Reliability of the Home Falls and Accidents Screening Tool (HOME FAST) for identifying older people at increased risk of falls

Purpose : The Home Falls and Accidents Screening Tool (HOME FAST) was designed as part of a comprehensive health assessment instrument to measure falls risk for older people within their home environment. This paper describes the evaluation of the inter-rater reliability of the HOME FAST. Method : Forty home visits were undertaken, in urban and rural settings of the UK, by pairs of raters, one of whom was an expert rater. Occupational therapists, occupational therapy assistants and a social worker rated each home using the HOME FAST concurrently with an expert rater. The kappa statistic was used to determine the degree of agreement between pairs of raters. Results : The overall kappa value for the checklist was 0.62, indicating a fair to good level of agreement between raters. 'Hazardous outside paths' was the only item that demonstrated poor agreement (kappa=0.30). The expert rater consistently identified more hazards than the other raters, and the level of agreement was stable between raters irrespective of the number of hazards present in the homes visited. Conclusions : Definitions of non-applicable household features and improving the objectivity of the operational definitions for recognizing hazards that demand more qualitative judgements will enhance the reliability of the HOME FAST.     

Evaluation of the clinical utility of the Home Falls and Accidents Screening Tool (HOME FAST)

Purpose: The HOME FAST was developed and trialled in Australia as a screening tool designed to be used by any health professional to identify older people at increased risk of falls and to facilitate referral for more detailed assessment and intervention. This study aimed to evaluate the clinical utility of the HOME FAST from the perspective of users.

Method: A mixed-methods approach using survey data (n?=?32), focus group data (n?=?46) and interview data (n?=?5) from occupational therapists, physiotherapists, community nurses and other health professionals working in hospitals, community services and private practice, located in the UK, Canada and Australia. Data were integrated using a matrix of quantitative and qualitative data that aligned the findings with established theoretical constructs of clinical utility.

Results: Findings across the data sources provide evidence of the clinical utility of the HOME FAST, and these findings align with theoretical constructs about how a tool such as the HOME FAST is adopted in practice.

Conclusion: The HOME FAST can be used in a variety of international setting in developed countries and by different health professionals as a screening tool. A manual would assist in the consistent application of the HOME FAST.

• Implications for Rehabilitation

• Hazards in the home environment are a key contributor to falls risk for older people

• The Home Falls and Accidents Screening Tool (HOME FAST) was designed for any health professional to screen older people at increased risk of falling because of home hazards.

• Even with psychometric evidence of the reliability and validity of a tool, it is critical that the tool can be easily adopted by clinicians (clinical utility), otherwise its applicability to practice and research is limited.

• An international mixed-method study has provided evidence of the clinical utility of the HOME FAST.

     

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department

Objective: To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED. Methods: A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross‐sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non‐consecutive participants. Participants were categorized as non‐fallers, frail mechanical or active mechanical fallers. Self‐reported falls in past 6 months and hospital admission were documented. Results: Participant age and sex (median age 74, interquartile range 65–82 years; male 59%, 74/126, 95% CI 50–67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9–21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non‐faller (relative risk [RR]: 1.5, 95% CI 1.0–2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0–10.9, Fisher's Exact test P= 0.02) or a non‐faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0–2.1, P= 0.001). Malnourished participants had an increased risk of self‐reported falls over 6 months (RR: 1.5, 95% CI 1.0–2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well‐nourished (RR: 5.3, 95% CI 1.4–20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78–92%) of participants assessed as malnourished by Subjective Global Assessment. Conclusions: Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.     

Validating the Falls Behavioural (FaB) scale for older people: a Rasch analysis

Purpose. Rasch modelling was used to establish the validity and robustness of the Falls Behavioural (FaB) Scale for Older people.

Methods. The sample comprised 678 community-residing elderly people aged 65 - 98 years. Data were analysed by calculating goodness of fit statistics, principal components analysis of residuals and by exploring the effectiveness of the category rating response-scale.

Results. A partial-credit rating scale was the best fitting solution and the major change to the original version of the FaB. Analysis supported a 29-item intervention version and a briefer 24-item outcome evaluation (research) version. The latter produced item mean infit statistics of 1.00 (Z = 0.0, SD = 0.33) and mean outfit statistics of 1.03 (Z = 0.0, SD = 0.53), a person separation of 2.36 and internal reliability of 0.85.

Conclusion. The 29 item partial rating scale is valid, reliable and would be useful in clinical situations when used as a prompt for discussion and in raising clients' awareness of potential hazards; it also can be used as an outcome measure. The short form is a useful alternate for evaluating the effectiveness of fall reduction interventions that aim to encourage protective strategies when negotiating the environment, mobilizing and doing activities of daily living. Both scales would be improved by adding very difficult and very easy items to increase the range of ability levels of the people to whom it can be applied with precision.     

Validating the Falls Behavioural (FaB) scale for older people: A Rasch analysis

Purpose. Rasch modelling was used to establish the validity and robustness of the Falls Behavioural (FaB) Scale for Older people.

Methods. The sample comprised 678 community-residing elderly people aged 65 – 98 years. Data were analysed by calculating goodness of fit statistics, principal components analysis of residuals and by exploring the effectiveness of the category rating response-scale.

Results. A partial-credit rating scale was the best fitting solution and the major change to the original version of the FaB. Analysis supported a 29-item intervention version and a briefer 24-item outcome evaluation (research) version. The latter produced item mean infit statistics of 1.00 (Z = 0.0, SD = 0.33) and mean outfit statistics of 1.03 (Z = 0.0, SD = 0.53), a person separation of 2.36 and internal reliability of 0.85.

Conclusion. The 29 item partial rating scale is valid, reliable and would be useful in clinical situations when used as a prompt for discussion and in raising clients' awareness of potential hazards; it also can be used as an outcome measure. The short form is a useful alternate for evaluating the effectiveness of fall reduction interventions that aim to encourage protective strategies when negotiating the environment, mobilizing and doing activities of daily living. Both scales would be improved by adding very difficult and very easy items to increase the range of ability levels of the people to whom it can be applied with precision.     

Cross-cultural validation of the Falls Efficacy Scale-International to assess concerns about falls among Hungarian community-living older people

Abstract

Purpose: The Falls Efficacy Scale-International (FES-I) is a reliable and valid tool for assessing concerns about falling. Our aims were to translate, culturally adapt, and evaluate the main psychometric characteristics (internal consistency, reproducibility, and convergent construct validity) of the Hungarian version of the FES-I on a sample of community-living older adults.

Methods: After translating and culturally adapting the original scale, 165 community-living older adults (aged 60?years or over) participated in the measurements and filled in the questionnaire. After two weeks, a subsample of 64 persons filled in the FES-I again to determine the test–retest reliability.

Results: The test–retest analysis showed excellent reliability: Intraclass Correlation Coefficient was 0.831. The FES-I Hungarian consisted of two factors that showed good internal consistency: Cronbach’s alpha 0.95 (Factor 1), 0.89 (Factor 2), and 0.93 (whole scale). The FES-I was able to discriminate the participants based on gender and fall history. It showed a significant correlation with the Timed Up and Go test (r?=?0.740) and the general health perception (r?=??0.713).

Conclusions: Translation and cultural adaptation of the original scale were successful. The Hungarian version proved to be a reliable, valid tool confirming that it can be used in future clinical and scientific work with Hungarian older people.

• Implications for rehabilitation

• Excessive concerns about falls may lead to avoidance of activities, decreasing functional abilities, increasing of risk of a future fall, ultimately premature nursing home admission.

• The Falls Efficacy Scale-International is a widespread tool for assessing concerns about falls.

• The Hungarian version of Falls Efficacy Scale-International has an excellent test–retest reliability, good internal consistency, and acceptable construct validity.

• The Hungarian version of Falls Efficacy Scale-International is a valid and reliable tool for measuring the concerns about falls among Hungarian-speaking community-living older people in everyday clinical practice and scientific studies.

     

Proof of concept for perturbation-based balance training in older adults at a high risk for falls

Bieryla KA, Madigan ML. Proof of concept for perturbation-based balance training in older adults at a high risk for falls.

Objective

To investigate the efficacy of perturbation-based balance training (PBBT) on time to stabilization (TTS) after a nonstepping response to a postural perturbation in older adults at a high risk for falls.

Design

Single-subject design. Participants completed 4 baseline tests, 1 month of PBBT, and posttraining tests both 1 week and 1 month after training.

Setting

Assisted-living facility.

Participants

Older adults (N=5; mean ± SD age, 85±6.5y; residents of assisted-living facility) at a high risk for falls.

Intervention

PBBT involved 3 sessions a week for 4 weeks. Each session involved standing for 50 trials on a pneumatic instrumented moving platform that translated 0 to 0.08m forward or 0 to 0.13m backward in approximately 390ms (average velocity, 0.25m/s).

Main Outcome Measures

Time to stabilization of center of pressure (COP) after a perturbation on the moving platform.

Results

TTS of COP was 41.6% shorter than baseline tests (P<.001) 1 week after completing PBBT and 46.3% shorter than baseline tests (P<.001) 1 month after completing PBBT.

Conclusions

PBBT improved TTS after a postural perturbation in older adults at a high risk for falls, and these improvements were retained for 1 month.     

Falls in older people: the role of assessment in prevention and care

Falls among older people constitute a serious public health problem, which has a substantial impact on both the person and on healthcare services. Falls assessment can be divided into a number of types. Community nurses are well placed to use falls risk checklists to identify older people who may be at risk of falling and then offer these individuals a more in-depth assessment. In addition, community nurses have a role to play in assessing older people who have recently fallen to prevent future falls and potential injury. Falls prevention programmes centre on the identification of risk factors and the planning and delivery of interventions designed to eliminate or ameliorate these risks. A falls assessment should include a review of intrinsic factors such as mobility, lower extremity functioning, vision, medications, footwear and past medical history. It is also important to consider extrinsic factors such as tripping, slipping and other environmental hazards.     

The circumstances of falls among people with Parkinson's disease and the use of Falls Diaries to facilitate reporting

Purpose. Falls are common in Parkinson's disease (PD). Falls Diaries are one way of recording fall frequency and the surrounding circumstances; completing them encourages recall, and their content focuses intervention. We reviewed the diaries completed by people with PD during a randomized controlled trial (RCT) of fall prevention to ascertain the key circumstances surrounding falls. Method. We asked independently mobile, cognitively intact people with a diagnosis of PD to maintain a Falls Diary throughout a six-month RCT. We sent monthly diary sheets on which to answer questions about the 'Location', 'Fall-related activity', 'Perceived cause', 'Landing' and 'Consequences' of every fall. We coded responses and counted frequencies. Results. Of the 142 RCT participants (mean age 72 years; mean years since diagnosis 8), 135 completed the trial and their diary. We excluded 11 (8%) for missing data and/or unintelligible writing. The 124 remaining diaries recorded 639 falls: 80% happened at home, commonly in bedrooms, living areas, kitchens and gardens. Fallers had been ambulant in 45% of events, standing in 32% and transferring in 21%. Six 'activity-cause combinations' accounted for 55% of falls (tripping 13%; freezing, festination and retropulsion 11%; and postural instability when bending or reaching 9%, transferring 8%, walking 7% and washing or dressing 7%). Misjudgement and distraction played a part in 12% of falls described. Conclusions. Of over 600 falls surveyed, most happened at home, provoked by postural instability, tripping and freezing. Environmental adaptation and cognitive training should be trialled in falls prevention in PD, plus or minus traditional movement rehabilitation. Most participants completed Falls Diaries successfully. We advocate diary use, with follow-up interviews, in research and clinically. People with handwriting difficulty may require a typed diary, proxy diarist or interview.     

The circumstances of falls among people with Parkinson's disease and the use of Falls Diaries to facilitate reporting

Purpose. Falls are common in Parkinson's disease (PD). Falls Diaries are one way of recording fall frequency and the surrounding circumstances; completing them encourages recall, and their content focuses intervention. We reviewed the diaries completed by people with PD during a randomized controlled trial (RCT) of fall prevention to ascertain the key circumstances surrounding falls.

Method. We asked independently mobile, cognitively intact people with a diagnosis of PD to maintain a Falls Diary throughout a six-month RCT. We sent monthly diary sheets on which to answer questions about the ‘Location’, ‘Fall-related activity’, ‘Perceived cause’, ‘Landing’ and ‘Consequences’ of every fall. We coded responses and counted frequencies.

Results. Of the 142 RCT participants (mean age 72 years; mean years since diagnosis 8), 135 completed the trial and their diary. We excluded 11 (8%) for missing data and/or unintelligible writing. The 124 remaining diaries recorded 639 falls: 80% happened at home, commonly in bedrooms, living areas, kitchens and gardens. Fallers had been ambulant in 45% of events, standing in 32% and transferring in 21%. Six ‘activity-cause combinations’ accounted for 55% of falls (tripping 13%; freezing, festination and retropulsion 11%; and postural instability when bending or reaching 9%, transferring 8%, walking 7% and washing or dressing 7%). Misjudgement and distraction played a part in 12% of falls described.

Conclusions. Of over 600 falls surveyed, most happened at home, provoked by postural instability, tripping and freezing. Environmental adaptation and cognitive training should be trialled in falls prevention in PD, plus or minus traditional movement rehabilitation. Most participants completed Falls Diaries successfully. We advocate diary use, with follow-up interviews, in research and clinically. People with handwriting difficulty may require a typed diary, proxy diarist or interview.