Falls prevention education between older adults and healthcare providers during transition from hospital to community-living

2017-03-01T02:58:20Z (GMT) by Lee, Den-Ching Angel
Background: Falls are a problem for older adults. In particular, older hospitalised adults and those recently discharged from hospital have been shown to be at an increased risk of falls compared to older adults living in the community. Falls impact negatively on the physical and psychosocial well-being of older adults. They increase the burden of care for their family, caregivers and the healthcare system. However, many falls in older adults are preventable. Cochrane reviews demonstrated many strategies were effective in preventing falls in the hospital and community settings. However, older adults were shown to have little knowledge of protective strategies they could engage in preventing falls. It is therefore apparent that many of them may not become involved in effective falls prevention activities during hospitalisation and after discharge without active education from their healthcare providers about what strategies they should be using. There is a new piece of evidence from the most recent Cochrane review that providing education to patients targeting individual risk factors can reduce their risk of falling in hospital, however, it is unclear whether education intervention is effective in reducing their risk of falling following discharge from hospital. Objectives: The objectives of the thesis were to investigate whether provision of education intervention to older adults could potentially increase the uptake of falls prevention activities, and prevent falls during hospitalisation and after discharge to the community. It explored what falls prevention education and how frequently it was being provided to older adults and their caregivers. It also investigated the barriers and facilitators to this education taking place. Methods: A research program incorporating four studies that utilised qualitative and quantitative designs was conducted. The first study was a systematic review and meta-analysis. Five health science databases were searched up to November 2012. Studies that investigated patient education as a single intervention or in a multifactorial falls prevention program in the hospital and/or post-discharge community settings were eligible for inclusion. Standard meta-analysis methods were used to assess the effectiveness of patient education compared to usual care. Primary outcomes were incidence of falls, falls-related injury and healthcare use due to falls. Secondary outcomes were mechanisms of behavioural change that may reduce the risk of falls, for example awareness of falls and falls prevention strategies. Qualitative data were analysed by critical narrative review. The second study was a qualitative study. Six participant groups of older patients (n=16), caregivers (n=8), allied health and nursing professionals (n=33), hospital doctors from acute wards (n=8), hospital doctors from subacute wards (n=10) and general practitioners (n=9) were interviewed using either semi-structured interviews or focus groups. All participants were recruited from three hospitals of Monash Health in Victoria, Australia except for general practitioners who were recruited from the community of Melbourne. Data were analysed with thematic analysis. The third study was a prospective cohort study. Data were collected from 394 older community dwellers in Victoria, Australia using a baseline survey (response rate of 61%), and 245 of these participated in a follow-up survey one year later. Survey domains were drawn from constructs of behavioural change models. Survey format consisted of yes and no responses, Likert scale and open/closed-ended responses. Quantitative data were analysed with regression analysis consistent with the categories of data. Qualitative data that were obtained from open-ended questions were coded and analysed with content analysis. The fourth study was a prospective cohort study. Data were collected from 155 older hospitalised adults prior to discharge from hospital using a baseline survey (response rate of 72%), of whom 123 participated in a three and/or six month follow-up surveys in the community. Participants were recruited from three hospitals of Monash Health in Victoria, Australia. Questionnaires captured predictive factors that may predispose older adults to fall. Data related to the proportion of older adults who could recall having discussed falls and falls prevention strategies with a health professional, content of these discussions and strategies that were recommended or undertaken to prevent falls within six months post-discharge were examined. Survey format consisted of open/closed-ended responses. Qualitative data that were obtained from open-ended questions were coded and analysed with content analysis. Results: Systematic review of falls prevention programs that contained patient education were shown to be effective in reducing fall rates amongst hospital inpatients and post-discharge populations, and in reducing the proportion of patients who became fallers in the hospital. Patient education generally increased knowledge about falls and awareness of prevention strategies in older adults. However, the uptake of strategies may be dependent on the activities being targeted.  The other studies in the research program found few older adults discussed with their healthcare providers about falls. Twenty percent of older adults in the community reported having had a discussion about falls with their general practitioners, of which 15% initiated the discussion. About 15% reported having had a discussion or having initiated a discussion about falls with other health professionals. Forty-four percent of older adults reported having had a discussion about falls with either their general practitioners and/or other health professionals within six months after discharge from the hospital. Older adults commonly reported that they were asked if they had fallen over, and the reason of fall if they did fall, with further discussion about injuries that arose from falling within six months post-discharge. Very few recalled discussing screening for risk of future falls or interventions to prevent falls. Older adults in the community reported discussing falls prevention strategies with their general practitioners and other health professionals. However, discussions held post-discharge and in the community were mostly focussed on interventions that had an absence of evidence of effectiveness in preventing falls. Moreover, most of the interventions that were undertaken had no evidence of benefit for the prevention of falls. More than half of those that were prescribed with exercises for the prevention of falls post-discharge did not do the exercises. Falls prevention information provided to older adults in the hospital was found to be typically “activity-specific”. In addition, health professionals generally gave advice that was “discipline-specific” to their professional background rather than discussing with older adults about their personal risk factors of falls and giving relevant evidence-based falls prevention information. Mixed messages or potentially incorrect messages were sometimes conveyed to patients and their families due to miscommunication between hospital staff, and staff members who had different clinical considerations. Barriers to discussion about falls that were identified in hospitals included health professionals perceiving a difference in their falls prevention responsibility, time limitations, competing priorities, lack of falls prevention knowledge, lack of suitable educational resources for falls prevention, reactive approach to falls prevention, older adults’ beliefs, perceptions and attitudes towards fall risks and falls prevention. Barriers to discussion about falls that were identified in the community included older adults having a low perceived risk of falls or harm from falls, not seeing their health professionals at the time of fall, and having limited time at consultation to discuss falls. Older adults in the community who had anxiety or depression, chronic medical conditions such as diabetes or having a self-reported fall in the last 12 months were more likely to have a discussion of falls with general practitioners. Older adults in the community who had a higher perception of risk of sustaining a serious injury from falling were more likely to discuss about falls with other health professionals. Information provision about falls prevention during transition from hospital to community-living seemed to be more favourable if older adults were admitted to a subacute ward during their hospital stay. Likewise, information provision during transition was more likely to occur if they had fallen, if they were referred for rehabilitation after discharge from the hospital or if they had asked about falls. Older adults in the community reported increased participation in exercises for the prevention of falls after they completed a survey that targeted evidence-based falls prevention activities. The participants reported they had an increased threat appraisal towards their perceptions about falls and personal risk of falls. They described implementation of different strategies to prevent falls after participation in the survey. Discussion: The results of the studies in the research program complemented each other and demonstrated relatively consistent findings across the studies undertaken. Current approaches to discussion about falls between older adults and their health professionals in hospitals and post-discharge to the community could be argued as being suboptimal. There was a low frequency of falls discussion between older adults and their healthcare providers. In addition, the amount of evidence-based information or advice being provided to older adults to prevent falls during the discussions was scarce. Therefore, the discussions that did take place were unlikely to assist with the prevention of future falls. (...)