Older people and falls: health status,quality of life,lifestyle, care networks,prevention and views on service use following a recent fall

Aim and objective. This study has investigated older people’s experiences of a recent fall, its impact on their health, lifestyle, quality of life, care networks, prevention and their views on service use. Background. Falls are common in older people and prevalence increases with age. Falls prevention is a major policy and service initiative. Design. An exploratory, qualitative design involving two time points. Method. A convenience sample of 27 older people from two primary care trusts who had a recent fall. Taped semi structured qualitative interviews were conducted and repeated at follow up to detect change over time and repeat falls. Data were collected on their experience of falls, health, activities of living, lifestyle, quality of life, use of services, prevention of falls, informal care and social networks. Content analysis of transcribed interviews identified key themes. Results. The majority of people fell indoors (n = 23), were repeat fallers (n = 22) with more than half alone when they fell (n = 15). For five people it was their first ever fall. Participants in primary care trust 1 had a higher mean age than those in primary care trust 2 and had more injurious falls (n = 12, mean age 87 years vs. n = 15, mean age 81 years). The majority of non‐injurious falls went unreported to formal services. Falls can result in a decline in health status, ability to undertake activities of living, lifestyle and quality of life. Conclusions. Local informal care and support networks are as important as formal care for older people at risk of falls or who have fallen. Access to falls prevention programmes and services is limited for people living in more rural communities. Relevance to practice. Falls prevention initiatives and services should work with local communities, agencies and informal carers to ensure equitable access and provision of information, resources and care to meet the needs of older people at risk or who have fallen.     

老年人跌倒的相关因素及预防护理

总结了老年人跌倒的原因、流行概况、危害、预防方法和护理干预措施,提出预防老年人跌倒发生的重点是加强对老年人家庭及社会的健康教育、重视自我保护、纠正不良环境因素、及时治疗急慢性病。使老年人跌倒得到更好的预防,使更多的老年人免受跌倒的伤害和影响。     

Inadequate acute hospital beds and the limits of primary care and prevention

Metropolitan Australia is suffering from a serious shortage of acute hospital beds. Simplistic comparisons with the Organisation for Economic Co‐operation and Development bed numbers are misleading because of the hybrid Australian public/private hospital system. The unavailability of most private beds for acute emergency cases and urban/rural bed imbalances have not been adequately considered. There is a lack of advocacy for acute bed availability. This attitude permeates government, health professions and the health bureaucracy. Planners, politicians, analysts and the media have adopted false hopes of reducing acute demand by prevention and primary care strategies, vital as these services are to a balanced healthcare system. This paper directly challenges the ideology that says Australia depends too heavily on hospital‐based healthcare. Rebuilding the bed base requires recognition of the need for an adequate acute hospital service and strong advocacy for bed‐based care in the medical and nursing professionals who should be driving policy. The forces opposing bed‐based care are strong and solutions might include legislative definition of bed numbers and availability.     

Development of a simple scoring tool in the primary care setting for prediction of recurrent falls in men and women aged 65 years and over living in the community

Aim. We documented the number of falls and falls risk profile over two years to derive a falls risks prediction score. Background. Simple falls risk assessment tools not requiring equipment or trained personnel may be used as a first step in the primary care setting to identify older people at risk who may be referred for further falls risk assessment in special clinics. Design. Survey. Method. Men (n = 1941) and 1949 women aged 65 years and over living in the community were followed up for two years to document the number of falls. Information was collected regarding demography, socioeconomic status, medical history, functional limitations, lifestyle factors and psychosocial functioning. Measurements include body mass index, grip strength and stride length. Logistic regression was used to determine significant predictions of falls and to calculate predictive scores. Result. Twelve factors in men and nine factors in women were used to construct a risk score. The AUC of the receiver operating characteristic curve was >0·70 for both men and women and a cut off score of ≥8 gave sensitivity and specificity values between 60–78%. The factors included chronic disease, drugs, functional limitation, lifestyle, education and psychosocial factors. When applied to future predictions, only low energy level and clumsiness in both hands in men and feeling downhearted in women, were significant factors. Conclusions. A risk assessment tool with a cut off score of ≥8 developed from a two‐year prospective study of falls may be used in the community setting as an initial first step for screening out those at low risk of falls. Relevance to clinical practice. A simple tool may be used in the community to screen out those at risk for falls, concentrating trained healthcare professionals’ time on detailed falls assessment and intervention for those classified as being at risk.     

A failed fall prevention study in an acute care setting: Lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest-post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.     

Evaluation of three fall-risk assessment tools in an acute care setting

AIM: This paper is a report of a study to evaluate the validity of three fall-risk assessment tools to identify patients at high risk for falls. BACKGROUND: Patient falls make up 38% of all adverse events occurring in hospital settings, and may result in physical injury and undesirable emotional and financial outcomes. No single fall-risk assessment tool has been conclusively validated. METHOD: The Morse Fall Scale, St Thomas Risk Assessment Tool in Falling Elderly Inpatients, and Hendrich II Fall Risk Model were validated in inter-rater reliability and validity studies in 2003. This included assessment of the probability of disagreement, kappa-values, sensitivity, specificity, positive predictive values and negative predictive values of the assessment tools with the associated 95% CI. FINDINGS: One hundred and forty-four patients were recruited for the inter-rater reliability study. The probabilities of disagreement were between 2.8% and 9.7%, and 95% CI for all tools ranged from 1.1% to 15.7%. The kappa-values were all higher than 0.80. In the validity study, 5489 patients were recruited to observe 60 falls. The Morse Fall Scale at a cutoff score of 25 and Heindrich II Fall Risk Model at a cutoff score of 5 had strong sensitivity values of 88% and 70%, respectively. However, in comparison with the Morse Fall Scale (specificity = 48.3%), only the Heindrich II Fall Risk Model had a more acceptable level of specificity (61.5%). CONCLUSION: The Heindrich II Fall Risk Model is potentially useful in identifying patients at high risk for falls in acute care facilities.     

Older people and the relationship between hospital services and intermediate care: Results from a national evaluation

In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation of intermediate care, focusing on the relationship between hospital services and intermediate care. Participants included key managers and practitioners involved in the planning, management and delivery of intermediate care in five case study sites. During the study, they identified a range of tensions between hospital services and intermediate care, including concerns about the role and involvement of acute clinicians; the safety, quality and appropriateness of intermediate care; access to and eligibility for intermediate care; a lack of understanding and awareness of intermediate care; and the risk of intermediate care being dominated by acute pressures. Although participants were able to identify several practical ways forward, resolving such fundamental tensions seems to require significant and long-term cultural change in the relationship between acute and intermediate care. Overall, this study raises questions about the extent to which intermediate care will be able to rebalance the current health and social care system and make a substantial contribution to tackling ongoing concerns about emergency hospital admissions and delayed transfers of care.     

Implementation of a community pharmacy-based falls prevention program

Background

Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted falls prevention programs, which have been reported to reduce the risk for falls among older adults, usually include a medication review and modification component. Based on a literature search, no randomized trials that have examined the effectiveness of this component have been published.

Objective

The aim of this article was to report on a retrospective process evaluation of data from a randomized, controlled trial conducted to examine the effectiveness of a medication review intervention, delivered through community pharmacies, on the rate of falls among community-dwelling older adults.

Methods

Patients were recruited through 32 pharmacies in North Carolina. Participants were community-dwelling older adults at high risk for falls based on age (≥65 years), number of concurrent medications (≥4), and medication classes (emphasis on CNS-active agents). The process evaluation measured the recruitment of patients into the study, the process through which the intervention was delivered, the extent to which patients implemented the recommendations for intervention, and the acceptance of pharmacists' recommendations by prescribing physicians.

Results

Of the 7793 patients contacted for study participation, 981 (12.6%) responded to the initial inquiry. A total of 801 (81.7%) participated in an eligibility interview, of whom 342 (42.7%) were eligible. Baseline data collection was completed in 186 of eligible patients (54.4%), who were randomly assigned to the intervention group (n = 93) or the control group (n = 93). Pharmacists delivered a medication review to 73 of the patients (78.5%) in the intervention group, with 41 recommendations for changes in medication, of which 10 (24.4%) were implemented. Of the 31 prescribing physicians contacted with pharmacists' recommendations, 14 (45.2%) responded, and 10 (32.3%) authorized the changes.

Conclusions

Based on the findings from the present study, coordination of care between community pharmacists and prescribers needs to be improved for the realization of potential beneficial effects of medication management on falls prevention.