Fallers presenting to the ED: An update of the literature, current issues and patient participation

Transcription

1 School of Public Health and Preventive Medicine Fallers presenting to the ED: An update of the literature, current issues and patient participation Dr Anna Barker Leader of the Falls and Bone Health Team B.Phty, M.Phty (Geriatrics), PhD Health Services Research Unit Division of Health Services and Global Health Research Monash University Overview The problem The evidence base The gaps in current practice Where to from here

2 The problem Many older people present to the ED for management of injuries they sustain as a result of a fall Falls are the leading cause for ED presentations in older people» (Samaras, Chevalley et al. 2010) US studies have estimated that one older adult is treated in the ED for a fall every 15 seconds» (Centers for Disease Control and Prevention 2012). Current practice Australian and Canadian studies report that only 3 in every 100 older patients in this population receive care consistent with current guidelines» (Salter, Khan et al. 2006; Waldron, Dey et al. 2011) In the 6-months following an index fall ED presentation 13%-52% of older people experience subsequent falls» (Close, Ellis et al. 1999; Bloch, Jegou et al. 2009) 49% are re-hospitalised» (Bloch, Jegou et al. 2009)

3 The evidence base Secondary falls prevention trials in the ED population 11 RCTs have studied the impact of secondary falls prevention programs in older people presenting to ED following a fall The evidence base RCT of 712 older people presenting to seven EDs in Australia Multifactorial intervention utilising existing community services No effect on new falls, fall injuries or ED presentations in the one year follow-up» (Russell, Hill et al. 2010) Seven similar RCTs which also found multifactorial interventions for older people presenting to an ED with a fall to have no effect on falls or fall injuries» (Lightbody, Watkins et al. 2002; Pardessus, Puisieux et al. 2002; Shaw, Bond et al. 2003; Whitehead, Wundke et al. 2003; Hendriks, Bleijlevens et al. 2008; Vind, Andersen et al. 2009; de Vries, Peeters et al. 2010)

4 The evidence base 3 trials that have found a positive impact on falls Prevention of Falls in the Elderly Trial (PROFET) UK-based RCT of 397 older people demonstrated that an interdisciplinary program achieved a marked reduction in recurrent falls» (Close, Ellis et al. 1999) UK RCT of 313 older people presenting to ED with recurrent falls found a multifactorial intervention reduced falls by 36%» (Davison, Bond et al. 2005) PROFET intervention was tested in the Netherlands it was found to have no impact on falls» (Hendriks, Bleijlevens et al. 2008) The evidence base Australian RCT of 302 vitamin D deficient women who presented to an ED with a fall found a 19% reduction in falls risk after vitamin D and calcium supplementation» (Prince, Austin et al. 2008)

5 The evidence base Characteristics that appear to differentiate the successful trials from others Delivery of the intervention within one month of the index fall and greater intensity of the interventions» (Gates, Fisher et al. 2008) An Australian study of the barriers to implementing falls prevention strategies recommends programs in this setting should also focus on changing patients attitudes towards the intervention» (Whitehead, Wundke et al. 2006) The evidence base Poor patient participation Inadequate functional health literacy Limited focus on patient choice, engagement and empowerment Also appear to be critical factors that must be addressed to achieve successful falls prevention programs in this setting

6 Poor patient participation in falls prevention strategies A recent survey (n=5755) demonstrated that while older people may acknowledge concerns about falls risk, 63% have no interest in the programs offered» (Dorresteijn, Rixt Zijlstra et al. 2012) The RCT by Russell et al. found few fallers attended services referred to by ED staff falls clinic (<5%) physiotherapy (<30%) occupational therapy (<17%)» (Russell, Hill et al. 2010). Poor patient participation in falls prevention strategies One Australian study reported that 72% of patients in this setting are reluctant to attend exercise classes 59% are reluctant to cease psychotropic medications 43% are reluctant to have a home safety assessment» (Whitehead, Wundke et al. 2006) These results are consistent with overseas studies» (de Vries, Peeters et al. 2010)

7 Inadequate functional health literacy Functional health literacy is the degree to which individuals obtain, process, and understand basic health information Older adults with lower functional health literacy engage in less preventive behaviours than the general population» (White, Chen et al. 2008) The majority of older ED patients will not have adequate functional health literacy skills to enable effective uptake of recommendations or referrals made in the ED setting. US study reported 60% of older patients reported not understanding discharge information provided by ED staff Delayed access to secondary falls prevention services In the RCT by Russell et al, for those who did access secondary falls prevention (?) services recommended by ED staff, the time lag between ED presentation and attending the service was too long four months for falls clinics two months for physiotherapy three months for occupational therapy» (Russell, Hill et al. 2010)

8 Lack of patient choice, engagement and empowerment A systematic review of studies (N=24) investigating older people s perceptions of facilitators and barriers to participation in falls prevention activities» (Bunn, et al. 2008) Lack of patient choice, engagement and empowerment Facilitators Social support Low intensity exercise Greater education Involvement in decision-making A perception of the program as being relevant and life-enhancing Barriers Fatalism Denial and under-estimation of the risk of falling Stigma associated with programs for older people

9 Summary There is evidence that only a minority of older people presenting to an ED following a fall follow recommendations provided by ED staff. It is also known that there are deficits in the quality of care provided to older people presenting to the ED as a result of a fall. It is therefore not surprising that success in achieving secondary fall prevention remains poor. Where to from here? Patient-centered care models that address the key factors inhibiting the successful implementation of falls prevention programs Poor patient participation Delayed service delivery Limited focus on patient choice, engagement and empowerment may not yet have been fully developed, nor effectively implemented» (Redfern, Briffa et al. 2009)

10 Where to from here RESPOND project: RESPOND to the first fall to prevent the second 16 investigators from across Australia and UK 11 partner organisations NHMRC funding $1.5 million Test an innovative post-ed discharge program designed to reduce secondary falls in older people. Project RESPOND Patient-centred education with behavior change strategies Proven to be effective in the secondary prevention of cardiovascular events. RESPOND aims to improve patients knowledge and ability to navigate the complex healthcare system. See:

11 Project RESPOND Design A single-blind multi-center RCT, of the RESPOND program versus standard (unspecified) post-discharge care care. 528 community-dwelling persons, aged 60 years and older who present to the Royal Perth and Alfred Hospital EDs with a fall or fall-related injury, or have had two or more falls in the previous year, and are discharged within 72hrs will be recruited over a 12 month period. Project RESPOND Intervention Risk factor assessment and risk stratification Education Targeted risk factor management driven by patient choice, empowerment and goal-setting Telephone follow-up, to support and review behaviour change and goals Re-assessment

12 Stay tuned for more information on RESPOND!