Advanced Practice Nurses for Fall Incidence PrevenTion in Very Old Robust Adults

Introduction and objectives

The 2020s witnessed the emergence of Advanced Practice Nurses (APN) as a novel paramedical profession in France, bolstering the primary care workforce and service landscape. These nurses are expected to reinforce various dimensions of primary care, including therapeutic education, prevention, screening, and clinical and therapeutic follow-up of patients. There is a need regarding the evaluation of APN led intervention in the prevention of falls in non-frail elderly.

APN-FIT is a pragmatic, hybrid type 1, multicenter, randomized open-label superiority trial addressing this question. The study population will include primary care patients aged over 80 years old, classified as vigorous (according to Clinical Frailty Scale) and able to follow a tailored intervention program. The study will be conducted in seven local primary-care centers in the Pays de la Loire region of France.

Preselection will be done by GPs and APNs, recruitment will be done by APNs in their local caregiving center. APNs will perform a complete comprehensive geriatric assessment (CGA) for each participant at enrolment, followed by a detailed analysis of the resulting data and the emission of a panel of recommendation. A 1:1 randomization of participants will be conducted using a random block size ranging from 4 to 6, stratified by APN.

All participants will benefit from a CGA at inclusion and M12. A home-based physical activity program, over a period of 7 weeks, with twice-weekly sessions (45 min each), will also be proposed to all participants. In the intervention group, each APN will schedule follow-ups at 1, 3, 6, 9, and 12 months post-inclusion. Each participant will be contacted every two months (i.e 2,4,6,8,10 onths) by the research assistant or nurse for data collection on falls and secondary outcome criteria in a blinded approach. All participants will be assessed for a new CGA at M12 by a research nurse.

Quantitative main analysis

The primary outcome is the number of falls recorded at 12 months.

Secondary outcomes include:

• Number of falls and severe falls as defined by the World Fall Guidelines at each time point
• Level of independence, evaluated by Katz' index and Lawton's instrumental activities of daily living
• Level of healthcare utilization
• Level of emergency care service utilization
• Frailty measured with the Clinical Frailty Scale and ICOPE monitor score
• Cognitive performance
• Mental health status
• Nutritional status
• Quality of life evaluated by EQ-5D-5L

A cost-utility analysis (CUA) will be conducted, from a collective perspective and one-year time horizon.

Ancillary study of implementation

An ancillary study will be conducted to facilitate a deeper understanding of the efficacy elements observed in the main study. Its purpose is to determine optimal implementation conditions for practical deployment in the field. The data collection for this ancillary study is primarily opportunistic, coinciding with the data collection necessary to address the main study's primary objective. The indicators described by Proctor and colleagues will be used for the evaluation : acceptability, relevance, adoption, efficiency, feasibility, fidelity, scope and sustainability.

The implementation will undergo evaluation at patient level and healthcare provider level. Individual and group interviews will be conducted. Discourse saturation will be sought. The survey of professionals will occur during initial observations and focus groups. The data analysis will draw from the sociology of professions. A sequential thematic analysis of discourse and a visual examination of non-verbal communication elements and social interactions will be used to capture factors that facilitate or limit program implementation.

Inclusion criteria

• Aged 80 or over;
• Vigorous according to the " Clinical Frailty Scale " (scores 1, 2, 3) ;
• Having a referring primary care physician working in pairs with the local Advanced Practice Nurse;
• affiliated to a Health Care Plan
• Informed and having signed consent to participate in the research.

Exclusion criteria

• Under guardianship or trusteeship;
• Unable to travel to the primary care office or unable to follow the adapted physical activity program;
• Poor understanding of French.