REDUCING FALLS 2 Abstract Clinical Problem: Falls and fall related injuries are a major health problem for the elderly population, leading to broken bones, increased hospital stays and readmissions, and even fall deaths. Objective: To assess whether implementing a standardized exercise program, with an emphasis in strength building, for elderly patients over the age of 65 living in nursing homes will decrease the amount of falls over six months. Search Engine & Key Words: PubMed was the primary search engine used for finding relevant literature related to the topic. The key words used for our search were: ELDERLY, FALL RISK, NURSING INTERVENTION, and EXERCISE. Results: As evidence from the literature, fall risk was reduced in residents living in nursing homes who participated in strength building exercises compared to the control group that did not. Conclusion: A standardized exercise program in nursing homes has shown to be effective in decreasing the amount of falls in elderly residents over 65 years old and should be implemented in care.
REDUCING FALLS 3 Reducing Falls in the Elderly Population
According to the Centers for Disease Control and Prevention (CDC, 2013), falls among older adults are the leading cause of fatal and nonfatal injuries. One in three older adults (ages 65 and above) fall every year. In 2010, the CDC (2013) reported 2.3 million nonfatal fall injuries among older adults that were treated in emergency departments. More than 662,000 of these patients were hospitalized, leading to $30 billion spent in medical costs related to falls. The CDC (2013) recommends that older adults exercise regularly in order to reduce fall risk. Exercising regularly can increase leg strength and improve balance, both important components in fall prevention. In order to promote regular exercise in nursing homes and other long-term care facilities, physical therapists and nurses should work together to develop a standardized exercise program with an emphasis on strength building. Physical therapists can develop the standardized exercise program while nurses carry out the responsibility of monitoring and recording the number of falls. Among the population of patients over 65 years of age living in nursing homes, how does implementing strength building exercises, compared to not exercising, decrease falls over six months? Literature Search PubMed was the primary search engine used for finding relevant literature related to this topic. The key words used for our search were: ELDERLY, FALL RISK, NURSING INTERVENTION, and EXERCISE. Literature Review According to Caker et al. (2010), the purpose of this randomized clinical trial was to determine whether adding jumping training to a regular combined exercise program would improve the balance fall risk and quality of life for older adults living in a long-term care facility. REDUCING FALLS 4 The six-week trial included 66 participants that were randomly assigned to either the combined exercises (COM) group, which covered stretching, strength, and other aerobic exercises, or the COM group plus jumping (COMpJ). There were 30 participants from the COM group and 36 from the COMpJ group. The assessments were performed at baseline and at the end of the six- week trial period. The Berg Balance Test and Biodex Balance System were used as the assessments for measuring balance and fall risks. The Biodex Balance System measured postural stability, which encompassed overall (OA), the anterior/posterior (AP), the medial/lateral (ML) stability scores, and fall risk, or overall stability index (OSI). The improvements for the Berg score, postural stability test, and the OSI score were statistically better in the COMpJ group compared to the COM group at the end of the six-week trial period (p<0.05) (Cakar et al., 2010). The strengths of this trial were that it was randomized, none of the subjects were injured during the trial, and that there were no statistically significant differences between the participants demographics, clinical, and functional measures at baseline (P>0.05). The biggest weakness of this study was the amount of participants. At the end of the trial, there were 66 participants, which may prove to be insignificant when analyzing the data. Although there were fewer participants than ideal, the results still indicate that jumping training combined with a standardized exercise program does improve stability, therefore reducing fall risk in the elderly population. According to Serra-Rexach et al. (2011), the purpose of this randomized controlled trial was to determine whether a light-to-moderate intensity exercise-training program would increase muscle strength, and therefore decrease falls in participants ages 90 years and above living in a geriatric nursing home. The trial exercise program was eight weeks with a four week detraining REDUCING FALLS 5 following. The trial was randomized using a computer generated randomization sequence. As Table 1 of the Literature Review states, 40 participants were randomly assigned to either the training (intervention) group (N=20) or the control group (N=20). The participants in the control group participated in 40-45 minutes of mobility exercises per day, five days a week (Monday though Friday). The participants in the intervention group performed the same mobility exercises as the control group, except for only two days a week (Tuesday and Thursday), and spent the remaining three days of the week participating in training sessions. The primary outcome measured was leg strength, while the secondary outcome was based on assessing other skeletal muscles. See Table 1 for the results of the study. The strengths of this trial were that it was randomized, all participants were required to sign written consent forms prior to participating, the control group and intervention group were clearly defined, the primary and secondary outcomes were clearly defined, and the staff was blinded to the participant randomization assignment. The most significant limitation in this study was the amount of participants, N=48, which may prove to be insignificant when considering the validity of the study. However, despite the amount of participants, the results do indicate that training programs used to improve muscle strength in elderly adults can effectively reduce the amount of falls. The study by Vogler et al. (2009) was conducted to address why people recently discharged from hospitals and other care facilities are at increased risk for falls and readmission to the hospital. The trial lasted for 12 weeks and consisted of 180 people. The trial aimed to compare the effects of a weight-bearing (WB) exercise program, seated strengthening (or seated resistance, SR) exercises, and no-exercise social visits (CG) on risk factors related to falls. The patients were randomly placed in to one of the three groups: SR (n=60), WB exercises (n=60), REDUCING FALLS 6 and CG social visits (n=60). Randomization was performed in blocks of 15 subjects by computer-generated random numbers. Eligible subjects were 65 years and older with no medical exclusions to exercise. The fall risk factors were measured at baseline and at the end of 12 weeks using the PPA Composite Fall Risk score, Maximal Balance Range, and Coordinated Stability score as the primary outcome measures. At the end of the 12 weeks, there was a significant difference in PPA fall risk scores, resulting in both the SR group and WB group performing significantly better than the CG group. The PPA scores at the end of 12 weeks were SR (0.991.30), the WB (1.111.38), and CG (1.441.32). In Coordinated Stability, there were substantial improvements for the WB group compared with both the SR and CG group. The Maximal Balance Range measuring assessment resulted in considerable improvements between the WB group and CG group (Vogler, Sherrington, Ogle, & Lord, 2009). The strengths of this trial include: (1) The trial was randomized; (2) primary and secondary outcomes were clearly stated; (3) drop out rates in the program were low; (4) compliance with the interventions was good. Based on the strengths, the results of this study appear valid. The results of this study indicate that fall risk decreases significantly when WB and SR exercises are used compared to when no exercises are performed. The National Institute for Health and Care Excellence (NICE, 2013) also provides implementation guidelines for preventing falls in older adults. According to NICE (2013), individualized multi-factorial interventions, including strength and balance training along with exercise programs in extended care settings, can improve fall risk and decrease the amount of falls in the elderly population.
REDUCING FALLS 7 Synthesis The literature for all three trials emphasized different strength building exercises to reduce falls, including jumping, weight-bearing exercises, and seated strengthening exercises. While all of the studies used indicate that exercise does decrease the amount of falls in older adults, it is unclear as to which exercise specifically is the most beneficial. Furthermore, the exercise programs from the studies did improve strength, but improved balance, mobility, and stability as well. It is indistinct which component had the biggest impact in reducing falls in the elderly population. There was limited literature to support how strength building exercises decrease falls in older adults. The studies that were used were focused around the elderly population, however, not all participants were living in nursing homes. The literature was chosen based on the evidence that all three trials indicate that weight-bearing exercises improve strength, reduce falls in the elderly population, and improve overall quality of life. Proposed Practice Change Clinical recommendations include providing a standardized exercise program, with an emphasis in strength building, in nursing home care. Nursing homes should implement an exercise program that lasts for 45 minutes with a 15-minute cool down session immediately following. Patients will be required to exercise three days a week, alternating days, for six months in order decrease the amount of falls. Change Strategy In order to promote staff and team engagement, an extensive training and education course would be provided to all staff members involved in the implementation of the exercise program. Presenting research and statistical data that supports the implementation is also REDUCING FALLS 8 imperative. When presenting data, it is important to explain how reducing falls among patients can directly affect the nursing home and staff. Less falls means less medical costs related to fall injuries and less paperwork associated with incident reports. Having fewer falls also makes the nursing facility more desirable, therefore potentially increasing revenue for the facility and compensation for the staff members. Roll Out Plan The design of the roll out plan is based on the Iowa model of Evidence-Based Practice to promote quality care. The Iowa model starts off by identifying triggers based on scientific knowledge, leading to questions regarding current practice standards. Knowledge Focused Triggers 1. New Research or Other Literature. Research concludes that weight-bearing exercises are beneficial in improving strength and reducing the amount of falls in the elderly population. 2. National Agency or Organizational Standards and Guidelines 3. Philosophies of Care. All nursing homes should be dedicated to reducing the number of falls for all residents. Is this topic a priority for the organization? Yes. June 2014 to July 2014: Form a team. The team will include physical therapists, nurses, and nursing home staff. July 2014 to August 2014: Assemble Relevant Research and Related Literature. Relevant literature based on randomized controlled trials will be used for implementation of the proposed evidence based study. August 2014 to September 2014: Critique and Synthesize Research for Use in Practice. REDUCING FALLS 9 Is there a sufficient base? Yes. Pilot the Change in Practice 1. September 2014 to August 2014: Select Outcomes to be Achieved. Reduction of falls in nursing homes. 2. August 2014 to November 2014: Collect Baseline Data. Baseline data includes obtaining statistics that currently exist regarding falls among the elderly population. Gathering data from each of the participants is also imperative, and should include identifying the patients fall history and assessing gait, balance and mobility, and muscle weakness prior to implementing the project. A neurological exam, as well as other tests to rule out other medical conditions, will also be conducted. 3. November 2014 through December 2014: Design Evidence-Based Practice (EBP) Guidelines (s). Participants will be elderly adults, over the age of 65 years old, residing in nursing homes. Elderly adults excluded from the standardized exercise program include residents with terminal illnesses, recent myocardial infarction, unstable cardiovascular disease or other medical conditions, neuromuscular disease, recent fractures, and dementia. 4. Implement EBP on the Pilot Units. The pilot will last for six months, beginning from January 2015 through June 2015, in participating nursing homes. 5. June 2015 to October 2015: Evaluate Process and Outcomes. Evaluation will be based on a decreased number of reported falls when compared to the control group. 6. October 2015 through December 2015: Modify the Practice Guideline. Modification will be based on the results from the standardized exercise program. Results should indicate a REDUCING FALLS 10 reduction in falls in elderly patients 65 years and older. Modification may also be made depending on the participants ability to perform the required exercises and training. Is the change appropriate for adoption in practice? If yes. Institute the Change in Practice. The change in practice will be implemented in January 2016. Monitor and Analyze Structure, Process, and Outcome Data Environment. Implementing a standardized exercise program will promote a safer environment for all patients. Staff. Staff involvement includes nurses and physical therapists. Physical therapists will develop a standardized exercise program, focusing on strength building, while nurses ensure that exercises are being completed on the patients designated days. The nurses are also responsible for monitoring and recording the number of falls. Cost. Less falls means less medical costs related to fall injuries and more money saved by the nursing facility. Patient and Family. Patients and families are likely to feel more satisfaction and comfort knowing that the nursing staff is taking initiative to increase the care and safety among patients. Literature shows that increasing strength and balance promotes independence and improves the overall quality of life in patients. Disseminate Results. Results from the evidence based research study should be shared with all employees and participants involved in the study, as well as with other nursing homes and long- term care facilities. Project Evaluation The project implementation will be evaluated based on assessing the amount of falls that occurred over a six month time period. The amounts of falls will be measured based on the REDUCING FALLS 11 number of incident reports recorded when compared to the control group. Success will be achieved if the average number of falls for participants in the standardized exercise program is 10% less than the control group. Dissemination of EBP Methods to disseminate the change locally and regionally include informing other nursing homes of the evidence based research performed. Further publishing could later be done nationally to include statistical results and data of the evidence in reducing the number of falls in nursing homes. The clinical setting includes nursing homes and other long-term care facilities for a population of elderly adults ages 65 years and above. Other possible clinical settings include geriatric floors in the hospital and rehabilitation centers.
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References Cakar, E., Dincer, U., Kiralp, M. Z., Cakar D. B., Durmus, O., Kilac, H., . . . Alper, C. (2010). Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility. European Journal of Physical and Rehabilitation Medicine, 46(1), 59-77. Centers for Disease Control and Prevention. (2013). Falls among older adults: An overview. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Melnyk, B. M., & Overholt, E. (2011). Evidence-based practice in nursing & healthcare: a guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. National Institute for Health and Care Excellence (NICE). (2013). Falls: assessment and prevention of falls in older people. London (UK): National Institute for Health and Care Excellence Serra-Rexach, J., Bustamonte-Ara, N., Villaran, M. H., Gil, P. G., Ibanez, M., Sanz, N., . . . Lucia, A. (2011). Short-term, light-to moderate-intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. The American Geriatrics Society, 59(4), 594-602. doi: 10.1111/j.1532-5415.2011.03356.x Vogler, C., Sherrington, C., Ogle, S., & Lord, S. (2009). Reducing risk of falling in older people discharged from the hospital: A randomized controlled trial comparing seated exercises, weigh-bearing exercises, and social visits. Archives of Physical Medicine and Rehabilitation, 90(8), 1317-1324. doi: 10.1016/i.apmr.2009.01.030
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Table 1 Literature Review Reference Aims Design and Measures Sample Outcomes / statistics Cakar, E., Dincer, U., Kiralp, M. Z., Cakar D. B., Durmus, O., Kilac, H., . . . Alper, C. (2010). Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long- term care facility. European Journal of Physical and Rehabilitation Medicine, 46(1), 59-77.
To determine if adding jumping training to a regular combined exercise program would improve the balance fall risk and quality of life for older adults living in a long-term care facility. The Berg Balance Test and Biodex Balance System. The Biodex Balance System was used to assess balance, neuromuscular control and fall risk. 66 participants that were randomly assigned to either the combined exercises (COM) group, which covered stretching, strength, and other aerobic exercises, or the COM group plus jumping (COMpJ). The improvements for the Berg score, postural stability test, and the OSI score were statistically better in the COMpJ group compared to the COM group at the end of the six- week trial period (p<0.05). Serra-Rexach, J., Bustamonte-Ara, N., Villaran, M. H., Gil, P. G., Ibanez, M., Sanz, N., . . . Lucia, A. (2011). Short- term, light-to moderate- intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. The American Geriatrics Society, 59(4), 594-602. doi: 10.1111/j.1532- 5415.2011.03356.x
To determine if a light to moderate intensity exercise training program would increase muscle strength, therefore decreasing fall risks in participants ages 90 years and above living in a geriatric nursing home. The primary outcome measured dynamic muscular strength of the lower body. The secondary outcome was to assess other skeletal muscles that were not specifically trained during the program. 40 participants that were randomly assigned to either the intervention (training) group (N=20) or the control group (N=20). The results concluded that the intervention group had significant gains (+17% on average) in muscle strength, proving useful for fall prevention in older adults. REDUCING FALLS 14 Vogler, C., Sherrington, C., Ogle, S., & Lord, S. (2009). Reducing risk of falling in older people discharged from the hospital: a randomized controlled trial comparing seated exercises, weigh-bearing exercises, and social visits. Archives of Physical Medicine and Rehabilitation, 90(8), 1317- 1324. doi: 10.1016/i.apmr.2009.01.030
The trial aimed to compare the effects of a weight- bearing (WB) exercise program, seated strengthening (or seated resistance, SR) exercises, and no-exercise social visits (CG) on risk factors related to falls. The fall risk factors were measured using the PPA Composite Fall Risk score, Maximal Balance Range, and Coordinated Stability score as the primary outcome measures. Randomization was performed in blocks of 15 subjects by computer- generated random numbers, for eligible subjects 65 years and older with no medical exclusions to exercise (N=180). The PPA scores were SR (0.991.30), the WB (1.111.38), and CG (1.441.32). In Coordinated Stability, there were substantial improvements for the WB group compared with both the SR and CG group. The Maximal Balance Range measuring assessment resulted in considerable improvements between the WB group and CG group.