Falls among community-dwelling older adults in the Philippines and Viet Nam: Results from nationally representative samples

Falls are a significant public health issue globally. However, studies with nationally representative samples have yet to be done to understand falls among older adults in the Philippines and Viet Nam. Using a biopsychosocial perspective, this study investigated the prevalence of falls and their associated factors among community-dwelling older adults in these countries. Cross-sectional data were drawn from the baseline survey of the Longitudinal Study of Ageing and Health in the Philippines (2018, N = 4,606) and the Longitudinal Study of Ageing and Health in Viet Nam (2018, N = 4,378). The outcome variables were any falls in the past year. Independent variables included sociodemographic factors (age, sex, education, living in urban areas, living alone, social network size), biophysical factors (vision, chronic conditions, functional impairments, pain locations, insomnia symptoms, sleep medications, grip strength, walking speed, postural control), and psychological factors (depressive symptoms). Descriptive analysis and logistic regression analysis were used to analyze the data. The results showed that 17.7 % and 7.3 % of older Filipino and Vietnamese adults fell in the year before the study. Significant factors associated with the odds of any falls among Filipino older adults were having a higher level of education, living in urban areas, living with others, experiencing more functional impairments, reporting one or more pain locations, and having poor grip strength. In Viet Nam, having more chronic conditions, experiencing more functional impairments, and reporting two or more pain locations were found to be associated with higher odds of any falls. The population in the Philippines and Viet Nam is aging rapidly. Findings from this study are timely in identifying at-risk individuals and preparing for effective fall prevention strategies.

The Vietnamese version of the Home Falls and Accidents Screening Tool (HOME FAST) - A preliminary study of validity and inter-rater reliability

Introduction

The Vietnamese Home Falls and Accidents Screening Tool (HOME FAST) was developed to measure the number of home hazards present in the homes of older Vietnamese people and the risk of falls.

Methods

The HOME FAST and the HOME FAST manual were translated into Vietnamese by an independent translator and underwent backward translation by local health professionals into English to evaluate the accuracy of the translation. A panel of 14 Vietnamese health professionals evaluated the validity of the HOME FAST translation and rated the clarity and cultural relevance of each item. Ratings were evaluated using the content validity index (CVI). Reliability in ratings of the HOME FAST was evaluated using intra-class correlations (ICC), and ratings took place within the homes of two older Vietnamese people by six assessors.

Results

In all, 22 out of 25 Vietnamese HOME FAST items were considered to have met content validity standards using the CVI. The ICC for home visit one was 0.94 (95% CI 0.87-0.97) and for home visit two was ICC 0.95 (95% CI 0.91-0.98) indicating high reliability.

Discussion and conclusion

Bathroom items showed the most inconsistency in ratings indicating cultural differences in bathing activities. Descriptors of HOME FAST items will be reviewed for use in Vietnam to account for cultural and environmental differences. A larger pilot study is planned with older people living in the community in Vietnam to include calendar ascertainment of falls to determine if home hazards are associated with falling.

A validity study to consult on a protocol of a home hazard management program for falls prevention among community dwelling stroke survivors

OBJECTIVE

A fall after a stroke is common but the consequences can be devastating not only for the stroke survivors, but also for caregivers, healthcare, and the society. However, research on falls prevention among the stroke population are limited, particularly on home hazards assessment and home modifications, demanding for a study to be conducted. The aim of the study is to validate the protocol and content of a home hazard management program guided by the Person-Environment-Occupation (PEO) Model for falls prevention among community dwelling stroke survivors.

METHOD

Researchers developed their own questionnaire for content validation which consist of 23 items that covers two domains, namely justification for telehealth home hazard management practice and the protocol's overall methodology. Occupational therapists with at least one year of experience in conducting a home hazard assessment were consulted for the content validation of a two-group clinical controlled trial protocol utilizing a home hazard assessment, home modifications and education over the usual care. Written consent was obtained prior to the study. The occupational therapists were given a Google Form link to review the protocol and intervention based on the questionnaire and rated each item using a four-point Likert scale for relevance and feasibility. Open-ended feedback was also recorded on the google form. Content Validity Index (CVI), Modified Kappa Index and Cronbach's Alpha was calculated for the content validity and reliability analysis.

RESULTS

A total of sixteen occupational therapists participated in the study. 43.7% of participants had a master's degree, 93.7% worked in the government sector and 56.2% had six years and more experience on conducting home hazard assessments. Content validity of the protocol is satisfactory for relevancy and feasibility (CVI = 0.84, ranging from 0.5 to 1.00), and for the reliability (α = 0.94 (relevance) and α = 0.97 (feasibility), respectively. The Modified Kappa ranged from 0.38 to 1.00 for all items. Feedback was also received regarding the design and procedure of the study protocol which included participant's selection criteria, sample size, equipment provided, cost, location, and care for the participants during the intervention.

CONCLUSIONS

Introducing a home hazard management program to prevent falls among the stroke population is viewed relevant and feasible. Practical suggestions from the consultation panel were adopted, and minor adjustments were required to strengthen the protocol's overall methodology. This study established a rigorous and robust experimental protocol for future undertaking.

Development of the Home-Based Fall Prevention Knowledge (HFPK) questionnaire to assess home-based fall prevention knowledge levels among older adults in China

Background

Falls are one of the main reasons for mortality and morbidity in older adults. However, despite adoption of prevention strategies, the number of falls in older adults has not declined. This study aimed to develop a questionnaire to assess fall prevention knowledge and explore associated factors among Chinese community-dwelling older adults.

Methods

The Home-Based Fall Prevention Knowledge (HFPK) questionnaire was developed by Delphi expert consultation. We tested the internal consistency, reliability, and content validity of the HFPK. A total of 374 community-dwelling older adults participated in this study. The HFPK was used to assess their fall prevention knowledge.

Results

After being evaluated by 15 experts, the item content validity index ranged from 0.867 to 1, and the scale content validity index was 0.985, which met the criterion for content validity. Cronbach’s α coefficient was 0.933, which satisfied the reliability criterion. Stepwise linear regression analysis showed that fall prevention knowledge was significantly associated with having higher education, being female, having a higher monthly income, people who were public officials before retirement, and having fewer children (p < 0.05).

Conclusion

Fall prevention knowledge should be improved among older males and those with lower education, lower monthly income, people who were not public officials before retirement, and more children.

Implementing best practice occupational therapist‐led environmental assessment and modification to prevent falls: A qualitative study of two regional and rural public health services in Australia

BACKGROUND

Occupational therapist-led environmental assessment and modification (EAM) is effective in reducing falls for populations at high risk. Two regional and rural public health services in Queensland devised an implementation strategy to embed best practice occupational therapist-led EAM.

METHODS

A qualitative study was conducted to compare the determinants of implementation success across the different health services, using the COM-B model of behaviour change. Six semi-structured interviews were completed with occupational therapists involved at each site, following 12 months of implementation. Interview data were triangulated with minutes from three combined site steering committee meetings, eight local steering committee meetings, and field notes. Thematic analysis was completed to compare barriers and facilitators to best practice uptake of EAM and differences in outcomes between the two sites.

RESULTS

Both sites commenced implementation with similar states of capability and motivation. After 12 months, one site considered that practice change had been embedded as noted in steering committee minutes and comments; however, the other site observed limited progress. According to the COM-B analysis, opportunity (the factors that lie outside the individual's control) had a significant influence on how both sites were able to respond to the practice change and navigate some of the unexpected challenges that emerged, including the COVID-19 pandemic. Existing team structure, multiple responsibilities of key stakeholders, differences in access to resources, and lack of connection between complementary services meant that COVID-19 disruptions were only a catalyst for unveiling other systemic issues.

CONCLUSION

This study highlights the power of external factors on influencing behaviour change for best practice implementation. Learnings from the study will provide deeper understanding of completing implementation projects in regional and rural contexts and support the future implementation of EAM in occupational therapy clinical settings.

The effect of age on in-hospital mortality among elderly people who sustained fall-related traumatic brain injuries at home: A retrospective study of a multicenter emergency department-based injury surveillance database

BACKGROUND

People older than 65 years tend to have traumatic brain injuries (TBIs) more frequently and have a higher mortality rate after TBI than younger individuals. The aim of this study was to determine the effects of age on in-hospital mortality among patients who had fall-related TBIs at home, emphasizing the effect of specific locations in the house on the outcome.

METHODS

This cross-sectional study was conducted using the Emergency Department-based Injury In-Depth Surveillance (EDIIS) database in South Korea. Patients aged 65 years or older with a slip or fall injury, accidental injury at home, and no major diagnosis other than TBI were included. The primary outcome was in-hospital mortality. Subgroup analysis was conducted to determine the effect of locations on the relationship between age and in-hospital mortality.

RESULTS

Of the 2,571,442 patients in the EDIIS database, 9,747 were included in this study. The most common injury location was room or bedroom (29.1%), followed by living room or kitchen (23.0%), bathroom (20.2%), stairs (15.8%), and outdoor spaces of the house (11.9%). There was a significant association between increased in-hospital mortality and oldest old age. The stairs or outdoor spaces of the house was significantly associated with in-hospital mortality compared to rooms inside the house. The oldest age group showed a higher association with in-hospital mortality than the young-old group, especially in the bathroom, stairs, and outdoor spaces of the house.

CONCLUSIONS

Elderly individuals over the age of 85 are the most vulnerable to fall-related TBI mortality at home. A fall prevention strategy for the oldest-old is needed, especially for the bathroom, stairs, and the ancillary space outside the house.

Self-assessment of the home environment to plan for successful ageing: Report from a digital health co-design workshop

Many middle aged and older people will need to adapt or modify their home in order to age in place. Arming older people and their families with the knowledge and tools to assess their home and plan simple modifications ahead of time will decrease reliance on professional assessment. The objective of this project was to co-design a tool which enables people to assess their own home environment and make future plans for ageing in the home. We recruited members of the public who were aged 60 or older to attend a series of two co-design workshops. Thirteen participants worked through a series of discussions and activities including appraising different types of tools available and mapping what a digital health tool might look like. Participants had a good understanding of the main types of home hazards in their own homes and the types of modifications which may be useful. Participants believed the concept of the tool would be worthwhile and identified a number of features which were important including a checklist, examples of good design which was both accessible and aesthetically pleasing and links to other resources such as websites which provide advice about to make basic home improvements. Some also wanted to share the results of their assessment with family or friends. Participants highlighted that features of the neighbourhood, such as safety and proximity to shops and cafes, were also important when considering the suitability of their home for ageing in place. Findings will be used to develop a prototype for usability testing.

Cross-Cultural Adaptation and Reliability of the Home Falls and Accidents Screening Tool (HOME FAST) in Assessing Fall-Risk Home Hazards for Stroke Using Technologies over a Conventional Home Visit

Objective

This study is aimed at translating the Home Falls and Accidents Screening Tool (HOME FAST) into the three main languages spoken in Malaysia and investigating its reliability through an alternative technology-based evaluation.

Methods

Translation into three languages and cross-cultural adaptation of the HOME FAST was conducted via the five steps adopted from the Mapi Institute. For interrater reliability, occupational therapists who attended a face-to-face home hazard workshop were recruited. Each therapist rated the HOME FAST by using the provided combination of videos and photographs of stroke survivors manoeuvring in their home. For test-retest reliability, the same occupational therapists were invited to rate the same combination of photographs and videos again. Reliability was analysed using Gwet's AC₁ and Bland and Altman's plot to describe agreement.

Results

The translation challenges were minimal and rectifiable. A Bahasa Melayu, Mandarin, and Tamil versions of the HOME FAST were developed. Overall interrater reliability for both video (AC₁ = 0.91) and photograph (AC₁ = 0.91) were good. The test-retest reliability yielded similar outcome (video: overall AC₁ = 0.92 and photograph: overall AC₁ = 0.93).

Conclusion

Using alternative technology (video and photograph) to do a home hazard assessment was feasible. However, the asynchronous nature of these methods has limitations in clarifying certain aspects in the home. Moving forward, potential investigation on other technologies such as telehealth for synchronous and real-time interaction is warranted.

Reliability of HOME FAST BRAZIL-Self-Reported Version for Community-Dwelling Older Adults

Objective: Verify the intra- and inter-rater reliability of the HOME FAST BRAZIL—Self-reported version and correlate household environmental risks with the history of falls by community-dwelling older adults.

Method: Cross sectional study with 50 community-dwelling older adults who were screened by the cut-off point of the Mini Mental State Exam and replied to the HOME FAST BRAZIL—Self-reported version using two evaluators, on three occasions. The reliability analysis was determined by the Intra-class Correlation Coefficient (ICC), considering ICC > 0.70 as adequate. To test the correlations, the Spearman test was used.

Results: The mean age of the participants was 73.2 ± 5.8 years. The inter- rater reliability of HOME FAST BRAZIL—Self-reported version was ICC 0.83 (IC95%, 0.70–0.90) and the Intra- reliability ICC 0.85 (IC95%, 0.74–0.91). A risk of falls was verified in 88% of the sample and four environmental risks presented significant correlations with the history of falls.

Conclusions: The HOME FAST BRAZIL—Self-reported version presented adequate reliability for the evaluation of household environmental risks for community-dwelling older adults. Risks such as inadequate armchairs/ sofas, the absence of anti-slip mats in the shower recess, the presence of pets and inadequate beds require attention in the evaluation of household risks, due to their correlation with the occurrence of falls.

The Effects of a Home-Based Combined Motor Control and Ergonomic Program on Functional Ability and Fear of Falling: A Randomized Controlled Trial

Objectives

Physical exercise is a key intervention for improving functional ability and preventing falls in older people. However, the implemented interventions targeted balance, gait, and muscle strength, while little is known regarding motor control exercises in this population. Therefore, this study aimed to investigate the effects of a 12-week home-based motor control exercise program combined with an ergonomic home modification (the McHeELP program).

Patients and methods

Fifty-two older people (aged ≥65 years), who had experienced at least one fall incident in the past 12 months, were randomly assigned into two groups; the McHeELP group (McHeELP-G) (n=26) that received the McHeELP program and the control group (CG) (n=26). Physical performance measures (PPMs) and patient-reported outcomes (PROs) were used to evaluate participants. At baseline, 3rd month (post-intervention), and again at 6th month (follow up), balance control was assessed using the Tandem stance test (Tandem) and the Functional Reach Test (FRT). Functionality was assessed by the 4 meters walking test (4MWT), Timed Up and Go (TUG) test, 30 seconds-Sit to stand test and the Greek version of Lower Extremity Functional Scale (LEFS-Greek). The Greek version of the Falls Self-efficacy International scale (FES-I_GREEK) was used for the evaluation of "fear-of-falling" (FOF). The home falls and accidents screening tool (HOMEFAST) is used to identify home hazards. Two-way mixed ANOVA model, independent samples t-test, One-factor Repeated Measures ANOVA model and ANCOVA model were used for the statistical analysis of the data.

Results

Homogeneity was found between McHeELP-G and CG regarding the demographic and clinical characteristics, and no statistically significant difference was found at baseline measurements of PROs and PPMs, except HOMEFAST (p=0.031). Post-intervention (3rd month), the comparison of the absolute values between groups revealed that the McHeELP-G achieved statistically significant better balance control (longer Tandem stance test and higher values of FRT), better functionality [faster gait speed (4MWT), shorter TUG performance time, and a higher number of repetitions at 30 seconds-Sit to stand] (all p-values <0.05), while no difference was found for LEFS-Greek score (p=0.095), compared to CG. In addition, McHeELP-G reported lesser FOF than CG [lower FES-I_GREEK score (p=0.041)], and fewer home-hazards [lower HOMEFAST score (p=0.041)]. At follow up measurement (6th month), all PPMs scores of McHeELP-G, regarding balance control and functionality, were remained statistically significant (all p-values <0.005), and the FES-I_GREEK score (p=0.034), while no difference was found between groups for LEFS-Greek score (p=0.146) and HOMEFAST score (p=0.185). Sensitivity analysis (from baseline to 3rd and 6th month) revealed similar findings to the "comparison of the absolute values between groups" analysis. The within-group changes from baseline to 3rd month of McHeELP-G were statistically significant improved for all PPMs and PROs (all p-values <0.05), while in CG, statistical significant difference was found for TUG, FRT-right, and HOMEFAST (p<0.05). Those within-group changes were also preserved until 6th month.

Conclusions

The study's findings provide encouraging evidence that McHeELP program may increase functional ability and decrease FOF of older people. However, further research is required for a thorough understanding of the effect of McHeELP program. 

Fall Risk Assessment Scales: A Systematic Literature Review

Background: Falls are recognized globally as a major public health problem. Although the elderly are the most affected population, it should be noted that the pediatric population is also very susceptible to the risk of falling. The fall risk approach is the assessment tool. There are different types of tools used in both clinical and territorial settings. Material and methods: In the month of January 2021, a literature search was undertaken of MEDLINE, CINHAL and The Cochrane Database, adopting as limits: last 10 years, abstract available, and English and Italian language. The search terms used were “Accidental Falls” AND “Risk Assessment” and “Fall Risk Assessment Tool” or “Fall Risk Assessment Tools”. Results: From the 115 selected articles, 38 different fall risk assessment tools were identified, divided into two groups: the first with the main tools present in the literature, and the second represented by tools of some specific areas, of lesser use and with less supporting literature. Most of these articles are prospective cohort or cross-sectional studies. All articles focus on presenting, creating or validating fall risk assessment tools. Conclusion: Due to the multidimensional nature of falling risk, there is no “ideal” tool that can be used in any context or that performs a perfect risk assessment. For this reason, a simultaneous application of multiple tools is recommended, and a direct and in-depth analysis by the healthcare professional is essential.

Motor Control and Ergonomic Intervention Home-Based Program: A Pilot Trial Performed in the Framework of the Motor Control Home Ergonomics Elderlies' Prevention of Falls (McHeELP) Project

Objectives Falls are a serious problem that can reduce living autonomy and health-related quality of life of older adults. A decrease in the muscular strength of the lower limbs and the deterioration of balance or motor performance deficits may lead to falls. "Motor Control Home Ergonomics Elderlies' Prevention of Falls" (McHeELP) is a novel motor control exercise program combined with ergonomic arrangements of the home environment. This pilot trial is conducted in order to examine the feasibility and acceptability of the McHeELP program, the selection of the most appropriate outcome measures, and the exact sample size calculation that should be used for the randomized controlled trial (RCT) with Clinical Trial Identifier: ISRCTN15936467. Patients and methods Twenty older adults (aged ≥65 years) who had experienced at least one fall-incident in the past 12 months have participated in the trial; they were randomized in a 1:1 ratio to the McHeELP group (McHeELP-G) and the Control group (CG). The McHeELP-G received a personalized therapeutic motor control and learning exercise program performed three times per week for 12 weeks. Regarding McHeELP - home modification, a booklet that contained basic advice and tips on the modification for their inside and outside home environment was provided to the participants. Objective and self-reported outcome measures, collected at baseline and post-intervention (end of the third month), included functional, fear of falling, and quality of life measurements. Results The McHeELP intervention was very feasible and acceptable to the participants, and the adherence was excellent (100%). The majority of outcome measures seemed appropriate and significant differences were also revealed between the two groups. Specifically, post-intervention statistically significant improvement was found in the 4 meters walking test, Timed Up and Go test, Sit to Stand test, Tandem Stance test, Functional Reach test, Foot tapping test, EuroQoL-5D-5L - visual analog scale (VAS), Lower Extremity Functional Scale, Falls Self-Efficacy International Scale, and Home Falls and Accidents Screening Tool (HOMEFAST) questionnaire of McHeELP-G (all p-values ≤0.002). No statistically significant difference was observed in the mobility, self-care, usual activities, pain/discomfort subscales of Euro QoL-5D-5L (all p-values >0.05), except the anxiety/depression subscale of McHeELP-G (p=0.008). Moreover, no statistically significant improvement was found regarding McHeELP participants' knee flexion/extension restriction and ankle dorsiflexion/plantar-flexion restrictions. Regarding CG, no statistically significant difference was found (p>0.05), except the Tandem Stance test (p=0.003) and HOMEFAST (p<0.001). Referring to the future McHeELP RCT, it was estimated that a sample size of 25 evaluable patients per group is required. Conclusions This pilot trial's findings suggest that it is feasible to deliver an RCT of the McHeLP program to this population. Exercise programs that are easy to administer need to be developed and implemented to reduce the burden of falls in older adults.

The Brazilian version of the Home Falls and Accidents Screening Tool (HOME FAST): translation, cross-cultural adaptation, validation and reliability

Abstract Objective: to translate and cross-culturally adapt the Home Falls and Accidents Screening Tool - HOME FAST into Brazilian Portuguese and to evaluate its construct validity and intra-and inter-rater reliability. Method: a cross-sectional study was carried out that included older people aged 60 years or older. Translation and cross-cultural adaptation were carried out in the following stages: 1. Translation, 2. Synthesis, 3. Back translation, 4. Expert panel (review and pre-final version), 5. Pre-testing, 6. Analysis by the expert panel and the final version of the instrument. The Berg Balance Scale - BBS was used to test construct validity (Spearman correlation coefficient). Additionally, intra-and inter-rater reliability analysis was conducted using the Intraclass Correlation Coefficient (ICC) and the Bland-Altman plot. Results were considered significant at p<0.05. Results: the HOME FAST-Brazil was applied to 53 older people with a mean age of 71(5) years; 79% (42) of whom were female and 21% (11) of whom were male. The translation and cross-cultural adaptation process resulted in similar versions among translations. The correlation of the total score of HOME FAST-Brazil with the BBS was ρ=-0.241, p=0.041. The reliability rate was ICC=0.99 and 0.92 (intra-and inter-rater, respectively). Conclusion: The HOME FAST-Brazil, translated and cross-culturally adapted to Brazilian Portuguese, was shown to have construct validity and excellent intra-and inter-rater reliability.

A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review

BACKGROUND

Falls occurring on stairs or in bathrooms are associated with a high risk of injuries among older adults. Home environmental assessments are frequently used to guide fall-prevention interventions. The aims of this review were to describe how, where, by whom, and for whom environmental hazard checklists are used, and to examine the characteristics of environmental hazard assessment checklists with specific attention to features of bathrooms and stairs/steps assessed in them.

METHODS

Studies published before January 5, 2018, were identified using several databases. Publications reporting the use and/or evaluation of environmental hazard checklists were eligible if they assessed bathrooms or stairs/steps in homes of older adults (≥65 years). Content analysis was conducted on publications that provided a complete list of specific environmental hazards assessed. Checklist items related to bathrooms and stairs/steps were extracted and categorized as structural or non-structural and as objective or subjective.

RESULTS

1119 studies were appraised. A pool of 136 published articles and 4 checklists from the grey literature were included in this scoping review. Content analysis was conducted on 42 unique checklists. There was no widely used checklist and no obvious consensus definition of either environmental hazards overall or of single hazards listed in checklists. Checklists varied greatly with respect to what rooms were assessed, whether or not outdoor stair/steps hazards were assessed, and how responses were coded. Few checklists examined person-environment fit. The majority of checklists were not oriented towards structural hazards in bathrooms. Although the majority of checklists assessing stair/steps hazards evaluated structural hazards, most features assessed were not related to the construction geometry of stairs/steps. Objective features of bathrooms and stairs/steps that would deem them safe were rarely specified. Rather, adequacy of their characteristics was mostly subjectively determined by the evaluator with little or no guidance or training.

CONCLUSION

The lack of standard definitions and objective criteria for assessing environmental hazards for falls is limiting meaningful cross-study comparisons and slowing advances in this field. To inform population health interventions aimed at preventing falls, such as building code regulations or municipal housing by-laws, it is essential to include objectively-assessed structural hazards in environmental checklists.

Failure of falls risk screening tools to predict outcome: a prospective cohort study

Objective

To compare the Falls Risk for Older Persons—Community Setting Screening Tool (FROP Com Screen) with the Two-Item Screening Tool in older adults presenting to the ED.

Methods

A prospective cohort study, comparing the efficacy of the two falls risk assessment tools by applying them simultaneously in a sample of hospital ED presentations.

Results

Two hundred and one patients over 65 years old were recruited. Thirty-six per cent reported falls in the 6-month follow-up period. The area under the receiver operating characteristic curve was 0.57 (95% CI 0.48 to 0.66) for the FROP Com Screen and 0.54 (95% CI 0.45 to 0.63) for the Two-Item Screening Tool. FROP Com Screen had a sensitivity of 39% (95% CI 0.27 to 0.51) and a specificity of 70% (95% CI 0.61 to 0.78), while the Two-Item Screening Tool had a sensitivity of 48% (95% CI 0.36 to 0.60) and a specificity of 57% (95% CI 0.47 to 0.66).

Conclusion

Both tools have limited predictive ability in the ED setting.

The interrater and test-retest reliability of the Home Falls and Accidents Screening Tool (HOME FAST) in Malaysia: Using raters with a range of professional backgrounds

RATIONALE, AIMS AND OBJECTIVES

Falls can be a devastating issue for older people living in the community, including those living in Malaysia. Health professionals and community members have a responsibility to ensure that older people have a safe home environment to reduce the risk of falls. Using a standardised screening tool is beneficial to intervene early with this group. The Home Falls and Accidents Screening Tool (HOME FAST) should be considered for this purpose; however, its use in Malaysia has not been studied. Therefore, the aim of this study was to evaluate the interrater and test-retest reliability of the HOME FAST with multiple professionals in the Malaysian context.

METHODS

A cross-sectional design was used to evaluate interrater reliability where the HOME FAST was used simultaneously in the homes of older people by 2 raters and a prospective design was used to evaluate test-retest reliability with a separate group of older people at different times in their homes. Both studies took place in an urban area of Kuala Lumpur.

RESULTS

Professionals from 9 professional backgrounds participated as raters in this study, and a group of 51 community older people were recruited for the interrater reliability study and another group of 30 for the test-retest reliability study. The overall agreement was moderate for interrater reliability and good for test-retest reliability. The HOME FAST was consistently rated by different professionals, and no bias was found among the multiple raters.

CONCLUSION

The HOME FAST can be used with confidence by a variety of professionals across different settings. The HOME FAST can become a universal tool to screen for home hazards related to falls.

The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

Determining the Effectiveness of a Falls Prevention Programme to Enhance Quality of Life: An Occupational Therapy Perspective

Falls are common in older people and become more frequent with advancing age. Falling in older people is associated with mortality, decreased mobility, premature nursing home admissions and a reduced ability to perform activities of daily living. In an attempt to reduce the incidence of falls, the National Service Framework for Older People has emphasised the need to develop falls services that provide support for older people who have fallen and use health promotion initiatives. While there is evidence to suggest that home modifications can reduce falls in older people, there has been little research to evaluate the effectiveness of occupational therapy falls prevention programmes.

This paper reports the findings of an evaluation of a multifaceted falls prevention programme, which aimed to determine whether occupational therapy could enhance quality of life by educating people aged 65 years and over about the risk of falls. A pre-intervention and post-intervention non-standardised self-administered questionnaire was completed at week 1 and at week 14. Of the 172 older people attending the falls prevention programme, 78 (45%) completed both questionnaires.

The findings from this study suggest that an occupational therapy falls prevention programme can reduce the impact of falls on older people by enhancing confidence to perform activities, which in turn can increase quality of life. However, further research is needed to determine the effectiveness of anxiety management techniques.

Older People and Mobility in the Home: in Search of Useful Assistive Technologies

A number of assistive technologies exist to help older people with their indoor mobility needs and there is an increasing recognition that older people are capable of being critical and active consumers of these technologies. This paper reports on a study that used focus groups and informal trials to explore older people's perspectives on their indoor mobility problems, their ideas on what assistive technologies might resolve these problems and their evaluation of assistive technologies that were developed in response to these ideas.

The analysis of the results from the four focus groups led to the development of a stair-climbing aid and a new cataloguing aid. The analysis of the results from the informal trials produced useful feedback on the design of the two products and indicated some limitations to the focus group methodology which could be addressed in future research.

Falling from Grace or into Expert Hands? Alternative Accounts about Falling in Older People

Falls in older people are a priority area for both research and clinical intervention in the United Kingdom. There is, however, currently an absence of research exploring the meaning and interpretation of a fall.

Semi-structured interviews were conducted with 20 therapists and with eight older people with fractured hips. The therapists' accounts appeared to draw on a ‘risk discourse’ which constructed a fall as a predictable and preventable event, highlighting individual patient characteristics as causative factors and suggesting that therapists were more knowledgeable about this subject. The accounts of the older inpatients, conversely, made use of a ‘moral discourse’, in which commendable personal qualities and competencies were emphasised.

It is suggested that this work has implications for therapy in that many falls prevention initiatives and health promotion materials may be falsely premised on an acceptance of vulnerability by older people.

Falls in rural and remote community dwelling older adults: a review of the literature

OBJECTIVE

Falls in older adults represent a significant challenge in Australia; however, the focus is often on urban-dwelling older adults. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI).

DESIGN

A literature review was conducted searching Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare publication catalogue.

SETTING

Rural and remote Australia.

PARTICIPANTS

Rural and remote community dwelling Australians aged 50 years and older.

INTERVENTION

Literature review.

MAIN OUTCOME MEASURES

Falls epidemiology and effective falls prevention interventions.

RESULTS

Twenty references were identified: 14 related to falls epidemiology and 7 to FPI. No significant differences were found between rural, remote and major cities residents in relation to falls hospitalisation, falls mortality or fall-related injuries sustained. There are a wide assortment of health professionals and non-health professionals who are involved in providing FPI in rural and remote Australia. However, there was limited information on the effectiveness of these interventions in influencing falls outcomes.

CONCLUSION

Few studies explored falls and their prevention in rural and remote Australia. The limited literature on the topic suggests that a change in focus to one that utilises existing services and resources will be required to create sustainable outcomes. Four areas are proposed for concentrated effort to reduce the impact of fall-related injury in rural and remote Australia: integration and collaboration among health professionals, promotion of physical activity across the lifespan, community involvement and ownership of interventions, and evaluation and publication of findings.

A Prospective Community-Based Study of Falls among Older People in Australia: Frequency, Circumstances, and Consequences

Falls among the population of older people are a major international public health concern. Few prospective studies have been conducted in Australia with a healthy, rural and urban community sample that measure a broad range of health-related potential risk factors for falls. This study aims to identify the nature and circumstances of falls experienced by people aged 70 years and older, and explores any health and environmental variables associated with falls over a 6-month period. A total of 264 participants kept calendars and recorded information about falls. Health status measures were taken prior to the study period. Falls occurred mainly during mobility and housework activities causing a wide range of minor but notable injuries, and were associated with psychosocial factors as well as medical risk factors. The need for occupational therapists to develop specific programs for healthy older people living in the community is identified, as well as the need for cross-national falls research.

Predicting geriatric falls following an episode of emergency department care: a systematic review

BACKGROUND

Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored.

OBJECTIVES

This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity.

METHODS

A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED.

RESULTS

A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%.

CONCLUSIONS

This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.

Nurses' understandings of suitable footwear for older people

PURPOSE

The purpose of this paper is to gain insight into nurses' understandings of what constitutes suitable footwear for older people in care homes.

DESIGN/METHODOLOGY/APPROACH

An exploratory descriptive qualitative survey was carried out of 20 registered nurses employed in six Scottish care homes for older people. Data were collected using a semi-structured questionnaire that included five open-ended questions. Content analysis was used to theme footwear perceptions.

FINDINGS

Participants had several views about what encompasses safe footwear; some were erroneous. The link between inappropriate footwear and falls was recognised by 80 per cent of respondents, but some were unclear about the features that effect or inhibit safety. No UK or international standardised guidelines were identified that advise nurses about appropriate footwear for older people.

PRACTICAL IMPLICATIONS

It is unknown whether respondents represent the nurse population because findings are restricted by a small sample size. Nonetheless, the group showed variable understanding of what constitutes safe footwear for older people and links with fall prevention. Improved nurse-education about what comprises safe footwear and the links with falls prevention in older people is required. Structured guidelines to direct nurse educators about what to teach student nurses about appropriate footwear for older people may work towards reducing falls.

ORIGINALITY/VALUE

No guidelines to direct nurses about appropriate footwear for older people in care homes have been written. Key points have been developed.

Can Fire and Rescue Services and the National Health Service work together to improve the safety and wellbeing of vulnerable older people? Design of a proof of concept study

Background

Older adults are at increased risk both of falling and of experiencing accidental domestic fire. In addition to advanced age, these adverse events share the risk factors of balance or mobility problems, cognitive impairment and socioeconomic deprivation. For both events, the consequences include significant injury and death, and considerable socioeconomic costs for the individual and informal carers, as well as for emergency services, health and social care agencies.

Secondary prevention services for older people who have fallen or who are identifiable as being at high risk of falling include NHS Falls clinics, where a multidisciplinary team offers an individualised multifactorial targeted intervention including strength and balance exercise programmes, medication changes and home hazard modification. A similar preventative approach is employed by most Fire and Rescue Services who conduct Home Fire Safety Visits to assess and, if necessary, remedy domestic fire risk, fit free smoke alarms with instruction for use and maintenance, and plan an escape route. We propose that the similarity of population at risk, location, specific risk factors and the commonality of preventative approaches employed could offer net gains in terms of feasibility, effectiveness and acceptability if activities within these two preventative approaches were to be combined.

Methods/Design

This prospective proof of concept study, currently being conducted in two London boroughs, (Southwark and Lambeth) aims to reduce the incidence of both fires and falls in community-dwelling older adults. It comprises two concurrent 12-month interventions: the integration of 1) fall risk assessments into the Brigade's Home Fire Safety Visit and 2) fire risk assessments into Falls services by inviting older clinic attendees to book a Visit. Our primary objective is to examine the feasibility and effectiveness of these interventions. Furthermore, we are evaluating their acceptability and value to key stakeholders and services users.

Discussion

If our approach proves feasible and the risk assessment is both effective and acceptable, we envisage advocating a partnership model of working more broadly to fire and rescue services and health services in Britain, such that effective integration of preventative services for older people becomes routine for an ageing population.

A systematic review of accidental injury from fire, wandering and medication self-administration errors for older adults with and without dementia

The assessment of risk of injury in the home is important for older adults when considering whether they are able to live independently. The purpose of this systematic review is to determine the frequency of injury for persons with dementia and the general older adult population, from three sources: fires/burns, medication self-administration errors and wandering. Relevant articles (n=74) were screened and 16 studies were retained for independent review. The studies, although subject to selection and information bias, showed low proportions of morbidity and mortality from the three sources of injury. Data did not allow direct comparison of morbidity and mortality for persons with dementia and the general older adult population; however, data trends suggested greater event frequencies with medication self-administration and wandering for persons with dementia. Assessment targeting these sources of injury should have less emphasis in the general older adult population compared to persons with dementia.

Primary biliary cirrhosis is associated with falls and significant fall related injury

BACKGROUND

Osteoporosis and autonomic dysfunction are prevalent in the autoimmune liver disease primary biliary cirrhosis (PBC). Postural hypotension is one consequence of autonomic dysfunction and is a recognized risk factor for falls, which, alongside osteoporosis could lead to significant injury and fractures.

AIM

To determine the prevalence and sequelae of falls in PBC and to identify modifiable risk factors.

DESIGN

Cross-sectional, geographical, population census of PBC and two control groups: primary sclerosing cholangitis and a community dwelling population. Multidisciplinary falls assessment of a representative group of PBC.

METHODS

Symptom assessment tools, completed by the three cohorts, determined the prevalence of falls, injuries and associated symptoms. Multidisciplinary assessments, adhering to NICE guidelines, identified modifiable fall associations.

RESULTS

Significantly more of the PBC population had fallen (72% P < 0.001) than both control groups. Fifty-five percent had fallen in the last year (P < 0.001), and 22% more than once in the last year (P < 0.01). Seventy percent of PBC fallers were injured, 27% fractured a bone and 19% were admitted to hospital, all significantly more common than controls. Postural dizziness was significantly worse in fallers (P < 0.001), as were balance (P < 0.001) and lower limb strength (P = 0.002). Lower limb strength was independently associated with number of falls in previous year (beta = 0.184, P < 0.001).

CONCLUSION

Falls and resultant injury are prevalent in PBC and more common than previously recognized. Addressing postural dizziness, poor balance and lower limb weakness using a multidisciplinary approach has the potential to reduce falls, morbidity and mortality and as a result improve quality of life.

Perceptions of health professionals about effective practice in falls prevention

PURPOSE

Falls prevention is a practice context with a rapidly expanding evidence-base. However, little is known about the implementation of this evidence into practice by health professionals. This study aimed to explore how falls prevention evidence is applied in practice internationally by health professionals working in the homes of older people, and to identify the perceived barriers and effective strategies in implementing falls prevention programs.

METHOD

A qualitative study design using a grounded theory approach was selected. Data were collected via focus groups or individual, semi-structured interviews with 50 health professionals from Australia, the UK and Canada. All participants visited older people in their homes as part of their usual practice. Data analysis used the constant comparative method.

RESULTS

Three themes emerged from the data: (i) client experiences of falls prevention, (ii) professional skills and clinical reasoning in falls prevention and (iii) service issues in falls prevention.

CONCLUSIONS

The complexity of delivering an evidence-based, multi-disciplinary falls prevention intervention that is acceptable to clients was described by participants. Challenges were identified in applying the evidence according to the resources and experience of health professionals in the systems within which they work.

Randomised controlled trial of health assessments for older Australian veterans and war widows

OBJECTIVE

To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death.

DESIGN

Randomised controlled trial of the effect of health assessments over 3 years.

PARTICIPANTS AND SETTING

1569 community-living veterans and war widows receiving full benefits from the Department of Veterans' Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942).

INTERVENTION

Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner.

MAIN OUTCOME MEASURES

Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up.

RESULTS

3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05-1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40-2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01).

CONCLUSIONS

Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.