1. Identify a problem and explain the problem:
Background: The project proposal is related to the prevention of fall among elderly. The incidence of falls is high among the elderly population. Studies suggest that elderly who fall once, are more likely to fall in the future. A number of conditions like poor eye vision or transient ischemic attacks or pets or general body weakness or other miscellaneous reasons, can increase the risk of fall in the elderly population. Falls can be particularly serious and life changing for elderly. It can make them dependent on others and also increases the chances of admission to critical facilities. Fear of falling, often restricts elderly from going out of the house or engage in activities. This can make them socially isolated and physically weak. Fall is often considered a normal part of the aging process. (Rubenstein, 2013)
The statistical figures regarding fall rates and associated morbidities in the elderly are quite worrisome. One in three adults above age of 65+ have reported fall at least once in a year in the U.S. It is a common reason for emergency room visits among geriatrics and accounts for 90% of the hip fractures reported in the population. Falling is a frequent problem among many elderly people and is a side effect of the aging process. Factors like hypotension, orthostatic dizziness, sleep medication or side effects of other medications, weakening of muscles, bones and other environmental hazards, are commonly reported in fall associated with the elderly population. The fall is often slightly more fatal in men, when compared to women. Very often, it is difficult for elderly patients with fall associated fracture to return back to normal health. It increases dependency. The majority of the incidence of fall occurs inside the house than outside the house. Rugs, pets, or other slippery items on the floor, can make the elderly to topple and fall. The factors that cause the patient to fall can be intrinsic and could be associated with the aging process. (Rubenstein, 2013)
Certain intrinsic factors associated with aging, like poor vision, poor reflexes, strength, difficulty in coordinating movements, Parkinson’s, Diabetes, macular degeneration, arthritis and stroke can increase risk of falling in the elderly population. Extrinsic factors like medication, alcohol, other environmental and occupational hazards, can also increase risk of falling in the elderly. (Rubenstein, 2013)
Changes in once environment and behavior, could help to reduce falls to a certain extent. Poor lighting, uneven surfaces and clutters in the floor can increase the risk of falls. It would be wise to correct these factors if present in the house. Wet floor, throw rugs, loose carpets can also cause people to slip and fall. Lack of grab bar in the showers or bathtub and lack of railing in the stairways, can prove to be dangerous for elderly population. Eliminating risking environment can help reduce the incidence of falling. Likewise, home modifications to make the living space more safe is also suggested as a way to prevent falling. (Fuller, 2000)
There are a number of evidences in the literature that support the use of mild exercise to prevent fall in elderly. Bone disorders like osteoporosis and vitamin D deficiency needs to be corrected before venturing to do exercises. Likewise, an annual checkup may also help to identify health problems. Certain anxiety medications and sleep medications can increase risk of falling, and their intake must be discussed with the health care team. There is a need to discover ways and strategies to reduce the incidence of fall in the geriatric population. Education and community workshop may help to create awareness in the population. But, without a proper solution to the problem, the aging population will be helpless about this situation. In this project, I look into the beneficial effects of exercise in reducing incidence of fall and in building confidence or quality of care in the geriatric population. Very often the panic reaction associated with fall, rather than the fall itself can cause more harm to the elderly. (Fuller, 2000)
2. Discuss your problem based on literature evidence:
Literature evidence:
El-Khoury et al., made a systematic review of literature, to identify the extent to which fall prevention exercises can prevent falls in the elderly. In his review, he analyzed 17 trials, involving a total of 4305 participants. Only trials involving elderly aged 60 years and above were included in the study. The meta-analysis of these trials revealed that exercise had a significant effect in preventing all categories of fall. The studies evaluated in this review were heterogeneous in nature. In spite of this, the exercise did have an influence in preventing falls. The study concluded that exercise programs that were designed to reduce fall incidence in elderly, also resulted in reducing the severity of fall injury. (El-Khoury, Cassou, Charles, & Dargent-Molina, 2015)
A Cochrane review published in 2009, evaluated different interventions used to reduce the incidence of fall in a community of elders. A total of 159 trials with 79,193 participants, were included in the review. In majority of the studies, the intervention that was used to reduce falls was compared with another intervention that did not aim to reduce falls. Though multiple interventions were reviewed in these trials, an exercise was the single most dominant (59 trial) intervention in these studies. Of the multiple interventions that was evaluated in this paper, exercises significantly reduced rate of fall and risk of falling. Home based exercises proved useful, as were exercises done outside home. Tai chi exercise was found to reduce the risk of falling in the participants. Exercise also reduced the incidence of fall related fracture. The risk ratio for exercise was lower than other interventions, suggesting the beneficial effect of exercise in reducing falls, over other intervention. Vitamin D supplementation, correction of vision did not prove to reduce risk of falls. On the other hand, home modification, safety measures, use of pacemakers in elderly with carotid sinus hypersensitivity, cataract eye surgery, gradual withdrawal of psychotic medications helped to reduce the risk of falls. (Gillespie et al., 2012)
Tai Chi is a wellness exercise that originated from China. It is a balance based exercise and improve strength, balance, function and awareness. In a couple of studies, Tai Chi, was found to be beneficial in reducing incidence of fall. It was also found to improve postural stability in Parkinson’s.
In a study conducted among people with Parkinson’s aged 40 to 85 years, 60 minutes Tai Chi exercise, twice a week for 6 months was found to improve postural stability and functional outcome in patients with moderate to severe Parkinson. It is a quantitative study that give a clear picture of the benefits of TaiChi on postural stability and directional accuracy in Parkinson’s. The fall rate was monitored in the patient using a daily ‘fall calendar’. The gait was measured using computerized 4.3-m (14 ft) walkway (GAITRite, CIR Systems). Tai Chi was significantly better than stretching and other intensive exercises that are used to treat postural abnormalities in patients. The study well planned study, with little scope for bias. Exercise is an integral part of treating Parkinson’s as there is progressive loss of motor function and postural stability in the patient. The incidence of risk is high in the patient. The postural stability in the patient was measured using computerized dynamic posturography. (Li et al., 2012)
3. Analyze the situation from the current data and identify an area that might contribute to addressing the problem.
4. Proposing a solution to the problem on the basis of evidence
Tai Chi is an internal form of Chinese martial arts. It can be adopted as low impact, relaxing exercise that can provide a number of health benefits to the elderly. The research evidence that it helps to reduce risk is particularly interesting and is thus proposed as an intervention to reduce falls in the geriatric population. This meditative form of exercise not only trains the body, but also helps to heal the mind. It can help reduce anxiety and thus help to reduce the use of psychotic medications. It addition, it relieves stress and to some extent the pain associated with arthritis. It improves strength and stability of joints. Tai Chi exercises could benefit seniors in care homes and communities as well. The exercise is already adopted in many communities and care homes. The promotion of this practice can help to reduce the incidence of falling. It is easy to learn and does not require strain or excessive effort like other intensive exercises. There are different forms of Tai Chi and Qigong Tai Chi is based on healing and rejuvenation. It is easy to practice and involves fun and interesting steps. Teaching the elderly population these few steps of Tai Chi exercise and encouraging them to practice it under supervision can help to build confidence in the intervention. Tai Chi is recommended by Centre for Disease Prevention and evidence based practice for preventing falls. It is also adopted by many other countries like Australia in their fall prevention program.
5. Resources to implement the innovation:
The first step would be identifying the right Tai Chi teachers who can train teachers and educators. These educators, in turn will lead Tai Chi exercise in each community center or care homes. There are many forms of Tai Chi and the right program needs to be chosen for the particular problem. The Qigong Tai Chi is commonly recommended for elderly age group as it involves slow movements and is easy to practice. Tai Chi is now taught by quite a few trainers. This will require human resource, the cost of advertising, recruiting, space to train educators, and assessment of trainer’s competency before introducing them to the field. There is need for initial investment for this purpose. If volunteers choose to donate their time for this purpose, then it the cost of paying the educators can be saved.
The second step towards implementing the program is to identify the elderly population in the communities and care homes with a significantly high prevalence of ‘falling problem’. Geriatric health care services will also help to identify elderly population who has reported recurrent fall incidence. The innovation will be introduced community wise or in a group of elderly people or in elderly care homes. The trainer will create awareness about the problem and educate the subjects on the need to prevent falling. They can also introduce the benefits of accommodating exercise into their life. In this phase, the incidence of fall and the fall rate among the elders in the community can be measured using a ‘fall calendar’ and medical history. The resources needed for the second step will be trained healthcare social workers who can help identify groups and population at risk in the community, so as to create awareness about this problem. The job will require travelling and communication. In addition, a fall calendar can be provided as a complement to the elderly population.
The third phase would be to introduce Tai Chi and train the elderly on Tai Chi. This would be a time consuming step. For elderly people to be motivated into adopting a new behavior will require persuasion and encouragement. The acceptance rate of Tai Chi, subjects reporting for regular classes, subject who drop out of Tai Chi classes, any complaints related to learning and implementing Tai Chi exercise into the daily life of the elderly, will be evaluated during this stage. The standard Tai Chi exercise regimen would be at least 60 minutes of Tai Chi, twice a day. The adherence to routine and the experience of the trainers and the elderly undertaking classes will be evaluated during this phase. During the third phase, trainers will visit community center or care homes, where the elderly can gather for the Tai Chi session. It is expected that the space and facility for this will be created by the community or care homes.
Following a one-year period, the incidence of fall in the population, fall rate or frequency of fall, will be measured in the elderly group that underwent training. The incidence of fall, fall rate and overall quality of life will be determined and compared with that of previous years. This will help to identify trends and improvement associated with the new behavior. This will help to understand the advantages, if any, of introducing Tai Chi in the elderly community.
Cost benefit analysis of the proposed innovation:
There is no prior study that has looked into the cost of implementing Tai Chi, probably because Tai Chi does not require any sophisticated equipment. A qualified trainer can teach Tai Chi and the subject can do it in their home and community. It only requires a certain amount of time dedicated for the purpose. A 60 minutes of Tai Chi, twice a day would be feasible to most people. Training and getting into the stream of the practice will require motivation and effort. Tai Chi can be practiced regularly for 20 minutes a day during the initial training period.
According to the estimate by the National Health Service, falls in elderly cost the U.K health care ~ £4.6 million a day and this is a huge amount ("Falls amongst the elderly cost the NHS millions daily - BBC News", 2016). The time spend in hospital and the disabilities that accompany such fall can make the elderly patient a lifelong dependent. Tai Chi does not require any special cost and its benefit of reducing fall rate in elderly can be extremely beneficial to healthcare economy. According to an estimate by Centre for Disease Prevention, the direct medical cost (played by patient and insurance) for falls, was ~ $34 billion in the year 2013. Fall injuries are among the most expensive medical injuries and on an average it may cost the patient around ~35,000 per fall. Head injuries and hip injuries are common in fall injuries. Thus, reducing the incidence of fall in the population will not only save money, but also save suffering. Most estimates do not calculate indirect cost associated with fall, as it varies from patient to patient and is difficult to obtain a correct estimate. Disability, dependence, loss of time, time lost from work or household duties and the reduced quality of life are some of the indirect consequences of fall injury in elderly. ("Important Facts about Falls | Home and Recreational Safety | CDC Injury Center", 2016)
6. Time line for implementation of the proposal is provided in the table below:
7. Identifying key stakeholders and identifying patterns that is appropriate for implementation: The key stakeholders in this project are the research team members, the funding committee and participants of the elderly group. The Research team will be a multidisciplinary team involving medical social workers, nurses, volunteers from the community, Tai Chi trainers and research staff who will help with data collection, analysis, briefing and policy management. The financial bodies will be healthcare center or any society that wants to fund such a study that will be useful to the society. The elderly population are the direct beneficiary from this project. This intervention is expected to improve the quality of their life and reduces recurrence of fall. As a team manager, I will ensure effective coordination between stakeholder and streamlining of events.
8. Implementation of the proposed innovation and evaluation of its success: The innovation will be implemented first in one community or a group of elderly people who report a high fall incidence. After monitoring the implementation and success of Tai Chi intervention in this community, it will be extended to other groups.
B. Role as a scientist: In the role of the scientist, I look at the problem of falling in elderly as an age related problem that occurs from loss of strength to distal extremities and loss of ability to coordinate once movements. I look into scientific evidences and identify the list of causes that can make the elderly fall. The scientific investigation helps to identify the gravity of the problem and the need to prevent the fall among elderly. Based on evidence based literature, I find exercise to be a useful intervention and it could be beneficial to a majority of this population.
Role as a detective: In my role as a detective, I make a systematic plan to check if the identified innovation can benefit the elderly as identified through scientific investigation. For this, I propose a pilot study that will help check the intervention in a closed community of elderly with high incidence of fall.
Manager of the healing environment: As a promoter and manager of healing environment, it is my duty to find the best solution for a health problem and apply the solution to achieve wellbeing. As a manger, my role involves motivating people to adopt healthy related ideas and behavior.
References
El-Khoury, F., Cassou, B., Charles, M., & Dargent-Molina, P. (2015). The effect of fall prevention exercise programs on fall induced injuries in community dwelling older adults. British Journal of Sports Medicine, 49(20), 1348-1348. http://dx.doi.org/10.1136/bmj.f6234
Falls amongst the elderly cost the NHS millions daily - BBC News. (2016). BBC News. Retrieved 22 June 2016, from http://www.bbc.com/news/10353642
Fuller, G. (2000). Falls in the Elderly. Am Fam Physician, 61(7), 2159-2168.
Gillespie, L., Robertson, M., Gillespie, W., Sherrington, C., Gates, S., Clemson, L., & Lamb, S. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. http://dx.doi.org/10.1002/14651858.cd007146.pub3
Important Facts about Falls | Home and Recreational Safety | CDC Injury Center. (2016). Cdc.gov. Retrieved 22 June 2016, from http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
Li, F., Harmer, P., Fitzgerald, K., Eckstrom, E., Stock, R., & Galver, J. et al. (2012). Tai Chi and Postural Stability in Patients with Parkinson's Disease. New England Journal Of Medicine, 366(6), 511-519. http://dx.doi.org/10.1056/nejmoa1107911
Rubenstein, L. (2013). Falls in the Elderly. Merck Manuals Professional Edition. Retrieved 22 June 2016, from http://www.merckmanuals.com/professional/geriatrics/falls-in-the- elderly/falls-in-the-elderly
