January 10th, 2018
Effectiveness of Alarms in Avoiding Risk of Falls in Geriatric population – literature review
To answer the PICO question as to whether use of alarms is effective in reducing the risk of falls for the geriatric population in the nursing homes as compared to other tools, I searched for articles on various online databases, websites for organizations such as Centers for Disease Control and Prevention (CDC), and search engines such as Google scholar. Specifically, I was interested in recent (from 2005) studies that assessed such efficacy based on empirical analyses, were conducted with a geriatric sample from a nursing home or compared various preventative initiatives in such an environment, with alarms being a core preventative initiative evaluated. From this initial inclusion criterion, I identified only one study (Capezuti, Brush, Lane, Rabinowitz, & Secic, 2008), which met all the inclusion factors, but in a relevant and recent review, an outdated study (Tideiksaar 1993, as cited in Cameron et al. 2010, p.27), had found no significant difference in the number of falls where beds were fitted alarms and control groups.
Following this initial search, I broadened my search to include reviews, case studies and articles from CDC that identified effectiveness of bed alarms and those that identified the effectiveness of alternative or complementary initiatives, which I intended to use to compare their effect with those of the alarms. I also expanded the inclusion period to include studies from 2000, and quite a number of studies met the criterion from which I selected four studies. The four additional studies that I review below include an empirical study that assessed effect of a BUCINATOR bed-exit alarm system that simulated geriatric populations’ behaviour using student nurses (Hilbe, Schulc, Linder & Them, 2010) and a systematic review by Cameron et al. (2010) of interventions that are used in nursing homes and hospitals to reduce falls in older people. Additionally, I review two case studies: one by Massapro (2006) – an organization focusing on establishing and disseminating innovative approaches to healthcare provision – that assessed impact of eliminating alarms in a 45-bed unit Massachusetts nursing home, and the second, on Park Place Nursing and Rehabilitation Center, which was featured in Nursing Homes (Buch, 2005).
A study that presents significant implications for the continued use of alarms in nursing homes as tools to avert falls of geriatric population is that by Capezuti et al. (2010). In this study, the authors “examined the effectiveness of bed-exit alarms in detecting actions that could lead to a fall or injury” by assessing how accurate two types of bed-exit alarms (a pressure-sensitive system and a dual sensor system comprised of a pressure sensitive alarm and a infra red (IR) beam detector) were at detecting bed-exit movements (p. 27). As part of the assessments, the study also evaluated the occurrence of false alarm events (where alarms were activated without the participant attempting to get out of the bed) and described differences in participant’s movements as they tried to get out of bed.
The study sample comprised of 16 nursing home residents drawn from a 120-bed capacity non-profit nursing home in Philadelphia (p. 28). The inclusion criteria was based on three characteristics: the participants were cognitively impaired, were challenged in either getting out of the bed or walking safely, and were perceived to be at high risk of bed-related fall by the nursing staff. The study observed the participants for 256 nights, then evaluated the data obtained from the video records and the logs maintained by observers who had been trained before being assigned to observe the participants’ movements, set the recording equipment and implement safety precautions (p. 28). Out of failure of recording equipment, results from two of the participants were unusable thus eliminated from the analysis. For the remainder of the sample, 4 had only been evaluated with the pressure-sensitive system during the entire period of the study, 7 were only evaluated with the dual sensor system for the duration of the study and 3 were evaluated via interchanging the dual system with the pressure-sensitive system on various nights that the study lasted (p. 29). Analyses were first conducted to identify the accuracy: evaluated according to the number of true positives (alarm activated – lit a small bulb next to the headboard – when the participants’ movement bed-exit movements), true negatives (failed to indicate in non-exit movements), false positive (alarm indicating in a non-exit movement), and false negatives (failure of an alarm to indicate a bed-exiting movement) (p. 29). The study findings were wide-ranging.
Firstly, the study found out that the two alarms differed in their accuracy in predicting bed-exit movements. The dual sensor alarm for instance exhibited a number of true positive that was significantly higher than that of the pressure-sensitive alarm (Capezuti et al. 2008, p. 29-30). Despite its accuracy, the dual sensor alarm however did not eliminate all risk cases, thus reinforcing the need to employ other strategies to better the risk identification by alarms (p. 30).
Secondly, the study found out that the effectiveness of bed alarms could be influenced by the ways in which the participants exited the bed. The participants’ bed-exiting movements were predominantly in three fashions. Firstly, was the “typical” waking up fashion that involved “sitting up and swinging legs off bed in one synchronous, quick movement”, although some of these had difficult in the rise performance thus took a longer period to rise than those with synchronous trunk-leg movements (Capezuti et al. 2008, p. 29). Secondly, some of the participants used the bed as the support against which they pushed their arms severally to elevate their trunk before “moving their legs over the side of the bed” (p. 29). The third category “ rolled their trunk onto the bed’s edge and then the legs slid off the side of the bed with the trunk and head following” (p. 29). Such differences reinforce the need of using additional preventative mechanisms to identify movements.
In nursing homes, the falls of the residents is a common occurring phenomenon. For instance, the Centers for Disease Control and Prevention – CDC – (2009) observes that on average, there are about 100 to 200 falls each year in a 100-bed capacity nursing home (para. 1), and most of such falls are not reported. With the number of people aged 65 years and above who live in nursing homes estimated to continue increasing (CDC, 2009), falls in such settings may increasingly become a public health challenge. Such is for instance aggravated by observations that majority of the falls usually occur with residents whose walking ability is curtailed, and the serious injuries that some of the falls result into (CDC, 2009). For instance, falls are indicated to contribute to as much as 1,800 annual deaths in nursing homes, with 10 to 20% of falls noted to cause serious injuries and 2 to 6% resulting in fractures (CDC, 2009). Accordingly, such falls do not only lead to disability, impaired functional capabilities and reduced quality of life, but also could result into psychological disorders such as anxiety, and depression out of a fear of falling (CDC, 2009). Thus, falls in the nursing home present a significant barrier to enhancing the quality of care in such settings.
From such prevalence rates of falls in nursing homes, attempts to identify factors that make such an environment a risk prone setting have been made. Some explanations have been suggested that such falls are contributed by the comparatively more frail characteristic of adults in nursing homes, older age, higher prevalence of chronic illnesses in this population and high incidence of walking problems as compared to those in living in the community (CDC, 2009). Other explanations have been that such residents have impaired memory processes, and have challenges in performing basic activities of daily living thus necessitating the assistance of another individual to perform such activities (CDC, 2009).
Various factors have been suggested to lead to falls in nursing homes, among them the residents’ muscle weaknesses and challenges in movement (CDC, 2009). Falls arising from this antecedent have been estimated to account for 24% of falls in nursing homes (CDC, 2009), a factor that has led to the establishment of supervised or unsupervised exercises to boost aspects such as respective resident’s balance, co-ordination, resistance and flexibility (Cameron et al. 2010). Secondly, falls resulting from environmental hazards in the nursing care settings are estimated at 16 to 27 %, with examples of hazards commonly occurring in nursing homes being brought about by wet floors, inappropriate bed height and poor lighting. Such hazards have been behind the preventative initiatives such as having low-bed height in residents’ rooms (Anderson, Boshier & Hanna, 2011). Thirdly, medications, especially those that affect the central nervous system are a source of falls in the nursing homes (CDC, 2009). Other sources of falls are related to wearing poorly fitting shoes and incorrect use of walking aids (CDC, 2009). Such indications of antecedents of falls have led to the use of various preventative initiatives.
With the suggestion that majority of falls in nursing homes take place in the resident’s room as one tries to get in or out of bed (Capezuti et al. 2002), use of bed-exit alarms has been a preventative strategy employed to alert the nursing staff of the resident’s movement, in addition or as an alternative to bedrails, low height beds and bed-side floor mats (Anderson, Boshier & Hanna, 2011). At their introduction, personal alarms that served to alert the care provider of the movement of a resident (in situations spanning from in bed, to chairs) were highly lauded by various stakeholders as a solution to avert most of the falls in nursing homes (Button, n.d.). Hower, with their increasing application, various challenges with their use have been highlighted. Firstly, it has been suggested that the alarms could provide a false sense of security, where the care providers, knowing that the alarm would sound in case of movement of the resident, may avoid their routine check-ups on the resident or result into delayed responses that may not avert the effect of the fall (Button, n.d.). A second concern that has been raised with the use of alarms has been their effect of causing noise pollution thus argued to be a disturbance to the residents (Button, n.d.). Additionally, expectations that the alarm would sound in case of any movement could enhance anxiety in the residents and unsettled feelings or the noise could anger those other residents sharing the facilities thus being a possible source of stress and depression (Button, n.d.). Similarly, in the fear of triggering the alarms, residents may avoid any form of movement, which could present risks for such other conditions as pressure ulcers (Button, n.d.).
A different study presented a case study that argued out the possibility of reducing falls by eliminating resident alarms (Masspro, n.d). In one of the pilot studies, removal of alarms from the residents who did not have any fall for a significant period of time did not become susceptible to falls since the core causative factors such as urinary tract infections had been effectively dealt with. With such initial success, inclusion of more tresidents whose root cause of falls had been identified and addressed into the group where the alarms were removed also provided support for the removal of alarms. Apart from these benefits, the removal of the alarms also was associated with improvement in the quality of life of the residents following the elimination of the alarm nuisance. Go to part 3 here.