Week 3 Assignment
Lori L. Lindsey-Clarkston
Lakeview College of Nursing
RN 302 Nursing Research

Research Proposal
	Fall risk in the elderly with dementia is not a new phenomenon but it is a topic that has not been researched extensively nor are there any standard tools that are used as evidence based practice.  As a result the purpose of this paper is to propose a solution to prevent or decrease falls in the elderly population who suffer from dementia.  Specifically can improved screening tools such as gait ability/training, safe use of adaptive devices for mobility and devices such as walkers or wheelchairs prevent or decrease fall incidence among the elderly with dementia problems.  This proposed study seeks to answer this question and thus provide nurses with evidence based research on which they can build their practice.  
Framework and Methodology
	This study will be performed as a quasi-experimental study.  Burns and Grove define a quasi-experimental study as one that examines the effect of an independent variable or intervention on a dependent variable or outcome (2009).  Therefore, this study will use both an experimental and a control group.  The experimental group will include individuals who live independently in their homes that are served by PhysioCare Home Health Care in conjunction with two assisted living facilities and four skilled nursing rehabilitation facilities that the individuals in the study either continue to live or have recently been discharged from.  The data will be used on past, current, and present clients by using screening techniques by skilled nurses for risks for falls, the level of dementia the client exhibits or is being treated for, and safety with assistive devices. Physical therapist and occupational therapist will have input regarding safe device use education if needed for the clients involved.  The control group will be individuals in the same living situation and have similar gait abnormalities or muscle weakness that requires use of assistive devices as needed the difference in this group will be no diagnosis of  dementia of any type. 
The research will continue of a period of three years.  Additionally once the client is discharged from home care services follow up will continue for a one year period to track fall rates and hospitalizations due to falls. The research is slated to begin July 1, 2011 and will end July 1, 2014.  Individuals considered for the research will have a start of care date no earlier than June 23, 2011 with PhysioCare Home Health Care and the last date for an individual to be accepted for research will be May 5, 2014 due to the length of service period for home health care of nine weeks between certifications.  Throughout the research study new patients will be accepted for both groups.  Although perhaps a true experimental study that includes two concurrent groups as well as random sampling to obtain subjects, random assignment to control and experimental groups, rigorous control of the treatment, and designs that controlled threats to validity would lead to more conclusive results, it is not ideal for this particular study.  This is because withholding screening techniques or providing potentially inadequate screening techniques would present an ethical dilemma in regards to patient care (Burns, 2009).
Protection of Patients’ Rights
	Informed consent will be obtained from clients agreeing to participate in the study after being given complete details of the study, having any questions answered, and samples of similar studies provided or explained.  Participants also have the right to remove themselves from the study at any time.  Information will be provided in the like to individuals in the experimental and control group although the individual will not have knowledge of which group they are in until the end of the entire study.  Through these steps validity of the study will be maintained and information obtained can be claimed as evidence based practice.  
Variables in the Study
	Independent variables in this study include fall risk level according to evaluation, level of dementia as diagnosed by physician, and safety knowledge level with use of assistive devices according to evaluation tool use by skilled nursing staff.  These will be evaluated on a weekly basis for each individual in the both the controlled and experimental group enrolled in the research project.  
Data Collection
	Data will be collected on forms weekly with home visits by either the nurse case manager or physical therapist case manager. Information such as gender, age, education, race, income, employment status, diagnosis, and marital history will be collected on admission to the study.  An extensive medical history will be collected one time before admission to determine what group the participant will be in during the research study.  Continuing medical condition monitoring will be executed throughout the research study until client is dismissed from home care services.  The data collection forms will be signed by the nurse or physical therapist case manager and supervising physician weekly.  There will be many physicians involved as the primary care physician for each participant will be the supervising physician for each case, this works for continuity of care for each client as the physicians are already involved in the case due to the home health care agency involved.  
	Limitations to this study include the research is only being done through one home health care agency with six medical assistive facilities in one area.  If other home health agencies were involved the accuracy of the results may be increased and the number of the participants would most likely triple.   This in itself would increase the variation in demographics and the study would have more profound results. The agency involved only serves clients with private pay insurance and Medicare which narrows the economic status of the clients which may alter the results to a higher level due to the type of healthcare services provided.  Medicaid recipients being left out in the elderly population for the research study changes the learning curve for safety issues and healthcare access of the client. Unfortunately society jurisdicts these difference in healthcare access to poverty level individuals.  
Literature Review
	A research study proposal dictates present literature review.  The current scholarly research addressing the subject of falls among the elderly population with dementia were selected due to the information presented on incidence, level of dementia, improvement in care, and related injuries.  Three individual research articles will be inspected for factors such as design type, methodology, variables, and results and conclusions.
Article one review:
	The methodology for this article was a cohort study with two years of follow-up.  Cohorts are defined by Burns as samples in a time-dimensional study within the field of epidemiology (2009).  The cohort for the study consisted of newly admitted residents of randomly selected nursing homes in Maryland stratified by geographic region and facility size (Van Doorn et al, 2003).  Dementia status of participants was determined in accordance with Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised Criteria, by geriatric psychiatrist and neurologist with review by a second team and a geriatrician when there was conflict of diagnosis (Van Doorn et al, 2003).  Risk factors for falls included age, sex, race, education, and marital status, hearing impairment, ambulatory status, orientation, and continence status these were obtained by nurse interview of the client. 
	Dependent variables in the study included the number of falls and the number of those of injurious falls (Van Doorn et al, 2003).  Fall risks for individuals are the independent variables for the study. Confounding variables include level of dementia.  Burns defines confounding variables as those that have the potential to affect the outcome of a study, which are recognized before the study is initiated but that cannot be controlled, or variables not recognized until the study is in progress (2009).  Fall risks factors can be found in table one of the article.  Out of 2,015 cohort members 48.2% were classified as having dementia (Van Doorn et al, 2003).  Over the two years of the study residents with dementia stayed in the nursing home 364 days and residents without dementia stayed 200 days (Van Doorn et al, 2003).  1017 people fell 5,348 times during the two year follow up period the rate of falls among those with dementia was 4.05 per person-year in the nursing home and 2.33 per person-year in those without dementia (Van Doorn et al, 2003).  Dementia was not considered a significant risk factor in falls that involved injury. 
	In conclusion the article states that one limitation was the circumstances of the fall, such as activity and time would help in establishing the cause of the fall (Van Doorn et al, 2003).  The long term care setting should be able to provide closer monitoring and evaluation of fall risks due to the 24/7 care ethic of the facility.  Fall risk should be identified at admission and prevention should be initiated at that time.  Basic fall prevention techniques can be implemented and would include proper footwear for ambulatory clients, identifying weakness, dizziness, use of hip protectors, placing clients with dementia closer to nursing stations for ease of monitoring (Van Doorn et al, 2003).
Article two review:
	The methodology used in article two is longitudinal cohort study (Allan et al., 2009).  According to Burns and Grove a longitudinal study is a design that is used to examines changes in the same subjects over an extended period of time, therefore participates are committed to detailed interviews or required to complete numerous forms at various times during the study (Allan et al., 2009).  Participants in the study were recruited due to having Lewy Body dementia.  Certain levels of dementia were excluded according to the DSM IV criteria.  
	The variables in the study include level and kind of dementia diagnosis, medication regimen, autonomic symptoms, symptomatic orthostatic hypotension, depression, and physical limitation the participants exhibit (Allan et al., 2009).  This is the first study that took many factors into consideration to research.  The study took place over a twelve month period.   There were 224 participants that agreed to the study with 140 being diagnosed with dementia (Allan et al., 2009).  The baseline characteristics are outlined in table one.  Participants or caregivers kept fall diaries 81.6% were returned with 82.9% of those being diagnosed with dementia.  The rate of falls reported among dementia patients were high showing 9118 per 1000 per years (Allan et al., 2009).  The incidence of falls throughout the study is depicted in table two.  
	Predictors of falls such as age, gender, level and duration of dementia, residence, and risk scales used are reported in table three.  Predictors such as depression, autonomic symptoms, blood pressure, medication use, and level of physical activity are reported in table four.  The conclusion from the research shows that older people with dementia are eight times likely to experience a fall with the predictors that are outlined are present.  Patients with Lewy Body dementia were at the highest risk.  History of falling for the participants was also taken into consideration for this research (Allan et al., 2009).  The strength of the study is depicted in the fact of compliance of the fall diaries being completed with caregiver support in filling out the information or participating in interviews when the level of dementia in the client did not allow them to speak for themselves.  The limitations in the study include how the participants were recruited could have been biased as they were solicited from secondary care clinics therefore the disease state of dementia was more progressive.  Exclusive research in the study was phasic measurement of blood pressure throughout the study (Allan et al., 2009).  The conclusion states that clinical practice to help reduce or prevent falls among this population should focus on blood pressure issues of the client and maintenance of depression symptoms and gait training for balance and endurance (Allan et al., 2009).  
Article three review:
	The study is a qualitative research that does not present much information and is broad.  The variables include functional decline, depression, social isolation, and nursing home admission (Ferris, 2008).  The research took place over a three month period at a 100-bed nursing home facility.  The assessment tool used is the Minimum Data Set required by federal regulations for use in nursing homes it determines history of falls, cognition, impulsivity, vision, ambulation, continence, use of high risk medications (antihypertensive, diuretics, and hypoglycemic), use of assistive devices for transfer or ambulation, attached equipment (catheters, intravenous lines, or oxygen), and familiarity of environment (Ferris, 2008).  
	The research was inconclusive.  Researchers stated that post fall assessments would be helpful to bring in factors that caused the fall and to record any injury sustained.  Each client should be assessed individually for fall risk upon admission to any facility.  Providing a safe environment for residents in congregate situations falls can be prevented.  Ongoing assessment needs to be done to determine change in status, fall and injury prevention should be a part of the patients care plan (Ferris, 2008).  
Conclusion
	Falls among the elderly are unfortunately common no matter where the elder lives.  There are some variables that increase the risk and with dementia of any level involved the risk is even higher.  The research for falls in the elderly with dementia is sparse.  There are no standard tools that are used in practice other than those required by law for residents of nursing homes.  Physicians and nurses who are taking care of patients that live independently in the community do not have a standardized tool to use to assess fall risk.  This study will seek to find a tool that healthcare providers can use to assess fall risk and then educate patients and caregivers how to prevent or lessen the risk for falls.  

References
Allan, M., Ballard, C., Rowan, E., Kenny, R. (2009). Incidence and prediction of falls in
     dementia: A prospective study in older people. PloS ONE, 4(5): e5521. 
     Doi:10.1371/journal.pone.0005521.  Retrieved June 1, 2011 from 
     http://www.ncbi.nln.nih.gov/pmc/articles/pmc2677107/pdf/pone.0005521.pdf.
Burns, N., Grove, S. (2009). The practice of nursing research (6th ed.). St. Louis, MO: Saunders 
      Elsevier.
Ferris, M. (2008). Fall preventions in long-term care: Practical advice to improve care. Topics in 
     advanced practice nursing ejournal, 8(3), 1-4. Retrieved June 1, 2011 from 
     http://www.medscape.com/viewarticle/579951.
Harlein, J., Dassen, T., Halfens, R.J.G., & Heinze, C. (2009). Fall risk factors in older people 
      with dementia or cognitive impairment: A systemic review. Journal of Advanced Nursing, 
      65(5), 922-933. Retrieved May 27, 2011.
VanDoorn, C., Gruber-Baldini, A., Zimmerman, S., Hebel, J., Port, C., Baumgarten, M., Quinn, 
      C., Taler, G., May, C., Magaziner, J. (2003). Dementia as a risk factor for falls and fall 
      injuries among nursing home residents. American Geriatric Society, 51(9), 1213-1218. 
      Retrieved June 1, 2011 from http://www.medscape.com/viewarticle/460913.