Nursing Interventions to Prevent Falls in the Elderly - Research Paper Example

? NURSING ACTION OR INTERVENTION DESIGNED TO IMPROVE FALL RISK CARE IN THE GERIATRICS POPULATION Affiliation Introduction Geriatric Care Geriatrics is basically sub-specialty of internal family medicine while Geriatric care refers to the professional nursing of elderly people.Geriatrics is different from Gerontology that is aging process but sometimes it is referred to as “Medical Gerontology”. Scope of Geriatrics Because of ageing human body loses its resilience and hence becomes prone to different diseases and develops complications from mild problems like mild gastroenteritis can lead to severe dehydration andloss of balance and fall due to vertigo. Common chronic problems like hindered vision, hearing failure and impaired memory arise in old age which leadsto different problems and severe distress. Elderly people are generally subjected to polypharmacy (using multiple medications) due to multiple problems of old age. A study shows that there are about as many elderly who take nonprescription drugs as take prescription drugs. This however, may cause adverse drug effects (categorized as serious, life-threating and fatal)if the drugs interact with each other within the body.Another complexity is the refusal of elderly people to cooperate due to the fear of consequences of treatmentand they reject taking any medical care. However, many of these problems are treatable, if proper nursing measures are taken. Overview: Falls in Elderly Falls among elderly are not related to normal aging; rather, they are regarded as a geriatric syndrome because of discrete multifactorial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating (vertigo, syncope) causes. We have taken two studies into consideration based on the randomized trials of the elderly people living in: Homes (Day et al., 2002) Residential care facilities (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002) There has been a lot of research in the past decade on randomized controlled trials based on fall prevention. Day et al. (2002) report that exercise, minimization in medication, professional support services and home modifications have proved to be effective interventions as supported by RCT.Trails of multiple interventions have also shown to be effective in fall prevention. While in another study Jensen, Lundin-Olsson, Nyberg & Gustafson (2002) has designed a hypothesis intervention program based on specific multiple risk factors for falls in elderly residents of residential care facilities and conducted RCT for fall prevention. Designs Study-I Day et al., (2002) designed the evidence based study which targeted fall risk factors: strength, balance disorder, impaired vision, and home hazards (included because of its extensive presence although no strong evidence was available). The study used a full factorial design, designating eight groups on the basis of three interventions. Seven groups availed at least one intervention and the remaining one group didn’t till the end of the study.“Adaptive Biased Coin” technique was used to select the participants. A flow chart of the scheme is provided in appendix-I. Placement – CityofWhitehorse, Melbourne, Australia Participant Age– 70 years and above (residing at own homes) Data Assessment– The researchers compared and divided individuals into different groups according to the available data on the basis of higher percentage: Sample size–On the basis of 25%annualfall-reductionconsidered to be an achievable target the studies required 914 participants and 1143 participants for a non-intervention assessment and main effect comparison(annual fall-rateof 35 per 100 individuals) allowing a 20% dropout. Study-II Jenson’s (2002) study was designed onelderly people (having cognitive dysfunction)residing in residentialcare facilities. The study reports that out of 25 residents, nine met the criterion and were split into groups A and B (based on age, number and type of facility setting and record of previous falls). To maintain the discreetness the medical staff of both groups was separately chosen. A baseline assessment period of 5 weeks was set and after that both groups were randomized into control and intervention groups. An 11 week intervention period was followed by a 34 week follow-up and evaluation period and the outcomes were measured afterwards. A flow chart of the scheme is given in the appendix-II. Placement –Residential Care Facilities, Umea, Sweden. Participant Age – 65 years and above. Data Assessment –The median age was found to be 83 years (range 65-100 years). The staff in the study included 8 physiotherapists, 20 nurses and 273 aides. Sample size–439 residents were selected in a cross-sectional manner. Out of these 37 residents declined to be engaged in the activity, got hospitalized or expired before trials. 402 participants remained. Assessments Study-I:Information from the participants was gained by an independent mediator and a baseline assessment was performed which covered all aspects of the study. Risk factors were assessed and were randomized into intervention group.Risk factors were reassessed after 18 months (in 442 random individuals). 177 individuals were measured strength and balance in the final exercise class of 15 weeks training and 79 were selected for final reassessment. Study-II:Baseline information from the residents was collected and recorded in a questionnaire by the physician.Each resident’s physician completed a questionnaire.MMSE (Median-Mini Mental state Examination) was used to examine global cognitive function. Fall risks were assessed and residents who were older had a higher exposure to risk. Residential facilities were inspected for environmental hazards (barriers, slippery floor etc.).Other baseline characteristics are confined in Table 1 (see table section). Interventions Both studies used different intervention strategies based on the targeted risk-factors. Exercise–The researchers used a professionally designed physical exercise program to enhance balance and strength by improving muscle flexibility and vigor (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002; Day et al., 2002). The regular exercise routine depended on individual capability (Day et al., 2002). Hazards Management-Potentially harmful objects were either modified or replaced. Other improvements include replacement of loose carpets, doorsteps repair, arrangement of grip-bars, secure bedding and firm mattresses in bedrooms and bathrooms (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002; Day et al., 2002). Staff Education& Guidance– An educational session was held in order to educate the medical staff for fall-risk prevention and strategies.Researchers engaged staff in frequent discussions. A secure transportationof fall-prone residents under professional supervision and by enhancing transfer techniques and accommodating bed-side alarms was the most convenient outcome.Post-fall reports were also discussed weekly in order to determine fall factors (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). Protecting Aids-Twenty-nine residents were provided with walking aids (wheelchairs, crutches and fitted foot-wear) or got their personal aids repaired.Keeping in view the common risk factors for fractures, residents prone to hip-fracture were provided with free hip-protectors and 72% patients agreed to use them(Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). Medication Modifications –Residents were either prescribed alternate drugs or pharmacologic treatmentsduring 11-week intervention course, because the side-effects of existing drugs and certain medical conditions were suspected to enhance fall-risk(Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). Outcomes In both studies the primary outcomes was the individual reporting of number of falls and time of occurrence.Jensen and colleagues recorded the secondary outcome which was number of post-fall injuries. Analyses: Tools Used Day et al.(2002) calculated the variations in risk-factor levels and mean scores for all three interventions.“Main effects mode” was used for comparison between intervention and control groups.Three-way and two-way mixed factorial analysis of variance models was used to identify changes inquadriceps strength and balance measures andFisher's test of exact probability to distinguish stereopsis measures between intervention and control groups while changes in the rest of the measures were assessed via paired samples t tests. Jensen and colleagues (2002) calculated the incidence and hazard rates of falls. Due to the possibility of dependency of residents the statistical analyses using Logistic, Poisson (incidence rate) and Cox regressions and a few baseline factors (MMSE score, Barthel index score, history of falls, sex and age) were adjusted for clustering. They also performed subgroup interaction analysis to assess first fall intervention effect using four variables low and high risk and intervention and control groups. Both studies used Cox regression analysis for determining fall-rates. The soft-wares used were EGRET and S­PLUS (Day, 2002) and Stata 7.0 (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). Results Therandomized controlled trialswere professionally designed, and supervised, cost effective, and the results showed a significant reduction in falls and fractures even when clustering is taken into account, (Day et al., 2002; Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002) albeit the poor compliance of home exercises sessions (Day, 2002).No femoral fractures were noticed in people using hip protection (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). Day’s home-based program had the smallest durationas compared to other reported programs. Participants were successful inachieving balance and thus, fall reduction via exercise. Moreover, increased awareness of fall related risks also enabled a significant decline in falls. Professional home modifications and vision treatments also proved to be helpful if not very ample, in reducing fall-risk among the elderly with previous falls history.However, an excellent outcome was observed when the integrated effect of all interventions was assessed (Day et al., 2002; Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002) and the exercise program and specifically its balance component gave the most significant outcomes (Day et al., 2002). Limitations The studies proved to be successful however, there were some limitations. The feasibility of the participants in the intervention groups and those who were receiving intense training were likely to under-report their falls statuses (Day et al., 2002; Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). In residential care centerssome of the staff members were accountable for many facilitieswhere the groups were meant to be separated from each other and the randomization of the facilities was required. Moreover, the educational programs and discussions made the discreteness irrelevant (Jensen, Lundin-Olsson, Nyberg & Gustafson, 2002). The compliance of home based exercises was rather poor as the daily exercises were done twice a week.Other than exercise the other two interventions, home hazard management and vision correction had lesser combined effect even though the effects were higher in the specifically targeted groups (Day et al., 2002). Discussion What changes/improvement could be made? Apart from a few limitations the intervention studies were proved to be successful. However, a few improvements and interventions could be introduced: To prevent falls in the elderly whose length of stay (LOS) in facilities is four or more months and possess no history of fall-fracture,Tai Chi is recommended.However, for residents whose length of stay (LOS) is less than four months the evidence is insufficient. Individuals at risk of falling, and their care-takers,should be offered information, both verbal and written regarding: What measures can be taken to prevent further falls? How to stay motivated if fall prevention strategies including exercise or strength and balancing components are prescribed? How to cope if they have a fall, including how to call for help The preventable nature of some falls. Modification of fall-risks and their physical and psychological advantages. Deficiency of vitamin-D can lead to impairment of muscles and bones and most probably neuromuscularfunction, via CNS-mediated pathways. Regular use of combined calcium and vitamin D3supplementation has been found to reduce fracturerates in older people.Although there is insufficient evidence that correction of vitamin D levels may reduce thetendency for falling, there is uncertainty aboutits relative contribution to fracture reduction, the dose and route of administration. References Day, L.,Fildes, B., Gordon, I.,Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomized factorial trials of falls prevention among older people living in their own homes.British Medical Journal, 325(128), 1-6. doi: 10.1136/bmj.325.7356.128 Jensen, J.,Lundin-Olsson, L., Nyberg, L., & Gustafson, Y., (2002).Fall and Injury Prevention in Older People Living in Residential CareFacilities: A Cluster Randomized Trial. Annals of Internal Medicine, 136, 733-741. Appendix-I Study Design (Day et al., 2002) Appendix-II Study Design (Jensen,lundin-Olsson, Nyberg & Gustafson, 2002) Table 1 (Jensen,Lundin-Olsson, Nyberg & Gustafson, 2002) Read More