Вы находитесь на странице: 1из 14

Running head: REDUCING FALLS 1

Reducing Falls in the Elderly Population



Brittaney Bures
University of South Florida























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.













REDUCING FALLS 12

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

REDUCING FALLS 13

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.

Вам также может понравиться