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TAKING ASSISTIVE DEVICES OUT OF THE CLOSET Nancy Edwards, RN, PhD, CHSRF/CIHR Nursing Chair School of Nursing, University of Ottawa Kunin-Lunenfeld Applied.

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Presentation on theme: "TAKING ASSISTIVE DEVICES OUT OF THE CLOSET Nancy Edwards, RN, PhD, CHSRF/CIHR Nursing Chair School of Nursing, University of Ottawa Kunin-Lunenfeld Applied."— Presentation transcript:

1 TAKING ASSISTIVE DEVICES OUT OF THE CLOSET Nancy Edwards, RN, PhD, CHSRF/CIHR Nursing Chair School of Nursing, University of Ottawa Kunin-Lunenfeld Applied Research Unit Baycrest Centre for Geriatric Care 3 rd Annual Conference

2 Overview A short tale: From fall prevention to assistive devices A short tale: From fall prevention to assistive devices Why are assistive devices in the closet? Why are assistive devices in the closet? How can we get assistive devices out of the closet? How can we get assistive devices out of the closet? Whose closets? Whose closets? A population health perspective A population health perspective

3 A short tale: From fall prevention to assistive devices A short tale: From fall prevention to assistive devices Falls -- Assistive devices Falls -- Assistive devices Independence – foreground Independence – foreground Falls - background Falls - background Personal, environmental and device-based barriers to assistive device use Personal, environmental and device-based barriers to assistive device use Contrast of clinical versus community action approach to tackling assistive devices Contrast of clinical versus community action approach to tackling assistive devices

4  1 in 3 community-dwelling Canadian seniors experience a fall each year (It is estimated that only 1 in 13 falls are reported)  In 1997, falls accounted for 20% of all injury deaths among seniors  56% of all people admitted to hospital with injuries due to falls are over 65  The estimated annual direct costs of falls is $2.4 billion – caring for seniors injured from a fall represents 41% of these costs, or $1 billion Health Canada / Veterans Affairs Canada Falls Prevention Initiative, Fact Sheet No. 6, 2002 FACTS ON FALLS AMONG SENIORS

5 FALLS IN OLDER ADULT What is a fall?  A fall is "an event that results in a person coming to rest inadvertently on the ground or floor or other lower level." This could include an event where the person landed on the ground, tripped on stairs, slipped, or lost his or her balance and hit against an object like a chair or bed. Kellogg International Work Group, 1987; RNAO, 2002, Nursing Best Practice Guideline Prevention.

6 POST-FALL SYNDROME Fall Loss of Confidence Activity Restriction Loss of Mobility Increased Dependence

7 “Only frail seniors need to worry about serious falls” SENIOR’S PERSPECTIVES REGARDING FALLS “People will think I’m too old to live by myself if I use a cane” “My home is not a home without the scatter rugs” “My doctor is in charge of my medications” “My home is safe from falls because I can avoid all the hazards”

8 I dropped something and reached for it. I fell, bumped my head on the night table and rolled on the floor. I can’t get up because of an operation on my knees. I crawled up using my comforter, got onto the bed, fell forward and my nose started to bleed. The next morning, my back hurt, and I had a purple lump on my head. My nephew came over. He was angry because I wasn’t using my cane. He told people in the building to notify him if they see me without my cane. A SENIOR RECOUNTS HIS FALL

9 WHAT ASSISTIVE DEVICES ARE MEANT TO DO Minimize the effects of many age-related changes:  impaired mobility  range of motion  balance  coordination  muscular strength  endurance Axtell & Yasuda, 1993; Bynum & Rogers, 1987; Tinetti, 1986

10 The Biomechanical View: Maintaining & improving mobility Increase standing and walking base of support and stability Increase standing and walking base of support and stability Provide proprioreceptive feedback through the handle Provide proprioreceptive feedback through the handle Shift the load on weight-bearing joints to the upper limb Shift the load on weight-bearing joints to the upper limb Provides a visual presence of support and instill confidence during ambulation Provides a visual presence of support and instill confidence during ambulation (R Tideiksaar, 2003) (R Tideiksaar, 2003)

11 The Psychosocial View: Social support, sense of confidence Canes provide increased confidence for performance of daily activities (Dean & Ross, 1993, Aminzadeh & Edwards, 1997) Canes provide increased confidence for performance of daily activities (Dean & Ross, 1993, Aminzadeh & Edwards, 1997) Individuals hold unique preferences for image and autonomy (Pippin & Fernie, 1997) Individuals hold unique preferences for image and autonomy (Pippin & Fernie, 1997) Device acceptance is dependent on context (Pippin & Fernie, 1997) Device acceptance is dependent on context (Pippin & Fernie, 1997) Habitual versus seasonal patterns of device use (Edwards, et al., 1999) Habitual versus seasonal patterns of device use (Edwards, et al., 1999)

12 Perceived Importance of risk factors for falls among community dwelling elderly (n=68/52) Braun, 1998 Risk Factor Importance for a fall among general elderly (they fall) Importance for a personal fall (I am likely to fall) Grab bars not present or not in a helpful position 7.7 (2.4) 2.7 (3.3) Handrails not present or poorly positioned 7.7 (2.7) 4.6 (3.4) Coordination or balance problem 8.2 (2.1) 2.7 (3.3) Doing unsafe or risky things 8.0 (2.7) 1.9 (2.5) Sidewalks poorly maintained 8.7 (1.8) 7.2 (2.8)

13  Older adults estimate standing reach more accurately than bending reach  Older adults tend to overestimate reach ability and negate the “safety factor”  Greatest overestimation of bending reach ability was observed for the most motor-impaired elderly Robinovitch (1998); Robinovitch & Cronin (1999) SENIOR’S PERSPECTIVES ON THEIR ABILITIES

14 Possession of Selected Devices Assistive Device Possession Sweden (n=734) (Sonn & Grimby, 1994) Possession Belgium (n=117) (Roelands et al., 2002) Grab bars 15.9%15.9% Walking canes 15.3%59.1% Bath seat 8.2% Free standing lifting pole -26.1% Anti-slip bathmat -67.8%

15 Mobility aids: Canes WHAT DEVICES ARE WE TALKING ABOUT? Figure 1. Schematic of two types of hip protector (A) worn over clothing and (B) worn within specially designed underwear Hip protectors Bath safety devices

16 WHY BATHROOM ASSISTIVE DEVICES  10-15% of falls happen in bathroom  73% result in injuries  55% of bathroom falls are related to bathing activities of these, almost 2/3 happen during transfers  ~ 50% of seniors have difficulty with bath transfers (either getting in/out or up/down) (Aminzadeh et al., 2001)

17  80% of seniors who have grab bars use them (Aminzadeh et al., 2001)  A lab study noted that 99% of participants spontaneously used grab bars when available (Sveistrup et al., 2003)  In the absence of proper grab bars, seniors use hazardous supports (Aminzadeh, Edwards, Lockett, 1999) WHY BATHROOM GRAB BARS?

18 Canadian Standards Association Ontario Building Code Ottawa/Carleton Common US Uniform Federal Accessibility Standards OPTIMAL GRAB BAR PLACEMENT (Sveistrup, Lockett, Aminzadeh, Edwards, 2003)    X

19 WHY CANES?  they have been linked to improved independence and/or reduced risk or perceived risk of falls  seniors are often reluctant to use these or abandon use  they are most likely to be independently sought by seniors, and are often selected and used incorrectly Aminzadeh & Edwards, 1997

20 Cane Fitter and Appropriateness of Cane Length (Dean & Ross, 1993) Cane Fitter Cane length within 2 cm of wrist crease Cane length > 2 cm of wrist crease Total Health care worker 27 (56%) 21 (44%) 48 (100%) Non-health care worker 36 (38%) 60 (62%) 96 (100%) P<.05

21 WHY HIP PROTECTORS?  1993/94: 23,375 hip fractures reported in Canada - this number will increase to 88,124 annually by the year 2041 (CMAJ, 1998).  Hip fractures are the 3 rd most common type of fracture following a fall – 19% of all fractures (Statistics Canada, 1999).  Of all fractures, hip fractures cause the greatest number of deaths and lead to the most severe health problems and reduced quality of life (Wolinsky 1997; Hall 2000).  40% of hospital admissions following falls are related to hip fractures (HC, 2003).  The average 1 year cost of a hip fracture is $27,527 - annually in Canada cost of $650 million (expected to rise to $2.4 billion by 2041) (Wiktorowicz et al., 2001).

22 WHY HIP PROTECTORS  12 months following a fracture: 20 to 24% of individuals older than age 50 will die within 12 months of suffering a hip fracture 24 to 40 % will require nursing home care 40% are still unable to walk independently 50% will require an assistive device like a cane or walker 60% will need help with one essential activity of daily living (e.g. bathing, dressing, food preparation) 80% are unable to perform at least one instrumental activity of daily living ( National Osteoporosis Association, 2003)  80% of participants in one study said they would rather be dead than experience the loss of independence and quality of life resulting from a bad hip fracture and the subsequent admission to a nursing home (Salkeld et al., 2000)

23 60-90% OF HIP FRACTURES ARE CAUSED BY FALLS (Lauritzen & Askegaard, 1992)

24 HOW HIP PROTECTORS CAN PREVENT HIP FRACTURES  Shields placed against the unprotected hip  Energy absorbing (soft pads)  Energy shunting: Disperse impact across a wider area (typically hard shells*) (Lips & Ooms, 2000) * Some energy shunting materials are made of materials that are not hard plastic, e.g. HipShield is made of Trauma-Lite, the material used in motorcycle wear

25 Hip Protectors: Patterns of Use Sveistrup & Lockett, 2003 StudyInitialvisit 1 mo 6 mos 12 mos 24 mos Hindso199857%-77%58%- McAughey & McAdoo, %-35%-- VanSchoor et al., %45%37%- Cameroon et al., %-57%42%

26 DO ASSISTIVE DEVICES PREVENT FALLS? Canes: Review of literature concluded that “any links between AD use and falls in seniors are tenuous, at best” (Watzke, 2001) Research inconclusive because:  people who use assistive devices are at higher risk of falling  poor compliance with use of device  most interventions have targeted multiple risk factors  most studies descriptive in nature – unable to draw conclusions  some video data studies, but in long-term care facilities  poor controls in studies – studies needed that compare seniors using their mobility aid to those who should but are not using AD

27 Grab bars: Men with no grab bars were 3.7 times as likely to fall as men with grab bars (Sattin et al., 1998) DO ASSISTIVE DEVICES PREVENT FALLS?

28 Hip protectors: A review from the Cochrane group of elderly people in nursing homes, residential care, or supportive living at home concluded that “hip protectors appear to reduce the risk of hip fracture within a selected population at high risk of sustaining a hip fracture. The genereralization of the results is unknown beyond high-risk populations.” (Parker et al., 2003 ) NOTE: ENERGY SHUNTING + ABSORBING MOST EFFECTIVE

29 Assistive devices as innovations

30 The Diffusion of Innovation Relative advantage Extent to which an innovation is perceived as better than the idea it replaces Compatibility Consistency of intervention with existing norms, values, past experiences or needs Complexity Difficulty in understanding or using an innovation Trialability Option to experiment with an innovation before making a final choice about its use Observability Extent to which innovation results are visible to others

31 Assistive Devices: An application of Roger’s Diffusion Theory Canes Hip protectors Grab bars Relative advantage ??? CompatibilityMediumLowMedium ComplexityMediumMediumHigh TrialabilityHighLowLow ObservabilityMediumLowLow

32 Hip Protectors: An application of Roger’s Diffusion Theory Relative advantage Hubacher & Huguenin, 2000 Individuals with a positive opinion of hip protector wearing comfort 3X more likely to wear them than those with a negative opinion of comfort Compatibility Cameron & Quine, 1994; Hubacher & Huguenin, 2000 Hip protector undergarments are longer than conventional undergarments and not “very sexy” Seniors convinced that the hip protector was not externally visible wore the protector 4X longer than those who thought it was visible Complexity McAughey, % of seniors thought hip protectors would be difficult to put on and take off to use the toilet

33 Assistive Devices: An application of Roger’s Diffusion Theory CharacteristicsCanes Hip protectors Grab bars Relative advantage Waistband of undergarments uncomfortably tight Compatibility People will think I’m too old to live alone It will decrease property values Complexity Can’t hold my shopping bag, purse and cane Who will install it? Trialability “Try before purchasing” Observability

34 Promoting the use of Assistive Devices to prevent falls among seniors and veterans. University of Ottawa, CAOT Funded by Health Canada and Veterans Affairs Canada

35 PROJECT GOALS A Population Health Approach To increase acceptance of assistive devices by Canadians, including seniors, veterans, caregivers and community stakeholders. To increase the visibility & availability of assistive devices in the community.

36 1. To increase the ability of seniors and veterans, and caregivers to make an informed choice about assistive devices. PROJECT OBJECTIVES 2. To encourage retailers to actively promote sales of assistive devices. 3. To encourage hoteliers, builders and retailers to model & correctly display installed bathroom devices.

37 THEORETICAL FRAMEWORK Social environment -retail - public -Private (e.g.home) Built environment Community demand Product and building standards Empirical evidence Policy environment Purchase or acquisition Installation &/or adaptation Appropriate use of assistive devices Public Opinion High profile Innovators (retailers, hoteliers, builders) Demonstrate characteristics of innovation Media e.g. advertising, PSAS Enhance independent living Reduce risk and severity of falls

38 PROJECT COMPONENTS Community Profile and awareness Recruit and Train Community Action Team & Senior Champs Recruit Local Businesses Retailers Homebuilders Hoteliers Baseline Evaluation Post Evaluation

39 OUR FOCUS Bath safety devices Canes Hip protectors

40  Nanaimo, British Columbia  Calgary, Alberta  Gatineau, Quebec  Prince Edward Island PILOT SITES

41 RETAILERS  Provide a selection of AD’s.  Help customers with choice, installation and proper use of the AD’s being sold.  Display AD’s as they would appear in a home.  Promote AD’s to help increase awareness and acceptance.

42 HOTELIERS  Install grab bars in all guest rooms.  Provide non-slip bath mats for the inside and outside of bathtubs and showers in all guest rooms.  Promote the availability of bathtub seats, non-slip mats and grab bars in promotional material.

43 BUILDERS  Install and display assistive devices in model homes.  Provide adequate reinforcement in bath areas to support retrofitting of bathtub and shower grab bars.  Promote assistive devices as a standard feature in new construction.

44 OTHER STRATEGIES REQUIRED Better product design  Better comfort and fit  Aesthetically more appealing,  More precise sizing “Access bathtub”

45 Policy and legislation Policy and legislation  Universal access to grab bars: eliminates many person-, device- and environment-based barriers to use  Cost subsidies: financial incentives, insurance coverage OTHER STRATEGIES REQUIRED

46 RESOURCES Community Health Research Unit: Health Canada: Canadian Centre for Activity and Aging – Home Support Exercise Program Active Living Coalition for Older Adults

47 Peterborough County Health Unit- Partners in Aging…Prevent Falls for Older Adults (705) Fax (705) Canadian Mortgage and Housing Corporation Sunnybrook and Women’s College Falls and Mobility Network- November 17 th Ontario Assistive Device Program Veterans Affairs RESOURCES

48 QUESTIONS? Presentation available:


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