Angela Dickinson

A systematic review of older people's perceptions of facilitators and barriers to participation in falls-prevention interventions

ABSTRACT The prevention of falls is currently high on the health policy agenda in the United Kingdom, which has led to the establishment of many falls-prevention services. If these are to be effective, however, the acceptability of services to older people needs to be considered. This paper reports a systematic review of studies of older peoples perceptions of these interventions. The papers for review were identified by searching electronic databases, checking reference lists, and contacting experts. Two authors independently screened the studies and extracted data on the factors relating to participation in, or adherence to, falls-prevention strategies. Twenty-four studies were identified, of which 12 were qualitative. Only one study specifically examined interventions that promote participation in falls-prevention programmes; the others explored older peoples attitudes and views. The factors that facilitated participation included social support, low intensity exercise, greater education, involvement in decision-making, and a perception of the programmes as relevant and life-enhancing. Barriers to participation included fatalism, denial and under-estimation of the risk of falling, poor self-efficacy, no previous history of exercise, fear of falling, poor health and functional ability, low health expectations and the stigma associated with programmes that targeted older people.

Effectiveness of interventions to improve, maintain or facilitate oral food and/or drink intake in people with dementia: systematic review

© 2014 Abdelhamid et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

The “con” of concept analysis: A discussion paper which explores and critiques the ontological focus, reliability and antecedents of concept analysis frameworks

This paper draws on the work of Paley and Duncan et al in order to extend and engender debate regarding the use of Concept Analysis frameworks. Despite the apparent plethora of Concept Analysis frameworks used in nursing studies we found that over half of those used were derived from the work of one author. This paper explores the suitability and use of these frameworks and is set at a time when the numbers of published concept analysis papers are increasing. For the purpose of this study thirteen commonly used frameworks, identified from the nursing journals 1993 to 2005, were explored to reveal their origins, ontological and philosophical stance, and any common elements. The frameworks were critiqued and links made between their antecedents. It was noted if the articles contained discussion of any possible tensions between the ontological perspective of the framework used, the process of analysis, praxis and possible nursing theory developments. It was found that the thirteen identified frameworks are mainly based on hermeneutic propositions regarding understandings and are interpretive procedures founded on self-reflective modes of discovery. Six frameworks rely on or include the use of casuistry. Seven of the frameworks identified are predicated on, or adapt the work of Wilson, a school master writing for his pupils. Wilsons framework has a simplistic eleven step, binary and reductionist structure. Other frameworks identified include Morse et als framework which this article suggests employs a contestable theory of concept maturity. Based on the findings revealed through our exploration of the use of concept analysis frameworks in the nursing literature, concerns were raised regarding the unjustified adaptation and alterations and the uncritical use of the frameworks. There is little evidence that these frameworks provide the necessary depth, rigor or replicability to enable the development in nursing theory which they underpin.

The role of health professionals in promoting the uptake of fall prevention interventions: a qualitative study of older people's views

BACKGROUND uptake of and adherence to fall prevention interventions is often poor and we know little about older peoples perceptions of and beliefs about fall prevention interventions and how these affect uptake. OBJECTIVE to explore older peoples perceptions of the facilitators and barriers to participation in fall prevention interventions in the UK. METHODS we undertook a qualitative study with older people who had taken part in or declined to participate in fall prevention interventions using semi-structured interviews (n = 65), and 17 focus groups (n = 122) with older people (including 32 Asian and 30 Chinese older people). This took place in community settings in four geographical areas of the South of England. The mean age of participants was 75 years (range 60-95). Data analysis used a constant comparative method. RESULTS older people reported that health professionals and their response to reported falls played a major role in referral to and uptake of interventions, both facilitating and hindering uptake. Health professionals frequently failed to refer people to fall prevention interventions following reports of falls and fall-related injuries. CONCLUSIONS consideration should be given to inclusion of opportunistic and routine questioning of older people about recent falls by practitioners in primary care settings. Referrals should be made to appropriate services and interventions for those who have experienced a fall to prevent further injuries or fracture.

‘Seamless care? Just a list would have helped!’ Older people and their carer’s experiences of support with medication on discharge home from hospital

Background  Many older people use one or more prescribed medicines on a daily basis. Effective medicines management at hospital discharge can support appropriate use of medicines following discharge and help avoid unnecessary hospital re‐admission. Many people, however, feel they receive insufficient information about medicines on discharge from hospital.

Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis.

BackgroundEating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.MethodsWe comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis.ResultsForty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders’ questions.ConclusionsWe found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes.Systematic review registrationThe systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero [1].

Preventing falls among older people with mental health problems: A systematic review

BackgroundFalls are a leading cause of mortality and morbidity in older people and the risk of falling is exacerbated by mental health conditions. Existing reviews have focused on people with dementia and cognitive impairment, but not those with other mental health conditions or in mental health settings. The objective of this review is to evaluate the effectiveness of fall prevention interventions for older people with mental health problems being cared for across all settings.MethodsA systematic review of fall prevention interventions for older people with mental health conditions. We undertook electronic database and lateral searches to identify studies reporting data on falls or fall related injuries. Searches were initially conducted in February 2011 and updated in November 2012 and October 2013; no date restrictions were applied. Studies were assessed for risk of bias. Due to heterogeneity results were not pooled but are reported narratively.ResultsSeventeen RCTs and four uncontrolled studies met the inclusion criteria; 11 involved single interventions and ten multifactorial. Evidence relating to fall reduction was inconsistent. Eight of 14 studies found a reduction in fallers (statistically significant in five), and nine of 14 reported a significant reduction in rate or number of falls. Four studies found a non-significant increase in falls. Multifactorial, multi-disciplinary interventions and those involving exercise, medication review and increasing staff awareness appear to reduce the risk of falls but evidence is mixed and study quality varied. Changes to the environment such as increased supervision or sensory stimulation to reduce agitation may be promising for people with dementia but further evaluation is needed. Most of the studies were undertaken in nursing and residential homes, and none in mental health hospital settings.ConclusionsThere is a dearth of falls research in mental health settings or which focus on patients with mental health problems despite the high number of falls experienced by this population group. This review highlights the lack of robust evidence to support practitioners to implement practices that prevent people with mental health problems from falling.

Nutritional education for community dwelling older people: a systematic review of randomised controlled trials.

OBJECTIVES To evaluate the effectiveness of nutritional education or advice on physical function, emotional health, quality of life, nutritional indices, anthropometric indicators, mortality, service use and costs of care in people over 65 years of age living at home. DESIGN Systematic review of randomised controlled trials (RCTs). DATA SOURCES PUBMED, CINAHL, PSYCINFO, the Cochrane Central Register of Controlled Trials and the National Research Register. METHODS We included studies evaluating nutritional education or advice for people aged 65 and over living in their own homes that measured one or more of the following outcomes: physical function, emotional well being, service use, dietary change and other anthropometric indicators. Studies were assessed for risk of bias on six domains. Due to high heterogeneity, results were not pooled but are reported narratively. RESULTS Twenty-three studies met our inclusion criteria. All but one of the interventions were delivered by health care professionals; ten were delivered by nurses. The review found evidence to suggest that nutritional education or advice can be used to positively influence diet and improve physical function. There was also evidence that some biochemical markers can be positively affected, although these are surrogate outcomes and are generally disease specific. Several studies indicated that complex interventions, with nutritional education as a component, also reduce depression. The evidence from this review on the impact on weight change was inconclusive. There was no evidence of an improvement in anxiety, quality of life, service use, costs of care or mortality. However, many studies were at moderate or high risk of bias, and for some outcomes the data were insufficient to make judgments about effectiveness. CONCLUSIONS This review indicates that nutritional education or advice can positively affect physical function and diet, whilst complex interventions with nutritional education as a component, can reduce depression in people over 65 years who live at home. However, more research is needed to determine whether outcomes are influenced by types of intervention, morbidity, and socioeconomic circumstance of participants. RELEVANCE TO CLINICAL PRACTICE Nutritional education, alone or as part of a complex intervention, can improve diet and physical function and may reduce depression in the over 65 s living at home.

Implementing the Single Assessment Process: Opportunities and challenges

The Single Assessment Process (SAP) has been introduced as part of the National Service Framework for Older People and has major implications for health and social care. The aim of this study was to evaluate a pilot introduction of the Single Assessment Process in the South-East of England. A qualitative case study design incorporating observation and semi-structured interviews were used to collect data. Assessment visits were observed and recorded, and interviews were carried out with older people and their carers (n = 9), health and social care practitioners, operational managers, and other key individuals involved in the pilot (n = 26). Overall the evaluation found three major themes that had an impact on the implementation of the Single Assessment Process. These were: the process of implementing policy and change, the health and social care boundary, and communication and sharing of assessments. Front-line practitioners (street-level bureaucrats) had a major impact on the SAP implementation, particularly through their reluctance to engage with the process, work together and share assessments. Success of the national SAP implementation will depend on the extent to which those working directly with older people can be engaged in the policy process.

Practitioner and lay perspectives of the service provision of nutrition information leaflets in primary care.

BACKGROUND In primary care, leaflets are often used to communicate health information. Increasingly, primary healthcare practitioners need to provide dietary advice. There is limited research exploring how nutrition information leaflets are used in primary care. The present study explored practitioner and lay experiences with respect to providing and receiving nutrition information in primary care, focusing in particular on the use of leaflets for nutrition information. METHODS A qualitative design was used incorporating focus groups with 57 practitioners based at seven general practitioner practices and a purposive sample of 30 lay participants attending six Consumer Health Organisations within one primary care trust. Focus groups were taped and transcribed verbatim and data were analysed thematically, assisted by computer software n6® (QSR International Pty Ltd, Melbourne, Australia). RESULTS Practitioners discussed barriers to giving nutritional advice, access to leaflets, lay receptiveness to advice and their perceptions about the value of leaflets to lay people. Food was not considered in terms of its nutritional components by lay participants and the need for nutritional information was not perceived to be relevant until they had received a medical diagnosis. Lay participants discussed the importance of receiving nutritional advice relating to their medical diagnosis and the altered status of written information that was delivered personally. Practitioner and lay groups suggested improvements to ensure that nutritional advice be supported by relevant and appropriate written information. CONCLUSIONS This research has underlined the continuing importance of nutrition information leaflets and concludes that there is particular value in involving lay participants in the development of nutrition information leaflets.