CI: 0.30–0.73, P < 0.001, some problems with memorising: HR: 0.49, 95% CI: 0.32–0.73, P = 0.001) and bowel incontinence (HR: 0.41, 95% CI: 0.25–0.66, P < 0.001) were predictors for a lower probability of ending hip protector use. Factors related to a high risk of falling were important predictors for both uptake and adherence. The fact that neither memory impairments nor incontinence (bowel) seemed to be barriers to hip protector use is important since these characteristics are common among nursing-home residents and tertiary prevention such as the use of hip protectors is probably the most feasible intervention to prevent hip fractures in this group.     

Effectiveness of a multifaceted intervention on falls in nursing home residents

OBJECTIVES: To evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers. DESIGN: Prospective, cluster-randomized, controlled 12-month trial. SETTING: Six community nursing homes in Germany. PARTICIPANTS: Long-stay residents (n = 981) aged 60 and older; mean age 85; 79% female. INTERVENTIONS: Staff and resident education on fall prevention, advice on environmental adaptations, progressive balance and resistance training, and hip protectors. MEASUREMENTS: Falls, fallers, and fractures. RESULTS: The incidence density rate of falls per 1,000 resident years (RY) was 2,558 for the control group (CG) and 1,399 for the intervention group (IG) (relative risk (RR) = 0.55, 95% confidence interval (CI) = 0.41-0.73). Two hundred forty-seven (52.3%) fallers were detected in the CG and 188 (36.9%) in the IG (RR = 0.75, 95% CI = 0.57-0.98). The incidence density rate of frequent fallers (>2/year) was 115 (24.4%) for the CG and 66 (13.0%) for the IG (RR = 0.56, 95% CI = 0.35-0.89). The incidence density rate of hip fractures per 1,000 RY was 39 for the CG and 43 for the IG (RR = 1.11, 95% CI = 0.49-2.51). Other fractures were diagnosed with an incidence density rate of 52 per 1,000 RY for CG and 41 per 1,000 RY for IG (RR = 0.78, 95% CI = 0.57-1.07). CONCLUSION: The incidence density rate of falls and fallers differed considerably between the control and intervention groups. The study was underpowered to demonstrate a significant difference of hip or nonhip fractures. Because of a low fracture rate in both groups, the investigation of fracture rates would have required a larger sample size to detect an effect of the intervention.     

Acceptability and compliance with wearing energy-shunting hip protectors: a 6-month prospective follow-up in a Finnish nursing home

OBJECTIVES: To assess the acceptability and compliance with use of an energy-shunting hip protector in institutionalized elderly people. DESIGN AND SETTING: A 6 month prospective follow-up in a Finnish nursing home. PARTICIPANTS: 19 ambulatory nursing home residents with a high risk of hip fracture. MAIN OUTCOME MEASURES: The proportion of the residents who were willing to use the device, the number of hours of wearing the protector and the attitudes of the study subjects and the caregivers towards the appearance, comfort, fit, efficacy and laundering of the protector. RESULTS: 12 of the 19 ambulatory residents (63%) agreed to use the protector. During the study period, these subjects wore the protector on average for more than 90% of their active days, i.e. the days they were mobile. Two subjects wore the protectors at night time; the rest only during waking hours. Mean wearing time during waking hours exceeded 90%. CONCLUSION: External hip joint protectors are a feasible strategy to prevent hip fractures in institutionalized elderly people. The attitude, education and motivation of the staff may be a factor in achieving good user compliance. Further community-based studies on acceptability and compliance in wearing external hip joint protectors are needed for verification of benefits to the general population of older people.     

A cost-benefit analysis of external hip protectors in the nursing home setting

OBJECTIVES: To estimate potential cost savings generated by a program of hip protectors in the nursing home from a Medicare perspective. DESIGN: A state-transition Markov model considering short-term and long-term outcomes of hip protectors for a hypothetical nursing home population, stratified by age, sex, and functional status. Costs, transition probabilities between health states, and estimates of hip protectors' effectiveness were derived from published secondary data. SETTING: Nursing home facilities in the United States. PARTICIPANTS: Hypothetical cohort of permanent nursing home residents aged 65 and older without a previous hip fracture. INTERVENTION: Program of hip protectors reimbursed by Medicare. MEASUREMENTS: Number of fractures, life years, and dollars saved. RESULTS: Three pairs of hip protectors replaced annually would result in a weighted average lifetime absolute risk reduction for hip fracture of 8.5%, with net lifetime savings to Medicare of 223 dollars per resident. When the annual cost of hip protectors is less than 151 dollars per person, relative risk of fracture is less than or equal to 0.65 with hip protectors, or adherence is greater than 42%, hip protectors are cost saving to Medicare over a wide range of assumptions. Extrapolating these results to the estimated population of U.S. nursing home residents without a previous hip fracture, Medicare could save 136 million dollars in the first year of a hip-protector reimbursement program. CONCLUSION: From a Medicare perspective, hip protectors are a cost-saving intervention in the nursing home setting when hip protector effectiveness is less than or equal to 0.65 over the remaining lifetime of subjects.     

Fall Direction, Bone Mineral Density, and Function: Risk Factors for Hip Fracture in Frail Nursing Home Elderly

Purpose: To determine the importance of fall characteristics, body habitus, function, and hip bone mineral density as independent risk factors for hip fracture in frail nursing home residents.Subjects and Methods: In this prospective, case-control study of a single, long-term care facility, we enrolled 132 ambulatory residents (95 women and 37 men) aged 65 and older, including 32 cases (fallers with hip fracture) and 100 controls (fallers with no hip fracture). Principal risk factors included fall characteristics, body habitus, measures of functional assessment, and hip bone mineral density by dual-energy X-ray absorptiometry.Results: In multivariate analysis, including only those with knowledge of the fall direction (n = 100), those who fell and suffered a hip fracture were more likely to have fallen sideways (odds ratio 5.7, 95% confidence interval [CI] 1.7 to 18, P = 0.004) and have a low hip bone mineral density (odds ratio 1.9, 95% CI 0.97 to 3.7, P = 0.06) than those who fell and did not fracture. When all participants were included (n = 132) and subjects who did not know fall direction were coded as not having fallen to the side, a fall to the side (odds ratio 3.9, 95% CI 1.3 to 11, P = 0.01), low hip bone density (odds ratio 1.8, 95% CI 1.03 to 3, P = 0.04), and impaired mobility (odds ratios 6.4, 95% CI 1.9 to 21, P = 0.002) were independently associated with hip fracture. Sixty-seven percent of subjects (87% with and 62% without hip fracture) had a total hip bone mineral density greater than 2.5 SD below adult peak bone mass and were therefore classified as having osteoporosis using World Health Organization criteria.Conclusions: Among frail elderly nursing home fallers, the preponderance of whom are osteoporotic, a fall to the side, a low hip bone density, and impairment in mobility are all important and independent risk factors for hip fracture. These data suggest that, among the frailest elderly, measures to reduce the severity of a sideways fall and improve mobility touch on new domains of risk, independent of bone mineral density, that need to be targeted for hip fracture prevention in this high-risk group.     

Effectiveness of a multifactorial intervention to reduce physical restraints in nursing home residents

OBJECTIVES: To evaluate the effectiveness of a multifactorial intervention to reduce the use of physical restraints in residents of nursing homes. DESIGN: Cluster‐randomized controlled trial. SETTING: Forty‐five nursing homes in Germany. PARTICIPANTS: Three hundred thirty‐three residents who were being restrained at the start of the intervention. INTERVENTION: Persons responsible for the intervention in the nursing homes attended a 6‐hour training course that included education about the reasons restraints are used, the adverse effects, and alternatives to their use. Technical aids, such as hip protectors and sensor mats, were provided. The training was designed to give the change agents tools for problem‐solving to prevent behavioral symptoms and injuries from falls without using physical restraints. MEASUREMENTS: The main outcome was the complete cessation of physical restraint use on 3 consecutive days 3 months after the start of the intervention. Secondary outcomes were partial reductions in restraint use, percentage of fallers, number of psychoactive drugs, and occurrence of behavioral symptoms. RESULTS: The probability of being unrestrained in the intervention group (IG) was more than twice that in the control group (CG) at the end of the study (odds ratio=2.16, 95% confidence interval=1.05–4.46). A partial reduction of restraint use was also about twice as often achieved in the IG as in the CG. No negative effect was observed regarding medication or behavioral symptoms. The percentage of fallers was higher in the IG. CONCLUSION: The intervention reduced restraint use without a significant increase in falling, behavioral symptoms, or medication.     

Increased use of hip protectors in nursing homes: economic analysis of a cluster randomized, controlled trial

OBJECTIVES: To assess the cost-efficacy of an intervention program aimed at reducing hip fractures. DESIGN: Economic evaluation within an 18-month cluster randomized trial. SETTING: Forty-nine nursing homes in Hamburg, Germany. PARTICIPANTS: Residents with a high risk of falling (intervention group (IG), n=459; control group (CG), n=483). INTERVENTION: Education session for nurses, who subsequently educated residents, and provision of three hip protectors per resident. CG care was optimized by providing brief information to nurses about hip protectors and providing two protectors per nursing home for demonstration purposes. MEASUREMENTS: Main outcomes were hip fractures, costs, and incremental cost-effectiveness ratio (ICER). RESULTS: The intervention was effective in reducing hip fractures (21 in the IG vs 42 in the CG) and resulted in a cost difference of 51 dollars per participant in favor of the CG (95% confidence interval covering cost saving of 242 dollars to cost expense of 325 dollars). Costs per additional hip fracture avoided were 1,234 dollars. Sensitivity analyses aimed at investigating robustness of the results to a real practice implementation scenario resulted in ICERs varying from 439 dollars to 1,693 dollars. Taking into account lower hip protector reimbursement levels, the intervention program would be cost saving (break-even point within the base case analysis=22 dollars per hip protector). CONCLUSION: A program consisting of education and provision of hip protectors might produce a slight increase in costs or might even be cost saving if the price of the hip protector could be decreased.     

Hip protectors improve falls self-efficacy

OBJECTIVES: To investigate the effect of use of external hip protectors on subjects' fear of falling and falls self-efficacy (belief in their own ability to avoid falling). DESIGN: Randomized controlled trial. SETTING: Aged-care health services in Sydney, Australia. PARTICIPANTS: 131 women aged 75 years or older, who had two or more falls or one fall requiring hospital admission in the previous year and who live at home. Sixty-one subjects were in the intervention group and 70 in the control group. INTERVENTION: Use of external hip protectors and encouragement to use the protectors by an adherence nurse. MEASUREMENTS: At the time of enrolment into a wider study examining the effect of hip protectors on hip fractures, participants recruited at home completed an assessment of fear of falling and falls efficacy as measured by the Falls Efficacy Scale and the Modified Falls Efficacy Scale. At 4-month follow-up, these scales were readministered by an observer who was not aware of the allocation of the participant to intervention or control groups. RESULTS: Fear of falling and falls self-efficacy, as measured by the Falls Efficacy and Modified Falls Efficacy Scales, were similar at baseline in both groups. Fear of falling was present at follow-up in 43% of subjects using hip protectors and 57% of the control group (chi2 = 2.58, P = 0.11). Hip protector users had greater improvement in falls self-efficacy at follow-up as measured by the Falls Efficacy Scale (t = 2.44, P = 0.016) and the Modified Falls Efficacy Scale (t = 2.08, P = 0.039). CONCLUSION: Hip protectors improve falls self-efficacy. As users of hip protectors feel more confident that they can complete tasks safely, they may become more physically active and require less assistance with activities of daily living.     

Hip protectors in aged-care facilities: a randomized trial of use by individual higher-risk residents.

OBJECTIVES: To investigate the effect of use of external hip protectors on occurrence of hip fracture. DESIGN: Randomized controlled trial, with randomization at the individual level. SETTING: residential aged-care facilities in urban areas of New South Wales, Australia. PARTICIPANTS: 174 women, aged 75 years and older, who had had two or more falls or one fall requiring hospital admission in the previous 3 months, and who lived in hostels or nursing homes. Eighty-six subjects were in the intervention group and 88 in the control group. INTERVENTION: Use of external hip protectors and encouragement by nurses to use the protectors. MEASUREMENTS: Follow-up visits at approximately 2 weeks and 2, 10 and 18 months to determine falls and fall injury (including hip fracture); we also measured adherence to hip protector use. RESULTS: The mean age of participants was 85; they lived in 32 different aged-care facilities, two-thirds of which were nursing homes. Intervention and control groups had similar baseline characteristics, with a mean Barthel index of 58 at enrollment and a mean Short Portable Mental Status Questionnaire score of six errors, indicating severe disability and major cognitive impairment. During follow-up, a mean of 4.6 falls per person occurred. There was no difference in mortality, with 28 deaths in each group. Eight hip fractures occurred in the intervention group and seven in the control group (hazard ratio 1.46; 95% confidence interval 0.53-4.51). No hip fractures occurred when hip protectors were being worn as directed. Adherence was about 57% over the duration of the study and hip protectors were worn at the time of 54% of falls in the intervention group. Adherence varied markedly between institutions, but the greatest was about 80%. CONCLUSION: Hip protectors were not effective in reducing the incidence of hip fractures in this study, but because of low statistical power, a reduction in risk of hip fracture of up to 50% may not have been detected. There was limited adherence with their use, resulting in a large number of falls occurring without hip protectors in place. All hip fractures in the intervention group occurred when hip protectors were not being used.     

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES: To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.
DESIGN: Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.
SETTING: Eleven medical and surgical units in one 600-bed teaching hospital.
PARTICIPANTS: One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.
MEASUREMENTS: Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient–registered nurse (RN) ratio, patient–total nursing staff ratio, and skill mix.
RESULTS: Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient–RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38–2.68, P < .001; weekend day and patient–total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37–2.66, P < .001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37–2.67, P < .001).
CONCLUSION: Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.     

Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts

OBJECTIVES: To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction. DESIGN: Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design. SETTING: Three nonprofit, religion-affiliated nursing homes in a metropolitan area. PARTICIPANTS: The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years. MEASUREMENTS: Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined. RESULTS: Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use. CONCLUSION: Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.     

Randomised controlled trial of hip protectors for the prevention of second hip fractures

OBJECTIVE: to assess whether the use of Safehip hip protectors would prevent second hip fractures among men and women living in the community. DESIGN: pragmatic randomised controlled trial. SETTING: people living in the community. PARTICIPANTS: men and women aged 70 years and over who had sustained one hip fracture and who were living in the community. RESULTS: 366 men and women who were either living outside residential care or were about to be discharged back home were randomised to receive three pairs of hip protectors or to act as controls. Approximately 34% of participants allocated to receive hip protectors wore them every day. After a median follow up of 14 months 8 participants had a second hip fracture with 6 in the intervention and 2 in the control group (Odds Ratio for second hip fracture=3.10, 95% confidence interval 0.62-15.58). Hip protectors had no effect on risk of other fractures or on falls. CONCLUSION: this trial does not suggest a benefit of the studied hip protector among people living outside residential accommodation.     

Orthostatic hypotension does not predict recurrent falling in a nursing home population

ObjectiveMost studies regard orthostatic hypotension (OH) as a causal factor for falls. However, the evidence is lacking for this assumption. We aimed to investigate the relationship between orthostatic hypotension and fall incidents in nursing home residents.MethodsA total of 249 patients was included in a prospective observational cohort study of nursing home residents. Falls were prospectively registered. Cox proportional hazard modelling and the conditional frailty model were used to analyse the relationship between OH and (recurrent) falling.ResultsAmong the 249 patients, 450 falls were recorded during follow-up and OH was present in 93 out of 249 patients. No significant associations were found between OH and the first fall incident (Hazard Ratio (HR) 1.01 (95% Confidence Interval (CI) 0.60–1.69) and recurrent falling (HR 1.21 (95%CI 0.65–2.24)).ConclusionsAlthough falling and OH were both highly prevalent in nursing home residents, no relationship between OH and falling was found.     

An in-service evaluation of hip protector use in residential homes

BACKGROUND: The establishment of a hip protector service has allowed us to study eligibility, acceptability and compliance with use, reasons for non-use, and the effect of dementia, confusion, incontinence and risk of falling. METHODS: All residents in all residential homes in Poole were assessed at baseline. All eligible residents were offered 1 week's trial of protectors and those who wished to continue were given a set of protectors. Compliance was assessed at 3, 6 and 12 months. Percentages shown for compliance exclude those who died, were transferred, had lost data or in whom follow-up was not yet completed. RESULTS: Over 18 months, 873 residents from 47 homes were identified (mean age 88 years, female:male 4.5:1). Of these, 745 were considered eligible to wear protectors (86%) and 535 agreed to wear them after 1 week (72%). Compliance over 12 months was 78%. Most wearers wore protectors every day. At 3 months, 83% of demented compared to 73% of not demented residents (P = 0.023), 86% of always confused, 77% of sometimes confused and 72% of never confused (P < 0.009) and 82% of incontinent compared to 73% of continent residents (P = 0.024) were wearing hip protectors. There was a positive linear trend between the risk of falling and compliance (P = 0.048). CONCLUSIONS: The results suggest that there is a 48% chance of a resident wearing the protectors after 1 year. The higher compliance among those with dementia, confusion, incontinence and at high risk of falling supports the concept that hip protectors are worn by those at greatest risk of fracture.     

Will elderly rest home residents wear hip protectors?

BACKGROUND: Hip fracture is a common cause of morbidity and mortality in elderly people, for whom osteoporosis, the risk of falling and direct trauma to the hip during the fall are the major risk factors. External hip protectors have been developed which reduce the risk of hip fracture after a fall. However, compliance with their use is uncertain. We addressed this issue in a sample of elderly Dorset rest home residents over a 3-month period. METHODS: 31 rest homes agreed to participate. Of the 288 female subjects approached, 141 gave their informed consent and 101 were allocated to the intervention arm of the study. Their ages ranged from 64 to 98 years, and 44% reported a fall during the preceding 12 months. Each subject was fitted with three pairs of protector pads (Sahvatex, Denmark) sewn into specially designed undergarments. Randomly timed fortnightly visits were made to each subject to assess compliance for 12 weeks. FINDINGS: 27 subjects were compliant for the whole study period; 54 wore the protector pads for less than a week, largely for reasons of poor fitting or discomfort; the remainder withdrew at varying intervals between 1 and 12 weeks. During the study period, there were nine recorded falls onto the hip, six of which occurred in women wearing protectors. None resulted in hip fracture. CONCLUSION: Approximately 50% of elderly rest home residents who are mentally able would wear hip protectors in order to prevent hip fractures. Long-term compliance drops to about 30%. Compliance could be increased substantially if the pads and undergarments were modified to enhance their fit and to reduce the discomfort associated with their use.     

Validation of a quality of life questionnaire measuring the subjective fear of falling in nursing home residents

A quality of life scale was developed to measure the subjective fear of falling in nursing home residents. We assessed the dimensions fear of falling, daily living and social life within a randomized controlled trial of hip protector use. The Nottingham Health Profile (NHP) was used for validation. Statistical analysis covered factor analysis, internal consistency of subscales, construct and discriminant validity. Factor analysis revealed three reliable components (Cronbach's Alpha): fear of falling (0.92), social restriction due to limited mobility (0.74) and restriction by clothes due to the hip protector (0.72). The subscales fear of falling and social restriction were significantly intercorrelated with all subscales of the NHP. The new tool is a reliable and valid measure of fear of falling in nursing home residents. However, generalizability and applicability are limited by the small proportion of subjects able to complete the tests.