Annotation of a Qualitative Research Article

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Assignment: Annotation of a Qualitative Research Article

Submit: Annotation of a Qualitative Research Article

This week, you will submit the annotation of a qualitative research article on a topic of your interest.

The assignment:

  • Annotate one qualitative research article from a peer-reviewed journal on a topic of your interest.
  • Provide the reference list entry for this article in APA Style followed by a three-paragraph annotation that includes:
  • Format your annotation in Times New Roman, 12-point font, double-spaced. A separate References list page is not needed for this assignment.
  • Submit your annotation by Day 7.
Qualitative Research Article

PATIENT PERSPECTIVES Older people and falls: health status, quality of life, lifestyle, care networks, prevention and views on service use following a recent fall

 Brenda Roe, Fiona Howell, Konstantinos Riniotis, Roger Beech, Peter Crome and Bie Nio Ong

 Aim and objective. This study has investigated older people’s experiences of a recent fall, its impact on their health, lifestyle, quality of life, care networks, prevention and their views on service use. Background. Falls are common in older people and prevalence increases with age. Falls prevention is a major policy and service initiative. Design. An exploratory, qualitative design involving two time points. Method. A convenience sample of 27 older people from two primary care trusts who had a recent fall. Taped semi structured qualitative interviews were conducted and repeated at follow up to detect change over time and repeat falls. Data were collected on their experience of falls, health, activities of living, lifestyle, quality of life, use of services, prevention of falls, informal care and social networks. Content analysis of transcribed interviews identified key themes. Results. The majority of people fell indoors (n = 23), were repeat fallers (n = 22) with more than half alone when they fell (n = 15). For five people it was their first ever fall. Participants in primary care trust 1 had a higher mean age than those in primary care trust 2 and had more injurious falls (n = 12, mean age 87 years vs. n = 15, mean age 81 years). The majority of non-injurious falls went unreported to formal services. Falls can result in a decline in health status, ability to undertake activities of living, lifestyle and quality of life. Conclusions. Local informal care and support networks are as important as formal care for older people at risk of falls or who have fallen.  Access to falls prevention programmes and services is limited for people living in more rural communities. Relevance to practice. Falls prevention initiatives and services should work with local communities, agencies and informal carers to ensure equitable access and provision of information, resources and care to meet the needs of older people at risk or who have fallen. 

Key words: care networks, falls, health status, nursing, older people, prevention

 Accepted for publication: 31 October 2008 

Introduction 

Falls are a public health issue that particularly affect older people and result in injury, hospitalisation, premature death and impaired mobility. Along with these factors, loss of independence, social isolation and fear of falls result in costs to individuals, families and public services. An awareness of the costs and consequences of falls by governments, UK or worldwide has targeted policies and health and social care initiatives at falls prevention (DH 2003, 2004, Todd & Skelton 2004). Systematic reviews have also examined the evidence base for what such initiatives should comprise (Gillespie et al. 2003, Chang et al. 2004). Few studies have investigated the consequence of falls from the perspective of older people. This paper reports qualitative research findings examining the impact of falls in relation to co-morbidity, lifestyle, health status, quality of life, care networks, prevention and views of services received. These findings form part of a broader study that has investigated older people’s experiences of recent falls, using narratives as the basis for service development and delivery. 

Background 

Between 18–32% of older people living in the community fall each year which can cause injury, hospitalisation, mortality, restricted mobility and fear of falling (Lee et al. 2006). One in three people aged 65 years and above living in the community fall once a year and this increases to one in two people for those aged 80 years and above (O’Loughlin et al. 1993, Tinetti et al. 1998). Women are more likely than men to fall (Yasamura et al. 1994). Having experienced a fall one in three older people will fall again within the following year (O’Loughlin et al. 1993, Luukinen et al. 1994, Tinetti et al. 1998). Impaired mobility and independence can result in admission to institutional care, hospital or care home and premature death (Lee et al. 2006). Falls in older people have significant costs to both individuals and health services (Englander et al. 1996, NICE 2004). Randomised controlled trials (RCTs) have been undertaken to identify effective and cost effective interventions for prevention and treatment (Gillespie et al. 2003, Chang et al. 2004, Hauer et al. 2006). Two systematic reviews of RCTs found that multi-factorial assessment and management programmes are effective (Gillespie et al. 2003, Chang et al. 2004), although it is not possible to identify which components are effective (Chang et al. 2004).

 Methods 

Aim 

The objectives of the study were: • To explore the experiences of older people who had a recent fall and its impacts on their health, well-being, quality of life and related factors. • To explore older people’s experiences and views of formal services following a fall and the role of social networks and informal care.

 Design

 Semi-structured qualitative interviews were conducted during 2003–2004 in two primary care trusts (PCTs) with people aged 65 years and above who had experienced a recent fall. Follow up interviews were conducted three to four months later to detect change over time and repeat falls. A recent fall was defined as having occurred within the last 10 days and classified as a first ever fall, new, or repeat fall. 

Settings 

The study took place in two PCTs, one mainly rural with several towns and having an established falls prevention programme and a community hospital clinic (PCT 1) and the other was urban rural areas radiating outward, having a less established falls prevention service and falls clinic in a hospital setting (PCT 2). Sample A convenience sample of 27 older people who had a recent fall (n = 26 within the last 10 days, n = 1 within 16 days) participated in initial interviews (12 PCT 1, 15 PCT 2). A 100 and 94% response rates were achieved for PCT 1 and PCT 2, respectively. In PCT 2 one man refused to participate in the study. More women than men were interviewed (22 vs. 5) with the mean age of older people interviewed in PCT 1 being older (mean age 87 years) than those interviewed in PCT 2 (mean age 81 years) (Table 1).

 Data collection

Participants were recruited via Community Health Services, Intermediate Care, Accident and Emergency, Ambulance Services and Day Centres. Once informed consent had been obtained interviews were conducted in a place that ensured privacy (by KR PCT 1 and FH PCT 2) during 2003–2004 and were tape-recorded. Data were obtained on their experiences of the fall, health and well-being, activities of daily living, informal care and support networks, use of services and prevention. A follow up interview was undertaken 3–4 months later and information obtained on similar themes.

 Pilot study 

The first three interviews undertaken in each location were pilot work to test the feasibility of recruitment and operational definitions. Recruiting participants within seven days of a recent fall proved difficult and the operational definition was modified to become within 10 days of having a fall. No changes were made to the methods of recruitment or the semi structured interview schedule; consequently the data from these six interviews were retained in the main data set. 

Data management and analysis 

Tapes were transcribed following each interview and checked as a true record with line identification for participants and interviewers included. All transcripts were anonymous. Content analysis was undertaken and themes identified independently by three members of the team (one member for transcripts from each PCT, KR and FH and one member across all transcripts). Themes identified were based on saturation of data and coding was agreed in team meetings, by discussion and consensus. 

Reliability and validity

 Reliability checks were undertaken on the themes derived within a selection of complete interviews and across themes by two members of the team. A high level of agreement was obtained and minor differences eliminated by discussion and consensus. The validity of information was verified and clarified for each participant during interview by lines of questioning. 

Ethics considerations 

Informed consent was obtained prior to initial interviews taking place. Assurance was given that data would be confidential and that participants’ identities would be anonymous with unique identity codes used in tapes and transcripts. Ethics approvals were obtained from Local Research Ethics Committees for both PCTs prior to the study. Results

 Sample 

Twenty-seven people had initial interviews following their recent fall. (Table 1) Eighteen follow up interviews were conducted (PCT1 n = 8, PCT n = 10) and the mean age difference of participants remained with those from PCT 1 being slightly older than those in PCT 2. Reasons for participants being lost to follow up were due to acute illness (n = 5), having died (n = 2) or lost to contact, suggesting possible re-location (n = 2). Initial interviews were undertaken for more than half the participants in PCT1 in hospital (n = 7), three were in nursing homes as part of Intermediate Care and two at home. In PCT 2 all initial interviews were undertaken at home except for one participant in a day centre. All follow up interviews were undertaken at home for both PCTs. The majority of participants were living in their own homes (houses n = 17 with one living downstairs, bungalows n = 2, apartment in extra care housing n = 1, sheltered housing n = 4) with slightly more than half of them living alone (n = 13) (Table 1). All participants in PCT 1 had injurious falls involving dislocated joints or fractures requiring hospital treatment as in-patients, while those in PCT 2 sustained minor injuries such as soft tissue injury, bumps or bruises, although one man had fractured a wrist that went undetected until interview. For five participants this was a first ever fall but for the majority (n = 22) it was a repeat fall, with participants in PCT2 having falls within the previous days, weeks, month or year and apparently more frequently but with less injurious consequences than participants in PCT 1 (Table 1). This may be a reflection of their being a slightly younger population in PCT 2 but with recently emerging medical morbidities. Four participants had a repeat fall between the initial and follow up interview.

Location of falls 

The majority of falls occurred indoors (n = 23) with nearly half occurring in the morning (n = 12, one in the shower and two downstairs), fewer in the afternoon (n = 7) and five participants fell at night while getting up to go to the toilet, use a commode or getting ready for bed. The majority of participants were alone when they fell (n = 15), eight of them were able to get up by crawling and raising themselves up onto chairs or beds, while the remainder relied upon people to help them such as carers, spouses, friends, neighbours, workmen or ambulance crews having lain on the floor for 15–30 minutes (Table 1). These findings illustrate the context of falls for older people.

Co-morbidity

 In keeping with their chronological age most participants had at least one self-reported chronic long term condition with few having multiple co-morbidities. Conditions ranged from stroke, cancer, osteoporosis, hypo-tension, hypertension, dizziness and impaired vision. Seven participants claimed that their fall was a direct consequence of their impaired vision, due to cataracts or blindness in one eye. Four people were immediately seen by paramedics following their fall (PCT2). In this PCT, GPs routinely refer to the paramedics when they are alerted that an older person has had a fall. The paramedics undertook a clinical assessment of potential causes and enquired about the use of alcohol. Six older people interviewed made reference to alcohol either because they were prompted to by the paramedics or because of their own observations or those of their GP. For example, the paramedics used humour and suggested diluting drink, as illustrated by Quote 1 (Table 2). Other comments also demonstrated that the paramedics enquired about the use of alcohol (Quote 2, Table 2) and that alcohol was either a perceived feature or potential observation or judgment of falls in public (Quotes 3 and 4, Table 2). GPs also enquired about the use of alcohol in older people who had a fall (Quote 5, Table 2). Some of the falls were attributable to the above medical conditions and co-morbidities. Of note is that the more injurious falls and consequences were experienced by participants in PCT 1, which may be a reflection of where the convenience sample were recruited from but also their increased mean age compared to those from PCT 2. Participants in PCT2 received less injurious soft tissue injuries reflected also by the health services they required but of note was their frequency of falls which had been within the previous days, weeks and month compared with those from PCT 1 which were recalled as being some years ago. It would seem that people in PCT 2 might have been experiencing a change in their medical conditions, which had resulted in recent falls, all of which warranted further medical investigations, although not all of these falls were known about by formal health services.

Care and support networks

 Formal services and informal support networks were documented for all participants interviewed. Care and support networks were categorised according to a typology developed from their responses and included both informal and formal care and networks, which included, independent, informal family (local), informal family, friends, neighbours (local), informal friends and neighbours (local) for those without family, informal family and formal care services and finally formal care only (Table 3). Wenger (1989) developed a typology for informal support networks and three of these types, family dependent, local integrated support and local self-contained equated to informal family, informal family, friend and neighbours and informal friends and neighbours in the present study. A minority of participants were independent before their initial fall and fewer after. A similar proportion of participants relied on informal networks or a combination of informal and formal networks before their fall. Similar proportions relied on informal and formal networks after their fall but fewer solely informal networks continued following a fall. Following their fall a small proportion required only formal care and limited to those in PCT 1 who had the most serious falls and injuries (Table 3). One woman had moved into a nursing home following her fall and hospitalisation, with her husband, subsequently dying while she was in hospital. The consequences of her fall and other life events were a source of understandable distress to her (Quote 6, Table 2). Following their initial fall, it appeared that changes occurred in individuals’ independent living, use of informal support networks and formal care, resulting in either an increase of formal care or a combination of formal care and informal networks. Informal networks included family, neighbours and friends. Support and companionship provided by neighbours was valued and they were judged to be ‘friends’ as illustrated by one woman who described her neighbour, ‘She’s been marvelous to me really. I do value her friendship’ and another two women (Quotes 7 and 8, Table 2). Since their fall, family, neighbours and friends were visiting more frequently as illustrated by one woman ‘The family come more often’. (See also, Quote 9, Table 2). It was also clear that families worried about their relative who had fallen, illustrated by a daughter (Quote 10, Table 2). It was acknowledged that communities were changing due to people moving or friends dying as natural consequence of the life course (Quotes 11 and 12, Table 2). Neighbours in communities took care of each other and provided support and generally ‘looked out for one another’, as said by one man who had recently fallen but who kept an eye on his neighbour in their rural community (Quote 13, Table 2).

Health status 

People’s health status before and after their fall was an important factor which, for some, meant that a change in their health status was a consequence of the fall itself, while for others their change in health status may have been the cause of their fall or falls. A minority of people described their health as being good prior to their fall (n = 6). For example, Mrs H, aged 98 years described her typical active domestic day involving food preparation, meals, housework, cleaning and tidying while her husband did some gardening. Another woman, Mrs I aged 65 years and who was the youngest respondent, lived with her son. She was independent and able to undertake all her ADLs and IADLs and was involved with her family network. She fell while outdoors going to the shops saying that she ‘tripped on the pavement’, prior to this there ‘was nothing wrong with me’ Consequently, she fractured her hip and a follow-up interview was not possible as she was still hospitalised and too poorly. One previously active woman, Mrs V Aged 81 years, described her health status as good before her fall but following her fall as ‘not good’. She started having repeat falls around three years previously. At the time of the study, she was falling about twice a month, but she had two falls in the previous seven days. Prior to her falls, she went dancing and on holiday with friends. She had stopped going away on holiday, no longer went dancing, and would not go out unaccompanied. She suffered from osteo-arthritis and depression and was due to go to attend a falls programme at the clinic but was unable to attend as she collapsed and was admitted to hospital. Hers was a ‘diminishing world’ with a reduced health status and restricted activities and social networks. Another woman viewed her health as good both before and following her fall. She lived alone since her husband died 17 years ago and continued to live in their home of 60 years. She had two daughters nearby who visited and her neighbours also who were friends. She fell on her path returning from a shopping trip (See Quote 14, Table 2). Similarly another woman, Mrs Y aged 83 years, described her health following her fall as good and improving. She lived alone but had her daughter and son-in- law nearby, who provided help and support. Her most recent fall was a consequence of her impaired mobility following a stroke she had been recovering from, and she was being supported by a comprehensive care package of formal and informal care. Only one person described her health status before her fall as not being good, and she was currently living in an assisted living retirement community. A small minority described their health status as being ‘not good’ or worse following their fall (n = 8, including Mrs V aged 81 years, who had previously reported good health), typified by two older people with deteriorating health trajectories marked by ill health, increased need and dependency (Quotes 15 and 16, Table 2).

Lifestyle, well-being and quality of life

 Reflecting on their life and activities before their fall a small minority of people (n = 6) described their lives as being good, as illustrated by Quotes 17 and 18 (Table 2). Only one person described their quality of life as (quite) good following their fall (Quote 19, Table 2). Two people described their quality of life as being good before their fall but their lives had changed following it (See Quote 20, Table 2). For one woman her quality of life was not good before or following the fall. A small minority of people described their life as not being good following their fall (n = 6) and for one person, both their quality of life and health status were no longer good following their fall, which appears to affirm the reliability and validity of their views and responses (S10).

Falls prevention 

Concerning the prevention of falls and future falls, some people did not know how they could be prevented and stated they did not know. They were a minority. Others who reflected on the cause of their fall reported that they take life more ‘slowly’ or would be ‘more careful’ in future (See Quotes 21 and 22, Table 2). Some individuals stated that they would no longer go outdoors, or only if accompanied, to prevent a further fall. A minority of people had personal body worn alarms that they could press for assistance should they fall (n = 3). Other prevention strategies involved the use of equipment with handrails (See quote 22, Table 2 from Mrs X), Zimmer frames and crutches being the more popular. Installing a stair lift was rare. Handrails fitted by social services were generally considered very useful. Going up and down stairs was difficult for some people and was an area of risk. Use of Zimmer frames was contentious, with some frames being too heavy and not used. Lighter frames, with wheels and a carry bag to help transport things were more popular as were trolleys for moving trays of food. Some people were embarrassed using a Zimmer frame, viewing it as sign of ‘old age’ and therefore ageist (Quote 23, Table 2). Mrs X aged 94 years also said ‘I’ve got a stick but I’m too proud to use it’. Other adaptive strategies comprised moving furniture, removing rugs, making everyday objects accessible and, in more than one location, going ‘bare footed’ or replacing old worn slippers. More extreme adaptations involved moving beds downstairs and furniture upstairs, initiated by their family or son without consultation and could be a source of distress (Quote 24, Table 2). One of these women did manage to have her bed returned upstairs by the time of the follow-up interview because this was her goal as her mobility improved. Families, sons and daughters were fearful of their parents falling and they often tried to be helpful by providing more care and assistance or advising their parent to stop doing things that put them at risk (Quote 25, Table 2). Only three people were referred in PCT 2 to the falls prevention clinic but only one had attended due to the others becoming poorly and their being unable to attend. None of the older people in PCT1 had been referred to the more established falls prevention clinic and this was situated in the northern sector of the PCT not readily accessible to those in the south. Only a minority of people had access to physiotherapy and this was restricted to a limited time at home, at the day centre or as part of intermediate care. Two people were considering moving into a care home as their care needs increased, although for some who had moved into sheltered accommodation, this did not necessarily prevent falls occurring or being able to call for help, as a woman who relinquished her body worn alarm found out to her cost

Views on services

 A minority of people (n = 8) expressed views about the services or care they had received as a consequence of their falls, half of which were positive and half were negative. Intermediate care facilities provided by nursing homes either as a ‘step-up’ facility or ‘step-down’ facility, were favoured by the people who had used them, as evidenced by Mrs B aged 86 years who had a fractured femur (Quote 26, Table 2). A focus of intermediate care is providing people with Care Closer to Home (DH 2006) and this would appear to be what people wanted as indicated by the statement from Mrs L aged 84 years, who attended a local residential home for respite and day care but who, as a consequence of her fall, had to be admitted to a hospital some distance away from her home as opposed to her local community hospital (Quote 27, Table 2).

The geographical aspect of urban vs. rural settings, equity and access to services and health professionals, was also a concern as voiced by several people (Quotes 28 and 29, Table 2). Older people at risk of falls and living in rural or isolated settings are vulnerable and provision should be made to ensure their welfare and well-being.

Discussion 

The majority of people interviewed were living in their own homes, were women, nearly half of the participants lived alone and with the majority of falls happening indoors. Those interviewed in PCT1 were older, had a higher mean age and more injurious falls than those in PCT2, which may reflect how the samples were recruited but also that falls and injury increase with age (Robbins et al. 1989, O’Loughlin et al. 1993, Todd & Skelton 2004). In PCT 2, the majority of falls were not injurious and went unreported to formal health services and is in keeping with existing evidence (Age Concern 1997).

Co-morbidity and chronic disease

 Common risk factors for falls include living alone, (Wickham et al. 1989) co-morbidity and chronic disease (Nevitt et al. 1989, Luukinen et al. 1995, Tinetti et al. 1996, Lawlor et al. 2003), sedentary lifestyle (Skelton 2001), impaired mobility (American Geriatrics Society, British Geriatrics Society and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2001), poly-pharmacy and impaired cognition (Campbell et al. 1989, Koski et al. 1996, 1998). Deficiencies in nutrition (Tinetti et al. 1996) and visual impairment (Jack et al. 1995, Ivers et al. 1998) are also risk factors and feature as part of risk assessment for prevention. In our study, most participants had at least one chronic long-term condition and few having multiple chronic conditions. The frequency of falls in those interviewed in PCT2 appeared to have increased with recent days and weeks, which may indicate deterioration in their medical condition. Falls were attributed to a direct consequence of impaired vision by several participants. These findings are in keeping with the existing evidence. Paramedics in PCT 2 appeared to screen for use of alcohol in older people they attended that had fallen and did so by the use of humour. Other participants also mentioned alcohol and falls. Alcohol use as part of explicit risk assessment and prevention of falls strategies is not overtly mentioned (Todd & Skelton 2004) although it is suggested it should be considered when working with older people as part of broader public health programmes (Cryer 1998, Kempton et al. 2000). While the samples in this study were convenience and cannot be claimed to be representative of the general older population who fall, it would appear that drug and alcohol use and their implications in ageing and older people is a warranted area of enquiry (McInnes & Powell 1994, Phillips & Katz 2001, Gilhooly 2005, Beynon et al. 2007) and certainly needs consideration with falls (Lally et al. 2007).

Health status, lifestyle and quality of life before and after falls A small minority of people described their health status and quality of life as being good before their fall. Following their fall, a small minority reported a decline in their health status and quality of life and their fall seemed a key event that marked a deteriorating illness trajectory, ill health, increased need and dependency. Only a few people at follow-up described their health status as improving following their fall and their quality of life as quite good. These people were focused on their activities of daily living and re-ablement. People’s perception of their health status, lifestyle and quality of life are important factors to be considered with older people who fall and inform the basis of their care plan. 

Formal and informal care 

Older people relied on informal networks before and after their fall, with informal networks similar to the typology described by Wenger (1989). There was an increased reliance on formal services following their fall, which denotes their change in health status and consequences of their fall impacting their ability to undertake activities of daily living and remain independent. Older people who fall are more likely to fall again within the year (O’Loughlin et al. 1993), more likely to sustain injuries, reducing mobility and independence (Tinetti & Speechley 1989, Freeman et al. 2002). Twenty percent of frequent fallers followed up at one year are more likely to be hospitalised, in long term care or have died (Lord et al. 1992). This denotes a need for formal services to work with informal networks and older people to tailor individualised care and the prevention of future falls and strategies.

Falls prevention

 People adopted a variety of strategies to prevent a further fall comprising mainly lifestyle and extrinsic factors such as, ‘taking life more slowly’, restricting outdoor activities despite most falls having occurred indoors or having someone with them, moving furniture and use of equipment such as grab rails, body worn alarms, Zimmer frames or sticks. Only two people considered moving into a care home while, for one woman, it was a reality due to her specific circumstances. Only a minority of people had access to time limited physiotherapy and very few were referred to a falls prevention clinic and programme. Falls prevention is a major health policy in developed countries (Todd & Skelton 2004) and yet our findings indicate that prevention strategies and programmes were not targeted or widely accessible to older people living in the community. Systematic reviews of randomised controlled trials of interventions for the prevention of falls have concluded multi-factorial risk assessment and individualised home based exercises targeted to those most at risk are effective (Gillespie et al. 2003, Chang et al. 2004). However, community based group exercise interventions have not been found to reduce the occurrence of falls although other health and social benefits may accrue (Gillespie et al. 2003) and environmental modification alone does not reduce the risk of falling (Chang et al. 2004). Gillespie et al. (2003) concluded that home assessment in people with a history of falls within the previous year may be effective but more research is required. Both systematic reviews conclude that education alone is not effective. Risk assessment and prevention initiatives for older people in specific settings, such as hospital (Oliver et al. 2004), care homes (Oliver & Masud 2004) or community (Gillespie et al. 2003, Chang et al. 2004) are warranted. 

Views on services

 Intermediate care and Care Closer to Home featured favourably with those who had experience of it. A variety of intermediate care services with varying evidence of effectiveness are available targeted at different groups of people with medical conditions and health and social care needs (Young 2002, Roe & Beech 2005). Older people who have experienced falls are frequent users of intermediate care, with ‘step up’ facilities in care homes preventing hospital admission (Roe et al. 2003), which was also the case for some people in this study. Generally, people were positive about the formal care and services they received as a consequence of their fall and of the invaluable support provided by family, friends and neighbours. A concern raised was the geographical aspect of accessing formal services when older people lived in rural settings and were at risk of falls. Older people in these settings had difficulty in accessing services and were vulnerable. They often relied on informal networks ‘on each other to look out for each other’. Formal services and care specific to falls and older people need to take account not only of their appropriateness but also equitable access particularly for those living in more rural locations

Limitations of the study

 The findings of qualitative research cannot be generalised to all populations; however, the findings contribute to a developing body of research exploring the consequence of falls from individuals’ and their families’ perspectives. Interviewing older people having their first-ever fall would have been ideal, although identifying them proved difficult as not all people who fall, particularly those without an injurious fall, come to the attention of healthcare professionals (Age Concern 1997). A pragmatic approach was adopted and convenience samples of people who had fallen within the previous 10 days were recruited. Recruitment location related to findings on severity and consequences of falls and age and explains the differences between PCT 1 and PCT 2. These samples have provided an opportunity to explore the consequences of falls across age cohorts in later life.

Conclusion 

The findings of our study confirm existing evidence that falls occur in older people and are associated with chronic illness, deteriorating co-morbidity, increasing age and more injurious consequences in older ‘old’ people. They have deleterious impacts on older people’s lifestyle, quality of life and health status. Non-injurious falls in older people tend to go un-noted by formal services. Local informal care and support networks are as important as formal care and prevention programmes. Equitable access to health services in relation to falls is limited by where older people reside with those in rural communities potentially more isolated. Falls prevention initiatives should work with local communities and agencies to ensure equitable access and provision of information, resource, services and care.

Acknowledgements 

This study was funded by an internal grant from The Medical School, Keele University and data collected was included in an MA Gerontology awarded to Fiona Howell and an MSc in Geriatric Medicine awarded to Konstantinos Riniotis from Keele University. Thank you to the staff of the primary care trusts that facilitated this study and to the older people who agreed to be interviewed. Thank you also to Sue Humphries for transcribing the tapes and Frank Ward, Age Concern Chester for his advice.

Contributions

 Study design: BR, RB, BO, PC; data collection and analysis: BR, FH, KR and manuscript preparation: BR, FH, KR, RB, BO, PC.

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Lee JSW, Kowk T, Leung PC & Woo J (2006) Medical illnesses are more important than medications as risk factors of falls in older community dwellers? A cross-sectional study. Age and Ageing 35, 246–251. Lord SR, McLean D & Strathers G (1992) Physiological factors for falls among lderly persons living in the community. New England Journal of Medicine 319, 1701–1707. Luukinen H, Koski K, Hitunene L & Kiveal SK (1994) Incidence rate of falls in an aged population in Northern Finland. Journal of Clinical Epidemiology 47, 8. Luukinen H, Koski K, Laippala P & Kivela SL (1995) Predictors for recurrent falls among the home dwelling elderly. Scandinavian Journal of Primary Health Care 13, 294–299. McInnes E & Powell J (1994) Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed? British Medical Journal 308, 444–446. Nevitt MC, Cummings SRM, Kidd S & Black D (1989) Risk factors for recurrent nonsyncopal falls. A prospective study. Journal of the American Medical Association 261, 2663–2668. NICE (2004) The Assessment and Prevention of Falls in Older People. Guideline 021. National Institute for Health and Clinical Excellence, London. Available at: http://www.nice.org.uk/CG021. (accessed 5 November 2007). O’Loughlin JL, Robitaille Y, Boivin JF & Suissa S (1993) Incidence of risk factors for falls and injurious falls among community-dwelling elderly. American Journal of Epidemiology 137, 342–354. Oliver D & Masud T (2004) Preventing falls and injuries in care homes. Age and Ageing 33, 532–535. Oliver D, Daly F, Martin C & McMurdo ME (2004) Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age and Ageing 33, 122–130. Phillips P & Katz A (2001) Substance misuse in older adults: an emerging policy priority. NT Research 6, 898–905. Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D & Fine G (1989) Predictors of falls among elderly people. Results of two population based studies. Archives of Internal Medicine 149, 1628–1633. Roe B & Beech R (2005) Intermediate and Continuing Care: Policy and Practice. Blackwell Publishing, Oxford. Roe B, Daly S, Shenton G & Lochhead Y (2003) Development and evaluation of intermediate care. Journal of Clinical Nursing 12, 341–350. Skelton DA (2001) Effects of physical activity on postural stability. Age and Ageing 20, 33–39. Tinetti ME & Speechley M (1989) Prevention of falls among the elderly. New England Journal of Medicine 320, 1055– 1059. Tinetti M, Doucette J, Claus E & Marottoli R (1996) Risk factors for serious injury during falls by older persons in the community. Journal of the American Geriatrics Society 43, 1214–1221. Tinetti ME, Speechley M & Ginter SF (1998) Risk factors for falls among elderly persons living in the community. New England Journal of Medicine 319, 1701–1707. Todd C & Skelton D (2004) What are the Main Risk Factors for Falls Among Older People and What are the Most Effective Interventions to Prevent Falls. World Health Organisation Regional Office for Europe, Copenhagen. Health Evidence Network (HEN) Report Available at: (http://www.euro.who.int/document/E82552.pdf (accessed 30 November 2007). Wenger CG (1989) Support networks in old age: constructing a typology. In Growing Old in the Twentieth Century, (Jeffreys M ed). Routledge, London, pp. 266–285. Wickham C, Cooper C, Margetts BM & Barker DJ (1989) Muscle strength, activity, housing and the risk of falls in elderly people. Age and Ageing 18, 47–51. Yasamura S, Haga H, Nagai H, Suzuli T, Amanho H & Shibata H (1994) Rate of falls and correlates among elderly people living in urban community Japan. Age and Ageing 23, 323–327. Young J (2002) The evidence base for intermediate care. Clinics in geriatric medicine 32, 11–14.

Table 1 

Characteristics of participants according to primary care trust Participants PCT 1 n = 12 PCT 2 n = 15 Female 12 10 Male 0 5 Mean age 87 years 81 years Age range 65–98 years 71–94 years Type of interview Initial 12 15 Follow-up 8 10 Residence Own home 8 14 Sheltered accommodation 4 0 Retirement community 0 1 Type of fall First ever 3 2 Repeat 9 13 Location of fall Indoors 10 13 Outdoors 2 2 Time of fall Morning 5 7 Afternoon 4 3 Night time 1 4 Alone when fell 6 9 Injuries sustained Fractures 12 1 Soft tissue 0 14

Table 2

 Data table of direct quotes according to themes Quote, participant and theme Direct quote Co-morbidity and alcohol Quote 1 Mrs R, aged 82 years ‘Well these two paramedics came and I didn’t get to know their name at all but one of them says what have you done like and then he had a bit of a joke, he says you’ll have learn take more water with it, you know like they do. And I said yea. So he had me get… held me hand while I got up and that and he says well we’ll take you up the accident unit by all means he said but do you want sit up there 4 hours he said because he said you’ve just really give yourself a good shaking up’. Quote 2 Mrs S, aged 78 years ‘Cause a lot of people drink and I don’t drink I said, only tea. I didn’t know if he was referring to other things but I don’t ‘cause I know a lot of silent drinkers round here. I know one that keeps falling all the time, breaking her arms and doing things. However, I only drink tea. I never go in pubs. I’ve never been in pubs. We weren’t allowed to when we were brought up’. Quote 3 Mr N, aged 83 years, fractured wrist ‘My wife did her usual ‘‘you have drunk too much’’, which incidentally was not true I’d only drunk half a bottle of wine. She rang for the paramedics who came. He got me on my feet, got me to bed. Very, very charmingly I might add’. Quote 4 Mr O, aged 79 years ‘But I mean when I went to Hanley, I was wandering up there one wednesday morning, I come out, collapsed in the town square. I had help there then come back home in a taxi. Oh some of them (people) are all right. Some people think you’re drunk and there you are. Well that’s the impression I get. They see you fall on the floor and ‘‘oh he’s bloody drunk’’ you know and that’s it It’s a great shame. That is the modern way of life that is’. Quote 5 Mrs X, aged 94 years ‘Betty (daughter) was in and he (GP) says to her does your mother drink? And she says, no not as I know of why? What’s the matter? He says well there’s alcohol in her blood. But you know what I have alcohol… I used to, I don’t have it now… I used to have a little drop … one spoonful of whiskey in my porridge in a morning. Yea it was lovely that was. It used to make it lovely. And about a couple of inches of sherry a night. And that’s all I used to have. And yet I’d got alcohol in my blood. No I don’t drink any more. I still have a drop of sherry at night. I don’t see why I shouldn’t at my age. It helps me sleep you see’. Care and support networks Quote 6 Mrs G, aged 90 years ‘I can’t go home because there’s nobody there to look after me. I know I can’t. I know that I’ve got to stay here and as long as I live. I know I can’t (go home) …I’ve lost my husband and there’s nobody there (Mrs G cries). Old bones don’t take kindly to breakages. I just… like I said I’ve got to be here. Because I’d like to go home. I’d be at home. Just living, living day by day’. Quote 7 Mrs X, aged 94 years ‘And my neighbour, my neighbour from across there (helped her when she fell on her path). Well they ‘re friends really, aren’t they, they are not just neighbours’. Quote 8 Mrs R, aged 72 years ‘And OJ but she is, she’s unknown good. She’s a neighbour from heaven she really is. She came and she says, what have you done? And I said and she said… so she made me a cup of tea’. Quote 9 Mrs K, aged 91 years, with a fractured pubic ramus ‘My son comes ‘cause he doesn’t live too far away and he comes nearly every day and does my shopping and all that and the banking and everything like that ‘cause I’m 91 years old’. Quote 10 Daughter of Mrs Q, aged 81 years ‘I think we’re more worried about you because when she falls it tends to be sort of you know when she’s unsteady on her feet and you know and if we’re not about, that’s the thing if we’re not about, we keep saying you know press the thing (personal body worn alarm)’. Quote 11 Mrs T, aged 78 years ‘Oh of course, we’re close, but there are a lot of new people moving in now. You know all our children grew up together, we moved in new houses and that you know altogether so we’ve always been friendly with each other. But now I mean they pass here now, you don’t know them’. Quote 12 Mr T, aged 71 years who lives with his wife ‘And a lot of them have died. Since we’ve finished work it’s marvellous how many have died, you wouldn’t believe it’. Quote 13 Mr Z, aged 76 years living in a rural community ‘the chap next door, he’s 80 odd you know, he’s been in hospital, him there, I just whip round… you know I keep and eye on him you know. But that’s how we’ve been all our life. We’ve just looked after one another…’ Health Status Quote 14 Mrs X, aged 91 years ‘I’ve outlived everybody in my family. I don’t know why. Why’s God chosen me to let me live this long? I don’t know why I’m still here. It must be (good health). I don’t seem ill, I don’t feel ill at all. I mean I’ve got a pain (because of her fall) I know that but it’s not an illness is it? And hopefully that’ll go’

Table 2 (Continued)

 Quote, participant and theme Direct quote Quote 15 Mrs D, aged 85 years, living alone, sustained a fractured pubic ramus ‘Well I hope I get better. I’ve never really thought about not getting better. Well gradually going worse actually. Yes. I’ve never been out except when I’ve been to the hospital or…?’ Quote 16 Mrs D, aged 85 years, living alone, sustained a fractured pubic ramus ‘Well I can’t do anything much. I can get upstairs with a nurse behind me and one stick and it hurts. The same coming down. The nurse is in front and erm…I sit in this blessed thing (chair) until… they come at night, put me to bed. There is a toilet through there, I can manage to get there now but oh it was painful at first, it was unbearable. Well, I’ve got that used to giving into things that er… I’ve given in sort of thing. I was going to The County Show. I don’t think I shall be able to go now I can’t see that I shall be able to go, well I’m pretty sure I shan’t now. I can get about but it hurts. Oh I’ve got to use the 2 crutches now’. Lifestyle, well-being and quality of Life Quote 17 Mrs A, aged 89 years ‘My life was perfectly all right. I was sculpting, painting and…writing that sort of thing, which is my way of life and I went on with it. You see I was perfectly all right and then suddenly this fall, which put a stop to it all. I try to paint or write and the hands won’t do it. They won’t work. I… I can’t concentrate on what I’m doing. I have no concentration whatever. And I was so good at it you see, I’d spent all my life doing the painting, drawing etc. It’s knocked it on the head. It’s finished it’. Quote 18 Mrs C, Aged 98 years living in sheltered accommodation ‘(Life) It was very good really because…I’ve got a very nice flat. Well it was just very routine really. We go for lunch four days a week. We get our own breakfast and we get our own tea and then at the weekend we get our own meals but I sometimes go to my daughter’s at the weekend and have the weekend with them and er… we can go down, we go down in the lounge and sit with all the other people talking. I’ve had a very good life. I’ve always liked to be where there’s music. Because, I like music and singing and I’ve done a lot of dancing and I’ve been in drama. I’ve had a very… with the Mothers’ Union and I was in the WI the Women’s Institute and I’ve had a good life. Well I don’t do any much now only just walk round the corridors and I have one or two very good friends in there that we just go and have a little chat with each other and that’s about all now’. Quote 19 Mrs E, aged 92 years ‘(Life) It’s been quite… not bad at all. I’ve managed. I manage. I manage very well. If I can’t do anything or I haven’t got it done and Mrs. Ball comes down to see me she’ll do it for me. I’m lucky like but she… it makes me put a bit of a spurt on see ‘cause I don’t want her to come do all my jobs all the time but she’s very good to me. She’s been marvellous to me really. I do value her friendship. Oh it’s slowed me down granted, I can’t go… I can’t go like I used to go by any means’. Quote 20 Mrs J, aged 76 years ‘No not active but a nice daily life. I could do a few things for myself. I’m very independent if I can be but I’ll have to rely on people more now yes but before if there was nobody about I used to just get it slowly, go along slowly with it, but now I know I will have to rely on somebody…’ ‘Well it’s changed a little bit of course, it’s made me slow down and I have to rely on my daughter for a lot of things…’ Falls prevention Quote 21 Mrs W, aged 94 years ‘Well I must say I must take a bit more care and when I am getting up I think to myself I musn’t go too near there (The Fire) in case I fall again. So it must have made me more careful’. Quote 22 Mrs X, aged 94 years ‘Well I’m just very very careful when I go out there now, I catch hold of the side door before I put my foot down. And do you know though love, I’ve got two rails on my stairs, social services put me another rail on my stairs and I can go up them stairs and come down like I don’t know what. I can do that better than walking. Isn’t it strange’. Quote 23 Mrs J, aged 76 years, fractured left neck of femur ‘Now I don’t bother but at first I felt very guilty. Well there’s other people… there’s a lady up the top of the road here, she’s 94 and she still walks down the town and I feel embarrassed with that (Zimmer). So yea, I do, because I’ve always been independent, I feel embarrassed now when I’ve got to use anything like that, yea. I couldn’t accept it at first to be honest but… Same with the ladies that come in a morning to get me up and rub my joints, I didn’t like it at first but now… they’re nice, very, very nice and I’ve accepted it, ….But that’s me, I’m independent, yes’. Quote 24 Mrs V, aged 81 years ‘I haven’t got (to) go upstairs… I wouldn’t dare go upstairs now on my own. I would be frightened of falling. And I’ve been warned as I haven’t got (to) go up. (by) My son. They’ve taken all my stuff up there, my table and chairs. (So you gave them permission to do that?) Well it was the same difference if I hadn’t...’

Table 2 (Continued)

 Quote, participant and theme Direct quote Quote 25 Mrs W’s, aged 94 years, daughter ‘This is what we’ve had to do. It’s to think and put things in their place. Simple little things that she knows where things are you know? I mean we’ve learnt that ourselves. You said about moving the furniture about, which we have. We moved the kitchen… I mean that first time I shall always remember David saying, you want teabags not fresh tea. Silly simple little things like that you see. And from then on this is what we’ve had to do and think about but we’ve thought about things that’ll make things quicker for you and easier’. Views on services Quote 26 Mrs B, aged 86 years, fractured femur ‘I was very, very well looked after. I was very well looked (after) in Cherry House and then I had three weeks of carers, two weeks from Cherry House and they came in four times a day which was excellent and then I had another week on the Social Services and then I decided to finish then and make my own arrangements after that. So I had three weeks. I had two weeks in hospital, two weeks in Cherry House and three weeks carers, which I though was very good’. Quote 27 Mrs L, aged 84 years ‘Well the only thing as I think, this place is too far from where we live and we could have done with… because we’ve got a hospital near home and all that. I think that something… myself I think something could have been done nearer home. While I’m telling you about the Infirmary, they could have taken me there’. Quote 28 Mrs W, aged 94 years, daughter ‘No, nobody did. …(visit by health professionals) I only said to my husband the other day, the doctor never comes, the nurse never comes, no-one visits unless we send for them. Now ….I think they ought to quite honestly’. Quote 29 Mr Z, aged 76 years ‘You’re forgotten out here you know. Nobody ever comes out and visit or anything like that out here. You know these places you know (rural). Nobody really… in my opinion I think there ought to be a register in every little council places or towns or whatever…A register of people, elderly people over a certain say certain age or something like that. So that somebody from time to time…… should go an pay a visit…… to see if them… if they’re there you know. I mean the chap next door, he’s 80 odd you know, he’s been in hospital, him there, I just whip round… you know I keep and eye on him you know. But that’s how we’ve been all our life. We’ve just looked after one another’.

Table 3 

Informal and formal care and support networks according to primary care trust Care and support network Before fall PCT 1 PCT2 After fall PCT 1 PCT 2 Independent 1 3 0 2 Informal family (local) 2 1 0 0 Informal family, Friends, neighbours (local) 32 21 Informal friends, neighbours (local) 30 20 Informal family and formal services 38 37 Formal services only 0 0 4 0

Summary

For each source listed, you will begin with a summary of the information you found in that specific source. The summary section gives your reader an overview of the important information from that source. Remember that you are focusing on a source's method and results, not paraphrasing the article's argument or evidence.

The questions below can help you produce an appropriate, scholarly summary:

  • What is the topic of the source?
  • What actions did the author perform within the study and why?
  • What were the methods of the author?
  • What was the theoretical basis for the study?
  • What were the conclusions of the study?

Remember, a summary should be similar to an abstract of a source and written in past tense (e.g. "The authors found that…" or "The studies showed…"), but it should not be the source's abstract. Each summary should be written in your own words.

Critique/Analysis

After each summary, your annotations should include a critique or analysis of each source. In this section, you will want to focus on the strengths of the article or the study (the things that would make your reader want to read this source), but do not be afraid to address any deficiencies or areas that need improvement. The idea of a critique is that you act as a critic—addressing both the good and the bad.

In your critique/analysis, you will want to answer some or all of the following questions (taken from the KAM Guidebook):

  • Was the research question well framed and significant?
  • How well did the authors relate the research question to the existing body of knowledge?
  • Did the article make an original contribution to the existing body of knowledge?
  • Was the theoretical framework for the study adequate and appropriate?
  • Has the researcher communicated clearly and fully?
  • Was the research method appropriate?
  • Is there a better way to find answers to the research question?
  • Was the sample size sufficient?
  • Were there adequate controls for researcher bias?
  • Is the research replicable?
  • What were the limitations in this study?
  • How generalizable are the findings?
  • Are the conclusions justified by the results?
  • Did the writer take into account differing social and cultural contexts?

Application

Finally, the last part of each annotation should justify the source's use and address how the source might fit into your own research. Consider a few questions:

  • How is this source different than others in the same field or on the same topic?
  • How does this source inform your future research?
  • Does this article fill a gap in the literature?
  • How would you be able to apply this method to your area of focus or project?
  • Is the article universal?

Remember, annotated bibliographies do not use personal pronouns, so be sure to avoid using I, you, me, my, our, we, and us.

Example

The example annotation below includes the citation, a summary in the first paragraph, the critique/analysis in the second paragraph, and the application in the third paragraph.

Gathman, A. C., & Nessan, C. L. (1997). Fowler's stages of faith development in an honors science-and-religion seminar. Zygon,32(3), 407–414. Retrieved from http://www.zygonjournal.org/

The authors described the construction and rationale of an honors course in science and religion that was pedagogically based on Lawson's learning cycle model. In Lawson's model, the student writes a short paper on a subject before a presentation of the material and then writes a longer paper reevaluating and supporting his or her views. Using content analysis, the authors compared the students' answers in the first and second essays, evaluating them based on Fowler's stages of development. The authors presented examples of student writing with their analysis of the students' faith stages. The results demonstrated development in stages 2 through 5.

The authors made no mention of how to support spiritual development in the course. There was no correlation between grades and level of faith development. Instead, they were interested in the interface between religion and science, teaching material on ways of knowing, creation myths, evolutionary theory, and ethics. They exposed students to Fowler's ideas but did not relate the faith development theory to student work in the classroom. There appears to have been no effort to modify the course content based on the predominant stage of development, and it is probably a credit to their teaching that they were able to conduct the course with such diversity in student faith development. However, since Fowler's work is based largely within a Western Christian setting, some attention to differences in faith among class members would have been a useful addition to the study. 

Fowler's work would seem to lend itself to research of this sort, but this model is the only example found in recent literature. This study demonstrates the best use of the model, which is assessment. While the theory claimed high predictive ability, the change process that the authors chronicled is so slow and idiosyncratic that it would be difficult to design and implement research that had as its goal measurement of moveme

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