Translating Falls Prevention Knowledge to Adults With Dementia
Purpose of the Study: Falls prevention evidence is strong, but little is known about uptake of strategies for people living with dementia (PLWD). This mixed-method systematic review aimed to integrate evidence of falls prevention efficacy with views/experiences of PLWD.
Design and Methods: Eight electronic databases were searched. Inclusion criteria included quantitative or qualitative studies examining knowledge translation of falls prevention strategies in community-dwelling PLWD and/or their caregiver. Study quality was assessed, and findings are narratively described.
Results: Six quantitative and five qualitative studies were included. Study quality was mixed. Quantitative studies showed limited evidence of effectiveness on reduction in falls risk, falls and hospitalization rates, nursing home admission, decline in activities of daily living, and adherence to strategies. Qualitative themes showed inclusion of caregiver and health professionals as key to program success, but many factors influence participation.
Implications: Synthesizing the findings generated a new understanding of falls prevention for this high-risk group. A focus upon health professional and caregiver involvement and accommodation of individual preferences may result in increased engagement with falls prevention strategies.
In recent years, falls prevention among community-dwelling older people has been the focus of much research. Despite this increased focus, the rate and impact of falls in community-dwelling older Australians remains relatively unchanged (AIHW, 2012b; Gillespie et al., 2012). Individually, 30%–40% of older people fall in a 12-month period (Moyer, 2012), approximately 5%–10% resulting in serious injury, such as fracture or head injury (Rubenstein, Josephson, Rubenstein, & Josephson, 2006). At a system level, nearly three in four injury-related hospitalizations for older Australians result from falls, with approximately 20% of these resulting in direct admission to residential care (Bradley, 2012).
Strong evidence, gathered over 20 years, supports the efficacy of falls prevention for community-dwelling older people (AIHW, 2012b; Gillespie et al., 2012). A recent Cochrane review concluded several single and multifactorial falls prevention strategies effective in reducing falls, including exercises for strength/balance and cataract surgery (Gillespie et al., 2012). However, the evidence for education-based interventions, a hallmark of falls prevention programs, remains weak (Gillespie et al., 2012). Similarly, evidence from an overview of medicine use found passive forms of education and information provision, such as provision of information brochures in isolation, rarely had a major effect (Ryan et al., 2011).
Dementia is an umbrella term for over 100 different diseases impacting brain function (AIHW, 2012a). Dementia is recognized as a risk for falls (Allan et al., 2009), with people living with dementia (PLWD) experiencing a greater rate of falls than cognitively intact older adults (prevalence reported between 47% and 90%; Allan et al., 2009; Shaw, 2007). Cognitively intact older adults and PLWD share some falls risk factors (environmental hazards; previous falls), whereas others (decreased executive functioning; visuo-spatial difficulties) are more specific to PLWD (Whitney, Close, Jackson, & Lord, 2012). A strong link has been established between psychotropic medication use and increased risk of falls (Hill & Wee, 2012; Woolcott et al., 2009), including drugs commonly used to manage behavioral and psychological symptoms of dementia. Research is also underway, linking changes in brain executive functioning (e.g., planning and attention) to postural instability (Muir, Gopaul, & Montero Odasso, 2012). The impact of dementia on participation in falls prevention programs and adoption of strategies is less well understood. Escalating numbers of PLWD within Australia, with a higher falls rate than the wider community (AIHW, 2012a), drive a growing need for health professionals to understand participation of PLWD with falls prevention strategies.
Falls prevention programs are designed to utilize effective preventive strategies, often involve multidisciplinary health-care teams trained in evidence-based strategies, and include education to build risk awareness (World Health Organisation, 2012). Although an unfamiliar concept for many older adults (Managing Innovation Marketing Consultancy Network, 2000), falls prevention can be particularly challenging for PLWD and their caregivers. Possibly, this is related to limitations of executive function making it more difficult to adapt knowledge to life context, or alternatively, perhaps, falls prevention programs are not designed for the specific needs of PLWD. PLWD have voiced their desire to remain involved in decision making and be included in their care (Beuscher & Grando, 2009). They also have the ability to learn and retain new information when appropriately presented (Small, 2012). Falls prevention programs commonly embed sharing of knowledge and encompass informed and active communication and participation although often not explicitly.
Enhancing engagement of PLWD may involve the informal caregiver. Caregivers, persons providing assistance to the PLWD for everyday activities (AIHW, 2012a), often act as gatekeepers for use of health services and implementing falls prevention strategies (Horton & Arber, 2004). Anxiety, fear of falling for the care recipient, and personal experience/attitudes may impact a caregiver's ability to implement falls prevention strategies for the care recipient (Buri & Dawson, 2000; Dow, Meyer, Moore, & Hill, in press; Horton & Arber, 2004).
Knowledge translation (KT) is required to narrow the research-to-practice gap (Ward, Smith, Foy, House, & Hamer, 2010). KT is defined as "a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve health" (Canadian Institutes of Health Research, 2012). Two taxonomies developed by the Cochrane Consumers and Communication Review Group (Hill, 2011), adapted and used throughout this review (Table 1), provide a useful and more specific KT framework to understand the complexity of falls prevention interventions and outcomes and particularly to disentangle the way in which KT may happen at the individual level. The interventions taxonomy emphasizes purposeful interventions for "communication and participation," strategies that "inform, educate, communicate with, support, skill, change behavior, engage and seek participation within individual or collective contexts" (Hill, Lowe, & Ryan, 2011). The outcomes relate to this range of purposes.
Strong evidence exists for falls prevention for community-dwelling older people, but there is limited evidence for effective approaches for PLWD (Gillespie et al., 2012). Indeed, most studies in the recent Cochrane fall prevention (community setting) review excluded this population group (Gillespie et al., 2012). This systematic review aims to critically evaluate and synthesize the literature concerning KT strategies for falls prevention for PLWD and/or their caregivers. This mixed-method review, chosen to provide a rich and practical understanding (Pluye, Gagnon, Griffiths, & Johnson-Lafleur, 2009), draws on evidence of effect of interventions and views/experiences of participants in relation to falls prevention programs. The review has two objectives:
Abstract and Introduction
Abstract
Purpose of the Study: Falls prevention evidence is strong, but little is known about uptake of strategies for people living with dementia (PLWD). This mixed-method systematic review aimed to integrate evidence of falls prevention efficacy with views/experiences of PLWD.
Design and Methods: Eight electronic databases were searched. Inclusion criteria included quantitative or qualitative studies examining knowledge translation of falls prevention strategies in community-dwelling PLWD and/or their caregiver. Study quality was assessed, and findings are narratively described.
Results: Six quantitative and five qualitative studies were included. Study quality was mixed. Quantitative studies showed limited evidence of effectiveness on reduction in falls risk, falls and hospitalization rates, nursing home admission, decline in activities of daily living, and adherence to strategies. Qualitative themes showed inclusion of caregiver and health professionals as key to program success, but many factors influence participation.
Implications: Synthesizing the findings generated a new understanding of falls prevention for this high-risk group. A focus upon health professional and caregiver involvement and accommodation of individual preferences may result in increased engagement with falls prevention strategies.
Introduction
In recent years, falls prevention among community-dwelling older people has been the focus of much research. Despite this increased focus, the rate and impact of falls in community-dwelling older Australians remains relatively unchanged (AIHW, 2012b; Gillespie et al., 2012). Individually, 30%–40% of older people fall in a 12-month period (Moyer, 2012), approximately 5%–10% resulting in serious injury, such as fracture or head injury (Rubenstein, Josephson, Rubenstein, & Josephson, 2006). At a system level, nearly three in four injury-related hospitalizations for older Australians result from falls, with approximately 20% of these resulting in direct admission to residential care (Bradley, 2012).
Strong evidence, gathered over 20 years, supports the efficacy of falls prevention for community-dwelling older people (AIHW, 2012b; Gillespie et al., 2012). A recent Cochrane review concluded several single and multifactorial falls prevention strategies effective in reducing falls, including exercises for strength/balance and cataract surgery (Gillespie et al., 2012). However, the evidence for education-based interventions, a hallmark of falls prevention programs, remains weak (Gillespie et al., 2012). Similarly, evidence from an overview of medicine use found passive forms of education and information provision, such as provision of information brochures in isolation, rarely had a major effect (Ryan et al., 2011).
Dementia is an umbrella term for over 100 different diseases impacting brain function (AIHW, 2012a). Dementia is recognized as a risk for falls (Allan et al., 2009), with people living with dementia (PLWD) experiencing a greater rate of falls than cognitively intact older adults (prevalence reported between 47% and 90%; Allan et al., 2009; Shaw, 2007). Cognitively intact older adults and PLWD share some falls risk factors (environmental hazards; previous falls), whereas others (decreased executive functioning; visuo-spatial difficulties) are more specific to PLWD (Whitney, Close, Jackson, & Lord, 2012). A strong link has been established between psychotropic medication use and increased risk of falls (Hill & Wee, 2012; Woolcott et al., 2009), including drugs commonly used to manage behavioral and psychological symptoms of dementia. Research is also underway, linking changes in brain executive functioning (e.g., planning and attention) to postural instability (Muir, Gopaul, & Montero Odasso, 2012). The impact of dementia on participation in falls prevention programs and adoption of strategies is less well understood. Escalating numbers of PLWD within Australia, with a higher falls rate than the wider community (AIHW, 2012a), drive a growing need for health professionals to understand participation of PLWD with falls prevention strategies.
Falls prevention programs are designed to utilize effective preventive strategies, often involve multidisciplinary health-care teams trained in evidence-based strategies, and include education to build risk awareness (World Health Organisation, 2012). Although an unfamiliar concept for many older adults (Managing Innovation Marketing Consultancy Network, 2000), falls prevention can be particularly challenging for PLWD and their caregivers. Possibly, this is related to limitations of executive function making it more difficult to adapt knowledge to life context, or alternatively, perhaps, falls prevention programs are not designed for the specific needs of PLWD. PLWD have voiced their desire to remain involved in decision making and be included in their care (Beuscher & Grando, 2009). They also have the ability to learn and retain new information when appropriately presented (Small, 2012). Falls prevention programs commonly embed sharing of knowledge and encompass informed and active communication and participation although often not explicitly.
Enhancing engagement of PLWD may involve the informal caregiver. Caregivers, persons providing assistance to the PLWD for everyday activities (AIHW, 2012a), often act as gatekeepers for use of health services and implementing falls prevention strategies (Horton & Arber, 2004). Anxiety, fear of falling for the care recipient, and personal experience/attitudes may impact a caregiver's ability to implement falls prevention strategies for the care recipient (Buri & Dawson, 2000; Dow, Meyer, Moore, & Hill, in press; Horton & Arber, 2004).
Knowledge translation (KT) is required to narrow the research-to-practice gap (Ward, Smith, Foy, House, & Hamer, 2010). KT is defined as "a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve health" (Canadian Institutes of Health Research, 2012). Two taxonomies developed by the Cochrane Consumers and Communication Review Group (Hill, 2011), adapted and used throughout this review (Table 1), provide a useful and more specific KT framework to understand the complexity of falls prevention interventions and outcomes and particularly to disentangle the way in which KT may happen at the individual level. The interventions taxonomy emphasizes purposeful interventions for "communication and participation," strategies that "inform, educate, communicate with, support, skill, change behavior, engage and seek participation within individual or collective contexts" (Hill, Lowe, & Ryan, 2011). The outcomes relate to this range of purposes.
Strong evidence exists for falls prevention for community-dwelling older people, but there is limited evidence for effective approaches for PLWD (Gillespie et al., 2012). Indeed, most studies in the recent Cochrane fall prevention (community setting) review excluded this population group (Gillespie et al., 2012). This systematic review aims to critically evaluate and synthesize the literature concerning KT strategies for falls prevention for PLWD and/or their caregivers. This mixed-method review, chosen to provide a rich and practical understanding (Pluye, Gagnon, Griffiths, & Johnson-Lafleur, 2009), draws on evidence of effect of interventions and views/experiences of participants in relation to falls prevention programs. The review has two objectives:
To identify the effects of interventions for transferring knowledge to PLWD and their caregivers on outcomes related to falls and/or communication and participation in falls prevention strategies.
To synthesize research on the views/experiences of PLWD and their caregivers related to communication of, and participation in, falls prevention programs.
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