PICOT Proposal



Effects of Exercise on Elderly Falls

Christopher Kwong

University of South Florida

University of South Florida, College of Nursing

NUR 4169C EBP for Baccalaureate Nurses

EBP Paper Formative

Abstract

Clinical problem: Among older adults falls are the leading cause of fatal and nonfatal injuries (Center for Disease Control and Prevention, 2013). Falls are relatively common, a high cost to families, the community and hospitals, and are potentially preventable.

Objective of the paper: To demonstrate the dangers and costs of falls to the individual and the medical industry as a whole, and help implement a strength training program in the elderly population of nursing homes to limit fall risks.

Search engines: ScicnceDirect, PubMed

Results: Three different RCT studies demonstrating that nursing home subjects utilizing various exercise programs, specifically strength training, significantly reduced their risk of falling.

Conclusions: Evidence in the literature supported the idea that strength training exercise regimens can improve fall risk in the elderly population of nursing homes. These findings may have significant implications to hospital policy and protocol regarding physical therapy treatment and even implications in the community towards emphasizing such practices into daily routine to improve elderly fall risk and safety.

Introduction

“In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized. In 2010, the direct medical cost of falls, adjusted for inflation, was $30 billion” (CDC, 2013). Among older adults, those sixty-five and older, falls are the leading cause of fatal and nonfatal injuries. One out of every three elderly falls each year. Among older adults, falls are the single highest cases of fatal and nonfatal injuries (CDC, 2013). Falls are relatively common, a high cost to families, the community and hospitals, and are potentially preventable. Decreasing the amount of falls in the elderly population will save patient and hospital costs. The paper examines the question: in the elderly population of nursing homes, how does implementing exercise compared to not exercising decrease falls over six months? Implementation of such a plan would require management and organizational support for this improvement to resident safety and recognizing the decrease to overall medical costs as well as resident and family stress over falls. The paper seeks a solution to a preventable situation.

Literature Search

Utilized primarily ScienceDirect database which is accessible through the University of South Florida library website. Also referenced the government’s PubMed database. Limited the searches to ‘elderly’, ‘exercise’, and ‘fall’, searching only for randomized control trials within the last five years.

Literature Review

Hospitalized studies were difficult to find and some post-discharge studies have been done with the elderly, but following older adults in the community setting is challenging. The following studies were used as the basis for synthesizing later. See Table 1 at the end of the paper for quick comparison.

Cakar et al. (2010) looked to determine whether regular combined exercise programs, consisting of strength, stretching and aerobic exercises and additional jumping training, improve balance, fall risk, quality of life and depression status of older people living in residential care. Sixty-six subjects were randomly grouped as combined exercises program group (COM), COM plus jumping (COMpJ), and a control group. Berg balance test and Biodex Balance System were used in the assessment of the dynamic balance and fall risk. The balance improvement and fall risk reduction were observed in both groups. However, the improvements were statistically better in the jumping combined group. Strengths of this study included the 40-week study period or 17-week exercises periods, the study specifically targeted balance and gait deficits, and targets a seldom-studied group of long-term care facility residents versus community-dwelling geriatric patients. Limitations included difficultly convincing people to keep on attending the protocol and screening for even longer should be more beneficial. The study shows the association between exercise and improved balance, especially so when jumping is a part of the exercise routine. Based on those strengths, the study appears valid.

Serra- Rexach et al. (2011) assess the effects of an 8-week exercise-training program with special focus on light- to moderate-intensity resistance exercises and the subsequent 4-week training cessation period on muscle strength and functional capacity in participants aged 90 and older in a geriatric nursing home. Subjects (n=40) were randomly assigned to an intervention or control group, assessed using the Functional Ambulation Classification (FAC) scale. Falls were 1.2 falls fewer per participant. Exercise training, even of short duration, can increase muscle strength while decreasing fall risk in nonagenarians. Few resistance intervention studies have followed a real RCT design, but this study met the criteria. Other strengths include assessment of groups following detraining that showed still improved balance compared to baseline. Limitations of this study are that the control group was performing passive exercises on their own because of Spanish cultural norms for that population which may have influenced results and other variables were not examined in the study such as balance and joint mobility. This study shows improved balance and mobility with resistance based exercise training in this population. Based on those strengths, the study appears valid.

Vogler, Sherrington, Ogle, & Lord (2009) compare the efficacy of seated and weight-bearing exercises on fall risk factors in older people recently discharged from the hospital. This twelve-week, randomized control trial follows subjects (n=180) that are sixty-five years old and older. Subjects had impaired performance in all primary outcome measures, indicating that those recently discharged from the hospital are older and more impaired than the general community population of older people. Primary outcome measures were the PPA composite fall risk score and tests of ability to lean while standing, the Maximal Balance Range and Coordinated Stability test. Both seated resistance and weight bearing exercises greatly lowered the risk of falling. The weight bearing exercise intervention, however, showed additional benefits to seated resistance in that it produced fewer musculoskeletal adverse events and provided improvements in leaning balance measures that may have additional protection against falling in this at-risk group. There were more adverse events in the seated resistance group than the weight-bearing group. Given that seated resistance exercises are not physiologic movements, there may be added wear on the joints when weights are added. Strengths of the study included low dropout rates, good compliance and the control group received an attention program to account for the potential effects that socialization might have on the outcome measures of the trial. Limitations of this kind of study include exclusion criteria. Though limited, it had to exclude people it considered unsafe to prescribe home exercise such as those with moderate to severe cognitive impairment and unstable cardiac conditions as examples. Also, the weight-bearing group may not have performed the exercises in as challenging a manner as they would have under supervision, for fear of falling. This study provides evidence that weight training can improve balance in the elderly. Based on those strengths, the study appears valid.

Synthesis

All studies examined exercise as an intervention in older adults, those at least sixty-five or older. It was discovered that regular exercise training in long term care facilities can have beneficial effects related to balance. Even over a short time span, exercise training can increase a person’s muscle strength and decrease the risk of falling. This increase in muscle strength is maintained over a short cessation, or detraining, period as well. Patients could potentially then alternate where over three months they train for two months then recover for a month.

Not known is what exercise type is the single most effective improver of balance or fall risk reduction. Several different types are looked at in these studies from jumping, to strength training, to seated exercise, and combinations of them. Because different assessment tools were utilized in these studies, it is hard to analyze the most ideal method, but there is consensus that strength training is better than any one of the previous listed methods or passive range of motion exercises alone. Further study would need to be done to understand the effectiveness of combination exercise programs. Also, hospitalized patients have not been studied much in this area, and difficulties in studying elderly in the community as previously mentioned are challenges that make it difficult to draw generalizations from these types of studies.

Proposed Practice Change

From the data it would seem appropriate to suggest the implementation of an exercise-training program in nursing homes as a means of preventing falls by its residents. “Fall rates in residential care are three times those of the elderly people living in the community” (Cakar et al., 2010). Exercise programs with an emphasis on strength training should be implemented in nursing homes to reduce the number of falls in the elderly. The clinical recommendation is to incorporate strength training three times a week over a six-month period, which includes a detraining rest and recovery period of two weeks for every eight weeks of training.

Change Strategy

Strategies to promote staff engagement in the new policy would include a discussion of the dangers and physical, emotional and financial cost of falls to the nursing home’s residents to create an increased sense of urgency in the matter. Next, present research evidence supporting exercise as an effective fall prevention measure in the elderly. Explain how fewer falls affects the staff directly in terms of the nursing home’s incidence rate, perception of the nursing home, and less incident report paperwork to complete just as some examples. Gravitate to those team members who seem particularly interested in exercise themselves, inspire them to discuss with their peers the additional benefits to exercise for their residents such as improved gastric motility, better appetites, and improving resident interaction and socialization.

Roll Out Plan

Nurses have been questioned in the past and wanted a more streamlined, mentored linear process when going through an evidence-based practice roll out. The John Hopkins Nursing Evidence-Based Practice process has three main components: practice question, evidence and translation (Ciliska et al., 2011).

Practice question:

- Identify an EBP question: In the elderly population of nursing homes, how does implementing exercise compared to not exercising decrease falls over six months?

- Define scope of practice question: If exercise is shown to help decrease falls in the elderly population, should this be implemented as a protocol for all residents?

- Assign responsibility for leadership: Ensure accurate reporting by staff on falls and encourage positive attitudes towards the project.

- Recruit multidisciplinary team: Physical therapists or exercise trainers and independent data collectors will be needed as the staff may inadvertently skew the data.

Evidence:

- Conduct internal and external search for evidence: Internally examine nursing home’s recent fall data and interview residents to collect self-report data on balance and walking strength, while externally examining current EBP on fall risk reduction in elderly nursing home patients.

- Critique all types of evidence: Review and cross-examination of evidence by the whole project team.

- Summarize evidence.

- Rate strength of evidence: If evidence is lacking or new evidence is discovered, refinement of the search strategy might be necessary, moving the team back through prior stages of the process.

- Develop recommendations for change in processes or systems of care based on the strength of evidence.

Translation:

- Determine appropriateness and feasibility of translating recommendations into the specific practice setting: Very feasible plan that can easily be incorporated into the weekly agenda of residents with the exception of those with certain physical limitations or disabilities, mental disorders, or those with medications or conditions where physical activity is counter indicated.

- Create action plan: Recruit and gather consent from residents participating in the forty-five minute, three times a week exercise training program lasting six months. Gather patient baseline data.

- Implement change.

- Evaluate outcomes.

- Report results of preliminary evaluation to decision makers: Any safety issues or significantly unusual data that arise should be looked into immediately.

- Secure support from decision makers to implement recommended change internally.

- Identify next steps: Review of process needed? Do minor changes need to be applied? If considering changing the nursing home policy, then who needs to be informed or consented?

- Communicate findings.

Project Evaluation

Data collectors recruited for the project will need to submit the finalized data collected. Evaluation and comparison of resident individual and facility’s fall rates at baseline and after implementing change as well as changes in leg muscle strength, balance and postural stability scales, BMI, and adherence. Assess patients’ self-report of strength and stability as well. Survey the subjects, project team and staff on the change and their input. A decrease in fall rates will be the primary indicator of success for the project.

Dissemination of EBP

Evaluate and review all feedback on the project for possible modifications that may improve the data and responses. If implementation and incorporation of this strength training exercise program has statistically significant improvement in fall rates at the nursing home, share this evidence-based practice improvement with those who oversee the facility to discuss implementation across the organization. Potentially reach out to other nurse managers of other long-term care facilities and suggest a similar practice project change proposal.

Overgeneralization of this data is easy so caution is warranted, but potential application of strength training exercise programs for reducing falls in patients are in hospital settings, skilled nursing facilities, as part of discharge planning, and community health organizations are all realistic. More evidence-based studies in those specific settings may be needed before proceeding.

References

Cakar, E., Dincer, U., Kiraip, M.Z., Cakar, D.B., Durmos, O., Kilac, H., . . . Alper, C. (2010).

Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility. European Journal of Physical Rehabilitation Medicine, 46(1), 59-67.

Center for Disease Control and Prevention (CDC). (2013). Fall risks among older adults.

Retrieved from

Ciliska, D., DiCenso, A., Melnyk, B.M., Fineout-Overhold, E., Stetler, C.B., Cullen, L., . . .

Dang, D. (2011). Models to guide implementation of evidence-based practice. Evidence-

based practice (pp. 271). Philadelphia, PA: Wolters Kluwer Health.

Serra-Rexach, J.A., Bustamante-Ara, N., Hierro Villarán, M., González, G.P., Sanaz

Ibánez, M.J., . . . Lucia, A. (2011). Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. Journal of the American Geriatrics Society, 59(4), 594-602. Doi: 10.1111/j.1532-5415.2011.03356.x

Vogler, C.M., Sherrington, C., Ogle, S.J., Lord, S.R. (2009). Reducing risk of falling in

older people discharged from hospital: a randomized controlled trial comparing seated exercises, weight-bearing exercises, and social visits. Archives of Physical Medicine and Rehabilitation, 90(8), 1317-1324. Doi: 10.1016/j.apmr.2009.01.030

Table 1

Literature Review

Reference (Cakar et al., 2010) (Serra-Rexach et al., 2011) (Vogler et al., 2009)

Aim Whether combined Assess muscle strength with Compare seated

exercise programs improve exercise program in nursing exercise to weighted

fall risk in nursing home. home. to none on fall risk

factors.

Design/ RCT, Berg & Biodex RCT, FAC scale RCT, Physiological

Measures balance scales Profile Assessment

(PPA)

Sample n=66, age 65 or older, n=40, age 90 and older, n=180, age 65or older

30 in jumping group, 20 control (no exercise) 60 seated exercise,

36 in non-jumping group 20 experimental group 60 weighted exercise,

60 control group

(social visitation)

Outcomes Balance improvement and Exercise training even in Both exercise

fall risk reduction in both short duration can increase programs reduced fall

groups, however statistically muscle strength while risk score, with

better in jumping group. decreasing fall risk in weighted exercise

nonagenarians. offering additional

benefits of reaction

time and less

soreness.

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