further exploring hip protector use

Australasian Journal on Ageing Vol 25 No 4 December 2006 215ndash217

215

copy 2006 The AuthorsJournal compilation copy 2006 COTA

DOI 101111j1741-6612200600190x

Blackwell Publishing Asia

Brief Report

Further exploring hip protector use

Further exploring hip protector use

Karen Tavener-Smith

Division of Population Health and Planning South Eastern Sydney and Illawarra Health Wollongong New South Wales Australia

Guy De Vet

Coledale District Hospital Coledale New South Wales Australia

Objective

To explore hip protector adherence in high-risk older people

Methods

In-depth interviews were conducted with 14 older people (andor their carers) discharged from hospital with hip protectors Four outpatients were recruited to supplement numbers Thematic analysis was carried out on the interview data

Results

Hip protector use largely paralleled daily dressing routines this contributed to periods of disuse and partial adherence Another factor in abandoning hip protector use was a fatalistic view of an end of life stage where injury prevention was not actively sought Committed carers who demonstrated understanding and support were vital in encouraging ongoing use

Conclusion

Daily routines of a lifetime reluctance to change and a readiness to endure the potential risk of hip fracture discouraged use of hip protectors Family and carer support was vital for continuation These findings can assist with strategies to improve adherence

Key words

adherence carer support community hip protectors

Introduction

Current research has confirmed that external hip protector usecan prevent up to half the number of potential hip fracturesbut tolerability and consistent usage remain ongoing issues[12] To be effective hip protectors must be worn at all times[34] Issues such as comfort cost and difficulty in adjustinghave all been reported as reasons of non-adherence [5ndash7]Coledale District Hospital in southern New South WalesAustralia established a comprehensive programme for the useof hip protectors Patients used hip protectors during admissionwith many agreeing to continue use on discharge Outpatientswere also prescribed hip protectors Full adherence constitutedwearing the protectors for a 24-h period except when bathing[8] This study sought to further explore hip protector adherencein high-risk older people

Method

Semistructured in-depth interviews were conducted withpatients 65 years and older who had been discharged over a

16-month period during 2001ndash2002 An experienced occu-pational therapist conducted all interviews using a questionguide which included details on health activities of dailyliving hip protectors and self-reported adherence Thematicanalysis was conducted on recorded interview notes supple-mented by details from the tape recordings Brief summarieswere made for each participant under category headings Thestudy was approved by the Human Research Ethics Committeeof the University of Wollongong

Results

Of the 21 potential study participants seven were unavailablefor interview as five had died and two had left the region Theremaining 14 agreed to an interview with four outpatientssupplementing numbers Nine participants were interviewedalone whereas seven were interviewed with a family memberFamily members were the main source of information for theremaining two participants as their relative had sufferedcognitive deterioration

Participants were largely frail older women Only one malewas interviewed The mean age of participants was 837 yearsOver half were living in their own home (

n

= 10) with theremainder in residential hostel accommodation (

n

= 4) andnursing home (

n

= 4) The majority of inpatients had a longstay in hospital undergoing rehabilitation (average of 328days) Seven participants were interviewed within the first3 months of discharge This included the four outpatientswho were interviewed around 2 months after dischargeThree participants were interviewed between 3 to 12 monthsand eight participants a year after discharge

Most participants reported multiple health problems with27 suffering a previous stroke 38 osteoarthritis and 38having some degree of dementia or Alzheimerrsquos diseaseSix participants had a previous fracture of the hip and three-quarters had a history of two or more falls in the preceding12 months About half were living independently with minimalassistance whereas the remainder were frail and requiredassistance with daily living tasks

The majority of participants and their family carers reporteda good understanding of hip protector benefits in preventingfracture Many credited their structured patient programmefor this Family members who participated spoke very positivelyof the benefits

Nine participants reported that they were no longer wearinghip protectors while five (including two outpatients) reportedwearing them for lsquosome of the timersquo during the day Only fourwere fully adherent and all had been previous inpatients Of

Correspondence to Ms Karen Tavener-Smith South Eastern Sydney and Illawarra Health Email karentavenersmithsesiahshealthnswgovau

aja_190fm Page 215 Wednesday October 18 2006 1115 AM

T a v e n e r - S m i t h K D e V e t G

216

Australasian Journal on Ageing Vol 25 No 4 December 2006 215ndash217copy 2006 The Authors

Journal compilation copy 2006 COTA

the five participants who were partially adherent three tendedto wear hip protectors for the majority of day but usually onlyafter showering and dressing Whereas two wore hip protectorsonly during outdoor activities in the garden or the shopsbecause they believed these environments posed a greater riskto safety than indoors No participants with previous hipfracture were wearing hip protectors

Nine participants suffered from urinary incontinence and haddone so for some time and of these five were no longer wearinghip protectors The remaining four received maximumassistance with personal care The majority of non-wearershad ceased using hip protectors within 4ndash6 weeks of dischargeMost reported that they had first stopped wearing hip protectorsat night Two hostel residents reported busy staff with limitedtime as a reason for discontinuing use

The four fully adherent participants had two factors incommon All had very committed family members monitoringand encouraging use and they also received a high level ofsupport with activities of daily living Two were in nursinghomes one in hostel accommodation and the other received amaximum of care at home

A number of common hip protector adherence themeswere identified The central themes are illustrated in Table 1Consideration was also given to issues different from themain themes

The study found that the inpatient opportunity to learn aboutand trial hip protectors without obligation enabled older peo-

ple to make an informed choice on discharge The peer supportof other lsquohip protectorrsquo inpatients on the ward was raised as astrong motivator for adherence

Discussion

This qualitative study has expanded on a number of themesthat contribute to a deeper understanding of hip protectoradherence The most prevalent theme was that hip protectorswere seen as a lsquogarment of clothingrsquo and were worn as it fittedinto the daily routine of getting dressed and undressed Partici-pants donned their hip protectors when they dressed followinga shower even though this meant unprotected hours duringbreakfast and tidying up the house Hip protectors were notworn at night General discomfort associated in part with notusually wearing lsquounderwearrsquo at night and restrictions withnight toileting were reasons given by the participants Therewas reluctance to change the daily routines of a lifetime to usehip protectors as prescribed

Some older people had made a clear choice to no longer wearhip protectors They related a philosophical view about theirlife stage and chose to risk hip fracture rather than persist withthe onerous task of wearing hip protectors In general theseparticipants were frail elderly people who were managingwith minimal supports and understood the benefits of hipprotectors They discussed knowing the risks and the potentialof loss of independence but were fatalistic This is dissimilarto findings by Salkeld et al [9] where the gravity of falling andhip fracture was dominant in the minds of older women Thefact that none of the participants with previous hip fracturecontinued with hip protector use added to this notion

Table 1 Quotes illustrating emerging themes on adherence

Issues Selected quotes

Patterns of usage parallel daily personal care routines

lsquoI have me breakfast first and take me tablets wash up clean up take out rubbish and put everything in the bins and then clean up the kitchen nothing much to do and then have me shower and get dressed and put me hip protectors on rsquo ndash 83-year-old lady very independent lives alonelsquoI donrsquot feel I need to wear them all the time I usually put them on after I have had my showerrsquo ndash 85-year-old lady living with husband at home has personal care support

Carer support is vital lsquo it sort of just fizzled out at first I wore them but gradually no one mentioned them and they were left in the cupboard The staff did not encourage me to wear themrsquo ndash 83-year-old lady in hostel care lsquoI think they are a wonderful idea give you confidence they say they workrsquo ndash daughter of a 92-year-old lady in nursing home lsquoI am very keen for my husband to wear themrsquo ndash wife of 73-year-old man living at home

Fatalistic about life stage lsquoMy health is good Irsquom very careful does not matter at my agersquo ndash 90-year-old lady living at homelsquoThey were comfortable but I stopped wearing them didnrsquot feel I needed themrsquo ndash 88-year-old lady in hostel

Physical frailty makes usage difficult lsquoI found them very difficult to put on I couldnrsquot get them up I did manage to push them down to get them off this is the main issue with mersquo ndash 83-year-old lady living in hostel carelsquoI first stopped wearing hip protectors at night because I could not get them off when using the commodersquo ndash 81-year-old lady in hostel care

Physical discomfort contributes to disuse

lsquoMum wore hip protectors for about a month after leaving hospital she then started to hate it saying lsquoI donrsquot need themrsquo they just started to annoy her the bulkiness of them found them a bit hard Like a shellrsquo ndash daughter of an 88-year-old lady now in nursing home carelsquoHip protectors felt very uncomfortable my thigh is sensitive to pain after operationrsquo ndash 90-year-old lady living at home

Hip protectors are not affordable lsquoFor the money I think they are dreadful I honestly do I canrsquot see the money in them I canrsquot for the life of me nearly $A100 for two pairs of pants and two hip thingsrsquo ndash 83-year-old lady lives alonelsquoToo expensive for people on the pension but I knew I had to do it out of the pensionrsquo ndash 92-year-old lady was in community but now in nursing home


F u r t h e r e x p l o r i n g h i p p r o t e c t o r u s e


217


Our small sample has highlighted the importance of carerrsquosunderstanding and support A family member very committedto hip protectors was common to all fully adherent partici-pants Relatives also reported the importance of supportingcare staff to maintain adherence Family support in terms ofmotivation to continue use and importantly to assist with costwas also evident in partial wearers

Our study has confirmed findings [110] that positive attitudesof staff towards hip protectors were required for continueduse in residential care Interestingly we found also that a per-ception of being too demanding of overburdened carers canimpact negatively on use Within the constraints of providingcare in residential settings managers and staff should seek toactively promote usage and be cautious not to convey themessage that assisting with hip protectors is an inconvenience

Other themes identified in the study are consistent with currenthip protector research and are illustrated by the quotes Brieflyparticipants particularly those with upper limb weakness spokeof the considerable physical effort in putting on hip protectorsand the resulting loss of daily living independence Incontinencewas exacerbated by hip protector usage Hip protector designbeing of a firm fit and the bulky feel of the shields impacted ondaily comfort All these factors contributed to disuse Costswere a concern to participants living solely on an aged pension

Our findings suggest that the comfort and familiarity oflifelong routines can be perceived to be threatened by theintroduction and added responsibility of a new device (hip pro-tectors) In this small sample there was a view that even withdesign improvements hip protectors may still be regarded aslsquoforeignrsquo and may not be readily accepted by older peopleWith current hip protector designs usage generally meantincreased dependence which was a powerful deterrent to con-tinued use in a population where independence is paramount

Our study has added some weight to adherence-improvingstrategies Educational approaches could focus on the dailyroutine lsquowindow periodsrsquo to convince older people of thenecessity for vigilance Health professionals need to activelyengage the support of family and carers in motivating olderpeople to maintain usage There are many factors that impacton continuing with hip protector use and it often takes only asingle factor to initiate disuse Peer support could be an influ-ential strategy in residential settings and even the community

Hip protectors should be one of a number of therapeutic choicesoffered to high-risk older people in preventing hip fractureHowever the investment of therapeutic time in pursuing use ofhip protectors by unmotivated older people is not warrantedThe challenge to motivate lies in hip protectors being very user

friendly complementary to the lifestyles of older people andavailable at reasonable cost so that the benefits outweigh anypersonal disadvantages

Acknowledgements

This research was supported by a grant from the formerIllawarra Health Thanks to the patients and their carers whoagreed to share their time and views with us Thanks to thededicated staff at Coledale Hospital Illawarra Health FallsWorking Group and all colleagues for their support throughall stages of this project particularly Lucia Apolloni SusanFurber and Tania Starr Thanks also to Dr I D Cameron forhis advice and encouragement

Key Points

bull Health professionals need to actively educate andengage the support of family and carers

bull Educational approaches could focus on the dailyroutine lsquowindow periodsrsquo to convince older peopleof the necessity for vigilance

bull Investment of therapeutic time in pursuing usage ofhip protectors by poorly motivated high-risk olderpeople is not warranted

References

1 Cameron ID Hip protectors prevent fractures but adherence is a problem

British Medical Journal

2002 324 375ndash3762 Parker MJ Gillespie LD Gillespie WJ

Hip protectors for preventinghip fractures in the elderly

The Cochrane Database of SystemicReviews 2004 Issue 3 Art NoCD0011255pub2DOI10100214651858CDOO1255pub2 Abstract available from URL httpwwwupdate-softwarecomAbstractsab001255htm

3 Lord SR Sherrington C Menz HB

Falls in Older People Risk Factors andStrategies for Prevention

Victoria Cambridge University 20014 Cameron ID Cumming RG Kurrle SE et al Randomised trial of hip protector

use by frail older women living in their own homes

Injury Prevention

2003 9 138ndash1415 McAughey JM McAdoo M Acceptability of hip protectors was 35 at six

months in the community

Letters to the editor


2002 324 1454 (June)6 Birks C Lockwood K Cameron I et al Hip protectors results of a user

survey

Australasian Journal on Ageing

1999 18 23ndash267 Cameron I Venman J et al Hip protectors in aged care facilities a ran-

domised trial of use by individual higher risk residents

Age and Ageing

2001 30 477ndash4818 Kurrle SE Cameron ID Quine S Cumming RG Adherence with hip

protectors a proposal for standardised definitions

Osteoporosis Inter-national

2004 15 1ndash49 Salkeld G Cameron ID Cumming RG Kurrle SE Quine S Quality of life

related to fear of falling and hip fracture in older women a time trade offstudy


2000 320 341ndash34610 Hubacher M Wettstein A Acceptance of hip protectors for hip fracture

prevention in nursing homes

Osteoporosis International

2001 12 794ndash799


T a v e n e r - S m i t h K D e V e t G

216

Australasian Journal on Ageing Vol 25 No 4 December 2006 215ndash217copy 2006 The Authors

Journal compilation copy 2006 COTA

the five participants who were partially adherent three tendedto wear hip protectors for the majority of day but usually onlyafter showering and dressing Whereas two wore hip protectorsonly during outdoor activities in the garden or the shopsbecause they believed these environments posed a greater riskto safety than indoors No participants with previous hipfracture were wearing hip protectors

Nine participants suffered from urinary incontinence and haddone so for some time and of these five were no longer wearinghip protectors The remaining four received maximumassistance with personal care The majority of non-wearershad ceased using hip protectors within 4ndash6 weeks of dischargeMost reported that they had first stopped wearing hip protectorsat night Two hostel residents reported busy staff with limitedtime as a reason for discontinuing use

The four fully adherent participants had two factors incommon All had very committed family members monitoringand encouraging use and they also received a high level ofsupport with activities of daily living Two were in nursinghomes one in hostel accommodation and the other received amaximum of care at home

A number of common hip protector adherence themeswere identified The central themes are illustrated in Table 1Consideration was also given to issues different from themain themes

The study found that the inpatient opportunity to learn aboutand trial hip protectors without obligation enabled older peo-

ple to make an informed choice on discharge The peer supportof other lsquohip protectorrsquo inpatients on the ward was raised as astrong motivator for adherence

Discussion

This qualitative study has expanded on a number of themesthat contribute to a deeper understanding of hip protectoradherence The most prevalent theme was that hip protectorswere seen as a lsquogarment of clothingrsquo and were worn as it fittedinto the daily routine of getting dressed and undressed Partici-pants donned their hip protectors when they dressed followinga shower even though this meant unprotected hours duringbreakfast and tidying up the house Hip protectors were notworn at night General discomfort associated in part with notusually wearing lsquounderwearrsquo at night and restrictions withnight toileting were reasons given by the participants Therewas reluctance to change the daily routines of a lifetime to usehip protectors as prescribed

Some older people had made a clear choice to no longer wearhip protectors They related a philosophical view about theirlife stage and chose to risk hip fracture rather than persist withthe onerous task of wearing hip protectors In general theseparticipants were frail elderly people who were managingwith minimal supports and understood the benefits of hipprotectors They discussed knowing the risks and the potentialof loss of independence but were fatalistic This is dissimilarto findings by Salkeld et al [9] where the gravity of falling andhip fracture was dominant in the minds of older women Thefact that none of the participants with previous hip fracturecontinued with hip protector use added to this notion

Table 1 Quotes illustrating emerging themes on adherence

Issues Selected quotes

Patterns of usage parallel daily personal care routines

lsquoI have me breakfast first and take me tablets wash up clean up take out rubbish and put everything in the bins and then clean up the kitchen nothing much to do and then have me shower and get dressed and put me hip protectors on rsquo ndash 83-year-old lady very independent lives alonelsquoI donrsquot feel I need to wear them all the time I usually put them on after I have had my showerrsquo ndash 85-year-old lady living with husband at home has personal care support

Carer support is vital lsquo it sort of just fizzled out at first I wore them but gradually no one mentioned them and they were left in the cupboard The staff did not encourage me to wear themrsquo ndash 83-year-old lady in hostel care lsquoI think they are a wonderful idea give you confidence they say they workrsquo ndash daughter of a 92-year-old lady in nursing home lsquoI am very keen for my husband to wear themrsquo ndash wife of 73-year-old man living at home

Fatalistic about life stage lsquoMy health is good Irsquom very careful does not matter at my agersquo ndash 90-year-old lady living at homelsquoThey were comfortable but I stopped wearing them didnrsquot feel I needed themrsquo ndash 88-year-old lady in hostel

Physical frailty makes usage difficult lsquoI found them very difficult to put on I couldnrsquot get them up I did manage to push them down to get them off this is the main issue with mersquo ndash 83-year-old lady living in hostel carelsquoI first stopped wearing hip protectors at night because I could not get them off when using the commodersquo ndash 81-year-old lady in hostel care

Physical discomfort contributes to disuse

lsquoMum wore hip protectors for about a month after leaving hospital she then started to hate it saying lsquoI donrsquot need themrsquo they just started to annoy her the bulkiness of them found them a bit hard Like a shellrsquo ndash daughter of an 88-year-old lady now in nursing home carelsquoHip protectors felt very uncomfortable my thigh is sensitive to pain after operationrsquo ndash 90-year-old lady living at home

Hip protectors are not affordable lsquoFor the money I think they are dreadful I honestly do I canrsquot see the money in them I canrsquot for the life of me nearly $A100 for two pairs of pants and two hip thingsrsquo ndash 83-year-old lady lives alonelsquoToo expensive for people on the pension but I knew I had to do it out of the pensionrsquo ndash 92-year-old lady was in community but now in nursing home

aja_190fm 16 Wednesday October 18 2006 1115 AM



217









Acknowledgements


Key Points




References










Injury Prevention






survey




Age and Ageing










2001 12 794ndash799




217









Acknowledgements


Key Points




References










Injury Prevention






survey




Age and Ageing










2001 12 794ndash799


further exploring hip protector use

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