Louise Allan is a Geriatrician with a specialist interest in the Neurology and Psychiatry of Old Age. Her research interests include the non-Alzheimer’s dementias and the physical health of people with dementia. She will be speaking at the upcoming BGS Spring Meeting in Nottingham.
Between 47-90% of people with dementia (PWD) fall at least once a year (almost ten times more often than controls). After a fall, PWD are less likely to recover well, more likely to be hospitalised, are hospitalised for longer and are more likely to require increased care. We currently know little about the care received by these patients. There is evidence to suggest that staff may perceive PWD as less capable of rehabilitation and staff in community services providing follow-up care may not have specific training in the care of PWD.
There is presently little evidence to guide the management of such falls and fall related injuries, and yet there are potentially substantial benefits to be gained if the outcome of these falls and injuries could be improved. The DIFRID study aims to provide the evidence needed for the design of an appropriate healthcare intervention for such PWD and to assess the feasibility of its delivery in the clinical setting. The original brief for this trial from the NIHR Health Technology Assessment Programme asked us to focus on PWD who had sustained a fall related injury. As a result of work undertaken so far, our brief has now changed to include all PWD who have sustained a fall, either with or without an injury, requiring healthcare attention.
The overall aim of this study is to assess through a series of work packages whether it is possible to design a complex intervention to improve the outcome of falls in people with dementia living in their own homes.
In work package 1 we examined the literature regarding interventions for PWD after a fall. Using Cochrane methodology, we found that, due to high heterogeneity across the studies, definitive conclusions could not be reached. Given the paucity of the literature found using Cochrane methodology, we also conducted a realist review. Following stakeholder engagement work we developed a theory of how the composition of an intervention may help to address the specific challenges of rehabilitation with PWD following a fall.
In work package 2 we aimed to understand current practice and describe current usual care. We quantified the numbers of PWD with a fall-related injury presenting to primary care, paramedics and the emergency department (ED). We captured usual care by asking a number of patients to keep prospective diaries of their experiences. We also interviewed selected PWD, carers and health and social care staff providing or commissioning their care to identify care needs; explore the opportunities for and the barriers to improvement in their care; and identify and prioritise the outcomes. We observed existing falls interventions (e.g. exercise classes; falls clinics) to identify areas of good practice.
In work package 3 we developed a new intervention. A consensus panel of expert health and social care professionals and PPI members reviewed the findings of WPs 1 and 2 and made recommendations regarding the content and delivery of the new intervention.
We are now undertaking work package 4 which will assess the feasibility of delivery of the new intervention within present NHS structures, and test acceptability, adherence to delivery of the intervention and outcome measurement. We will also test the procedures for recruitment of participants. This will allow us to assess the feasibility of a future trial and, if appropriate, to make recommendations as to the optimum design and setting for the trial and identify potential facilitators and barriers to success.
Further information about the trial can be found at https://research.ncl.ac.uk/difrid/