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Introduction
Fall prevention in geriatric patients remains one of the most pressing issues in nursing. Older people, especially those with dementia and other cognitive impairments, are at higher risk of falling and sustaining injuries. Physical exercise is frequently proposed as an effective fall risk reduction intervention (Toots et al., 2019). Hence, the thesis is: exercise programs should reduce fall risk by delaying the physical decline of the patients. Nevertheless, the potential benefits of exercise as a fall prevention technique should be explored more to make an informed conclusion on its usefulness in geriatric care. This paper critically evaluates two quantitative and two qualitative studies on fall prevention in geriatric patients to answer a related PICOT question.
Updated PICOT Question
In geriatric patients, what is the effect of physical exercise-based interventions on fall risk prevention compared to the standard care process after a 3-month intervention program?
Background of Studies
The first qualitative study by Burgon et al. (2019) focused on exploring the experiences of healthcare professionals working in fall prevention and memory assessment (p. 1). The study was part of a large-scope project to test and develop fall prevention interventions for patients with dementia. Thus, the research question was: Which themes are most common in fall prevention in elderly adults with dementia? The second qualitative study explored the effects of physical exercise on various dimensions of older patients lives. Gonçalves et al. (2020) contributed to nursing by establishing criteria for the Core Outcome Set, a guideline for evaluating exercise-based interventions in geriatric patients. Essentially, the papers research question was: which health outcomes are most important in exercise-based interventions?
Regarding quantitative studies, Toots et al. (2019) explored the effects of a high-intensity physical exercise program on fall rates and injury incidence in geriatric patients with dementia. In that regard, the authors set two research questions: will high-intensity exercise intervention affect the number of falls? and will the effects be consistent across different genders, dementia types, and improvement in patients balance? Furthermore, Brett et al. (2021) explored whether intervention delivery was more effective in a single long session or multiple short sessions. This study had two research questions stemming from the corresponding objectives. The first one was: will exercise-based intervention improve the physical performance of nursing home residents and reduce the fall risk? The second question was, will shorter-duration, high-frequency interventions produce more beneficial outcomes in patients with dementia?
Support of the Nursing Studies Problem
The qualitative study by Burgon et al. (2019) is directly related to the PICOT question through the evaluation of feedback on the efficacy of exercise as a fall prevention method. The qualitative study by Gonçalves et al. (2020) has a less direct relation to the PICOT question. The researchers explored the overall effect of physical activity in elderly patients with dementia rather than its fall prevention aspect. Nevertheless, the paper still provides insight into the potential efficacy of exercise by examining such fall prevention predictions as patients strength, agility, and stamina. Overall, the exercise-based interventions in both qualitative studies were primarily focused on strength and balance training in older adults with dementia. These methods and comparison groups are similar to those stated in the PICOT question.
In terms of quantitative studies, Toots et al. (2019) studied the impact of high-intensity physical exercise on fall rates and injury incidence in older adults. Likewise, Brett et al. (2021) attempted to find evidence of physical exercise efficacy as a fall risk management intervention. Overall, both studies focused on the fall prevention aspect of exercise programs. In that regard, the results of these studies have a direct connection to the PICOT question. Control groups in both studies received standard care, while the intervention groups completed prescribed physical exercise programs. As such, the quantitative studies provided solid empirical evidence on whether exercise-based interventions benefit geriatric patients, the main population group in the PICOT question.
Method of Studies
Both qualitative articles utilized a research method based on in-depth semi-structured interviews. However, the authors used slightly different interview execution techniques in their papers. Burgon et al. (2019) used only a face-to-face technique; meanwhile, Gonçalves et al. (2020) offered the respondents a choice between face-to-face, phone, and video formats. Such flexibility can be explained by the difference in sampling since Burgon et al. (2019) interviewed healthcare professionals exclusively, while Gonçalves et al. (2020) also talked to patients with dementia and their carers. The in-depth semi-structured interview followed by a thematic analysis was a solid choice for eliciting real-world perspectives and experiences. However, the studies based on a semi-structured interview methodology frequently lack generalizability since arranging long conversations with people from a large research sample is too time-consuming.
The quantitative studies utilized a common research design of randomized controlled trials (RCTs) with subsequent statistical analysis. Participants were randomly assigned to the intervention and control groups to determine the exact efficacy of exercise as a fall prevention method. However, the researchers deployed RCTs in a slightly different fashion. Toots et al. (2019) divided 186 participants into control and intervention groups. Each group was divided into 18 clusters of three to eight participants living together to reduce the result contamination effect. Brett et al. (2021) divided 60 participants into one control and two intervention groups consisting of 20 individuals. Overall, the main advantage of RCTs lies in establishing a straightforward causal relationship and controlling bias. However, standalone RCTs rarely demonstrate results that can be generalized and applied to a broad population sample because patient groups frequently differ from people treated in standard settings.
Results of Studies
In qualitative studies, Burgon et al. (2019) found healthcare professionals general approval of exercise-based interventions deployment as a fall prevention method in elderly patients with dementia. However, the respondents also believed that patient engagement depends on their pre-dementia interest in physical exercise. Furthermore, any decision to deploy exercise-based interventions should be based on patients safety and ability to perform the exercises (Maula et al., 2019). Additionally, Gonçalves et al. (2020) found that physical activity positively contributed to mental and physical well-being, the most important health outcomes for older adults. At the same time, the researchers advised supervision to prevent falls during physical activity.
The quantitative studies had rather polarizing findings likely affected by respective research settings. Toots et al. (2019) found that fall incidents in elderly patients with dementia were not affected by a high-intensity physical exercise program. In addition, patients gender, dementia type, and balance improvement did not affect fall rates. However, patients in the intervention group sustained fewer fall-related injuries: 5 in 87 falls compared to 14 in 89 in the control group. These results suggest that exercise programs have a beneficial impact outside of fall prevention.
In contrast, Brett et al. (2021) found that exercise-based interventions significantly reduced the median number of falls in two intervention groups. The levels of improvement were comparable between the group that performed a weekly 45-minute exercise session and the group where the intervention was delivered in three 15-minute sessions per week. Overall, these results are consistent with Bjerk et al. (2019) and Patti et al. (2021), who confirmed the positive impact of physical exercise on older adults.
Ethical Considerations
Qualitative studies had similar ethical considerations associated with the research design. Firstly, the authors had to obtain an agreement to share the respondents answers with the public. Secondly, they had to minimize any distress or harm during the interview process. The first consideration was taken into account in a similar manner. Burgon et al. (2019) and Gonçalves et al. (2020) obtained informed consent from all participants. The second ethical issue was resolved differently Burgon et al. (2019) made participants more comfortable by assigning a fellow medical professional to an interviewers duty. Gonçalves et al. (2020) offered different options for giving an interview face-to-face, video, or phone format.
Both quantitative studies had similar ethical considerations and methods of addressing them. Most importantly, the researchers had to obtain informed consent from participants. Toots et al. (2019) approached all participants personally and received oral permission that was additionally confirmed by the participants close relatives. Brett et al. (2021) invited all potential participants and their caregivers to an information session, where participants, or people making decisions on their behalf, provided written consent. In addition, the authors had to receive special approval from ethical review boards before commencing the study.
Outcomes Comparison
The anticipated outcomes for the PICOT question are significant fall rate reduction in geriatric patients and improvement in patients physical performance. Therefore, the expected answer to the PICOT question is the confirmation of exercise-based interventions effectiveness in geriatric care. In that regard, the qualitative studies provided empirical evidence confirming the interventions usefulness as an anti-fall practice. The quantitative studies were less consistent in their findings since Toots et al. (2019) have not confirmed the fall reduction effect of exercises in their research sample. Nevertheless, even in more skeptical studies, physical exercises have been associated with reducing fall-related injuries. Therefore, the results of the four chosen articles have mostly matched with anticipated outcomes.
Proposed Evidence-Based Practice Change
The nursing problem of falls and fall-related injuries in geriatric patients challenged healthcare practitioners. Since falls are particularly dangerous to older adults, scholars and nursing professionals had to develop and test practical interventions that could mitigate the issue. In that regard, the PICOT question acted as a link between the problem and the academic work. In turn, the articles provided empirical evidence, thus demonstrating the value of physical exercise-based interventions. Therefore, one can recommend prescribing geriatric patients a physical exercise program. Exercises have demonstrated their overall effectiveness by reducing fall rates in most settings and leading to an overall improvement in patients physical performance. However, the best evidence-based practice suggests deploying exercise interventions under supervision to ensure patients safety and customizing programs according to their physical ability.
Conclusion
In summary, qualitative and quantitative studies confirmed the efficacy of exercise-based interventions in fall prevention in geriatric patients. However, geriatric patients need supervision and moral support throughout the intervention delivery process. Otherwise, they may fall and sustain injuries or become too frustrated and agitated to exercise effectively. In addition, positive effects may not manifest in flat fall rate reduction. Instead, the patients may become more resistant to injuries or achieve progress in physical performance. Nevertheless, correctly delivered exercise-based interventions seem to be a promising path toward fall risk reduction.
References
Brett, L., Stapley, P., Meedya, S., & Traynor, V. (2021). Effect of physical exercise on physical performance and fall incidents of individuals living with dementia in nursing homes: A randomized controlled trial. Physiotherapy Theory and Practice, 37(1), 38-51. Web.
Bjerk, M., Brovold, T., Skelton, D. A., Liu-Ambrose, T., & Bergland, A. (2019). Effects of a falls prevention exercise programme on health-related quality of life in older home care recipients: A randomised controlled trial. Age and Ageing, 48(2), 213-219. Web.
Burgon, C., Darby, J., Pollock, K., van der Wardt, V., Peach, T., Beck, L., Logan, P., & Harwood, R. H. (2019). Perspectives of healthcare professionals in England on falls interventions for people with dementia: A qualitative interview study. BMJ Open, 9(2), e025702. Web.
Gonçalves, A. C., Marques, A., Samuel, D., & Demain, S. (2020). Outcomes of physical activity for people living with dementia: Qualitative study to inform a Core Outcome Set. Physiotherapy, 108, 129-139. Web.
Maula, A., LaFond, N., Orton, E., Iliffe, S., Audsley, S., Vedhara, K., & Kendrick, D. (2019). Use it or lose it: A qualitative study of the maintenance of physical activity in older adults. BMC Geriatrics, 19(1), 1-12. Web.
Patti, A., Zangla, D., Sahin, F. N., Cataldi, S., Lavanco, G., Palma, A., & Fischietti, F. (2021). Physical exercise and prevention of falls. Effects of a Pilates training method compared with a general physical activity program: A randomized controlled trial. Medicine, 100(13), e25289. Web.
Toots, A., Wiklund, R., Littbrand, H., Nordin, E., Nordström, P., Lundin-Olsson, L., Gustafson, Y., & Rosendahl, E. (2019). The effects of exercise on falls in older people with dementia living in nursing homes: A randomized controlled trial. Journal of the American Medical Directors Association, 20(7), 835-842. Web.
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