DOI: 10.1111/ajag.12068
Letters to the Editor Falls prevention research in residential aged care is itself tripped up by medical clearance issues Dear Editor, Australia’s residential aged care (RAC) population is projected to more than treble by 2050 [1]. This increase will have significant implications for health-care expenditure [2]. Falls in older adults are common, and are a major cause of morbidity and mortality, in RAC, 60% of residents will fall each year, many will fall more than once [3]. There is compelling evidence that exercise, and specifically resistance and weightbearing exercise programs can prevent falls in older adults [4–7]. While most trials have considered communitydwelling older people, research for exercise intervention in RAC has returned inconsistent data [5,8]. Current clinical practice guidelines suggest that there is insufficient evidence to recommend for or against the use of exercise programs in RAC and further research is recommended [6,8]. To address this, a randomised controlled trial is currently being undertaken to investigate the effect of strength and balance exercise versus usual care on falls and fear of falling, mobility, quality of life, cognition and cost-effectiveness, in RAC settings. To ensure participant safety, medical clearance is sought from treating general practitioners (GP) as part of the recruitment process. In general, GP consent to such programs is positive. However the inability to obtain medical clearance can have significant implications for both the individual and evidence-based knowledge development. In this case, a professional indemnity insurance provider recommended GPs not to take responsibility for participation in exercise research. This barrier to participation precludes residents from supervised exercise which may improve their functional capacity and quality of life. The implications for research include recruitment difficulty, population bias and potential bias estimation of the treatment effect. For GPs, a conflict of interest occurs between duty of care to their client, their clients’ wishes and complying with the indemnity advice. Excluded residents argue that their right to decide to participate should be respected if their exclusion is not based on a medical condition, but on a blanket decision by the GP. A request to the Ethics Committee to alter the approved protocol and enable individuals to provide written requests concerning their personal wish to participate, and guarantee no indemnity claim, was unsuccessful. Identification of effective interventions to reduce falls in residential aged care has the potential to significantly benefit older individuals and reduce the health-care burden. The problem is when the research process itself fails and medical Australasian Journal on Ageing, Vol 32 No 4 December 2013, 247–249 © 2013 ACOTA
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clearance cannot be obtained, or be bypassed, then suitable participants are excluded. Jennifer Hewitt Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia Kathryn Refshauge Office of the Dean, Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia Timothy Henwood Blue Care Research & Practice Development Centre, School of Nursing and Midwifery, University of Queensland, Toowong, Queensland, Australia Stephen Goodall Centre for Health Economic Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia Lindy Clemson Ageing, Work & Health Research Unit, Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
References 1 2 3
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Steering Committee of the Report on Government Service Provision. Report on Government Services 2012. Productivity Commission, Canberra. 2012. Church J, Goodall S, Norman R, Haas M. An economic evaluation of community and residential aged care falls prevention strategies in NSW. Sydney: NSW Ministry of Health; 2011. Lord SR, March LM, Cameron ID et al. Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided. Journal of the American Geriatrics Society 2003; 51: 1645– 1650. Gillespie L, Handoll H. Prevention of falls and fall-related injuries in older people. Injury Prevention 2009; 15: 354–355. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: An updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22: 78–83. Panel on Prevention of Falls in Older Persons American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society 2011; 59: 148–157. Tiedemann A, Sherrington C, Close JC, Lord SR. Exercise and Sports Science Australia position statement on exercise and falls prevention in older people. Journal of Science and Medicine in Sport 2011; 14: 489–495. Cameron ID, Gillespie LD, Robertson MC et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012; (12): CD005465. 247
Letters to the Editor Falls prevention research in residential aged care is itself tripped up by medical clearance issues Dear Editor, Australia’s residential aged care (RAC) population is projected to more than treble by 2050 [1]. This increase will have significant implications for health-care expenditure [2]. Falls in older adults are common, and are a major cause of morbidity and mortality, in RAC, 60% of residents will fall each year, many will fall more than once [3]. There is compelling evidence that exercise, and specifically resistance and weightbearing exercise programs can prevent falls in older adults [4–7]. While most trials have considered communitydwelling older people, research for exercise intervention in RAC has returned inconsistent data [5,8]. Current clinical practice guidelines suggest that there is insufficient evidence to recommend for or against the use of exercise programs in RAC and further research is recommended [6,8]. To address this, a randomised controlled trial is currently being undertaken to investigate the effect of strength and balance exercise versus usual care on falls and fear of falling, mobility, quality of life, cognition and cost-effectiveness, in RAC settings. To ensure participant safety, medical clearance is sought from treating general practitioners (GP) as part of the recruitment process. In general, GP consent to such programs is positive. However the inability to obtain medical clearance can have significant implications for both the individual and evidence-based knowledge development. In this case, a professional indemnity insurance provider recommended GPs not to take responsibility for participation in exercise research. This barrier to participation precludes residents from supervised exercise which may improve their functional capacity and quality of life. The implications for research include recruitment difficulty, population bias and potential bias estimation of the treatment effect. For GPs, a conflict of interest occurs between duty of care to their client, their clients’ wishes and complying with the indemnity advice. Excluded residents argue that their right to decide to participate should be respected if their exclusion is not based on a medical condition, but on a blanket decision by the GP. A request to the Ethics Committee to alter the approved protocol and enable individuals to provide written requests concerning their personal wish to participate, and guarantee no indemnity claim, was unsuccessful. Identification of effective interventions to reduce falls in residential aged care has the potential to significantly benefit older individuals and reduce the health-care burden. The problem is when the research process itself fails and medical Australasian Journal on Ageing, Vol 32 No 4 December 2013, 247–249 © 2013 ACOTA
bs_bs_banner
clearance cannot be obtained, or be bypassed, then suitable participants are excluded. Jennifer Hewitt Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia Kathryn Refshauge Office of the Dean, Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia Timothy Henwood Blue Care Research & Practice Development Centre, School of Nursing and Midwifery, University of Queensland, Toowong, Queensland, Australia Stephen Goodall Centre for Health Economic Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia Lindy Clemson Ageing, Work & Health Research Unit, Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
References 1 2 3
4 5
6
7
8
Steering Committee of the Report on Government Service Provision. Report on Government Services 2012. Productivity Commission, Canberra. 2012. Church J, Goodall S, Norman R, Haas M. An economic evaluation of community and residential aged care falls prevention strategies in NSW. Sydney: NSW Ministry of Health; 2011. Lord SR, March LM, Cameron ID et al. Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided. Journal of the American Geriatrics Society 2003; 51: 1645– 1650. Gillespie L, Handoll H. Prevention of falls and fall-related injuries in older people. Injury Prevention 2009; 15: 354–355. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: An updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22: 78–83. Panel on Prevention of Falls in Older Persons American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society 2011; 59: 148–157. Tiedemann A, Sherrington C, Close JC, Lord SR. Exercise and Sports Science Australia position statement on exercise and falls prevention in older people. Journal of Science and Medicine in Sport 2011; 14: 489–495. Cameron ID, Gillespie LD, Robertson MC et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012; (12): CD005465. 247
