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      Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Falls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program—RESPOND—had an effect on falls and fall injuries in older people presenting to the ED after a fall.

          Methods and findings

          Community-dwelling people aged 60–90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis—217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43–0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51–1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15–0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts ( n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events.

          Conclusions

          In this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED.

          Trial registration

          Australian New Zealand Clinical Trials Registry ( ACTRN12614000336684).

          Abstract

          Darshini Ayton and colleagues report on a fall prevention programme for people discharged from the emergency department post-fall, evaluated in a randomised controlled trial.

          Author summary

          Why was this study done?
          • Falls are a leading reason that older adults present to emergency departments (EDs).

          • There is systematic review evidence for interventions to reduce falls in older people living in the community.

          • When similar interventions are applied to those presenting to the ED with a fall, there is a lack of effectiveness.

          What did the researchers do and find?
          • A randomised-controlled trial was undertaken to investigate whether a 6-month telephone-based patient-centred program—RESPOND—reduced falls and fall injuries in older people presenting to the ED after a fall.

          • RESPOND is a patient-centred falls prevention program developed specifically for community-dwelling older people presenting to the ED with a fall. It consists of a home-based risk assessment; 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and linkages to existing services.

          • RESPOND had an effect on falls and fractures but not fall injuries.

          What do these findings mean?
          • Our study provides evidence for a telephone-based, patient-centred falls prevention program to reduce falls and fractures in older people presenting to the ED with a fall.

          • This approach may empower and support older people to participate in falls prevention activities.

          Related collections

          Most cited references 37

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          Interventions for preventing falls in older people living in the community

          Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009. To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers. Randomised trials of interventions to reduce falls in community-dwelling older people. Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate. We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors. Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.
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            Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.

            We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.
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              Older patients in the emergency department: a review.

              Older patients account for up to a quarter of all emergency department (ED) visits. Atypical clinical presentation of illness, a high prevalence of cognitive disorders, and the presence of multiple comorbidities complicate their evaluation and management. Increased frailty, delayed diagnosis, and greater illness severity contribute to a higher risk of adverse outcomes. This article will review the most common conditions encountered in older patients, including delirium, dementia, falls, and polypharmacy, and suggest simple and efficient strategies for their evaluation and management. It will discuss age-related changes in the signs and symptoms of acute coronary events, abdominal pain, and infection, examine the yield of different diagnostic approaches in this population, and list the underlying medical problems present in half of all "social" admission cases. Complete geriatric assessments are time consuming and beyond the scope of most EDs. We propose a strategy based on the targeting of high-risk patients and provide examples of simple and efficient tools that are appropriate for ED use. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                24 May 2019
                May 2019
                : 16
                : 5
                Affiliations
                [1 ] School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
                [2 ] Alfred Health, Melbourne, Victoria, Australia
                [3 ] School of Medicine, University of Western Australia, Perth, Western Australia, Australia
                [4 ] Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
                [5 ] Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
                [6 ] Melbourne EpiCentre, University of Melbourne, Melbourne, Victoria, Australia
                [7 ] Melbourne EpiCentre, Melbourne Health, Melbourne, Victoria, Australia
                [8 ] School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
                [9 ] Allied Health Research Unit, Monash Health, Melbourne, Victoria, Australia
                [10 ] School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
                [11 ] Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
                [12 ] Department of Psychology and Ageing & Dementia Research Centre, Faculty of Science and Technology, Bournemouth University, Poole, United Kingdom
                [13 ] Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
                [14 ] Health Networks Branch, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia
                [15 ] Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
                University of Cambridge, UNITED KINGDOM
                Author notes

                I have read the journal's policy and the authors of this manuscript have the following competing interests: TH reports personal fees from DorsaVi Pty, Ltd., for provision of economic evaluation consultancy service. DA and RM report salaries supported by the NHMRC for project funding as part of the Partnership Projects scheme. AB and JL report grants from the NHMRC during the conduct of the study. EB and EM report grants from the NHMRC supporting their salaries. All other authors have no conflicts of interest.

                Article
                PMEDICINE-D-18-03428
                10.1371/journal.pmed.1002807
                6534288
                31125354
                © 2019 Barker et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 2, Tables: 3, Pages: 18
                Product
                Funding
                Funded by: National Health and Medical Research Council
                Award ID: APP1056802
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000925, National Health and Medical Research Council;
                Award ID: 1067236
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000925, National Health and Medical Research Council;
                Award ID: APP1143538
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000925, National Health and Medical Research Council;
                Award ID: 1052442
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;
                Award ID: CDF-2015-08-030
                Award Recipient :
                This project was funded under the Australian National Health and Medical Research Council's Partnership Projects funding scheme (project number APP1056802), with financial and in-kind contributions from the following partner organisations: Health Strategy and Networks Branch, Strategic System Policy and Planning, Department of Health, WA*; Aged and Continuing Care Directorate, Department of Health, WA; Royal Perth Hospital*; Curtin University*; The University of Western Australia*; The Royal Perth Hospital Medical Research Foundation; Sir Charles Gairdner Hospital (SCGH) Area Rehabilitation and Aged Care Falls Specialist Program; Injury Control Council of Western Australia (ICCWA); The George Institute for Global Health; The Alfred Hospital*; Monash University*; Integrated Care, Victorian Department of Health. (*Note, authors are employees or have affiliations with these partner organisations.) RM, DA, EB, and EM’s salaries were supported by this grant. AB was funded by an NHMRC Career Development Fellowship (APP1067236). JR was funded by an NHMRC Career Development Fellowship Level 2 (APP1143538). JL was funded by an Early Career Fellowship funded by the NHMRC (APP1052442). SRN was funded by a National Institute for Health Research Career Development Fellowship (CDF-2015-08-030).
                Categories
                Research Article
                Medicine and Health Sciences
                Epidemiology
                Medical Risk Factors
                Traumatic Injury Risk Factors
                Falls
                Medicine and Health Sciences
                Public and Occupational Health
                Traumatic Injury Risk Factors
                Falls
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Medicine and Health Sciences
                Epidemiology
                Medical Risk Factors
                People and Places
                Population Groupings
                Age Groups
                Elderly
                Medicine and Health Sciences
                Health Care
                Quality of Life
                Medicine and Health Sciences
                Ophthalmology
                Engineering and Technology
                Equipment
                Communication Equipment
                Telephones
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Hospitals
                Custom metadata
                Informed consent was not obtained from participants for the publication of the data sets generated and analysed during the current study. Therefore, to ensure the participants’ rights to privacy and to protect their identities, the raw data will not be made publicly available; however, we will provide de-identified aggregated data on request. Please contact Jayamini Illesinghe, School Manager of Monash University School of Public Health and Preventive Medicine, at jayamini.illesinghe@ 123456monash.edu for all data requests.

                Medicine

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