Development of a tool for prediction of falls in rehabilitation settings (Predict_FIRST): a prospective cohort study

The relationship between fall incidents and place of birth in residential aged care facilities: a retrospective longitudinal cohort study

BACKGROUND

Older populations in residential aged care facilities (RACFs) in many immigrant-receiving countries are now being increasingly culturally and linguistically diverse (CALD). CALD populations require tailored social and health services to support their needs and improve health outcomes. Falls among the elderly are common and can have significant health and psychosocial consequences. There is some evidence to suggest that country of birth may influence risk of falls among older people, but such evidence has been scarce. This study aimed to determine the association between place of birth and the incidence of falls in RACFs.

METHODS

Routinely collected incident data relating to 5,628 residents aged ≥ 65 years in 25 RACFs in Sydney, New South Wales, Australia were used. RACF residents were classified into two groups, Australia-born (N = 4,086) and overseas-born (N = 1,542). Overseas-born RACF residents were further categorised into two subgroups: overseas-English-speaking-country (N = 743) and overseas-non-English-speaking-country (N = 799). Outcomes measures were rate of all falls, injurious falls and falls requiring hospitalisation. Multilevel binary negative regression was used to examine the relationship between fall risk and place of birth.

RESULTS

Incidence rates of all falls, injurious falls and falls requiring hospitalisation were 8.62, 3.72 and 1.07 incidents per 1,000 resident days, respectively, among the Australia-born RACF residents, but were higher at 11.02, 4.13 and 1.65, respectively, among the overseas-born RACF residents. Within those born overseas, fall rates were higher among the overseas-non-English-speaking-country-born residents (11.32, 4.29 and 2.22, respectively) than those overseas-English-speaking-country-born (10.70, 3.96 and 1.05, respectively). After controlling for confounders, the overseas-born RACF residents overall experienced a higher risk of all three types of falls (incidence rate ratios: [IRR] = 1.278, 95% confidence interval [CI] = 1.131, 1.443; injurious falls: IRR = 1.164 [95% CI = 1.013, 1.338]; falls requiring hospitalisation: IRR = 1.460 [95% CI = 1.199, 1.777]) than the Australia-born RACF residents. Among the overseas-born RACF residents, males, respite residents and those overseas-non-English-speaking-country-born experienced higher rates of falls.

CONCLUSIONS

Fall incidence in RACFs varies significantly by place of birth. With increasingly diverse RACF populations, fall intervention and prevention programs should consider cultural and linguistical backgrounds of RACF residents. Greater attention to understand the mechanisms for the differences by place of birth in risk profiles is warranted.

Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia

BACKGROUND

Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning.

METHODS

A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses.

RESULTS

One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each.

CONCLUSIONS

Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.

Falls and fracture risk screening in primary care: update and validation of a postal screening tool for community dwelling older adults recruited to UK Prevention of Falls Injury Trial (PreFIT)

BACKGROUND

Postal screening has not previously been validated as a method for identifying fall and fracture risk in community-dwelling populations. We examined prognostic performance of a postal risk screener used in the UK Prevention of Falls Injury Trial (PreFIT; ISRCTN71002650), to predict any fall, recurrent falls, and fractures over 12 months. We tested whether adding variables would improve screener performance.

METHODS

Nine thousand eight hundred and eight community-dwelling participants, aged 70 years and older, and 63 general practices in the UK National Health Service (NHS) were included in a large, pragmatic cluster randomised trial comparing screen and treat fall prevention interventions. The short postal screener was sent to all participants in the trial intervention arms as an A4 sheet to be completed and returned to the GP (n = 6,580). The postal screener items were embedded in the baseline pre-randomisation postal questionnaire for all arms of the trial (n = 9,808). We assessed discrimination and calibration using area under the curve (AUC). We identified additional predictors using data from the control arm and applied these coefficients to internal validation models in the intervention arm participants. We used logistic regression to identify additional predictor variables.

FINDINGS

A total of 10,743 falls and 307 fractures were reported over 12 months. Over one third of participants 3,349/8,136 (41%) fell at least once over 12 month follow up. Response to the postal screener was high (5,779/6,580; 88%). Prediction models showed similar discriminatory ability in both control and intervention arms, with discrimination values for any fall AUC 0.67 (95% CI 0.65 to 0.68), and recurrent falls (AUC 0.71; 95% CI 0.69, 0.72) but poorer discrimination for fractures (AUC 0.60; 95% CI 0.56, 0.64). Additional predictor variables improved prediction of falls but had modest effect on fracture, where AUC rose to 0.71 (95% CI 0.67 to 0.74). Calibration slopes were very close to 1.

CONCLUSION

A short fall risk postal screener was acceptable for use in primary care but fall prediction was limited, although consistent with other tools. Fracture and fall prediction were only partially reliant on fall risk although were improved with the additional variables.

Inter-rater reliability and predictive accuracy of the Shkuratova Assessment of Falls-risk in Rehabilitation (SAFER) tool

Despite the recognised importance of falls prevention in rehabilitation settings, there is limited research focusing on falls risk assessment tools designed to guide both patient screening and therapy. This study evaluated the predictive accuracy and inter-rater reliability of the Shkuratova Assessment of Falls-risk in Rehabilitation settings (SAFER) tool. The study was conducted at a subacute rehabilitation facility in Australia. Patient assessments were performed on admission to subacute care by trained physiotherapists, and the incidence of falls was documented prospectively. Of the 147 patients, 45 had at least one fall and were compared to 102 who had no falls. The inter-rater reliability of the SAFER tool when used by trained physiotherapists was high with the level of agreement for individual items ranging from 74 to 99%. Thirty-two (76%) patients who experienced a fall during their admission and 46 (44%) who did not fall were identified as having a high falls-risk. Using a SAFER tool cut-off of 12/26: sensitivity is 69%, specificity is 66%, area under the curve 0.71 (95% confidence interval: 0.62-0.80). The high negative predictive values at a range of cut-offs provided strong evidence that patients identified as having a low falls-risk were unlikely to experience a fall. Performing a comprehensive assessment of specific deficits in gait, balance and mobility on admission provided a streamlined approach to identification of patients who would benefit from tailored falls prevention interventions.

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.

Stepping impairment and falls in older adults: A systematic review and meta-analysis of volitional and reactive step tests

OBJECTIVE

To systematically examine stepping performance as a risk factor for falls. More specifically, we examined (i) if step tests can distinguish fallers from non-fallers and (ii) the type of step test (e.g. volitional vs reactive stepping) that is required to distinguish fallers from non-fallers.

DATA SOURCE

PubMed, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and reference lists of included articles.

STUDY SELECTION

Cross-sectional and cohort studies that assessed the association between at least one step test and falls in older people (age ≥ 60 and/or mean age of 65).

RESULTS

A meta-analysis of 61 studies (n = 9536) showed stepping performance was significantly worse in fallers compared to non-fallers (Cohen'sd 0.56, 95 % CI 0.48 to 0.64, p < 0.001, I² 66 %). This was the case for both volitional and reactive step tests. Twenty-three studies (n = 3615) were included in a diagnostic meta-analysis that showed that step tests have moderate sensitivity (0.70, 95 % CI 0.62 to 0.77), specificity (0.68, 95 % CI 0.58 to 0.77) and area under the receiver operating characteristics curve (AUC) (0.75, 95 % CI 0.59 to 0.86) in discriminating fallers from non-fallers.

CONCLUSIONS

This large systematic review demonstrated that both volitional and reactive stepping impairments are significant fall risk factors among older adults. Step tests can identify fallers from non-fallers with moderate accuracy.

Diagnostic Balance Tests for Assessing Risk of Falls and Distinguishing Older Adult Fallers and Non-Fallers: A Systematic Review with Meta-Analysis

Falls are a major cause of injury and morbidity in older adults. To reduce the incidence of falls, a systematic assessment of the risk of falling is of paramount importance. The purpose of this systematic review was to provide a comprehensive comparison of the diagnostic balance tests used to predict falls and for distinguishing older adults with and without a history of falls. We conducted a systematic review of the studies in which instrumented (force plate body sway assessment) or other non-instrumented balance tests were used. We analyzed the data from 19 prospective and 48 retrospective/case-control studies. Among the non-instrumented tests, the single-leg stance test appears to be the most promising for discrimination between fallers and non-fallers. In terms of body sway measures, the center-of-pressure area was most consistently associated with falls. No evidence was found for increased benefit of the body sway test when cognitive tasks were added, or the vision was eliminated. While our analyses are limited due to the unbalanced representation of different test and outcome measures across studies, we can recommend the single-leg test for the assessment of the risk of falling, and the measurements of body sway for a more comprehensive assessment.

External validation of the recurrent falls risk scale in community-dwelling stroke individuals

OBJECTIVE

To externally validate the Recurrent Fall Risk Scale (ReFR) in community-dwelling stroke survivors.

METHODS

Cohort of stroke survivors with independent gait ability recruited from a reference outpatient stroke clinic. Besides sociodemographic and clinical data, the following scales were used: Modified Barthel Index (mBI), ReFR scale and National Institutes of Health Stroke Scale (NIHSS). Participants were followed up for 12 months to record the incidence of falls. Accuracy of the ReFR scale was measured by the area under the ROC curve.

RESULTS

One hundred and thirteen individuals were recruited between April 2016 and November 2016: mean age 54 years (± 14), 55% women, median time since the last stroke 24 months (range 12 -48 months), posterior vascular territory affected in 35% of the sample. Median NIHSS was 3 (range 1 to 6), median mBI 49 (range 46-50), median ReFR 3 (range 2 to 5). During the follow-up period, 32 (33%) subjects had at least one fall and 18 (19%) were recurrent fallers (two or more falls). The accuracy of ReFR scale was 0.67 (95% CI = 0.54-0.79), p = 0.026.

CONCLUSION

This study externally validated the ReFR as a tool to predict recurrent falls in individuals after stroke.

Reducing falls through the implementation of a multicomponent intervention on a rural mixed rehabilitation ward

PROBLEM

There is an absence of literature to guide staff in how falls can be reduced in a diverse patient population on a mixed acute/subacute rehabilitation unit, especially one with daily fluctuations in acuity that occurs due to frequent changes in its acute/rehabilitation patient ratio.

DESIGN

Pre-intervention and post-intervention audits.

SETTING

The Rehabilitation Unit at Tamworth Rural Referral Hospital in Tamworth, NSW.

KEY MEASURES FOR IMPROVEMENT

Improvement in the number of falls and repeat fallers.

STRATEGIES FOR CHANGE

A multicomponent intervention involving: (a) in-service education sessions for nursing staff about falls risk-increasing drugs, (b) patient and family education regarding falls risks and prevention strategies, (c) improving documentation of incident reports by using a set template, (d) ensuring that the correct patient mobility status information is handed over between nursing shifts and physiotherapists providing timely and regular updates, (e) the introduction of the 'traffic light mobility system' and (f) enhancing the use of existing falls prevention strategies.

EFFECTS OF CHANGE

The total falls reduced in number from 36 falls to 19 with a decrease in the number of repeat fallers from 8 to 4. There was also increased compliance with existing falls risk tools and improved documentation of each falls incident which provided insight into activities and times with higher falls risk.

LESSONS LEARNT

A multicomponent approach remained effective even when applied to a mixed acute/subacute rehabilitation ward setting.

Neither Timed Up and Go test nor Short Physical Performance Battery predict future falls among independent adults aged ≥75 years living in the community

Objectives:

Previous research has shown that balance and gait difficulties are predictors of falls. The aim of this study was to evaluate the predictive validity of two tools reporting on balance and gait among older community-living adults independent in personal activities of daily living (p-ADL).

Methods:

Prospective study design. Baseline assessment included the Timed Up and Go test (TUG) and the Short Physical Performance Battery (SPPB). Following baseline, falls were recorded monthly for one year by 202 participants (70.1% women) who were independent in p-ADL, and at least 75 years old (79.2±3.5). ROC-curves were made and AUC were calculated.

Results:

Forty-seven percent of the participants reported falls. AUCs calculated for TUG were 0.5 (95%CI: 0.5-0.6) for those with at least one fall, and 0.5 (95% CI: 0.5-0.6) for recurrent fallers. Corresponding figures for SPPB were 0.5 (95% CI: 0.5-0.6) and 0.5 (95% CI: 0.5-0.6).

Conclusion:

This study does not support a recommendation to use the Timed Up and Go test or the Short Physical Performance Battery as tools for the identification of fall-prone persons among older adults living in the community. These results reinforce the need for further research into appropriate tools for identifying independent but fall-prone older adults.

Fall Prevention in a Primary Care Setting

BACKGROUND

Falls and fall-related injuries are common in community-dwelling elderly people. Effective multifactorial fall prevention programs in the primary care setting may be a promising approach to reduce the incidence rate of falls.

METHODS

In a cluster randomized trial in 33 general practices 378 people living independently and at high risk of falling (65 to 94 years old; 285 women) were allocated to either a 16 week exercise-based fall prevention program including muscle strengthening and challenging balance training exercises, combined with a 12 week home-based exercise program (222 participants), or to usual care (156 participants). The main outcome was number of falls over a period of 12 months. Secondary outcomes were the number of fall-related injuries, physical function (Timed-Up-and-Go-Test, TUG, Chair-Stand-Test, CST, modified Romberg Test), and fear of falling.

RESULTS

In the intervention group (n=222 patients in 17 general practices) 291 falls occurred, compared to 367 falls in the usual care group (n=156 patients in 16 general practices). We observed a lower incidence rate for falls in the intervention group (incidence rate ratio/IRR: 0.54; 95% confidence interval (CI): [0.35; 0.84], p=0.007) and for fall-related injuries (IRR: 0.66; [0.42; 0.94], p=0.033). Additionally, patients in the intervention group showed significant improvements in secondary endpoints (TUG: -2.39 s, [-3.91; -0.87], p=0.014; mRomberg: 1.70 s, [0.35; 3.04], p=0.037; fear of falling: -2.28 points, [-3.87; -0.69], p=0.022) compared to usual care.

CONCLUSION

A complex falls prevention program in a primary care setting was effective in reducing falls and fall-related injuries in community dwelling older adults at risk.

Two weeks of additional standing balance circuit classes during inpatient rehabilitation are cost saving and effective: an economic evaluation

QUESTION

Among people admitted for inpatient rehabilitation, is usual care plus standing balance circuit classes more cost-effective than usual care alone?

DESIGN

Cost-effectiveness study embedded within a randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

162 rehabilitation inpatients from a metropolitan hospital in Sydney, Australia.

INTERVENTION

The experimental group received a 1-hour standing balance circuit class, delivered three times a week for 2 weeks, in addition to usual therapy. The circuit classes were supervised by one physiotherapist and one physiotherapy assistant for up to eight patients. The control group received usual therapy alone.

OUTCOME MEASURES

Costs were estimated from routinely collected hospital use data in the 3 months after randomisation. The functional outcome measure was mobility measured at 3 months using the Short Physical Performance Battery administered by a blinded assessor. An incremental analysis was conducted and the joint probability distribution of costs and outcomes was examined using bootstrapping.

RESULTS

The median cost savings for the intervention group was AUD4,741 (95% CI 137 to 9,372) per participant; 94% of bootstraps showed that the intervention was both effective and cost saving.

CONCLUSIONS

Two weeks of additional standing balance circuit classes delivered in addition to usual therapy resulted in decreased healthcare costs at 3 months in hospital inpatients admitted for rehabilitation. There is a high probability that this intervention is both cost saving and effective.

REGISTRATION

ACTRN12611000412932. [Treacy D, Howard K, Hayes A, Hassett L, Schurr K, Sherrington C (2018) Two weeks of additional standing balance circuit classes during inpatient rehabilitation are cost saving and effective: an economic evaluation. Journal of Physiotherapy 64: 41-47].

Development of the Sydney Falls Risk Screening Tool in brain injury rehabilitation: A multisite prospective cohort study

AIMS AND OBJECTIVES

To develop a falls risk screening tool (FRST) sensitive to the traumatic brain injury rehabilitation population.

BACKGROUND

Falls are the most frequently recorded patient safety incident within the hospital context. The inpatient traumatic brain injury rehabilitation population is one particular population that has been identified as at high risk of falls. However, no FRST has been developed for this patient population. Consequently in the traumatic brain injury rehabilitation population, there is the real possibility that nurses are using falls risk screening tools that have a poor clinical utility.

DESIGN

Multisite prospective cohort study.

METHODS

Univariate and multiple logistic regression modelling techniques (backward elimination, elastic net and hierarchical) were used to examine each variable's association with patients who fell. The resulting FRST's clinical validity was examined.

RESULTS

Of the 140 patients in the study, 41 (29%) fell. Through multiple logistic regression modelling, 11 variables were identified as predictors for falls. Using hierarchical logistic regression, five of these were identified for inclusion in the resulting falls risk screening tool: prescribed mobility aid (such as, wheelchair or frame), a fall since admission to hospital, impulsive behaviour, impaired orientation and bladder and/or bowel incontinence. The resulting FRST has good clinical validity (sensitivity = 0.9; specificity = 0.62; area under the curve = 0.87; Youden index = 0.54). The tool was significantly more accurate (p = .037 on DeLong test) in discriminating fallers from nonfallers than the Ontario Modified STRATIFY FRST.

CONCLUSION

A FRST has been developed using a comprehensive statistical framework, and evidence has been provided of this tool's clinical validity.

RELEVANCE TO CLINICAL PRACTICE

The developed tool, the Sydney Falls Risk Screening Tool, should be considered for use in brain injury rehabilitation populations.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

INTRODUCTION

People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone.

METHODS AND ANALYSIS

A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach.

ETHICS AND DISSEMINATION

The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12614000936628. Pre-results.

Development and Evaluation of an Online Fall-Risk Questionnaire for Nonfrail Community-Dwelling Elderly Persons: A Pilot Study

Introduction. Falls are frequent in older adults and may have serious consequences but awareness of fall-risk is often low. A questionnaire might raise awareness of fall-risk; therefore we set out to construct and test such a questionnaire. Methods. Fall-risk factors and their odds ratios were extracted from meta-analyses and a questionnaire was devised to cover these risk factors. A formula to estimate the probability of future falls was set up using the extracted odds ratios. The understandability of the questionnaire and discrimination and calibration of the prediction formula were tested in a cohort study with a six-month follow-up. Community-dwelling persons over 60 years were recruited by an e-mail snowball-sampling method. Results and Discussion. We included 134 persons. Response rates for the monthly fall-related follow-up varied between the months and ranged from low 38% to high 90%. The proportion of present risk factors was low. Twenty-five participants reported falls. Discrimination was moderate (AUC: 0.67, 95% CI 0.54 to 0.81). The understandability, with the exception of five questions, was good. The wording of the questions needs to be improved and measures to increase the monthly response rates are needed before test-retest reliability and final predictive value can be assessed.

Predicting falls: considerations for screening tool selection vs. screening tool development

AIMS

This paper discusses considerations for falls risk screening tool selection vs. the need to develop new tools.

BACKGROUND

Inpatient falls are a complex patient safety issue that represent a significant burden for the healthcare system. In the inpatient context, falls risk screening tools are most often used for predicting falls, but in some populations assessment tools are more suited, however in others, a clinician's clinical judgment may be just as effective. Limited external validity is a central issue with falls risk screening tools when used in different populations than the original study. There is clinical need for guidance regarding screening tool selection vs. the need to development new tools and how to effect change in relation to the prediction of falls.

DESIGN

Discussion paper.

DATA SOURCES

This discussion paper is based on our own experiences and research and is supported by literature.

IMPLICATIONS FOR NURSING

This paper provides clinicians with a better understanding of considerations for falls risk screening tool selection vs. the need to develop new tools. In doing so, it provides clinicians guidance on how to critique the efficacy and utility of their falls risk screening tool. This paper equips clinicians for effecting change in relation to the prediction of falls.

CONCLUSION

Falls risk prediction is a particularly complex patient safety issue. Clinicians need to be aware of the limitations of their tool used to predict falls.

Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: a randomised trial

QUESTION

Does adding video/computer-based interactive exercises to inpatient geriatric and neurological rehabilitation improve mobility outcomes? Is it feasible and safe?

DESIGN

Randomised trial.

PARTICIPANTS

Fifty-eight rehabilitation inpatients.

INTERVENTION

Physiotherapist-prescribed, tailored, video/computer-based interactive exercises for 1 hour on weekdays, mainly involving stepping and weight-shifting exercises.

OUTCOME MEASURES

The primary outcome was the Short Physical Performance Battery (0 to 3) at 2 weeks. Secondary outcomes were: Maximal Balance Range (mm); Step Test (step count); Rivermead Mobility Index (0 to 15); activity levels; Activity Measure for Post Acute Care Basic Mobility (18 to 72) and Daily Activity (15 to 60); Falls Efficacy Scale (10 to 40), ED5D utility score (0 to 1); Reintegration to Normal Living Index (0 to 100); System Usability Scale (0 to 100) and Physical Activity Enjoyment Scale (0 to 126). Safety was determined from adverse events during intervention.

RESULTS

At 2 weeks the between-group difference in the primary outcome (0.1, 95% CI -0.2 to 0.3) was not statistically significant. The intervention group performed significantly better than usual care for Maximal Balance Range (38mm difference after baseline adjustment, 95% CI 6 to 69). Other secondary outcomes were not statistically significant. Fifty-eight (55%) of the eligible patients agreed to participate, 25/29 (86%) completed the intervention and 10 (39%) attended > 70% of sessions, with a mean of 5.6 sessions (SD 3.3) attended and overall average duration of 4.5hours (SD 3.1). Average scores were 62 (SD 21) for the System Usability Scale and 62 (SD 8) for the Physical Activity Enjoyment Scale. There were no adverse events.

CONCLUSION

The addition of video/computer-based interactive exercises to usual rehabilitation is a safe and feasible way to increase exercise dose, but is not suitable for all. Adding the exercises to usual rehabilitation resulted in task-specific improvements in balance but not overall mobility.

REGISTRATION

ACTRN12613000610730.

Effects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: A randomized controlled trial

OBJECTIVE

The purpose of our study was to evaluate the effects of six weeks of Pilates regarding functional balance, fear of falling and pain in community living women older than 65 years old with chronic low-back pain.

STUDY DESIGN

A single blind controlled randomized trial of six weeks of Pilates in addition to physiotherapy treatment (n=50) vs. physiotherapy treatment alone (n=47) was conducted on 97 community living women (71.14 ± 3.30 years) with chronic low-back pain (CLBP).

MAIN OUTCOME MEASURES

Main outcome measures were fear of falling (FoF), assessed by the Falls Efficacy Scale-international; functional mobility and balance, measured with the Timed up and Go Test; and pain, evaluated using the numeric rating scale.

RESULTS

Only the Pilates group showed improvement in FoF (ES; d=.68) and functional mobility and balance (ES; d=1.12) after treatment, and also had better results in pain (ES; d=1.46) than the physiotherapy-only group.

CONCLUSIONS

Six weeks of Pilates exercises may be effective in fall prevention through the improvement of FoF, functional balance, and pain in Spanish women over 65 years old with CLBP.

Additional standing balance circuit classes during inpatient rehabilitation improved balance outcomes: an assessor-blinded randomised controlled trial

OBJECTIVE

to evaluate the impact on balance (postural control) of six 1-h circuit classes that targeted balance in addition to usual therapy for rehabilitation inpatients.

DESIGN

a randomised controlled trial with 2-week and 3-month follow-up.

PARTICIPANTS

one hundred and sixty-two general rehabilitation inpatients, Bankstown-Lidcombe Hospital, Australia.

INTERVENTION

intervention group participants received six 1-h circuit classes over a 2-week period in addition to usual therapy. Control group participants received usual therapy.

RESULTS

standing balance performance (primary outcome) was better in the intervention group than in the control group at 2 weeks (between-group difference after adjusting for baseline values 3.3 s; 95% confidence interval (CI) 0.84 to 5.7, P = 0.009), but the between-group difference was not statistically significant at 3 months (3.4 s; 95% CI -0.56 to 7.38, P = 0.092). Intervention group outcomes were significantly better than the control groups for mobility performance (Short Physical Performance Battery) at 2 weeks (1.19, 95% CI 0.52 to 1.87, P <0.01) and 3 months (1.00, 95% CI 0.00 to 2.00, P < 0.049) and self-reported functioning (AM-PAC) at 2 weeks (5.39, 95% CI 1.20 to 9.57, P = 0.012). The intervention group had a 4.1-day shorter rehabilitation unit stay (95% CI -8.3 to 0.16, P = 0.059) and a lower risk of readmission in the 3 months after randomisation (incidence rate ratio 0.70, 95% CI 0.42 to 1.18, P = 0.184), but these differences were not statistically significant.

CONCLUSION

two weeks of standing balance circuit classes in addition to usual therapy improved balance in general rehabilitation inpatients at 2 weeks.

Self-reported chronic pain is associated with physical performance in older people leaving aged care rehabilitation

Background/objectives

The impact of pain on the physical performance of patients in aged care rehabilitation is not known. The study sought to assess 1) the prevalence of pain in older people being discharged from inpatient rehabilitation; 2) the association between self-reported pain and physical performance in people being discharged from inpatient rehabilitation; and 3) the association between self-reported pain and physical performance in this population, after adjusting for potential confounding factors.

Methods

This was an observational cross-sectional study of 420 older people at two inpatient aged care rehabilitation units. Physical performance was assessed using the Lower Limb Summary Performance Score. Pain was assessed with questions about the extent to which participants were troubled by pain, the duration of symptoms, and the impact of chronic pain on everyday activity. Depression and the number of comorbidities were assessed by questionnaire and medical file audit. Cognition was assessed with the Mini-Mental State Examination.

Results

Thirty percent of participants reported chronic pain (pain lasting more than 3 months), and 17% reported that this pain interfered with daily activities to a moderate or greater extent. Chronic pain (P=0.013) and chronic pain affecting daily activities (P<0.001) were associated with a poorer Lower Limb Summary Performance Score. The relationship between chronic pain affecting daily activities and Lower Limb Summary Performance Score remained significant (P=0.001) after adjusting for depression, age, comorbidities, and Mini-Mental State Examination score. This model explained 10% of the variability in physical performance.

Conclusion

One-third of participants reported chronic pain, and close to one-fifth reported that this pain interfered with daily activities. Chronic pain was associated with impaired physical performance, and this relationship persisted after adjusting for likely confounding factors.

Men older than 50 yrs are more likely to fall than women under similar conditions of health, body composition, and balance

OBJECTIVE

The aim of this study was to analyze the contribution of sex to the occurrence of falls, accounting for comorbidities and differences in physical fitness.

DESIGN

This was a cross-sectional study of 587 community-dwelling adults who were older than 50 yrs. Falls, comorbidities (number of diseases and physical impairments), and physical fitness (body composition, lower and upper body strength and flexibility, agility, aerobic endurance, and balance) were evaluated via questionnaires, bioimpedance, and Fullerton batteries, respectively.

RESULTS

Compared with the men, the women presented a 10% higher fall prevalence, 1.7 more diseases/impairments, 10% more body fat, 26% less lean body mass, and poorer physical capacity (P < 0.05). Multivariate logistic regression revealed that male sex (odds ratio [OR], 2.723; 95% confidence interval [CI], 1.190-6.230) increased the likelihood of falling, after adjustment for comorbidities (OR, 1.213; 95% CI, 1.109-1.328), lean mass (OR, 0.958; 95% CI, 0.927-0.989), fat mass (OR, 1.053; 95% CI, 1.021-1.086), and balance (OR, 0.942; 95% CI, 0.914-0.971), which were the main risk factors of falls.

CONCLUSIONS

Women are more susceptible to falling, presumably because they have poorer health and physical fitness than do men. However, when the values for comorbidities, lean and fat body mass, and balance were similar, the men demonstrated a higher probability of falling. Age is not a significant risk factor of falls under favorable conditions of health, body composition, and balance.

Testing the reliability of the Fall Risk Screening Tool in an elderly ambulatory population

AIM

To identify and test the reliability of a fall risk screening tool in an ambulatory outpatient clinic.

BACKGROUND

The Fall Risk Screening Tool (Albert Lea Medical Center, MN, USA) was scripted for an interview format.

METHOD

Two interviewers separately screened a convenience sample of 111 patients (age ≥ 65 years) in an ambulatory outpatient clinic in a northeastern US city.

RESULT

The interviewers' scoring of fall risk categories was similar. There was good internal consistency (Cronbach's α = 0.834-0.889) and inter-rater reliability [intra-class correlation coefficients (ICC) = 0.824-0.881] for total, Risk Factor and Client's Health Status subscales. The Physical Environment scores indicated acceptable internal consistency (Cronbach's α = 0.742) and adequate reliability (ICC = 0.688). Two Physical Environment items (furniture and medical equipment condition) had low reliabilities [Kappa (K) = 0.323, P = 0.08; K = -0.078, P = 0.648), respectively.

CONCLUSION

The scripted Fall Risk Screening Tool demonstrated good reliability in this sample. Rewording two Physical Environment items will be considered.

IMPLICATIONS FOR NURSING MANAGEMENT

A reliable instrument such as the scripted Fall Risk Screening Tool provides a standardised assessment for identifying high fall risk patients. This tool is especially useful because it assesses personal, behavioural and environmental factors specific to community-dwelling patients; the interview format also facilitates patient-provider interaction.

Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people

The risk assessment of falls is important, but still unsatisfactory and time-consuming. Our objective was to assess quantitative ultrasound (QUS) in the risk assessment of falls. Our study was designed as epidemiological cross-sectional study occurring from March 2009 to February 2010 by community survey at a medical center. The participants were collected from systemic sample of 1,200 community-dwelling people (Male/Female = 524/676) 40 years old and over in Yunlin County, Mid-Taiwan. Structural questionnaires including socioeconomic status, living status, smoking and drinking habits, exercise and medical history were completed. Quantitative ultrasound (QUS) at the non-dominant distal radial area (QUS-R) and the left calcaneal area (QUS-C) were measured. The overall prevalence of falls was 19.8%. In men, the independently associated factors for falls were age (OR: 1.04; 95%CI: 1.01~1.06), fracture history (OR: 1.89; 95%CI: 1.12~3.19), osteoarthritis history (OR: 3.66; 95%CI: 1.15~11.64) and speed of sound (OR: 0.99; 95%CI: 0.99~1.00; p<0.05) by QUS-R. In women, the independently associated factors for falls were current drinking (OR: 3.54; 95%CI: 1.35∼9.31) and broadband ultrasound attenuation (OR: 0.98; 95%CI: 0.97~0.99; p<0.01) by QUS-C. The cutoffs at -2.5< T-score<-1 derived using QUS-R (OR: 2.85; 95%CI: 1.64~4.96; p<0.01) in men or T-score ≦-2.5 derived using QUS-C (OR: 2.72; 95%CI: 1.42~5.21; p<0.01) in women showed an independent association with falls. The lowest T-score derived using either QUS-R or QUS-C was also revealed as an independent factor for falls in both men (OR: 2.13; 95%CI: 1.03~4.43; p<0.05) and women (OR: 2.36; 95%CI: 1.13~4.91; p<0.05).

CONCLUSIONS

Quantitative ultrasounds, measured either at the radial or calcaneal area, are convenient tools by which to assess the risk of falls in middle-aged and elderly people.

Balance circuit classes to improve balance among rehabilitation inpatients: a protocol for a randomised controlled trial

Background

Impaired balance and mobility are common among rehabilitation inpatients. Poor balance and mobility lead to an increased risk of falling. Specific balance exercise has been shown to improve balance and reduce falls within the community setting. However few studies have measured the effects of balance exercises on balance within the inpatient setting.

The aim of this randomised controlled trial is to investigate whether the addition of circuit classes targeting balance to usual therapy lead to greater improvements in balance among rehabilitation inpatients than usual therapy alone.

Methods/Design

A single centre, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. One hundred and sixty two patients admitted to the general rehabilitation ward at Bankstown-Lidcombe Hospital will be recruited. Eligible participants will have no medical contraindications to exercise and will be able to: fully weight bear; stand unaided independently for at least 30 seconds; and participate in group therapy sessions with minimal supervision.

Participants will be randomly allocated to an intervention group or usual-care control group. Both groups will receive standard rehabilitation intervention that includes physiotherapy mobility training and exercise for at least two hours on each week day. The intervention group will also receive six 1-hour circuit classes of supervised balance exercises designed to maximise the ability to make postural adjustments in standing, stepping and walking.

The primary outcome is balance. Balance will be assessed by measuring the total time the participant can stand unsupported in five different positions; feet apart, feet together, semi-tandem, tandem and single-leg-stance. Secondary outcomes include mobility, self reported physical functioning, falls and hospital readmissions. Performance on the outcome measures will be assessed before randomisation and at two-weeks and three-months after randomisation by physiotherapists unaware of intervention group allocation.

Discussion

This study will determine the impact of additional balance circuit classes on balance among rehabilitation inpatients. The results will provide essential information to guide evidence-based physiotherapy at the study site as well as across other rehabilitation inpatient settings.

Trial registration

The protocol for this study is registered with the Australian New Zealand, Clinical Trials Registry: ACTRN=12611000412932

The maximal width of the base of support (BSW): clinical applicability and reliability of a preferred-standing test for measuring the risk of falling

The aim of this study was to test the reliability and validity of a preferred-standing test for measuring the risk of falling. The preferred-standing position of elderly fallers and non-fallers and healthy young adults was measured. The maximal BSW was measured. The absolute and relative reliability and discriminant validity were assessed. The expanded timed get-up-and-go test (ETGUG), one-leg stance test (OS), tandem stance (TS), and falls efficacy scale international version (FES-I) were used to determine criterion validity. In total, 146 persons (102 females, 44 males; mean age 55±22 years, range 20-94) were recruited. Forty elderly community dwellers (8 fallers) and 26 young adults were tested twice to determine the test-retest reliability. The BSW showed acceptable test-retest reliability (Intraclass correlation coefficient, ICC2,1=0.77-0.83) and inter-rater reliability (ICC3,1=0.77-0.95) for all groups. The standard error of measurement (SEM) was between 0.77 and 1.87, and the smallest detectable change (SDC) was between 2.14cm and 5.19cm. The Bland-Altman plot revealed no systematic errors. There was significant difference between elderly fallers and non-fallers (F(1/75)=11.951; p=0.001. Spearman's rho coefficient values showed no correlation between the BSW and the ETGUG (-0.17, p=0.47), OLS (-0.04, p=0.65), TS (-0.11, p=0.21), and FES-I (-0.10; p=0.27). Only the BSW was a significant predictor for falling (odds ratio=0.736, p=0.007). The reliability and validity of the BSW protocol were acceptable overall. Prospective studies are warranted to evaluate the predictive value of the BSW for determining the risk of falling.

Predictors of a fall event in hospitalized patients with cancer

PURPOSE/OBJECTIVES

To determine predictors of fall events in hospitalized patients with cancer and develop a scoring system to predict fall events.

DESIGN

Retrospective medical record review.

SETTING

A 1,200-bed tertiary care hospital in northeastern Ohio.

SAMPLE

145 patients with cancer who did not have a fall event were randomly selected from all oncology admissions from February 2006-January 2007 and compared to 143 hospitalized patients with cancer who had a fall event during the same period.

METHODS

Multivariable logistic regression models predicting falls were fit. Risk score analysis was completed using bootstrap samples to evaluate discrimination between patients who did or did not fall and agreement between predicted and actual fall status. A nomogram of risk scores was created.

MAIN RESEARCH VARIABLES

Fall episodes during hospitalization and patient characteristics that predict falls.

FINDINGS

While patients were hospitalized for cancer care, their predictors of a fall episode were low pain level, abnormal gait, cancer type, presence of metastasis, antidepressant and antipsychotic medication use, and blood product use (all p < 0.02); risk model c-statistic was 0.89.

CONCLUSIONS

For hospitalized patients with cancer, predictors reflecting greater fall episode risk can be assessed easily by nursing staff and acted on when the risk is sufficiently high.

IMPLICATIONS FOR NURSING

Understanding specific risk factors of falls in an adult oncology population may lead to interventions that reduce fall risk.

Fall risk six weeks from onset of stroke and the ability of the Prediction of Falls in Rehabilitation Settings Tool and motor function to predict falls

Objective:

To investigate whether the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST) and motor function could be used to identify people at risk of falling during the first six weeks after stroke, and to compare the risk of falling according to Predict FIRST with real falls frequency.

Design:

A longitudinal, prospective study.

Patients:

Sixty-eight people newly diagnosed with stroke admitted to an acute stroke unit.

Methods:

The participants underwent an assessment of motor ability (Modified Motor Assessment Scale according to Uppsala University Hospital version 99 (M-MAS UAS-99)) and falls risk (Predict FIRST) on the first to fourth day at the acute stroke unit. Falls occurring in the acute stroke unit were recorded and falls occurring after discharge were reported by telephone follow-up. The prediction of falls was analysed with binary logistic regression.

Results:

Fourteen of the patients (21%) fell at least once during the first six weeks after stroke. The strongest significant predictor for falls was a high score on Predict FIRST (odds ratio 5.21, confidence interval (CI) 1.10–24.78) followed by M-MAS UAS-99 parts C–E (odds ratio 0.65, CI 0.44–0.95). Predict FIRST underestimated the risk of falling as the median fall risk was 9% according to Predict FIRST.

Conclusion:

Although Predict FIRST has the ability to predict falls in people with recent onset of stroke, there is some underestimation of fall risk.

Burden of Clostridium difficile on the healthcare system

There are few high-quality studies of the costs of Clostridium difficile infection (CDI), and the majority of studies focus on the costs of CDI in acute-care facilities. Analysis of the best available data, from 2008, indicates that CDI may have resulted in $4.8 billion in excess costs in US acute-care facilities. Other areas of CDI-attributable excess costs that need to be investigated are costs of increased discharges to long-term care facilities, of CDI with onset in long-term care facilities, of recurrent CDI, and of additional adverse events caused by CDI.

Reducing falls among geriatric rehabilitation patients: a controlled clinical trial

Objective:

To evaluate the effectiveness of an intervention programme to reduce falls among geriatric rehabilitation patients.

Design:

Pre/post-test design with independent pre-test and matched post-test samples.

Setting:

Inpatient geriatric wards in a rehabilitation hospital.

Participants:

Seventy-six matched pairs ( n = 152) of geriatric rehabilitation patients from one control and one intervention ward participated in the study, and 36 nursing staff surveys were completed.

Intervention:

The intervention programme was developed based on interviews and systematic reviews. Educational materials were distributed to patients and families, and preventive measures were implemented.

Main outcome measures:

The rates of falls before and after the intervention both within and between the wards were compared, and surveys were completed.

Results:

The matched patients presented no significant differences on age, gender or medical conditions. The falls rates, proportion of fallers and length of stay was higher among those in the control ward ( P< 0.043). The percentage of fallers and the rate of falls/1000 patient days were lower on the intervention ward after implementation: odds ratio (95% confidence interval) = −2.9 (−6.6, −1.2) and −1.8 (−6.0, 0.5). Thirty of 36 respondents considered the tool to be helpful and beneficial for use on other wards.

Conclusion:

The intervention programme was effective in reducing falls among geriatric rehabilitation patients.

Implementing falls prevention research into policy and practice in Australia: past, present and future

INTRODUCTION

Falls in older Australians are a significant public health issue with one in three older people falling one or more times each year.

METHOD

Many fall prevention randomized controlled trials have been conducted in Australia as well as across the world.

RESULTS

The findings of these studies now constitute a substantial evidence base that can provide direction for health and lifestyle interventions for preventing falls in older people. This research evidence has contributed to health policy in Australia to some extent, but is yet to be widely implemented into practice. This opinion piece overviews previous policy initiatives and describes a new Partnership research program funded by the Australian National Health and Medical Research Council (NHMRC), which seeks to further influence health policy and address the ongoing research-practice gap.

Implementing falls prevention research into policy and practice: an overview of a new National Health and Medical Research Council Partnership Grant

Preventing falls and fall-related injuries among older people is an urgent public health challenge. This paper provides an overview of the background to and research planned for a 5-year National Health and Medical Research Council Partnership Grant on implementing falls prevention research findings into policy and practice. This program represents a partnership between key Australian falls prevention researchers, policy makers and information technology companies which aims to: (1) fill gaps in evidence relating to the prevention of falls in older people, involving new research studies of risk factor assessment and interventions for falls prevention; (2) translate evidence into policy and practice, examining the usefulness of new risk-identification tools in clinical practice; and (3) disseminate evidence to health professionals working with older people, via presentations, new evidence-based guidelines, improved resources and learning tools, to improve the workforce capacity to prevent falls and associated injuries in the future.