Discuss the types of statistical tests

Discuss the types of statistical tests ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discuss the types of statistical tests Write a paper with minimum 1000 words discussing the application of data analysis, reliability and validity, and assorted statistical tests used in health related research. (articles will be provided). Please Include the following in your paper: Discuss the types of statistical tests State the types of study used in each article. Discuss the types of statistical tests used within each article and why they have been chosen. Discuss the applicability of the chosen statistical test and why the statistical test was chosen. Discuss the differences between parametric and nonparametric tests and how they were applied in the articles you chose. Evaluate how the factors of reliability and validity are accounted for in the articles (of instruments and surveys or in the design and data collection conducted). Summarize how the chosen studies could be applied within the context of your practice. Please cite any additional scholarly research sources published within the last 5 years. attachment_1 attachment_2 attachment_3 DOI: 10.1111/ajag.12047 Review Article Do continence management strategies reduce falls? A systematic review Frances A Batchelor National Ageing Research Institute, Melbourne, Victoria, Australia Briony Dow and May-Ann Low National Ageing Research Institute and University of Melbourne, Melbourne, Victoria, Australia Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls. Key words: accidental falls, geriatrics, review, systematic, urinary incontinence. Introduction Falls and incontinence are common health issues in older people. For example, in Australia, approximately one in three people over the age of 65 experience at least one fall each year [1]. This rate of falls further increases with age [2]. Falls cause 80% of injury-related hospital admissions in people aged 65 and over [3] and result in high total healthcare costs [4]. Worldwide rates of urinary incontinence in older people have been reported to range from 4.4 to 34.1% in men and from 4.8 to 55.1% in women [5], with this rate Correspondence to: Dr Frances Batchelor, National Ageing Research Institute, PO Box 2127, The Royal Melbourne Hospital. Email: [email protected] Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA bs_bs_banner increasing with age [6]. Urinary incontinence may be due to physical stress causing leakage (e.g. coughing, jumping) or symptoms of urgency and nocturia (waking during the night because of the need to void) associated with an overactive bladder. Urinary incontinence is one of the recognised risk factors for falls [7–9]. A systematic review by Chiarelli et al. [10] identified increased odds of falling of 1.45 (95% confidence interval 1.36–1.54) in the presence of any type of urinary incontinence. Incontinence is also a risk factor for recurrent falls [11]. Discuss the types of statistical tests. A lower risk of falls exists in the presence of stress incontinence compared to urge incontinence; however, a mix of the two poses the greatest risk [10]. Incontinence may lead to a fall through various mechanisms including slips on wet surfaces; rushing to the toilet resulting in tripping; symptoms of a urinary tract infection that predispose an individual to falls, such as delirium, drowsiness, urinary frequency; and nocturia in conjunction with impaired vision and balance, as well as postural hypotension due to medication [12,13]. A significant amount of research has been conducted into interventions that promote continence. Pelvic floor muscle training (PFMT) involves strengthening the muscles of the pelvic floor to increase urethral closure pressure and thus prevent urine leakage. It is a conservative intervention recommended as first line of management for urinary incontinence, although it seems that those with stress incontinence benefit the most [14]. Feedback or biofeedback may be used as an adjunct to PFMT, as more patients tend to report an improvement with its use [15]. Other forms of conservative management include bladder or habit training in which patients are given scheduled voiding (to improve bladder capacity, aiming for 3–4 hours of intervals). However, there is limited evidence for effectiveness of these interventions in treating urinary incontinence [16,17]. Lifestyle changes may also be recommended to improve continence, such as weight loss, fluid management, cessation of smoking and reduced strenuous activity [18]. While the association between continence problems and falls is well established, it is unlikely that the relationship is causative, particularly as both incontinence and falls are associated with other factors such as cognitive impairment and mobility problems. However, it is still unclear whether improving continence through the application of any continence management interventions would also lead to a decrease in falls. The aim of this study, therefore, was to identify continence management interventions in older adults (from community 211 B a t c h e l o r FA , D o w B a n d L o w M – A and residential care settings) that were effective in decreasing fall incidence by systematically reviewing the current literature. resolved by consensus and a third independent reviewer was available to be consulted if disagreements could not be resolved. Materials and methods Data synthesis Because of the heterogeneity across studies, this systematic review is presented as a narrative summary. This allowed for initial data exploration and identification of gaps in research. A meta-analysis was not conducted as results were not able to be combined. Identification and selection criteria A systematic search of the following databases was conducted: MEDLINE, CINAHL, PsycINFO, Web of Science, PEDro and Scopus. All databases were examined from their date of inception until March 2012. Search terms consisted of ‘falls, accidental falls’, and ‘continence’, ‘incontinence, urinary incontinence’ with MeSH headings as appropriate. A secondary search through the reference lists of relevant studies was also conducted. From the initial search, titles and abstracts were reviewed to determine if a study was suitable for inclusion. Full articles were retrieved for studies that were not clearly excluded from review of the title and abstract, and they were reviewed to determine eligibility for inclusion. Inclusion criteria Study design • Intervention studies Participants • Aged ?65 years Discuss the types of statistical tests • Any type of incontinence Intervention • Any continence management intervention Results Description of studies The primary search strategies yielded 1328 studies that were potentially relevant. These were then screened by title and abstract and 1313 studies were rejected. The full texts of the remaining 18 potentially relevant articles were retrieved for further screening. Of these, 14 articles did not meet the inclusion criteria (refer to Figure 1 for details). A total of four studies were therefore deemed appropriate for review [20–23]. Characteristics of studies Table 1 summarises the characteristics and results of the included studies. Participant characteristics Participants in the included studies were aged 65 or older (as per inclusion criteria). Although the search strategy was not Figure 1: Search results. Outcome measures • Fall-related outcomes (e.g. fall rate, proportion of falls) Exclusion criteria • Papers written in languages other than English • Studies where continence management strategies were not the main component of the intervention Method of review Quality appraisal All articles retrieved that satisfied the criteria stated above were assessed independently by two reviewers with any disagreements being resolved by consensus or through consultation with a third independent reviewer, if necessary. The quality of each study was appraised using a critical review form and guidelines for quantitative studies developed by Law et al. [19]. Data extraction Two reviewers independently extracted relevant data including participant inclusion and exclusion criteria, setting, intervention and control protocols, outcome measures, and results using a customised table. All disagreements were 212 Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA Aged ?66, commenced treatment with oxybutynin or tolterodine for pharmaceutical management of urinary incontinence in Ontario, Canada, between 1 April 2002 and 31 December 2008. Female, average age 80, incontinent of urine and/or had urgency related to an overactive bladder, 55% had dementia Gomes et al. (2011) [22] Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA Incontinence of urine (as identified by nursing home staff and verified by checks for wetness); free of catheter; ability to follow a simple one-step instruction; not being on Medicare Part A reimbursement for post-acute skilled care or terminal illness Schnelle et al. (2003) [20] Terminal illness; bed bound; non-communicative; delirium; Lewy body dementia; history of ?3 UTIs in previous year or current infection; post-void residual urine volume ?150 mL; urethral diverticulum; bladder tumour or stone; severe pelvic organ prolapse or vaginitis; genitourinary surgery within past 6 months; hepatic disease; severe CVD; myasthenia gravis; SCI; bowel movement < every 3 days; history of gastrointestinal obstruction or decreased motility; current drug therapy for urinary incontinence; current use of acetylcholinesterase inhibitor or bisphosphonate; investigational drug, systemic or ophthalmic cholinomimetic drug, diphenhydramine, or gastrointestinal antispasmodic within 2 weeks before trial NA Male, patients with terminal illness NA Exclusion criteria 4 nursing homes (one non-profit, 3 propriety), USA Twelve skilled nursing homes, USA Long-term care facility, USA Canada Setting Research staff implemented the intervention 5 days a week, every 2 hours, between 08.00 and 16.00 hours for 8 months. Patients were prompted to toilet and change if they were wet. Before or after this, they were encouraged to walk or, if not ambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times using minimum assistance. During one trial each day, upper body resistance training was performed. Before and after each trial, patients were offered fluids with a prompting protocol that significantly increased fluid intake. Discuss the types of statistical tests Target goals for the exercise were set individually and adjusted on a weekly basis. (n = 92) Individualised treatment plan by continence care nurse including anticholinergics, topical oestrogen, PFMT +/- biofeedback administered by registered nurses, dietary changes (elimination of caffeine and increased daily fluid and fibre intakes), prompted toileting (n = 27) 4 weeks of treatment with once-daily oral extended-release oxybutynin 5 mg (n = 26) Patients prescribed with oxybutynin (n = 40 563) Patients prescribed with tolterodine (n = 40 563) Intervention/s Usual care from nursing home staff (n = 98) Placebo (n = 24) NA NA Control People who had fallen during 8 months of intervention period, as documented in records. Compared to 6 months baseline measurement pre intervention. Fall incidence during the 3 months prior, during (4 weeks) or 3 months after the trial, as documented in incident reports and progress notes Hospital visit for a fall within 90 days of drug initiation (identified on the Canadian Institute for Health Information Discharge Abstract Database and National Ambulatory Care Reporting System) Fall incidence over 1-year intervention period as documented in medical record Outcome measure Control group: 14 at baseline; 21 at follow-up. Intervention group: 11 at baseline; 13 at follow-up. Authors report a significant difference between groups when comparing the change in number of people who had fallen pre and post intervention. No differences between groups in the 3 months prior to trial (27%, 33%; P = 0.62), during (19.2%, 16.7%; P = 0.81) or 3 months after (30.8%, 41.7%; P = 0.42). No difference in median change in number of falls per month (P = 0.24–0.66). No treatment or period effect for the number of falls per month over time of observation (treatment effect, P = 0.24; period effect, P = 0.51). 321 (0.79%) tolterodine users compared with 294 (0.72%) oxybutynin users experienced a fall-related hospital visit within 90 days of drug initiation. No difference in risk. Falls decreased from 18 to 7 (61% decrease) compared to 1 year prior to intervention. Result i n t e r v e n t i o n s a n d CVD, cardiovascular disease; GDS, Global Deterioration Scale; MMSE, Mini-Mental State Examination; PFMT, pelvic floor muscle training; SCI, spinal cord injury; UTI, urinary tract infection; NA, not addressed. Female, aged ?65, resident for ?3 months in long-stay nursing home unit, MMSE score 5–23, GDS score 3–6, urinary incontinence, ability to swallow medication intact, medication adherence rate ?80% during week before screening Lackner et al. (2008) [23] Klay & Marfyak (2005) [21] Inclusion criteria Study Table 1: Summary of included studies C o n t i n e n c e f a l l s 213 B a t c h e l o r limited to urinary incontinence, all the included studies targeted only those with urinary incontinence. One study [21] also included participants with symptoms of urgency from an overactive bladder. Two of the studies included female participants only [21,23]. Three of the trials were conducted in nursing homes [20,21,23], and the study by Gomes et al. [22] was not restricted to a particular setting. Interventions Two studies investigated the effect of pharmacological agents: Gomes et al. [22] compared oxybutynin with tolterodine within a 90-day period, and Lackner et al. [23] investigated the effect of 5-mg extended-release oxybutynin administered once daily for 4 weeks compared to a placebo. One study implemented prompted toileting every 2 hours between 08.00 and 16.00 hours in conjunction with a lowintensity exercise program over 8 months (also known as functional incidental training) [20]. Klay & Marfyak [21] investigated the use of a continence specialist nurse in designing an individualised treatment plan from a range of interventions including the use of anticholinergics, topical oestrogen, PFMT with or without biofeedback administered by registered nurses, dietary changes (elimination of caffeine and increased daily fluid and fibre intakes) and prompted toileting over the course of 1 year. Outcome measures Three studies reported the number of falls as an outcome measure but across varying time periods [21–23]. Gomes et al. [22] recorded falls that resulted in a hospital visit within 90 days from drug administration from data collected from relevant emergency department and hospital admission databases. Two of the studies [21,23] calculated the number of falls throughout the intervention period, which ranged from 4 weeks [23] to 1 year [21]. Lackner et al. [23] also compared fall incidence 3 months post intervention. Data were collected from documentation in the patients’ medical records. Lackner et al. [23] used incidence reports in addition to medical records for data collection. One study reported the number of people who had fallen only, comparing the difference pre-post intervention [20]. Effectiveness Of the three studies that used statistical tests to evaluate differences between groups [20,22,23], only the study by Schnelle et al. found a significant difference [20]. Discuss the types of statistical tests They found a difference between control and intervention groups for proportion of people who had fallen but not fall rate when comparing pre and post intervention. Lackner et al. [23] reported no difference in falls either during the intervention or in the 3 months post intervention, compared to the placebo group. Klay & Marfyak [21] administered a patientspecific program from a range of interventions designed by a continence nurse specialist and reported a post-intervention decrease in falls of 61% compared to pre-intervention; however, no statistical analysis was reported. 214 FA , D o w B a n d L o w M – A Methodological quality The methodological quality of studies is summarised in Table 2. Of the four studies examined, two trials [20,23] were randomised controlled trials (RCTs). However, there was lack of therapist blinding and the study by Schnelle et al. [20] lacked participant blinding and intention-to-treat analysis. One study [22] was a retrospective, population, cohort study design. This allowed a large sample size to be investigated; however, lack of features such as a comparison group, randomisation and blinding resulted in unknown biases in patient selection and data analysis. Patient characteristics were not adequately described. Klay & Marfyak [21] conducted a preand post-study without a control group, comparing number of falls in the year prior to the year after intervention. The difference in the outcome was not examined statistically. There was generally a lack of justification of sample size, with only one study [20] doing so (see Tables 1 and 2). Discussion This review found very few studies that investigated the impact of continence management interventions on falls, with only one intervention found to produce a statistically significant reduction in people who had fallen [20]. This intervention consisted of a regime of prompted toileting and a physical activity component undertaken every 2 hours with long-term care residents. In addition to the decrease in the proportion of people who had fallen seen in the intervention group, the study authors also reported differences in favour of the intervention group in frequency of urinary incontinence, physical activity and mobility endurance [20]. It is therefore difficult to isolate the effect of the continence management strategy on falls. The study by Klay & Marfyak [21] involved a multifactorial intervention. In this study, the intervention was individually tailored and therefore different for each of the 27 participants. Although they reported a reduction in fall incidence, the methodological quality of this study was poor. The small sample size and lack of a control group limited the validity and generalisability of these findings. However, the positive finding suggests that future studies might benefit from an individually tailored, multifactorial approach. It is important to note that the primary aim of the studies included in this review was not to investigate fall occurrence, and thus the study designs were not targeted directly at this outcome. The studies investigating the use of anticholinergics [22,23] sought to determine any adverse effects of these medications within this population, including a potential increase in falls due to the anticholinergic effects [24]. The use of antimuscarinics (e.g. oxybutynin, tolterodine) has been found to reduce the incidence of incontinence when compared to placebo or no treatment [25], thereby possibly decreasing falls. However, because of the anticholinergic side effects of these medications, they may also contribute to increased fall risk. This may have countered any benefits of improving continence on the incidence of falls, thereby limiting study findings. A scoping review examining the use of Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA i n t e r v e n t i o n s a n d f a l l s ? ? … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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Discuss the types of statistical tests

Discuss the types of statistical tests ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discuss the types of statistical tests Write a paper with minimum 1000 words discussing the application of data analysis, reliability and validity, and assorted statistical tests used in health related research. (articles will be provided). Please Include the following in your paper: Discuss the types of statistical tests State the types of study used in each article. Discuss the types of statistical tests used within each article and why they have been chosen. Discuss the applicability of the chosen statistical test and why the statistical test was chosen. Discuss the differences between parametric and nonparametric tests and how they were applied in the articles you chose. Evaluate how the factors of reliability and validity are accounted for in the articles (of instruments and surveys or in the design and data collection conducted). Summarize how the chosen studies could be applied within the context of your practice. Please cite any additional scholarly research sources published within the last 5 years. attachment_1 attachment_2 attachment_3 DOI: 10.1111/ajag.12047 Review Article Do continence management strategies reduce falls? A systematic review Frances A Batchelor National Ageing Research Institute, Melbourne, Victoria, Australia Briony Dow and May-Ann Low National Ageing Research Institute and University of Melbourne, Melbourne, Victoria, Australia Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls. Key words: accidental falls, geriatrics, review, systematic, urinary incontinence. Introduction Falls and incontinence are common health issues in older people. For example, in Australia, approximately one in three people over the age of 65 experience at least one fall each year [1]. This rate of falls further increases with age [2]. Falls cause 80% of injury-related hospital admissions in people aged 65 and over [3] and result in high total healthcare costs [4]. Worldwide rates of urinary incontinence in older people have been reported to range from 4.4 to 34.1% in men and from 4.8 to 55.1% in women [5], with this rate Correspondence to: Dr Frances Batchelor, National Ageing Research Institute, PO Box 2127, The Royal Melbourne Hospital. Email: [email protected] Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA bs_bs_banner increasing with age [6]. Urinary incontinence may be due to physical stress causing leakage (e.g. coughing, jumping) or symptoms of urgency and nocturia (waking during the night because of the need to void) associated with an overactive bladder. Urinary incontinence is one of the recognised risk factors for falls [7–9]. A systematic review by Chiarelli et al. [10] identified increased odds of falling of 1.45 (95% confidence interval 1.36–1.54) in the presence of any type of urinary incontinence. Incontinence is also a risk factor for recurrent falls [11]. Discuss the types of statistical tests. A lower risk of falls exists in the presence of stress incontinence compared to urge incontinence; however, a mix of the two poses the greatest risk [10]. Incontinence may lead to a fall through various mechanisms including slips on wet surfaces; rushing to the toilet resulting in tripping; symptoms of a urinary tract infection that predispose an individual to falls, such as delirium, drowsiness, urinary frequency; and nocturia in conjunction with impaired vision and balance, as well as postural hypotension due to medication [12,13]. A significant amount of research has been conducted into interventions that promote continence. Pelvic floor muscle training (PFMT) involves strengthening the muscles of the pelvic floor to increase urethral closure pressure and thus prevent urine leakage. It is a conservative intervention recommended as first line of management for urinary incontinence, although it seems that those with stress incontinence benefit the most [14]. Feedback or biofeedback may be used as an adjunct to PFMT, as more patients tend to report an improvement with its use [15]. Other forms of conservative management include bladder or habit training in which patients are given scheduled voiding (to improve bladder capacity, aiming for 3–4 hours of intervals). However, there is limited evidence for effectiveness of these interventions in treating urinary incontinence [16,17]. Lifestyle changes may also be recommended to improve continence, such as weight loss, fluid management, cessation of smoking and reduced strenuous activity [18]. While the association between continence problems and falls is well established, it is unlikely that the relationship is causative, particularly as both incontinence and falls are associated with other factors such as cognitive impairment and mobility problems. However, it is still unclear whether improving continence through the application of any continence management interventions would also lead to a decrease in falls. The aim of this study, therefore, was to identify continence management interventions in older adults (from community 211 B a t c h e l o r FA , D o w B a n d L o w M – A and residential care settings) that were effective in decreasing fall incidence by systematically reviewing the current literature. resolved by consensus and a third independent reviewer was available to be consulted if disagreements could not be resolved. Materials and methods Data synthesis Because of the heterogeneity across studies, this systematic review is presented as a narrative summary. This allowed for initial data exploration and identification of gaps in research. A meta-analysis was not conducted as results were not able to be combined. Identification and selection criteria A systematic search of the following databases was conducted: MEDLINE, CINAHL, PsycINFO, Web of Science, PEDro and Scopus. All databases were examined from their date of inception until March 2012. Search terms consisted of ‘falls, accidental falls’, and ‘continence’, ‘incontinence, urinary incontinence’ with MeSH headings as appropriate. A secondary search through the reference lists of relevant studies was also conducted. From the initial search, titles and abstracts were reviewed to determine if a study was suitable for inclusion. Full articles were retrieved for studies that were not clearly excluded from review of the title and abstract, and they were reviewed to determine eligibility for inclusion. Inclusion criteria Study design • Intervention studies Participants • Aged ?65 years Discuss the types of statistical tests • Any type of incontinence Intervention • Any continence management intervention Results Description of studies The primary search strategies yielded 1328 studies that were potentially relevant. These were then screened by title and abstract and 1313 studies were rejected. The full texts of the remaining 18 potentially relevant articles were retrieved for further screening. Of these, 14 articles did not meet the inclusion criteria (refer to Figure 1 for details). A total of four studies were therefore deemed appropriate for review [20–23]. Characteristics of studies Table 1 summarises the characteristics and results of the included studies. Participant characteristics Participants in the included studies were aged 65 or older (as per inclusion criteria). Although the search strategy was not Figure 1: Search results. Outcome measures • Fall-related outcomes (e.g. fall rate, proportion of falls) Exclusion criteria • Papers written in languages other than English • Studies where continence management strategies were not the main component of the intervention Method of review Quality appraisal All articles retrieved that satisfied the criteria stated above were assessed independently by two reviewers with any disagreements being resolved by consensus or through consultation with a third independent reviewer, if necessary. The quality of each study was appraised using a critical review form and guidelines for quantitative studies developed by Law et al. [19]. Data extraction Two reviewers independently extracted relevant data including participant inclusion and exclusion criteria, setting, intervention and control protocols, outcome measures, and results using a customised table. All disagreements were 212 Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA Aged ?66, commenced treatment with oxybutynin or tolterodine for pharmaceutical management of urinary incontinence in Ontario, Canada, between 1 April 2002 and 31 December 2008. Female, average age 80, incontinent of urine and/or had urgency related to an overactive bladder, 55% had dementia Gomes et al. (2011) [22] Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA Incontinence of urine (as identified by nursing home staff and verified by checks for wetness); free of catheter; ability to follow a simple one-step instruction; not being on Medicare Part A reimbursement for post-acute skilled care or terminal illness Schnelle et al. (2003) [20] Terminal illness; bed bound; non-communicative; delirium; Lewy body dementia; history of ?3 UTIs in previous year or current infection; post-void residual urine volume ?150 mL; urethral diverticulum; bladder tumour or stone; severe pelvic organ prolapse or vaginitis; genitourinary surgery within past 6 months; hepatic disease; severe CVD; myasthenia gravis; SCI; bowel movement < every 3 days; history of gastrointestinal obstruction or decreased motility; current drug therapy for urinary incontinence; current use of acetylcholinesterase inhibitor or bisphosphonate; investigational drug, systemic or ophthalmic cholinomimetic drug, diphenhydramine, or gastrointestinal antispasmodic within 2 weeks before trial NA Male, patients with terminal illness NA Exclusion criteria 4 nursing homes (one non-profit, 3 propriety), USA Twelve skilled nursing homes, USA Long-term care facility, USA Canada Setting Research staff implemented the intervention 5 days a week, every 2 hours, between 08.00 and 16.00 hours for 8 months. Patients were prompted to toilet and change if they were wet. Before or after this, they were encouraged to walk or, if not ambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times using minimum assistance. During one trial each day, upper body resistance training was performed. Before and after each trial, patients were offered fluids with a prompting protocol that significantly increased fluid intake. Discuss the types of statistical tests Target goals for the exercise were set individually and adjusted on a weekly basis. (n = 92) Individualised treatment plan by continence care nurse including anticholinergics, topical oestrogen, PFMT +/- biofeedback administered by registered nurses, dietary changes (elimination of caffeine and increased daily fluid and fibre intakes), prompted toileting (n = 27) 4 weeks of treatment with once-daily oral extended-release oxybutynin 5 mg (n = 26) Patients prescribed with oxybutynin (n = 40 563) Patients prescribed with tolterodine (n = 40 563) Intervention/s Usual care from nursing home staff (n = 98) Placebo (n = 24) NA NA Control People who had fallen during 8 months of intervention period, as documented in records. Compared to 6 months baseline measurement pre intervention. Fall incidence during the 3 months prior, during (4 weeks) or 3 months after the trial, as documented in incident reports and progress notes Hospital visit for a fall within 90 days of drug initiation (identified on the Canadian Institute for Health Information Discharge Abstract Database and National Ambulatory Care Reporting System) Fall incidence over 1-year intervention period as documented in medical record Outcome measure Control group: 14 at baseline; 21 at follow-up. Intervention group: 11 at baseline; 13 at follow-up. Authors report a significant difference between groups when comparing the change in number of people who had fallen pre and post intervention. No differences between groups in the 3 months prior to trial (27%, 33%; P = 0.62), during (19.2%, 16.7%; P = 0.81) or 3 months after (30.8%, 41.7%; P = 0.42). No difference in median change in number of falls per month (P = 0.24–0.66). No treatment or period effect for the number of falls per month over time of observation (treatment effect, P = 0.24; period effect, P = 0.51). 321 (0.79%) tolterodine users compared with 294 (0.72%) oxybutynin users experienced a fall-related hospital visit within 90 days of drug initiation. No difference in risk. Falls decreased from 18 to 7 (61% decrease) compared to 1 year prior to intervention. Result i n t e r v e n t i o n s a n d CVD, cardiovascular disease; GDS, Global Deterioration Scale; MMSE, Mini-Mental State Examination; PFMT, pelvic floor muscle training; SCI, spinal cord injury; UTI, urinary tract infection; NA, not addressed. Female, aged ?65, resident for ?3 months in long-stay nursing home unit, MMSE score 5–23, GDS score 3–6, urinary incontinence, ability to swallow medication intact, medication adherence rate ?80% during week before screening Lackner et al. (2008) [23] Klay & Marfyak (2005) [21] Inclusion criteria Study Table 1: Summary of included studies C o n t i n e n c e f a l l s 213 B a t c h e l o r limited to urinary incontinence, all the included studies targeted only those with urinary incontinence. One study [21] also included participants with symptoms of urgency from an overactive bladder. Two of the studies included female participants only [21,23]. Three of the trials were conducted in nursing homes [20,21,23], and the study by Gomes et al. [22] was not restricted to a particular setting. Interventions Two studies investigated the effect of pharmacological agents: Gomes et al. [22] compared oxybutynin with tolterodine within a 90-day period, and Lackner et al. [23] investigated the effect of 5-mg extended-release oxybutynin administered once daily for 4 weeks compared to a placebo. One study implemented prompted toileting every 2 hours between 08.00 and 16.00 hours in conjunction with a lowintensity exercise program over 8 months (also known as functional incidental training) [20]. Klay & Marfyak [21] investigated the use of a continence specialist nurse in designing an individualised treatment plan from a range of interventions including the use of anticholinergics, topical oestrogen, PFMT with or without biofeedback administered by registered nurses, dietary changes (elimination of caffeine and increased daily fluid and fibre intakes) and prompted toileting over the course of 1 year. Outcome measures Three studies reported the number of falls as an outcome measure but across varying time periods [21–23]. Gomes et al. [22] recorded falls that resulted in a hospital visit within 90 days from drug administration from data collected from relevant emergency department and hospital admission databases. Two of the studies [21,23] calculated the number of falls throughout the intervention period, which ranged from 4 weeks [23] to 1 year [21]. Lackner et al. [23] also compared fall incidence 3 months post intervention. Data were collected from documentation in the patients’ medical records. Lackner et al. [23] used incidence reports in addition to medical records for data collection. One study reported the number of people who had fallen only, comparing the difference pre-post intervention [20]. Effectiveness Of the three studies that used statistical tests to evaluate differences between groups [20,22,23], only the study by Schnelle et al. found a significant difference [20]. Discuss the types of statistical tests They found a difference between control and intervention groups for proportion of people who had fallen but not fall rate when comparing pre and post intervention. Lackner et al. [23] reported no difference in falls either during the intervention or in the 3 months post intervention, compared to the placebo group. Klay & Marfyak [21] administered a patientspecific program from a range of interventions designed by a continence nurse specialist and reported a post-intervention decrease in falls of 61% compared to pre-intervention; however, no statistical analysis was reported. 214 FA , D o w B a n d L o w M – A Methodological quality The methodological quality of studies is summarised in Table 2. Of the four studies examined, two trials [20,23] were randomised controlled trials (RCTs). However, there was lack of therapist blinding and the study by Schnelle et al. [20] lacked participant blinding and intention-to-treat analysis. One study [22] was a retrospective, population, cohort study design. This allowed a large sample size to be investigated; however, lack of features such as a comparison group, randomisation and blinding resulted in unknown biases in patient selection and data analysis. Patient characteristics were not adequately described. Klay & Marfyak [21] conducted a preand post-study without a control group, comparing number of falls in the year prior to the year after intervention. The difference in the outcome was not examined statistically. There was generally a lack of justification of sample size, with only one study [20] doing so (see Tables 1 and 2). Discussion This review found very few studies that investigated the impact of continence management interventions on falls, with only one intervention found to produce a statistically significant reduction in people who had fallen [20]. This intervention consisted of a regime of prompted toileting and a physical activity component undertaken every 2 hours with long-term care residents. In addition to the decrease in the proportion of people who had fallen seen in the intervention group, the study authors also reported differences in favour of the intervention group in frequency of urinary incontinence, physical activity and mobility endurance [20]. It is therefore difficult to isolate the effect of the continence management strategy on falls. The study by Klay & Marfyak [21] involved a multifactorial intervention. In this study, the intervention was individually tailored and therefore different for each of the 27 participants. Although they reported a reduction in fall incidence, the methodological quality of this study was poor. The small sample size and lack of a control group limited the validity and generalisability of these findings. However, the positive finding suggests that future studies might benefit from an individually tailored, multifactorial approach. It is important to note that the primary aim of the studies included in this review was not to investigate fall occurrence, and thus the study designs were not targeted directly at this outcome. The studies investigating the use of anticholinergics [22,23] sought to determine any adverse effects of these medications within this population, including a potential increase in falls due to the anticholinergic effects [24]. The use of antimuscarinics (e.g. oxybutynin, tolterodine) has been found to reduce the incidence of incontinence when compared to placebo or no treatment [25], thereby possibly decreasing falls. However, because of the anticholinergic side effects of these medications, they may also contribute to increased fall risk. This may have countered any benefits of improving continence on the incidence of falls, thereby limiting study findings. A scoping review examining the use of Australasian Journal on Ageing, Vol 32 No 4 December 2013, 211–216 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA i n t e r v e n t i o n s a n d f a l l s ? ? … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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