Falls prevention-hip protector

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Falls prevention-hip protector

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• 94.08.11

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• Falls can be due to multiple factors such as
  underlying physical illnesses, impaired balance,
  medications, or environmental hazards, often in
  combination (Kellogg 1987).
• The aetiology of the fracture is also multi
  factorial but the three principal factors can be
  summarised as a combination of a fall, loss of
  protective mechanisms (for example putting out
  the arms to break the fall) and weaker bone
  strength (Cummings 1989).

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• The fracture is usually the result of a fall. The
  impact with the ground is usually on the side in
  the region of the hip (Hopkinson-W 1998).
• Hip fractures are fractures in the area of bone
  immediately distal to the articular cartilage of
  the hip to a level of about five centimetres
  below the lower border of the lesser trochanter.

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Hip fractures ????

• The majority of these fractures occur in an older
  population with an average age of around 80
  years.
• Females predominate over males by about four to
  one (Thorngren K-G 2002).

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Hip fractures ???? 1

• The number of hip fracture patients continues to
  rise due to a combination of an increasingly
  elderly population and a continued increase in
  the age specific incidence in some countries.

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Hip fractures ???? 2
hip fracture Annual cost consequences
2005 Honkanen by 2040, USA annual500000 240 billion -
2005 Halloran 1995 England Wales 57000 - 1/5 dying within three months of surgery
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Hip fractures ???? 3
Rate of hip fracture consequences
2000 Zimmerman Nursing home 44 per 1000 per year Mortality rate 39 in one year
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• The use of padding worn around the hip has been
  advocated as a measure of reducing the impact of
  the fall and thereby the chance of fracturing the
  hip.
• Various types of padded hip protectors have been
  developed. Most consist of plastic shields or
  foam pads, which are kept in place by pockets
  within specially designed underwear.

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??EBN??????

• Hip fracture in older people usually results from
  a fall on the hip. Hip protectors have been
  advocated as a means to reduce the risk of
  sustaining a hip fracture.

Hip Protector ?!?! ??? ????
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STEP 1 Asking an answerable
clinical question

• Practice reflection
• Decision making

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• To determine if external hip protectors reduce
  the incidence of hip fractures in older people
  following a fall.

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EBN??PICO

• ?Hip protectors??????????????????????
• P65???????
• I??Hip protectors (?????)
• C???Hip protectors
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??? Hip Protector?
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Hip Protection Pads
Hip protection is important because accidental
falls are a leading cause of hospitalization,
injury deaths, and disabilities for seniors.
Among women aged 65-74, hip fractures are the
largest single kind of injury resulting from
these falls, representing 35 of related
hospitalizations. For women aged 85 and older,
the hospitalization rate increases to 58.
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External Hip Protector (EHP)

• consist of a simple padding or shield-like device
• worn like underwear over the trochanters
• absorbs or shunts the force of impact during a
  fall.

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Hip Protector ?? 1

• Advantages of Functionality
• Can be worn either over garments or under
  garments
• Wearers can use toilet without removing hip
  protection
• Easily fitted to wearer
• Easily installed by wearer or care giver
• Fully adjustable for form and fit

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Hip Protector ?? 2

• Advantage of Construction
• All materials are odor/moisture resistant
• Multiple layers of air shock impact absorbers for
  comfort and maximum safety
• All materials are soft and gentle to the skin and
  will not transmit impact of falls directly to the
  pelvis, femur, or trochanter
• All straps are slightly elasticized for fit and
  comfort

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Hip Protector ?? 3

• Advantages of Design
• No sharp edges or hard surfaces
• Protector and belts weigh less than two ounces
• Flexible enough for showering, walking, standing,
  sitting, lying, sleeping
• Can absorb energy of 200 pounds failing 30 inches
  
• Uniformly distributed maximum pressure on hip
  area after fall is less than 2 lb/in2
• Belt are resistant to removal by wearers with
  dementia

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STEP 2 Search evidences

• Research awareness
• Systematic review

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• ??? ????????????
• ??MEDLINE?CINAHL
• ??ProQuest
• ??PubMed
• ??Cochrane

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Search strategy

• ????
• 1. effective fall preventions
• 2. fall
• 3. ?? (nursing home , community, psychiatry ward)

• ?????
• 4. hip protector
• 5. hip fracture
• 6. fall preventions

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????

• ?? 0 ?
• MEDLINE?CINAHL 8 ?
• ProQuest 3 ?
• PubMed 15 ?
• Cochrane 5 ?

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Reference

• Birks YF, Hildreth R, Campbell P et al.
  Randomized controlled trial of hip protectors for
  the prevention of second hip fractures. Age
  Ageing 200332 442444.
• Butler M, Coggan C, Norton R. A qualitative
  investigation into the receptivity to hip
  protective underwear among staff and residents of
  residential institutions. N Z Med J 1998111
  383385
• Burl JB, Centola J, Bonner A et al. Hip protector
  compliance A 13-month study on factors and cost
  in a long-term care facility. J Am Med Dir Assoc
  20034 245250
• Cameron ID, Venman J, Kurrle SE et al. Hip
  protectors in aged-care facilities A randomized
  trial of use by individual higher-risk residents.
  Age Ageing 200130 477481
• Chan DK, Hillier G, Coore M et al. Effectiveness
  and acceptability of a newly designed hip
  protector A pilot study. Arch Gerontol Geriatr
  200030 2534.
• Colon-Emeric CS, Datta SK, Matchar DB. An
  economic analysis of external hip protector use
  in ambulatory nursing facility residents. Age
  Ageing 200332 4752 

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Reference

• Ekman A, Mallmin H, Michaelsson K et al. External
  hip protectors to prevent osteoporotic hip
  fractures. Lancet 1997350 563564
• Gross G, Chen T-H, Flaherty C. Hip pads
  Effective fracture prevention. Adv Phys Ther
  200011 4546. 
• Harada A, Mizuno M, Takemura M et al. Hip
  fracture prevention trial using hip protectors in
  Japanese nursing homes. Osteoporos Int 200112
  215221.
• Hubacher M, Wettstein A. Acceptance of hip
  protectors for hip fracture prevention in nursing
  homes. Osteoporos Int 200112 794799.
• Kannus P, Parkkari J, Niemi S et al. Prevention
  of hip fracture in elderly people with use of a
  hip protector. N
• Kumar BA, Parker MJ. Are hip protectors cost
  effective? Injury 200031 693695. Engl J Med
  2000343 15061513.

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Reference

• Lauritzen JB, Petersen MM, Lund B. Effect of
  external hip protectors on hip fractures. Lancet
  1993341 1113.
• Meyer G, Warnke A, Bender R et al. Effect on hip
  fractures of increased use of hip protectors in
  nursing homes Cluster randomized controlled
  trial. BMJ 2003326 76.
• Parker MJ, Gillespie LD, Gillespie WJ. Hip
  protectors for preventing hip fractures in the
  elderly. Cochrane Database Syst Rev
  2003CD001255.
• Parkkari J, Heikkila J, Kannus P. Acceptability
  and compliance with wearing energy-shunting hip
  protectors A 6-month prospective follow-up in a
  Finnish nursing home. Age Ageing 199827
  225229.
• Segui-Gomez M, Keuffel E, Frick KD. Cost and
  effectiveness of hip protectors among the
  elderly. Int J Technol Assess Health Care
  200218 5566.

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Reference

• van Schoor NM, Deville WL, Bouter LM et al.
  Acceptance and compliance with external hip
  protectors A systematic review of the
  literature. Osteoporos Int 200213 917924.
• van Schoor NM, Smit JH, Twisk JW et al.
  Prevention of hip fractures by external hip
  protectors A randomized controlled trial. JAMA
  2003289 19571962.
• Van Schoor NM, Asma G, Smit JH et al. The
  Amsterdam Hip Protector Study Compliance and
  determinants of compliance. Osteoporos Int
  200314 353359.
• Villar MTA, Hill P, Inskip H et al. Will elderly
  rest home residents wear hip protectors? Age
  Ageing 199827 195198.
• Waldegger L, Cranney A, Man-Son-Hing M et al.
  Cost-effectiveness of hip protectors in
  institutional dwelling elderly. Osteoporos Int
  200314 243250.
• Wiener SL, Andersson GB, Nyhus LM et al. Force
  reduction by an external hip protector on the
  human hip after falls. Clin Orthop 2002398
  157168  

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Reference

• van Schoor NM, Deville WL, Bouter LM et al.
  Acceptance and compliance with external hip
  protectors A systematic review of the
  literature. Osteoporos Int 200213 917924.
• van Schoor NM, Smit JH, Twisk JW et al.
  Prevention of hip fractures by external hip
  protectors A randomized controlled trial. JAMA
  2003289 19571962.
• Van Schoor NM, Asma G, Smit JH et al. The
  Amsterdam Hip Protector Study Compliance and
  determinants of compliance. Osteoporos Int
  200314 353359.
• Villar MTA, Hill P, Inskip H et al. Will elderly
  rest home residents wear hip protectors? Age
  Ageing 199827 195198.
• Waldegger L, Cranney A, Man-Son-Hing M et al.
  Cost-effectiveness of hip protectors in
  institutional dwelling elderly. Osteoporos Int
  200314 243250.
• Wiener SL, Andersson GB, Nyhus LM et al. Force
  reduction by an external hip protector on the
  human hip after falls. Clin Orthop 2002398
  157168
• .

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STEP 3Critical appraisal the evidences
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Interventions likely to be beneficial

• Multidisciplinary, multifactor,
  health/environmental risk factor
  screening/intervention programs in the community
  both for an unselected population of older
  people, and for
• older people with a history of falling or
  selected because of known risk factors, and in
  residential care facilities.
• A program of muscle strengthening and balance
  retraining, individually prescribed at home by a
  trained health professional.
• Home hazard assessment and modification that is
  professionally prescribed for older people with a
  history of falling.
• Withdrawal of psychotropic medication.
• Cardiac pacing for fallers with cardio inhibitory
  carotid sinus hypersensitivity .
• A 15 week Tai Chi group exercise intervention.

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Interventions of unknown effectiveness
Group-delivered exercise interventions. Individual lower limb strength training. Nutritional supplementation. Vitamin D supplementation, with or without calcium . Home hazard modification in association with advice on optimizing medication, or in association with an education package on exercise and reducing fall risk Pharmacological therapy. Interventions using a cognitive/behavioral approach alone. Home hazard modification for older people without a history of falling. Hormone replacement therapy. Correction of visual deficiency .
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Literature review
Title/Publication year Purpose/Design Results
External hip protectors again hip fractures. A randomized study in a nursing home Lauritzen , 1993 Danish To investigate the effect of an EHP. RCT10/28 NH 665 residents I 247 subjects, 8 hip Fr (non-wearing) C 418 subjects, 31 hip Fr Relative risk of hip Fr 0.44(950.21-0.91) Level II
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Literature review
Title/Publication year Purpose/Design Results
Prevention of hip fracture in elderly people with use of a hip protector Kannus, 2000 Finland To investigate the effect of an EHP on the risk of these age-related factures. RCT 1801 elderly adults I rate of hip facture21.3 per 1000 person-years (4 subjects worn the EHP, 9 didnt) C rate of hip fracture46 per 1000 person-years (67 hip Fr) Level II
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Literature review
Title/ Publication year Purpose/ Design Results
Effectiveness and acceptability of a newly designed hip protector a pilot study Chan, 2000 Australia To assess the benefit of using the EHP to prevent fracture / RCT 71 subjects I 40subjects falls191 , 3hip fracture (non-worn while falling) compliance50.3 C 31 subject falls101, 6 fracture RR 0.264 (95CI0.073-0.959) Level II
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Literature review
Title/ Publication year Purpose/ Design Results
Hip protectors in aged- care facilities a randomized trial of use by individual higher-risk residents Cameron, 2001 Australia To investigate the effect of use EHP on occurrence of hip fracture / RCT 174 subjects EHP is not effective in reducing the incident of hip fracture. no hip fractures occurred when EHP were worn. (compliance57) Reduction in risk of hip fracture 50 Level II
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Literature review
Title/ Publication year Purpose/ Design Results
Hip fracture prevention trial using hip protector in Japanese nursing Harada, 2001 Japan To investigate the effect of the hip protector among Japanese elderly in nursing home / prospective-randomized study 164subjects(1996-1999) I fall 131 2 non-hip fracture, 1 hip Fr ( annual hip fracture rate 2.0)(annual hip fracture rate per fall 0.8) Cfall 90 8 hip fracture ( annual hip fracture rate 19.8)( annual hip fracture rate per fall 8.2) Level II
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Literature review
Title/ Publication year Purpose/ Design Results
Effect on hip fracture of increased use of hip protectors in nursing homes cluster randomized controlled trial Meyer, 2003 German To investigate the effect of education in nursing staff and residents on increasing the adherence of hip protector in nursing home Cluster RCT49 NH , 568 subjects , 15months I 292 subjects , 21 hip Fr(68 compliance) C 276 subjects , 42 hip Fr(15 compliance) Level II
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Literature review
Title/ Publication year Purpose/ Design Results
Hip protectors what is their role in the prevention of femoral fracture? Ruggieri , 2000 French To investigate the effect of use EHP on occurrence of hip fracture / RCT 13 hip fractures, only one worn EHP Review 5 RCT
Cost-effectiveness of hip protectors in institutional dwelling elderly Waldegger, 2003 Canada Meta-analysis of RCTs EHP vs. non-EHP relative risk of hip fracture of 0.4 Meta-analysis RCT
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Literature review
Title/ Publication year Purpose/design results
A Cost-Benefit Analysis of External Hip Protectors in the Nursing Home Setting/ Honkanen, 2005 USA To estimate potential cost saving by a program of hip protectors in the nursing home from a Medicare perspective /state-transition Markov model 1.65-year-old female residents lifetime hip fracture risk Female21.1 9.3 Male 13.0 5.3 2.Age 85 Female14 6.1 Male7.9 3.3
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Review( Parker , 2005)

• Search database
• Cochrane, Medline, CINAHL
• Main results
• 1. Eleven trials conducted in nursing home
  showed evidenced of significant reduction in hip
  fracture incidence (RR0.77 95CI 0.62 to
  0.97 )

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Review

• 2. Three trials involving 5135 community dwelling
  participants showed Level II
• from the provision of hip protectors (RR 1.16
  95 CI 0.85 to 1.59)ance
• 3. Compliance with wearing hip protectors remains
  a problem.

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STEP 4 Applying Evidence to Patients
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• ?????????????????,? Withdrawal of psychotropic
  medication.
• ??????,????????????,? muscle strengthening and
  balance retraining
• ???????????????,? 15 week Tai Chi group exercise
  intervention.
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• ??????????????????????? ? Home hazard
  assessment,?????????????????????
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4.?????????? hip protectors?
Title/ Publication year Purpose/design Results Level
Are hip protectors cost effective?/2000 UK To assess the cost effectiveness of EHP in preventing hip fracture in elderly/ 4 years prospective audit Long-term compliance is 36 (251/694 ) Treat a hip fracture 7200 EHPcost 113/person/year III
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STEP 5Evaluate self performance

• Self-evaluation in Step 1-4
• Self-evaluation and compare

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Self-evaluation in STEP 1

• Am I asking any clinical questions at all?
• Am I asking well-formulated (3-part) questions?
• Am I using a "map" to locate my knowledge gaps
  and articulate questions?
• Can I get myself unstuck when asking questions?

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STEP 1 ?????
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Self-evaluation in STEP 2

• Am I searching at all?
• Do I know the best sources of current evidence
  for my clinical discipline?
• Have I achieved immediate access to searching
  hardware, software and the best evidence for my
  clinical discipline?
• Am I finding useful external evidence from a
  widening array of sources?

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STEP 2 ?????

• Systematic Review
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• Research Awareness
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Self-evaluation in STEP 3

• Am I critically appraising external evidence at
  all?
• Are the critical appraisal guides becoming easier
  for me to apply?
• Am I becoming more accurate and efficient in
  applying some of the critical appraisal measures?
  

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STEP 3 ?????

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Self-evaluation in STEP 4

• Have I conducted any clinical decision analyses?
  YES
• Am I becoming more accurate and efficient in
  adjusting some of the critical appraisal measures
  to fit my individual patients? YES, but
• Have I carried out any audits of my diagnostic,
  therapeutic or other EBM performance? NOT YET
• Am I integrating my critical appraisals into my
  practice at all? NO

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APPLYING or not

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STEP 5 ?????

• Self-evaluation and compare
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