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PICO(T) Questions and an Evidence-Based Approach

It is of utmost importance to develop new patient care practices or implement changes to the existing ones, thus making them reflective of the recent trends in the field. The so-called PICO(T) method is used to guide the process of data collection since it allows practitioners to formulate specific questions. This paper is aimed at applying the abovementioned framework to the issue of the potential low-cost strategies to prevent injurious falls in elderly patients.

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PICO(T)

Despite the presence of multiple studies specifying appropriate approaches to the prevention of falls, modern researchers are still searching for additional cost-effective strategies that would be of benefit to nurses and elderly patients. Multiple interventions for fall reduction involve the use of technology, such as bed alarm systems, which can be both resource-consuming and unreliable. Today, researchers widely discuss the fall prevention potential of methods that are cost-saving and easy to implement, such as the use of vitamin supplements.

This paper explores the following question: does the regular intake of vitamin D supplements reduce the incidence of injurious falls in patients aged 65 and older if compared to receiving no supplements? The time frame is not particularly relevant in this case, so this element has not been included.

Sources of Evidence

Evidence to support nursing and medical interventions can come from a variety of sources. The four sources of evidence that touch upon the identified research question include recent studies of different types published in peer-reviewed journals. The evidence to inform decision-making concerning vitamin supplements as a fall prevention strategy comes from a single RCT by Smith, Gallagher, and Suiter (2017) and a meta-analysis of trials by Tricco et al. (2017). Other sources of evidence are the systematic reviews of randomized trials conducted by Tang, Juraschek, and Appel (2018) and by Bolland, Grey, and Avenell (2018).

Since the sources may provide conflicting findings regarding the effectiveness of supplements for fall prevention in elderly adults, it will be of utmost importance to classify the studies in terms of relevance to the research question. Thus, after reviewing the key findings reported in the four sources, it will be critical to evaluate the studies based on their relevance and ability to inform clinical decision-making.

Key Findings

The most enthusiastic findings are reported in the single RCT by Smith et al. (2017). In the study, more than a hundred women aged from 57 to 90 were randomly divided into eight participant groups that received one of the seven doses of vitamin D or placebo drugs (Smith et al., 2017). There were no significant decreases in fall rates in the groups receiving high and low doses of vitamin D compared to placebo. However, the daily intake of medium doses (1600-3200 IU) resulted in a reduction of fall rates (58% in placebo against 30% in patients taking medium doses of the vitamin) (Smith et al., 2017, p. 320).

The systematic review by Tricco et al. (2017) does not include studies focusing solely on the uses of vitamin D but notes that such measures are among the elements of multi-interventional strategies that are effective. Based on the meta-analysis of RCTs, fall prevention strategies using a combination of quality improvement interventions, multifactorial assessment, and vitamin D/calcium supplements are much more effective compared to usual care (Tricco et al., 2017).

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The authors of other articles take a more critical approach to the potential of vitamin D intake as a fall prevention strategy. Thus, Tang et al. (2018) analyzed thirty RCTs devoted to vitamin D in fall prevention with reference to three important trial characteristics. The characteristics were the inclusion of participants with vitamin D deficiency, the use of oral supplementations taken daily, and efforts to minimize recall bias. The trials were highly methodologically heterogeneous, which explained the presence of conflicting conclusions and decreased the reliability of the studies citing vitamin D as an effective fall prevention strategy (Tang et al., 2018).

Bolland et al. (2018) analyzed more than thirty RCTs focusing on vitamin D and fall rates and did not find significant effects of the vitamin D intake on the incidence of injurious falls. Around 60% of trials included in the meta-analysis focused specifically on people aged 65 or older (Bolland et al., 2018, p. 850).

Relevance of Findings

To determine the most relevant studies, an emphasis was placed on such factors as sample size, levels of evidence, and the analysis of vitamin D use as an independent measure. The source by Tang et al. (2018) is based on the analysis of thirty large studies, including up to nine thousand elderly adults as participants. Moreover, being a review of RCTs, it provides level I evidence and analyzes vitamin D supplements as a separate fall prevention strategy.

Another study that meets all of the criteria is the systematic review by Bolland et al. (2018). It focuses solely on vitamin D supplementation, presents a source of level I evidence, and analyzes thirty-seven studies with up to four thousand participants (Bolland et al., 2018). Both selected studies report the absence of solid evidence that would support the recommendation to use vitamin D supplements to decrease the risks of falls.

Conclusion

To sum up, the problem of falls is still recognized as one of the leading issues surrounding patient care and safety. The PICO(T) framework is applied to determine whether the administration of vitamin D supplements can reduce the incidence of falls in patients of advanced age. Based on the findings reported by Tang et al. (2018) and Bolland et al. (2018), there are no strong links between vitamin D use and decreases in fall rates. Considering that, it is too early to recommend vitamin D supplements as a strategy for fall prevention.

References

Bolland, M. J., Grey, A., & Avenell, A. (2018). Effects of vitamin D supplementation on musculoskeletal health: A systematic review, meta-analysis, and trial sequential analysis. The Lancet Diabetes & Endocrinology, 6(11), 847-858.

Smith, L. M., Gallagher, J. C., & Suiter, C. (2017). Medium doses of daily vitamin D decrease falls and higher doses of daily vitamin D3 increase falls: A randomized clinical trial. The Journal of Steroid Biochemistry and Molecular Biology, 173, 317-322.

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Tang, O., Juraschek, S. P., & Appel, L. J. (2018). Design features of randomized clinical trials of vitamin D and falls: A systematic review. Nutrients, 10(8), 1-9.

Tricco, A. C., Thomas, S. M., Veroniki, A. A., Hamid, J. S., Cogo, E., Strifler, L.,… Riva, J. J. (2017). Comparisons of interventions for preventing falls in older adults: A systematic review and meta-analysis. JAMA, 318(17), 1687-1699.

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