Trauma is the eighth leading cause of death in elderly persons,1 who are rapidly growing as a proportion of the overall population.2 Those 65 years and older are disproportionately at risk for poor outcomes following injury. The aging process affects visual, cognitive, and psychomotor skills, and even simple tasks of daily living can put older adults at risk for injury.3,4 The Centers for Disease Control and Prevention reported more than 36,000 unintentional injury deaths among elderly Americans in 2005. Sixty-three percent of these deaths were caused by falls and transportation-related injuries.5 The US Consumer Product Safety Commission estimates that from 1991 to 2002, more than 1.4 million older adults were treated in hospital emergency departments for injuries associated with products they live with and use everyday.6 The commission further reports that for 2002, the total cost of injury in this population was $106 billion, including the $16.5 billion spent on the 3,300 trauma patients who died from product-related injuries.6 It is estimated that by 2030, there will be more than 70 million people—1 in 5 of the population—older than 65 years.6 These statistics add urgency to the need for effective injury prevention strategies for this population.
Falls are the greatest source of injury for older adults, who are hospitalized for fall-related injuries 5 times more often than they are for injuries from other causes.7 The majority of these falls occur at home, and nearly 60% result in an emergency department visit.8 In the United States in 2005, more than 1.8 million individuals older than 65 years were treated in emergency departments for injures sustained from a fall, whereas 433,000 were hospitalized from the event.9 In an analysis of mortality and cost, Stevens et al10 showed that traumatic brain injuries and lower extremity injuries were together responsible for 79% of costs and 78% of fall-related deaths among seniors. These injuries and deaths create a large financial drain on healthcare resources. In 2000, direct medical cost for fatal fall injuries was 0.2 billion and the cost of nonfatal fall injuries approached 19 billion.6
Those who fall are 2 to 3 times more likely to fall again.11 A history of falls may reduce confidence and increase the fear of falling, resulting in more limited physical activity, deconditioning, and loss of independence.12 Many seniors live alone, and older women are more likely to be widowed than men. In the United States, older women outnumber men and account for 58% of the population 65 years and older and for 68% of those who are 85 years and older.13
In spite of the trauma statistics for older adults, funding for comprehensive injury prevention programs targeted for seniors has lagged behind prevention funding for children and teens, whose resources include the Safe Kids Worldwide14 and ThinkFirst15 programs. The American Trauma Society16 and the Emergency Nurses Association17 have produced instructional materials for seniors that combine slide shows and print materials, but none of these have been subjected to research to validate their effectiveness. The American Academy of Orthopaedic Surgeons12 and the Centers for Disease Control and Prevention18 also provide simple print resources for older adults. The American Association of Retired Persons (AARP) offers a popular Driver Safety Program for older adults (formerly called “AARP 55 ALIVE”), but it has not been subjected to research regarding its ability to alter behavior or outcomes. The AARP Driver Safety Program is an 8-hour course (usually taught over 2 days) and is also available online.19
The purpose of this before-and-after observational study was to develop a research-based educational program for seniors and to measure its effectiveness. Our goal was to offer a series of short programs that could be administered in a single session and to include elements of safe driving practices, fall prevention, home safety, and pedestrian safety.
We searched MEDLINE, using the key words elderly falls, fall prevention, elderly trauma, injury prevention, and safety awareness programs to identify studies that evaluated the effectiveness of injury prevention education for older adults. We found a limited number of published studies that focused on validated fall-risk assessment tools or the impact of behavioral modification, exercise programs, and home safety checks on fall rates and hip fracture occurrences in older adults. The search produced no studies evaluating outcomes following short educational programs alone.20–27
A subcommittee of the 20-member Michigan Trauma Nurse Council chose to develop original materials for the Senior Lifestyles and Injury Prevention project, including individual educational modules for each key area of risk: (1) Motor Vehicle Safety, (2) Fall Prevention, (3) Home Safety, and (4) Pedestrian Safety. The Michigan Trauma Nurse Council consists of trauma nurse coordinators and educators from across the state of Michigan. Each educational module was composed of an instructor manual, a PowerPoint presentation, an original pre-post test, a short quality-of-life assessment tool, and a safety tip brochure. The Senior Lifestyles and Injury Prevention subcommittee reviewed each PowerPoint presentation and its pre-post test for face and construct validity. Content and study design were also shared with a gerontology nursing expert from the Gerontological Institute at the University of Michigan's School of Nursing, who advised the group regarding the choice of PowerPoint backgrounds and font size to maximize readability by older adult audiences (D. Algase, Professor and Faculty Associate, Institute of Gerontology at the University of Michigan School of Nursing, Ann Arbor, Personal interview, April 2003). The final PowerPoint lectures used only plain backgrounds without special effects. The typeface was black or navy with a Times New Roman or Arial font.28–30
The Short Form Health Survey Instrument (SF-12)31 was selected to evaluate quality of life in this study, instead of the longer SF-36 version, because of its documented ease of use.32 The SF-12 (QualityMetric, Lincoln, Rhode Island), a brief, reliable, 12-item subset of the original SF-36, measures the same 8 domains of health as the SF-36. The 8 domains are physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Research on the SF-12 suggests that the shorter profile provides scores that are less precise for individuals, but these scores are acceptable for large group studies.33 Many healthcare organizations and researchers have used the SF-12 to monitor quality of life and outcomes, including the National Commission on Quality Assurance.33,34
Each PowerPoint lecture was designed for delivery in 20 to 30 minutes to accommodate variability in spans of attention in this age group.28,35 The goal was to provide a program that could be implemented in a 1-hour session from start to finish, including the pretest, baseline SF-12, PowerPoint educational intervention and enrollment in the study. During enrollment, participants were asked to complete a self-addressed stamped envelope (SASE) if they were willing to be contacted for follow-up. Completion of the SASE served as implied consent. Content of the test items included the participants' behavior and, to a lesser extent, their safety-related knowledge. Demographic information at the end of the pretest consisted of age, gender, and county of residence. For the Motor Vehicle Safety test, the demographic section also requested information about frequency of driving. For the Home Safety, Pedestrian Safety, and Fall Prevention tests, the demographic section included information about type of residence. Follow-up mailings consisted of a repeat test taken at 12 weeks postsession, along with the repeat SF-12 survey. These were both sent and returned through the US Postal Service. Twelve-week follow-up was perceived to be adequate time for individuals to implement behavior and environmental changes such as installing night lights and grab bars and changing their type of footwear.
Following institutional review board approval of the study, a convenience sample of elderly adults 65 years and older was recruited for the pilot and feasibility testing. These pilot sessions included (1) completion of the pretest, (2) completion of the SF-12, (3) presentation of the educational PowerPoint module, and (4) measurement of total time needed for completion of the full offering. Participants were also asked to evaluate (1) content of the educational PowerPoint module, (2) readability of the pre-posttest and handouts, (3) clarity of all instructions and materials, and (4) whether the test questions appropriately reflected the PowerPoint content. Minor course modifications were made following review of the pilot results, including the addition and deletion of some PowerPoint slides and the allowance for a short break. Participants in the pilot were not included in the final analysis. Trauma centers were subsequently invited to send staff to a train-the-trainer session where instructors' manuals and teaching “kits” were disseminated and reviewed.
This was a multicenter study with a convenience sample of ambulatory adults 65 years and older recruited through community outreach by Michigan trauma centers. Some recruitment took place at senior citizen centers, AARP chapters, and assisted-living facilities and through hospital educational outreach for older adults. Participants were not prohibited from attending programs in more than 1 of the 4 risk areas. The primary outcome variable was improvement in test scores. The secondary outcome measure was change in SF-12 quality-of-life scores.
Each module was analyzed using the Pearson correlation coefficients, t tests, and chi-square tests, all with a significance level of P < .05. The goal was a sample size for each of the module of 84 participants to achieve an α value of .05 and power of at least 0.80. All tests were conducted using NCSS software (NCSS, Kaysville, Utah).
Our initial sample consisted of 414 older adults who attended the educational sessions and completed pretesting. Fifty-seven attended the Motor Vehicle Safety session, 101 attended Fall Prevention, 168 attended Home Safety, and 88 attended Pedestrian Safety. Participants attending the educational sessions were predominantly female (81.6%) and their mean age was older than 70 years. Of these, 226 (54.6%) went on to complete their posttests and repeat SF-12 surveys at 12 weeks postintervention. The response rate varied by safety module, from a low of 48.8% for Home Safety to a high of 65.9% for Motor Vehicle Safety (Table 1).
Home Safety and Pedestrian Safety
The response rate for the Home Safety and Pedestrian Safety groups combined was 54.7% (140 respondents) of the initial 256 who attended these 2 educational sessions. Older adults in these 2 groups lived primarily in their home or in apartments, at 74.4% and 72.3%, respectively. No significant effects were noted for either their pre-posttests or pre-post SF-12 quality-of-life scales (P > .05). These 2 groups, Home Safety and Pedestrian Safety, comprised 61.9% of the final sample of 226 older adults in the 4 risk areas who responded and completed their posttesting.
Motor Vehicle Safety
There were 30 participants in the Motor Vehicle Safety program who completed posttests and follow-up SF-12 surveys, reflecting a 52.6% response rate within this group. This group represented 13.3% of the final 226 respondents in all 4 groups combined. Eighty-one percent of the Motor Vehicle Safety group indicated that they were frequent drivers. Motor Vehicle Safety participants showed significant improvement between pre-posttests (P < .05), with scores increasing from 80.4 (SEM = 2.8) to 88.5 (SEM = 2.0) (Table 2). However, there were no significant changes in their pre-post SF-12 quality-of-life scale scores.
There were 56 respondents in the Fall Prevention group who completed follow-up tests and SF-12 surveys, reflecting a 55.5% response rate. This group showed significant improvement between pre-posttests (P ≤ .05), with test scores increasing from 60.9 (SEM = 2.8) to 67.0 (SEM = 2.7) (see Table 2). In addition, numerous SF-12 quality-of-life subscores from the initial screening of this group were significantly inversely correlated with their pretest scores (Pearson's correlation coefficient, P ≤ .05). These significant correlations included the SF-12 subscores for Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, and the Physical Component Summary. This finding suggests that the lower one scored on the physical functioning scales of the SF-12, the higher the score on the pretest. One interpretation of this finding could be that people who were most at risk were also most aware that they were at risk. In addition, improved posttest scores were correlated with significant improvements in the SF-12 quality-of-life subscores for General Health, Social Functioning, Role Emotional, Mental Health, and the Mental Component Summary. The data suggest that the educational intervention was associated with improvement on the test, which, in turn, was associated with higher SF-12 quality-of-life scores in these areas. While the participants in this Fall Prevention group comprised only 24.8% of the 226 older adults who completed follow-up testing, this was the only group demonstrating changes in both their posttests and their SF-12 quality-of-life scores.
DISCUSSION AND CONCLUSIONS
In summary, there was higher female participation in all 4 modules, which is consistent with a higher proportion of women in the population older than 65 years. There were no significant behavioral, knowledge, or quality-of-life improvements noted following the Home Safety or Pedestrian Safety program. Participants in the Motor Vehicle Safety program showed improvements in pre-posttest scores, but their SF-12 quality-of-life scores did not improve. Only the Fall Prevention participants demonstrated statistically significant improvements in behavior and awareness, as well as correlated improvement in some of the SF-12 quality-of-life subscale scores. These findings from the Fall Prevention group suggest that senior adults with quality-of-life limitations may be more aware of their increased risk and more willing to implement changes to enhance safety. The SF-12 quality-of-life subscale improvement for the Fall Prevention participants may be related to self-perception of improvement in daily life following behavior changes and increased knowledge of how to avoid falls.
Older adults presented program planners with many challenges. More time was often needed to assist with completion of paperwork, answer questions, help with snacks, and provide for bathroom needs. Those with hearing problems were bothered by environmental noise and some had trouble hearing the presentation. Some participants lacked the visual, writing, and reading skills necessary to complete the SF-12 or the SASE, and nonlegible handwriting on the SASE impeded sending second notices.
Finally, given the limited improvement in scores for most of the participants in this study, with 61.9% of participants showing no change, we cannot determine whether a short (30-minute) educational offering with a 12-week follow-up is the optimal intervention for this age group or for the content provided. However, findings from the Fall Prevention subgroup suggest that older adults in this risk area may be more responsive to a brief educational intervention. Further research is needed to determine best practices for injury prevention education for seniors in all risk areas.
The authors acknowledge several limitations and threats to validity in this study. First, selection bias makes it difficult to generalize our findings because our sample of elderly participants was self-selected and may not be representative of the broader population of seniors. Nonrandomized observational studies such as this one introduce the risk that other variables occurring over time (and that are not accounted for in this before-and-after design) can influence the findings on the posttest. Furthermore, self-reported behavior may introduce reporting bias if participants fail to accurately report their behavior or inflate their improvement out of a sense of wanting to please the program facilitators. For some participants, the 12-week interval was too long a period to maintain good memory of the program, and this may have introduced recall bias. There may have been variability in the quality of the instruction and group interaction during the presentations, and we did not correlate changes in posttest scores to the individual course presenters. Sample size varied among participants in each module, and a larger sample size across all 4 modules would have provided for a better evaluation of each of them.
A rapidly growing geriatric population has confronted the US healthcare system with many challenges and opportunities that are likely to increase substantially in the coming decades. Among the most significant challenges is the prevention of injury or reinjury in older adults. Lack of attention to this problem will have an impact on both individual quality-of-life and escalating healthcare costs. Moving forward, adult trauma centers must develop and evaluate optimal injury prevention programs for falls, motor vehicle crashes, motor pedestrian crashes, and home-related injuries for seniors. The evaluation of these injury prevention programs will require careful measurement and research aimed at identifying the most efficient and effective and least costly of these methods. Since embarking on this project in 2003, there has been progressive evidence of focused resource allocation by state and federal agencies, hospitals, home care agencies, professional organizations, and private enterprise. Despite the difficulties inherent in studying this demographic, the need for this work remains clear.
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