Complex health care interventions in geriatrics. Development and evaluation of a multifactoral falls-prevention intervention.
Year: 2011
Type: dissertation
Abstract: A Our society's population is aging rapidly.As of the year 2010, 2.5 million Dutch people, representing 15% of the population, were over 65, and the percentage of the population over 65 is expected to reach 25% in 2040. 1 Among older persons, geriatric syndromes are highly prevalent.A geriatric syndrome is a multifactorial health condition that occurs when the accumulated effects of impairments render an older person vulnerable to situational challenges.Thus, the use of the term "syndrome" in a geriatric context emphasizes multiple causation of a unified manifestation. 2 Falling is among these frequently encountered multicausal problems.The ability to transfer and walk safely depends on coordination among sensory systems (vision, vestibular, and proprioception) as well as on coordination of the central and peripheral nervous systems and the cardiopulmonary and musculoskeletal body systems.Falls that occur during ordinary daily activities generally result from disease or impairment of one or more systems, making falling a geriatric syndrome.2;3 Falls Prevalence, risk factors and consequences of falls More than one-third of community-living persons older than 65 years of age fall each year.Previous falls, strength, gait, and balance impairments, and medications are the strongest risk factors for falling.3 The risk of falling increases with the number of risk factors.The 1-year risk of falling increased from 8% to 78% as the number of factors present increased from 0 to 4 or more.3 Approximately 10% of falls result in a major injury such as a hip fracture (1-2%), other fractures (3-5%) serious soft tissue injury, or traumatic brain injury (5%).3;4 In the Netherlands, falls are the leading cause of accidental death in persons older than 65. 4 Psychological consequences such as fear of falling are also frequently reported in this age group.3;5 There are strong indications that older people who are afraid of falling and consequently avoid activities enter a debilitating spiral of loss of confidence, restriction of physical activities and social participation, physical frailty, falls, and loss of independence.6 Falls are major contributors to functional decline and health care utilization and are associated with high health care costs. Falls in frail community-dwelling older personsFrail older persons are at an increased risk of falls.3;7-9 Frailty is considered to be highly prevalent with increasing age and to confer high risk for adverse health outcomes, including mortality, institutionalization and hospitalization.Fried posed a widely accepted definition of frailty.10 According to that definition, frailty is a biological syndrome of decreased reserve and several (multifaceted) components that act both independently and interdependently.27 However, complex interventions are difficult to develop, document, and reproduce, and randomized controlled trials, which are required to demonstrate their effectiveness, are usually costly and challenging.28 Campbell et al. described the framework used by the UK Medical Research Council (MRC) for the development, evaluation and implementation of complex interventions (figure 1).In this framework, a phased approach in the development and evaluation of complex interventions is advocated.In this thesis, we carried out the process of development and evaluation of our intervention in a manner very similar to the phased approach recommended by the MRC.Although the MRC framework has not yet been widely referenced in the geriatric literature, 26;29-31 we believe that this framework may be of great value in geriatric research. Medical Research Council frameworkIn 2000, the MRC developed a framework based on the linear sequenced phases that are used in drug development.27 In 2008, a revised version of this framework was published in which the process of developing and evaluating complex interventions was described by cyclical phases (Figure 1).28;32 In the development phase, the best available evidence and appropriate theories are identified and the process and outcomes are modeled.Modeling refers to defining and combining the components of the intervention; it further involves delineating an intervention's components, identifying how they may be interrelated, and understanding how key components may relate to either surrogate endpoints or final outcomes.The feasibility and piloting phase includes the implementation of testing procedures to assess the feasibility of the intervention and subsequent evaluation, the estimation of the likely recruitment rate and retention rate of the research subjects, and the calculation of appropriate sample sizes.The evaluation phase is the phase of the randomized controlled trial (RCT) in which the final intervention is evaluated.Both the design of the RCT and the intervention are developed based on information from the development phase and from the feasibility study.Ideally, the RCT is accompanied by a process-evaluation and cost-effectiveness study.In the implementation phase, the results are disseminated as widely and persuasively as possible, and further research is undertaken to assist and monitor the process of implementation.32 The implementation phase is beyond the scope of this thesis.
Author: Miriam C. Faes
Language: English
Field: Health Professions
Domain: Health Sciences
Open Access status: green
Funders: ZonMw, Radboud Universiteit
OpenAlex ID: W1493060150