Young HML1, Goodliffe S1, Eborall H2, Conroy S3, Greenwood S4, Singh S5, Smith A1, Burton J1
1University of Leicester and University Hospitals of Leicester NHS Trust, Dept of Infection, Immunity & Inflammation & John Walls Renal Unit, Leicester, United Kingdom, 2University of Leicester, Dept of Health Sciences,Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Leicester, United Kingdom, 3University of Leicester, Dept of Health Sciences, Leicester, United Kingdom, 4King’s College Hospital and Department of Renal Medicine, King’s College London, Dept of Physiotherapy and Renal Medicine, London, United Kingdom, 5University Hospitals of Leicester NHS Trust, Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Unit, Dept of Respiratory Medicine, Leicester, United Kingdom
Background: Frailty develops earlier and advances at an accelerated rate in patients receiving haemodialysis. Outcomes are poor and include increased risk of falls.
Purpose: The aim of this study was to explore the experiences of patients living with haemodialysis, frailty and falls. This information is crucial to enhancing patient safety and care, and to inform tailored interventions to improve outcomes.
Methods: A purposive sample of vulnerable or frail (Clinical Frailty Scale, CFS Score 4-7) adult haemodialysis patients who had experienced at least one fall within the last six months were recruited. In-depth, semi-structured qualitative interviews were digitally recorded, transcribed verbatim and analysed using a constant comparative approach.
Results: Eighteen participants (seven women; median age, 66 (IQR 60-75) years; time on HD 25 (IQR 15-75) months, eight white British, CCI 6 (IQR 5-7)) who had experienced a median of 3(IQR 2-4) falls within the last 6 months, were interviewed.
Exhaustion and weakness were the most prevalent characteristics of frailty, which led to 'slowing down' and low levels of physical activity, worsened by hospital admissions and inactivity during haemodialysis. Unintentional weight loss was more complex. Some participants reported gaining weight due to fluid overload, whilst others reported weight loss that was attributed to forgetting or choosing not to eat and difficulties with following a renal diet.
Participants described difficulty managing multiple conflicting health issues, struggling with functional activities, pain and loneliness. They attributed falls to multiple factors, particularly lower limb weakness. Balance dysfunction whilst walking outdoors, negotiating stairs and slopes, turning, and performing multiple tasks simultaneously, was also common.
Falls were rarely reported and often normalised. Those who did discuss their falls with the healthcare team likened their attempts to 'talking to the wall', with concerns being ignored or explained away. None had been referred to a falls clinic or prevention programme. Consequences of falling included; fracture, damage to their dialysis access, long-term musculoskeletal complications, pain, loss of confidence and disruption to the wider family.
Participants predominantly used problem-focused coping strategies to help them to live with frailty and falls, primarily relying upon family support and adapting challenging activities and environments. Emotion-focused coping was used to a lesser extent and included avoidance, practicing gratitude and acceptance. Not all strategies appeared to result in positive adaptation or prevention of further falls.
Conclusion(s): This is the first study to describe the experiences of haemodialysis patients who are frail and fall. Existing services could be improved by screening for frailty, enquiring about falls and organising care to reduce duplication and burden. Further research is needed to confirm factors identified as contributing to frailty and falls, and to develop and test tailored interventions.
Implications: Physiotherapists involved in the care of patients receiving haemodialysis should routinely screen for frailty, ask about falls and refer to rehabilitation services. Involving family in care decisions, utilising empathetic communication and avoiding unnecessary duplication of assessments may also improve patients' experiences. Approaches to physiotherapy that foster positive coping mechanisms and build resilience may be more beneficial than those that encourage reliance on adaptations and aids.
Keywords: frailty, falls, haemodialysis
Funding acknowledgements: NIHR BRC Leicester, CLAHRC East Midlands and NIHR Grant award number: (HY) DRF-2016-09-015, (SG) ICA-CL-2017-03-020 and (JOB) CS-2013-13-014.
Purpose: The aim of this study was to explore the experiences of patients living with haemodialysis, frailty and falls. This information is crucial to enhancing patient safety and care, and to inform tailored interventions to improve outcomes.
Methods: A purposive sample of vulnerable or frail (Clinical Frailty Scale, CFS Score 4-7) adult haemodialysis patients who had experienced at least one fall within the last six months were recruited. In-depth, semi-structured qualitative interviews were digitally recorded, transcribed verbatim and analysed using a constant comparative approach.
Results: Eighteen participants (seven women; median age, 66 (IQR 60-75) years; time on HD 25 (IQR 15-75) months, eight white British, CCI 6 (IQR 5-7)) who had experienced a median of 3(IQR 2-4) falls within the last 6 months, were interviewed.
Exhaustion and weakness were the most prevalent characteristics of frailty, which led to 'slowing down' and low levels of physical activity, worsened by hospital admissions and inactivity during haemodialysis. Unintentional weight loss was more complex. Some participants reported gaining weight due to fluid overload, whilst others reported weight loss that was attributed to forgetting or choosing not to eat and difficulties with following a renal diet.
Participants described difficulty managing multiple conflicting health issues, struggling with functional activities, pain and loneliness. They attributed falls to multiple factors, particularly lower limb weakness. Balance dysfunction whilst walking outdoors, negotiating stairs and slopes, turning, and performing multiple tasks simultaneously, was also common.
Falls were rarely reported and often normalised. Those who did discuss their falls with the healthcare team likened their attempts to 'talking to the wall', with concerns being ignored or explained away. None had been referred to a falls clinic or prevention programme. Consequences of falling included; fracture, damage to their dialysis access, long-term musculoskeletal complications, pain, loss of confidence and disruption to the wider family.
Participants predominantly used problem-focused coping strategies to help them to live with frailty and falls, primarily relying upon family support and adapting challenging activities and environments. Emotion-focused coping was used to a lesser extent and included avoidance, practicing gratitude and acceptance. Not all strategies appeared to result in positive adaptation or prevention of further falls.
Conclusion(s): This is the first study to describe the experiences of haemodialysis patients who are frail and fall. Existing services could be improved by screening for frailty, enquiring about falls and organising care to reduce duplication and burden. Further research is needed to confirm factors identified as contributing to frailty and falls, and to develop and test tailored interventions.
Implications: Physiotherapists involved in the care of patients receiving haemodialysis should routinely screen for frailty, ask about falls and refer to rehabilitation services. Involving family in care decisions, utilising empathetic communication and avoiding unnecessary duplication of assessments may also improve patients' experiences. Approaches to physiotherapy that foster positive coping mechanisms and build resilience may be more beneficial than those that encourage reliance on adaptations and aids.
Keywords: frailty, falls, haemodialysis
Funding acknowledgements: NIHR BRC Leicester, CLAHRC East Midlands and NIHR Grant award number: (HY) DRF-2016-09-015, (SG) ICA-CL-2017-03-020 and (JOB) CS-2013-13-014.
Topic: Older people; Disability & rehabilitation; Health promotion & wellbeing/healthy ageing
Ethics approval required: Yes
Institution: University of Leicester
Ethics committee: NRES Committee South West - Central Bristol Research Ethics Committee
Ethics number: 17/SW/0048
All authors, affiliations and abstracts have been published as submitted.
