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The effectiveness of physiotherapy interventions in hospital to prevent falls in the elderly

Literature Review: An introduction to the proposed area of study

There findings of research, published in the literature has highlighted that falls in the elderly generation can be caused by a variety of factors or by a combination of factors, which include poor balance, side effects of medication, impaired vision, reduced physical mobility and environmental hazards. (Masud, 2001) Furthermore, it has been found that there are more than 20 risk factors linked to falls. The role of a physiotherapist is to help older adults prevent falls and also provide post-injury rehabilitation in the event of a fall. (Fransis, 2001)

Falling is an important and costly issue within healthcare and is costly on the NHS resources. Furthermore, falling is thought to be one of the leading causes of injury and the sixth leading cause of death for the elderly and a lot of the expenditure used for geriatric care is used in the treatment of fall-related injuries to senior citizens. Preventing falls in the elderly is thus of primary concern and it is essential that the mechanisms employed are effective. Furthermore, it is highly probable that the elderly within the hospital setting are more likely to be prone to taking a fall and suffering an injury due to the nature of the fact that they are in hospital for health-related problems. In the event that such an incidence arises, it is likely that the individual would be likely to have to remain in hospital for a longer period of time, hence increasing their usage of the hospital resources.

In Britain, it is thought that one in three older people in the community and one in two older people in institutions (including hospitals) fall every year. (Talbot et al, 2005) Out of these individuals, approximately 5-10% require some medical attention (Woolf and Akesson, 2004) as a result and hip fracture, and consequent repair is the most common injury and most costly intervention required in such cases.

According to the literature there are many physiotherapy interventions which are likely to prove to be beneficial in preventing falls in the elderly and many which may be effectively implemented within the hospital setting. Such interventions include a program of muscle strengthening and balance retraining. (Damush and Damush, 1999) This programme is thought to be best prescribed on an individual basis by a trained health professional.
 
Clinical trials have also shown that a multifactorial falls risk assessment and management program is the most effective component of a falls prevention program. The next most effective programme in fall prevention strategy was identified as being exercise. The literature also suggests that there is a strong evidence base regarding the use of balance exercises in fall prevention strategies, and that the implementation of a home physiotherapy program for women aged over 80 years old regardless of their risk factor status. (Gardner et al, 2000) This is because due to the natural impact of aging on an individuals health, and consequently, due to the aging process, it would be likely that a lot of these women would enter hospital at some point in their near future. Providing them with physiotherapy interventions at home may thus help minimize their risk of falling, both at home and upon admission to a hospital ward. A study conducted by Rezmovitz et al (2003) showed that an intervention programme designed to improve balance of elderly women was also beneficial in reducing the likelihood of the women experiencing falls. The study involved the implementation of a 12-week program, which was designed to improve lower-body function, was also able to improve the static balance and overall well being of women age 70-86. (Rezmovitz et al, 2003)This indicates that if the elderly who have been admitted to hospital were provided with such physiotherapy interventions, their chance of falling both in the hospital setting and when they return home would be greatly reduced.

Screening programmes for hospitalized elderly individuals who are deemed to be likely to experience a fall could also prove to be an effective means of reducing the number of falls occurring in elderly patients. The literature notes that there are many of factors, which are likely to increase an individual’s risk of falling. Such factors include mobility impairments, having suffered a stroke, and suffering from Parkinson’s disease or dizziness. (Coutinho et al, 2008)Hence, regardless of whether or not an older person has had a fall in the past, a physiotherapist should assess each individual upon admission to the hospital. Assessment of the individuals postural stability, muscular strength and risk of falling, would be highly beneficial as this would enable an offer of the appropriate physiotherapy treatment and exercise prescription to be made on an individual level for each patient. This would mean that the treatment provided for each individual was unique and was maximally suited for the individual in question and hence would be likely to reduce the individual’s risk of falling most effectively.

The literature is also rife with the importance and the impact of multidisciplinary and multi-professional teams working together. It is thought that when physiotherapists work with physicians and occupational therapists, physiotherapists can help reduce falls among older people in the most effective ways possible through the support which other team members can offer and this can aid in the prevention of the medical, emotional and economic consequences of experiencing a fall. It is also thought that offering physiotherapeutic interventions to individuals who have suffered from falls in the past during their rehabilitation programmes may have a positive impact upon fall reduction in the future. Hence, rehabilitation of elderly individuals who have previously suffered from falls may have an impact upon their future chances of suffering a fall, and therefore rehabilitation programmes should be investigated to see whether they are effective in their role in fall reduction.

Chapter 2: Aims of the research project

The main aims of the research project are to:

  • To conduct a literature review to highlight the different methods of physiotherapeutic intervention possible for preventing the number of falls within the hospital setting and to visit the opportunities that are available to improve these methods in current practice.
  • To review and analyze the current structure and methodologies employed for the reduction of falls of the elderly in the community and to see whether any of these strategies could be effectively implemented in a hospital based setting.
  • To evaluate the patient profile of candidates likely to experience a fall within the hospital setting and to investigate what physical intervention strategies/adaptations to their bed or other furniture in hospital which are in place to reduce their chances of falling.
  • To critically analyze the literature published regarding research trials, which have been conducted so that a true image of the most effective methods of fall reduction in the elderly can be successfully acquired.
  • To make recommendations as to how fall prevention strategies may be implemented effectively within the hospital setting through the use of physiotherapist’s skills and techniques to reduce the number of falls occurring within elderly in-patients.

Personal aims include:

  • Completion of the compulsory component for the award of a Masters degree in neurological physiotherapy
  • Preparation for employment.

Chapter 3: Objectives

The main objectives of the research project are to discover:

  • The impact of the different methodologies, which are commonly used by physiotherapists.
  • Identify common developments in physiotherapy and how the needs of different patients are met in a patient centered care model for fall reduction.
  • Overview the most common obstacles for successful fall reduction strategies.
  • Additionally, the research will provide the opportunity for the meeting of personal objectives:
  • To extend knowledge regarding physiotherapy interventions within the hospital setting, how a multi-disciplinary team can work together effectively to improve patient outcomes and to provide an insight into how the needs of different patients are met through physiotherapy interventions.
  • To gain skills in conducting a systematic literature review and learn how to critically assess the literature and statistical analysis published in research trials.

Chapter 4: Literature Review and Research methodology

The main body of the dissertation will be focused around the conduction of a literature review. This will be centered around articles published in books, peer-reviewed journals, in the media and on reliable internet sites, such as the British nursing index, Psycinfo, Ovid Medline, ASSIA, CINAHL, Cochrane database, to ensure that a wide range of sources are used and thus the most reliable and up to date knowledge is gained for the purposes of this study. Most of the literature and collected and used in this study will be accessed through the University Library using a selection of tertiary and secondary information sources such as the library catalogue, commercial and educational bibliographic databases and Internet search engines and directories.

Systematic reviews are important and a useful approach for healthcare staff to take in order to explore issues important to current practices. The process of undertaking the review in this study will therefore be presented with a focus on the first stage of identifying literature, and then this will draw upon the related challenges that the literature presents in the review, which draws on multiple bodies of work published by numerous authors. Furthermore, as the production of a systematic literature review within the realms of integrated care is a complex undertaking, which will comprise a variety of different sectors, organizations, care settings, professionals, and other users, with their own bodies of knowledge, the literature search strategy and review process will include the use of an inclusive approach through the performance of a wide search of a range of databases (Such as those noted above) and the use of nonspecific terminology. The selection criteria for the selection of the most relevant articles for inclusion in the review will involve an assessment of any inappropriateness of study design hierarchies, which may be noted whilst assessing the published literature. Finally, the systematic review will end by drawing any conclusions, which were noted in the literature and suggesting possibilities for improving the search strategy. Furthermore, it is important that one considers the fact that while such a literature review might provide a basis for research and practice, the ability of the review team to call upon a wide range of skills, experience, and knowledge across the information management field and the care system is crucial. This acknowledgement of the limitations of the study is crucial in determining the uses of the study and any possibilities for suggested improvements.

Chapter 5: Methods of Data Collection

Research will be conducted by examining the literature published in the Cochrane library, as one of the main research tools as this provides peer-assessed literature. In order to assess how successful the strategies, which have been implemented in fall reduction, some information may be acquired from the websites of specific NHS hospitals. Furthermore, the strategies may be compared to those implemented within the private hospital sector and thus information may be acquired and used through looking at literature published on websites such as the Nuffield hospital. The Department of Health website may offer an insight into statistics of the occurrence of falls and the NHS plan; a plan for investment and reform may offer an insight into the strategies which are being implemented by the NHS in order to reduce the number of falls occurring within secondary care. This will be an area of investigation.

Chapter 6: safety, ethical and confidential issues

It is important that any research which is conducted throughout the completion of this dissertation is done so safely and ethically according to the guidelines provided by the Research Ethics Framework and, within the context of good ethical practice all confidential issues which are addressed will be regarded as such and hence no reference to any explicit data which would effect the maintenance of confidentiality will be made. All research will also be conducted safely and appropriately.

Chapter 7: Scope of study and research limitations

The study seeks to analyze the physiotherapeutic interventions available in order to reduce the number of falls experienced by the elderly within the hospital setting. An overview the different methods which have been employed in the past and their affectivity will be addressed so that conclusions may be drawn regarding which methods are the most effective for reducing falls. The paper will look at different studies, which have been conducted and will evaluate the reliability of these studies and address and limitations, which each study has shown. Primary research would provide an insightful and valuable contribution to the research and would greatly enhance the reliability of the information collected, as it would be highly beneficial if the different methodologies noted to be effective in the literature could be trialed in practice and thus a comparison of the different methods conducted at a personal level. It may have also been useful if the opinions of physiotherapists and other healthcare professionals themselves could be sought directly so that an insight into there first hand views. On the affectivity of different methodologies used to reduce falls in the elderly could be sought.  However, due to time limitations this aim may not be entirely feasible, in which case the majority of the information about the methods employed by physiotherapists pre-published research findings published within reliable literature sources. The main challenge will most likely be associated with acquiring accurate and up-to-date information about the most current, up-to-date methods in use within the hospital setting as methods employed are constantly changing as new, more effective strategies are developed and the time lag between development, implementation and publication of these new methodologies.

Chapter 8: Conclusions and proposed chapter headings

In completion of this research and dissertation, I hope to acquire a significant knowledge and understanding of how and why physiotherapy interventions can aid fall reduction in hospital setting. I also hope to gain an understanding of the neurological basis of falling and the mechanisms and circuitry within the brain (primarily in the brain stem) and spinal cord, which leads to a loss of balance inducing a fall. I also hope that an insight into the different options available for the treatment of injuries associated with falling and their implications both for the patient and for the NHS. This information will hopefully be successfully relayed to the reader. In order to help the reader to access the information within my dissertation as easily as possible, the dissertation will be sectioned into the following chapters:

Chapter 1: Introduction
Chapter 2: Methodology
Chapter 3: Research findings and discussion
Chapter 4: Conclusions

Chapter 9: Supporting literature

Possible literature which will provide an information source for the completion of this dissertation include:

The Cochrane library
The Department of Health publications
The Royal College of physiotherapy publications

Alongside numerous other information sources which will be found in the literature review process.

References

  • Coutinho ESF, Fletcher A, Bloch KV, and Rodrigues LC (2008) Risk factors for falls with severe fracture in elderly people living in a middle-income country: a case control study. BMC Geriatrics 8 pp 8-21.
  • Damush T, Damush J (1999). The effects of strength training on strength and health related quality of life in older adult women. Gerontologist; 39 pp 705-710.
  • Francis RM (2001). Falls and fractures. Age Ageing, 30 pp25–28.
  • Gardner MM, Robertson MC, Campbell AJ. (2000) Exercise in preventing falls and fall related injuries in older people: A review of randomized controlled trials. British Journal of Sports Medicine; 34 pp 7-17.
  • Masud T, Morris RO (2001) . Epidemiology of falls. Age Ageing;30:pp3–7.
  • Panneman MJ, Goettsch WG, Kramarz P, Herings RM. (2003) The costs of benzodiazepine-associated hospital-treated fall injuries in the EU: a Pharmo study. Drugs Aging. 20 pp 833–839.
  • Rezmovitz, J, Taunton JE, Rhodes, E, Martin A, Zumbo B, (2003) The effects of a lower body resistance-training program on static balance and well-being in older adult women. BCMJ, 45, No. 9, pp 449-455.
  • Talbot LA, Musiol RJ, Witham EK, Metter EJ. (2005) Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury. BMC Public Health. 5 pp 86.
  • Woolf AD, Akesson K. (2004) Preventing fractures in elderly people. BMJ. 327 pp 89–95.