Falls in Older Adults and Their Risk Factors

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Introduction

Falls have recently become one of the most documented cases in hospitalization, especially when it concerns acute medical units. Although falls can touch all groups of the population, most of them happen to geriatric people (Murphy, Labont, Klock, & Houser, 2008). Falls are known to bring about higher mortality, morbidity, functional decrease, and premature institutionalization. Although intrinsic factors (such as gait dysfunction, balance disturbances, weakness, sensory impairment, and illness) are rather logical reasons for falls, extrinsic factors (such as equipment failure, trip dangers, or others) are always underestimated being no less hazardous. Elders are particularly susceptible to falls because they are often at risk (Murphy, Labont, Klock, & Houser, 2008).

Hence, the project will explicate the significance of the environmental factor for the elderly people, aged 65 years old and more that are exposed to falls. Thus, the purpose of this paper is to define whether the number of falls is likely to reduce with the change of the environment or it will remain equal to that existing under the normal environment. Moreover, the study at hand is aimed to find out whether the change of the physical environment of elderly patients is crucial in performing effective fall prevention.

Background

Falls are significant health risks among people aged beyond 65 years (Murphy, Labont, Klock, & Houser, 2008). Although falls are associated with various risk factors, the environment constitutes one of the leading causes of falls among senior citizens. Slippery floors, lack of handrails, and loose rugs are also environmental factors that contribute to falls among the elderly citizens. Indeed, other factors such as old-age instability, poor eyesight, and historical background of ailments, for instance, depression and arthritis, contribute to falls when interacting with environment. Hence, there is a need to improve the interior house environment, the immediate external environment of the dwellings of old people, and even the pedestrian surroundings to minimize incidents of falls among high-risk people. One way of accomplishing this goal is by complying with strict building guidelines to enhance the safety of the elderly people. Secondly, there is the need to conduct environmental assessment and/or put in place interventions for reducing falls. Although past literature documents no significant reduction of falls due to environmental assessment, it is important to remove hazards such as loose rugs and slippery floors that can increase the risk of falls among senior citizens. Environmental modification as a mechanism for reducing falls among senior citizens has the benefit of cutting down costs incurred in emergency admissions that arise from injuries sustained from falls (Schwendimann, Bühler, De Geest, & Milisen, 2006).

Clinical Significance

Primarily, it is essential to point out that the problem of falls in elderly patients aged 65 years old and above is highly acute and needs to be addressed in a most efficient manner. Hence, in their research, Ambrose, Paul, and Hausdorf (2013) show that about 40% of patients has an experience of falling (p. 51). The researchers point out the fact that such falls cause a series of negative consequences including severe injuries and psychological fears of losing the balance (Ambrose, Paul, & Hausdorff, 2013). It is evident from the study that the need for an effective intervention for designed specifically for this population is very strong. Thus, the question consequently comes up regarding the choice of the approach to falls prevention. In other words, it is critical to decide which factor of danger should be primarily addressed in order to help elderly people avoid falls. Researchers distinguish various factors that affect the risk rate of falls in elderly patients, including fragility of bones, altered physiologic reactions, and negligent management of medication (Schwendimann, Bühler, De Geest, & Milisen, 2006). Besides the enumerated causes, such aspects as impaired balance, elderly age, and surrounding environment are commonly pointed out (Leland, Elliot, O’Malley, & Murphy, 2012).

Theoretical Framework

The theoretical framework to guide this evidence-based project is the hypothesis that environmental factor in falls prevention is a constituent of paramount significance, whose impact on successful fall prevention cannot be overestimated (Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson, & Lamb, 2012). Florence Nightingale’s Environment Theory is probably the first attempt to emphasize the importance of the outer conditions. The Theory claims that the environment should assist patients in their recovery, and biologic processes are directly affected by the external factors, such as air, water, light, and cleanness (Selanders, 2010). Therefore, changing the environment is one of the ways of reducing the risk, in this case, risk of fall. It is assumed that external risk prevention is one of the key ways affecting the rates of falls in elderly patients (Selanders, 2010).

It should be noted that the method of fall prevention through changing the environment has been discussed intensively throughout the past decades. Thus, it is assumed that a positive change in the home environment is likely to reduce the risks of falling. First of all, the environmental factor implies physical factors that might increase the risks of falls in elderly people (Leland et al., 2012). Hence, for instance, such items as floor mats, bathroom handrails, rugs, etc. can represent a hazard to the mobility of elderly people in case they are poorly fixed or installed.

In the meantime, the physical side of the environmental factor is not the only aspect that is significant for fall prevention. Hence, some studies have been carried out in order to evaluate the psychological aspect of the environmental factor in the framework of falls prevention program. Thence, for instance, recent research has revealed that a consistent home modification results in a series of positive outcomes.

The examined population was comprised of elderly patients exposed to falls. According to its findings, the change in the environment can reduce the psychological fear of falls in elderly people. Otherwise stated, it is proposed that a large number of falls in elderly patients might be partially explained by the fact that they experience severe psychological pressure because they are afraid of repeated falling. Therefore, all the research literature at hand proves that it is essential to create such an environment that will be psychologically comforting and will contribute to the feeling of safety in elderly people (Chase, 2012).

Rationale for Falls Prevention Environment

A successful strategy for preventing falls needs to consider all factors that contribute to falling among people aged 65 years and above. Such people have psychological fears that they have lost balance. Balance is an important factor that determines the capability of an individual to move while in a variety of environments, including rough terrain, smooth floor, climbing staircases, and/or walking on carpeted floors among others (Pighills, Torgerson, Sheldon, Drummond, & Bland, 2011). Therefore, a discussion of fall prevention among people of different ages must not fail to include the environmental factor. The rationale for selecting environmental modification as the Florence Nightingale’s Environment Theory reviewed in terms of how it helps in preventing falls among people aged 65 years and above is founded on the notion that people must always interact with the environment in their daily activities. Any other theory attempts to explain how well people should interact with environment when moving to ensure that falls do not occur.

Falls among old people constitute a leading cause of mortality. Despite putting amicable efforts to try various interventions for preventing falls, there remains a wide variation of components of interventions in a clinical context. Hence, policymakers, patients, and clinicians have not yet clearly understood the essential aspects of preventing falls. This challenge underlines the rationale for selecting environmental modification as an important theory for helping to understand the potential interventions to falls in the attempt to reduce mortality and morbidity associated with falls among senior citizens.

Literature on falls prevention among old people identifies various factors that contribute to falls, including reduced strength that naturally comes with old age, the number of medications taken, and other factors that are external to the old people such as the nature of the floor and lighting conditions. However, environmental conditions remain important factors in which all other risk factors collectively interact to the extent that when the number of risk factors rises, the risk of fall linearly goes up (Shilpa, Sengupta & Anoop, 2015). It is important to note that interventions to falls focus on reducing the risk factors. However, the essential aspects are not well understood. To this extent, this paper focuses on examining literature on falls that arise from the condition of the environment. This review has the implication of helping to develop a greater understanding of how the environment contributes to falls and the possible interventions for reducing falls through appropriate environmental modifications.

Literature Review

Majority of households have elements that can potentially cause falls. Such aspects include slippery floors, poor lighting conditions, loose rugs, walkways that have obstructions, and unstable furniture (Shilpa et al., 2015). Coincidentally, many elderly people relate their falls to trips and/or slips while at home or within the immediate surroundings (Pighills et al., 2011). Responding to this concern, researchers have proposed the making of appropriate modifications at home as an integral and incredibly important aspect of preventing falls. Nevertheless, Shilpa et al. (2015) point out that the contribution of the environment in increasing the risk of falls is not straightforward. This assertion is important since people’s physical abilities and problems that the environment poses do not interact in a simplistic manner. This situation lowers chances of deducing cause-effect relationships.

Clinicians theoretically contend that the environmental condition is an important contributing factor to morbidity and mortality, which are associated with falls. However, all buildings are built in compliance with specified standards to guarantee safety for all. This requirement eliminates any possibility of modifying the household environment to help in demonstrating the contribution of home-related hazards in increasing falls among the elderly people (Shilpa et al., 2015). Therefore, the only data available on this cause-effect relationship is where safety assessments reveal that falls occur due to non-compliance of a house hosting elderly people with building requirements. Therefore, testing of the efficacy of the environmental interventions in preventing falls among old people cannot be practically understood. However, the contribution of falls in impairing the health of old people warrants scholars to study it, despite difficulties in demonstrating the efficacy of the environment in contributing to the problem.

Falls are common among old people. Indeed, Kumar et al. (2013) asserted that falls involved loosing balance unintentionally to the extent of leaving an individual in contact with the ground, floor, or any other surface. They emphasized not only helplessness but also potential dangerous outcomes of the situation.

To demonstrate the intensity of the problem, Shilpa et al. (2015) quote the World Health Organization’s data gathered in 2008 indicating that 424,000 people die annually due to fall-related causes. Fall injuries correspond to 11% of the total unintentional damages that lead to deaths across the world.

El-Sobkey (2011) asserts that 33% of people who are more than 65 years old fall every year. Moreover, most of these people cannot avoid deplorable consequences for their health and psychological attitude to safety and health issues (El-Sobkey, 2011).

In the Indian context, Gutta, Joseph, Chakraborty, and Alexander (2013) state that 51.5% of the total elderly population has reported to have fallen at least once. Impaired balance, diseases such as arthritis, visual problems, and even depression are some of the strongest factors that contribute to falls. Traumatic injuries of the brain, fractured hips, and injuries in upper limbs are major causes of admissions that relate to falls among the elderly people. Gutta et al. (2013) insist that despite the ability to demonstrate the interaction of various factors that lead to falls, people should understand that it is possible to prevent these occurrences via appropriate environmental modifications.

Gyllencreutz, Bjornstig, Rolfsman, and Saveman (2015) studied falls among senior citizens in a Swedish context. The researchers state that their main concern was to examine injuries related to senior citizens with an important focus on healthcare costs encountered by the study group because of falls. However, the study only focused on pedestrian falls. Using methods of quantitative research, injury data and questionnaires, the researchers reported that 300 elderly people had attended an emergency department with injuries sustained from falls. Majority of these people suffered from fractures. About 20% of the studied sample was hospitalized. This number incurred 6.3 million Euros within a period of 8 days. Findings included that ice was a major environmental factor that contributed to the falls. While some of the elderly people claimed they were not responsible for the fall, some others proposed important outdoor environmental improvements to reduce the problem. Those who evaded responsibility claimed that the municipality should take the blame. The authors recommend using preventive products, consistent preventive maintenance of roads, and alteration of people’s behaviors (Gyllencreutz et al., 2015).

In the context of the United States, falls constitute the leading cause of death among people aged 65 years and above. To reduce these health problems, Gutta et al. (2013) propose the importance of home modification to ensure that frail people are free from hazards that contribute significantly to falls. This strategy is important since many falls (over 50%) occur inside homes among old people. More than 23% of falls occur within the vicinity of houses while about 22% occur far away from the residences of the old people (Gutta et al., 2013). Hence, many of the falls among old people occur within their dwellings. One mechanism for reducing these risks is by ensuring that such residences of old people do not have loose rugs on which they can trip over. The houses should have handrails installed. The replication of the environmental variable is in many situations of falls implies that it is sensible to reduce environmental hazards, especially within dwellings for old people to manage the problem of falls.

England exemplifies how home modification can be integrated into the national policy for promoting the health of the elderly. As a national policy, England recommends an assessment of living environments to be conducted with the primary objective of identifying and eliminating all potential hazards. To accomplish this objective, builders and homeowners should hire only highly skilled personnel. The nation upholds this requirement, despite difficulties in relating falls’ epidemiological studies with the manner in which hazards lead to falls. In addition, studies on environmental assessments coupled with home modifications give rise to conflicting results (Pighills et al., 2011). Nevertheless, this observation does not suggest that appropriate home modifications should not be adopted to manage the risks of falls among the old people.

The estimate of environmental assessment and modifications, including how these two strategies contribute to the reduction of falls varies based participants’ level of risk. This level varies with age, the history of taking medications, stability, and the person conducting the estimates. A meta-analysis of modifications based on the environmental assessment has reported about 21% decrease in falls (Pighills et al., 2011). Such analysis has also concluded that occupational therapists play an important role in providing interventions to old people. The interventions effectively reduce falls among high-risk groups. The most successful intercessions comprehensively evaluate and/or identify falls hazards by not only deploying validated assessment tools but also conducting an intensive analysis of participants while in their environments. Such interventions also guarantee adequate and effective follow-ups accompanied by supportive measures that increase the participants’ adaptability to the environment.

One of the important hindrances to providing effective interventions and modifications that reduce the risk of falls among the elderly people is the availability and affordability of professionals to offer the services. Where their services are available, they are prohibitive in terms of cost. Therefore, a potential intervention is to evaluate whether untrained people who have ardent access to falls of high-risk elderly people can effectively provide the much-needed services. However, such evaluation is difficult since no study has been conducted evaluating the differences in effectiveness of trained and untrained people in the provision of environmental interventions that address the issue of falls among the vulnerable elderly people. Indeed, Pighills et al. (2011) report, “all non-occupational therapists (OT)-lead trials were of low intensity and in low-risk populations” (p.27). This finding does not tackle the problem of addressing falls that can be prevented through environmental interventions among high-risk groups.

A drop of falls among senior citizens is necessary and significant if deaths that are related to fall injuries among this group of people is reduced. In case of falls that occur outside the home environment, community planners need to guarantee accessibility to pedestrian environments among people aged 65 years and above (Edwards, 2011). In addition, emphasis should be placed on ensuring that outdoor and indoor environments are safe for the elderly people. This recommendation underlines the need for conducting environmental assessment coupled with modification that can help to improve the mobility of senior citizens in a less risky manner (Pighills et al., 2011). While the aid of a trained or untrained person may be important in ensuring that the elderly people do not fall, it is imperative to ensure that they retain their freedom of independent mobility.

Research Design

Research can be designed as either qualitative or quantitative. It can also deploy mixed methods (pragmatic research design) or take the form of participatory or advocacy research framework. The research at takes a pragmatic approach. It offers a discussion of EBP’s project research design, describes the research population, mechanisms for protecting the participants, methodology deployed in data analysis, and the timeline for the research.

The research will use the mixed approach combining qualitative and quantitative methods, and a pragmatic research design. Freshwater, Sherwood, and Drury (2006) posit, “Pragmatic researchers grant themselves the freedom to use any of the methods, techniques, and procedures that are typically associated with quantitative or qualitative research” (p.295). The selected methods depend on a researchers’ perception and evaluation of methods that best suit the particular type of study. In the research on elderly falls, the best design should comprise methods that can complement each other. This assertion underlines the logic for designing the research as a pragmatic study, which uses aspects of qualitative and quantitative research.

The effectiveness of qualitative study requires the demonstration of various features of excellence. Qualitative research has some drawbacks such as the lack of validity since it is important to add rigor, subjectivity, and creativity in a scientific process. Rigor is incredibly important in all systematic qualitative researches (Finlay, 2006). In such researches, the deployed data only needs to follow a certain criterion in establishing differences or relationships.

The current research determines the prevalence of falls experiences among elderly people living in the three homes. It establishes the mechanisms, which the homes have adopted to prevent and/or manage falls among elderly people. In determining the prevalence levels, the quantification of falls experiences is important. This goal can only be realized if quantitative data is also collected.

Instrumentation

The instrument deployed in the data collection is the interview, which allows to collect both statistical (quantitative) and qualitative data simultaneously, assessing the percentage of the respondent as well as the content of their answers. Elderly people will provide quantitative and qualitative information about their experiences with falls. The method includes a survey, which will be vital in interpreting the study. The interview will involve structured questions, which are known to be best for quantitative interviews since they do not need extra information from a respondent (Leedy & Ormrod, 2005). The research will use the face-to-face interview, which will help in establishing a good rapport with the participants to win their cooperation. In addition, besides clarifying ambiguity in answers, the interview approach can provide information for follow-up.

Participants, Sample and sampling

The students to be interviewed will be sampled randomly from the three elderly homes. The focus will be on the extent to which people think their lifestyles dictate their consumption behaviors. Quantitative research begins with the selection of a sample size or the number of research subjects. The sample size varies according to the expected statistical confidence levels. The proposed research emphasizes defining the role that the change of the physical environment of elderly patients plays in performing effective fall prevention. A reasonable sample will be selected to obtain reliable information. Therefore, selecting a sample size that can yield powerful qualitative and quantitative information will be pivotal in making appropriate recommendations on the necessary changes in elderly people’s physical environments to reduce falls. While selecting the subjects of the study, certain parameters of the sample must be known. Saunders, Thornhill, and Lewis (2009) identify them as confidence interval or error margin, the size of the studied population, the expected confidence level, and the Standard Deviation (SD).

In this research, the total number of over 65-year-old people in the three elderly homes may be important. Although this number may be obtained from the respective elderly homes’ administration, the research may still be conducted without it. In most studies, the population is commonly unknown (Saunders et al., 2009). The only important thing is to determine the most appropriate demographic group of the study. The demographic group for this research comprises elderly people of 65-year-old or beyond. Only people in this category will be included in the research. Elderly people below this age limit are excluded as their dependence on the environment is not so evident and demonstrative in terms of falling because their coordination and general physical health is much better.

After determining the target group, establishing research confidence interval follows. Samples are never perfect, which means that the importance of setting limits for the permissible error or the confidence level. Scott (2011) reckons, “Confidence level determines how much higher or lower (than the population) researchers are willing to let their sample mean to fall in” (p.89). The current research uses a standard value of +/-5. This range means that the research will use 95%confidence interval.

Standard deviation refers to the degree to which the interviewee responses should vary. This research uses a SD value of 0.5, which is the most convenient figure that gives the chosen population portion a recommendable size. Different confidence levels correspond to the different Z-score values. A 95% confidence level corresponds to a Z-score value of 1.96. This value makes it possible to compute the sample size.

Substituting the chosen values in the equation yields 385 as the sample size or the required number of subjects.

Procedure

At the beginning of the interview, the researchers will explain to the respondents the research purpose and its significance to the management of health challenge associated with falls. A respondent will be interviewed for a maximum of 10 minutes. The interview will begin by capturing a respondent’s demographic information such as his or her educational background, age, and gender. In order to obtain more detailed information, questionnaires will also be administered to collect information on the respondents’ experiences with falls, admission rates due to injuries associated with falls, and their perceptions on the necessary remedies for dealing with the problem. No control groups will be deployed. The research will be conducted according to the following procedure.

The established 385 copies of interview questions will be distributed without selecting the target audience in the elderly home
The respondents will indicate their data in the questionnaires
After collecting the filled questionnaires, the next step would involve analysis
After the analysis, the results will be presented followed by a discussion of the findings

Participant Protection

Although face-to-face interviews are administered to help in collecting both quantitative and qualitative data, it is necessary to keep the identity of the research participants protected. Where the qualitative data for a specific interview with a participant is referred in the interviews, pseudonyms will be employed. The participants will also be assured that the information provided will be treated with utmost confidentiality and anonymity. This plan will avoid the shifting of blame and liabilities concerning falls experienced by elderly people within their homes to the designers or owners of the facilities. Hence, the research fulfills its goals from a neutral position.

Data Analysis Methods

The analysis of the data generated will yield numerical data that will need to be analyzed to draw inferences. For example, correlation and relationships will have to be determined. This process requires data processing and analysis skills, which the researcher does not currently possess. Therefore, the services of a qualified statistician will come in handy in order to come up with the results how many elderly people really suffer from falls not because of their state of health but because of unfavorable living conditions.

Project Timeline

Week 1: Review and submit proposal to the IRB and get approval from the setting in which I will be conducting the EBP research
Week 2: Consult with the elderly homes to secure an interview opportunity
Week 3: Review data analysis software programs and consult with the instructor to determine the one that is appropriate for use
Week 4: Collect data assuming the proposal has been approved by the IRB
Week 5: Recruit the data analyst
Week 6-7: Analyze data and submit findings

Conclusion

Research methodology describes the processes through which researchers acquire data on a given topic. It also shows the tools used in the analysis of the results in addition to the mechanisms of interpreting the results. Research methods have diverse characteristics. The selection of an appropriate methodology depends on the available resources, objectives, and goals of the research. The selected methods need to fulfill certain requirements to arrive at valid results and recommendations that can lead to solutions of the problem under scrutiny.

The research proved that falls prevention is a complex multi-faceted process, which is influenced from both the inside and the outside. Environmental danger prevention turned out to be acceptable to elderly participants of the survey (especially by those who are uncapable of managing intrinsic factors owing to the state of health) and feasible to provide. It showed rather promising results, proving that this multicomponent intervention to diminish the outcomes of the disability should be evaluated in a larger trial in order to address all possible aspects.

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