Exploring seniors' views on the use of assistive devices in fall prevention

The bath environment, the bathing task, and the older adult: A review and future directions for bathing disability research

PURPOSE

To review existing research studies to identify optimal intervention strategies for remediation and prevention of bathing disability and future directions for bathing disability research.

METHOD

Bathing disability, defined as problems in the interaction between the person and the environment during bathing performance, is examined through a comprehensive, narrative literature review.

RESULTS

Most studies focus on the relationship between the person and the environment (such as assistive device use and environmental hazards) while fewer studies focus on analysis of the bathing task or the interaction of the person, environment, and bathing task. Of intervention studies, most do not focus solely on remediation of bathing disability and outcomes vary widely.

CONCLUSIONS

In order to help remediate and prevent bathing disability, it will be necessary to better understand and measure the person-environment-occupation interaction involved in bathing as it relates to specific groups of older adults.

A systematic review of older people's perceptions of facilitators and barriers to participation in falls-prevention interventions

The prevention of falls is currently high on the health policy agenda in the United Kingdom, which has led to the establishment of many falls-prevention services. If these are to be effective, however, the acceptability of services to older people needs to be considered. This paper reports a systematic review of studies of older people's perceptions of these interventions. The papers for review were identified by searching electronic databases, checking reference lists, and contacting experts. Two authors independently screened the studies and extracted data on the factors relating to participation in, or adherence to, falls-prevention strategies. Twenty-four studies were identified, of which 12 were qualitative. Only one study specifically examined interventions that promote participation in falls-prevention programmes; the others explored older people's attitudes and views. The factors that facilitated participation included social support, low intensity exercise, greater education, involvement in decision-making, and a perception of the programmes as relevant and life-enhancing. Barriers to participation included fatalism, denial and under-estimation of the risk of falling, poor self-efficacy, no previous history of exercise, fear of falling, poor health and functional ability, low health expectations and the stigma associated with programmes that targeted older people.

Falls and fear of falling among community-dwelling seniors: the dynamic tension between exercising precaution and striving for independence

The purpose of this phenomenological study was to explore the everyday experience of community-dwelling elders, with particular attention to seniors' perceptions of safety, fear of falling, independence, and quality of life. We also aimed to identify contextual factors that influence the health of elders who had fallen and/or had a fear of falling. Data from in-depth interviews with a purposeful sample (n = 9) of elders were analysed using interpretative analysis procedures. Both individual and team analysis was undertaken until interpretations of the experiences of the participants were inductively developed and crystallized into a holistic interpretation of the participants' shared experience. The holistic experience was comprised of two opposing, dynamic life forces: exercising precaution and striving for independence. Within each life force, participants used five major strategies that simultaneously constrained and expanded their life space. Health-promoting practice and policy implications, as well as areas for further research, are discussed.

Changes in Dual-task Voice Reaction Time Among Elders Who Use Assistive Devices

PURPOSE

Assistive devices are prescribed for a variety of reasons and have the obvious benefit of enhancing gait performance for some individuals. However, the use of an assistive device may make walking a more complex and cognitively challenging task. The purpose of this study was to use a dual-task voice reaction time (VRT) paradigm to examine the attentional demands of walking with an assistive device in a group of elderly adults.

METHODS

Standing and walking VRTs were measured in a sample of 105 elderly adults who ambulated independently with either a rolling walker (RW; mean age = 87.8 +/- 5.5 yrs), a straight cane (SC; mean age = 84.1 +/- 5.6 yrs), or used no device (ND; mean age = 79. 9 +/- 4.5 yrs). A 3 (group) by 2 (task condition) ANOVA with repeated measures on the last factor was used to examine between and within group differences in VRTs.

RESULTS

The main effects of group (p = 0.004) and task (P < 0.001) and the interaction of group with task (P = 0.025) were all statistically significant. There were no statistically significant between group differences in standing VRT. Between group differences appeared during the walking task, VRT for the RW group was significantly longer than for the ND group. When examining within group difference, walking VRT was significantly longer than standing VRT for the SC and RW groups.

CONCLUSIONS

The results demonstrated that there is an increase in the attentional demands of walking for elderly adults who are experienced assistive device users. The increased attention required to walk with an assistive device may be a factor leading to increased fall risk.

Performance-oriented mobility assessment (POMA) balance score indicates need for assistive device

PURPOSE

To determine (1) if older adults using an assistive device (AD) score lower on the Performance-Oriented Mobility Assessment (POMA) balance subscale (B-subscale) than individuals not using an AD; and (2) if a cut-score of 12 would indicate the need to use an AD.

METHODS

Elderly persons (n = 82, mean age = 82.1 years) were surveyed about AD use, health status, activity level and fall history. A one-time assessment of balance was conducted using the B-subscale. The 'arising task' was repeated to evaluate performance on the sit-to-stand task without using hands.

RESULTS

A significant difference in B-subscale scores was observed between the two groups (AD; no AD), (P < 0.001). AD use was associated with lower activity level and health status. A cut-score of 12 points indicated device use (P = 0.000). The repeated 'arising task' demonstrated that 76.8% performed the task without using hands for support.

CONCLUSION

Older adults using an AD will score lower on the B-subscale and report lower activity level and health status. A score of less than 12 on the B-subscale is indicative of AD need. Older adults who use an AD and self-report a falls history will score lower on the B-subscale than individuals using an AD and no reported history of falls.

Assistive devices for balance and mobility: Benefits, demands, and adverse consequences

OBJECTIVES

To provide information on the advantages and possible disadvantages of using canes and walkers.

DATA SOURCES

English-language articles were identified by searching MEDLINE and PubMed (1966-May 2003) for key words cane or walker , excluding articles unrelated to mobility aids. Bibliographies were reviewed and ISI Web of Science citation searches were run to identify additional references. Over 1000 articles were selected for further evaluation.

STUDY SELECTION

We extracted all studies of single-tip canes or pickup walkers addressing: (1) functional, biomechanic, or neuromotor benefits; (2) biomechanic, attentional, neuromotor, metabolic, or physiologic demands; and (3) falls, injuries, or other problems. We included approximately 10% of the articles originally identified.

DATA EXTRACTION

The methodology of each selected article, and findings relevant to the benefits, demands, or adverse effects of cane or walker use were summarized.

DATA SYNTHESIS

Findings were synthesized by considering their relation to basic biomechanic principles. Some biomechanic findings appear to support the clinical view that canes and walkers can improve balance and mobility for older adults and people with other clinical conditions. However, a large proportion of users experience difficulties, and the use of such devices is associated with increased risk of falling. A small number of studies have characterized some of the specific demands and problems associated with using mobility aids.

CONCLUSIONS

Clinical and biomechanic evaluations of canes and walkers confirm that these devices can improve balance and mobility. However, they can also interfere with ones ability to maintain balance in certain situations, and the strength and metabolic demands can be excessive. More research is needed to identify and solve specific problems. Such research may lead to improved designs and guidelines for safer use of canes and walkers.

A New Conceptual Model for Assistive Technology Outcomes Research and Practice

Predictive conceptual models help us frame research questions, interpret results, and guide clinical practice. Although numerous models have appeared in the assistive technology (AT) literature, none has been shown to predict AT usage. The lack of a valid predictive model indicates the need for development of new approaches to modeling AT outcomes. This article proposes a user-centered conceptual model that predicts AT usage as a function of the perceived relative advantages of AT. Device usage is not modeled as a one-time, all-or-nothing proposition, but as a decision process recurring over time. The influence of parallel interventions working concurrently with, or as an alternative to, AT is a central consideration that ultimately drives AT usage. Usage is shown as a proximal influence on AT impact, and AT impact is shown to be a predictor of future use. Research is cited supporting various elements of the new model.

Evidence Review on Older People's Views and Experiences of Falls Prevention Strategies

BACKGROUND

A systematic review was undertaken of qualitative and quantitative studies and reviews that focus on older people's views and experiences of falls prevention. The review was undertaken to provide an additional dimension to the clinical effectiveness evidence provided by a Cochrane review on falls prevention (Gillespie et al. 2003) to inform the development of a national guideline on falls prevention in older people. As guideline recommendations or policies relating to preventive strategies have the potential to increase health care costs, it is important that all sources of evidence are reviewed by guideline development groups so that an understanding is achieved of the acceptability and sustainability of interventions in relation to different groups and settings.

METHOD

Accordingly, this review examined the literature on the views, preferences, and experiences of older people in relation to falls prevention strategies. Twenty-four studies meeting the inclusion criteria were critically reviewed and were then summarized into evidence tables. The key facilitators and barriers to participation in falls prevention programs were derived from the commonly occurring and consistent themes arising from the reviewed studies. The implications of these findings for the clinical effectiveness review conclusions were then taken into account.

FINDINGS

Several important findings emerged. These included preferences for falls prevention strategies not involving behaviour change among some groups, the need to promote the social value of falls prevention programs, and the importance of identifying and addressing factors associated with activity avoidance.

CONCLUSIONS AND IMPLICATIONS

In terms of the impact of these findings on the Cochrane review, the most important implication is that although trials of multifactorial falls prevention packages have reported beneficial results, in clinical practice it is important to consult with individual potential participants and find out what characteristics they are willing to modify, and what changes they are prepared to make to reduce their risk of falling. Otherwise, there is the risk that expensive programs are not properly targeted or fail to achieve maximum participation rates. Further work on the most robust and pragmatic methods of synthesizing disparate studies on patients' views and preferences to inform evidence-based guideline recommendations is needed.

Development and evaluation of an instrument to measure seniors' attitudes toward the use of bathroom grab bars

Bath grab bars can minimize the effects of many age-related deficits that may contribute to bath-related falls. Despite their potential value, bathroom safety devices remain largely underutilized by many community-living older adults and knowledge concerning attitudinal factors that influence the use of grab bars is sparse. This void of knowledge is due, at least in part, to the lack of instruments to measure the psychosocial constructs influencing bathroom safety device use. This study examined the psychometric properties of a newly developed Grab Bar Use Attitude scale (GUAS). Instrument formation, including item generation, evaluation by a panel of experts, and pilot testing of the draft instrument to establish its face and content validity, was followed by instrument validation using 546 community-living seniors. Results of principal components analysis of the GUAS revealed a two-factor solution, explaining 56% of the variance. The two constructs may best be described as functional/safety and psychosocial consequences of using grab bars. Psychometric analyses of the 9-item scale provided empirical evidence of the internal consistency of the total scale and each subscale. Finally, the GUAS distinguished between regular grab bar users and nonregular users. Implications for use are discussed.

Factors associated with cane use among community dwelling older adults

Guided by the Theory of Planned Behavior (TPB), this study examined factors associated with cane use among community dwelling older adults. Data were collected in a cross-sectional survey of a convenience sample of 106 community residing older adults in Ottawa, Canada. Using a stepwise discriminant analysis, subjective norms, attitudes, and age surfaced as the key variables associated with cane use in this sample. The discriminant function accounted for 67% of the variance in cane use and correctly classified 91% of cases (Wilks's lambda = 0.33, lambda2 = 110.12, df = 3, p < 0.0001). The findings provide evidence for the utility of the TPB in its application to understanding cane use behaviors of older persons and have important implications for the design of theory-based fall prevention interventions to enhance the acceptance and effective use of mobility aids.

Using mass media within health-promoting practice: a nursing perspective

For some time health professionals have recognized the growing importance of utilizing mass media strategies as part of their health-promoting practice. The ever-evolving climate of technology and increasing reliance on mass communications has further reinforced the position of mass media initiatives. The enormous potential for mass media resources to reach certain audiences and influence their health-related behaviours has become particularly well established. Despite these facts, however, it is argued that the nursing profession has been less than pro-active in acknowledging, accommodating and adopting such practices. Consequently, the incorporation of health-related mass media initiatives into nursing's health-promotional role remains an elusive exercise. The maintenance of such a position, it is claimed, is potentially damaging for the profession as a whole. In light of this state of affairs, this paper seeks to review the literature surrounding the nature and processes of mass media strategies, their relevance to health promotion and nursing, how they are currently utilized and how they can be incorporated further into nursing practice. In conclusion, it is argued that nursing should seek to become a more active user of mass communication/media technology--especially in relation to its health-promotional practices.

Development and evaluation of the cane use cognitive mediator instrument

BACKGROUND

Canes are among the most underutilized assistive devices for older persons. A significant obstacle to understanding cane use behaviors of older adults is the lack of instruments measuring factors that may influence seniors' decisions to accept or reject these devices.

OBJECTIVES

Guided by the Theory of Planned Behavior, this study involved the development and evaluation of an instrument to measure cognitive determinants of cane use among community-living older adults.

METHOD

The two-phase design involved: a) instrument formation including item generation from four focus group interviews with seniors (n = 30), expert panel evaluation (n = 10), and pilot testing (n = 10); and b) instrument validation in a cross sectional survey (n = 106).

RESULTS

Psychometric analyses of survey data provided empirical evidence of the construct validity and reliability of the instrument. Principal components analysis verified the hypothesized four-factor solution, explaining 63.2% of variance. Independent t-tests yielded statistically significant differences (p < 0.001) in mean scores between the two contrasting groups of cane users (n = 51) and nonusers (n = 55) with respect to each of the four factors identified. Alpha coefficients of 0.81 to 0.96 indicated high internal consistency of the instrument.

CONCLUSIONS

The instrument can be used by clinicians and researchers to assess seniors' salient beliefs about the consequences of cane use, guide tailored intervention strategies to promote acceptance and effective use, and evaluate the effectiveness of interventions.