The Prevention of Falls Network for Dissemination (ProFouND) is a new EC funded initiative dedicated to bring about the dissemination and implementation of best practice in falls prevention across Europe.

ProFouND comprises 21 partners from 12 countries, associate members from a further 10 countries. ProFouND aims to influence policy to increase awareness of falls and innovative prevention programmes amongst health and social care authorities, the commercial sector, NGOs and the general public so as to facilitate communities of interest and disseminate the work of the network to target groups across EU.

More specifically ProFouND’s objective is to embed evidence based fall prevention programmes for elderly people at risk of falls by using novel ICT and effective training programmes in at least 10 countries/15 regions by 2015 so as to facilitate widespread implementation. ProFouND will achieve this in three main ways.

First, by collating evidence-based resources to inform the development and content of a novel state-of-the-art online web-based expert system; the ProFouND Falls Prevention Application (PFPApp).

The PFPApp will enable the creation of tailored, customised, up-to-date best practice guidance, that can be context and individual specific. For example, a Falls Prevention practitioner in assessing the needs of an elderly patient would ask a series of questions to inform the inclusion of best practice guidance from a database of predefined evidence-based articles. This advice, on aspects of health including for example Vision Impairment, Vitamin D supplements or Strength and Balance Training, etc… would be presented in an easily assimilable and attractive printable leaflet, branded with institutional logos, contact information and other bespoke information according to what is available in the local area.

Second, ProFouND, in collaboration with Later Life Training, will provide a cascade model training programme using face to face and e-learning approaches to create a cadre of accredited exercise trainers across Europe to implement exercise regimens that have been proven to reduce falls amongst older people. The idea here is that once trained, these trainers would then in turn train instructors to deliver classes directly to people who need this kind of intervention.

Third, ProFouND will also create an “ICT for Falls Forum” to identify evidence based solutions that can help reduce falls and engage with industry to promote development and adoption of these solutions. This forum will run events and reach out to promote MHealth capabilities and European competitiveness in the sector.

ProFaNE.co will of course be reporting on major developments and ProFouND will soon invite anyone interested in this work to apply for membership through the ProFouND Network Website. In the mean time you can find out more about the project and each the eight work packages and download the ProFouND leaflet (.pdf click on the image to the right). You can also sign up for updates and by telling your friends and colleagues you will help the project greatly and we strongly encourage you to do so.

Finally, if you have spotted the similarity between the ProFaNE and ProFouND names and logo design, this is because the ProFouND project was conceived and developed by some of the same people as ProFaNE and we see them as very different but very complementary projects. Professor Chris Todd, Professor Dawn Skelton and myself first discussed ProFouND in January 2012 and we are delighted that we have this opportunity to work with all the people and organisations involved and hope to bring about significant improvements to the lives of countless people in Europe and beyond. We hope you will join us on this journey and help us make a change!

Emerging evidence suggests that the fashion for really low baggy pants poses a significant increase of risk of falls to ageing populations.

Several studies have shown that wearing loose, oversize pants poses two main risks; the first is associated with the bottom of the pants trailing on the floor leading to a very high risk that the material will be caught under the shoe causing imbalance and probably a trip, stumble or even fall. The second is the risk of total garment fail where the carefully balanced waistline drops below the critical ‘hold point’ and the pants fall down. If this happens while moving the consequences are inevitable.

UPDATE: Of course this is an April Fool and in keeping with tradition, after 12 noon we should not try to make anyone take it seriously.

While young people may have the strength, balance and agility to correct many of these fashion induced stumbles and avoid a fall, with age these reflexes can deteriorate and as the people who follow this fashion trend mature, we can expect to see a significant increase in falls and fractures.

Internationally renowned falls prevention expert Professor Dawn Skelton confirmed that the findings support her long held belief that these pants were cause for concern and added “apart from anything else, they look ridiculous, I mean, who wants to see someone else’s underpants on their way to work?”

There are several news stories that also add credence to this research. A thief was foiled by his own fashion sense as he tried, and failed, to make a getaway with a stolen create of beer:

Rather more serious was the case of gunman Hector Quinones who, after murdering his victims, tripped and fell three stories to his death because his pants fell down. You can read the full story here.

Fortunately it’s not all bad news, there are several interventions that can completely eliminate this increased risk of falls. Practitioners who come into contact with anyone wearing dangerous clothing should first of all advise against wearing these ill-fitting pants in the first place, however we understand that there may be some resistance to this. A secondary option is to encourage the use of braces, of course this may also be regarded as a fashion faux pas, but researchers and policy makers in the US are negotiating with several prominent fashion lables and rap music stars to try and influence the poulation. Other methods that may be successful can be found here.

In the most reluctant cases funding may be available for a certain number of invisible suspender belts made just for men with baggy pants. Details will be published when available.

Further to the announcement that profane.co is now a member of the Falls and Fractures Alliance, we are very proud to present the first in a brand new series of dedicated sections of the profane.co website based on the Map of Falls and Fracture Prevention. The Vision Impairment and Falls section is a comprehensive overview of everything you need to know about this important topic as a falls prevention professional.

We have also made updates to the Map of Falls and Fractures, thanks to David Langford and Lotte Evron for their contributions – very much appreciated. Also, if you see a ‘red dot’ next to a node, it means there is a dedicated profane.co section for that topic – the first being the new Vision and Falls section.

Prof Dawn Skelton gave a keynote at a conference in Kent this week. The presentation covered a recent review of the evidence behind falls prevention interventions (Cochrane Reviews and Exercise Reviews), links with Physical Activity Guidelines for Older People and some thoughts on implementation of assessment and intervention on lesser considered risk factors such as feet, eyes and continence. The day also included a very successful #fallschat on Twitter, an exercise class and more. Contact @uk_james for further information.

You can download Dawn’s presentation as a pdf handout, or you can download the full powerpoint presentation. You are welcome to use the presentation for your own awareness raising and training but please acknowledge Professor Skelton and http://profane.co to help build the worlds largest falls prevention professional online community.

“The National Osteoporosis Society and Age UK have established a new Falls and Fractures Alliance in England. By working together, members of the Alliance are better placed to achieve the common goals of preventing falls and fractures and, specifically, reducing the rate of hospital admissions for hip fractures and for falls-related injuries among older people.”

Along with BANT, CSP, SoR, BGS, RPharmS, RCP, RCN, SfE, NCF, COT, SCIE, BSR, ARUK, CoO, BOA and the NHFD, ProFaNE.co have committed to action plans for reducing the rate of hospital admissions for hip fractures and for falls-related injuries among older people between now and 2017. All of these action plans work towards supporting, promoting and realising The Falls and Fractures Declaration.

ProFaNE.co will continue to develop our community and the website and work towards creating a one-stop-shop for Falls Prevention information in support of falls prevention professionals.

To give you some idea of what we aim to achieve, over the next 5 years, sooner if we possibly can, ProFaNE.co will continue to create content covering all aspects of Falls Prevention. As part of our considerations we have produced a Map of Falls and Fracture Prevention to help guide us through this process and made this available publicly as a free download.

ProFaNE.co is a community, we are funded entirely by your subscriptions, we would not exist if you were not here, you are the most important aspect of everything we do and we are all here to help each other where possible. This means that every member can get involved and we would love to hear from you if:

• you have any resources that you think would be helpful to the community
• you would like to write an article (or two) for ProFaNE.co in your area of expertise
• you know of a event not listed
• you would like to report on your current project
• you have a question to ask the community
• you have any other ideas on how we can work together

You can read the complete ProFaNE.co Action Plan here.

Here’s what to do next…

1) Contribute: Think about how you can contribute and get in touch and let us know.

2) Disseminate: Send this link to others who you know will be interested.

or simply…

3) Let us know what you think in the comments section below…

Last updated: 18th February 2013

One of the most challenging aspects of working in Falls Prevention is its complexity, it is a truly multi-disciplinary subject area. To help give a quick overview of the major areas of interest ProFaNE.co are proud to present the Map of Falls and Fracture Prevention as a completely free, fully-interactive .pdf download. We truly hope this will be helpful for you, read on for more info.

To download the map ‘Right-click, save linked file as…’ on the image.

Notes:

The ProFaNE.co Map of Falls and Fracture Prevention is not finalised, complete or static. Changes can be made easily where required and we hope over time that it will become a definitive reference.

If you see a ‘red dot’ next to a node this means there is a dedicated section on profane.co on that topic – simply click the link on that node in the .pdf to access that section on the website.

We welcome comments, additions, corrections and of course, if you are an expert in any area we would be very interested to hear from you if you would like to create some relevant content. This helps us, it helps the community and of course, it helps you as part of your professional development, please do get in touch.

All the document links currently run a search for that term on the ProFaNE.co website, as we create specific pages for each subject we will update the .pdf accordingly.

All versions of the map are date stamped, i.e. they will have the month and year of publication in the document file name. You can always check back here to see if you have the latest version (currently February 2013) or of course, if you are a member we will make an announcement in the newsletter so you will always be up to date.

You are free to use the map in any way you choose so long as you provide a credit and link back to the profane.co website.

Here’s what to do next…

1) Contribute: If you see some way to improve the Map of Falls and Fracture Prevention get in touch and let us know.

2) Disseminate: Send this link to others who you know will be interested.

or simply…

3) Let us know what you think in the comments section below…

Age UK recently hosted a live webinar on Preventing falls among people living with dementia. The event attracted over 500 participants on the day, and is now available to view on demand online. You will also be able to download the presentations from the same page.

The webinar included presentations on

• Identifying risk factors for falls among people with dementia, Dr Louise Allan, Newcastle University
• Designing environments around the needs of those with dementia, Professor June Andrews, Dementia Services Development Centre University of Stirling
• Delivering falls prevention exercise for those living with dementia, Dr Helen Hawley- Hague, University of Manchester

This webinar forms part of a series of webinars which have previously been held as part of Falls Awareness Week. It offers professionals a chance to find out more about the latest research and good practice in falls prevention and is aimed at anyone working with older people with dementia. Please feel free to share this with any colleagues who you think may benefit from this webinar.

To view this webinar or any of the previous webinars on falls, please visit www.ageuk.org.uk/fallswebinar.

We have had a request about information about flooring and reducing injuries.

“I work for a foundation in Sweden that has the goal to solve significant problems in healthcare. Fall injuries seems to be a huge problem that grows with an ageing population. I would like to check with you if you know of any special floor that can be installed at geriatric centers, at home and/or in the hospital to actually reduce the injuries caused by a fall. Are there any such products available on the market? Are you recommending special flooring to reduce fall injuries? Are there any studies done on how one floor can reduce fall injuries compared to another? Results? Thanks for all the help I can get! Regards, Martin”

Professor Dawn Skelton reports. This is still an under-researched area, though more and more companies are marketing their flooring as ‘preventing injuries’. The CDC back in 2008 listed force reducing flooring as a gap in knowledge that Industry could address.

Back in 2004, Simpson et al. published a paper “Does the type of flooring affect the risk of hip fracture?” in Age and Ageing. This paper looked at impact, hip fracture and floor coverings. Their conclusions were that wooden carpeted floors were associated with the lowest number of hip fractures (compared to other forms of flooring).

However, there is a very recent paper by Glinka et al. looking at the injury protection and also the potential for increased risk of falls (with greater balance difficulties with thick deflective floors). This is definitely worth a read. They concluded that their results suggest that the safety floors they tested effectively addressed two competing demands required to reduce fall-related injury risk; namely the ability to absorb substantial impact energy without increasing footfall deflections – suggesting that safety floors are a promising intervention for reducing fall-related injury risk in older adults.

In 2011, a trial protocol for assessing the sustainability of the flooring in ward environments, estimating the cost-effectiveness of the floor and assessing how the floor affects patients and other users was published by Drahota. This trial is using a 8.3 mm thick vinyl floor covering with polyvinyl chloride foam backing (Tarkett Omnisports EXCEL). We await the results.

Another 2011 paper by Wright et al. considered the influence of novel compliant floors on balance control in older women. This study illustrates that the SmartCell and SofTile novel compliant floors have minimal influences on balance and balance control responses following externally induced perturbations in older community-dwelling women, and supports pilot installations of these floors to inform decisions regarding the development of clinical trials.

Laing et al. in 2009 also observed differences in the mean attenuation in peak femoral neck force provided by the SmartCell (24.5%), SofTile (47.2%), Firm Foam (76.6%), and Soft Foam (52.4%) floors. As impact velocity increased from 2 to 4m/s, force attenuation increased for SmartCell (from 17.3% to 33.7%) and SofTile (from 44.9% to 51.2%), but decreased for the Firm Foam (from 87.0% to 64.5%) and Soft Foam (from 66.1% to 37.9%) conditions. Regarding balance, there were no significant differences between the rigid, SmartCell, and SofTile floors in proportion of successful trials, Get Up and Go time, balance confidence or utility ratings. SofTile, Firm Foam, and Soft Foam caused significant increases (when compared to the rigid floor) in postural sway in the anterior-posterior and medial-lateral directions during standing. However, SmartCell increased sway only in the anterior-posterior direction. This study demonstrates that two commercially available compliant floors can attenuate femoral impact force by up to 50% while having only limited influence on balance in older women, and supports development of clinical trials to test their effectiveness in high-risk settings.

Indeed, the potential for increased falls risk using bedside falls mats was highlighted in a 2012 paper by Doig. In this study, the bevel-edged, bedside floor mat was a potential hazard for ambulatory patients, especially those with impaired gaits, using walkers and pushing mobile intravenous stands.

Some emerging research at the University of Manchester offers the potential for flooring to also let you know if someone has fallen.

One other possible issue to consider is the infection control or cleaning ability of these new floorings. For example, a paper by Kim has considered the friction on floor surfaces and what happens to their slip resistance when they are wet.

Here’s what to do next…

1) Contribute: Does anyone have experience of having any of these or similar flooring in their settings that they would like to share with Martin and other readers? Do you know of any other useful resources? Let us know in the comments below.

2) Disseminate: Send this link to others who you know will be interested.

or simply…

3) Let us know what you think in the comments section below…

• iconFES is a new app for the iPad that assesses fear of falling in older adults.
• iconFES records accurate data essential for assessing fall risk and creating fall prevention strategies, and trials also indicate that people find the app both simple and fun.

Fear of falling in older adults

Fear of falling often leads to a reduction in activity levels and community participation. Fear of falling may reflect a realistic appraisal of reduced functional abilities. However, fear of falling has also been associated with needless restriction in physical and social activities. This can have a substantial impact on a person’s quality of life.

Understanding a person’s fear of falling is necessary to properly determine their risk of falling as the two are reportedly linked. Our research has shown that fear of falling itself can increase the risk of falls independent of physiological fall risk, and is strongly associated with neurotic personality traits and depressive symptoms.

The Iconographical Falls Efficacy Scale (iconFES)

The Iconographical Falls Efficacy Scale (iconFES) is the first scale using pictures and including physically challenging activities. The use of pictures allows us to provide more detailed contextual elements to participants. For example, a person is very concerned about taking a bath but less concerned if there is a steady handrail to hold on to. A person’s level of concern about falls during a daily activity will most likely be influenced by the extent to which such environmental factors differ. The addition of pictures along with verbal phrases helps ensure all participants are envisaging the same situation when they answer the question in relation to their fear of falling.

iconFES has been used successfully in people with dementia. The iconFES is the first measure of fear of falling which compensates for reduced abstract abilities by using pictures to match the verbal descriptions. The iconFES response categories are presented as facial expressions as line drawings, which can facilitate completion of the scale and has been used successfully in people with dementia to assess mood.

Research translation into mobile apps

The transformation of our work into an app for the Apple iPad allows us to disseminate our knowledge and tools to more people across the world than previously possible. In order for health care to move forward, it is crucial to provide health professionals with up-to-date knowledge and resources to assist them in their clinical work. The app is designed for use by clinicians and doctors primarily and allow for quick and reliable assessment in clinical practice.

iconFES gives clinicians the opportunity to assess fear of falling more regularly in their older patients and for the results to be interpreted and shared with patients immediately. Furthermore, iconFES has promise as a treatment utility tool to identify activities that need guided exposure as part of a cognitive behavioural therapy program. In order to appropriately target older adults in falls prevention strategies, it is crucial to know a person’s level of fear of falling in different circumstances relative to their fall risk.

From a research point-of-view, advantages of using our apps assures highly reliable data as the data is entered just once (by the subject) and is saved verbatim for later analyses.

Older adults – regardless of whether they are tech-savvy or not – have been enjoying ‘having a go’ with the iPad. The large, vibrant screen makes the pictures more visible and the questions easier (and fun) to answer.

iconFES App specifications

Within the app, each user is able to individualise the settings. The settings for each app are accessible through the iPad settings.

• Low price
• Short (10 questions) and long (30 questions) form versions
• Easy to see high contrast images
• Available in a wide range of languages (a list we will keep updating through upgrades)
• Available for different living circumstances – people living in a house, in an apartment, in highly populated cities
• Immediate updates as research results become available, e.g. provision of normative values
• Results can be sent via email and synced with a computer via iTunes

Here’s what to do next:

1) Find out more:For further information you can find out more about the iconFES app development or more about NeuRA apps.

2) Contribute: Let us know what you think in the comments below. Have you used the iconFES in your work? Share your experiences with the profane community.

3) Share: If you know of someone who would find this article useful, please forward them a link.

4) Buy: Have an iPad and want to try for yourself? It’s only £2.99/$4.99

About the Author

Kim Delbaere is a Research Fellow and Group Leader at Neuroscience Research Australia (www.neura.edu.au). Kim Delbaere is an emerging leading international researcher in the area of falls and fear of falling in older people. Her research has enhanced the understanding interrelationships between falls and various physiological, psychological and cognitive factors. Her future work focuses on finding a feasible solution to deliver self-management programs for falls prevention. The overall aim of her research group at NeuRA is to find a feasible solution which supports independent ageing, ideally in a home environment.

To eliminate any confusion over what should happen on the ward, Professor Dawn Skelton reports on a recent review by Georgie Garrick, and comparison of the literature on early mobilisation and later rehabilitation following hip fracture. The literature that looks at the provision of falls prevention interventions and advice to people post hip fracture is also considered. Read on to make sure you are fully informed and look out for a special profane.co members discount on the upcoming HCC event – Meeting the NICE Quality Standard for Hip Fracture.

Why early mobilization?

Early mobilisation (i.e. getting out of bed) is effective in lowering the risk of post-operative complications and should be take place within 24 hours of hip fracture surgery (SIGN, 2009; BOA, 2007). This is normally performed by the physiotherapists in the acute care orthopaedic wards (Thomas et al, 2011) and should encourage standing on the operated leg: this active acute intervention allows a higher proportion of patients to return directly home with a shorter hospital stay. Once an individual has been identified as having a rehabilitation need, and is waiting to be transferred to the rehabilitation unit, physiotherapy interventions need to continue within the acute care wards, especially in the early post-operative days; this will prevent patients becoming demoralised and deconditioned (BOA, 2007).

Oldmeadow et al (2006) found that early mobilisation also improves functional recovery in community dwelling individuals following a hip fracture. 60 patients in an Australian university teaching hospital were randomly allocated to either an early [post-operative day one or two] or delayed [post-operative day three or four] ambulation group. Routine physiotherapy was delivered once per day; this consisted of walking re-education and bed exercises as per the study protocol. Only 2 physiotherapists provided the treatment. The participant’s functional ability was determined by distance walked, bed mobility, and negotiation of a step seven day post-surgery. Those in the early ambulation group had a significantly better functional recovery than those in the delayed ambulation group: they were able to walk twice as far and required less assistance to do so; and they had a shorter length of stay. This study supports recommendations from SIGN (2009) and the BOA (2007). These results may have been somewhat different had both groups been given the same number of days of mobilising opportunities; as it was, the early ambulation group had more opportunities to re-educate their walking.

Penrod et al (2004) examined the relationship between the amount of physiotherapy patients received post hip fracture and functional ability at 2 and 6 months after discharge. They did not exclude those with a cognitive impairment and 443 participants were included in the trial. Data was collected on the number of days in which the patient received physiotherapy from day of surgery to post-operative day [POD] three, and the number of physiotherapy and occupational therapy sessions the patient received, and for how long, from POD four until eight weeks after admission; some this was self-reported data as they had already been discharged home. A mobility outcome measure was used; the ability to walk 150 feet and climb up and down stairs. Results showed that more physiotherapy in the first days after surgery was associated with a significantly better walking ability at 2 months; but was no longer significant at 6 months.

What about later rehabilitation?

In Denmark, Laurisden et al (2002) randomised 88 participants, all less than three weeks post-surgery and identified as having rehabilitation needs. Participants were evenly randomised to the intervention group of intensive training for 2 hours/3 days a week or the control group of standardised daily (Monday-Friday) physiotherapy lasting 15 to 30 minutes. Each group received identical training programmes comprising; bench exercises, gait, balance, co-ordination, stair climbing and for some participants, hydrotherapy. Unfortunately, no further information is shared regarding the repetitions, intensity, type or timing of the exercises. The interventions continued until five specific functional objectives had been achieved and the time taken to do so was measured. There was no sub-analysis or consideration of premorbid functional abilities and half of the intervention group dropped out, mainly due to orthopaedic complications or participants lack of desire to perform to such an intense level. Nearly a third of the control group also dropped out for the same reasons. There was no significant difference found between the two groups in relation to the length of the training period; it tended to be shorter in the intervention group, but the intervention group had a significantly shorter length of stay. Those who completed the trial across both groups had more chance of using walking sticks at discharge.

Whilst it is an attractive feature for both the individuals and care providers, intensive physiotherapy did not seem to reduce the duration of rehabilitation for the majority of the sample. In real terms, this intervention may be difficult to carry out as it may not be possible to work with individuals away from the ward setting for two full hours. However the three times a week intervention may be attractive at times where staffing is particularly short. This study did not include the fitter or the frailer hip fracture individuals who did not fit the criteria of needing rehabilitation so the results can only be generalised to the study population.

Australian researchers, Moseley et al (2009) also investigated increased intensity of exercise in those with a fractured hip in an attempt to develop a best practice programme; they recruited 160 individuals with rehabilitation needs at around two weeks post-surgery. Those with a cognitive impairment were included if a carer was available to supervise the exercise programme. The intervention group was given higher dose weight-bearing exercises twice daily for a total of 60 minutes per day for 16 weeks, and the control group was given lower dose limited weight-bearing exercises for a total of 30 minutes per day for four weeks. Individuals discharged home within the study duration carried on with the intervention at home. The exercises for both groups were briefly described. Outcomes were assessed at baseline, four weeks and 16 weeks by blinded assessors. Primary outcomes were knee extension strength and walking speed, with secondary outcomes relating to function, balance, fear of falling and quality of life amongst others. Both groups experienced substantial recovery during the study period and no harm was caused by the higher dose intervention. However, there were no significant differences between groups for primary outcomes at either 4 or 16 weeks. This may have been due to insufficient differences between the interventions and their short duration, or the outcome measures were not sensitive enough to the functional changes observed. The intervention group did have significantly faster sit to stand times, and managed more steps on the step testing, at 4 and 16 weeks. Interestingly, in this study, a third of participants with a cognitive impairment had a statistical and clinically relevant improvement in functioning when given the high dose intervention.

Weight-bearing exercises were also explored by Sherrington et al (2003). Participants were recruited who were within three weeks of having hip fracture surgery in an Australian hospital. Those with a cognitive impairment, or medical condition limiting their ability to exercise and those with a restriction on their weight-bearing status were excluded. 80 participants were randomised into one of two groups; the weight-bearing exercise (WBE) group which carried out exercises in standing, and the control group who performed all exercises in a non-weight-bearing (NWBE) position. Whilst the all exercises are described, there is little indication of the intensity at which they were performed. The treating physiotherapist individualised the exercise programme for each participant and progressed these as per the individual’s capabilities; extra exercises were also added in later if deemed appropriate. The intervention started in the in-patient setting and continued at home if the participant had been discharged before the end of the study. A physical assessment of strength, balance, gait and functional ability was carried out at baseline and on study completion two weeks later. The assessors were not blinded to group allocation. Results showed both groups perceived similar levels of difficulty performing the exercises and the drop-out rate was only 4%. The WBE group self-reported significantly better balance and better general health. However, this improvement was not reflected in the physical assessment, as no significant differences were found in strength, balance, gait or functional performance, or in length of stay. More in the WBE group needed a less supportive walking aid and improved in the lateral step up test, whilst more in the NWBE group improved on two of the non-weight-bearing isometric strength tests – showing support for specificity of training. The lack of between group differences may have been due to the fact that this study was performed very soon after the operation and participants generally needed support to carry out the exercises in standing to minimise weight-bearing pain; thus reducing the extent to which their balance was challenged. Overall, all participants showed an improvement in the order of 50% of initial values, indicating that the exercises in both groups are appropriate physiotherapy post hip fracture.

What about providing falls prevention interventions of advice to hip fracture patients?

Stenvall et al (2007) considered the effectiveness of a multifactorial falls prevention intervention and hypothesised that this approach could reduce inpatient falls and fall-related injuries in older adults with a femoral neck fracture. In a Swedish hospital, over a 30 month period, they identified 353 older adults initially eligible for participation in their study; a total of 154 were excluded for the following reasons: severe rheumatoid or osteoarthritis, pathological fracture, differing hip surgery method, severe renal failure, bedbound prior to sustaining the fracture, individual refusing to participate, not invited to take part as they had sustained their fracture whilst being an inpatient, and failure of inclusion routines. The remaining 199 individuals all consented to participate and were randomised to one of two post-operative care settings. The intervention group recovered in a geriatric unit specialising in orthopaedics: teams of staff delivered specific assessments, management and rehabilitation; they actively prevented, detected and treated postoperative complications and had all attended a four day educational course prior to the study starting. The teams sought to understand the root cause of the fall and worked together to plan the individuals care. For the 24 bedded unit they had at least a 1:1 staff: patient ratio and 2 full-time physiotherapists and occupational therapists, plus a part-time dietician working within the team. Each individual’s rehabilitation focussed on functional retraining with emphasis on falls risk factors and they all received a home visit by the occupational therapist. The control group recovered in a specialised orthopaedic ward following conventional postoperative routines with transfer to a geriatric rehabilitation ward for those requiring longer rehabilitation: individual care planning was used. There was no staff training, no attempt to understand the root cause of the fall and minimal teamwork. Assessments for postoperative complications were made, but not as systematically as for the intervention group. The nursing and physiotherapy staffing were equitable in this group, but there was less occupational therapy staff and no dietician. Rehabilitation focussed on mobilising with the physiotherapy and care staff, and lucid patients were given greater priority. The occupational therapy input consisted of a consultation only: no home visits were made. Less emphasis was focussed on falls risk factors. Neither group of staff were aware of the study, and the post study assessing geriatrician was blinded to group allocation. Various medical, social and functional data were gathered. Outcome measures included the number of falls and time to first fall: post-operative cognitive status, and length of stay. Results showed a lower number of falls; lower falls rate incidence and lower falls risk in the intervention group, alongside a shorter length of stay. A higher number of individuals with dementia fell in the control group. Those who fell sustaining a serious injury came only from the control group. Around a third of all falls happened on a day when the individual was delirious. The authors concluded that their multidisciplinary multifactorial approach to falls prevention was successful. This study reinforces the fact that despite having a very rich staff: patient ratio, the occurrence and risk of falls still exists, but given that individuals are needing to take an element of risk when living in a rehabilitation unit in order to improve and gain independence, then it is not unexpected. The study placed much emphasis on the team work and individual care planning that took place for the intervention group, however this was also similarly provided for the individuals on the geriatric control group ward where half their falls took place, therefore this alone cannot be considered responsible for the more successful outcome of the intervention group. Instead it may be related to the rehabilitation elements delivered: there was a huge disparity between the two groups. Identifying the nature of the injurious fall and the individual’s falls-risk factors, and subsequently targeting of those which are modifiable with a tailored intervention, and an environment where there was rehabilitation available five days a week, delivering a functional retraining programme and focussing on falls-risk factors, that falls were lower in the intervention group. This is a stark contrast to the rehabilitation element delivered to the control group especially during their stay on the orthopaedic ward.

The role of a post-discharge home visit by an occupational therapist, in reducing the risk of falling in a sample of post hip fracture women, during their inpatient stay in an Italian rehabilitation hospital was assessed by Di Monaco et al (2008). 270 women were identified throughout the study period of 26 months; 141 of these were excluded as they did not meet the inclusion criteria of: community dwelling, planning to return home on discharge, fall induced hip fracture and above a specified score on cognitive testing. Ten individuals refused to take part; leaving 119 for randomisation. 16 participants lost eligibility after randomisation as they were unable to return home, and a further eight were lost to follow up. Therefore 45 participants received the intervention, and 50 received the control. As part of the usual rehabilitation routine, all participants received the standardised multidisciplinary team intervention to prevent falls: this consisted of between one and three hours a day, five days a week, exercises to improve strength and balance, advice and training on use of assistive devices, and training in activities of daily living. This was delivered by physiotherapists and occupational therapists. Everyone had at least three hours devoted to the assessment of home hazards against a standardised checklist by a skilled occupational therapist: this looked into their home environment and their behaviour during activities of daily living. From here, targeted modifications to the home and to behaviours were suggested to the individuals in order to prevent falls. A falls prevention brochure was also given. Medications were reviewed by a geriatrician, and alterations to these were made accordingly. All women were supplemented with oral calcium and vitamin D. All participants were instructed to record the number of falls occurring after discharge in order to report back to the occupational therapist when she visited them at home approximately six months post discharge. Specific to the intervention group, at a median of 20 days following discharge, an occupational therapist performed a home visit. This allowed for assessment of environmental hazards, behaviours during activities of daily living and use of assistive devices; it was followed by suggestion of targeted modifications to minimise falls. Adherence to the advice given to all participants when they were an in-patient was measured, as well as to the advice given to the intervention group at their first home visit. Analysis of results showed more falls in the control group than the intervention group. This did not prove significant until adjustments were made for observation length, functional ability, and body height, giving a significantly lower proportion of fallers in the intervention group. In relation to adherence to advice, the intervention group also had a lower overall risk (8.8%) of having a fall compared to the control group (26%).

The authors acknowledge that their falls risk calculation is much lower than that of other occupational therapy home visit studies: this could be due to the specificity of the hip fracture population sample – having already endured a hip fracture, they and their families may be more acutely aware of the need to prevent further falls for fear of sustaining another serious injury. Also, this study only included those who were highly functioning cognitively, hence the expectation of them to accept advice and adhere to it. The same group, in 2012, considered the adherence to the interventions and number of falls recorded 6 months after the intervention. Unsurprisingly they found that uncorrected environmental and behavioural risk factors and poor adherence to targeted recommendations for fall prevention significantly predicted the risk of falling in community-dwelling women who sustained a fall-related hip fracture.

The results of both studies are lacking in their ability to be generalised to the overall hip fracture population: this is proved by the number of actual participants compared against the total number of individuals presenting with a hip fracture. Strict inclusion criteria reduced participant numbers to 58% for Stenvall et al (2007) and to 44% for Di Monaco et al (2008). Whilst Stenvall et al’s (2007) inclusion criteria appear more restrictive in nature regarding existing co-morbidities, they did not exclude cognitive impairment – providing a more typical study sample than Di Monaco et al (2008) who did, and since the Italian study was set in a rehabilitation unit, it may have missed out on the fitter individuals who were not requiring rehabilitation and were able to go home direct from the acute orthopaedic setting. Both studies also had small sample sizes.

Related Event

For those of you in the UK interested in hip fracture and the National Institute of Clinical Excellence standards, there is a conference in October that you may be interested in:

Meeting the NICE Quality Standard for Hip Fracture

Wednesday 10th October 2012, London

This conference, chaired by Dr Colin Currie, Clinical Lead (Geriatrics) The National Hip Fracture Database, focuses on meeting the new national Quality Standard for Hip Fracture in your service and organisation. Implementing the NICE Quality Standard in practice: what needs to change and how can we monitor implementation at a clinical practice, ward, directorate and organizational level The panel will give short presentations and then discuss how they plan to implement the new NICE quality standard for Hip Fracture in their practice and organization.

For more information and details of a special profane.co members discount view the ‘Meeting the NICE Quality Standard for Hip Fracture’ event details page.

Thank You!

A huge thanks to Georgie Garrick, who provided a very recent literature review and great insight into early rehabilitation as part of her recently successful Masters in Rehabilitation (Falls Prevention). Congratulations Georgie for becoming the first person in the UK with a Falls Prevention Masters!

Here’s what to do next…

1) Contribute: Do you have other examples of post-operative rehabilitation care that you want to share with us? Or are you a researcher with an ongoing study or work you want to let the falls community know about? Let us know in the comments below

2) Disseminate: Send this link to others who you know will be interested.

or simply…

3) Let us know what you think in the comments section below…