CLINICAL

CARE OF THE ELDERLY

Accidents in elderly care: a randomised controlled trial (Part 3)

Ann Bowling BSc, MSc, PhD, is Senior Lecturer, Juliet Formby DCRT, is Research Assistant, and Kenneth Grant FFPHM is District General Manager, Needs Assessment Unit, The Academic Department of General Practice and Primary Care, The Medical Colleges of St Bartholomew’s and the London Hospitals (University of London).

This paper reports the data on accidents from a ran­ domised controlled trial evaluating health author­ ity-funded nursing home and long stay care of the elderly ward care in one inner London health dis­ trict. Respondents randomised to NILS nursing homes experienced a higher accident rate than respondents randomised to conventional long stay hospital wards for elderly people. Respondents in the homes also experienced an earlier decline in func­ tional and mental ability than those in hospital. These disadvantages have to be balanced against the previously published observational data from the evaluation, which clearly indicated that quality of life in the homes was superior to that in the wards. The conclusion from this study is that earlier decline infunctional and mental ability and increased acci­ dent risk in the more flexible environments of the nursing homes have to be balanced against an in­ ferior quality of life in the large traditional hospi­ tal wards; such assessments are not easy to make on behalf of other people. This final part of the report details the authors’ conclusions.

This study shows that the patients randomised to nursing home beds were at far greater risk of having an accident than those randomised to a hospital bed, and that this risk was great­ est among those who were mobile rather than bed or chair fast. The observational component of the study reported that there were signs of visible unhappiness in 74 per cent ol observations on the hospital ward where most of the hospital study patients resided, in comparison with 2123 per cent of the observations in nursing homes. It also reported that there was evidence of detachment of more than half the patients in 74 per cent of observational sessions on the ward, in comparison with between 3-20 per cent of the sessions in the homes (25, 26). The authors judged the observational study to be an essential component of the evaluation, given patients’ and residents’ reluctance to criticise their environments and their low expectations of standards within them. The low level of critical responses among elderly people living in institutions has been

commented on by other authors (30, 31). Enhanced quality of everyday life in the homes has to be balanced against an earlier physical and mental deterioration, and a high­ er accident rate among respondents in the homes in comparison to patients in the wards. The higher accident rate was possibly due to the flexibility of the home environment and their freedom to move about between day areas and bedrooms, which resulted in more falls. The staff in one of the homes called a meeting to discuss the high accident rate among resi­ dents; they decided that this reflected the pol­ icy of encouraging residents’ independence and mobility. Thus, while the cause of the acci­ dents might have been positive in relation to quality of life, the outcome was negative in terms of health consequences.

Faster deterioration The higher number of accidents among the residents might also explain their faster rate of physical and mental deterioration in com­ parison with the ward patients, although cor­ relation analyses of accidents with Crichton Royal Behaviour Rating Scale (CRBRS) scores over time provide little support for this. Although the hospital patients had a far high­ er input from the occupational therapists, this was not associated with their levels of physi­ cal and mental functioning (unpublished analyses). Possibly their earlier deterioration was associated with their additional move (from assessment bed in the hospital to the homes). There is some empirical evidence to support this hypothesis (32). The outcomes of a policy of encouraging independence and mobility at the expense of risk of accident, and the reverse policy of fos­ tering dependence but with low accident risk, needs to be assessed. Experience of an accident did not directly lead to a decline in level of functioning, selfassessed health status or to subsequent levels of life satisfaction. However, in extreme old age a fall is a shock to the system even if phys-

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CLINICAL CARE OF THE ELDERLY t .

One of the main questions posed by the study is whether elderly people should be protected' against accidents through restraint, or be freed to maintain independence in mobility, but increase the risk of falls, through a more flexible management approach.

I A second issue relates to the type of risk involved. Is there a serious risk to health? Is the risk really related to the feelings of guilt or inconvenience of the carer rather than to the well-being of the individual concerned? These issues relating to individual human rights need to be weighed up in relation to individ­ ual patients and residents, rather than dog­ matically adhering to a rigid policy of cither constraining all patients ‘at risk’ of a fall, or giving all those at risk the choice of falling. These are important issues for health care ethics, research on quality of life and quality of care, and environmental determinism (34). In conclusion, Bond el al (17, 18) stated that they had no evidence to suggest the NHS Limited choice nursing homes ‘should not' be introduced, and People receiving care services, whether from that NHS nursing homes should be consid­ professionals or informal carers, may find their ered as a policy option since the quality of the degree of choice in relation to risk-taking lim­ environment was preferred by residents and ited. For example, hospital patients in the there was no apparent disadvantage in terms study presented here, who were perceived by of survival or functional ability. The findings nurses to be at risk of falling, were observed of the study in City and Hackney, however, by the researcher to be subjected to the use of are that the residents of the homes were dis­ cot sides on their beds and the use of fixed tea advantaged in terms of a faster rate of decline trays on chairs as constraints. These con­ in functional ability, a temporary greater rate straints were not used in the nursing homes. of decline in mental confusion, and a higher Residents were given the choice of mobility accident rate. and the risk of falling. This raises several Nevertheless, data on the quality of every­ issues. Should constraints to mobility, and day life indicate that each setting has differ­ hence to dignity and choice, be used at all? ent advantages and disadvantages. The hospital Should they be used with those who are men­ setting had a patients’ club which was demon­ tally confused and at risk of falling, with those strated by the observational study ro be the who have had a stroke and are at risk of slip­ most positive environment of all. Physical de­ ping out of their chairs, with those with a his­ cline and accident risk must be balanced against tory of repeated falls? an inferior quality of life: such assessments are

ical injury and long-term limitations on level of functioning are not evident. Moreover, the interview material showed that between a fifth to a half of respondents over time reported falls as one of their current health problems. This leads to the ethical debate about risk taking. Individuals who live in the communi­ ty have the choice about whether to take risks in all aspects of daily life, although in some societies rules are made to minimise some of these - for example, car seat-belt legislation and smoking bans in public places (33). To attempt to avoid all risks may lead to other risks.

26 Nursing Standard April 22/Volume 6/Number 31/1992

TONY DARIJNGTON

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CLINICAL CARE OF THE ELDERLY not easy to make on behalf of other people. What can be concluded is that if the out­ come of greater freedom and flexibility in nursing homes is an increased degree of risk, then managers and staff of these institutions have a responsibility to ensure that all possi­ ble preventative measures have been taken. It has been suggested that preventative measures in institutions include identifying and observ­ ing high-risk individuals and ensuring a bar­ rier free environment (35), beds with adjustable heights, chairs with correct backs

Acknowledgements: We would like to thank Carol Gibson, Jenny Stanley and Lisa Williams for administrative and secretarial support on this project, Margaret Bye in the Geriatric Department Office for so efficiently referring all new eligible patients to the study, Peter Browne for computing advice and support, Morag Farquhar for her helpful comments and the staff, patients, residents and relatives who gave us so much of their time. The study was funded by North East Thames Regional Health Authority and City and Hackney Health Authority.

References 1. Central Statistical Office. Annual Abstract of Statistics. London, 11MSO. 1987. 2. International Labour Office. From Pyramid to Pillar - Population Change and Social Security in Europe. Geneva, ILO. 1990. 3. Ask ham J et al. A Review of Research on Falls Among Elderly People. London, Age Concern Institute of Gerontology, King’s College.U 990. 4. Wild D et al. How dangerous are falls in old people at home/ British MedicalJournal. 1981. 282, 266268. 5. Consumer Safety Unit. Accidents and Elderly People. Twelfth Annual Report. London, CSU. 1988. 6. Engel H O. Accident proneness and illness proneness: a review. Journal of the Royal Society of Medicine. 1991 • 84, 163-164. 7. Morse J et al. Characteristics of the fall-prone patient. The Gerontologist. 1987. 27, 516-520. 8. Waterston J A. Falls in the elder­ ly - future strategies.yo//r/W of the Royal Society of Medicine. 1991 84, 189-191. 9. Kalchthaler T et al. Falls in the institutionalised elderly. Journal of the American Geriatric Society. 1978. 26,424-428. 10. Margulec I et al. Epidemiological study of accidents among residents of homes for the aged. Journal of Gerontology. 1970. 25, 342-346. 1 1. Sehested P, Scverin-Nielson T. Falls by hospitalised elderly patients: causes, prevention. Geriatrics. 1987. 101-108. 12. Cummings S et al. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiological Review. 1985. 7, 178-208. 13- Morris E, Isaacs B. The preven­ tion of falls in a geriatric hospital. Age and Ageing. 1980. 9, 181-185. 14. Wood house P et al. Falls and disability in old people's homes. Journal of Clinical Experimental Gerontology. 1983- 5, 309-321. 15. Department of Health and

and arm rests (36), ensuring non-slippery floors and adequate provision of hand rails (7), and of course educating elderly people and care/nursing staff about high-risk situations. The range of such measures has been reviewed (3). It seems fitting to conclude with an often used quote from Churchill on the contentious issue of'environmental determinism’ (34), on which research is inconclusive in general, but in the case of care of elderly people, appears to have some foundation: ‘We shape our dwel­ lings and afterwards our dwellings shape us.

Social Security. The Experimental NHS Nursing Home for Elderly People. London, HMSO. 1985. 16 Pearson J et al. Problems of care in a private nursing home. British MedicalJournal. 1990. 301, 371372. 17. Bond J et al. Evaluation of Continuing Care Accommodation for Elderly People. The Randomised Controlled Trial of the Experimental NHS Nursing Flomes and Conventional Continuing Care Wards in NHS Hospitals. University of Newcastle upon Tyne, Health Care Research Unit. 198918. Bond J et al. Measurement of outcomes within a multi-centred randomised controlled trial in the evaluation of the experimental NHS nursing homes. Age and Ageing. 1989- 18, 292-302. 19- Bond J et al. The reliability of a survey psychiatric assessment schedule for the elderly. British Journal of Psychiatry. 1980. 137, 148-162. 20 Evans G et al. The Management of Mental and Physical Impairment in Non-Specialist Residential Homes for the Elderly. University of Manchester, Department of Psychiatry and Community Medicine. Research Report No 4. 1981. 21 Hamilton M. The development of a rating scale for primary depres­ sive illness. British Journal of Social and Clinical Psychology. 1967. 6, 278-296. 22. Hodkinson H M. Evaluation of a mental test score for the assess­ ment of mental impairment in the elderly. Age and Ageing. 1972. 1, 233-238. 23- Neugarten B L et al. The mea­ surement of life satisfaction. Journal of Gerontology. 1961. 16, 134-141. 24. Pattie A, Gillcard C. Manual of the Clifton Assessment Procedures for the Elderly. Sevcnoaks, Hoddcr and Stoughton. 197925. Clark P, Bowling A. Observational study of quality of life in NHS nursing homes and a long stay geriatric ward for the elderly. Ageing and Society. 1989- 9,

123-148. 26. (dark P, Bowling A. Quality of everyday life in long stay institu­ tions for the elderly. An observa­ tional study of long stay hospital and nursing home care. Social Science and Medicine. 1990. 30, 1201-1210. 27. Bowling A, Formby J. Everyday life in institutional settings. In Ebrahim S et al (Eds). Flealth Care for Older Women. Oxford, Oxford University Press. (In press). 28. Freiman J A et al. The impor­ tance of Beta, the type II error and sample size in relation to design and interpretation of the ran­ domised control trial. The New EnglandJournal of Medicine. 1978. 299, 690-69329- Bowling A et al. A randomised controlled trial of nursing home and traditional hospital ward care for the elderly. Age and Ageing. (In press). 30 Willcocks D et al. Private laves in Public Places. London, Tavistock Publications. 1987. 31 Breemhaar B et al. Perceptions and behaviour among elderly hospi­ tal patients: description and expla­ nation of age differences in satisfaction knowledge, emotions and behaviour. Social Science and Medicine. 1990. 31,1377-1385. 32 Aldrich C, Mendhoff E. Relocation of the aged and disabled: a mortality study. Journal of the American Geriatric Society. 1963- 11, 401-408. 33- Norman A. Models of care in dementia: defining adequate stan­ dards. In Katona C L (Ed). Dementia Disorders. London, Chapman and Hall. 1989. 34. Parker J. Images of health, urban design and human well­ being. The Statistician. 1990. 39, 191-197. 35 Gibson M (Ed). The prevention of falls in later life. Danish iMedical Bulletin: Gerontology Special Supplement Series. 1987. 4, 34. 36 Clarke-Williams M. Ward fur­ niture and equipment. In Denham M (Ed). Care of the Long Stay Elderly Patient. London, Croom Helm. 1983-

April 22/Volume 6/Number 31/1992 Nursing Standard 27

Accidents in elderly care: a randomised controlled trial (part 3).

This paper reports the data on accidents from a randomised controlled trial evaluating health authority-funded nursing home and long stay care of the ...
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