Romke van Balen

Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors

The objective of this review was to systematically describe and analyze fear of falling (FoF) in patients after a hip fracture, focusing on measurement instruments for FoF, the prevalence of FoF, factors associated with FoF, and interventions that may reduce FoF. Fifteen relevant studies were found through a systematic literature review, in which the PubMed, Embase, PsychINFO, and CINAHL databases were searched. Some of these studies indicated that 50% or more of patients with a hip fracture suffer from FoF, although adequate instruments still have to be validated for this specific group. FoF was associated with several negative rehabilitation outcomes, such as loss of mobility, institutionalization, and mortality. FoF was also related to less time spent on exercise and an increase in falls, although knowledge about risk factors, the prevalence over a longer time period, and the exact causal relations with important health outcomes is limited. Most studies suffer from selection bias by excluding patients with physical and cognitive disorders. Hence, more research is required, including in patients who are frail and have comorbidities. Only when knowledge such as this becomes available can interventions be implemented to address FoF and improve rehabilitation outcomes after a hip fracture.

Quality of life after hip fracture: a comparison of four health status measures in 208 patients.

Objectives: We compared four health status measures for the evaluation of quality of life after hip fracture. Methods: Two hundred and eight elderly hip fracture patients were followed up to 4 months after hospital admission. We used two interviewer-administered instruments (the Rehabilitation Activities Profile (RAP) and the Barthel Index (BI)) that focus on functional status, and two self-assessment instruments (the Nottingham Health Profile (NHP) and the COOP/WONCA charts) that additionally include psychological and social health domains. The score distribution, internal consistency, construct validity, and sensitivity to change were investigated. Results: At 4 months only 18% of surviving patients had reached the same level of functioning as before the fracture and, compared with reference values, lower scores of health status were found in the areas of physical mobility and emotional reactions. The number of comorbidities at hospital admission was the most important prognostic factor for recovery of health status at 4 months. The RAP and the BI both performed well in the assessment of functional status in regard to score distribution, internal consistency and construct validity. In contrast to the BI, the RAP also assessed instrumental activities of daily living and perceived problems with existing disabilities. The generic health status measures produced no added value in the assessment of functional status. The NHP covered a wider range of psychological health dimensions (emotion, pain, energy, and sleep) and had better psychometric properties than COOP/WONCA. None of the four instruments performed well in assessing social functioning. Conclusions: To assess health status after hip fracture, we recommend the RAP for functional status and the NHP for changes in emotion, pain, and energy. These instruments detected poor recovery in functional and emotional status at 4 months after fracture.

Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home.

Hip fracture patients occupy more and more hospital beds. One of the strategies for coping with this problem is early discharge from the hospital to institutions with rehabilitation facilities. We studied whether early discharge affects outcome and costs. 208 elderly patients with a hip fracture were followed up to 4 months after the fracture. First, a group of 102 patients stayed in our hospital for the usual period (median 18 days). Then, 106 patients were assigned to a group for early discharge (median 11 days). We measured disabilities, health-related quality of life and cognition at 1 week, 1, and 4 months after hospitalization. To calculate total societal costs, inpatient days, the efforts of professionals in- and outside institutions, and interventions/examinations were recorded during this 4-month period. At 4 months, we found no differences in mortality, ADL level, complications, quality of life, and type of residence. More patients in the early discharge group were discharged to nursing homes with rehabilitation facilities (76% versus 53%), but the median total stay in hospital and nursing home was the same (26 days). Early discharge from hospital did not substantially reduce the total costs (conventional management ] 15,338 per patient and early discharge ] 14,281 per patient), but merely shifted them from the hospital to the nursing home.

Fear of Falling in Patients With Hip Fractures: Prevalence and Related Psychological Factors

OBJECTIVE To determine the prevalence of fear of falling (FoF) in patients after a hip fracture, to investigate the relation with time after fracture, and to assess associations between FoF and other psychological factors. DESIGN Cross-sectional study performed between September 2010 and March 2011 in elderly patients after a hip fracture. SETTING Ten postacute geriatric rehabilitation wards in Dutch nursing homes. PARTICIPANTS A total of 100 patients aged ≥65 years with a hip fracture admitted to a geriatric rehabilitation ward. MEASUREMENTS FoF and related concepts such as falls-related self-efficacy, depression, and anxiety were measured by means of self-assessment instruments. RESULTS Of all patients, 36% had a little FoF and 27% had quite a bit or very much FoF. Scores on the Falls Efficacy Scale-International were 30.6 in the first 4 weeks after hip fracture, 35.6 in the second 4 weeks, and 29.4 in the period ≥8 weeks after fracture. In these 3 periods, the prevalence rates of FoF were 62%, 68%, and 59%, respectively. Significant correlations were found between FoF and anxiety (P < .001), and self-efficacy (P < .001). CONCLUSION In these patients with a hip fracture, FoF is common and is correlated with anxiety and falls-related self-efficacy. During rehabilitation, FoF is greatest in the second 4 weeks after hip fracture. More studies are needed to explore the determinants of FoF and develop interventions to reduce FoF and improve outcome after rehabilitation.

Fear of falling after hip fracture in vulnerable older persons rehabilitating in a skilled nursing facility.

OBJECTIVE To identify factors that explain differences in patients with high and low levels of fear of falling after a hip fracture. DESIGN Cross-sectional study in 10 skilled nursing facilities in the Netherlands. PATIENTS A total of 100 patients aged ≥ 65 years admitted to a skilled nursing facility after a hip fracture. METHODS Participants were divided into 2 groups; low and high level of fear of falling, based on median Falls Efficacy Score - International. Data relating to factors that might explain fear of falling were collected, including demographic variables, aspects of functioning, psychological factors, and comorbidities. For every factor a univariate logistic regression was conducted. For the multivariate regression model a backward procedure was used in which variables with p < 0.05 were included. RESULTS Walking ability and activities of daily living before fracture, number of complications, activities of daily living after fracture, anxiety and self-efficacy were significantly associated univariately with fear of falling. Multivariate analysis showed that walking ability before fracture (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.14-0.83), activities of daily living after fracture (OR 0.89, 95% CI 0.80-0.99), and anxiety (OR 1.22, 95% CI 1.05-1.42) were independently associated with fear of falling. CONCLUSION Impaired walking ability before fracture, impaired activities of daily living after fracture, and increased anxiety help distinguish between older persons with high and low levels of fear of falling after hip fracture. Because the last 2 factors are modifiable, this information enables the development of specific interventions for older persons with a high level of fear of falling.

Reliability and validity of the Falls Efficacy Scale-International after hip fracture in patients aged ≥65 years

Abstract Purpose: To assess the measurement properties of the Falls Efficacy Scale-International (FES-I) in patients after a hip fracture aged ≥ 65 years. Methods: In a sample of 100 patients, we examined the structural validity, internal consistency and construct validity. For the structural validity a confirmatory factor analysis was carried out. For construct validity predetermined hypotheses were tested. In a second sample of 21 older patients the inter-rater reliability was evaluated. Results: The factor analysis yielded strong evidence that the FES-I is uni-dimensional in patients with a hip fracture; the Cronbach’s alpha was 0.94. When testing the reliability, the intra-class correlation coefficient was 0.72, while the Standard Error of Measurement was 6.4 and the Smallest Detectable Change was 17.7 (on a scale from 16 to 64). The Spearman correlation of the FES-I with the one-item fear of falling instrument was high (r = 0.68). The correlation was moderate with instruments measuring functional performance constructs and low with instruments measuring psychological constructs. Conclusions: Reliability and structural validity of the FES-I in patients after a hip fracture are good. The construct validity appears more closely related to functional performance constructs than to psychological constructs, suggesting that the concept measured by the FES-I may not capture all aspects of fear of falling. Implications for Rehabilitation The Falls Efficacy Scale-International (FES-I), which is commonly used to measure fear of falling in community-dwelling older persons, can also be used to assess fear of falling in patients after a hip fracture. The reliability and the structural validity of the FES-I for these hip patients are good, whereas the construct validity of the FES-I is not optimal. The FES-I may not capture all aspects of fear of falling and may be more closely related to functional performance than to psychological concepts such as anxiety.

Wat is verantwoorde behandeling van ouderen in een zorginstelling

Abstract Summary How to define sound medical treatment for the elderly in nursing homesBased on further concepts of nursing home medicine / general geriatric medicine and major changes in healthcare assurance in the Netherlands, new priorities have to be formulated for research.Under the terms of de Dutch Law of Quality in Health Care Facilities, nursing home medical practitioners have to give a professional interpretation of sound medical treatment. Undertreatment has to be changed into patientoriented, effective and efficient medical treatment.SamenvattingOp basis van de vernieuwde Taaken Functie Verpleeghuisarts/Sociaal Geriater is het noodzakelijk opnieuw prioriteiten vast te stellen ter onderbouwing van de gewijzigde inhoud van het beroep. Dit geldt temeer nu de Minister van VWS een nieuwe Zorgverzekeringswet en Wet Maatschappelijke Ondersteuning en (mogelijk) een aangepaste AWBZ voorbereidt.Dit artikel gaat in op enkele prioriteiten in de verpleeghuisgeneeskundige cq medische behandeling van ouderen als onderdeel van ‘verantwoorde zorg’ zoals bedoeld in de Kwaliteitswet Zorginstellingen. Beoogd wordt de geneeskundige onderbehandeling van vele chronische aandoeningen zo spoedig mogelijk te wijzigen in doelmatige, effectieve en patiëntgerichte geneeskundige behandeling. Sleutelwoorden: verantwoorde zorg, onderbehandeling, chronische aandoeningen.