None listed
Conditions
Brief summary
In 2008-2009 the Ambulance Service of NSW responded to 672,000 emergency incidents. For the same period, “falls” was the reported problem to triple zero operators in almost 90,000 cases with those 65+ comprising 58% of all fallers. The non-conveyance rate for older fallers is 23% however little is known about the outcomes for these people. Work undertaken in the UK reported similar rates of non-conveyance and also demonstrated that 47% of older people not conveyed following a fall are re-attended by the Ambulance Service within two weeks. This study proposes to test the hypothesis that: rapid, timely and tailored intervention in older people who are not conveyed to hospital following a fall will lead to a significant reduction in future falls, fall related injury and unplanned use of emergency and acute hospital services. A randomised controlled trial design (n=234) will be used to test the impact of rapid access to a comprehensive assessment and intervention program. The study population will consist of people aged 65+ years who live in Randwick, Botany or Waverly, are attended by an ambulance as a result of a fall and who are considered to be appropriate to be left at home. Follow-up telephone contact will be made with all non-conveyed fallers initially to establish that there has been no acute deterioration in their health or level of function following their fall. Consenting patients will undergo a baseline assessment in their home within 72hrs of initial attendance and be provided with a written report with regard to falls risk factors identified. Intervention: The intervention group will receive falls prevention strategies based on the risk factors identified. The clinical researcher will pro-actively work with the older person to ensure that risk factors are addressed and interventions carried out. This will involve close liaison with the local Post Acute Care Service who will be part of delivering interventions including an evidence based exercise program and home safety assessment. Follow-up: Both the control and intervention groups will be followed up using monthly calendars and reply paid envelopes for a period of 6 months. Information will be collected with respect to falls, fall related injury, subsequent use of the ambulance service or hospital system and any visits to health care providers in the community. At the end of the six months, all participants will be reassessed by a researcher blinded to group allocation. Outcomes: The primary outcome measure will be the number of fallers and falls in the 6 month follow up period (measured using falls calendar data) Additional secondary outcome measures include: Number of falls requiring ED attendance and/or hospitalisation measured using calendar data and corroborated with NSW Centre for Health Record Linkage (CHeReL) data), Use of NSW Ambulance Service including time on scene (routinely collected Ambulance Service data) and re-attendance rates, Any ED presentation or hospitalisation including DRG and LOS data (measured using calendar data and corroborated with CHeReL data), Use of community services – GP visits, HMRs, ACAT referrals, use of PACS services etc (measured using monthly calendar data), Uptake and adherence to recommendations (based on initial and final assessments), Quality of Life at baseline and follow-up measured using the EQ5D
Interventions
The intervention group will be assessed for risk factors for falls and fractures. This will include medical and medication history, falls and fracture history, cognitive (GPCog) and physical function (IADL) and an objective measure of falls risk – QuickScreen. Physical activity will be measured using the IPAQ and the home environment will be assessed using the Homefast assessment scale. Quality of Life will be measured using the EQ5D and affect using the GDS-15. The anticipated duration of the
The intervention group will be assessed for risk factors for falls and fractures. This will include medical and medication history, falls and fracture history, cognitive (GPCog) and physical function (IADL) and an objective measure of falls risk – QuickScreen. Physical activity will be measured using the IPAQ and the home environment will be assessed using the Homefast assessment scale. Quality of Life will be measured using the EQ5D and affect using the GDS-15. The anticipated duration of the initial assessment is approximately 60 minutes. At the end of the assessment, the researcher will generate a list of risk factors identified and written suggestions as to how they might be addressed using a template and capacity for free text to individualise some advice. The intervention group will then receive falls prevention strategies based on risk factors identified. The clinical researcher will pro-actively work with the older person to ensure that risk factors are addressed and interventions carried out. Exercise in the form of strength and balance training will be recommended and it is anticipated that the majority of the intervention group will be offered this intervention. This will be in the form of the Otago Exercise Program and delivered by the PACS service physiotherapist. Participants will also be referred on to local evidence-based exercise programs (not all delivered through health care) to ensure that they continue exercising on completion of the Otago Exercise Program. Issues related to safety in the home environment will be referred to the PACS Occupational Therapist. People with poor vision (and no recent visual assessment) will be referred to their usual eye-care provider or a local optometrist. Participants taking medications known to increase falls risk will be referred to their GP and encouraged to discuss the ongoing need for these medications. A Home Medication Review will also be encouraged particularly where there is evidence of impaired cognition or any reported difficulties taking medications. A template will be designed to minimise any additional work for GPs. PACS nurses will ensure that appropriate changes are followed through and assist in any issues arising regarding medication For complex patients with multiple problems, a referral to the POW falls clinic or POW aged care clinics will be organised. Again, a template will be designed to aid with the referral process and minimise additional work for the local GP. Participants from the intervention group will be asked to fill out an Attitudes to Falls-Related Interventions Scale, to possibly identify and then address the specific concerns raised by particular individuals. Participants will be reassessed after 6 months using a shorted version of the initial assessment tool. Assessment is estimated to take about 30-45 minutes. Reassessment will be completed by a researcher blinded to group allocation and will be conducted at the participants home. Further, participants will be followed up using monthly calendars and reply paid envelopes for a period of 12 months. Information will be collected with respect to falls, fall related injury, subsequent use of the ambulance service or hospital system and any visits to health care providers in the community. The monthly falls calenders are a single page questionnaire with only 2 questions. Participants are asked to fill it out either after using health care services or after having a fall, or at the end of the month if the participant did not fall. This process is estimated to take no more than 5 minutes.
Sponsors
Associate Professor Jacqueline Close
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Prevention
Masking
Blinded (masking used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Elderly fallers, aged 65+ Attended to by ambulance service due to a fall Not conveyed to hospital
Exclusion criteria
Participants with cognitive impairment who do not have a regular carer because of the issue of consent and accurate recall of fall events Participants with limited English language skills, who have no carer to translate for the duration of the study, which would prevent them from giving informed consent, complete assessments and understand instructions if in the intervention group.
Outcome results
None listed