AN INTEGRATED LOOK AT FALLS PREVENTION IN AN AGING POPULATION BOBBI SYMES. Integrated Studies Final Project Essay (MAIS 700)

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1 AN INTEGRATED LOOK AT FALLS PREVENTION IN AN AGING POPULATION By BOBBI SYMES Integrated Studies Final Project Essay (MAIS 700) Submitted to Dr. Michael Gismondi in partial fulfillment of the requirements for the degree of Master of Arts Integrated Studies Athabasca, Alberta January, 2013

2 Abstract Experiencing a fall can have devastating physical and psychological effects on an older person. Within this population a fall can have tragic results including loss of independence, chronic pain, reduced quality of life, disability and death. The risk of falling is complex and multifactorial, as are the causes of these falls. Reducing the incidence and severity of falls among a rapidly aging population demands a proactive, systematic, and interdisciplinary approach to prevention (Scott, et al 2010). A public health approach was reviewed as an interdisciplinary approach to the issue of falls and falls injury prevention. Such an approach is designed to draw on scientific evidence and professional expertise from a wide range of disciplines to resolve issues that impact large populations (Scott et al, 2010). This paper describes the use of a Public Health Framework as an easy to follow staged approach to falls and related injury prevention involving multiple stakeholders. It was found that such an approach could easily be implemented by those organizations looking for a model that can be easily integrated into existing practice. 2

3 Table of Contents Abstract... 2 Table of Contents... 3 Introduction... 4 Background... 5 Evidence based Best Practices... 6 Discipline Based Theories... 7 Interdisciplinary Based Theories... 9 An Integrated Approach to Falls Prevention...12 An Integrated Framework for Falls Prevention...14 Materials and Methods...16 Conclusion...17 Appendix A: Definitions...19 References

4 An Integrated Look at Falls Prevention in an Aging Population Introduction Experiencing a fall can have devastating physical and psychological effects on an older person. Within this population a fall can have tragic results including loss of independence, chronic pain, reduced quality of life, disability and death. The risk of falling is complex and multifactorial, as are the causes of these falls. Reducing the incidence and severity of falls among a rapidly aging population demands a proactive, systematic, and interdisciplinary approach to prevention (Scott, et al 2010). In Canada, falls is considered a public health priority recognized by the Public Health Agency of Canada (PHAC) as the most costly and complex injury issues facing seniors (2005). Some claim that a public health approach is well suited to the issue of fall and injury prevention, as it is designed to draw on scientific evidence and professional expertise from a wide range of disciplines to resolve issues that impact large populations (Scott et al 2010). This approach relies on a thorough analysis of the problem and its causes in order to develop effective solutions (Segui Gomez M & MacKenzie EJ, 2003). The purpose of this project is to review the public health approach for appropriateness as an interdisciplinary approach to falls prevention. In particular, I wanted to identify a) the need for an interdisciplinary approach to falls prevention; 4

5 and b) review the public health approach for appropriateness as an interdisciplinary approach to falls prevention. Background In Canada, falls are the leading cause of injury related deaths and hospitalizations among older adults (WHO, 2007, Scott et al, 2004). About 30% of community dwelling seniors and 50% of those in long term care (LTC) will experience at least one fall each year. Recent statistics show that there are over 73,000 hospitalizations due to falls among Canadian seniors each year (Scott, Wagar, & Elliot, 2010) at a medical cost of approximately $2.0 billion per year (SMARTRISK, 2009). In older adults falls are the main contributor (90%) of hip fractures (Grisso, Schwarz, Wishner et al, 1990; Spaite, Criss, Valenzuela et al, 1990) and wrist fractures (Palvanen, Kannus, Parkkari, et al, 2000), and head injuries (60%) (Robinovitch et al, 2012; CIHR, 2006). Clearly, developing improved methods for preventing falls and fall related injuries in seniors is a major public health priority. Preventing falls in older adults can be a daunting task. A diverse range of physiological and situational variables contributes to falls, and individuals who fall often present with multiple risk factors. Furthermore, determining the mechanisms of falls is often challenging as most falls go unwitnessed and unreported. At a patient level, this prevents care providers from accurately diagnosing and treating the cause of falls as well as any injuries resulting from the fall. At a population level, it impairs the development of more senior friendly environments, valid fall 5

6 assessment tools, and effective community based fall prevention strategies (Robinovitch, 2011; Scott, 2009). Evidence based Best Practices In Canada and internationally, professional organizations and governments have established guidelines for fall prevention based on reviews of research evidence. Best practice guidelines prepared by professional organizations are generally considered prescriptive for professional practice (PHAC, 2005). Professional organizations at each of the Provincial, National and International levels have developed practice guidelines on seniors falls and injury prevention. For example, in British Columbia (BC) the BC Falls and Injury Prevention Coalition took the lead on the development of a framework and toolkit called the Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention. This was created as a joint initiative for the prevention of falls and related injuries in residential care. The development of the Toolkit was a collaborative process including multiple stakeholders from residential care and government. Nationally, the Registered Nurses Association of Ontario are well known for their professional practice guideline, RNAO: Prevention of Falls and Injuries in the Older Adult, which includes best practices that address patient education and post fall prevention. Internationally, one of the most widely adopted guidelines is the Guideline for the Prevention of Falls in Older Persons of the American Geriatrics Society (AGS), prepared in collaboration with the British Geriatrics Society and the 6

7 American Academy of Orthopaedic Surgeons. As well, in the UK, the National Institute for Clinical Excellence (NICE) published The Assessment and Prevention of Falls in Older People (2004). This guideline outlines best practices based on clinical evidence and cost effectiveness. In Australia, the Department of Health and Aging has developed a national fall prevention initiative for older people. Research evidence feeding into these clinical professional guidelines stem from different theories that emerge within the existing literature. There are two basic approaches shown in the literature: single intervention strategies (such as exercise, vitamin D, or withdrawal of psychotropic drugs); or interdisciplinary programs, including simultaneous assessment and reduction of many of the individual s predisposing and situational risk factors. Examples of the various types of research that feed into these clinical guidelines are described below. Discipline Based Theories Single intervention or discipline based theories of fall and injury prevention have shown to be effective (see Table 1). Such approaches can be very successful in targeting injury risk and prevention at the individual level. One particularly successful approach to injury prevention is the use of hip protectors, which targets the injury site. Additionally, a traditional approach for bone fracture has been prevention and treatment of osteoporosis. This approach has been widely accepted in published work, and includes several recommendations (Kannus, 2005). Maximising peak bone mass and preventing bone loss by regular exercise, calcium, 7

8 vitamin D, and treatment of osteoporosis with pharmacological agents all have scientific basis and have been recommended by many authorities (Kannus, 2005). Table 1: Examples of Single Intervention or Discipline based theories to falls and injury prevention. Discipline Base Summary Authors Osteoporosis Those with osteoporosis are at increase risk of a fracture due to a fall. A Canadian Study found that a year after sustaining a low trauma fracture, less than 20 percent of these people had been diagnosed or treated for osteoporosis Osteoporosis Quadriceps strength and postural sway Chronic Conditions Gender Medication Osteoporosis Guidelines state that the risk for a fracture is increase when blood serum levels for 25 hydroxyvitamin D are below 75 nmol/l A study comparing community dwelling older persons who had not experienced a fall with those who fell and fractured their hip, found that poor quadriceps strength and the existence of postural sway were significant indicators for falls resulting in a hip fracture Certain chronic conditions are associated with higher fall related injury rates compared to falls without injury, including a history of anemia, rheumatic disorders, symptoms of stroke, cognitive impairment, users of psychotropic drugs, muscle weakness, balance and gait impairment and low body mass Female gender is shown in a number of studies to be associated with higher injury rates compared to men Use of benzodiazepine tranquilizers, psychotropic drugs and other sedatives is found to increase the risk of injury from a fall after controlling for age, gender, and prior health care utilization Equipment Flooring A study among hospital patients showed that 17 percent of falls on carpeted surfaces result in injuries, whereas 46 percent of falls on vinyl surfaces resulted in injuries Equipment Flooring There is growing evidence for the potential for fallrelated fracture prevention through the use of Equipment Hip Protectors compliant flooring Growing evidence on use of hip protectors to prevent or reduce injury resulting from falls Hajcsar, Hawker & Bogoch, 2000 Cameron et al, 2010; Hanley et al, 2010; Bischoff et al, 2003 Sherrington & Lord, 1998 Van Doorn et al, 2003; Tinetti & William, 1997; Thapa, Brockman, Gideon, Fought, & Ray, 1996; Tinetti, 1987;. Sadigh, Reimers, Anderson & Laflamme, 2004; Scott, Peck & Kendall, 2004; Van Doorn et al, 2003 Kallin, Gustafson, Sandman & Karlsson, 2004; Leipzig, Cumming & Tinetti, 1999; Monane & Avorn, 1996; Whooley et al, 1999 Healey, 1994 Robinovitch, 2009 Laing, Feldman et al (2011); Robinovitch et al (2009) Environmental The risk of a fall related fracture in residential Rapp,

9 Staffing care was shown in a recent study to be greatest during the first month after admission, independent of gender, different care needs or site of the fracture. Fracture rates in the first nine months of admission were approximately twice as high as those in the subsequent nine months Studies looking at the effectiveness of an enhanced supervision approach to the prevention of falls among institutionalized older people. A falls prevention aide intervention reduced the number of fallers and fall rates in the study cohort through close supervision, active interventions, and environmental modifications of targeted falls risk factors. Shimada, Tiedemann, Lord, & Suzuki, 2009; Donoghue, Graam, Miten Lewis, Murphy, & Gibbs, 2005; Although these studies show much promise and results, theoretically, an interdisciplinary approach should be more effective than its single intervention counterpart since causes and risk factors of falling are usually multiple. Interdisciplinary Based Theories The literature reviewed commonly concluded that there is compelling evidence to support the use of multidisciplinary, multifactorial, or interdisciplinary approaches to fall prevention. A comprehensive approach to fall prevention in an older population typically includes a combination of assessment and interventions. Excellent models of these types of interventions have been developed in Canada and elsewhere. For example, a study conducted in Edmonton has shown promise in reducing falls using a multifactorial, risk abatement approach as well as a cognitive behavioral and environmental focus. Another study includes nurse practitioners and physical therapists trained to conduct comprehensive assessments combined with tailored individualized interventions including personal safety, equipment use, and 9

10 medication. These types of assessments can also lead to facility wide interventions such as staff education and environmental modifications. Researchers in Toronto have developed a system to detect when someone falls at home. Using a ceiling mounted camera, the computer vision system tracks a person s movements. This project also includes the use of a prompting system that uses artificial intelligence to monitor older adults with dementia reminding them of common daily activities such as hand washing, dressing and cooking. The goal of this team is to create an intelligent home that allows people to age in place, giving them independence and reducing the burden on caregivers and the health care system. A group of Florida researchers demonstrated that a dynamic quantitative assessment of the variability of everyday movements (path tortuosity) is an independent predictor of fall risk which, when combined with other known risk factors for falls, can significantly improve the accuracy of fall prediction beyond that possible by other risk factors alone. One team of researchers in British Columbia are examining how intrinsic variables, such as the resident s sensory and motor function, cognitive abilities, and cardiovascular status, and environmental variables, such as clutter or lighting conditions, associate with the cause and circumstances of falls. 10

11 In British Columbia a multidisciplinary team draws on evidence to develop new technologies to prevent falls and fall related injuries in older adults using innovative approaches (such as video capture and wearable sensors) to determine the causes and circumstances of falls of older adults. This approach leads to the development and testing of the effectiveness of engineering interventions such as protective clothing and compliant flooring in reducing fall related injuries. Evidence shows that falls in older adults can be prevented through the application of multifactorial strategies offered by a qualified interdisciplinary team (Robinovitch et al, 2012; Cameron et al., 2010; Scott et al, 2009). Key strategies in an interdisciplinary approach include evidence based best practices, staff education and training, incident investigation, environmental modifications (e.g compliant flooring, universal design), hip protector use, medication reviews, optometry, podiatry, goal setting, resident fall prevention training, inspection, exercise and repair of assistive equipment (Robinovitch et al, 2012; Zecevik, 2011; Becker & Rapp, 2010; Becker et al., 2003; Jensen, Nyberg, Gustafson, & Lundin Olsson, 2003; Ray et al., 1997, ). What these studies show is that when examining falls it is important to understand what risk exists within a context of overlapping contributing factors. Figure 1 depicts the multifactorial nature of risk and the connection between the biological, social and economic, environmental and behavioural risk factors for falls justifying 11

12 the need to look beyond single intervention to a more integrated approach (Scott, 2009). Fig 1: Multifactorial nature of risk An Integrated Approach to Falls Prevention Effective falls prevention warrants an integrated evidence based approach from research through to practice. When considering a fully integrated approach we must consider how such integration might occur. Within the interdisciplinary literature, Newell (1998) describes integration as: Essentially holistic thinking, in which the different facets of a complex reality exposed through different disciplinary lenses are combined into a new whole that is larger than its constituent parts, that cannot be reduced to the separate disciplinary insights from which it emerged It requires an act of 12

13 creative imagination, a leap from the simplified perspectives that give the disciplines their power to a more holistic perspective of a richer more complex whole (p. 55). Scholarly thinking behind this claims that integration, or blending of disciplines, is the principle of interdisciplinary thinking (Repko, 2008). In his work, Repko identifies finding common ground as the starting block to integration, leading to a blending of knowledge from relevant disciplines to produce an interdisciplinary understanding of a particular problem. Klein states Integrated capacity and the ability to work in teams are coupled increasingly across all sectors of our lives, making comparative understanding of best practices all the more crucial (2009, p. 284). One such way to make certain integration occurs in falls prevention is to consider the social and policy context. Klein cites, Fleishman (1991) in describing the field of policy analysis: Policy analysis incorporates only a fraction of the contents of participating disciplines. Policy analysts construct an integrative lens and analytic framework that fit around a particular problem, choosing portions of disciplines that appear relevant to solving it and adding useful elements from statistics, operations research, history and ethics. The process starts where economics and political science leave off, building on disciplinary descriptions and inferences to formulate alternative solutions and project likely consequences (p. 290). 13

14 With respect to falls, such an approach starts with an examination at the individual level, defining the meaning of the fall for the individual and their family. As well, such an approach would review the setting s perception of the problem, characteristics of the setting that enable or inhibit program planning, and available resources. Finally, a social and policy context would reflect relevant sections of legislation, regulation and accreditation standards (if applicable). This particular model also works well within the context of Repko s emphasis on integration in interdisciplinary research as a process or something we must create (Klein, 2009). An Integrated Framework for Falls Prevention A Public Health Framework is an evidence based approach that relies on a thorough analysis of an underlying issue in order to develop practical and effective solutions that can be integrated into practice. Figure 2 depicts this staged approach, consisting of five program planning steps that build upon each other in a dynamic process and that exist within a social and policy context influenced by the older adults who are at risk, their families and care providers, as well as by current policies and legislation (Scott, 2007). The five stages within this framework include: 1. Defining the Problem: To properly define the problem of falls and related injuries there must be evidence of an assessment of the scope and nature of the problem for both the individual as well as the setting in which the fall occurred. 2. Identifying the Risk: There must be evidence of an assessment of the individual and the setting for fall risk factors. At the facility level this can be done upon admission, following a fall or a significant change in health status. 14

15 3. Examining Best Practices: There must be evidence of best practice interventions that are client centered and address the risk factors found for individuals and for the facility or site in general. 4. Translating the Knowledge: there must be evidence of interventions being applied in the form of care plans and facility wide strategies. Care planning should include participation from multidisciplinary staff, families as well as the older adults for development, implementation and evaluation. 5. Evaluating the Program: There must be evidence of ongoing evaluation at the person level as well as and facility wide care plans, with monitoring and reporting of falls and fall related injuries for the facility. Changes in the program planning steps should reflect the evaluation findings. 1. Adapted from Scott, V. et al (2007) Canadian Falls Prevention Curriculum 15

16 Together, these steps represent a systematic approach to fall prevention that relies on organizational commitment, leadership, staff training, and collaboration among researchers, policy makers, practitioners, older adults and their families for successful and sustainable programming for both the identification and reduction of risk resulting from falls. Materials and Methods The purpose of this project was to review the public health approach for appropriateness as an interdisciplinary approach to falls prevention. In particular, I wanted to identify a) the need for an interdisciplinary approach to falls prevention; and b) review the public health approach for appropriateness as an interdisciplinary approach to falls prevention. Information provided for this paper was compiled based on a literature review and synthesis of relevant information on recent studies and best practices currently being used by those who work with older adults at risk for falling and sustaining an injury. There is an abundance of literature in this area so the scope of the review was limited firstly to the 2010 Cochrane Systematic Review of fall prevention in residential and acute care facilities (Cameron et al, 2010). This was an extensive review of the literature that had already been compiled that reviewed the effectiveness of interventions designed to reduce falls by older people in nursing care facilities and hospitals. The reference list for this review lead to further publications in this area as did a search in relevant publications databases and an 16

17 internet search of grey literature in this area. Finally, after compiling this information I itemized the approaches found as either discipline based or interdisciplinary using the definitions found in the MAIS 700 course materials. Conclusion Across Canada, there are ever growing numbers of fall prevention strategies and interventions taking place within multiple settings including community, acute care and long term care. The key to targeting resources for prevention of falls and related injuries is enhanced knowledge on the scope and nature, which will lead to evidence based best practices. The findings from the studies reviewed presented a wide range of such interventions and theories ranging from single interventions performed by care staff to multifactorial strategies that are best implemented by an interdisciplinary team with the involvement of the older adult and their family members. The challenge, of course, remains in how best to translate this evidence into effective and sustainable change in practice. The public health approach to falls prevention provides a complex, evidence based method that relies on a thorough analysis of the problem and its causes leading to the development of practical solutions. The Public Health Framework described provides an easy to follow staged approach to falls and related injury prevention involving multiple stakeholders throughout including identifying risk factors, and designing and implementing solutions that are both person centered as well as those that can be targeted facility wide and shared as best practices. This approach 17

18 could easily be implanted by those organizations looking for a model that can be easily integrated into existing practice. 18

19 Appendix A: Definitions Fall: An unintentional coming to rest on the ground, floor or other lower level (Herman et al, 2006). Falls Prevention Program: A multifaceted approach to reducing falls and injuries resulting from falls. Integration: Holistic thinking, in which the different facets of a complex reality exposed through different disciplinary lenses are combined into a new whole that is larger than its constituent parts, that cannot be reduced to the separate disciplinary insights from which it emerged (Newell, 1998 as cited in Strober, 2012) Widely regarded as the primary methodology of interdisciplinarity. Interdisciplinary: Studies a complex problem (including mega ones) by drawing on disciplinary insights (and sometimes stakeholder views) and integrating them. By employing a research process that subsumes the methods of the relevant disciplines, interdisciplinary work does not privilege any particular disciplinary method or theory. Knowledge Translation: A dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users, which may vary in intensity, complexity, and level of engagement depending on the nature of the 19

20 research and the findings as well as the needs of the particular knowledge user (Canadian Institutes for Health Research). Multidisciplinary: Studies a topic from the perspective of several disciplines at one time but makes no attempt to integrate their insights. Multidisciplinary approaches tend to be dominated by the method and theory preferred by the home discipline. Multifactoral: Involving, dependent on, or controlled by several factors. Public Health: The science and art of promoting health, preventing disease, prolonging life and improving quality of life through the organized efforts of society. As such, public health combines sciences, skills, and beliefs directed to the maintenance and improvement of the health of all people through collective action. The programs, services, and institutions involved tend to emphasize two things: the prevention of disease, and the health needs of the population as a whole (Public Health Agency of Canada). Social Policy: Actions that affect the well being of members of a society through shaping the distribution of and access to goods and resources in that society. It is also an academic discipline focusing on the systematic evaluation of societies' responses to social need. Transdisciplinary: Concerns that which is at once between the disciplines, across different disciplines, and beyond all disciplines. Its goal is (a) the understanding of the present world, of which one of the imperatives is the unity of knowledge, and (b) the solution of mega and complex problems by drawing on and seeking to integrate disciplinary and stakeholder views on the basis of some overarching theory. 20

21 References 1. Aziz, O. & Robinovitch, S.N. (2011). "An analysis of the accuracy of wearable sensors for classifying the causes of falls in humans". #IEEE_J_NSRE#. Vol. 19(6), pp Cameron, I.D., Robinovitch, S., Birge, S., Kannus, P., Khan, K., Lauritzen, J., Howland, J., Evans, S., Minns, J., Laing, A., Cripton, P., Derler, S., Plant, D. & Kiel, D.P. (2010). Hip protectors: recommendations for conducting clinical trials an international consensus statement (part II). Osteoporosis Int., Jan, Vol. 21(1), pp Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Available at: violenceprevention/overview/publichealthapproach.html; Accessed March 10, Grisso, J.A., D.F. Schwarz, A.R. Wishner, B. Weene, J.H. Holmes, and R.L. Sutton. (1990). Injuries in an elderly inner city population. J Am Geriatric Soc, 38(12), p Herman M, Gallagher E, Scott VJ. (2006). The evolution of seniors falls prevention in British Columbia. Victoria: British Columbia Ministry of Health. 6. Public Health Agency of Canada. (2005). Report on Seniors Falls in Canada. Ottawa, ON. ISBN: Repko, Allen. (2012). Interdisciplinary research: Process and theory. 2nd ed. Los Angeles: Sage. 21

22 8. Repko, Allen, William H. Newell, Rick Szostak, eds. (2012). Case Studies in interdisciplinary research. Los Angeles: Sage. 9. Robinovitch, S. N., Feldman, F., Yang, Y, Schonnop, R, Lueng, PM, Sims Gould, J., Laughlin, M. (2012). Video capture of the circumstances of falls in elderly people residing in long term care: an observational study. The Lancet (12)61263 X 10. Scott, V., Lockhart, S., & Gallagher, E. (2007). Canadian falls prevention curriculum (CFPC). Vancouver (Canada): BC Injury Research and Prevention Unit. 11. Scott, V., Higginson, A., Sum, A., & Metcalfe, S. (2010). Falls and related injuries in residential care: A framework and toolkit for prevention. Vancouver, BC: Centre of Excellence for Mobility, Fall Prevention and Injury in Aging, Centre for Hip Health and Mobility. 12. Scott, V., Wagar, L., & Elliott, S. (2010). Falls & related injuries among older Canadians: Fall related hospitalizations & intervention initiatives. Prepared on behalf of the Public Health Agency of Canada, Division of Aging and Seniors. Victoria BC: Victoria Scott Consulting. 13. Scott, V., S. Peck, and P. Kendall. (2004). Prevention of Falls and Injuries Among the Elderly: A Special Report from the Office of the Provincial Health Officer. Provincial Health Office, B.C. Ministry of Health Services: Victoria, B.C. 14. Segui Gomez M, MacKenzie EJ. (2003). Measuring the public health impact of injuries. Epidemiol Rev 2003;25:

23 15. SMARTRISK (2009). The Economic Burden of Injury in Canada, SMARTRISK: Toronto, ON. 16. Spaite, D.W., E.A. Criss, T.D. Valenzuela, H.W. Meislin, and J. Ross. (1990). Geriatric injury: an analysis of prehospital demographics, mechanisms, and patterns. Ann Emerg Med, 19(12): p Strober, Myrah H. (2010). Interdisciplinary Conversations: Challenging Habits of Thought Stanford: Stanford University Press. AU Library E Book link: ocid= World Health Organization. (2007)., Global Report on Falls Prevention in Older Age. 23