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An Exercise Program to Improve Fall-Related Outcomes in Elderly Nursing Home Residents

Deborah Perry Schoenfelder and Linda M. Rubenstein

This study tested a 3-month ankle-strengthening and walking program designed to improve or maintain the fall-related outcomes of balance, ankle strength, walking speed, risk of falling, fear of falling, and condence to perform daily activities without falling (falls efcacy) in elderly nursing home residents. Nursing home residents (N 81) between the ages of 64 and 100 years participated in the study. Two of the fall-related outcomes, balance and fear of falling, were maintained or improved for the exercise group in comparison to the control group. 2004 Elsevier Inc. All rights reserved.

LDER ADULTS WHO RESIDE in nursing homes often have multiple health risks, including the risk of falling with the resultant potential for injury. Frail elders who fall are likely to fall repeatedly, further increasing their risk for serious injury. Fractures, soft-tissue injury and immobility may lead to long-term disability or death. The fear of falling again may inhibit physical activities necessary for good health and can compromise quality of life when older people restrict their activities beyond what is necessary for safety (Lachman, et al., 1998; Mustard & Mayer, 1997). There is promise that exercise can improve fallrelated outcomes. Results of a pilot study suggested that a walking and ankle-strengthening program could improve fall-related outcomes and prevent or slow physical deterioration in elderly nursing home residents (Schoenfelder, 2000). This follow-up study investigated the effectiveness of an ankle-strengthening and walking program for elderly nursing home residents in improving balance, ankle strength, and walking speed; decreasing risk of falling and fear of falling; and improving condence in performing daily activities without falling (falls efcacy).
BACKGROUND

annually, with a mean incidence rate of 1.5 falls per bed per year (Nygaard, 1998). Risk Factors Risk factors for falling are classied as intrinsic or extrinsic. Intrinsic factors are internal to the individual. Increased age, a history of falls, impaired balance, poor muscle strength including ankle strength, and slow walking speed are examples of intrinsic risk factors (Davis, Ross, Nevitt, & Wasnich, 1999; Mustard & Mayer, 1997). Other intrinsic risk factors include age-related physiologic changes and chronic conditions of various body systems, particularly cardiovascular, neurologic, musculoskeletal, and urologic conditions (Edwards & Lee, 1998; Tinetti & Williams, 1998). Gait and balance impairments are strong predictors for falling, and walking velocity has been found to be slower for older adults who fall than for older nonfallers (Cho & Kamen, 1998; Davis, Ross, Nevitt, Wasnich, 1999; Edwards & Lee, 1998). Acute health status changes also put older adults at
Deborah Perry Schoenfelder, PhD, RN, Clinical Associate Professor, College of Nursing, The University of Iowa, Iowa City, IA, USA; Linda M. Rubenstein, PhD, Assistant Research Scientist, Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA. Supported by grant # 1 R15 NR04220-01A1 through the National Institutes of Health. Address reprint requests to Deborah Perry Schoenfelder, PhD, RN, College of Nursing, The University of Iowa, 378 Nursing Building, University of Iowa, Iowa City, IA 52242. E-mail: deborah-schoenfelder@uiowa.edu 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1701-0004$30.00/0 doi:10.1016/j.apnr.2003.10.008
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Incidence Falls are the most frequently reported adverse incident in long-term care facilities (Gurwitz, Sanchez-Cross, Eckler, & Matulis, 1994). A fall can be dened as any event in which a person inadvertently or intentionally comes to rest on the ground or another low level (Tideiksaar, 1998). At least 40% of older nursing home residents fall
Applied Nursing Research, Vol. 17, No. 1 ( February), 2004: pp 21-31

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risk for falling (Kuehn & Sendelweck, 1995), as does adverse reactions to medications (Leipzig, Cumming, & Tinetti, 1999; Mustard & Mayer, 1997). In addition to being a consequence of falling, fear of falling has been identied as a risk factor for falling (Baloh, Jacobson, Enrietto, Corona, & Honrubia, 1998). There is evidence that falls efcacy, the condence that an individual has to do daily activities without falling, is an important factor to consider in fall prevention efforts (Tinetti, Richman, & Powell, 1990). Extrinsic risk factors for falling are those environmental hazards that increase the chances of falling such as the presence of throw rugs, low lighting, and slippery oors (North American Nursing Diagnosis Association, 2001; Schoenfelder, 2000). The way older persons function in and interact with their environments also affects their safety. One study suggested that those who are distracted by doing a familiar, manual task along with functional maneuvers are more apt to fall (Lundin-Olsson, Nyberg, & Gustafson, 1998). Exercise Studies Older adults benet from exercise of various types, including muscle strengthening exercises, exibility training, aerobic exercises, and walking to offset declining strength or to increase muscle strength and to improve balance and gait velocity (Chandler & Hadley, 1996). There is evidence that exercise can also reduce falling and risk of falling in older people. A review of controlled clinical trials reported that studies successfully reduced falls or risk of falls when strength and balance retraining, endurance training, and Tai Chi were used (Gardner, Robertson, & Campbell, 2000). The bulk of the research that tests the effects of exercise on fall-related outcomes for older adults has been done with community-dwelling elders. For example, in a study that used strength and balance exercises for older women living in the community, participants in the exercise group had improved balance and had a lower fall rate than the control group. The proportion of participants who were injured from a fall was lower in the exercise group (26.2%) than in the control group (39.1%) (Campbell et al., 1997). Buchner and colleagues (1997) tested the effect of strength and endurance training for older community-dwelling adults and found there was a signicant benecial effect of exercise on time to rst fall and on the overall fall

rate for exercisers that was not present for those in the control group. Walking is a common form of exercise and can be highly benecial for older adults. Older nursing home residents who participated in a walking program showed improvement in their ambulatory status (measured on a seven point scale ranging from independence to complete dependence) and a decrease in falls after participating in the program (Koroknay, Werner, Cohen-Manseld, & Braun, 1995).

Walking is a common form of exercise and can be highly benecial for older adults.

Although elderly nursing home residents are at a great risk for falling and deterioration of physical and functional abilities, this population has not been studied extensively to test the effects of exercise on fall-related outcomes. Keeping an exercise program uncomplicated and yet effective is key for beginning or sustaining a program so that nursing home staff will include a regularly scheduled program into their busy work days and elders will be more apt to exercise consistently. A simple program was chosen that included an ankle strengthening exercise followed by up to 10 minutes of supervised walking, so that equipment needs and time commitment for subjects and research staff were at a minimum. In addition, the combination of an ankle-strengthening exercise and walking program has not been reported in the literature.

Although elderly nursing home residents are at a great risk for falling and deterioration of physical and functional abilities, this population has not been studied extensively to test the effects of exercise on fallrelated outcomes.

FALL-RELATED OUTCOMES

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Procedure Participants were matched in pairs by Risk Assessment for Falls Scale II scores (RAFS II) and randomly assigned within each pair to the intervention or control group. When subjects were roommates or spouses, those individuals were assigned to the same group to lessen the possibility of contamination between the intervention and control groups. Subjects assigned to the intervention group participated in a 3-month ankle-strengthening and walking program and had data collected on demographics, mobility/activity information, balance, ankle strength, walking speed, fall risk data, fear of falling, and falls efcacy before the intervention and at 3 months (completion of the intervention) and 6 months after initiation of the intervention. Subjects in the control group were assessed for the same baseline data as the intervention group subjects. Data were gathered again at 3 and 6 months with no exercise intervention by the research team. The group did, however, receive an attention placebo to control for the effects of attention and motivational strategies. Subjects in the control group were visited weekly by the same research team member that conducted the exercise program. About 30 minutes was devoted each time to an activity such as book reading or friendly visiting. For all assessments conducted at 3 and 6 months, examiners doing the assessments had no contact with the participants other than the assessments once group assignments were made. The examiners were graduate and undergraduate students who were trained by the principal investigator to accurately collect the data and correctly and safely perform the exercise intervention. Intervention The 3-month supervised exercising was done three times weekly for about 15 to 20 minutes each time. The ankle-strengthening exercise was done rst followed by the supervised walking. The training program was tailored to individuals ability to do the ankle exercise at the beginning of the program and the distance and time the subject was able to walk for the timed 6-meter walk at pretest. The program was advanced as strength and endurance increased and the exercises were mastered. Equipment necessary for the exercise program in-

Figure 1. Relationship of independent variables and outcome variables.

The researchers hypothesized that the proportion of elders with consistent or improved fall-related outcomes would be signicantly higher for those individuals participating in the ankle strengthening and walking program than for those elders who did not participate. The fall-related outcomes for this study were balance, ankle strength, walking speed, falls risk, fear of falling, and condence to perform daily activities without falling (falls efcacy). The predicted relationship of the exercise program and the fall-related outcomes is depicted in Figure 1.
METHODS

Setting and Participants The study was conducted in 10 private, urban nursing homes in eastern Iowa, ranging in size from 68 beds to 178 beds. The procedures to protect human subjects in this study were reviewed and approved by The University of Iowa Institutional Review Board. Nursing home residents were recruited who (1) were at least 65 years old; (2) were able to ambulate independently or with an assistive device so that they could take part in the ankle-strengthening and walking program; (3) were able to speak English; (4) did not have an unstable physical condition, evidence of an endstage terminal illness, or a history of acting-out or abusive behavior, and (5) had a score of 20 or above on the Mini-Mental State Examination to be able to answer the interview questions and to understand and follow directions for the ankle strengthening and walking program. After obtaining signed informed consent, chart reviews were conducted by research team members to ascertain any chronic conditions. Physicians were contacted and asked to indicate potential participants who might have physical conditions that would contraindicate taking part in the exercise program.

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cluded any assistive device the subject used and a straight chair. A research team member closely supervised subjects as they exercised. Team members were graduate and undergraduate students who were trained by the principal investigator to safely supervise correct performance of the exercise intervention. Ankle-strengthening exercise. In addition to strengthening the ankles, this exercise served as a warmup for the walking program. The ankle strengthening exercise consisted of (1) standing upright with knees straight, slowly raise both heels until weight is on balls of the feet doing up to three sets of 10 to 15 repetitions, while holding onto the back of a straight chair, and then when able progressing to (2) bilateral heel raises (as described earlier) with ankle weights attached, increasing the weight when the subject is able to complete three sets of 10 to 15 repetitions. Walking program. Subjects walked for 10 minutes, if tolerated. Time was increased until 10 minutes of sustained walking was reached. If and when that goal was reached, subjects were encouraged to walk at a faster (yet safe and functional) pace for 10 uninterrupted minutes. Variables/Instruments Demographic information. Age, sex, marital status, race, education, and length of residence at the nursing home were collected. Mobility/activity information. Level of mobility was ascertained by asking participants whether they ambulate unassisted, with an assistive device, or with an assistive device and another person. Subjects were also observed for their mobility level when walking speed was measured. In addition, subjects were asked how often they walked, attended group exercise classes, and other activities/exercises in which they participated. Fear of falling. Subjects were asked How concerned are you about falling? to which they could respond not at all concerned, somewhat concerned, fairly concerned, or very concerned. If subjects responded somewhat, fairly, or very concerned, the follow-up question Do you think this concern has made you cut down on the activities that you used to do? was asked to which the subject could respond with a yes or no. Test-retest reliability for the rst question was acceptable (Kappa 0.66) and lower for the second

question (Kappa 0.36) (Tinetti, Richman, & Powell, 1990). Balance. Balance was measured by a stopwatch for up to 10 seconds in three stances: (1) parallel stance (Classic Romberg with feet together, side by side), (2) semitandem stance (toe of one foot beside heel of other foot), and (3) tandem stance (Sharpen Romberg stance, with heel of one foot touching and in a straight line with the toe of the other). No assistive devices were allowed, eyes were open during the stances, and arms could be in any position. Pearson correlation coefcients reported by Graybiel and Fregly (1966) for the parallel and tandem stances ranged from 0.57 to 0.96. Ankle strength. Ankle plantar exion strength was measured by having subjects place their dominant foot on a mechanical force transducer. The foot and upper leg were contained in an apparatus to stabilize the foot and leg and keep the knee exed at a 90 angle and to keep the plantar surface of the foot at a 90 angle with the lower leg. Then when seated, subjects attempted to plantar ex their foot against the mechanical force transducer, a spring gauge was moved, giving a measure of maximal ankle plantar exion strength. Three trials were conducted, and the greatest movement was recorded in newtons. Strength was corrected for body size by dividing the measure by the height of the subject (Lord, Caplan, & Ward, 1993). The mechanical force transducer was calibrated for accuracy by a technical expert from The University of Iowa Medical Instrument Shop who built the transducer and stabilizer. Walking speed. The time to walk six meters was measured in seconds with a stopwatch. Although the intent of the exercise program was not to walk at an exceedingly fast or unsafe pace, walking at a moderate or moderately fast pace was a reasonable goal for functional purposes. Cognition. The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) is an 11-item screening test of cognitive function. Scores range from 0 (severe dementia) to 30 (normal). The scale was used as one factor to determine inclusion in the study, using 20 as the cutoff score. A score of 23 or below has been established as indicative of cognitive impairment (Cockrell & Folstein, 1988). Testretest reliability over a 24-hour period was at least 0.89 in a psychiatric and neurologic population and interrater reliability was at least .82.

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Fall Risk Assessment. The RAFS II (Ross, Watson, Gyldenvand, & Reinboth, 1991) is a 13item tool that provides an indication of the risk of falling. The scale was used for assigning subjects in matched pairs to the intervention or control groups and to assess the outcome variable of risk for falls. Items assessed are length of time since admission, age, history of falling, balance, mental status, agitation, depression, anxiety, vision, communication, medications, chronic diseases, and urinary function. Total scores range from 1 to 39 with a score of 14 or greater indicating a high risk for potential of trauma by falling. The RAFS II was used in an acute care hospital and three extended care facilities and found to be 90% accurate for predicting falls (Gyldenvand, 1984). Falls efcacy. Falls efcacy was measured by using a modied Falls Efcacy Scale (FES). The Falls Efcacy Scale (Tinetti, Richman, & Powell, 1990) is a 10-item tool designed to assess the degree of perceived self-condence for avoiding a fall during each of 10 relatively nonhazardous activities of daily living routinely performed by community dwelling elders. Expert validation was accomplished by reaching consensus among therapists, nurses, and physicians concerning the activities to include in the FES. Test-retest reliability revealed a Pearsons correlation of 0.71 for a sample of community elders and residents of an intermediate care facility (Tinetti, Richman, & Powell, 1990). Internal consistency was shown with a Cronbachs alpha coefcient of 0.89 for a sample of community-dwelling older adults (Dayhoff, Baird, Bennett, & Backer, 1994). In consultation with a nursing home director of nursing and two gerontological nursing experts, the tool was modied so that the list of activities were appropriate for elderly nursing home residents and still measured the concept of falls efcacy (Schoenfelder, 2000). The items prepare meals not requiring carrying heavy or hot objects and answer the door or telephone were deleted because these items did not make sense for most residents within their nursing home settings. The two deleted items were replaced with the items do light housekeeping in your room (eg, clean up your nightstand or dresser) and get up at night to go to the bathroom. The item reach into cabinets or closets was modied to reach into closets and the item walk around the house was changed to walk

around the nursing home to better t typical activities for nursing home residents. Internal consistency was maintained in the modied version (Cronbachs alpha 0.99). Data Analysis The main study outcomes were balance, ankle strength, walking speed, risk of falling, fear of falling, and falls efcacy. Data were collected for all variables at baseline, 3 months, and 6 months. Comparisons were made between the intervention and control groups based on the proportion of elders who remained the same or improved versus those who declined by 3 and 6 months. Descriptive statistics were generated for the intervention and control groups at baseline. Tests for group differences used the Pearsons chi square test or Fishers Exact test for categorical data and either a t test (normal distributions) or Kruskal-Wallace (nonnormal distribution) test for continuous data. Exact nonparametric tests were used to assess variables with small cell sizes and for repeated measured analyses.
RESULTS

Sample Characteristics The initial sample (N 81) consisted of 62 women and 19 men between the ages of 64 and 100 years (mean 84.1). The demographic, mobility, and activity characteristics for the entire sample at pretest are summarized in Table 1. Fiftythree percent of the participants had fallen in the past year.

Mobility status was signicantly associated with age but not gender.

Baseline mean scores for selected sample characteristics and fall-related variables are reported in Table 2. There were no signicant baseline differences between the intervention and control groups for all outcome measures, also shown in Table 2. Study Results Mobility status at baseline was signicantly associated with balance, walking time, falls efcacy, and risk of falling (chi-square p values .05). Because of this association, all group and repeated measures analyses controlled for baseline mobility

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Table 1. Demographic, Mobility, and Activity Characteristics at Baseline


Total Sample (N 81) Frequency Percent Intervention Group (N 42) Frequency Percent Control Group (N 39) Frequency Percent

Demographic Variables Gender Female Male Age 64-69 70-79 80-89 90 and older Marital Status Widowed Married Divorced/separated Never married Mental status (MMSE) 20-23 24-30 Education Less than high school High school graduate/trade school Beyond high school and other than trade school Mobility Walks independently Uses assistive device Assistive device person Activity Walking 3 or more times/week 1 or 2 times/week Does not walk weekly Exercise Class 3 or more times/week 1 or 2 times/week Does not attend exercise classes

62 19 6 16 39 20 60 6 7 8 20 61 (N 79) 24 34 21 (N 80) 14 51 15 (N 80) 67 11 2 10 20 51

76.5 23.5 7.4 19.8 48.1 24.7 74.1 7.4 8.6 9.9 24.7 75.3 30.0 42.5 27.5 17.5 63.8 18.8

30 12 4 6 22 10 34 2 3 3 7 35 15 16 11 10 25 7 (N 41) 35 6 0 6 9 27

71.4 28.6 9.5 14.3 52.4 23.8 81.0 4.8 7.1 7.1 16.7 83.3 35.7 38.1 26.2 23.8 59.5 16.7

32 7 2 10 17 10 26 4 4 5 13 26 (N 38) 9 18 11 (N 38) 4 26 8

82.1 17.9 5.1 25.6 43.6 25.6 66.7 10.3 10.3 12.8 33.3 66.7 23.7 47.4 28.9 10.5 68.4 21.1

83.8 13.8 2.5 12.4 24.7 63.0

85.4 14.6 0 14.3 21.4 64.3

32 5 2 4 11 24

82.1 12.8 5.1 10.3 28.2 61.5

Abbreviation: MMSE, Mini-Mental State Examination.

status. Mobility status was signicantly associated with age but not gender. The mean age for independent walkers was 5 to 7 years younger than the mean ages for the assistance groups. Means for selected sample characteristics at the 3- and 6-month follow-ups are shown in Table 3, and the results for change at the two follow-ups are listed in Table 4. Most elders were able to complete the parallel stance for 10 seconds at baseline, and there was no signicant change within or between groups over time. Among those who used assistive devices and for all mobility levels combined, a signicantly larger proportion of the intervention group showed maintenance or improvement over

time with the semitandem stance compared with the control group at the completion of the exercise program at 3 months. This nding also remained signicant at 6 months, even though the intervention group had not done the supervised exercise program for 3 months. In the time period from 3 to 6 months, among those who used an assistive device, a signicantly larger proportion of the intervention group exhibited the same or improvement in fear of falling compared with the control group. Most other outcome variables exhibited nonsignicant changes over time in the predicted direction (indicated in bold in Table 3). Lack of signif-

FALL-RELATED OUTCOMES

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Table 2. Baseline Mean Scores for Selected Sample Characteristics


Total Sample Variable N Mean Score (SD) Intervention Group N Mean Score (SD) N Control Group Mean Score (SD) Difference in Intervention and Control Group mean scores (p Level, Wilcoxon Rank-Sum Test)

Age (in years) Mental status (MMSE score, range 0-30) Balance (up to 10 seconds) Parallel Semi-tandem Tandem Ankle strength (n/m) Walking speed (in seconds) Falls Risk (RAFS II score, range 1-39, 14 & above indicates high risk) Falls Efcacy Scale (range 0-100)

81 81 81 81 81 81 76

84.1 (7.7) 25.6 (2.9) 9.2 (2.5) 8.4 (3.7) 2.6 (3.5) 27.3 (16.4) 20.7 (14.7)

42 42 42 42 42 42 40

83.9 (7.9) 25.9 (2.5) 9.4 (2.2) 8.7 (2.9) 3.3 (4.0) 28.6 (16.9) 20.4 (16.4)

39 39 39 39 39 39 36

84.3 (7.5) 25.3 (3.3) 8.9 (2.8) 8.0 (4.5) 1.9 (2.7) 25.9 (15.9) 20.9 (12.8)

0.91 0.49 0.33 0.29 0.50 0.50 0.33

81 81

15.3 (3.3) 77.8 (21.2)

42 42

15.3 (3.3) 78.1 (20.3)

39 39

15.4 (3.3) 77.5 (22.4)

Fear of Falling (range 1-4)

81

2.4 (1.3)

42

2.2 (1.2)

39

2.5 (1.3)

0.83 0.94 0.12 (p level, CochranMantel-Haenszel methods)

Abbreviation: MMSE, Mini-Mental State Examination.

icance was most likely related to the small numbers of respondents in each mobility group.
DISCUSSION

There were signicant changes as hypothesized for semitandem stance. The exercise program emphasized balance and did indeed improve balance as measured by the semitandem stance. Not only was balance maintained or improved at the completion of the supervised exercise program, the effect remained signicant 3 months after completion of the program. This nding suggests that

interruption in an exercise program does not mean the positive effects are immediately lost. Reestablishing the exercise program after an illness or injury or hospitalization would therefore be warranted for elderly nursing home residents. The tandem stance was too difcult for most subjects to do and therefore did not show signicant maintenance or improvement. Fear of falling was signicantly affected, specifically from 3 to 6 months for intervention subjects who required an assistive device to ambulate. It is likely that concern for falling was raised during the

Table 3. Means (SD) for 3 Months and 6 Months Follow-up for Selected Sample characteristics
Total Sample 3 months Mean (SD) 6 months Mean (SD) Intervention Group 3 months Mean (SD) 6 months Mean (SD) Control Group 3 months Mean (SD) 6 months Mean (SD)

Variable

MMSE Score (range 0-30) Balance Parallel Semitandem Tandem Ankle strength (Newton/meters) Walking speed in seconds Fall risk (RAFSII, range 1-39)* Falls efcacy scale (range 1-100) Fear of falling (range 1-4)

66 23.5 (3.8) 67 67 67 67 67 67 66 66 9.2 (2.7) 8.5 (3.2) 3.7 (3.9) 29.7 (20.2) 19.6 (17.7) 15.7 (3.8) 76.8 (23.2) 2.4 (1.3)

58 22.9 (4.6) 58 58 58 58 58 58 58 58 9.2 (2.6) 7.5 (3.9) 3.0 (3.6) 30.2 (17.9) 19.5 (17.6) 15.3 (3.8) 79.3 (24.1) 2.5 (1.2)

33 24.5 (3.3) 33 33 33 33 33 33 33 33 9.6 (1.8) 9.0 (2.7) 4.6 (3.9) 33.8 (21.0) 20.6 (19.1) 15.2 (3.8) 79.6 (22.3) 2.6 (1.4)

30 24.0 (4.1) 30 30 30 30 30 30 30 30 9.0 (2.7) 8.2 (3.5) 3.6 (4.1) 36.2 (19.0) 20.5 (19.4) 15.3 (3.7) 78.6 (26.4) 2.5 (1.3)

33 22.6 (4.2) 34 34 34 34 34 34 33 33 8.8 (3.3) 8.0 (3.6) 2.7 (3.8) 25.7 (18.9) 18.7 (16.3) 16.3 (3.8) 74.0 (24.1) 2.3 (1.2)

28 21.8 (4.9) 28 28 28 28 28 28 28 28 9.3 (2.6) 6.8 (4.3) 2.4 (3.0) 23.8 (14.5) 18.5 (15.7) 15.3 (3.9) 80.1 (21.9) 2.5 (1.2)

Abbreviation: MMSE, Mini-Mental State Examination. *Fourteen and above indicates high risk.

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Table 4. Results for Change Over Time


Stay the Same or Improve versus Decline From Pretest to 3-Month Posttest Variable, Group, and Mobility Class Intervention Control p Value Stay the Same or Improve versus Decline From 3Month to 6-Month Posttest Intervention Control p Value

Semitandem Device and Person Device Only Independent All Levels Tandem Device and Person Device Only Independent All Levels Walking Speed Device and Person Device Only Independent All Levels Ankle Strength Device and Person Device Only Independent All Levels Fear of Falling Device and Person Device Only Independent All Levels FES Total Device and Person Device Only Independent All Levels RAFS Device and Person Device Only Independent All Levels

% (frequency) 80.0 (4) 100 (15) 88.9 (6) 93.1 (25) 50.0 (2) 55.6 (5) 50.0 (2) 53.0 (9) 60.0 (3) 50.0 (8) 22.2 (2) 43.3 (13) 33.3 (2) 52.9 (9) 55.6 (5) 50 (16) 66.7 (4) 76.5 (13) 100 (9) 81.3 (26) 50.0 (3) 64.7 (11) 55.6 (5) 59.4 (19) 100.0 (5) 93.3 (14) 78.8 (6) 89.5 (25)

% (frequency) 60.0 (3) 73.9 (14) 100 (3) 74.1 (20) 100 (3) 60.0 (6) 100 (1) 71.4 (10) 50.0 (5) 38.1 (8) 100.0 (3) 46.7 (14) 75 (6) 36.4 (8) 33.3 (1) 45.5 (15) 75.0 (6) 59.1 (13) 75.0 (3) 64.7 (22) 62.5 (5) 54.6 (12) 50 (2) 55.9 (19) 100 (8) 70.0 (14) 66.7 (2) 77.4 (24)

(Chi-square or Fishers Exact tests) 0.417 0.053* 0.436 0.057* NA 0.845 0NA 0.461 0.740 0.520 NA 0.795 0.277 0.345 0.502 0.806 0.733 0.318 0.308 0.171 0.529 0.744 0.853 0.808 NA 0.198 0.785 0.306

% (frequency) 20.0 (1) 86.7 (13) 89.0 (8) 75.9 (22) 25.0 (1) 66.7 (6) None 41.2 (7) 20.0 (1) 68.8 (11) 66.7 (6) 60.0 (18) 66.7 (4) 41.2 (7) 66.7 (6) 53.1 (17) 50.0 (3) 88.2 (15) 66.7 (6) 75.0 (24) 50.0 (3) 58.8 (10) 66.7 (9) 69.4 (19) 100.0 (4) 100.0 (10) 100.0 (6) 100.0 (20)

% (frequency) 40.0 (2) 47.4 (9) 33.3 (1) 44.4 (12) 0 (3) 30 (3) None 21.4 (3) 33.3 (2) 38.1 (8) 33.3 (1) 36.7 (11) 37.5 (3) 31.8 (7) None 30.3 (10) 87.5 (7) 44.5 (10) 50.0 (2) 55.9 (19) 75.0 (6) 54.6 (12) 50.0 (2) 58.2 (20) 100.0 (8) 100.0 (10) 100.0 (2) 100.0 (20)

(Chi-square or Fishers Exact tests) 0.487 0.030* 0.127 0.028* NA 0.179 NA 0.076 NA 0.099 0.523 0.121 0.592 0.738 0.182 0.080 0.249 0.008* 0.571 0.126 0.580 0.789 0.571 0.964 NA NA NA NA

NOTE. p Values are generated from chi-square tests, Fishers Exact tests, and likelihood ratio tests. Abbreviation: NA, not applicable. *bold print: p .054. bold print only: change in predicted direction.

exercise program for subjects who were increasing their level of exercise, having been more accustomed to a less active lifestyle. However, as time progressed, it may have been that exercise subjects became less fearful of falling after they saw that they could exercise and move about safely. It is difcult to know why fear of falling did not signicantly improve for the independent group and the device and person group. The results may be partially explained by the small numbers in each

group (independent; device and person) as compared with the device-only group. It was expected that ankle strength would be signicantly affected by the exercise program because there was an exercise specically targeted at strengthening ankles. Although the results were not signicant, the results for all mobility levels were in the predicted direction (p .08). Larger sample sizes would most likely show a signicant effect for this important fall-related outcome. Lower

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strength gain (knees and ankles) was signicantly associated with increase in gait speed and improved falls efcacy (Chandler, Duncan, Kochersberger, & Studenski, 1998), two of the fall-related outcomes in this study. Although ankle range of motion (ROM) was not measured in this study, the ankle exercise would probably increase dorsiexion and plantar exion ROM. Recent ndings suggest that interventions for increasing ankle ROM may increase balance and reduce falls in older adults (Mecagni, Smith, Roberts, & OSullivan, 2000).

Walking speed, falls risk, and falls efcacy also showed change over time in the predicted direction for some of the mobility levels.

Walking speed, falls risk, and falls efcacy also showed change over time in the predicted direction for some of the mobility levels. Again, having small numbers in each cell made it difcult to obtain signicant ndings. Nevertheless, the authors believe that walking speed, falls risk, and falls efcacy are important outcomes for evaluating the effectiveness of programs to prevent falls or stop the cycle of falling. Regarding walking speed, it would seem that frail elders might be more apt to walk on a routine basis (eg, to the bathroom and to the dining area) rather than propel themselves in a wheelchair if they were able to walk at a more functional speed. In addition, walking requires balance and the act of walking regularly probably improves balance as it did in this study. Reducing the risk for falling and increasing falls efcacy are also important outcomes to measure. Several of the risk factors in the RAFS II are modiable by health care intervention, and having condence in being able to perform activities without falling would likely lead to more active participation in those daily activities. Major strengths of this study were the use of a control group, excellent adherence to the exercise program and no reported adverse effects to the exercise program. No doubt adherence was at a high level because the exercises were supervised, conducted on a one-on-one basis, simple to do, and

not time consuming. Also, no falls or injuries occurred while exercising in this study and no physical complaints were expressed by the intervention subjects. There were limitations with this research. A major challenge is encountered any time researchers are attempting to obtain large sample sizes with very old adults who are frail. Recruitment was somewhat difcult in that some potential subjects were hesitant to start an exercise program. Attrition was also a limitation in this study that reduced the sample size to 67 at the 3-month follow-up and to 58 at the 6-month follow-up. Most of the attrition was due to extended illness or death. Another possible limitation that was anticipated was that subjects might tend to respond to certain questions according to how they believed the examiner would want them to respond (eg, condence levels on the FES). Subjects were instructed to respond according to how they truly felt rather than how they thought the examiner would want them to respond so as to minimize this potential limitation. In general, subjects voiced difculty responding to the FES 100-point scale. This difculty might be caused by having response labels only at the two ends of the scale, or the difculty might be caused by having too large of a scale (ie, 100 point) to conceptualize and translate into a condence level. Finally, because a large majority of older Iowans are white, it was expected that the study sample would not vary in ethnic or racial composition and that was the case. This needs to be considered when discussing generalizability of the results. Nevertheless, this study can be replicated in settings with more diverse populations in the future. The ndings in this study have implications for nursing research. The results show promise that a simple exercise plan can have positive effects on fall-related outcomes, especially balance and fear of falling as indicated by this study. The tests and instruments used in this research were, for the most part, easy to administer and score. The exception, as noted earlier, was the FES. Based on the difculty that subjects had responding to this instrument, the authors recommend using a tool to measure falls efcacy that has few numbered points and has descriptors for each of those points. Recommendations can be made for nursing practice based on this research. Nursing home staff can easily be trained to use the exercise program.

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Depending on the mobility of residents, the exercises can be done individually or in groups of two or more residents while maintaining safety. Along with implementing the exercise program, walking in general should be emphasized for residents, offering both tangible and intangible incentives for walking. The use of standardized nursing language for preventing falls is essential. By using the nursing diagnosis Risk for Falls (North American Nursing Diagnosis Association, 2001), risk factors can be linked with relevant nursing interventions to achieve the desired outcome of not falling in the rst place or not having a repeat fall, therefore avoiding possible injury. Correctly identifying risk factors will facilitate accurate selection of outcomes and interventions to address the diagnosis. For example, the Nursing Outcomes Classication outcomes Risk Control and Safety Behavior: Fall Prevention may be appropriate choices depending on the identied risk factors (Johnson, Maas, &

Moorhead, 2000). Examples of Nursing Interventions Classication interventions that address falling include Environmental Management: Safety; Fall Prevention; and Surveillance: Safety (McCloskey & Bulechek, 2000). The outcome indicators and intervention activities focus on decreasing or controlling the specic risk factors identied for individuals who are vulnerable to falling. The occurrence of falling in elderly nursing home residents is unfortunately not uncommon and of great concern to nurses and other health professionals caring for older nursing home residents. Interventions to decrease the chances of falling need to be identied through research efforts and applied in nursing practice. There is mounting evidence that exercise can improve fall-related outcomes for older adults, even frail elders. And there is promise that exercise, especially exercise to improve balance, can prevent or stop the cycle of falling.

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