Fluent Essays

1. Give a 3-4  lines detailed summary of the 6 articles attached . TOPIC: PREVENTION OF FALLS IN THE ELDERLY IN THE HEALTHCARE SETTING 1A. In 3-4 lines, Discuss one strength and one weakness for each of these six articles on why the article may or may not provide sufficient evidence for your practice change. (based on the practice change topic: PREVENTION OF FALLS IN THE ELDERLY IN THE HEALTHCARE SETTING) 2. A.Name two different methods for evaluating evidence. B.Compare and contrast these two methods. Disclaimer: This is a machine generated PDF of selected content from our products. This functionality is provided solely for your convenience and is in no way intended to replace original scanned PDF. Neither Cengage Learning nor its licensors make any representations or warranties with respect to the machine generated PDF. The PDF is automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. 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Independent Nurse: Professional - Fall prevention - Reducing falls among the elderly Author: Sarah Wild Date: June 17, 2005 From: GP Publisher: Haymarket Media Group Document Type: Article Length: 1,539 words Full Text: A new intergenerational approach is encouraging older people to overcome their fear and talk about falls, writes Sarah Wild. An elderly person dies every five hours in the UK as a result of falling, and statistics show that a third of people over the age of 65 fall at least once a year. In addition to the pain and suffering experienced by these patients, it puts a heavy burden on hospitals and emergency services, costing the NHS three times the budget allocated for primary care, mental health and CHD combined. Positive steps to reduce the number of falls have, however, been taken by proactive organisations such as Northumberland Care Trust, one of 21 sites selected to take part in a one-year programme co-ordinated by the National Falls Collaborative. Innovative ideas This has led to the development of some imaginative schemes that are designed to reduce falls in Northumberland by 30 per cent. Other goals set by the trust in 2003 included creating a falls register and increasing the number of elderly people who receive a personal and environmental risk assessment. In response to these targets, falls registers have been implemented in four GP practices involved in the programme and a risk assessment screening tool tried out in A&E, the community and by individuals. Falls prevention cards (pocket-sized checklists) have been circulated to home carers across Northumberland, and educational sessions offered to care home staff, for example 'podiatry upskilling' and 'low-vision training'. In addition to practical initiatives, exercise programmes have been developed, such as a handyman scheme to help older people carry out household tasks such as changing lightbulbs (opposite, below). To raise awareness of the issue of falls, and the many initiatives introduced to help prevent them, booklets and posters have been used alongside events such as the Autumn Falls Fair, involving 20 stands taken by relevant organisations. However, the most innovative method of disseminating information has only just been completed. The project, which is already the recipient of a Queen's Nursing Institute (QNI) Innovation and Creative Practice award, demonstrates an intergenerational appr-oach to combating falls. Jane Steven, project manager for the North Northumberland Falls Collaborative, explains how the initiative came about. 'We needed to tackle the problem that many elderly people don't tell anyone when they have fallen because they are embarrassed or afraid of being put into a care home,' she says. 'Others think falling is an inevitable consequence of getting old. We wanted a different way of getting the message across that would spark discussion, and I had the idea of getting older people to tell their falls stories, with younger people acting them out on video.' Expanding the concept Ms Steven developed this idea by liaising with Sue Spencer, a Sure Start health visitor in Berwick and chair of the Berwick Borough Safe Steps, which is designed to reduce the number of accidents involving children under the age of five. The proposed initiative was relevant to Ms Spencer as 39 per cent of children's accidents involve falls, and she considers public health to be an integral part of her health visitor role. Ms Steven also consulted colleagues from Berwick Borough Family Centre, plus Age Concern, who came up with the idea of using puppets to act out the stories, given the barriers to videoing children. The small rural town of Wooler was chosen for the project due to its large number of elderly inhabitants. Over-65s make up a third of the total population, compared with 17.59 per cent across the whole of Northumberland. Meanwhile, funding was secured from the QNI, which granted the initiative pounds 6,000, supplemented by around pounds 4,500 from Awards for All. This enabled project leaders Ms Steven and Ms Spencer to push ahead with finding artists to design and produce the puppets, enlist a professional video-maker and bring participants on board. Additional help with the project's organisation was provided by one of the parents involved in Sure Start, who was able to boost her management skills along the way. Finding older people to take part in the project turned out to be less straightforward than expected, as individuals approached were unsure what the scheme would involve - working with children to address a public health issue was a new concept for most of them. Sessions were designed to be fun and to encourage intergenerational interaction, and this involved a range of creative activities such as screenprinting. The participants were required to attend a two-and-a-half hour session per week, for six weeks, with the older people arriving an hour before the children. 'It was quite difficult finding older people to participate, even though Age Concern and the district nurse helped us to recruit them, as many have busy lives,' says Ms Spencer, who admits that targeting an existing social group might have been easier than approaching individuals to take part. 'We eventually found six participants, though this fell to a mainstay of five. The eight kids involved in the initiative came from an after-school group in Wooler, which meets at the Berwick Borough Family Centre.' The two artists, Nicola Balfour and Virginia Kennedy, facilitated the sessions together, building up a good relationship with participants. They were supported in this by Glynnis Reynolds, the representative from Age Concern, and video-maker Harry Henderson. Breaking the ice A core group of participants was established by the third week, when the theme of falling was formally introduced. 'To break the ice, we began by looking at historical pictures of Wooler and the older people talked about what it used to be like,' says Ms Steven. This progressed to the telling of falls stories, one of which, a tale of two elderly ladies who live next door and help each other to avoid falls, was chosen and interpreted by the children, and turned into a puppet show. 'A script was developed, puppets were made and the children performed a live visual show for their parents,' explains Ms Spencer. A video of the show was later filmed, creating an educational tool featuring clips of some of the intergenerational interaction that took place during the sessions, plus interviews with older people involved in local falls prevention schemes. The final product Feedback from focus groups was gained throughout the lengthy editing process, and 50 videos and 50 DVDs were recently completed, to be distributed among the project's participants. Copies will also be shown in schools and made available to carers and other local groups. 'The video acts as a general introduction to the topic of falls, without being overtly educational,' says Ms Steven. 'We've also produced a sheet that will act as a memory jogger to those showing the video, as we want groups to be able to use it themselves, without our involvement.' The project has achieved its dual purpose, according to Ms Spencer, and has boosted her management and creative skills too. 'As well as raising awareness of falls in elderly people, we raised awareness in children too, of their own falls and those of their grandparents,' she says. 'Jane and I benefited from a range of QNI workshops, covering subjects such as presentation skills, creativity and leadership. We also met colleagues from around the country, which was useful.' Although the scheme has been time-consuming, running from January 2004 to May this year, Ms Spencer would recommend it to nurse colleagues in other areas and plans to put her new skills to good use. 'I would repeat the exercise, even thought it takes up a lot of time,' she says. 'In future, we hope to use a similar intergenerational approach in another project, developing an interactive CD- ROM that could be used in schools.' TOP BENEFITS OF THE INTERGENERATIONAL INITIATIVE - Promoted partnership working between different agencies (Sure Start, Northumberland Falls Collaborative, Age Concern, Berwick Borough Family Centre and the wider community). - Encouraged interaction between children and older people, plus mutual understanding. - Raised participating children's awareness of falls, teaching them not only to be careful themselves, but also to be thoughtful towards older people (for example, not leaving toys on the stairs at home). It also encouraged their grandparents to inform someone if they have a fall. - Encouraged elderly people to talk openly about falls without embarrassment or fear of repercussions. - Allowed participants to develop creative skills and project leaders to boost their management and leadership skills. - Produced an educational tool that will raise awareness of falls across Northumberland. NORTHUMBERLAND'S KEY FALLS PREVENTION SCHEMES - Development of falls registers. - Provision of personal and environmental risk assessments. - Circulation of falls prevention cards (pocket-sized checklists) to home carers. - Autumn Falls Fair, involving 20 stands taken by different organisations to raise awareness of the danger of falls. - Information packs about falls distributed to older people at flu vaccination time. - Medication reviews. - Sloppy slippers scheme, whereby elderly people are able to exchange their old, ill-fitting slippers for new ones. - Handyman scheme, helping elderly people with household tasks. - Exercise programmes. - Falls education programme for carers. - Bottle-in-the-fridge scheme encouraging older people to write down relevant personal details and place them in a bottle in the fridge, so that they can be accessed in an emergency. - Intergenerational rural falls initiative. Copyright: COPYRIGHT 2005 Haymarket Media Group http://www.haymarket.com/home.aspx Source Citation (APA 7th Edition) Wild, S. (2005, June 17). Independent Nurse: Professional - Fall prevention - Reducing falls among the elderly. GP, 28. https://link.gale.com/apps/doc/A133363131/PPNU?u=canyonuniv&sid=bookmark-PPNU&xid=00beebb2 Gale Document Number: GALE|A133363131 http://www.haymarket.com/home.aspx Applied Nursing Research 57 (2021) 151392 Available online 26 November 2020 0897-1897/© 2020 Elsevier Inc. All rights reserved. Promoting older adult fall prevention education and awareness in a community setting: A nurse-led intervention☆ Tiffani Chidume, DNP, RN, CCRN, CHSE * Auburn University School of Nursing, United States of America A R T I C L E I N F O Keywords: Fall prevention Older adult Elderly Fall awareness Fall safety Fall education A B S T R A C T Background and objectives: Falls are costly and one of the most expensive medical conditions to treat. The implementation of fall prevention toolkits (FPTs), such as fall risk screenings and fall prevention education (FPE), have become progressively important in reducing fall incidences. Nurses have a greater role and responsibility to care for the aging population. The purpose of this project was to implement a FPT to adults age 65 and older that attended mobile IPE community clinics. Research design and methods: This project used quantitative pretest-posttests and an open-ended participant feedback survey. The Missouri Alliance for Home Care 10-question survey and components of the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) FPE were used to assess and educate participants on fall risks and fall prevention. An initial baseline fall assessment and fall education score was obtained at the mobile IPE clinics. Follow-up assessments occurred one month after the initial assessment and compared to the initial fall assessment and fall education scores with an additional open-ended participant survey. Results: In both fall risk assessment tools, lower scores indicated a lower fall risk; both fall risk assessment tool mean scores decreased over the one-month period. Discussion and implications: Future FPE implementation projects should consider providing needed resources the participants may need so there is no delay in increasing fall prevention and safety measures. The follow-up time period should also be increased to fortify FPE and keep participants engaged in fall prevention safety. 1. Identification of the problem “I’ve fallen and I can’t get up,” a memorable quote from a 1989 Life Alert commercial, is still recited with updated versions being aired daily. Though used to promote various emergency medical alert devices, it also highlights the dangers and incidence of falls in the older population. Bergen et al. (2016) reported one in four older adults, ages 65 and older, fall each year. In 2017, unintentional falls in persons age 65 and older were the leading cause of nonfatal injuries in the United States (US), accounting for 63.3% of the total number of unintentional falls (National Center for Injury Prevention and Control (NCIPC), 2017a). For the same time period and population, falls were the most contributing factor of unintentional injuries and the seventh leading cause of death in the US (NCPIC, 2017b). Falls are costly and one of the most expensive medical conditions to treat, costing more than $50 billion in 2015 alone (Centers for Disease Control and Prevention [CDC], 2019). The Centers for Disease Control and Prevention (CDC) estimates the financial burden for older adults may reach $67.7 billion in 2020 (2019). As older adults continue to age, falls are more common, take longer to recover from, and cost more to treat, likely due to prolonged hospital stays (Bergen et al., 2016; Frith, Hunter, Coffey, & Khan, 2019). Declining sensory disorders [eyesight, hearing, sensation, etc.], polypharmacy, and weakness are only a few of the possible causes of falls (Frith, Hunter, Coffey, & Khan, 2019). One fall incident increases the likelihood of subsequent falls (CDC, 2019). Fall risk prevention methods are key factors in care, regarding efforts of healthcare providers and caretakers to increase the safety of the older adult as well as decrease falls and costs associated with falls. Currently, Auburn University (School of Nursing, School of Phar- macy, College of Liberal Arts (Social Work), College of Human Sciences (Nutrition)) conducts mobile Interprofessional education (IPE) com- munity clinic visits to various sites that have an established partnership. ☆ The author reports no conflicts of interest involving this project or manuscript to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * 710 South Donahue Drive, Auburn University, AL 36849 E-mail address: [email protected] Contents lists available at ScienceDirect Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr https://doi.org/10.1016/j.apnr.2020.151392 Received 9 May 2020; Received in revised form 28 August 2020; Accepted 21 November 2020 mailto:[email protected] www.sciencedirect.com/science/journal/08971897 https://www.elsevier.com/locate/apnr https://doi.org/10.1016/j.apnr.2020.151392 https://doi.org/10.1016/j.apnr.2020.151392 https://doi.org/10.1016/j.apnr.2020.151392 http://crossmark.crossref.org/dialog/?doi=10.1016/j.apnr.2020.151392&domain=pdf Applied Nursing Research 57 (2021) 151392 2 A community social worker coordinates which sites the mobile clinic will visit based on the needs of the community. The mobile IPE com- munity clinic was commenced to assist older adults in the community with little or no access to healthcare obtain some form of access to healthcare. Clients receive free health screenings, education, and re- sources from the IPE groups. The older adult is the largest population that historically attended the clinics, as many of the clinics occured in senior centers or low- income housing units. At the clinics, client medications and diagnoses are reviewed and care plans are formulated by IPE teams. However, prior to the implementation of this fall prevention project, there was no fall risk assessment being completed. The mobile IPE clinic is often the most patient-centered care provided to those that attend and many are already a high risk for falls. For aging adults with possibly declining faculties, fall prevention and awareness should be assessed to decrease and possibly prevent falls. The purpose of this project was to implement a fall prevention toolkit (FPT) to older adults that attended mobile IPE community clinics. There were no fall prevention assessments or education provided along with the health, social, and nutrition assessments. The FPT included two fall risk assessments as well as fall safety and prevention education. The intent was to reduce falls and increase older adult knowledge about fall safety and prevention. The care disparity in this population required immediate attention. The FPT was intended to improve the health out- comes of older adults in the community. 2. Background Falls in any population can affect a persons’ mobility and quality of life. In the older adult, multiple factors, including vision impairment, environmental hazards or weakness, may contribute to falls (Bergen et al., 2016). For adults age 65 and older, the estimated falls that occur each year is 29 million; the equivalent of someone age 65 and older falling each second, every single day (Bergen et al., 2016; Sarmiento & Lee, 2017). Pohl et al. (2015) collected data on a qualitative focus group regarding older community-dwelling adults and fall precautions the participants were aware of and practiced. The study advised fall risk awareness should be introduced using various strategies and should be reinforced. The same study revealed that becoming aware of one’s increased fall risk can evoke different emotions in the elderly, often affecting pride and self-confidence (Pohl et al., 2015). The aging population may have reservations speaking with health- care providers about declining mobility and falls, but healthcare pro- viders should be screening and assessing for fall risks annually (American Geriatrics Society, 2011; Moncada & Mire, 2017). Further- more, healthcare providers should use fall risk scores as guidelines to decrease patient-specific fall risk problems, rather than using generic fall risk interventions (Titler et al., 2016). For instance, if a patient’s fall risk assessment reveals fear of falling as a trigger, strengthening exercises as well as the psychological root of why there is a fear of falling should be addressed. There should also be an evaluation for the [possible] need for an assistive device. Fall risk prevention awareness, assessments, and education are needed to improve healthcare outcomes in the aging population, opti- mally, to increase safety and decrease falls. The American Geriatrics Society/British Geriatrics Society (2011) developed clinical practice guidelines for the prevention of falls in older persons–with the under- standing that fall risk assessments are a vital element in reducing falls in the elderly population. Many fall prevention screening, awareness, and assessment tools are now available in response to numerous fall pre- vention/reduction initiatives (Moncada & Mire, 2017). Grealish et al. (2019) suggests, based on new evidence, that the focus should be concentrated on how fall prevention guidelines are utilized in conjunction with individualized corrective measures for the older adult. For some older adults, there is little or no perceived risk of falling; for others, there are hindrances to learn fall prevention tactics or even acknowledge a gradual decline in mobility and/or loss of functions (Bulsara et al., 2016; Pohl et al., 2015). The implementation of FPTs, such as fall risk screenings, home safety assessments, and FPE, have become increasingly important in reducing fall incidences (CDC, 2019; Olij et al., 2018). Research indicates that multifactorial screenings and assessments are preferred, considering no single aspect may be respon- sible for falls, but consider multiple issues that could be [responsible for falls] (American Geriatrics Society, 2011; Stevens & Phelan, 2013). The United States Preventive Services Task Force (USPSTF) (2018) recom- mends clinicians and older adult patients evaluate injury versus well- being regarding fall prevention measures. The evaluation of various medical diagnoses, fall history, and patient preferences may make a difference in the success of fall prevention of these community-dwelling elders (USPSTF, 2018). In early 2019, researchers found that sharing FPE information where older adults congregate and frequent has value and decreases barriers to learning about fall prevention (Kiami et al., 2019). Older adults in the community setting that have received increased FPE have the propensity to maintain independence and safer living conditions (Minnier et al., 2019). Fall prevention screening checklists are vital initial tools in identifying at-risk individuals, but should be validated before use (Chacko et al., 2017). Lusardi et al. (2017) found that most fall pre- vention screening and assessment tools are predictive in identifying older adults at higher risks for falling. The most significant predictor indicators are “medical history questions, self-report measures, and performance-based measures” (Lusardi et al., 2017, p. 33). Another recent study showed community-nurse recruitment for fall prevention activities in older community-dwelling adults, along with healthcare provider and researcher collaboration, played an integral part in the success of the study (Olij et al., 2019). Nurse-led FPE was also shown to have a greater impact on fall prevention behavior in the elderly population (Uymaz & Nahcivan, 2016). Even better results have been achieved with IPE teams collaborating with fall prevention awareness, assessments, and education implementation initiatives (McKenzie et al., 2017; Sullivan et al., 2015; Taylor et al., 2019). Concerning nursing care and the profession of nursing, nurses will have a greater role and re- sponsibility to care for, screen, and teach fall prevention methods to the aging population (Patton, 2018). 3. Conceptual framework and application to project Boykin and Schoenhofer’s Nursing as Caring Theory served as the theoretical underpinnings for the development and presentation of the assessments, education, and follow-up interactions. This grand theory is an in-depth analysis of what caring is, how caring has multiple mean- ings, and how caring affects everyone differently (Smith & Parker, 2015). The nursing as caring theory has a multidimensional framework, as it integrates assumptions and components from its theory and that of the nursing metaparadigm (Masters, 2015). The tenets of the nursing as caring theory relate to the imple- mentation of an FPT in the elderly population in various ways. The elderly may become forgetful, but they are not forgotten. The nursing as caring theory applies to this project because the aging population is, in fact, the focus. The IPE community clinics are a means of older adults in the community gaining access to healthcare through free screenings and healthcare collaborations. The clinics also provide an environment for members of the community to congregate; “community” in a true sense of the word. Through interviewing and providing education, a nurse provided a form of caring. The follow-up phone communications in the subsequent month emphasized the notion that someone cares and is proactive in attempts to help decrease falls and increase fall risk awareness and education in the aging population. 3.1. Project methodology A design consisting of a quantitative pretest-posttest and an open- T. Chidume Applied Nursing Research 57 (2021) 151392 3 ended participant survey design was utilized. The project was consid- ered a practice change model in a specific type of setting (community clinics), and for a specifically aged population. The project setting occurred in various community settings in Lee County, Alabama and surrounding counties. The mobile IPE community clinics occurred on Fridays in low-income housing communities, assisted living facilities, community centers, and other rural settings. Participant criteria included being 65 or older, English speaking, with no exclusion for race or gender. The sample was n = 30. Partici- pants consisted of mostly women (73.3%), doubling the number of male participants (26.6%). Fifty percent of the participants lived indepen- dently in the community, 26.7% lived in an assisted living facility, and 23.3% lived in low-income housing. Physical mobility of the various participants included total ambulatory (requiring no assistance), mostly ambulatory (the use of assistive devices at times), and very limited (dependent on a motorized or manual wheelchair). 3.2. Intervention The intervention was the implementation of fall risk assessments and fall prevention education, the FPT, to older adults that attended IPE community clinics. The mobile IPE community clinic visits were scheduled, and the project advertised weeks in advance of actual IPE mobile clinics to gain possible participant interest. This was accom- plished by displaying flyers with project information in the various fa- cilities 1–2 weeks before implementation. Some word of mouth recruitment also occurred at the mobile IPE clinical sites. Upon arrival at the mobile IPE community clinical sites, interest was confirmed with self-identified participants who met the inclusion criteria. Prior to visits to the clinical sites, FPT packets were prepared, which included the consents, assessments, and educational resources. If the inclusion criteria were met, the participants were read the informed consent script regarding the project. All interested parties were provided instructions and signed an informed consent form. Participants also provided contact information for follow-up communication. Partici- pants were assigned by the number in which their assessment occurred and ushered to a quiet area by the nurse in order to provide privacy during the implementation of the FPT. Once the participants were seated and ready to proceed, the first fall risk assessment, the MAHC- 10, was evaluated. Once the individual baseline fall risk scores were obtained via the MAHC-10 assessment, a self-reported fall prevention safety education assessment, “Stay Inde- pendent”, was completed and calculated. Comparisons between the two fall risk assessment types will be discussed later. Next, a fall safety checklist with safety guidelines “Check for Safety”, were reviewed with the participants. Each question yielded an intervention to improve fall prevention safety and knowledge. For areas of improvement based on the “Check for Safety” guidelines, more time was spent teaching the participants how and why certain changes were needed to improve their safety. Lastly, a fall prevention educational pamphlet, “What You Can Do to Prevent Falls” was read to the participants and specific areas of improvement were circled on the pamphlet. The pamphlet was given to the participants to keep for reference. The participants were notified of exercises, such as Tai Chi and yoga, to improve balance and strength. The nurse emphasized the importance of the participants slowing down and making intentional movements, like counting to three between taking steps. Each project participant session took 30–50 min depending on participant need. Participants were given a copy of the informed consent for reference and contact information for the nurse and Insti- tutional Review Boards in case there were questions or concerns after the intervention. One month after the initial assessment, the two fall risk assessments were re-administered and the “Check for Safety” guidelines re-evaluated to assess if suggested improvements were made by the participants. The project-specific five-question follow-up survey was also completed during the follow-up. The follow-up questions requested additional in- formation on possible changes the participants made, as well as their evaluation of the FPE provided. 3.3. Instruments The first instrument used in this project is the Missouri Alliance for Home Care 10-question survey (MAHC-10). The MAHC-10 was devel- oped to assist home health agencies’ compliance with Centers for Medicare and Medicaid Services’ (CMS) Outcome and Assessment In- formation Set Criteria (OASIS-C) for home health patients (Calys et al., 2012). The MAHC-10 is multifactorial, standardized, and has been validated as a single tool to assess fall risks (Missouri Alliance for Home Care (MAHC), 2012). The validation study was a 2010 (July–October) four-month retrospective review of nine home health agencies located in Missouri. The sample size for the study was n = 2247. The MAHC-10 includes a fall risk assessment tool (survey), a fall report form, and a Microsoft Excel data entry form (MAHC, 2012). The 10-question assessment tool requires information such as age, comorbidities, medical, and fall history. A numerical value was assigned for each question. The tally of the questions was combined, resulting in the MAHC-10 fall risk score. The fall prevention benchmarking initiative was tested in 2010. The construct validity of MAHC-10 differentiates between “fallers” and “nonfallers” (Calys et al., 2012). Also, on the MAHC-10 fall prevention tool, “prior history of falls” is defined as, “An unintentional change in position resulting in coming to rest on the ground or at a lower level” (MAHC, 2012). The fall risk factors are consistent with the literature (Calys et al., 2012). “Fallers,” individuals that are high-risk for falls, are considered to have a fall risk score of 4 or more (Calys et al., 2012; MAHC, 2012). However, researchers suggest that each agency alter the fall risk score for their specific needs and indications. Individuals with scores of less than four were less likely to fall according to their medical histories and MAHC-10 assessments (Calys et al., 2012). The next instruments used in this project, “Stay Independent”, “Check for Safety”, and “What You Can Do to Prevent Falls,” are components of the Center for Disease Control and Prevention’s Stopping Elderly Acci- dents, Deaths, and Injuries (STEADI) initiative. The STEADI initiative was designed specifically for healthcare providers that cater to the older populations, which is especially important for patients who have fallen or are at risk for falling (Lee, 2017). The three essential STEADI com- ponents are screening, assessing, and appropriate interventions (CDC, 2016). The CDC’s intent with the STEADI initiative was to develop varying levels of resources for healthcare providers, resulting in improved health outcomes in the older adult (CDC, 2016). The STEADI fall prevention toolkit offers a wide range of fall pre- vention materials that are free to use, customizable, and may be downloaded. There is also an option to purchase components of the toolkit, printed by the CDC, instead of downloading and printing on-site. Materials include fall prevention screening materials, teaching mate- rials, care planning booklets, fact sheets, checklists, and exercise pocket guides. Anyone may use any part of the toolkit or the entire toolkit at the discretion of the user. The CDC also offers training classes on how to implement STEADI into practice as well as case studies. “Frequently Asked Questions” are also available on the website. For this project, the following STEADI components were utilized: a self-reported fall prevention safety education assessment, “Stay Inde- pendent”, a fall safety checklist with safety guidelines, “Check for Safety”, and a fall prevention educational pamphlet, “What You Can Do to Prevent Falls”, which the participants were given to keep. “Stay Independent” is a validated self-risk assessment brochure that brings awareness to risks of falling. The “yes” and “no” questions translate to numerical values to be tallied. Like the MAHC-10, a fall risk score of 4 or greater indicates a higher fall risk. “Check for Safety” is a home safety brochure that aids in identifying and correcting potential fall risks in the home setting. “What You Can Do to Prevent Falls” is an additional informational brochure that T. Chidume Applied Nursing Research 57 (2021) 151392 4 includes effective strategies to prevent and/or reduce falls (CDC, 2016). The STEADI initiative and materials were tested extensively for validity and reliability by various healthcare providers and using various methods, such as interviews and focus groups. Members of the focus group (n = 18) commented on how useful the tool was because the initiative did not focus on the patients only after falls, but is useful as a preventative measure for falls (Stevens & Phelan, 2013). The STEADI materials were found to be valid and considered to demonstrate empirical evidence in a 2017 study that used the 2011–2015 National Health and Aging Trends Study data. The sample size in the aforemen- tioned study was n = 7392 and consisted of adults age 65 and older (Lohman et al., 2017). Additionally, the STEADI initiative follows the American and British Geriatrics Societies’ Clinical Practice Guidelines (CDC, 2016). The project-specific, five-question follow-up survey was developed by the nurse with input from colleagues. The survey was completed during the follow-up phone call with participants. The follow-up ques- tions requested additional information concerning possible changes the participants made after the FPT implementation, if they had fallen since the FPE, as well as their evaluation of the FPE provided. The last ques- tion on the survey, “Is there anything else you would like for me to know,” allowed for participants to express additional feelings and con- cerns regarding fall prevention awareness, safety, and knowledge. 3.4. Data collection All data were collected by the nurse. Data and forms were trans- ported by the nurse in a locked travel bag. No identifiable information was included during the data analysis. All data were systematically logged on paper forms, tabulated, and evaluated using descriptive sta- tistics and parametric analysis (interviews and questionnaires). The data were entered in the Statistical Package for the Social Sciences (SPSS) version 24. Completed surveys and informed consent were placed in a locked file cabinet where they will be retained and accessible only by the nurse for five years. The MAHC-10 assessment tool was administered upon recruitment and obtained consent from older adult participants. The MAHC-10 fall risk assessment requested information such as the patient’s age, medi- cal, and fall history. Points were assigned for each assessment question. The numerical total of the points for each MAHC-10 assessment was the baseline fall risk assessment score. The numerical total of the points for each “Stay Independent” checklist, was the baseline FPE score. After one month, follow-up phone communication with participants occurred. The nurse communicated with the participants using the contact information given during the initial assessment. Participants were queried by reassessing the MAHC-10 fall risk and the “Stay Inde- pendent” self-reported checklist. Scripted follow-up questions were also asked. Over the six-week project period, 33 participants were obtained for the initial assessment and FPE. Of the 33 initial participants, 30 were available for the reassessment and follow-up questions. 3.5. Data analysis Statistical analysis of the project data was conducted using SPSS Version 24. The baseline fall risk assessment scores, FPE scores, and descriptive statistics were entered and analyzed in SPSS. After the follow-up phone call, new scores were tabulated, entered into SPSS, and analyzed. Prior to the FPE, the participants’ overall MAHC-10 score was (μ = 4.87, (SD = 1.978)); after receiving FPE, that level decreased to (μ = 4.83, (SD = 1.821)) in a month. Prior to the FPE, the participants’ overall “Stay Independent” score was (μ = 5.67, (SD = 3.977)); after receiving FPE, that level decreased to (μ = 5.53, (SD = 4.158)). See Table 1. The MAHC-10 fall risk assessment pre and post scores were statistically insignificant (p = 0.662, α = 0.05). The MAHC-10 paired t- test was (t = 0.441, p = 0.662) supports the fall prevention education to be statistically insignificant. The “Stay Independent” fall risk assessment pre and post scores were statistically insignificant (p = 0.255, α = 0.05). The “Stay Independent” paired t-test was (t = 1.161, p = 0.255). See Table 2. 3.6. Findings The overall scores of the thirty participants that completed both the initial and follow-up assessments did not change significantly in one month. The mean MAHC-10 initial assessment score was μ = 4.87 and the reassessment mean was μ = 4.83. The “Stay Independent” Fall Risk initial assessment produced a mean of μ = 5.67, with a follow-up mean of μ = 5.53. In both fall risk assessment tools, lower scores indicated a lower fall risk; both fall risk assessment tool means decreased over the project period. Upon reassessment via the follow-up phone call, a specific question regarding recent falls was used to evaluate if client falls decreased and to what degree, by comparing the baseline and reassessment scores. The question asks if there has been a fall in the past three months. In the initial assessment, six of the 30 participants admitted to falling in the past three months. There were two reported falls in the one month following the education. Because of the difference in time periods, no conclusion can be drawn. The home safety brochure, “Check for Safety,” aided in identifying potential fall risks in the home setting and guided individualized teaching points for the participants. Many of the questions focused on if there were stairs in the dwelling, how well-lit were the commonly used areas, and possible environmental hazards. During the follow-up phone call, specific areas of concern were reassessed to note any changes and improvements in the home environment. For example, for the question, “Do you have throw rugs on the floor,” participants were educated on removing the rugs or obtaining non-skid mats to go under them and explained why the rugs are a fall hazard. While none of the “Check for Safety” questions demonstrated statistical significance per the paired samples … Age and Ageing 2006; 35-S2: ii65–ii68 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. doi:10.1093/ageing/afl083 All rights reserved. For Permissions, please email: [email protected] ii65 The role of medical assessment and intervention in the prevention of falls CAMERON G. SWIFT Department of Health Care of the Elderly, King’s College School of Medicine, London, UK Address correspondence to: C. G. Swift. Email: [email protected] Abstract Evidence that falls amongst older people can be prevented now requires researchers and policy makers to elucidate the most comprehensive and cost-effective approach to implementation. The syndrome of falls and fractures in later life ref lects the combined age-associated influences of cumulative susceptibility to health problems and reduced adaptive reserve. The major contribution of health factors to falling has long been recognised clinically and has also emerged clearly in epidemiological studies of risk. A fall in an older adult, especially if recurrent, may be a key signal of unmet medical need and should accord- ingly trigger an in-depth diagnostic process and clinical intervention by an appropriately skilled physician. Although well- designed controlled studies specifying this approach as part of a multifactorial intervention are comparatively few, recent published trials have conf irmed the anticipated substantial returns in fall prevention achieved for community-dwelling patients with a history of falling. Larger-scale studies are now required, and further research is needed to achieve effective prevention strategies in institutional care. Combined calcium and vitamin D may act via neuromuscular and skeletal mecha- nisms in fracture prevention. The requirement for medical assessment has now appropriately been incorporated into national and international guidelines. Keywords: fall prevention, diagnosis, medical assessment, controlled studies, calcium and vitamin D Introduction The strength of evidence that falls in later life can be pre- vented has grown to the point where it can no longer be ignored by health policy makers and providers. Across a wide range of controlled intervention studies, the most compelling results have been obtained from the application of a multifactorial approach to those at high risk of falling [1]. Consequently, organised health service delivery initia- tives to deal with this major public health issue amongst older people are now strongly indicated. Inevitably, there is disparity in the range of service models being proposed, and a corresponding need for the development of consensus, driven by evidence, on the minimal requirements for maxi- mal cost-effectiveness. Further ‘best f it’ implementation studies are urgently required. Human ageing is in general characterised by random cellu- lar error accumulation, by a corresponding predisposition to pathological change, by reduced adaptive reserve and by increasing inter-individual variability. Clinically, the late-life ‘syndrome’ of falls and fractures is an excellent exemplar of these phenomena, in particular, the summative interaction of pathologies with reduced adaptive reserve. There are age-asso- ciated reductions in the reserve capacity of any or all of the entire spectrum of mechanisms involved in orthostatic control; at the same time, there is progressive vulnerability to a growing range of health-related perturbations (acute or chronic), perhaps especially those affecting central neurological control mechanisms. Examples include metabolic disturbance, reduced cerebral perfusion and its causes, small vessel disease, hypoxia, seizure-related problems, pyrexia and the effects of drugs. (Even uncontrolled, but otherwise uncomplicated, hyperten- sion has been found to cause subtle perfusion-related decre- ments in psychomotor performance) [2]. These all vary between individuals, so that the relative contributions of each or any require careful analysis and dissection in any one case. It is clear also from the epidemiological literature on risk factors that heath related causes play a prominent part. These are sometimes specific (e.g. cardioinhibitory or vaso- depressor carotid sinus syndrome). More commonly, how- ever, the effects of a combination of non-specif ic health problems summate with those of age-associated physiologi- cal change to cause falling [3–5]. Consequently, a fall in an older individual, though import- ant in its own right, is potentially a vital signal of unidentified or unresolved medical need. It follows that recurrent falls or other indicators of high falls risk should prompt a rigorous diagnostic process by an appropriately skilled physician at an early stage in the care pathway. This is distinct from the mere assembling of a list of apparent risk factors because an iterative process of accountable clinical judgement, decision making on priorities, and even occasional unitary diagnosis is entailed. mailto:[email protected] mailto:[email protected] C. G. Swift ii66 Although there is broad consensus amongst physicians and gerontologists on this, it remains inadequately described in the literature. This is partly because of differences in pat- terns of clinical service delivery, the lack of formal coding for a ‘fall’ in systems of disease nomenclature and a failure to explore this domain in sufficient depth within many so- called multidimensional clinical studies. In particular, there have been comparatively few intervention studies explicitly based on such an approach, although several have included the itemisation of the so-called health risk factors as part of ‘multidimensional’ assessment. UK-based studies incorporating in-depth physician assessment Opportunities to carry out studies of this nature have been presented in recent years under policy initiatives taking place within the British National Health Service (NHS). Since 1990, there has been a Department of Health require- ment (rather poorly evidence-based) for preventative health strategies for older people in primary care. At the same time, an NHS Research & Development (R&D) programme has invited bids for modest grants at regional and national level for health technology and health service evaluation studies. There is also a degree of uniformity in the extensively developed hospital-based geriatric medicine services, all of which undertake acute care with direct access to front-line facilities, including Accident and Emergency (A&E). A&E departments are almost by definition fruitful terri- tory for falls research. Eight per cent of adults over 70 attend A&E with a fall-related injury [6], of whom 30–40% are admitted [5]. About half of those sent home exhibit increased dependency [7–9]. The prevalence of under-diag- nosis of problems in A&E has also been described [10, 11]. In particular, documentation has focused on the injury, and a ‘fall’ has not been identified as such, let alone its causes sought. A modest regional R&D grant enabled our group to set up the 2-year PROFET study [12] as an experimental model of A&E-based multidimensional falls intervention incorporating in-depth physician diagnostic evaluation as a key element. Consecutive community-dwelling, cognitively intact A&E attendees over 65 were painstakingly identified by establishing a ‘register’ of all fallers, and randomised to control (usual care) (n = 213) and intervention (n = 184) groups. The intervention comprised specialist one-off physician (day-hospital) and occupational therapy (home) assessments using predetermined protocols and carried out within 3 weeks of the index fall. Medical assessment comprised an in-depth diagnostic approach based on detailed and systematic history and exami- nation of all relevant systems with investigation and/or refer- ral as indicated by standard criteria (including tilt-table and carotid sinus studies for unexplained falls, syncope or pos- tural hypotension). This was supplemented by measures of postural sway, cognition, anthropometric variables, balance testing and assessment of visual acuity and binocular vision. Home assessment comprised home-safety analysis, functional assessment (FIM), falls handicap inventory and footwear with provision of minor home adjustments, and advice and/or referral for adaptations where indicated. Of interest is that two-thirds of those randomised had fallen significantly during the previous year (population inci- dence usually one-third) and one-third were recurrent fallers—thus identifying the A&E attendees as a group at high risk. There was a substantial yield of medical need. In addi- tion to instances of a wide range of problems, including, for example, signif icant joint disease, impaired mobility or malignancy, this comprised the following: • contributory circulatory disorders (e.g. postural hypoten- sion, arrhythmias, carotid sinus syndrome, pacemaker failure) identified in 17%; • visual problems (reduced acuity 59%, poor stereoscopic vision 62%, cataract 35%); • leg weakness 28%; • peripheral neuropathic signs 20%; • balance impairment (one-leg stand) 72%; • impaired cognition (Mini-Mental Status Examination— MMSE)(initial exclusion based on Abbreviated Mental Test <7) 34%; • depression (Geriatric Depression Scale) 18%. Alongside this yield, occupational therapy assessment identified a range of environmental and functional problems. The results were fully reported elsewhere [12]. The primary endpoint of incidence of falls in the 12-month fol- low-up period was markedly reduced in the intervention group versus the control group (183 vs. 510), with evidence of early benefit within the first 4 months. The number and percentage of fallers were also reduced, as were the propor- tion of those experiencing three or more falls and the number of hospital admissions. In addition, functional abil- ity (as measured by the Barthel ADL index) was significantly preserved in the intervention group versus the control group, in whom it declined. In a meta-analysis of falls pre- vention studies, the marker of outcome achieved by this approach sits well to the ‘left’ in favour of benefit compared with other trials of multifactorial intervention [1]. Subsequently, a further NHS A&E-based study of 313 cognitively intact recurrent fallers with physician assessment essentially replicated these findings [13]. In this study under- taken in Newcastle, the number of falls was fewer by 36% in the intervention group (387 vs. 617), though the reduction in the proportion of fallers did not achieve statistical signifi- cance. In addition, there was a 5-fold reduction in the number of hospital bed days (131 vs. 688) consumed by the intervention group during the 12-month follow-up period. Taken alongside the sum of less direct evidence from other studies, these findings underpin the key role of in- depth medical assessment and the diagnostic process as a part of any effective multifactorial intervention approach. There is, however, a need for further studies. The limita- tions of the above evidence are emphasised below: • Both were confined to ‘cognitively intact’, community- dwelling individuals. (Living in an institution was an exclusion criterion for the PROFET study and a similar exclusion occurred de facto in the Newcastle study.) These and other exclusion criteria meant that only 397 of 1,031 Falls medical assessment ii67 eligible A&E attendees (over 6 months) were randomised in PROFET and only 313 of 5,090 (over 12 months) in Newcastle, where those reporting a single previous fall only (1,911) were also excluded. Hence the data relate to a highly selected population group. This group is, however, an important one. It appears to be representative of a subset of community-dwelling older people presenting to the health service with health-related risk factors ripe for detec- tion and fruitful intervention as part of a population-based opportunistic early case-finding strategy. The research potential of the group is also clearly very substantial. • Both studies were local and of small numbers. Larger-scale implementation studies are required to establish whether the benefits shown are translated at a wider population level. • Improvements in the elements of the medical, functional and environmental protocols are clearly possible to give an even greater yield, such as more sophisticated testing of vis- ual function, physical ability and the living environment. Medical assessment in the prevention of falls in those living in an institutional setting The optimal approach to falls prevention in institutional set- tings and sheltered accommodation remains unclear. As yet, no single or multifactorial strategy has been proven to be reli- ably effective [14], although there is some evidence that inter- ventions, such as hip protectors [15, 16], combined calcium and vitamin D [17, 18] and standard skeletal anti-resorptive therapy for those with established osteoporosis are beneficial in the prevention of fractures in this population of older people. The identif ication of effective measures to reduce falls in hospitals and in nursing and residential homes would be a major step forward. The burden of health need in these settings is self-evident. It is therefore likely that skilled diagnostic evaluation would be an essential element of any such strategy for falls pre- vention, once identif ied. However, the simple translation of the procedures effective in community-dwelling older adults to this group has not been found to be effective on its own. A study applying the same principles of A&E-based inter- vention (including diagnostic assessment) as those described above to 274 attendees with cognitive impairment was reported in 2003 [19]. In reality, the study sample turned out to be more than three-quarters institutionally based, and it is highly likely that this facet of those recruited contributed as much to the outcome as did their cognitive status. During the one-year follow-up, the 6% reduction in the proportion of patients falling (74%; 96/130 vs. 80%; 115/144) failed to achieve statistical signif icance, and no signif icant benefits in terms of secondary outcome measures were recorded. The likelihood is, therefore, that the prevention of falls in this population of older people will entail very specific, as yet unidentified, approaches in terms of the built environ- ment and multidisciplinary practice. These approaches will prove of central importance alongside the management of health-related problems. The question of Vitamin D and calcium is worthy of specif ic comment. It is not clear in what proportion the fracture-reducing effects of combined calcium and vitamin D in institutionally living older people [17, 18] are due to direct actions on bone health or to correction of other con- sequences of calcium and vitamin D deficiency, such as impaired psychomotor performance and skeletal muscle weakness predisposing to falls. Def iciency of vitamin D has been found to be common in patients attending a falls clinic [20] and is virtually universal in older people in resi- dential and nursing homes and in sheltered accommoda- tion [21]. Administration of Vitamin D replacement to falls clinic patients was found to enhance psychomotor per- formance and reduce postural sway compared with a con- trol group [22]. It is possible that at least some of its beneficial effect on fractures may be mediated via neu- romuscular mechanisms. Conclusions The place of medical assessment and intervention as part of falls risk assessment and management is logical in terms of an understanding of ageing processes and of the epidemiol- ogy of risk factors for falling. Recent studies have conf irmed the effectiveness of multifactorial interventions incorporating in-depth diagnosis and clinical management by specifically trained physicians; this approach is probably essential if the potential benef its of such interventions are to be fully realised. As with other elements of the multi- factorial approach, the precise contribution of medical assessment to effective prevention in the case of high-risk individuals in institutional settings is yet to be quantif ied. The prominent role of physician diagnosis and manage- ment in fall- and fracture-prevention in older people is now rightly enshrined in international consensus guidelines [23–28]. Key points • The place of medical assessment and intervention as part of falls risk assessment and management is logical in terms of an understanding of ageing processes and of the epidemiology of risk factors for falling. • Recent studies have confirmed the effectiveness of multi- factorial interventions incorporating in-depth diagnosis and clinical management by specifically trained physicians; this approach is probably essential if the potential benefits of such interventions are to be fully realised. • As with other elements of the multifactorial approach, the precise contribution of medical assessment to effect- ive prevention in the case of high-risk individuals in insti- tutional settings is yet to be quantified. • The precise mechanisms whereby combined calcium and vitamin D may reduce fractures in the institutional popu- lation remain unclear. • The prominent role of physician diagnosis and manage- ment in fall- and fracture- prevention in older people is now rightly enshrined in consensus guidelines. C. G. Swift ii68 Acknowledgements The following have been major contributors to research in the author’s own department referred to in this review: Theresa Allain, Jacqueline Close, Jugdeep Dhesi, Margaret Ellis, Ed Glucksman, Richard Hooper, Steve Jackson, Lalit Kalra, Arduino Mangoni and John Suckling. Conflicts of interest Shire Ltd. Occasional consultancy. References 1. Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328: 680–6. 2. Kalra L, Jackson SH, Swift CG. Neuropsychological test per- formance as an indicator of silent cerebrovascular disease in elderly hypertensives. Age Ageing 1994; 23: 517–23. 3. Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 1989; 149: 1628–33. 4. Tinetti ME, Doucette JT, Claus EB. 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Published by Oxford University Press. All rights reserved. Copyright of Age & Ageing is the property of British Geriatric Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. applied sciences Review Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review Joanna Piech 1,2,* and Krzysztof Czernicki 2 ���������� ������� Citation: Piech, J.; Czernicki, K. Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review. Appl. Sci. 2021, 11, 4098. https://doi.org/10.3390/ app11094098 Academic Editors: Youngho Lee and Elena Amaricai Received: 24 March 2021 Accepted: 27 April 2021 Published: 30 April 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Faculty of Health Sciences, Jagiellonian University Medical College, 33-332 Krakow, Poland 2 Department of Rehabilitation, Lesser Poland Orthopedic and Rehabilitation Hospital, 30-224 Krakow, Poland; [email protected] * Correspondence: [email protected] Abstract: The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed. Keywords: virtual reality; exergames; falls prevention; rehabilitation; elderly 1. Introduction Falls become a significant problem in the aging population. Falls are prominent factors of accidental or unintentional injuries implied by external causes [1,2]. The incidence of falls amongst elderly people, according to the World Health Organization, varies from 28–35% of individuals aged 65 and over, increasing to 32–42% for those over 70 years of age [1]. Falls result in the fear of falling, loss of independence, institutionalization, and eventually death [3]. Strategies to prevent falls are crucial to the well-being of the elderly population, and rehabilitation plays an important role among them. Standard rehabilitation protocol focused on the prevention of falls comprises kine- siotherapy (exercises) and education. Exercises should include training of body balance, coordination, gait, changing the body position, minimizing the possibility of an injury during a fall, and techniques of getting up properly after a fall. Exercises are effective in reducing the risk of falling [4]. Advances in medical technology resulted in the popularization of computer-assisted interventions in rehabilitation treatment. New technologies in rehabilitation comprise of a variety of biofeedback implementations into hardware platforms, motion capture systems augmented by biofeedback, augmented reality (AR) systems, and virtual reality (VR) systems. Technological appliances vary from adoptions of popular gaming hardware platforms to specialized systems with dedicated hardware and software. Software proto- cols, presuming adequate hardware implementation, can be integrated into a complete computer game, which may result in better adherence. An application of virtual reality Appl. Sci. 2021, 11, 4098. https://doi.org/10.3390/app11094098 https://www.mdpi.com/journal/applsci https://www.mdpi.com/journal/applsci https://www.mdpi.com https://orcid.org/0000-0003-2867-6902 https://orcid.org/0000-0002-4404-641X https://doi.org/10.3390/app11094098 https://doi.org/10.3390/app11094098 https://creativecommons.org/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.3390/app11094098 https://www.mdpi.com/journal/applsci https://www.mdpi.com/article/10.3390/app11094098?type=check_update&version=1 Appl. Sci. 2021, 11, 4098 2 of 20 techniques in exergames can result in even better immersion into “digital worlds” and leads to the proposal of reframing the interpretation of virtual reality into two components: virtual reality experience (VRE) and virtual reality systems (VRS) [5]. The virtual reality experience comprises at least four interrelated contributors: immersion, interaction, senso- rimotor contingencies, and illusions. Virtual reality systems refer to physical solutions to generate virtual reality experience. Among the contributors of VRE, the effectiveness of interaction bonds them all to- gether, eventually resulting in illusion. The interaction in VRE starts with visual exploration of the space, which can be provided by simple display, stereoscopic display, head-mounted display (HMD) with head tracker or more advanced motion-tracking systems. The experi- ence can be further augmented by spatial sound effects, haptic data gloves etc. Next level interaction can be provided by means of brain and other bodily inputs, leading to so-called neurogames, which use brain or muscle signals to control basic interaction features [5]. Such implementations require the application of brain–computer interfaces (BCI), which are capable to non-invasively collect and further interpret collected brain signals. Regard- ing the input concepts, one has to distinguish augmented reality, which combines virtual and real world, and virtual reality, which substitutes real world with multiple sensorial channels, leading to more or less complete artificial stimulation, creating non-immersive or immersive VR. BCIs can be used both in AR and VR applications [6,7]. In view of rapid technology advancements, solutions in the form of small brain implants are inevitably coming, forerun by experimental devices like scalable high-bandwidth brain-machine interface system [8]. Exergames are defined as the activity of playing video games that involve physical exertion. Interventions making use of exergames have a favorable effect on both motor and cognitive functions [9,10]. Exergames have promised a form of intervention, which improves physical function in older adults, while endangering few adverse effects [11]. Exergaming, as an interactive, entertaining and engaging form of exercise, may help to overcome traditional exercise barriers and improve adherence in the case of older adults. Exergames provide therapeutic applications for balance recovery and functional mobil- ity [12]. They can improve cognitive and physical functions on the basis of increased sensorial flow physical effort [9]. Recent studies augment benefits of VR in particular func- tions, like geographical distance estimations in relation to chosen locomotion techniques in virtual environment [13]. Exergaming, especially in older people, may have its drawbacks. There are at least two groups of factors, which have to be taken into account: the reluctance in accepting new technologies by elder people and the presence of adverse effects related directly to VR applications. The attitudes among elderly people toward using VR are still unclear, however, a recent study demonstrates the use and acceptance towards the adoption of VR among the older population [14]. The adverse effects of VR could be identified as non-related to intervention and related to intervention [11]. The former includes all medical events not related to therapeutic sessions, e.g., falls between sessions. The latter includes adverse events like injuries, falls or medical problems, and side effects during exercises, like tiredness, muscular pain, discomfort, and motion sickness. Visual and cognitive aftereffects, chiefly related to HMD applications, are defined as VR sickness [15]. VR sickness may lead to symptoms of nausea, eye strain, headaches, dizziness, and disorientation that last beyond the exposure period [16,17]. Based on recent research, the VR sickness seems to last for a relatively short period of time after training [18]. While exergaming has been proven as an effective standalone intervention, the evi- dence of its possible prevalence over standard rehabilitation protocols is scarce [19]. Appl. Sci. 2021, 11, 4098 3 of 20 Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools [20]. Rehabilitation is an important and necessary part of the treatment and prevention of many diseases. Therefore, its safe continuation during the pandemic prefers remote methods. Nowadays, healthcare has to deal with the challenges of providing patient care using modern technologies [21]. Their employment involves economic costs, employee training, and adaptation of the equipment to the treatment goals and the age profile groups of patients. The use of new technologies in rehabilitation carries the risk of exclusion of elderly people. Therefore, knowledge about the possibilities of the use and the adaptation of virtual reality in such a case appears to be particularly important. The influence of interventions based on new technologies on the course of rehabilita- tion, regarding their hypothetical advantage over standard rehabilitation, still remains an open question. This statement is also valid in the challenging problem of the prevention of falls among elderly people. The present study was conducted to determine, based on the current literature review, whether the virtual reality and exergames employed in rehabilitation significantly reduce the incidence of falls among elderly patients. An additional aim of this review was to assess the impact of this type of intervention on patients′ cognitive functions, quality of life, adherence, usability, and enjoyment of exergames in the process of rehabilitation. 2. Materials and Methods 2.1. Literature Search Strategy The aim of the literature review was the evaluation of the effectiveness of virtual reality rehabilitation among elderly patients in the prevention of fall risk. The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted following the PRISMA checklist [22]. A literature review was carried out in six databases: Medline, PubMed, Scopus, Embase, Web of Sciences, and PEDro. The tool used to create the research objective and search strategy was PICOT(T) [23]. • Population—healthy elderly • Intervention—virtual reality, exergames rehabilitation • Comparison—any intervention (standard rehabilitation, physical exercises, daily liv- ing activities) or no intervention • Outcomes—fall risk and prevention, body balance, walking, functional improvement, pain, cognition, quality of life • Time—last 5 years (January 2015–December 2020) • (Type of study)—randomized controlled trials The primary search keywords were “elderly”, “virtual reality”, “exergames” “rehabili- tation”, “falls”, and their synonyms. Keywords were combined using the Boolean operators “AND” and “OR”. The search strategy was flexible and adapted to the database search engines. For the PubMed, we used the following search scheme: ((((virtual reality OR augmented reality OR video games OR game * OR computer games OR wii OR exergames OR vr))) AND (((rehabilitation OR exercise * OR physical therapy OR physiotherapy OR physical activity OR activity OR training))) AND ((elderly OR aged OR older OR elder OR geriatric OR elderly people OR old people OR senior))) AND (((fall prevention OR preventing falls OR prevent falls OR falls OR falling))) AND (Randomized Controlled Trial[ptyp]). Each search strategy was checked by two authors. 2.2. Study Selection and Data Extra Action Firstly, two authors created the criteria for eligibility. When both authors had accepted the search strategy, one of them searched the databases (last search: January 2021). Then, two researchers reviewed all the studies (title, abstract, and full text) independently, using an automation tool—Rayyan [24]. The results were compared and all occurring conflicts at every stage of study selection and data extraction were solved through discussion. Appl. Sci. 2021, 11, 4098 4 of 20 Articles meeting the following criteria were included in the review: (1) published in the last 5 years (January 2015—December 2020); (2) English language; (3) randomized con- trolled trials (RCT); and (4) targeted for the healthy elderly, rehabilitation, and exergames. Studies were excluded due to: (1) publishing before 2015; (2) writing in a language other than English; (3) reports from books, case reports, observational, as well as interventional (non-randomized) clinical trials, and protocols of RCTs; and (4) do not concern the elderly, rehabilitation, and exergames. The data was extracted from articles by two authors. Quantitative variables were presented as mean, minimum, and maximum values. Qualitative variables were described as percentage frequencies. 2.3. Quality Assessment The methodological quality was assessed using the PEDro scale, which is considered relevant for RCTs related to physical therapy [25,26]. The scale evaluates internal validity of the trials (criteria 2–9) and information on statistics (criteria 10–11). Criterion 1 relates to external validity but is not considered when calculating the final score. The PEDro scale is only used to evaluate the research methodology. Therefore, the PEDro results do not provide evidence of clinical utility and cannot assess the effectiveness of an intervention in clinical practice [27]. The methodological evaluation of the included articles that were available in the PEDro database was taken from the website https://www.pedro.org.au/ (accessed on 5 January 2021).The remaining three articles [28–30] were rated on the 11-points PEDro scale by two authors independently, then the results were compared, and potential differences were resolved during the discussion. PEDros’ items were scored 0 if not reported or unclear, 1 when reported adequate. Research that received from 1–3 points was rated as poor quality, from 4–6 points was moderate quality, and above 7 points was assessed as high quality. 3. Results 3.1. Searching Results The selection of articles was carried out in accordance with PRISMA guidelines. After searching the databases and removing duplicates, 682 articles were screened by titles and abstracts. As a result of the selection, 114 articles were included in the analysis of the full texts. After the full-text selection, 93 publications were rejected and 21 studies were included in the qualitative synthesis. For details on the selection of studies and the reasons for their rejection, see Figure 1. PRISMA flowchart. 3.2. Characteristics of Included Studies and Participants Twenty-one RCTs were included in the analysis, involving a total of 1557 participants who were randomized to the study or control group, respectively. These were the healthy elderly with a mean age of 75.7 years who were examined for the risk of falls. Among the patients, the majority were women (female-to-male ratio of 1.6:1). Participants were recruited mainly from seniors residing in retirement homes and among rehabilitation ward inpatients. Post-intervention follow-up was used in 6 out of 21 studies and ranged from 6 weeks [31] to 1 year [32]. https://www.pedro.org.au/ Appl. Sci. 2021, 11, 4098 5 of 20Appl. Sci. 2021, 11, x FOR PEER REVIEW 5 of 20 Figure 1. Flowchart of the article selection process (2009 Preferred Reporting Items for Systematic Reviews and Me- ta-Analyses (PRISMA) flow diagram). 3.3. Technology of Intervention The main tool used for rehabilitation was virtual reality games. The exercise program was aimed at increasing muscle strength and improving body balance. In most cases, the training was based on Nintendo Wii balance boards [33–37], biofeedback [32,38], VR dancing [32,39], and exergames obtained for various physical exercises [28,39–43]. In addition to physical exercises, some studies also used exercises aimed at cognitive function and memory [32,39,40,43]. The experimental group received training under the supervision of a physio- therapist or trainer in 13/21 of the included studies. Unsupervised training focused on inter- ventions at the patient′s home [30,39,42]. The control group also consisted of the elderly who were usually treated with standard physiotherapy including balance exercises or preventive leaflets. The duration of the intervention ranged from a minimum of 10 days [44] to a maxi- mum of 6 months [32], an average of 8.9 weeks. It should be noted that in 8 out of the 21 studies, an intervention in the experimental group was based on VR training and the same standard intervention as in the control group (e.g., exercises or education leaflets). Other re- search works compared VR training standalone in the experimental group and usual care in the control group. Table 1 presents more information on the intervention use. Figure 1. Flowchart of the article selection process (2009 Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) flow diagram). 3.3. Technology of Intervention The main tool used for rehabilitation was virtual reality games. The exercise program was aimed at increasing muscle strength and improving body balance. In most cases, the training was based on Nintendo Wii balance boards [33–37], biofeedback [32,38], VR dancing [32,39], and exergames obtained for various physical exercises [28,39–43]. In addition to physical exercises, some studies also used exercises aimed at cognitive function and memory [32,39,40,43]. The experimental group received training under the supervision of a physiotherapist or trainer in 13/21 of the included studies. Unsupervised training focused on interventions at the patient′s home [30,39,42]. The control group also consisted of the elderly who were usually treated with standard physiotherapy including balance exercises or preventive leaflets. The duration of the intervention ranged from a minimum of 10 days [44] to a maximum of 6 months [32], an average of 8.9 weeks. It should be noted that in 8 out of the 21 studies, an intervention in the experimental group was based on VR training and the same standard intervention as in the control group (e.g., exercises or education leaflets). Other research works compared VR training standalone in the experimental group and usual care in the control group. Table 1 presents more information on the intervention use. Appl. Sci. 2021, 11, 4098 6 of 20 Table 1. Characteristics of intervention used in included studies. First Author Intervention in SG Intervention in CG Time of Intervention Yang C.M. et al. [45] The game Your Shape: Fitness Evolved II (Microsoft Kinect for Xbox 360) improving balance, strengthening and coordination, assisted by a trainer. Conventional exercises for falls prevention 5-week therapy with two 45-min sessions per week Ehrari H. et al. [28] Exergames (Moto tiles) assisted by a trainer. Normal daily living activities 12-week therapy, one-hour session, twice a week Adcock M. et al. [39] VR gaming conducted at home, improving balance (Tai Chi-inspired exercises), muscle strength (dancing), and cognition ([email protected] training systems). Normal daily living activities 16-week intervention with forty-eight sessions for 30–45 min each, three times a week Stanmore E.K. et al. [42] VR gaming with feedback + AGE UK Staying Steady Falls Prevention Leaflet + home exercise program AGE UK Staying Steady Falls Prevention Leaflet + home exercise program 12-week intervention performed 3 times per week Liao Y. et al. [40] Tano and LongGood programs—VR training using the Kinect system (Tai Chi inspired exercises, resistance, functional, and balance) integrated with VR glasses for cognitive training, supervised by a physiotherapist. Standard resistance and balance exercises integrated with cognitive training 12-week intervention, 60-min session, thrice a week Htut T. et al. [41] Exergames (Microsoft Kinect for X-box 360) directed to balance, limbs strength and cognition, conducted by a physiotherapist. Normal daily activities 8-week intervention, 30-min session, thrice a week Delbroek T. et al. [43] VR training (BioRescue) improving balance, muscle strength and cognition, assisted by a physiotherapist. Normal daily care 6-week intervention, from 18 to 30 min, twice a week Padala K.P. et al. [33] WiiFit training (Wii Balance Board) directed to balance and muscle strength, monitored by an assistant. Cognitive exercises using a computer program (Brain- Fitness) 8-week intervention, 45-min session, thrice a week Oesch P. et al. [44] Exergames (Windows Kinect®, the GameUp Project) focus on balance, leg strength, and mobility. Leaflet with training instruction 10 working days of training performed twice a day for 30 min each Levy F. et al. [29] VR training directed to walking in a 3D virtual reality world using head-mounted display and a wireless mouse. Without intervention 12-week intervention 40-min session, once a week Kwok B.C. et al. [34] Exergames (Wii Balance Board) and cardiovascular training. Cardiovascular training, balance, and strength training 12-week intervention, 20-min exergames and 20-min cardiovascular training per week van den Berg M. et al. [31] Video/computer-based interactive exercises involving stepping and weight-shifting exercises. Usual rehabilitation care 2-week intervention, one hour on weekdays Yeşilyaprak S.S. et al. [46] Balance exergames (BTS Nirvana VR). Conventional balance exercises 6-week intervention, three sessions per week Mirelman A. et al. [38] Treadmill training + VR and feedback. Standard care 6-week intervention, 45-min session, thrice a week Tsang W.W. et al. [35] Wii Fit (Wii Balance Board). Conventional balance training 6-week intervention one-hour session, thrice a week Eggenberger P. et al. [32] Exergames (treadmill walking) with simultaneous verbal memory training. Strength and balance exercises 6 months intervention one-hour session twice a week Appl. Sci. 2021, 11, 4098 7 of 20 Table 1. Cont. First Author Intervention in SG Intervention in CG Time of Intervention Gschwind Y.J. et al. [47] Balance exergames, strength exercises, and education booklet. Education booklet about evidence-based health and fall prevention advice 16-week intervention 120-min a week Gschwind Y.J. et al. [30] Exergames (Microsoft Kinect for X-box 360) and step mat training, unsupervised home training. Educational booklet about evidence-based health and fall prevention advice 16-week intervention Jung D.I. et al. [37] Exergames (Nintendo Wii Sports) and lumbar stabilization exercises. Without intervention 8-week intervention 30-min session, twice a week Park J. et al. [48] Exergame (3D VR Kayak program) and conventional exercise program. Conventional exercise program 6-week intervention, twice a week Whyatt et. al. [36] Balance exergames (Wii Balance Board). Normal activity (self-recorded diary) 5-week intervention, twice a week SG—study group, CG—control group, VR—virtual reality. Appl. Sci. 2021, 11, 4098 8 of 20 3.4. The Effectiveness of Virtual Reality and Exergames 3.4.1. Quantitative Outcomes Quantitative outcomes were assessed as the physical performance of patients (Table 2) and mainly contain the following activities: balance, gait ability, risk of falling, and muscle strength. The main tools used to evaluate the above variables were the Berg Balance Scale in 8/21 studies, the Timed Up and Go Test and its variants in 10/21 studies, the Falls Efficacy Scale-International and its variations (FES-I) in 6/21 studies, and the 10-to-2-min march test in 4/21 studies. Short Physical Performance Battery (SPPB) was used in 6/21 studies to evaluate physical activity and risk of disability in activities of daily living. The assessment of the impact of VR rehabilitation and exergames on physical function among the elderly varies in the analyzed studies. In 11 out of 21 studies, there was a significantly greater improvement among assessed specific outcomes for VR training than conventional therapy. Moreover, 8 of the 21 pieces of research assessed VR-based intervention as being effective as traditional treatment. On the other hand, 2 of the 21 analyzed studies [39,44] indicate no special benefits for VR intervention in comparison to standard therapy. These results indicate that new technologies used in rehabilitation could be equally effective in the improvement of specific physical function among elderly patients. However, the diversity in technologies used and research tools among included studies makes impossible to draw a clear conclusion that any intervention based on VR will be effective in the elderly in terms of improving physical function. Additionally, in the assessment of statistical significance of the results, many studies used only p-value to misinterpret the effectiveness of the application of the intervention. However, p-value only shows that an effect exists and does not reveal the size of the effect. In quantitative research, both p-value and size effect should be reported. Therefore, the lack of information on the size effect does not allow a full assessment of the effectiveness of the intervention. Appl. Sci. 2021, 11, 4098 9 of 20 Table 2. Quantitative Outcomes. First Author Outcomes Research Tools Results Yang C.M. et al. [45] Leg strength and endurance, balance, joint pain 30-s CST, TUG, FRT, OLST with eyes open and closed, VAS Both interventions improved balance, but only VR training improved FRT (p = 0.021) in comparison with controls. Ehrari H. et al. [28] Balance, leg strength and endurance, aerobic capacity, daily number of steps BBS, 30-s CST, 6MWT, SENS motion-sensors 24/7 Both interventions improved physical outcomes, but there was no significant difference between the SG and CG in measured outcomes. Adcock M. et al. [39] Gait analysis, single task walking and dual task walking, balance, leg strength and endurance, brain plasticity/brain volume Step length, step speed, step time, MTC by the Physilog®5, SPPB, SFT, MRI and VBM No significant improvement between the SG and CG in physical parameters and brain plasticity/volume (p > 0.05) with the exception of an interaction effect in the 30 s chair rises test (component of SFT) [F(1) = 5.076, p = 0.024, η2 = 0.01]. Stanmore E.K. et al. [42] Balance, mobility, physical activity, falls BBS, TUG, PASE, Short FES-I, FRAT including VAS pain and VAS fatigue Significant positive impact on balance (BBS: 6.2 95% CI 2.4 to 10.0; p = 0.003, IRR = 0.08), pain (VAS: −12.1, 95% CI −22.3 to −1.8, p = 0.024), fear of falling (FES-I: adjusted mean difference = −2.7, 95% CI −4.5 to −0.8, p = 0.007), and future falls prevention (IRR = 0.31 95% CI 0.16 to 0.62, p = 0.001) in the SG compared to CG. Liao Y. et al. [40] Gait analysis The GAIT Up system Both interventions presented significant improvements in single and motor gait performance and inhibition, but only VR improved cognitive dual-task gait (p = 0.003). Htut T. et al. [41] Balance, risk of falling, muscle strength, risk of falling, perception of exercise effort BBS, TUG, TUG-cog, 5TSTS, HGS, FES-I, Borg CR-10 All interventions improved physical strength, cognition, falls prevention, and body balance, but VR had a higher impact on physical as well as cognition performance. BBS: all interventions were significantly (p < 0.001) greater than the CG with the effect size of PE = 1.59, VR = 1.65, and BE = 1.52. TUG: PE group had a significant decrease in time compared with VR (p = 0.004, effect size = 0.93) and BE (p = 0.012, effect size = 0.75). 5TSTS: all interventions were significantly (PE p < 0.001; VR p < 0.001; and BE p = 0.036) compared with CG with the effect size of PE = 1.62, VR = 1.42, and BE = 0.60. HGS was significantly greater in PE (Left p < 0.005; Right p < 0.005) and VR (Left p < 0.005; Right p < 0.005) than the CG with the effect size for PE Left = 0.84 and Right = 0.90, and for VR was Left = 0.88 and Right = 0.83. FES-I: VR was significantly lower than PE (p = 0.036, effect size = 0.58), BE (p = 0.011, effect size = 0.77), and CG (p < 0.001, effect size = 1.24). Delbroek T. et al. [43] Balance, gait, dual-task performance (cognitive-motor) Tinetti-POMA scale, iTUG, iTUG … 주요어: 허약노인, 낙상, 교육, 운동, 근력 * 이 논문은 제1저자 홍차화의 2019년도 석사학위논문을 수정하여 작성한 것임. * This manuscript is a revision of the first author’s master’s thesis from Pusan National University. Year of 2019. Address reprint requests to : Lee, Haejung College of Nursing, Pusan National University, 49 Busandaehak-ro, Mulgeum-eup, Yangsan 50612, Korea Tel: +82-51-510-8344 Fax: +82-51-510-8308 E-mail: [email protected] Received: August 20, 2020 Revised: January 11, 2021 Accepted: March 8, 2021 Published online April 30, 2021 This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium. 70세 이상 시설거주 허약노인의 낙상예방을 위한 교육단독중재와 교육운동복합중재 효과 비교 홍차화 1 · 이해정 1 · 이미순 2 1 부산대학교 간호대학, 2 창신대학교 간호학과 Comparison of the Effects of Education Only and Exercise Training Combined with Education on Fall Prevention in Adults Aged 70 Years or Older Residing in Elderly Residential Facilities Hong, Chahwa 1 · Lee, Haejung 1 · Lee, Misoon 2 1 College of Nursing, Pusan National University, Yangsan 2 Department of Nursing, Changshin University, Changwon, Korea Purpose: To compare the effects of education only and exercise training combined with education on fall knowledge, fall efficacy, physical ac- tivity, and physical function in adults aged 70 years or older residing in elderly residential facilities. Method: A three-group pre- and post- test design was utilized: education only (EO; n = 23), education and TheraBand (ET; n = 22), and education and walking (EW; n = 22). Fall education was provided for all three groups. In addition, TheraBand exercise training was provided for the ET and a walking exercise for the EW. Data were collected from November 1st, 2017 to February 15th, 2019 and analyzed with χ2 test, paired t-test, and one-way ANOVA using IBM SPSS/WIN ver. 22.0. Results: Compared with the EO, the ET and the EW were more effective in terms of fall efficacy, physical activity, and lower extremity muscle strength. The EW showed higher improvement in walking abilities than the EO and the ET. Conclusion: Exercise training combined with education is more effective in preventing falls among community-dwelling adults aged 70 years or older. When considering fall prevention programs for older adults, both TheraBand and walking exercise training combined with education can be chosen based on the participant’s physical status. Aggressive strategies to improve daily walking are required to main- tain walking abilities among community-dwelling adults aged 70 years or older. Key words: Frail Elderly; Accidental Falls; Education; Exercise; Muscle Strength eISSN 2093- 758X J Korean Acad Nurs Vol.51 No.2, 173 https://doi.org/10.4040/jkan.20203 RESEARCH PAPER © 2021 Korean Society of Nursing Science https://jkan.or.kr 서 론 1. 연구의 필요성 낙상은 노인의 사고로 인한 사망원인 2위에 해당되는 노인 사 망의 중요한 원인 중 하나이다[1]. 2016년 고령자 안전사고의 47.4%가 낙상이었고, 낙상에 의한 사망사고의 약 80.0%는 70세 이상 노인이었으며 매년 증가하는 추세이다[2]. 낙상 발생 장소는 74.3%가 가정이었고, 3.5%가 복지시설이나 노인 요양시설이었으 https://orcid.org/0000-0003-2635-7676 https://orcid.org/0000-0003-0291-9945 https://orcid.org/0000-0003-3375-1030 http://crossmark.crossref.org/dialog/?doi=10.4040/jkan.20203&domain=pdf&date_stamp=2021-04-30 174 https://jkan.or.kr 홍차화 · 이해정 · 이미순 https://doi.org/10.4040/jkan.20203 며, 가정에서 발생하는 낙상은 침실이나 방에서 발생하는 경우가 23.6%로 가장 많았다[2]. 노인의 일상생활 중 발생하는 낙상사 고 비율은 전 연령층에서 발생하는 안전사고보다 11.0% 더 높은 것으로 나타나 지역사회에 거주하는 노인이 특히 낙상사고에 취 약함을 알 수 있었다[2]. 특히 70세 이상 노인은 낙상으로 인한 손상 정도가 심각할 수 있고 회복하는데 시간이 오래 걸리고 고 액의 의료비가 요구되며[3], 낙상으로 인한 사망 위험도도 증가 한다[2]. 그러므로 70세 이상 노인의 일상생활 중 발생하는 낙상 에 대한 각별한 주의와 관리가 필요하다[2]. 노인의 낙상 위험요인에는 신체적·심리적·환경적 요인이 있으며 신체적 요인에는 균형장애와 하지근력 저하가 포함되는데[4,5], 균형장애 정도가 심하고 하지근력이 저하되었거나 불안정할 때 낙상가능성은 증가하였다[4]. 심리적 요인에는 낙상효능감과 낙 상두려움이 포함되며 낙상효능감이 낮고 낙상두려움이 높을수록 낙상가능성은 증가하였다[4-6]. 환경적 요인에는 어두운 조명, 미끄러운 욕실 등이 포함되며 어두운 조명과 미끄러운 욕실에 노 출될 때 낙상가능성이 증가하였다[1,2]. 노인의 신체활동은 신체 기능의 중요한 요인으로 신체활동의 증진은 체력과 자립생활 능 력을 향상시키며 하지근력을 강화하고 균형장애와 보행의 불안정 성을 최소화하는 데 효과적이다[6,7]. 가사활동과 같은 저강도 신체활동의 비중이 높고 중정도 이상의 신체활동을 많이 하는 노 인은 낙상두려움이 낮았다[6,8]. 따라서 신체활동을 증진하는 것 은 노인의 낙상예방에 효과적인 전략일 수 있다. 낙상효능감과 낙상두려움은 낙상에 대한 대상자의 인지적 반응으로 신체적·환 경적 요인의 강화와 같은 낙상예방행위의 자발적 유지와 높은 상 관성이 있어 중재효과를 지속하는 데 효과적이다[9]. 낙상에 대 한 자기효능감과 낙상두려움은 유의한 상관관계가 있으며[10] 2014 노인실태조사에서 노인의 81.5%가 낙상두려움을 경험하는 것으로 나타났다. 낙상을 경험한 노인의 96.9%는 낙상두려움을 경험하였고 낙상에 대해 심리적 불안이 높은 노인이 낙상을 경험 할 확률이 높았다[11]. 낙상지식은 낙상효능감을 향상시키며[12] 낙상지식이 높을수록 낙상예방행위의 이행수준이 높고 낙상 발 생 가능성은 낮았다[13,14]. 따라서 낙상지식의 향상은 낙상위험 을 감소할 수 있는 전략으로 활용될 수 있으며, 노인이 낙상예방 행위를 지속할 수 있도록 낙상효능감과 낙상두려움에 대한 고려 역시 중요하다. 지금까지 낙상을 예방하기 위해 제공된 중재에 참여한 대상자 의 대부분은 60대 노인이었으며[5,15,16] 낙상의 빈도가 높고 낙 상 시 손상 정도가 심한 70세 이상 노인이 연구에 참여하는 비 율은 저조하여[3] 70세 이상 노인의 낙상예방에 효과적이며, 적 용 가능하고, 지속 가능한 중재에 대한 정보는 부족하다. 제공된 중재는 교육이나 운동을 단독으로 제공하거나[5,15,17] 교육과 운동을 복합적으로 제공[16,18,19]하였으며, 선택된 운동중재는 탄력밴드 혹은 덤벨을 이용한 근력운동[17,20,21], 걷기운동을 포함하는 유산소 운동[22-24] 등 다양하였다. 탄력밴드운동은 간단하게 부하의 강도를 조절할 수 있고 사용이 간편하여 노인 의 근력강화를 위해 많이 사용된다[21]. 노인에게 제공된 탄력밴 드를 이용한 12주 프로그램은 근력, 균형감(balance), 유연성, 보 행능력을 향상하였고[5,17] 낙상두려움을 감소시켰다[17]. 걷기 운동은 지역사회 노인의 71.7%가 실천하는 운동으로[1], 누구나 쉽게 활용할 수 있고 운동적응 능력에 따라 점진적으로 진행할 수 있으며 낙상 위험을 감소시킨다[7,25]. 또한 걷기운동은 체력, 일상생활능력, 낙상효능감 등을 향상시키는 효과가 있어[23] 노 인의 신체기능 증진을 위해 많이 이용된다[1]. 이러한 운동들은 비교적 쉽고 간단하게 적용할 수 있으며, 특히 효과적인 탄력밴 드와 걷기운동은 지역사회 노인의 낙상예방을 위해 많이 활용되 고 있으나 어떤 운동이 더 효과적인지에 대해서는 아직 알려진 바가 없다. 또한 낙상예방교육만 제공하였을 때와 운동과 함께 제공하였을 때 낙상예방효과에 차이가 있을지에 대한 탐색 역시 필요하다. 그러므로 70세 이상 노인의 낙상을 예방하기 위해 교 육단독중재와 교육과 탄력밴드나 걷기운동을 함께 제공하는 중 재 중 어떤 중재가 70세 이상 노인에게 더 용이하고 낙상예방에 더 효과적인지를 확인하는 것은 추후 지역사회에 거주하는 70세 이상 노인을 위한 낙상예방 전략개발에 중요한 근거를 제공할 것 이다. 2. 연구 목적 본 연구의 목적은 70세 이상 노인에게 제공한 낙상예방교육 단 독중재(이하 ‘교육단독중재군’)와 낙상예방교육과 함께 탄력밴드 운동(이하 ‘교육탄력밴드군’) 혹은 걷기운동(이하 ‘교육걷기운동 군’)을 제공한 복합중재가 낙상지식, 낙상효능감, 신체활동량, 신 체기능(하지근력, 보행능력, 균형감)에 미치는 효과를 비교·분석 하는 것이다. 3. 연구 가설 본 연구의 가설은 다음과 같다. 가설 1) 교육단독중재군, 교육탄력밴드군, 교육걷기운동군 간 중재 전·후 낙상지식의 변화는 유의한 차이가 있을 것 이다. 가설 2) 교육단독중재군, 교육탄력밴드군, 교육걷기운동군 간 중재 전·후 낙상효능감의 변화는 유의한 차이가 있을 것이다. 175 https://jkan.or.kr 고령 노인을 위한 낙상예방 중재 https://doi.org/10.4040/jkan.20203 가설 3) 교육단독중재군, 교육탄력밴드군, 교육걷기운동군 간 중재 전·후 신체활동량의 변화는 유의한 차이가 있을 것이다. 가설 4) 교육단독중재군, 교육탄력밴드군, 교육걷기운동군 간 중재 전·후 신체기능의 변화는 유의한 차이가 있을 것 이다. 연구 방법 1. 연구 설계 본 연구는 70세 이상 노인에게 제공된 낙상예방교육 단독중재 와 낙상예방교육과 탄력밴드운동 혹은 걷기운동을 포함하는 복 합중재가 낙상지식, 낙상효능감, 신체활동량, 신체기능(하지근력, 보행능력, 균형감)에 미치는 효과를 비교 분석하는 세 집단 사 전-사후 설계이다. 2. 연구 대상 본 연구의 대상자는 지역사회의 노인주거복지시설을 이용하는 70세 이상 노인이다. 노인주거복지시설은 노인들이 주거와 요양 을 목적으로 가정과 같은 주거공간에서 일상생활에 필요한 편의 를 제공받으며 생활하는 공간으로 양로시설, 노인공동생활가정, 노인복지주택 등을 말한다[26]. 대상자들의 자가 진술에 따라 선 정기준과 제외기준의 충족 여부를 결정하였다. 대상자 선정기준 은 국문 해독이 가능하며, 의사소통에 장애가 없고, 6개월 이내 에 골절 진단 혹은 골절 수술을 받지 않았으며, 탄력밴드운동을 수행하는 데 신체적 장애가 없고, 보조기구를 사용하거나 사용 하지 않고 스스로 30분 이상 걷기가 가능하며, 현재 다른 중재프 로그램이나 운동프로그램에 참여하지 않는 자이다. 대상자 제외 기준은 최근 1개월 내 주 150분 이상 규칙적 신체활동을 하고 있 거나 현재 의사로부터 움직임을 제한하고 안정을 취할 것을 권유 받은 자이다. 대상자 수는 G*Power 3.1.9.2 program을 이용하여 계산하였 다. 노인 낙상예방 프로그램의 효과를 메타 분석한 연구에서[27] 제시된 효과크기 범위(0.43~0.95)를 참고하여 큰 효과크기 (f = 0.40)를 기준으로 유의수준(α = .05), 검정력(1 - β = .80), 그룹 수(n = 3)로 산출한 결과, 총 필요한 대상자 수는 64명이었 다. 선행연구[28]를 토대로 약 35.0%의 탈락률을 고려하여 총 87명을 목표로 교육단독중재군 29명, 교육탄력밴드군 29명, 교 육걷기운동군 29명을 모집하였다. 본 연구의 주 연구자는 유사한 환경적 특성을 가진 4개의 주거 복지시설(A시 1개, B시 3개)을 방문하여 해당 시설장의 협조하 에 70세 이상 노인들과 일대일 면담을 통해 연구 참여에 동의를 얻어 87명의 대상자를 확보하였다. 연구 대상자들이 중재 기간 동안 그룹 활동에 쉽게 참여할 수 있도록 같은 시설에 있는 대상 자는 같은 그룹에 배정하였다. A시 1개 시설에서 모집된 대상자 29명은 교육탄력밴드군으로 배정하였고, A시 나머지 2개의 시설 에서 모집된 29명은 교육걷기운동군으로 배정하였다. B시 1개의 시설에서 모집된 29명은 교육단독중재군으로 배정하였다. 지역사회 노인 대상 선행연구[29]에서 총 12회의 중재 중 8회 (66.7%) 이상 참석하지 않은 대상자를 연구 대상자에서 제외한 기준을 참고하여 본 연구에서는 총 36회(주 3회, 12주)의 중재횟 수 중 25회 미만(69.4%)으로 참석한 대상자는 분석에서 제외하 였다. 교육단독중재군 5명, 교육탄력밴드군 3명, 교육걷기운동군 7명이 25회 미만의 참석률을 보여 연구 대상자에서 제외되었다. 추가적으로 교육단독중재군 중 1명이 사후조사 참여를 거부하였 고, 교육탄력밴드군 중 3명은 기저질환 악화로, 1명은 사후조사 … ACADEMIC LITERATURE REVIEW Role of physical activity in the prevention of falls and their consequences in the elderly Catarina L. N. Pereira & Peter Vogelaere & Fátima Baptista Received: 30 July 2007 /Accepted: 14 January 2008 /Published online: 23 February 2008 # EGREPA 2008 Abstract This work aims to provide an inventory of the risk factors and consequences of falling in the elderly, namely fractures, and to identify strategies to prevent falls and minimise their effects. Falls in elderly people are a major cause of injuries, leading to a general fear of falling, poorer quality of life and even death. The increase in life expectancy brought by developments in the medical and health sciences has not always brought enhanced quality of life. More elderly people live with reduced functional capacities resulting in a higher prevalence of falls and associated problems for themselves and for society. Risk factors for falling, commonly resulting from normal aging processes, have already been identified through multiple studies. Exercise may play an important role in fall prevention and their consequences. Although, effective strategies are usually multi-disciplinary and focus simultaneously on several risk factors. However, only large-scale prevention programmes can have significant effective social impact. To minimise occurrence and con- sequences of falls, policies to systematically implement prevention programmes should be established. Keywords Falls . Risk factors for falling . Elderly. Fractures . Physical activity Problems of falls Falls are a major health problem among the elderly. Thirty percent of people aged 65 and older living in community fall at least once a year [127], and this rate increases with age [108]. As life expectancy increases, there is a higher number of less healthy and less fit elderly people living longer with their infirmities [46, 89, 107]. Consequently, the risk of falls and their consequences is now greater than before [78, 129], as is illustrated by statistics from Finland [75]. Falls are the major cause of death related to mechanical injuries in the elderly, and the mortality rate increases when the individual fall rate increases [41, 45, 112]. According to Rubenstein et al. [119], about 4% of falls result in fractures and about 11% result in other serious injuries such as head trauma, soft tissue injuries and severe lacerations. Those who survive falling commonly restrict their activities due to soft tissue injuries and fractures [15, 80]. Besides injuries and more evident physical consequences, psychological consequences must also be considered: the fear of falling leads to a large percentage of the elderly individuals restricting their activities [22, 48, 130, 137]. Both of these reasons for loss of functionality can result in the “post-fall anxiety syndrome.” Less confidence in the ability to walk safely can lead to further functional decline, depression, feelings of helplessness, social isolation [83, 100, 119] and consequently a loss of quality of life [3]. Inevitably, also, falls and fear of falling are among the major reasons for the institutionalisation of elderly people [41, 49]. According to these factors, falls in the elderly and the resulting injuries have to be considered a social concern, Eur Rev Aging Phys Act (2008) 5:51–58 DOI 10.1007/s11556-008-0031-8 DO00031; No of Pages C. L. N. Pereira (*) : P. Vogelaere Department of Health and Well Being, University of Évora, Pavilhão Gimnodesportivo, Prolongamento da Rua de Monsaraz, 14, 7000 Évora, Portugal e-mail: [email protected] P. Vogelaere e-mail: [email protected] F. Baptista Exercise and Health Laboratory, Faculty of Human Movement, Technical University of Lisbon, Estrada da Costa, 1495-688 Cruz Quebrada, Portugal e-mail: [email protected] not only because of health care costs but also due to psychological problems associated with behavioural modifi- cations, which restrict functional mobility, thus promoting physical dependence and potential changes in lifestyle [135]. Risk factors for falling and fractures Falls are defined as any incident in which a person “suddenly and involuntary come to rest upon the ground or a surface lower than the original station” [62, 98]. Fall consequences, such as fractures, depend fundamentally on three factors: & Risk factors related to fall occurrences, such as health problems, activity and physical environment & Risk factors referring to bone strength, namely bone mineral density (BMD), bone structure or the spatial arrangement of the bone trabeculae and bone quality or the mechanical properties of the bone tissue & Risk factors associated to the impact of the fall, i.e. fall severity, floor material, soft tissue surrounding the impacted bone, etc. [8, 32, 51, 84, 85, 106] Fractures may occur in any bone of the skeleton. Humeral, fist, pelvis and hip fractures are positively correlated with age and usually result from the combined effects of osteoporosis and the fall proper [15, 76, 77, 95, 101, 105]. Fractures of the vertebrae, also common, are generally associated with osteoporosis [99] and produce a high rate of morbidity and mortality [102]. However, falls may not be the determinant factor of this occurrence in the spine. Table 1 presents the most cited risk factors for falling according to several authors [2, 3, 8, 9, 49, 51, 64, 65, 71, 72, 74, 76, 77, 85, 91, 100, 103, 106, 111, 113, 114, 116, 119, 120]. In the elderly living in communities, the majority of falls occur during usual activities, such as walking or changing position [129, 130]. They happen mostly at home, so that a “safe home” is fundamental [90, 129]. Only 5% of falls are the consequence of clearly hazardous activities, such as climbing on a chair or a ladder or participating in sport activities. About 10% of falls occur on stairs. It has been shown that going downstairs is more hazardous than climbing [129, 130]. Environmental factors are responsible for most falls, although they are not the main cause for Table 1 Risk factors for falling Intrinsic risk factors Extrinsic risk factors Chronic Temporary Activity Environmental Age over 75 years Loss of conscience Usual activities Indoor: Incapacity and chronic diseases usually associated to the degenerative process of aging: Medication/drugs/ alcohol Hazardous activities Bad lighting Degenerations and disturbances of the nervous and muscular–skeletal system functions and consequent decrease Other hallucinogenic substances Slippery floors, loose rugs, telephone threads, other objects of functional capacity: reaction speed, Ladders muscular strength, reflexes, balance, mobility, gait pattern and speed Stairways with steep steps, without walls and/or handrails Kitchen with difficult access to utensils and movable tables Bathroom without handrails for tub, shower and toilet and non- skid mat in tub or shower Bed too high or too low Urinary incontinence Outdoor: Deficient vision Uneven pavements, streets, paths Vestibular function disturbance Repair works, obstacles Audition loss Slippery floors Cognitive function disturbance Rain, snow and ice Insanity Traffic Depression Public transport Memory loss Animals Neurological pathologies such as Parkinson’s disease FootwearSecondary effects of medication 52 Eur Rev Aging Phys Act (2008) 5:51–58 falling. However, few falls result from unpredictable events [129]. According to Bath and Morgan [13], falls in outdoor and indoor environments present different risk profiles. Risk factors associated with outdoor falls are both intrinsic and extrinsic. Intrinsic risk factors include decreased functional capacities such as reduced strength and/or reduced gait velocity, while extrinsic factors are related to hazardous environments and performances outside habitual activities. Risk factors associated with indoor falls are mainly intrinsic and their occurrence increases when the elderly are housebound, due to poor health, frailty or to the use of high levels of prescribed medications. It is important to note that people falling at home present a higher mortality rate, although the relationship between causality and effect is still unclear. Table 2 provides a review of the risk factors for fractures due to falling [32, 60, 65, 74, 93, 94, 103, 105, 106, 122, 134]. Bone strength is determined 65–80% by BMD (quantity of bone mineral per square or cubic centimetre) and 20– 35% by bone structure (spatial arrangement of the bone trabeculae), as well as by bone quality (the material properties of bone tissue) [71, 106]. BMD, in turn, is determined by genetic and hormonal factors, body compo- sition, nutrition, physical activity, chronic diseases and the use of medication [16, 29, 35, 39, 71, 106, 111, 120]. Evaluation of BMD may be performed by dual-energy X-ray absorptiometry [25]. Osteoporosis is diagnosed in post-menopausal women and in men age 50 and older if BMD expressed as T-score is −2.5 or less at the lumbar spine, total hip of femoral neck [66]. The T-score indicates how many standard deviations (SDs), above or below the average value, the result in question actually lies. The reference standard from which the T-score is calculated is the BMD of the young adult age 20–29 years. A T-score between −1.0 and −2.5 SDs indicates low bone density or mass, also usually referred to as osteopenia. Contrary to osteoporosis, people with low bone mass are not necessar- ily at high fracture risk [21, 74]. The risk of falling and fracture is related to the number of existing risk factors and is potentiated by the interaction and cumulative effects of multiple risks [32, 36, 128, 130]. However, many of those risk factors can be avoided [128, 134] or reduced when some contributing factors are modified by intervention programmes [114, 122, 130], particularly, when these programmes are multi-factorial [37, 90, 115]. Prevention strategies for falls and fractures Most elderly people are not aware of their predisposition to fall nor identify their inherent risk factors, and thus they cannot express their limitations to a physicians or other healthcare personnel. Consequently, as prevention is often overlooked, the risk becomes evident only after a lesion or incapacity due to a fall [19, 28]. The correct diagnosis of this reality is fundamental. The use of proficient instruments to recognize the predisposed risk factors responsible for the occurrence of serious lesions and the evaluation of behavioural risk factors allow the identification of populations and individuals at risk [44, 98, 104, 115, 123]. This knowledge leads to the setting up and implementation of efficient intervention programmes— focussed on the existing risk factors and providing answers to the needs of the individual or specific population groups (age, gender, functional competence, clinical condition, type of performed activities, etc.) [62, 98, 104, 127]. Physical exercise programmes Independently of individual differences, fragilities or pathologies, light- to moderate-intensity exercise pro- grammes revealed to be effective in the prevention of falls and their consequences. Tai-chi, step, strength, Table 2 Risk factors for fractures due to falling Risk factors Risk factors inherent to the individual: Age (specially over 75 years) Female (vs. male) Family history of fractures due to osteoporosis (maternal hip fracture) Recurrent falls in previous year Previous fracture caused by a low energy impact Osteopenia, osteoporosis and associated disorders Low body weight (body mass index <19 kg/m2) Bone structure: geometry and lenght Corticosteroids treatments Hormonal factors Behaviour risk factors: Nutritional factors Low consumption of calcium (<700 mg/d) Vitamin D deficit (low exposition to sun light) Physical inactivity Tobacco Alcohol Factors that potentiate falls impact: Height (the taller the person the greater the impact) Decreased muscular and fat mass Lateral falls Point of impact on the bone (for instance the femoral neck) Loss of defence reflexes Floor surface No use of artificial shock absorber (reduction of the occurrence of fractures by 40%) Eur Rev Aging Phys Act (2008) 5:51–58 53 agility, stretching and multi-modal training or adhesion to specific programmes of exercise directed to prevent falls have reduced fall events, falls injuries and also fear of falling [2, 11, 20, 26, 27, 34, 38, 42, 86, 91, 116, 127]. Exercise may prevent falls and their consequences either in healthy old people or in elderly people with medical conditions like osteoporosis, Parkinson, diabetes, physical or visual impairment and even after a stroke [6, 10, 14, 38, 61, 82, 99, 110]. Maintenance or recovery of the elderly physical function- ality through such exercise programmes [1, 27, 33, 60, 73, 86, 87, 133], besides decreasing fall rate and its consequen- ces [18, 47, 92, 96], contribute to improving the quality of life [109]. To be effective, these programmes, performed on a daily basis, have to be focussed on functional capacities, such as coordination, agility, balance, mobility, muscular strength and flexibility [12, 50, 63, 113–115, 121, 123, 135]. They should also include multi-sensorial training [67, 116], as well as exercises like walking, stepping up- or downstairs, and carrying objects [2, 87, 116]. Training programmes aiming to improve weight-bearing bones and muscles can also improve functionality, reduce fall severity and even lower the mortality rate [24, 53, 69, 81, 124]. Regarding bone health, increase of bone strength during pre-puberty and adolescent years is fundamental for the prevention of osteoporosis and related fractures in older people [58, 72]. Mechanical loading such as high-impact and resistance exercise enhances peak bone mass during growing years and prevents bone loss during aging throughout bone formation stimulation [76, 81, 97, 124]. Recently, the use of high-frequency vibratory platforms has showed significant increase of bone mineral at the hip level, associated with an improvement of balance [57]. These exercise programmes need to be long-term projects, as any interruption will induce a reversibility of the benefits in health and function, especially at the muscle and skeleton levels [18, 23, 40, 81]. Moreover, decreases in physical performance associated with the lack of activity in the elderly are associated with dependence and the incapacity to perform daily tasks [52]. As it has been exposed, studies suggest that a moderate level of physical activity can reduce the risk of falls and prevent their consequences like fractures and other injuries [17, 55]. Even light or vigorous exercise can produce health benefits [18, 88]. However, there are no guidelines for exercise prescription, namely the optimal intensity and amount of activity necessary to prevent falls. “Staying active–staying safe” [4] does not mean the greater the amount of physical activity the better. In fact, several authors exposed that either inactivity or excessive physical activity may conduce to the occurrence of fall events, particularly when heavy tasks are involved [30, 54]. The higher rate of falls associated with inactivity seems to be due to the usual function decline of sedentary elderly people [38, 59, 97, 125]. The higher rate of falls associated with excessive physical activity may be due to the fact that people fall when they are moving, especially performing heavy tasks in a non- controlled environment, and then the probability of the occurrence of an accidental fall is amplified [7]. Multi-disciplinary programmes In addition to the evidence that interventions centred on physical exercise are beneficial, literature also reveals the importance of multi-faceted intervention in the prevention of falls and consequent fractures [43, 62, 90, 127]. Besides exercise, prevention programmes must include strategies to improve cognition, especially the capacity to perform dual- task walking to ensure appropriate nutrition, particularly ingestion of calcium and vitamin D, and when appropriate to change prescription of drugs with possible negative secondary effects. Home assessment performed by specialised personnel and continuous counselling about safety conditions in the house and its accesses are also recommended. Such work has to be performed in close consultation with the subjects in their local environment [5, 9, 43, 64, 68, 70, 117, 136]. It is not yet clear which is the most valuable component in a multi-factorial intervention programme. However, prevention programmes have already been implemented and are providing effective results [31, 56, 86, 103, 114, 126, 132]. Despite a universally successful prevention strategy is not applicable because falling and consequent fractures depend on each faller [62], preventive measures need to be implemented systematically and performed on a large scale [79, 118, 131]. Conclusion For the elderly, falls and fear of falling induce loss of autonomy and reduce the quality of life. Aside from the financial costs, falls cause both physical and psychological suffering. Risk factors for falling are multiple and well documented, as are their consequences. Most risk factors are due to normal aging processes and can be attenuated or eliminated. Others are intractable, which means that the elderly must simply learn to live with them. Physical exercise should be part of a multi-disciplinary strategy to prevent falls and their consequences to maxi- mise intervention benefits. 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