≥ 90% of participants will have increased clinician's awareness/knowledge of risk factors that increase fall risk and decrease the ability to age among community-dwelling older adults.
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≥ 90% of participants will have increased clinician's awareness/knowledge of risk factors that increase fall risk and decrease the ability to age among community-dwelling older adults.
After completing this continuing education course, the participant will be able to meet the following objectives:
One in five Americans will be 65 or older by 2030 (Lehning et al., 2017). It is estimated that between 2010-2050 the number of Americans age 85 and older will triple (Lehning et al., 2017). Aging in Place (AIP) is defined as the ability to live in one's own home and community safely, independently, and comfortably regardless of age, income, or ability level (CDC, 2009). AIP is an increasingly discussed topic. A study by the American Association of Retired Persons (AARP) found that 90% of adults aged 65 and older prefer to remain in their homes rather than moving into an assisted living facility or nursing home (Khalfani-Cox, 2017). Other factors contributing to adults' desire for AIP include the rising cost of institutional care and the independence and positive self-image associated with AIP (Lehning et al., 2017).
Additionally, research suggests that adults who live in active communities and participate in social activities have better health quality of life and recover faster from illnesses (Graham et al., 2014). Adults who live in their homes have a strong attachment to their homes and communities (Lehning et al., 2017). This attachment can foster better health and lead to an ability to navigate in their familiar home environment (Lehning et al., 2017). Thus, the ability of older adults to remain in their homes and communities can contribute to their overall health and wellness (Lehning et al., 2017).
Although there are numerous and obvious benefits for older adults to AIP and remain in their homes and communities, factors can impede this ability. Physical and cognitive deficits that occur with aging and a decreased ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) can affect older adults' ability to AIP (Lehning et al., 2017). Additionally, an inaccessible or unsafe home and an individual experiencing a fall or a series of falls in their home can prevent them from AIP.
The World Health Organization defines a fall as an event that results in a person coming to rest inadvertently on the ground or floor or other lower-level (WHO, 2018). Each year falls affect one in three adults aged 65 and older and 50% of adults 80 and older (Ambrose et al., 2013). Falls are the most common cause of traumatic brain injuries (TBIs) in older adults and account for 90% of hip fractures (Ambrose et., 2013). Falls account for the largest number of fatal and non-fatal injuries in adults age 65 and older (Burn et al., 2016).
Falls impact healthcare costs and can significantly affect the quality of life. In 2015, $637.2 million was spent due to fatal falls, and $31.3 billion was spent on non-fatal falls (Burn et al., 2016). Older adults who experience an injury after a fall can have difficulties with ADLs and IADLs and are less likely to participate in social and leisure activities (chase et al., 2012). Additionally, older adults who experience non-injurious falls can fear falling, resulting in decreased activity levels, strength, and endurance (chase et al., 2012).
Numerous factors cause falls in older adults. The fear of falling and other fall-related psychological concerns (FRPCs), such as anxiety, falls efficacy, and balance confidence, are common among community-dwelling older adults (Payette et al., 2016). Numerous intrinsic and extrinsic factors cause falls. Intrinsic fall risk factors include (Karlsson et al., 2013):
Extrinsic fall factors include (Karlsson et al., 2013):
Fall prevention programs can lower healthcare costs and reduce falls (Sherrington et al., 2016). There is a myriad of fall prevention programs available to community-based older adults. However, researchers debate as to which interventions should be included in an effective fall prevention program. These interventions can consist of one primary focus area or multiple areas.
Aging causes delayed postural responses, weight-shifting to avoid falls, and decreased muscle strength and tone (Ambrose et al., 2013). In their systemic review, Menz Auhl and Spink (2018) found that foot problems, including foot pain, bunions, and toe deformity, were associated with falls in older adults. Exercise-only interventions are an example of single interventions. Exercise interventions incorporate physical activities to reduce fall risk (Karlsson et al., 2013).
Home and environmental interventions are other single interventions. Environmental factors can contribute to falls (Ambrose et al., 2013). Fall hazards and inaccessibility increase fall risks, can affect the quality of life, and negatively affect an individual's ability to AIP (Horowitz et al., 2013). Home hazard programs that include home modifications and assessments or recommendations for home modifications have decreased fall risks and falls (Horowitz et al., 2013).
In their meta-analysis, Sherrington et al. (2017) examined 88 trials with 19,478 participants and found exercise reduced the rate of falls in community-dwelling older adults by 21%. The analysis noted better effects with exercise programs that challenged balance and were performed for more than 3 hours a week. The analysis noted that exercise also had a fall prevention effect in community-dwelling adults with Parkinson's disease. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation. Still, promising results were evident for people with Parkinson's disease and cognitive impairment (Sherrington et al., 2016).
In their fall prevention review, Karlsson et al. (2013) found that exercise programs that included strength training, balance, flexibility, and endurance training demonstrated the most effective fall-prevention strategies for community-based older adults. The review also found that group exercises incorporating gait, balance, or functional training reduced fall rates by 27% (Karlsson et al., 2013). Tai chi was shown to be the most effective exercise in decreasing the number of falls in a randomized control study discussed in the Karlsson et al. (2013) review. However, Chippendale and Boltz (2013) noted that while tai chi reduced the risk of falls, it was less effective for high-risk fallers individuals who experience fear of falling and have home environmental fall risk factors.
Exercise interventions to address fall prevention were supported in a systematic review authored by Chase et al. (2012). The Chase et al. (2012) review found that participants in a fall prevention program that included physical activity interventions such as balance retraining, exercise, lower-extremity strengthening, and use of a workstation format or tai chi demonstrated a decrease in fall risk and falls after activity, regardless of the exercise performed. However, previous studies found that exercise interventions demonstrated varying effectiveness in reducing fall risks and noted that the various methodologies and types of exercises made the studies difficult to compare.
Individuals may be more willing to participate in exercise-only fall intervention programs because they believe exercise may be more important than other fall prevention interventions. Additionally, exercise-only programs may be more cost-effective than multifactorial approaches and thus may be promoted more by policymakers and health professionals. There are inconsistencies with the recommended length of time for exercise fall prevention programs. There is also debate about the best exercise intervention for older adults. Participant activity levels and comfort with exercise should be considered when developing a fall prevention program. While exercise-only interventions have research to support their use, they may not address quality of life concerns, which affect AIP and home safety for community-dwelling older adults.
Exercise-only interventions are not the only type of single intervention supporting fall prevention. Research suggests that home modification programs can be a single component in a fall prevention program (Horowitz et al., 2016). In their study, Horowitz et al. (2016) cited a 2010 study in which the Home Safety Self-Assessment Tool (HSSAT) reduced home hazards, falls, and fear of falling. In their study using the HSSAT with 47 community-based older adults who attended senior centers, Horowitz et al. (2016) found the HSSAT assisted in creating home safety plans.
In a systematic review, Stark, Keglovits, Arbesman, and Lieberman (2017) found evidence to support home modification interventions beneficial in improving functional outcomes for frail older adults, individuals with low vision, and individuals with schizophrenia. Their review of a Level I study in which frail older adults received home modification recommendations by an occupational therapist (OT), assistance from a nurse, and home modifications by a technician, demonstrated strong evidence supporting home modifications for older adults. The Stark et al. (2017) review also found that home modification that included task lighting improved participants' quality of life for individuals with low vision. Additionally, specifically tailored home modification interventions for community-based individuals with schizophrenia demonstrated moderate evidence regarding the effectiveness of home modifications for that population (Pighills et al., 2015).
However, a 2012 scoping review article of OT in fall prevention indicated interventions involving home modification recommendations had varying effects on fall incidence, outcomes, and success rates. It noted that home modification interventions varied throughout studies, with some authors did not report sufficient details on the interventions. Specifically, it also pointed out that some studies had various control groups, where participants only received an education, while others received home assessments or no intervention.
Evidence suggests that interventions involving home modifications for community-dwelling older adults can improve functional outcomes (Horowitz et al., 2016). Home modifications can also reduce the need for paid caregivers and reduce stress (Horowitz et al., 2016). In their review, Karlsson et al (2013). found home safety programs significantly reduced fall rates in high-risk community-based older adults with a history of falls or multiple fall risk factors. In their critical review, Pighills, Ballinger, Pickering, and Chari (2015) found that environmental assessments and modifications conducted by OTs were clinically effective in reducing falls in high-risk individuals. Home modification interventions performed by OTs were more effective in fall reduction and the improvement of overall functional performance than interventions delivered by non-OT professionals (Horowitz et al., 2016). However, the Pighills et al. (2015) review also found that environmental assessments and modifications conducted by OTs were ineffective in reducing falls in low-risk community-dwelling individuals. Pighills et al. (2015) surmised that environmental modification and assessment interventions led by OTs effectively focus on the person, environment, and occupation (PEO). The PEO model examines the relationship between falls and the context of the individual's environment, behaviors, and intrinsic factors (Pighills et al., 2015).
There is inconsistent evidence to support home modification/environmental risk assessment-only interventions in fall prevention programs. It is noteworthy that authors may define what is involved in a home modification or environmental assessment differently. Some research may include the assessment of a home, while others consider home modification education. The profession and experience of the assessor are also important as research indicates interventions led by OTs were more effective in reducing falls in high-risk individuals (Pighills et al., 2015).
Multifactorial fall interventions are implemented with community-dwelling older adults and target risk factors identified through a fall risk factor assessment (AGS, 2011). The Panel on Prevention of Falls in Older Persons, AGS & BGS (Lavedan et al., 2018) report cites two meta-analyses that support multifactorial intervention approaches to prevent falls in older adults. Research indicates multifactorial fall prevention approaches for older adults reduce falls and deficits with ADLs and IADLs (chase et al., 2012). Components of multifactorial fall prevention programs can include (Horowitz et al., 2016):
Most multifactorial fall prevention program interventions include exercise and physical activity, medical assessment, medication adjustments, environmental modification, and education (AGS, 2011).
Fear of falling can cause individuals to avoid everyday functional activities they could otherwise perform. Factors contributing to a fear of falling include age decreased ADLs, a history of falling, activity restriction, balance, social and physical deconditioning. Anxiety and depression are also associated with fear of falling. Fall Related Psychological Concerns, FRCPs, are a group of related concepts such as fall-efficacy and balance confidence (Payette et al., 2016). A metanalysis by Payette, Bélanger, Léveillé, and Grenier (2016) on the relationship between anxiety and Fall Related Psychological Concerns (FRPCs) among community-dwelling older adults demonstrated the importance of examining anxiety within the context of FRPCs (Payette et al., 2016). It showed anxiety had a moderate to significant association with FRPCs among community-dwelling older adults and that the relationship does not change depending on fear of falling or falls-efficacy or balance confidence (Payette et al., 2016). The study demonstrated the importance of studying anxiety within FRPCs (Payette et al., 2016). Clinicians should, therefore, assess adults for fear of falling if they demonstrate anxiety and decreased motivation to perform functional activities.
The Payette et al. (2016) findings were affirmed in the longitudinal study by Laveda et al., a meta-analytic review by Schepens, Sen, Painter, and Murphy (2018) on fall-related efficacy and activity in community-dwelling older adults. In their longitudinal study, Laveda et al. (2018) looked at 640 individuals with a history of falls and a fear of falling over 24 months. Logistic regression analysis showed a strong association between a history of falls and the fear of falling (Lavedan et al., 2018). Being female, having comorbidities, depressive symptoms, and disability was also associated with the fear of falling (Lavedan et al., 2018). The study found that a history of falls within the previous year was a good indicator of an individual's fear of falling (Lavedan et al., 2018). It is, therefore, important for clinicians to assess clients' fear of falling and factors related to fear of falling to get a full picture of how their fear of falling can impact their functional performance and independence.
Further research supports the need for clinicians to assess the fear of falling as part of their comprehensive treatment planning. In their scoping review, Wipple, Hamel, and Talley (2017) reviewed 45 publications that examined effective evidence-based interventions that address the fear of falling among community-dwelling older adults. They found that effective interventions included those with ongoing support for participants, had extended treatment periods, and booster sessions (Whipple et al., 2017). Non-effective treatments also included one-time assessments without resources for participants to carry out the recommended improvements. Clinicians should address their client's fear of falling because it can significantly impact the client's overall function, including their willingness and comfort level in daily functional activities. Clinicians should address the fear of falling throughout sessions with clients as the research indicates that one-time education is insufficient.
Polypharmacy is defined as the regular use of five or more drugs and has increased fall risks among older adults (Zia et al., 2016). However, current research indicates that the types of medication and the number of medications taken can increase an individual's risk of falling (Zia et al., 2016). In their literature review, Ambrose et al. (2013) noted psychotropic medications, including those used to treat depression, dementia, and bipolar disorder, increase the risk of falling among community-dwelling older adults. Ambrose et al also noted that in a study with diabetics and a control group, the people with diabetes treated with insulin had a greater risk of falling than the non-diabetic controls. In their study, Tinetti et al (2014) found that antihypertensive medications increased the risk of a serious fall, especially among individuals with previous fall injuries. Zia et al (2016) found the use of two or more fall risk-increasing drugs (FRID), such as cardiovascular medications, drugs for the central nervous system, and antidiabetics heightened the risk of recurrent and injurious falls. The Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) indicated that the assessment, modification, and discontinuation of medication regimens is an effective component of fall reduction programs.
There is also debate regarding the use of vitamin D in preventing falls. In their article, Chien and Guo (2014) discussed a literature review that found vitamin D supplements for individuals with lower vitamin D levels resulted in fewer falls in community-dwelling individuals at risk for falling. However, in their literature review, Ambrose et al. (2013) noted no significant difference in the fall rate of individuals in the study versus the control group of community-dwelling older adults who used vitamin D supplements. Despite the conflicting views on the use of vitamin D, the Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) noted vitamin D supplements might reduce the number of falls in individuals with low levels of vitamin D but possibly only with certain types of vitamin D drugs. Specifically, 800 international units (IUs) per day of vitamin D supplements are recommended for older adults with Vitamin D deficiency and should be considered for individuals suspected of having the deficiency or who are at high risk for falling (AGS, 2011).
Clinicians can play an important role in medication management with their clients. Clinicians can educate older adults about strategies to open their medication containers, simplify medication routines, and help clients adhere to their medication timelines (OT, 2017). Individuals with a high incidence of hypertension may benefit from education about why taking medication for hypertension places them at increased risk of falling. Interventions could also include recommendations and referrals to other medical professionals to address their specific medication concerns. Likewise, individuals with low vitamin D levels could be educated about the benefits vitamin D may play in fall prevention.
Older adults' nutritional and hydration status has also been linked to falls (Hooper, 2015). polypharmacy, physiological changes in satiety, dysphagia, food access, and poorly fitting dentures contribute to malnutrition (Esquivel, 2017). Malnutrition in older adults can decrease bone mass and muscle strength and reduce cognitive abilities (Chien & Guo, 2014). Research indicates that malnutrition is a predictor of falls (Chien & Guo, 2014). In their longitudinal study, Chien and Guo (2014) found that the nutritional status of community-dwelling older adults age 53 and older in Taiwan was a predictor of falls. A French study involving elderly community-dwellers found that poor nutritional status was associated with a higher risk of falling and fractures in elderly French community-dwellers (Torres et al., 2015). In their prospective analysis, Insausti et al (2019) performed a prospective cohort study of 2,464 men and women ages 60 years or older recruited between 2008-2010 and followed up through 2012. Participants' baseline habitual protein intake was determined, and at the end of the study, they reported the number of falls they experienced in the preceding year (Torres et al., 2015). The results found that 21.2% of participants experienced at least one fall at the end of the study (Torres et al., 2015). The study results found that protein intake did not have a protective association against fall risk in older adults. However, the study found that participants with higher total protein intake tended to experience an unintentional weight loss of 4.5 kg or more in the preceding year (Torres et al., 2015).
Dehydration occurs when there is a loss of body mass of at least 1% (Hooper, 2015). Experiments that have induced dehydration have shown that an approximate 1% loss of body mass can occur in 13 hours, and a 2% loss can occur in 24 hours. Physiological changes, including loss of muscle mass, a decrease in thirst, and increased body fat, can put older adults at greater risk for dehydration (Hooper, 2015). Dehydration places older adults at increased risk of urinary tract infections, renal failure, confusion, and falls (AGS, 2011). The Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) includes hydration as a strategy for fall prevention among older adults.
Older adults may experience visual deficits such as spatial and depth perception deficits (Ambrose et al., 2013). Older adults with low vision are twice as likely to experience a fall than individuals without a visual loss (Blaylock & Vogtle, 2017). As a result of visual deficits with aging, some fall intervention programs may include visual deficits management.
In their scoping review, Blaylock and Vogtle (2017) examined 17 publications for evidence of community-based fall prevention interventions that "appear inclusive of or accessible to individuals with low vision" (Blaylock & Vogtle, 2017, p 140). Blaylock and Vogtle (2017). found interventions to address individuals with low vision may not be effective with non-correctable vision loss. The AGS and BGS also found no support for interventions for vision, as a systematic review indicated insufficient evidence supporting recommendations for vision assessments and interventions in reducing falls (AGS, 2011). Blaylock and Vogtle (2017) implied that clinicians should be aware that all evidence-based interventions may not be effective for all older adults, and more research is needed to address fall prevention for older adults with low vision. In a fall prevention program, individuals with low vision may not see written materials or visual demonstrations such as exercises (Blaylock & Vogtle, 2017). Therefore, specialized accommodations may be required for these individuals to participate in a fall prevention program.
Impaired cognition also plays a role in falls among community-dwelling older adults (Manning & Wolfson, 2017). Executive dysfunction is a cognitive factor that predicts falls (Manning & Wolfson, 2017). In a 12-month cohort study with community-dwelling older adults 70 and older in Canada, Davis et al (2017). found that processing speed was the most consistent predictor of falls among participants with a history of falls. The study found that poorer processing predicted the most indoor, outdoor, and non-injurious falls (Dabis et al., 2017). The Davis et al (2017) study also found that processing speed was the best predictor of participants having at least one mild to severe injury.
Individuals with both cognitive and visual deficits are at increased risk for falls. Cognitive functioning related to vision processing visual cognition has affected falls (Reed-Jones et al., 2013). Visual attention is also a component of visual processing. Reduced visual attention is associated with an increased likelihood of falling. Visual processing speed involves an individual's response time when avoiding obstacles, and deficits in this area reduce the successful avoidance of objects (Reed-Jones et al., 2013).
Fall prevention programs that include individuals with cognitive and visual deficits should include modifications that allow individuals to be successful. These modifications may include the use of information presented in a multi-sensory format such as audio, visual, and written materials. Additionally, individuals with cognitive and visual deficits may benefit from attending such a caregiver program. A caregiver's attendance may provide needed social and emotional support and assist the individual in implementing strategies in his or her home.
An older adult's footwear can increase his/her risk of falling. Shoes with high heels, worn soles, or shoes that are unbuckled or untied increase the risk of falling, as can wearing slippers, walking barefoot, or wearing only socks (Ambrose et al., 2013). Shoes with a low heel height reduce the risk of falling (AGS, 2011). However, there is debate about the appropriate heel height and type of shoe to wear to decrease fall risk. In their review, Ambrose et al (2013). noted compared to canvas shoes, shoes with heels greater than 2.5 cm increase the likelihood of falls. Poor-fitting shoes can affect plantar pressure, affecting balance and placing individuals at increased risk of falling (Ikpeze et al., 2015). Sneakers and wider and higher toe boxed shoes are examples of footwear that have been shown to evenly distribute plantar pressure, increase comfort, and promote appropriate balance and gait (Ikpeze et al., 2015). The AGS and BGS also recommended that older adults be aware that shoes with low heels and high surface contact can reduce fall risks (AGS, 2011). Although there is debate regarding the appropriate heel height, there appears to be sufficient research to support the inclusion of education on appropriate footwear as part of a fall prevention program.
The AGS and BGS recommend exercise as part of a multifactorial fall intervention program. Their recommendations include gait, balance, and strength training such as tai chi or physical therapy as part of a group or individual home program. The Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) noted that most positive trials included exercise programs longer than 12 weeks, with sessions occurring one to three times a week. In contrast to individual exercise programs for fall prevention, the Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) also noted exercise might be more effective when combined with other interventions, as these programs resulted in fewer falls. However, the panel also noted that exercise should be introduced with caution as it can increase falls in individuals with limited mobility who are not used to physical activity (AGS, 2011).
There is research to support exercise as part of an effective multifactorial fall prevention program. However, exercise as a program component should be carefully considered as it may increase falls in older adults with limited mobility (AGS, 2011). The gap in evidence regarding exercise interventions supports the need for further research. Research involving educating community-based older adults about various exercise components may be beneficial.
Home hazards such as poor lighting and loose rugs also place individuals at increased risk for falls (Ambrose et al., 2013). While there is mixed research regarding home modification alone as part of a fall prevention program, identifying and repairing home hazards is recommended as a part of a successful multifactorial fall prevention program (AGS, 2011). In their updated systematic review, Elliott and Leland examined evidence regarding the effectiveness of fall prevention interventions in improving quality of life, fall-related outcomes, occupational performance, and health care facility readmissions for community-dwelling older adults (Elliott & Leland, 2018). They analyzed 50 articles published between 2008 to 2015 (Elliott & Leland, 2018). Of those 50 articles, 37 provided Level I, 5, Level II, and 8, Level III evidence (Elliott & Leland, 2018). Single component interventions addressed a single fall risk, such as exercises. Multifactorial interventions addressed multiple risk factors such as nutrition, hydration, home modification, education, exercise, and medication management, while population-based interventions were existing effective population-based fall prevention programs, such as Stepping On or A Matter of Balance, or other population-based multicomponent interventions (Elliott & Leland, 2018). Another study mentioned in the Chase et al review found interventions involving five sessions provided by an OT who assessed home environmental hazards and a PT who addressed strengthening and balance, resulting in program participants having less difficulty with ADLs and IADLs reduced fear of falling and home hazards.
In their systematic review, Stark et al. (2017) found substantial evidence supporting home modifications by OTs as a component of a multifactorial fall intervention plan. In their review, Karlsson et al. (2013) found that individualized multifactorial interventions reduced the rate of falls in community-dwelling older adults by 25%. However, the same research found that multifactorial interventions did not reduce the number of individuals who fell (Karlsson et al., 2013).
There is conflicting research supporting home modification interventions as part of a multifactorial fall prevention program in community-based older adults. This contradictory evidence suggests a need for further research. Using the HSSAT as a component of a program to identify home hazards proved beneficial for community-based older adults who attended a senior center (Horowitz et al., 2016). Additional research could determine if the HSSAT would benefit community-based older adults as part of a multifactorial intervention program.
An AT device is "any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, used to increase, maintain, or improve functional capabilities of individuals with disabilities (ATIA, 2020)." AT devices can be placed on a continuum that includes no-tech, low-tech, mid-tech, and high-tech solutions (NATRI, 2020). The continuum is based on the device's complexity and the level of training needed to operate it. No-tech solutions do not require AT (NATRI, 2020). An example of a no-tech solution is placing frequently used items near users to prevent them from using a step ladder to retrieve items. Low-tech AT devices are relatively inexpensive, easy to use and maintain, and have simple features (Tools for Life, 2016). Examples of low-tech solutions include motion-sensor lights and bath mats. Mid-tech AT devices/solutions may be operated electronically or by a battery, have some complex features, and require some training (Tools for Life, 2016). Examples of mid-tech devices include some types of medication management systems and apps under $100 (Tools for Life, 2016). High-tech AT devices are often computerized, require higher extensive maintenance training, and might be expensive (Tools for Life, 2016). Examples of high-tech devices include stair lift systems and environmental control devices.
OTs can make recommendations regarding AT in the home for community-based older adults part of a fall prevention program (chase et al., 2012). Older adults' use of AT aligns with occupational therapy's focus on health promotion and wellness by improving overall health and preventing or reducing other illnesses, injuries, or disabilities.
In their study, Horowitz et al (2013) noted home modifications and AT that assisted mobility increased independence and safety with self-care tasks and reduced caregiver assistance hours.
Research has demonstrated that the use of technology for home care support is beneficial in helping older adults remain independent while reducing fall risks, medication errors, and caregiver stress (Stanley, 2015). AT, like fall prevention and medication management tools, automatic home lighting, and smart home innovations, have positively impacted health outcomes and the quality of life of older adults living independently in their communities (Stanley, 2015). Clinicians should consider using AT with clients to address areas that may prevent them from remaining safely in their homes and address deficits that occur as part of aging.
While research supports the use of AT as part of a fall prevention program, the Panel on Prevention of Falls in Older Persons, AGS & BGS (AGS, 2011) article does not make recommendations for or against assistive devices in a fall prevention program. A qualitative study about older adults' use of AT while AIP conducted on 53 community-dwelling older adults in the Netherlands found that many participants were fearful of being too dependent on technology (Peek et al., 2015). The Peek et al. (Peek et al., 2015) study also surmised that community-based older adults were unaware that technology could benefit them, and interventions need to consider the adults' social, personal, and physical environment.
The multiple risk factors that cause falls require an evidence-based fall prevention program specifically tailored to the needs of the population requiring the intervention. Identifying individuals at risk for falls is important in effective program planning.
Older adults are categorized according to their functional status based on their sensory, cognitive, and physical functions. In Tokyo, Japan, Centenarians were categorized as exceptional, normal, frail, and fragile. Individuals were considered exceptional if they were completely independent with their basic ADLs, had intact vision and hearing, and had excellent cognitive functioning. Participants were considered normal if they were somewhat independent with basic ADLs and had good cognitive functioning. Participants were categorized as frail if they demonstrated deficits with basic ADLs or had impaired cognitive functioning. Finally, individuals were categorized as fragile if they were utterly dependent on basic ADLs and had significantly impaired cognitive functioning. Considering older adults' functional status is important as it may also influence their risk factors for falls.
Fallers can be categorized by their frailty level. Frailty is "a geriatric syndrome resulting from cumulative age-related decline across multiple physiologic systems, impaired homeostatic reserve, and reduced capacity to resist stress (Mohler et al., 2016, p 655)." Frailty can be assessed using the components of the Fried Frailty Phenotype criteria that includes (Buckinx, 2015):
Individuals are considered non-frail if they do not meet any of the criteria, pre-frail if they meet one or two criteria, and frail if they meet three or more criteria (Buckinx, 2015). In his article, Kojima (2015) conducted a systematic review of literature and meta-analysis from 2010 to April 2015, examining future fall risk according to frailty among community-dwelling older adults with no language restrictions. Among community-dwelling older adults, frailty was a significant predictor of future fall risks, and frailty appeared to be higher in men than in women (Manning & Wolfson, 2017).
Fallers can also be categorized into first-time and recurrent fallers. In a 2010 study involving 1066 French community-dwelling adults age 65 and older, participants were separated into four groups, individuals who had:
Of the 1066 participants, 37.1% were fallers, 27.3% experienced one fall, and 9.8% were recurrent (two or more). That study found that institutionalization, age, taking several medications, and muscle weakness was related to falls, but no recurrence. However, the study also concluded that poor vision, lower limb proprioception, fear of falling, and being female were all fall markers.
A 2015 prospective cohort study with 248 community-dwelling older adults examined the connection between frailty and short-term incident future falls among community-dwelling older adults (Kokima et al., 2015). All participants were 65 years old or older and did not have a history of more than three falls (Kokima et al., 2015). Frailty was a significant and independent predictor of short-term future falls among community-dwelling older people who had volunteered for a physical activity study (Kokima et al., 2015).
This research can be used to customize fall prevention programs for individuals who have not experienced falls and for recurrent fallers. The research from this study can be used to develop programs for one-time and recurrent fallers (Kokima et al., 2015).
Linda is a 70-year-old female who lives alone in her ranch-style home. Linda had previously been independent with her ADLs and IADLs but has recently had a fall inside her home that resulted in her being very fearful of going into the bathroom and having anxiety when getting around her house. Linda was recently diagnosed with hypertension and started taking medications to manage her hypertension. She also has arthritis and glaucoma and is taking medications for those conditions. Linda noticed that her new hypertension medication makes her feel lightheaded at times, and she has almost fallen several times on the steps and in the living room. Linda has thrown rugs around the home, dimly light hallways and stairs, and patterned floor tiles in her kitchen and bathroom. Her family is concerned about her safety and would like Linda to undergo a home safety assessment to see if anything can be done to increase her independence and safety. What are some areas a clinician could assess and address regarding Linda's overall health and home safety concerns?
The clinician would complete a thorough home safety and fall assessment using a standardized or non-standardized assessment. However, it is essential to consider the intrinsic and extrinsic factors that cause falls and the client's specific needs and occupational performance.
In Linda's case, the clinician should educate Linda about how her medications can increase her risk of falling. Linda should be encouraged to speak with her physician about how her medications affect her home safety and encourage Linda to speak with her physician/pharmacist about altering her medicines if possible. As part of a complete room-by-room home safety and fall prevention assessment, Linda should be informed of the dangers of throw rugs and other home hazards and encourage removing such home hazards.
Since Linda has a diagnosis of glaucoma, she should be educated about the importance of color contrast and other low vision strategies, including the importance of proper lighting, LED light bulbs, and task lighting throughout her home. The assessment may include discussing the appropriate type of light needed for areas such as stairwells, hallways, bathrooms, and bedrooms. Linda may be encouraged to use motion sensor lights throughout the hallways, her bedroom, and the bathroom.
Part of the home assessment may include seeing how Linda can access items from a cabinet and pantry shelves in her kitchen and items in her closet. The clinician should also assess how Linda transfers in and out of her tub or shower and on and off the commode. Recommendations should be made regarding adaptive equipment such as grab bars and handheld showers and durable medical equipment such as shower and tub benches and raised commode seats that promote safety in the bathroom. The clinician would also demonstrate and teach Linda strategies to promote safety in these areas and provide family education and training.
Luke is a sixty-five-year-old who recently retired from his job. He lives with his wife, who has recently had a knee replacement and is a few years away from retiring. Although his wife was able to bounce back from her knee replacement surgery quickly, Luke is thinking ahead and would like to prepare his home so both he and his wife can age safely in place. They have a split-level home with the kitchen and living room on the main level and the master suite and two guest bedrooms on the second story level. Luke is also interested in learning more about how technology can assist him and his wife in AIP. Neither he nor his wife has difficulty accessing the steps to get to their master suite at present, but he is concerned that may be an issue in the future. What are some areas, strategies, recommendations, and technologies Luke can consider to help him remain safe in his home as he and his wife age?
A thorough home safety and fall assessment that can be standardized or non-standardized should be completed. Luke and his wife's occupational performance and safety concerns, interest, medication needs, current environmental supports, and financial resources should be considered. Options should be discussed with Luke and his wife, including strategies ranging from low to high-tech solutions that promote aging.
The clinician can discuss how having the master on the main level promotes aging in place if considering a major renovation for aging in place. If major renovations are not an option and the master bedroom needs to remain on the second story, ways to improve safety in accessing the master bedroom and other upstairs bedrooms are discussed with Luke and his wife. Safety recommendations include having handrails on both sides of the staircase, appropriate lighting in the staircase, and a light switch at the top and bottom of the staircase. Bathroom safety and aging-in-place options should also be discussed with Luke and his wife. These may include grab bars, raised commodes, bath/shower benches, and color contrast in the bathroom to promote safety.
The clinician can educate Luke and his wife about the various smart home technologies available that control devices such as light switches, thermostats, and appliances. If medication management is a concern, medication management apps that allow Luke and his wife to log their medications, learn about potential drug interactions, and include reminders to take their medications should be included in their education. Luke and his wife should also receive education about programs and financial resources available to help them age in place.
Fall prevention is a vast topic that requires clinicians to remain abreast of the latest evidence. The American Occupational Therapy Association, AOTA, has conducted extensive research on fall prevention and has created numerous resources, including tip sheets, fall prevention toolkits, and a fall prevention video. The Centers for Disease Control, CDC also have many fall prevention resources. These resources include podcasts and several fall prevention brochures. The AARP created the Home Fit Guide resource for seniors to increase their ability to remain safely in their homes as they age. Another helpful resource is the Home Safety Self-Assessment Tool, HSSAT, which the Occupational Therapy Geriatric Group developed at the University of Buffalo to share information about fall prevention in Erie County, New York.
Medication management is an important component of fall prevention. The following apps can be useful in medication management for community-based older adults.
Image obtained from Google Play website
Image obtained from Medisafe.com
Image obtained from Medicationactionplan.com
Image obtained from My-meds.com
Falls can have a devastating impact on an older adult's life, potentially affecting independence, self-confidence, and ability to remain safely in their home. Thus, clinicians must educate their clients and stay updated on the most available evidence for fall prevention for community-based older adults. Single focus fall intervention programs often include exercise interventions and home hazard interventions. Research supports multifactorial fall prevention approaches to prevent falls in older adults. Multifactorial fall prevention interventions often include education about:
AOTA, the CDC, AARP, and the University at Buffalo all maintain valuable fall prevention and aging resources for community-dwelling older adults. Providing patients with apps regarding medication management can also serve as a way clinician can better serve their clients with information and education about medication management.
Research indicates that most older adults want to remain in their homes. However, falls can prevent older adults from remaining safely in their homes and being active participants in their communities. Clinicians need to stay updated regarding the evidence supporting fall prevention programs.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.