Epidemiology of Falls in 25 Australian Residential Aged Care Facilities: A Retrospective Longitudinal Cohort Study Using Routinely Collected Data

Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach

OBJECTIVES

Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia.

MATERIALS AND METHODS

A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems.

RESULTS

The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts.

DISCUSSION

Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs.

CONCLUSION

Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Monitoring falls in residential aged care facilities: Agreement between falls incident reports and progress notes

OBJECTIVES

Accurate fall reporting is essential for assessing the effectiveness of fall prevention strategies. This study aimed to investigate the level of agreement between incident reports and resident progress notes as data sources for falls monitoring in residential aged care facilities.

METHODS

A retrospective observational study was conducted involving 46 older people from six residential aged care facilities who had consented to join the broader TOP UP trial. Fall events documented in the incident report system and resident progress notes over 12 months before randomisation were extracted by two independent reviewers using a standardised Excel form. Agreement between the two data collection methods was calculated using Cohen's kappa coefficient.

RESULTS

A total of 75 falls were recorded from 27 (59%) of the 46 participants who were 65% female, with an average age of 83 [SD 9] years. The incident reports captured 68 (90.7%) falls, while the progress notes captured 73 (97.3%) falls. Overall, there was a 75% agreement between falls recorded in progress notes and incident reports. Perfect agreement was identified for five facilities (n = 35), while one facility had a lower agreement rate of 29% (n = 11), which appeared to be attributable to staff shortages linked to the COVID-19 pandemic.

CONCLUSIONS

There was substantial agreement between incident reports and progress records. These findings support the use of incident reports for identifying falls in research or to investigate the effectiveness of fall prevention strategies in residential aged care facilities.

Effects of an Exercise Program to Reduce Falls in Older People Living in Long-Term Care: A Randomized Controlled Trial

OBJECTIVES

To investigate the effect of an exercise program on falls in intermediate and high-level long-term care (LTC) residents and to determine whether adherence, physical capacity, and cognition modified outcomes.

DESIGN

Randomized controlled trial.

SETTING AND PARTICIPANTS

Residents (n = 520, aged 84 ± 8 years) from 25 LTC facilities in New Zealand.

METHODS

Individually randomized to Staying UpRight, a physical therapist-led, balance and strength group exercise program delivered for 1 hour, twice weekly over 12 months. The control arm was dose-matched and used seated activities with no resistance. Falls were collected using routinely collected incident reports.

RESULTS

Baseline fall rates were 4.1 and 3.3 falls per person-year (ppy) for intervention and control groups. Fall rates over the trial period were 4.1 and 4.3 falls ppy respectively [P = .89, incidence rate ratio (IRR) 0.98, 95% CI 0.76, 1.27]. Over the 12-month trial period, 74% fell, with 63% of intervention and 61% of the control group falling more than once. Risk of falls (P = .56, hazard ratio 1.08, 95% CI 0.85, 1.36) and repeat falling or fallers sustaining an injury at trial completion were similar between groups. Fall rates per 100 hours walked did not differ between groups (P = .42, IRR 1.15, 95% CI 0.81, 1.63). Program delivery was suspended several times because of COVID-19, reducing average attendance to 26 hours over 12 months. Subgroup analyses of falls outcomes for those with the highest attendance (≥50% of classes), better physical capacity (Short Physical Performance Battery scores ≥8/12), or cognition (Montreal Cognitive Assessment scores ≥ 18/30) showed no significant impact of the program.

CONCLUSIONS/IMPLICATIONS

In intermediate and high-level care residents, the Staying UpRight program did not reduce fall rates or risk compared with a control activity, independent of age, sex, or care level. Inadequate exercise dose because of COVID-19-related interruptions to intervention delivery likely contributed to the null result.

"It's all about the money": an interpretive description of embedding physical therapy-led falls prevention group exercise in long-term care

BACKGROUND

Falls prevention interventions are effective for community dwelling older adults however, the same cannot be said for older adults living in long-term care (LTC). The Staying UpRight (SUp) randomized controlled trial was designed to test the effectiveness of a progressive strength and balance group exercise program delivered to LTC residents. This paper explores the factors impacting LTC providers' decisions to continue the program on completion of the funded trial period.

METHODS

A qualitative study using an Interpretive Description approach. Semi-structured interviews and focus groups were conducted with 15 LTC staff involved in the randomized controlled trial. Data were analysed using conventional content analysis.

RESULTS

Practice change occurred following participation in the trial with some facilities starting exercise groups, some increasing the number of exercise groups offered and physical therapists selecting elements of the program to adopt into their practice. Decisions about continuing with SUp as designed were constrained by organizational decisions regarding funding and resources. Three factors were identified which informed decision-making: business models and philosophies, requirements for evidence, and valuing physical therapy.

CONCLUSIONS

Managers and facilitators adapted SUp by selecting and delivering components of the program in response to the changes they had observed in participating residents. However, our findings highlight that while SUp was valued, the tight financial environment created by the current funding model in New Zealand did not support funding physical therapist delivered falls prevention exercise programs in LTC. This study may provide policy makers with important information on changes needed to support falls prevention service delivery in LTC.

TRIAL REGISTRATION

This study is a sub-study of a randomized controlled trial which was registered to the Australian New Zealand Clinical Trials Registry ACTRN12618001827224 on 09/11/2018. Universal trial number U1111-1217-7148.