Margaret Gottschalk

A Multifactorial Intervention to Reduce the Risk of Falling among Elderly People Living in the Community

BACKGROUND Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors. METHODS We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects). RESULTS During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted incidence-rate ratio for falling in the intervention group as compared with the control group was 0.69 (95 percent confidence interval, 0.52 to 0.90). Among the subjects who had a particular risk factor at base line, a smaller percentage of those in the intervention group than of those in the control group still had the risk factor at the time of reassessment, as follows: at least four prescription medications, 63 percent versus 86 percent, P = 0.009; balance impairment, 21 percent versus 46 percent, P = 0.001; impairment in toilet-transfer skills, 49 percent versus 65 percent, P = 0.05; and gait impairment, 45 percent versus 62 percent, P = 0.07. CONCLUSIONS The multiple-risk-factor intervention strategy resulted in a significant reduction in the risk of falling among elderly persons in the community. In addition, the proportion of persons who had the targeted risk factors for falling was reduced in the intervention group, as compared with the control group. Thus, risk-factor modification may partially explain the reduction in the risk of falling.

Effect of dissemination of evidence in reducing injuries from falls

BACKGROUND Falling is a common and morbid condition among elderly persons. Effective strategies to prevent falls have been identified but are underutilized. METHODS Using a nonrandomized design, we compared rates of injuries from falls in a region of Connecticut where clinicians had been exposed to interventions to change clinical practice (intervention region) and in a region where clinicians had not been exposed to such interventions (usual-care region). The interventions encouraged primary care clinicians and staff members involved in home care, outpatient rehabilitation, and senior centers to adopt effective risk assessments and strategies for the prevention of falls (e.g., medication reduction and balance and gait training). The outcomes were rates of serious fall-related injuries (hip and other fractures, head injuries, and joint dislocations) and fall-related use of medical services per 1000 person-years among persons who were 70 years of age or older. The interventions occurred from 2001 to 2004, and the evaluations took place from 2004 to 2006. RESULTS Before the interventions, the adjusted rates of serious fall-related injuries (per 1000 person-years) were 31.2 in the usual-care region and 31.9 in the intervention region. During the evaluation period, the adjusted rates were 31.4 and 28.6, respectively (adjusted rate ratio, 0.91; 95% Bayesian credibility interval, 0.88 to 0.94). Between the preintervention period and the evaluation period, the rate of fall-related use of medical services increased from 68.1 to 83.3 per 1000 person-years in the usual-care region and from 70.7 to 74.2 in the intervention region (adjusted rate ratio, 0.89; 95% credibility interval, 0.86 to 0.92). The percentages of clinicians who received intervention visits ranged from 62% (131 of 212 primary care offices) to 100% (26 of 26 home care agencies). CONCLUSIONS Dissemination of evidence about fall prevention, coupled with interventions to change clinical practice, may reduce fall-related injuries in elderly persons.

Home-based multicomponent rehabilitation program for older persons after hip fracture: A randomized trial

OBJECTIVE To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care. DESIGN A randomized controlled trial with 12 months of follow-up. SETTING General community; 27 home care agencies. PARTICIPANTS Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days. INTERVENTION Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care. MAIN OUTCOME MEASURES A battery of self-report and performance-based measures of physical and social function. RESULTS There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08). CONCLUSIONS The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.

Fall-risk assessment and management in clinical practice: Views from healthcare providers

Objectives: To determine the extent to which healthcare providers reportedly address evidence‐based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall‐risk factors.

Systematic home-based physical and functional therapy for older persons after hip fracture.

OBJECTIVE To describe the development, implementation, and results of a home-based rehabilitation protocol for older persons after hip fracture. DESIGN Demonstration study. SETTING Community. PARTICIPANTS One hundred forty-eight community-living, nondemented participants at least 65 years of age who underwent repair of a fractured hip at two local hospitals. INTERVENTION A linked assessment-intervention, home-based rehabilitation strategy. The physical therapy (PT) component of the intervention was designed to identify and ameliorate impairments in balance, strength, transfers, gait, and stair climbing; the functional therapy (FT) component was designed to identify and improve unsafe and/or inefficient performance of specific activities of daily living (ADL). MAIN OUTCOME MEASURES The percentage of participants able to complete each component and the extent of progress noted in strength, balance, transfers, gait, and daily functioning. RESULTS A total of 104 of the 148 participants (70%) completed the 6-month PT and FT program; 4 completed only PT and 6 refused both PT and FT. The remaining 32 participants (22%) received partial PT and FT that was terminated by death, hospitalization, or institutionalization. Seventy-seven percent of participants reported performing at least half of the recommended daily exercise sessions. Ninety-four percent and 96% of participants progressed in upper and lower extremity conditioning respectively; 33% progressed to the highest level in the graduated resisted exercise program. All participants progressed in the competency-based graded balance program, with 55% progressing to the fifth (most difficult) level. Similarly, the majority progressed in transfer maneuvers, stair climbing, and outdoor gait. One repetition maximum (RM) elbow extension increased from a mean of 5.8 (SD 4.6) pounds at baseline to 7.2 (SD 3.8) pounds at 6mo (t 2.22; p < .02). One RM knee extension increased from 5.8 (SD 5.8) pounds to 10.8 (SD 5.4) pounds (t = 8.06; p < .0001). The number of gait deviations decreased from 2.1 (SD 1.3) to 0.6 (SD 0.9) (p < .0001), while the mean modified Berg Balance Scale Score increased from 13.0 (SD 4.8) to 20.5 (SD 6.8) (t = 16.6; p < .0001). Finally, the Total ADL Score increased from a mean of 48.2 (SD 15.0) to 77.7 (SD 18.8) (t = 17.03; p = .0001). CONCLUSIONS This systematic assessment and intervention protocol, targeting impairments and ADL, was feasible, safe, and effective. Protocols such as the one presented should enhance the ability to implement rehabilitation programs for the increasing number of multiply impaired older persons receiving home-based therapy and to document the process and outcomes of this care.

Dissemination of an Evidence-Based Multicomponent Fall Risk-Assessment and -Management Strategy Throughout a Geographic Area

Objectives: To report on the penetration of, and identified barriers to and facilitators of, efforts to incorporate evidence‐based fall risk assessment and management into clinical practice throughout a defined geographic area.

Extent of Implementation of Evidence‐Based Fall Prevention Practices for Older Patients in Home Health Care

This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare‐certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence‐based fall prevention training between October 2001 and September 2004. The standardized in‐service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence‐based risk factors for falls in older adults—mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards—using techniques shown to be efficacious in clinical trials. Twenty‐six HHAs participated in these in‐service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self‐reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA‐level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence‐based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA‐level comparisons hold the potential to illustrate the extent of diffusion of evidence‐based fall prevention practices within and between agencies.

Effect of a restorative model of posthospital home care on hospital readmissions.

To compare readmissions of Medicare recipients of usual home care and a matched group of recipients of a restorative model of home care.

Integration of Fall Prevention into State Policy in Connecticut

PURPOSE OF STUDY To describe the ongoing efforts of the Connecticut Collaboration for Fall Prevention (CCFP) to move evidence regarding fall prevention into clinical practice and state policy. METHODS A university-based team developed methods of networking with existing statewide organizations to influence clinical practice and state policy. RESULTS We describe steps taken that led to funding and legislation of fall prevention efforts in the state of Connecticut. We summarize CCFPs direct outreach by tabulating the educational sessions delivered and the numbers and types of clinical care providers that were trained. Community organizations that had sustained clinical practices incorporating evidence-based fall prevention were subsequently funded through mini-grants to develop innovative interventional activities. These mini-grants targeted specific subpopulations of older persons at high risk for falls. IMPLICATIONS Building collaborative relationships with existing stakeholders and care providers throughout the state, CCFP continues to facilitate the integration of evidence-based fall prevention into clinical practice and state-funded policy using strategies that may be useful to others.