Falls Prevention Research Research Articles

Expanding the Health Belief Model for exploring inpatient fall risk perceptions: A methodology paper.

Inpatient falls among older adults are a relentless problem, and extant inpatient fall prevention research and interventions lack the older adults' perspectives and experiences of their own fall risk in the hospital. Theory-guided research is essential in nursing, and the purpose of this paper was to describe the process of developing a theoretical framework for a phenomenological nursing study exploring older adults' lived experiences of being at risk for falling in the hospital. Based on philosophical nursing underpinnings, the Health Belief Model (HBM) was selected as the theoretical model. The limitations of the model led to expansion of the model with established concepts associated with accidental falls among older adults. The HBM was selected as the guiding model due to its ability to capture a broad range of perceptions of a health threat. The HBM was expanded with the concepts of embarrassment, independence, fear of falling, dignity and positivity effect. The addition of these concepts made the theoretical framework more applicable to age-related developmental behaviours of older adult and more applicable to nursing research. The Expanded HBM theoretical framework may guide future nursing research to develop fall prevention interventions to decrease fall rates among hospitalized older adults. No Patient or Public Contribution.

Involvement of Older Adults, the Golden Resources, as a Primary Measure for Fall Prevention.

Falls remain the second leading cause of injury-related deaths worldwide; therefore, longstanding practical fall-prevention efforts are needed. Falls can also lead to a reduction in independence and quality of life among older adults. Fall-prevention research has found that early prevention promotes a prolonged independence. However, it remains unknown which intervention is most beneficial for early prevention and how these interventions should be implemented for long-term effects. In addition, the present and future burden on social and healthcare services contributes to a gap in needs and requires an evidence-based fall prevention. Research suggests that strength, balance, and functional training are effective in reducing falls and fall-related injuries. Such training could greatly impacting independence. Fear of falling and strategies for managing falls are the suggested components to be included when evaluating fall-prevention programs. Thus, the preservation of physical functions is highly relevant for both independence and quality of life. It also contributes to psychological and social well-being, which are important factors for enabling individuals to stay at home for as long as possible. To meet future challenges associated with the expected increase in the older population, older adults should be viewed as a golden resource. With assistance from professionals and researchers, they can learn and gain the ability to institute fall-prevention programs in their own environments. These environments are primarily beyond the responsibilities of the healthcare sector. Therefore, programs comprising current knowledge about fall prevention should be developed, evaluated, and implemented with older adults by using a "train-The-trainer" approach, where a natural collaboration is established between civil society and/or volunteers, healthcare professionals, and researchers. For sustainable and effective fall-prevention programs, a co-design and early collaborative approach should be used in the natural environment, before social and healthcare services are required.

The Effect of Dual-Task Motor-Cognitive Training in Adults with Neurological Diseases Who Are at Risk of Falling.

Falls are common in patients with neurological diseases and can be very problematic. Recently, there has been an increase in fall prevention research in people with neurological diseases; however, these studies are usually condition-specific (e.g., only MS, PD or stroke). Here, our aim was to evaluate and compare the efficacy of an advanced and innovative dual-task, motor-cognitive rehabilitation program in individuals with different neurological diseases who are at risk of falling. We recruited 95 consecutive adults with neurological diseases who are at risk of falling and divided them into four groups: 31 with cerebrovascular disease (CVD), 20 with Parkinson’s disease (PD), 23 with traumatic brain injury (TBI) and 21 with other neurological diseases (OND). Each patient completed a dual-task, motor-cognitive training program and underwent two test evaluations to assess balance, gait, fear of falling and walking performance at the pre-and post-intervention. We found that our experimental motor-cognitive, dual-task rehabilitation program was an effective method for improving walking balance, gait, walking endurance and speed, and fear of falling, and that it reduced the risk of falls in patients with different neurological diseases. This study presents an alternative approach for people with chronic neurological diseases and provides innovative data for managing this population.

A survey for characterizing details of fall events experienced by lower limb prosthesis users.

Despite their importance to fall prevention research, little is known about the details of real-world fall events experienced by lower limb prosthesis users. This gap can be attributed to the lack of a structured, population-specific fall survey to document these adverse health events. The objective of this project was to develop a survey capable of characterizing the circumstances and consequences of fall events in lower limb prosthesis users. Best practices in survey development, including focus groups and cognitive interviews with diverse samples of lower limb prosthesis users, were used to solicit input and feedback from target respondents, so survey content would be meaningful, clear, and applicable to lower limb prosthesis users. Focus group data were used to develop fall event definitions and construct a conceptual fall framework that guided the creation of potential survey questions and response options. Survey questions focused on the activity, surroundings, situation, mechanics, and consequences of fall events. Cognitive interviews revealed that with minor revisions, survey definitions, questions, and response options were clear, comprehensive, and applicable to the experiences of lower limb prosthesis users. Administration of the fall survey to a national sample of 235 lower limb prosthesis users in a cross-sectional preliminary validation study, found survey questions to function as intended. Revisions to the survey were made at each stage of development based on analysis of participant feedback and data. The structured, 37-question lower limb prosthesis user fall event survey developed in this study offers clinicians and researchers the means to document, monitor, and compare fall details that are meaningful and relevant to lower limb prosthesis users in a standardized and consistent manner. Data that can be collected with the developed survey are essential to establishing specific goals for fall prevention initiatives in lower limb prosthesis users.

Older Adults' Biobehavioral Fall Risks Were Affected by the COVID-19 Pandemic: Lessons Learned for Future Fall Prevention Research to Incorporate Multilevel Perspectives.

Background and ObjectivesExamining the impact of coronavirus disease 2019 (COVID-19) pandemic on fall risks may provide insight into how multilevel factors as described in National Institute of Nursing Research's (NINR’s) draft strategic plan can guide future fall prevention research. This article describes the affect of COVID-19 on fall risks from the perspective of older adults who live in assisted living facilities (ALFs), and explores the needs and approaches to implement fall prevention interventions at individual, social, community, and policy levels.Research Design and MethodsExploratory survey study. Participants from a fall prevention study at 2 ALFs in Oregon were invited to the study. Survey questions asked about COVID experience, and changes in fall risks and day-to-day activities in Spring 2020. Quantitative responses were analyzed using descriptive statistics and Cohen’s d effect sizes. Qualitative responses were analyzed using conventional content analysis.ResultsThirteen participants (age: M = 87.08, standard deviation = 6.52) responded. More participants reported feeling unsteady compared to pre-COVID data (38% vs. 62%), while the proportion of those worried about falling remained the same at 38%. Participants reported negligible decreases in importance of fall prevention and small decreases in confidence of fall prevention (Cohen’s d = −0.13 and −0.21, respectively). The themes related to the affect of COVID on fall risks were: not to worry about fall risks but be cautious and physical activity is important, but it’s hard during COVID. Impact of COVID on day-to-day activities were: varying degrees of concern for COVID, lack of social and community support, and finding unique ways to cope with COVID.Discussion and ImplicationsThese individual-level perspectives suggest that older adults were at increased risk for falling. Results exemplify the influence of broader-level factors (e.g., social, community, and policy) on individual biobehavioral factors (e.g., fall risks and health behaviors), and illustrate the value of examining multilevel factors in future fall prevention research.

Circumstances and outcomes of falls in hospital for adults with communication disability secondary to stroke: A qualitative synthesis

BACKGROUND: Falls are a significant patient safety concern in hospital. Adult patients with stroke, and those with communication disability, are at an increased risk of falls during their hospital admission compared to patients without stroke or communication disability. OBJECTIVE: The aim of this review is to determine the circumstances and outcomes of falls in hospitalised patients with communication disability following stroke. METHOD: A qualitative synthesis of 16 papers according to the Generic Reference Model of patient safety. This is a secondary analysis of studies in a systematic review of the association between communication disability after stroke and falls in hospitalised patients. RESULTS: In studies including participants with communication disability, falls commonly occurred at the patient bedside, during the day, and in transfers. However, no studies provided individual or group data specifically detailing the circumstances and outcomes of falls of the included participants with communication disability. CONCLUSION: Research to date provides scant evidence on the circumstances and outcomes of falls in hospital patients with communication disability after stroke. This review performs a useful function in highlighting a glaring gap in the literature and the urgent need to enrich hospital falls prevention research that includes patients with communication disability following stroke. Findings of this review are discussed in relation to providing a framework for analysis of for future research.

Using System Identification and Central Pattern Generators to Create Synthetic Gait Data

One way to accelerate fall prevention research is through the generation of synthetic gait data. The objective of this paper is to explore a proof-of-concept method using a central pattern generator (CPG) and system identification techniques to generate synthetic human gait data. The two neuron CPG model used in this paper actuated a single point mass that represented the height of the human hip. This continuous model was converted into a discrete system with four state variables – hip height, descending drive, and two CPG inhibition variables. To capture the step-to-step variation in the experimental dataset, we performed linear and nonlinear system identification on the discrete system. Compared to the experimental dataset, the linear model yielded a 12% error, while the nonlinear method yielded an 11% error, indicating that this system with the data used was predominantly linear. Using the identified linear model, we generated synthetic data by repeatedly applying the linear model to the current step's state to generate the next step's state. The resulting synthetic data had some similarity to the experimental data but clearly did not fully replicate the experimental signal properties, indicating that the methods used here have promise but are currently insufficient.

Recalled Number of Falls in the Past Year-Combined With Perceived Mobility-Predicts the Incidence of Future Falls in Unilateral Lower Limb Prosthesis Users.

Falls are a frequent and costly concern for lower limb prosthesis (LLP) users. At present, there are no models that clinicians can use to predict the incidence of future falls in LLP users. Assessing who is at risk for falls, therefore, remains a challenge. The purpose of this study was to test whether easily accessible clinical attributes and measurements predict the incidence of future falls in LLP users. In this prospective observational study, a secondary analysis of data from 60 LLP users was conducted. LLP users reported the number of falls that they recalled over the past year before prospectively reporting falls over a 6-month observation period via monthly telephone calls. Additional candidate predictor variables were recorded at baseline. Negative binomial regression was used to develop a model intended to predict the incidence of future falls. The final model, which included the number of recalled falls (incidence rate ratio = 1.13; 95% CI = 1.01 to 1.28) and Prosthetic Limb Users Survey of Mobility T-scores (incidence rate ratio = 0.949; 95% CI = 0.90 to 1.01), was significantly better than a null model at predicting the number of falls over the next 6months (χ22 = 9.76) and fit the observed prospective fall count data (χ256 = 54.78). The number of recalled falls and Prosthetic Limb Users Survey of Mobility T-scores predicted the incidence of falls over the next 6months in established, unilateral LLP users. The success and simplicity of the final model suggests that it may serve as a screening tool for clinicians to use for assessing risk of falls. Additional research to validate the proposed model in an independent sample of LLP users is needed. Owing to its simplicity, the final model may serve as a suitable screening measure for clinicians to ascertain an initial evaluation of fall risk in established unilateral LLP users. Analyzing falls data as counts rather than as a categorical variable may be an important methodological consideration for falls prevention research.

Improving Local Service Delivery to Prevent Falls in Community-Dwelling Older Adults: Translating Research to Practice

Unintentional falls are the leading cause of both fatal and nonfatal injuries among Americans 65 years of age and older and place an enormous burden on the health care system. As the population continues to age, preventing falls will be increasingly important for reducing morbidity, mortality, and medical costs. Evidence-based fall prevention interventions for older adults exist, but widespread adoption of these interventions is needed. Local health departments, Area Agencies on Aging, first responders, and health care professionals can all play important roles in implementing fall prevention programs. This article presents a conceptual model for local delivery of fall prevention programs for community-dwelling older adults. This model can serve as a guide for translating existing fall prevention research into practice.

Development of the Better Balance Program for People with Multiple Sclerosis: A Complex Fall-Prevention Intervention.

Approximately 56% of people with multiple sclerosis (MS) will fall in any 3-month period, with the potential for physical, psychological, and social consequences. Fall-prevention research for people with MS is in its infancy, with a timely need to develop theory-based interventions that reflect the complexity of falls. The clear articulation of the development of any complex intervention is paramount to its future evaluation, usability, and effectiveness. Our aim was to describe how the development of Better Balance, a complex multicomponent fall-prevention intervention for people with MS, was guided by the Medical Research Council framework for the development of complex interventions. Sources of information included existing literature, original research, clinician interviews, and views of people with MS. These sources were synthesized and refined through an iterative process of intervention development involving researchers, clinicians, and people with MS. The resulting intervention is outlined through a variety of key tasks supplementing the original Medical Research Council framework. Use of this framework resulted in a theoretically based and user-informed complex intervention designed to address the physiological, personal, and behavioral risk factors associated with falls in people with MS. The articulation of the systematic process used to develop Better Balance will inform the future evaluation and usability of the intervention.

Just Don’t Fall: An AI Agent’s Learning Journey Towards Posture Stabilisation

Learning to maintain postural balance while standing requires a significant, fine coordination effort between the neuromuscular system and the sensory system. It is one of the key contributing factors towards fall prevention, especially in the older population. Using artificial intelligence (AI), we can similarly teach an agent to maintain a standing posture, and thus teach the agent not to fall. In this paper, we investigate the learning progress of an AI agent and how it maintains a stable standing posture through reinforcement learning. We used the Deep Deterministic Policy Gradient method (DDPG) and the OpenSim musculoskeletal simulation environment based on OpenAI Gym. During training, the AI agent learnt three policies. First, it learnt to maintain the Centre-of-Gravity and Zero-Moment-Point in front of the body. Then, it learnt to shift the load of the entire body on one leg while using the other leg for fine tuning the balancing action. Finally, it started to learn the coordination between the two pre-trained policies. This study shows the potentials of using deep reinforcement learning in human movement studies. The learnt AI behaviour also exhibited attempts to achieve an unplanned goal because it correlated with the set goal (e.g., walking in order to prevent falling). The failed attempts to maintain a standing posture is an interesting by-product which can enrich the fall detection and prevention research efforts.

Tailoring a Comprehensive Bundled Intervention for ED Fall Prevention

IntroductionFalls in the emergency department pose an important challenge for patient safety. Multifactorial fall prevention bundles have been associated with a reduction in patient falls in the inpatient setting. The purpose of this project was to tailor and implement a comprehensive fall prevention bundle in our emergency department. MethodsFall bundle components for this intervention were selected on the basis of a review of fall prevention research and included fall risk assessment, safe ambulation, safe toileting, staff communication, early warning, and patient education. The fall risk assessment was tailored to the emergency department through an appraisal of select inpatient fall risk assessments, literature search for ED-specific fall risk factors, and a site-specific chart review, after which pertinent fall risk factors were integrated into a modified screening. Fall prevention materials that were both practical and applicable to the emergency department and facilitated patient safety along each bundle domain were selected for implementation at our site. ResultsThe tailored fall prevention bundle was championed by the interdisciplinary ED Fall Prevention Team and implemented over the course of 5 months in 1 emergency department. Education on fall prevention equipment was delivered in a peer-to-peer format, and an online module was designed to guide staff through the new fall risk assessment. The fall prevention bundle was adopted into clinical practice after staff education was completed, and the fall risk screening was merged into the electronic medical record. DiscussionED fall prevention requires a comprehensive bundled approach, which includes a fall risk screening and multifactorial interventions that are tailored to the ED setting. Successful implementation relies on the involvement of front-line staff from the design through the delivery of the bundled fall prevention measures. Continued inquiry and innovation in ED fall prevention will help provide a safer health care environment and improve patient outcomes.

Changes In the Incidence of Falls, the Process of the Information Provision to Medical Staff and that of the Risk Aversion for 4 Years of Fall Prevention Research for Cognitively Unscathed Patients who Require Assistance with Movement.

Changes In the Incidence of Falls, the Process of the Information Provision to Medical Staff and that of the Risk Aversion for 4 Years of Fall Prevention Research for Cognitively Unscathed Patients who Require Assistance with Movement.

Translating healthcare research evidence into practice: The role of linked boundary objects

Recent years have seen widespread interest in the process of evidence implementation and growth of implementation science. Whilst this work has drawn attention to the challenges and complexities of implementing evidence into everyday practice, for the most part, studies of implementation uphold the ideal of a linear ‘pipeline’ between research and front-line care. In contrast, this paper adopts a practice perspective on knowledge, and draws on science and technology studies concepts to identify how the socio-material environment contributes to the translation of evidence across multiple organisational and professional boundaries. Findings report on a qualitative case study of implementing fall prevention research evidence at a large teaching hospital in Portugal. Data is from forty-six in-depth semi-structured interviews with clinical and non-clinical staff.The case highlights how linked boundary objects bridge temporally sequential boundaries between research and different practice communities, hence facilitating the translation of research evidence into everyday practice. The initial boundary object (the ‘Morse’ fall risk assessment scale) contributed to evidence being taken up by specialist nurses within the hospital, while a second boundary object (a pink patient wristband) engendered a change in practice of a wider network of actors. Nevertheless, the symbolic connection between the two linked boundary objects remained precarious, dependent on networks of interaction and communication. The study highlights the role of material objects in the ongoing translation of research evidence into everyday clinical practice.

Falls Experiences and Prevention Preferences of Adults in Mid-life.

Falls prevention research and practice has focused primarily on older adults, yet healthy and productive aging does not begin at age 65. To help fill this gap in knowledge, the purpose of this study was to explore the falls experiences and prevention program preferences of adults in mid-life who had experienced falls or near falls. A qualitative study using content analysis was used. Multiple coders were employed to increase the reliability of the findings. Results revealed three major themes with regard to falls experiences including precursors to falls, physical implications, and functional implications. For prevention preferences, themes included a continuum of interest, convenience is key, money matters, people you trust prompt action, and preventing future injury. Study results reveal new insights regarding the falls experiences and prevention preferences of adults in mid-life and can serve as a starting point to inform prevention programs targeting this population.

Selecting a theoretical framework to guide a research study of older adults' perceptions and experiences of falling in the hospital

A paucity of research has explored the older adult's experience of falling in the hospital. Understanding the central concepts associated with a fall while hospitalized is essential for further fall prevention research and practice. The purpose of this paper is to describe the process of selecting a theoretical framework to guide a qualitative study exploring the older adult's experience of falling while hospitalized. An analysis of six established illness self-management theories and models from nursing and psychology was conducted using Walker and Avant's framework for theory analysis. The Health Belief Model was selected as the most appropriate theoretical framework, as it entails concepts applicable to the experience of falling and captures the complexity of the phenomenon of inpatient falls, which is important for nursing.

Risks factors for significant injury after geriatric falls

Elderly falls are a healthcare epidemic. We aimed to identify risk factors of serious falls by linking data on functional status from the Global Longitudinal Study of Osteoporosis in Women (GLOW) and our institutional trauma registry. 124 of 5,091 local women enrolled in GLOW were evaluated by our trauma team for injuries related to a fall during the study period. Median injury severity score was 9. The most common injuries were intertrochanteric femur fracture (n = 25, 9.8%) and skin contusion/hematoma to face (n = 12, 4.7%). Injured women were older than the uninjured cohort (median 80 versus 68 years), more likely to have cardiovascular disease and osteoarthritis, and less likely to have high cholesterol. Prospectively collected Short Form 36 (SF-36) baseline activity status revealed greater limitation in all assessed activities in women evaluated for fall-related injuries in our trauma center. In multivariable analysis, age (per 10 year increase) and two or more self-reported falls in the baseline survey were the strongest predictors of falling (both HR 2.4, p <0.0001 and p<0.001 respectively), followed by history of osteoarthritis (HR 1.6, p= 0.01). Functional status was no longer associated with risk of fall when adjusting for these factors. Functional status appears to be a surrogate marker for frailty. With the aging of the US population and long lifespan of American women, this finding has important implications for both fall prevention strategies and research intended to better understand why aging women fall as burdensome validated metrics may not be the best indicators of fall risk.

Commentary on “Fall prevention for people with learning disabilities: key points and recommendations for practitioners and researchers”

Purpose Age-related processes are marked by physiological, psychological and social decline, threatening health, quality of life, functional status and the mobility of individuals. As the impact of demographic change also begins to affect persons with intellectual disabilities (ID), issues and needs regarding the aging process are slowly entering the field of ID research. The paper aims to discuss these issues. Design/methodology/approach In the population of older people with ID, important, age-related events such as falls have prompted increasing research. Falls may lead to several negative health outcomes, require that an individual receives higher levels of care sometimes including hospitalisation and, in the worst case, hasten death. Falls also lead to psychological consequences such as fear of falling which fuels a vicious circle in which older persons afraid of falling reduce their physical activity, in turn hastening their functional decline. Findings Fall prevention in persons with ID is just evolving and further research is clearly necessary. This research can draw on the existing evidence from other fall prevention areas, especially the work carried out with the general older population. Originality/value As stated by Finlayson, a useful next step would be the development of a consensus on the definitions and methodology that should underpin future fall prevention research with persons with ID.

Falls prevention in community care: 10 years on.

BackgroundA million older people living in Australia receive community care services each year due to experiencing functional or mental health difficulties. This group may be at greater risk of falling than similar-aged people not receiving services. However, there is limited falls prevention research for this population.PurposeThe aim of this study was to identify the falls prevalence rates of older people from 10 Australian community care organizations and compare current falls prevention data to a study 10 years prior that utilized the same 10 organizations. This study also identified factors associated with falling for this population.Patients and methodsThis is a cross-sectional descriptive study, in which 5,338 questionnaires were mailed to a random sample of community care recipients aged ≥65 years.ResultsA total of 1,991 questionnaires were returned (37.3%), with 47.7% of respondents having fallen in the previous year, and 32.7% in the month prior to completing the questionnaire, similar to 10 years prior. Community care clients had a 50% higher falls rate than that reported for similar-aged people not receiving services, and this remained unchanged over the last 10 years. Eighty-six per cent of fallers had fallen once or twice, and 60% reported being injured. Thirty-six per cent of respondents reported not being able to get up independently, and only 27.4% of fallers were referred to a falls prevention program (significantly fewer than 10 years ago; 95% CI: 0.821–6.366, p=0.01). Balance issues (odds ratio [OR]: 2.06, 95% CI: 1.288–3.290, p=0.003) and perceived risk of falling in the future being “definite” (OR: 6.42, 95% CI: 1.890–21.808, p=0.003) or “unsure” (OR: 3.31, 95% CI: 1.144–9.544, p=0.027) were risk factors associated with falling. In contrast, individuals referred to a falls prevention intervention had a 47% reduced likelihood of having fallen (95% CI: 0.281–0.988, p=0.046).ConclusionCommunity care clients should have their falls risk routinely assessed, and at-risk individuals be offered falls prevention advice and referral to fall prevention programs.

Community Peer-Led Falls Prevention Presentations: What Do the Experts Suggest?

Falls among older adults are a major problem. Despite considerable progress in falls prevention research, older adults often show low motivation to engage in recommended preventive strategies. Peer-led falls prevention education for older adults may have potential for bridging the research evidence-practice gap, thereby promoting the uptake of falls prevention strategies. We evaluated peer educators' presentations of falls prevention education to community-dwelling older adults in regard to established criteria that were consistent with adult learning principles, the framework of health behaviour change, falls prevention guidelines, and recommendations for providing falls prevention information. We conducted a within-stage mixed model study using purposive and snowball sampling techniques to recruit 10 experts to evaluate video recordings of the delivery of three peer-led falls prevention presentations. Each expert viewed three videos and rated them usinga questionnaire containing both open-ended and closed items. There was a good level of expert agreement across the questionnaire domains. Though the experts rated some aspects of the presentations highly, they thought that the presentations were mainly didactic in delivery, not consistently personally relevant to the older adult audience, and did not encourage older adults to engage in the preventive strategies that were presented. Based on the experts' findings, we developed five key themes and recommendations for the effective delivery of peer-led falls prevention presentations. These included recommending that peer educators share falls prevention messages in a more interactive and experiential manner and that uptake of strategies should be facilitated by encouraging the older adults to develop a personalised action plan. Findings suggest that if peer-led falls prevention presentations capitalise on older adults' capability, opportunity, and motivation, the older adults may be more receptive to take up falls prevention messages.