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Efficacy Study Falls Prevention0001

Efficacy Study Falls Prevention0001 - Research Monograph...

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Unformatted text preview: Research Monograph Efficacy of Prescribed Therapeutic Recreation Protocols on Falls and Injuries in Nursing Home Residents with Dementia Name of Investigator: Linda L. Buettner, CTRS, PhD. Co-Director SW Florida Interdisciplinary Center for Positive Aging Associate Professor College of Health Professions Florida Gulf Coast University Fort Myers, Florida 33965—6565 Email: [email protected] Phone: 941—590—9697 Intervention sites: NYS Home for Veterans at Oxford Sherrill House House, Boston, MA Palo Alto VA Nursing Home, Palo Alto, CA Project Collaborators: Marcia Shalek, CTRS, Sherrill House, Boston, MA Alisa Krinsky, CTRS, Veterans Affairs Palo Alto Healthcare System Darius Talanis, Director of Recreation, Oxford Veterans Home, Oxford, NY This project was funded by a generous grant from the American Therapeutic Recreation Foundation Bernie Thorn Efficacy Research Fund. Special thanks to Suzanne Fitzsirnrnons, MS, GNP for assisting with the research project. Copyright © 2001. American Therapeutic Recreation Association, Alexandria, VA. IBSN 1—889435-19-8 INTRODUCTION AND SIGNIFICANCE The Health Care Financing Administration (HCFA), which recently changed it’s name to Centers for Medicare and Medicaid (CMS), is currently examining the use of physician ordered therapeutic recre- ation through analysis of Section T. of the MDS. Therapeutic recreation for persons with dementia to prevent falls and injuries is an appropriate therapeutic recreation program to be included. Many individuals are Medicare eligible because of prior hospital stays, but may not be treated on a rehabilitation unit because of disturbing behaviors related to dementia. It is theorized that therapeutic recreation specialists can play a crucial role in long term care settings, but practitioners do :iot always know what interventions to utilize and what outcomes to measure with these dif- ficult residents who are at high risk for falls. This study helps to show the value of thera— peutic recreation in nursing homes, and pro- :‘ide practitioners with tested protocols to reduce falls, injuries, and healthcare expenses. PURPOSE OF THIS STUDY Falls and injuries are a major problem for individuals with dementia who live in long term care settings. In addition to the pain and suffering, falls increase cost of care, and are censidered a major constraint to leisure func— iwning. The purpose of this study was to examine the efficacy of prescribed therapeutic recreation protocols on falls and injuries in old er adults with dementia in long term care. Tcltimately, the goal was to reduce the inci- dences of falls and injuries. Evidence of need and understanding of the problem of falls among long term care res- :dents with dementia made this a much-need- ed study. Current demographics indicate that the population has aged substantially in the past two decades, and it is estimated that by the 2020 we will have 52 million Americans over the age of 65 (US. Bureau of Census, 1991). The risk of serious injuries from a fall increases with age, therefore, as the popula- tion ages we will subsequently have more and more people incurring serious injuries from falls. Falls increase mortality and morbidity in persons over 65 years of age and produce seri- ous injuries. Falls increase length of stays in hospitals and nursing home rehabilitation units. The injuries produced from falls range from minor soft tissue injuries, to fractures and permanent disabilities, which bring about diminished quality of life and an increased use of health care services (Keil, O’Sullivan, Teno & Mor, 1991). The literature offers numerous studies that examine the prevalence and cost of falls in terms of dollars, in the eld— erly population. Focusing on the data from New York alone, it has been found that the average number of falls with resulting hip fractures from 1985—1996 in individuals over 65 years of age was $15,000 per year. During that time period it was determined that the older individual was, the greater the incidence of falls. Despite efforts and attention to reduc- ing falls the risk has remained the same with the exception being in the over 85 category, the risk in this group actually increased (Aharonoff, Koval, 8: Zuckerman, 1997). In the long term care setting it has been found that up to 50 percent of the residents fall each year (Tideiksaar, 1996). It is a serious, costly prob- lem that affects all practicing disciplines in the nursing home, including therapeutic recre- ation. The average hip replacement surgery costs society approximately $100,000. The additional economic impact on a nursing home resident whose fall requires hospitaliza- tion, amounts to $19,440 when tracked for a period of one year from the time of the inci- dent (Rizzo, et a1, 1998). If a facility could save two hip fractures per year, imagine the thera- peutic recreation staff it could hire! This con- tinuing high prevalence of falls and injuries is the major motivating factor for this research project, with the ultimate goal to prevent some of these events from occurring. Research Monograph 1 Advanced age also increases a person’s risk for cognitive impairments. It is estimated that 479: of persons over the age of 85 have some form of dementia (German, Rovner, Burton, Brandt, 8: Clark, 1992). Residents with dementia comprise 70% of the popula- tion in long term care facilities (German, et a1, 1992'). It is this group, nursing home residents with dementia, who were targeted in this study. They are often described as ”the most difficult to provide therapeutic programs,” yet they are in desperate need of therapeutic serv- ices (Buettner, 1994). The nursing home environment is current- ly ripe for quality improvement and for pre- scribed recreation therapy. With Section T. of the MDS currently under study we have the chance to prove the viability of therapeutic recreation services in long term care. This project met the needs of residents with dementia, saved health care dollars, and will advance the profession of recreation therapy by providing practitioners with empirically tested protocols. RESEARCH QUESTIONS 1. What times of day do most falls occur? 2. Will therapeutic recreation interventions reduce falls, injuries, and therefore, the cost of care for nursing home residents with dementia? DESCRIPTION OF THE RESEARCH SITES Three research sites were used for this study. All three sites had a certified therapeu— tic recreation specialist providing services to the residents. The New York State Home for Veterans at Oxford, NY was the primary research site and one of the leading state-run veteran’s facilities in the nation. This facility has a 240—bed capacity, 50% male and female, which is unique in long term care settings. The medical director and the administrator were both extremely interested in taking part in this project as the dementia unit was aver- 2 American Therapeutic Recreation Association aging over 50 falls per month. Sherrill House in Boston, MA serves older men and women needing nursing and rehabil— itation care and provides a wide range of medical services including post acute care, short-term rehabilitation, respite care, hospice care, and long-term care. A special care pro- gram for residents with Alzheimer’s disease rounds out the facility’s services. It is a 164- bed skilled nursing facility affiliated with Trinity Church in Boston and the Episcopal Diocese of Massachusetts. The philosophy of care emphasizes dignity and the right of resi- dents to remain in control of their own lives and decisions. Veterans Affairs Palo Alto Healthcare System has an Extended Care facility which provides a 150-bed nursing home with hos- pice, respite and transitional care programs. The 108-bed Intermediate Care Unit has a dementia unit, dementia respite program, two Geropsychiatric short stay programs, hospital based home care contracts for community nursing homes, Adult Day Health Care and Homemaker / Home Health Aide service pro- grams. This nursing facility is part of the lead- ing VA medical program in the nation and is affiliated with Stanford University. PROTOCOL BACKGROUND AND EQUIPMENT This protocol was used at Willard Psychiatric Center for the reduction of falls in frail older adults with long term disabilities (Buettner & Waikavicz, 1998). The protocol was never scientifically studied in the nursing home setting, but therapists did find that all three components were vital in the original program. Walking addressed the need for lower extremity strength and overall endurance. Exercise for function enhanced balance, upper body strength, and overall flexibility. This exercise program was designed and choreographed, in 1995, by resi- dents of special care unit. It provides an exer- cise routine with familiar music and move- ments while working on muscle groups and balance. The sensory air flow mat is an air compressor with a colorful 10' x 10' vinyl exer- cise mat attached that fills with air. The PI has used this equipment with older adults since 1985. It provides sensory stimulation in the form of air flowing up through the seams of the mat, and white noise. It is sometimes the only safe way to get frail, confused older adults to move, exercise, and relax. The senso— ry air flow mat provided practice in transfer- ring, relaxing tired muscles, and sensory inte- gration. The mat provided freedom of move- ment, balance training and relaxation for rest— less individuals. SUMMARY OF TR PROTOCOL 1. Map on a schematic drawing of the nursing home unit, the resident number, exact time, and exact location of each fall for a two month period. (See Appendix A.) 2. This data was be used to select residents for the falls prevention program, and provide information about the time of day these res- idents need activity. Two falls in one month or a fall in two consecutive months trigger enrollment in the program. 3. Residents selected for the falls prevention program received three therapeutic recre- ation programs, for a period of three months, to address the problem of strength, endurance, flexibility, balance, and the need for sensory motor activity. The programs were scheduled at the time of day when most falls occur, and in the location where the falls occur with the goal of increasing strength, endurance, flexibility, and provid— ing needed stimulation under the supervi- sion of a therapist. The programs were 1) daily graded walking program, 2) exercise for function three times weekly, and 3) sen— sory air mat therapy at least twice weekly. (Appendix B) 0 Attain physician order for Recreation Therapy Falls Prevention Program 0 Pick up resident for program ' Five days of morning walking group ‘ Three to five days of air mat therapy 0 Three to five days of exercise group 0 Pre-program bathroom visits and eye— glass check. 0 Attend program with recreation thera— pist (See Appendix C for Intervention Guidelines) STAFF REQUIREMENTS All research sites had a Certified Therapeutic Recreational Specialist (CTRS)TM overseeing the project staff at the site. One staff member was required for both the morn— ing walking and the exercise for function pro- grams. This staff member could be a member of the activity department, nursing depart- ment or therapy department. Airmat therapy required a trained CTRS and one other staff member to assist. CRITERIA AND METHOD OF PARTICIPANT SELECTION IRB approval was obtained from the IRB at Binghamton University and from the New York State Board of Health in March 2000. The Dean of the Decker School of Nursing also approved this project. The Board of the Sherrill House approved the program for the Boston site, and the Stanford University IRB approved the protocol for the Palo Alto site. Residents were included in the study: 1) if they resided in the facility for at least 60 days, 2) has an MMSE score of 23 or less, 3) over the age of 60, 4) had two or more falls in the past two months occurring between 7:00 am. and 9:00 p.m., 5) did not have a healing fracture, 6) not attending PT, 7) could walk either by self, with one assist or with an assistive device such as a cane or a walker, 8) has signed con- sent by family member or legal guardian and 9) has agreed to participate. RESEARCH DESIGN A pre-test, post-test randomized design Research Monograph 3 was used on the participants (n=27) in the study. These residents were randomly assigned to either group 1 (falls prevention treatment program) or group 2 (nursing home programs as usual). Group 1 received the falls prevention program for 3 months, while group 2 receives nursing home activities as usual. At the end of the two—month period all participants received the falls prevention pro- gram. Group 1 residents took part in the three prescribed programs in small groups of 3-5. A two-month baseline period was used to examine incident reports and the number of falls, to be used a pre-test data. Falls and injuries were recorded as post—test data during the two—month intervention period for all sub- jects. A record was kept of resulting injuries and the medical costs of any injury for all par- ticipants. This data was collected from inci— dent reports and quality improvement reports. Counting the actual number (O-X) occurring within the 30-day period opera- tionalized falls. Injuries were operationalized in dollars used to treat the injury. Means of Group 1 and Group 2 were compared using t- tests and AN OVAS. Data were collected from chart review and incident reports included basic demographic information (age, gender, diagnosis, health history, current activity profile and past leisure interests), MMSE score (cognitive func— tioning), depression diagnosis and score on the Geriatric Depression Scale, routine and PRN medications, and number of falls and resulting injuries. RESEARCH RESULTS Over the two month pre-test period researchers examined patterns in falls on the special care units (See Appendix A). It was clear that the afternoon change of shift time was the time in which programs needed to occur (2:30—4:00 pm). The next critical times were mornings and in the evening (see chart below). This information helped guide the establishment of the program times. Morning walking group was planned for 6:30 a.m., 4 American Therapeutic Recreation Association exercise for function for mid-afternoon, and relaxation for the evening using the sensory air flow mat. These may not sound like huge innovations, but most programs are not set up to meet the needs of the participants in this way. At most facilities, program times are gen- erally based on tradition in a nursing home, working around meetings, and the conven— ience of the staff (including the housekeepers). PRE-TEST FALLS TIME There were 13 subjects meeting criteria from the Oxford site, two of which passed away and did not complete the study. One of these men was from the control group and one was from the treatment group, their falls were removed from the final analysis. The two-month pre—test falls total was 92 falls at the Oxford site. The Sherrill House site started their project with 8 subjects, all 8 finished the study. The two-month total for these subjects was 24 falls. The Palo Alto VA site started their project with 6 subjects, all 6 finished the study. The two-month total for these subjects was 12 falls. All sites combined for a total of 128 falls among 27 subjects. (See Figure 1 on page 6.) From the three sites there were 12 females and 13 males that completed the two-month project. Two males were lost due to attrition. The mean age of participants was 83.3 (range 60-98) and racial mixture was 17 Caucasian, 5 African Americans and 3 Hispanic Americans. The dementia diagnoses were as follows: 10 with Alzheimer’s type dementia, 5 subjects with vascular dementia, 5 with Parkinson’s dementia, and 5 mixed or unknown types. The Mini—Mental State Exam scores on this group were very low, 9 had a score of zero and the group mean was 2.63. The average number of routine medications used daily was 5.79 per participant. Examining other diagnoses 8 subjects had depression, 7 had severe visual impairments, 8 had neurological problems, 5 had hyperten— sive diagnoses and only 2 had documented gait disorders in their medical charts. Prior to this program the average number of weekly activities was 1.89 and some of those activities were passive in nature such as listening to music or watching television. During the program the average went up to nearly 12 active programs per week for the treatment group. After the two—month intervention period, post-test falls data was gathered from incident reports and chart review. Falls, for the treat- ment group reduced from a total of 74 to 28 while the control group had an increase from 46 to 56 falls. (See Appendix B.) T—test analy- sis found the reduction of falls among the treatment group to be statistically significant at the .001 level. Dramatic and significant finding were also found in improvements in strength as measured on the weighted jug lifts in pounds. The treatment group strength went from lifting 2.70 to 4.5, while the control group lost strength, 2.73 to 2.60. Significant findings were also found in distance walked during morning walking group. The treat- ment group increased their daily morning walking distance from 220' to 1258‘ while the control group lost walking length, going from 260' to 223'. Cost of falls and injuries added up to $79,535 for the control group. Costs were determined based on research data on falls which includes staff time, supplies and out of facility expenses if incurred. The treatment group costs were $30,031, which included staff time to run the program. Savings estimate, not considering the pain and suffering of those who were falling was $49,504. (See Appendix D.) Other interesting points included the fact that five participants from Sherrill House and from Oxford Veterans Home had no falls dur- ing the intervention. All of them were women with Alzheimer’s of the dementia type. In addition, two out of the three individuals from the Palo Alto VA did not experience any further falls during the intervention. This intervention seemed to be particularly benefi- cial to women with Alzheimer’s type demen— tia. Two individuals who had multiple falls both passed away due to cerebral vascular accidents during the study. Perhaps if clini- cians find individuals with many unexplained falls it may be due to a life threatening med— ical condition, like reoccurring strokes, caus- ing them to be so restless and unsteady. No attempt was made to control for med— ications in this study. It would add a great deal if a physician or nurse practitioner could work with the recreation therapist to look to reduce unnecessary medications. Also inter- esting to note that a very high number of indi- viduals who were falling were depressed and being treated with antidepressants. The other striking problem in this high~risk group was that of visual impairments. It is common that visually impaired older adults either do not have access to their glasses, or the glasses are dirty or in disrepair. At the Oxford site the interventists were encouraged to find and wash each participant’s glasses before begin- ning the program. SUMMARY AND CONCLUSIONS This is a cost-effective outcome based intervention for recreation therapists provid— ing services to nursing home residents with dementia. This study found that there were specific times during the day when nursing home residents with dementia seem to experi— ence more falls than usual. For this sample, a majority of the falls occurred during three time periods during the waking hours. The . times of the highest incidences of falls were mid—afternoon at ”change of shift,” just after rising in the morning, and just before bedtime in the evening. This study also found that res- idents with dementia could be selected for falls prevention programs based on their his— tory of falls in the past 60—days and...
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