Falls prevention to improve health-related quality of life, physical function and falls self-efficacy in older adults receiving home care

Abstract

Background: Falls and fall-related injuries in older adults are associated with great burdens for the individuals, the health care system and society. Although they have a high incidence of falls, a high prevalence of fear of falling and a lower level of health-related quality of life (HRQOL), older adults receiving home care are underrepresented in research on older fallers. Effective interventions to prevent falls and improve HRQOL, physical function and falls selfefficacy in this population is of importance to meet current and future public health challenges. Aims: The first aim of the thesis was to provide an in-depth background for the study with detailed information on the project procedures. The second aim was to describe the characteristics of the population of home care recipients, including their HRQOL, physical function and falls self-efficacy, and to determine the relationship between these factors. The third aim was to evaluate the short- and longer-term effects of a falls prevention exercise programme on HRQOL, physical function and falls self-efficacy. The final aim was to examine the agreement between the two general measures of HRQOL, SF-6D and EQ-5D, employed when evaluating interventions in home care recipients. Methods: This thesis consists of five papers in which three different designs are employed. The first paper is a study protocol for the randomised controlled trial (RCT). The second paper presents a study with a cross-sectional observational design. In the third and fourth papers, a single-blinded parallel-group RCT, including a follow-up at 3 months and 6 months is presented. The fifth paper reports on a longitudinal study on the same data. The participants in all studies were 155 older adults receiving home care from six municipality health care services in Eastern Norway. Inclusion criteria were being over 67, receiving home care, having experienced at least on fall during the last 12 months, being able to walk with or without a walking aid and being able to communicate in Norwegian. Exclusion criteria were medical contraindications to exercise, life expectancy below 1 year, a Mini-Mental State Examination (MMSE) score below 23 and currently participating in other falls prevention programmes or trials. The intervention group received an individual home-based falls prevention exercise programme based on the Otago Exercise Programme (OEP) lasting 12 weeks. The control group received usual care. Assessments were carried out at baseline, at the end of the intervention at 3 months and at a 6-month follow-up. The primary outcome, HRQOL, was measured using the Short-Form 36 Health Survey (SF-36). Physical function was measured using the Bergs Balance Scale (BBS), the 30-second sit-to-stand test (STS), the 4-metre walk test (4MWT), instrumental activities of daily living (IADL) and walking habits. Falls self-efficacy was measured using the Falls Efficacy Scale International (FES-I). Nutritional status was measured using the Mini-Nutritional Assessment (MNA). At baseline, MMSE scores, demographic information and background variables were collected. Information on adverse events and exercise adherence was collected at 3 and 6 months. Results: The sample of older home care recipients included in this project had poor HRQOL, physical function and falls self-efficacy compared to the general older population. Paper II shows that better HRQOL was associated with better physical function and falls self-efficacy, when adjusted for baseline values such as sex, education, living alone and number of falls. Paper III shows that the intervention group improved their physical HRQOL and balance in the short term following a falls prevention exercise intervention. Further analysis revealed that the effects were greater for those who managed to complete the programme as prescribed and showed a negative impact on mental HRQOL for those who did not manage to complete the programme as prescribed. Paper IV shows that the improvement in physical HRQOL was sustained at follow-up. Further analysis demonstrated that the intervention increased the probability of maintaining exercise post-intervention and that this exercise mediated the effect of the intervention on physical HRQOL. Paper V shows that older adults with a higher mean HRQOL and/or better physical function scored higher on EQ-5D, while those with lower mean HRQOL and/or poorer physical function scored higher on SF-6D. EQ-5D was more responsive to changes in physical function compared to SF-6D. Conclusions: Home care recipients are a frail group of older adults with poor HRQOL, physical function and falls-self efficacy. A falls prevention exercise programme can improve their HRQOL and physical function in the short term and can help sustain their HRQOL in the longer term. SF-6D and EQ-5D are applicable when evaluating interventions in home care, but EQ-5D seems more responsive to changes in physical function. More research on this group is needed, particularly in terms of developing interventions and evaluating the effects of falls prevention programmes on mental HRQOL and falls self-efficacy