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Fall Prevention Education for Community-Dwelling Older Adults

3 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Saturday, June 25, 2022

0.3 AOTA CEUs Categories: Occupational Therapy and Foundational Knowledge;
Education Level: intermediate

FPTA Approval: CE20-704083. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥ 90% of participants will have increased clinician's awareness/knowledge of risk factors that increase fall risk and decrease the ability to age in place among community-dwelling older adults.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Report two factors that contribute to the fear of falling among community-based older adults.
  2. Relate two categories of medications that can cause falls.
  3. Correlate how cognition and vision are connected to falls.
  4. List two common exercise components in fall prevention programs.
  5. Predict factors that would qualify an older adult as being frail.
  6. Propose at least one no-tech, low-tech, mid-tech, and high-tech AT strategy/solution used when addressing fall prevention/aging in place among community-dwelling older adults.
  7. Choose three apps that can be used for medication management with community-dwelling older adults.
  8. Choose two fall prevention resources available to clinicians/community-dwelling older adults.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Jacqueline Wynter ()

Introduction

One in five Americans will be 65 or older by 2030.1 It is estimated that between 2010-2050 the number of Americans age 85 and older will triple.1 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.2 AIP is an increasingly discussed topic. A study by the American Association of Retired Persons (AARP) found 90% of adults age 65 and older prefer to remain in their homes as they age rather than moving into an assisted living facility or nursing home.3 Other factors contributing to adults' desire to AIP include the rising cost of institutional care and the independence and positive self-image associated with AIP.1

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.4 Adults who live in their homes have a strong attachment to their homes and communities.1 This attachment can foster better health and lead to an ability to navigate in their familiar home environment.1 Thus, the ability for older adults to remain in their homes and communities can contribute to their overall health and wellness.1

Factors Affecting Aging in Place

Although there are numerous and obvious benefits for older adults to AIP and remain in their homes and communities, there are also factors that 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.1 Additionally, an inaccessible or unsafe home, as well as 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 which results in a person coming to rest inadvertently on the ground or floor or other lower-level.5" Each year falls affect one in three adults aged 65 and older, and 50% of adults 80 and older.6 Falls are the most common cause of traumatic brain injuries (TBIs) in older adults and account for 90% of all hip fractures.6 Falls account for the largest number of fatal and non-fatal injuries in adults age 65 and older.7

Falls impact healthcare costs and can have a significant effect on the quality of life. In 2015, $637.2 million was spent as a result of fatal falls and $31.3 billion was spent on non-fatal falls.7 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.8 Additionally, older adults who experience non-injurious falls can develop a fear of falling resulting in decreased activity levels, strength, and endurance.8

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.9 Numerous intrinsic and extrinsic factors cause falls. Intrinsic fall risk factors include10:

  • Cognitive impairment
  • Musculoskeletal disease
  • Gait and balance disorders
  • Postural hypotension
  • Sensory impairments
  • A history of falls
  • Use of certain medications that include antidepressants, antihypertensive, diuretics, and anti-seizure medications

Extrinsic fall factors include10:

  • Environmental issues such as poor lighting
  • Inappropriate footwear
  • Uneven or slippery floors

Fall prevention programs can lower healthcare costs and reduce falls.11 There is a myriad of fall prevention programs available to community-based older adults. However, there is debate among researchers as to which interventions should be included in an effective fall prevention program. These interventions can include one primary focus area or multiple areas.

Single Focus Fall Prevention Interventions

Aging causes delayed postural responses, weight-shifting to avoid falls, and decreased muscle strength and tone.6 In their systemic review, Menz Auhl and Spink12 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.10

Home and environmental interventions are other single interventions. Environmental factors can contribute to falls.6 Fall hazards and inaccessibility increase fall risks, can affect the quality of life, and negatively affect an individual's ability to AIP.13 Home hazard programs that include home modifications and assessments or recommendations for home modifications have been shown to decrease fall risks and falls.13

Exercise Interventions

In their meta-analysis, Sherrington et al11 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.11

In their fall prevention review, Karlsson et al10 found 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 group exercises that incorporated gait, balance, or functional training reduced fall rates by 27%.10 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 al10 review. However, in their article, Chippendale and Boltz 14 noted. At the same time, 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.8 The Chase et al8 review found 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 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.

Home Hazard Interventions

Exercise-only interventions are not the only type of single interventions supporting fall prevention. Research suggests that home modification programs can be a single component in a fall prevention program.15 In their study, Horowitz et al15 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 al15 found the HSSAT assisted in the creation of home safety plans.

In a systematic review, Stark, Keglovits, Arbesman, and Lieberman16 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 al16 review also found that for individuals with low vision, home modifications that included task lighting resulted in improvements with participants' quality of life. Additionally, specifically tailored home modification interventions for community-based individuals with schizophrenia demonstrated moderate evidence regarding the effectiveness of home modifications for that population.17

However, a 2012 scoping review article of OT in fall prevention, indicated study interventions involving home modification recommendations had varying effects on fall incidence, outcomes, and success rates. It noted home modification interventions varied throughout studies, with some authors not reporting sufficient details on the interventions. Specifically, it also noted that some studies had various control groups, where participants only received an education, while others received home assessments or no intervention at all.

Evidence suggests that interventions involving home modifications for community-dwelling older adults can improve functional outcomes.15 Home modifications can also reduce the need for paid caregivers and reduce stress.13 In their review, Karlsson et al.10 found home safety programs significantly reduced fall rates in high-risk community-based older adults with a history of falls or with multiple fall risk factors. In their critical review, Pighills, Ballinger, Pickering, and Chari17 found environmental assessments and modifications conducted by OTs were clinically effective in the reduction of 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.15 However, the Pighills et al17 review also found environmental assessments and modifications conducted by OTs were not effective in reducing falls in low-risk community-dwelling individuals. Pighills et al17 surmised environmental modification and assessment interventions led by OTs are effective due to a 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.17

There is inconsistent evidence to support the use of 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 assessment of a home while others consider home modification education. The profession and experience of the assessor are also important as research indicates interventions lead by OTs were more effective in reducing falls in high-risk individuals.17

Multifactorial Fall Prevention Interventions

Multifactorial fall interventions are implemented with community-dwelling older adults and target risk factors identified through a fall risk factor assessment.18 The Panel on Prevention of Falls in Older Persons, AGS & BGS19 report cites two meta-analyses that support the use of 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.8 Components of multifactorial fall prevention programs can include6,8,15:

  1. Behavior modifications to address the fear of falling
  2. Exercise to improve balance, strength, and gait
  3. Medication management
  4. Managing postural hypotension
  5. Recommendation of appropriate footwear
  6. Home environmental modifications and education
  7. Community safety
  8. Management of vision deficits
  9. AT
  10. Education

Most interventions of a multifactorial fall prevention program include exercise and physical activity, medical assessment, medication adjustments, environmental modification, and education.18

Fear of Falling

Fear of falling can cause individuals to avoid everyday functional activities they could otherwise perform. Factors that contribute 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 falls-efficacy and balance confidence.9 A metanalysis by Payette, Bélanger, Léveillé, and Grenier 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.9 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.9 The study demonstrated the importance of studying anxiety within the context of FRPCs.9 Clinicians should, therefore, assess adults for fear of falling if they demonstrate anxiety and decreased motivation to perform functional activities.

The Payette et al9 findings were affirmed in the longitudinal study by Laveda et al., a meta-analytic review by Schepens, Sen, Painter, and Murphy19 on fall-related efficacy and activity in community-dwelling older adults. Their longitudinal study, Laveda et al., 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.19 Being female, having comorbidities, depressive symptoms, and disability was also associated with the fear of falling.19 The study found that a previous history of falls within the previous year was a good indicator of an individual's fear of falling.19 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 Talley20 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.20 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 have a significant impact on the client's overall function, including their willingness and comfort level in daily functional activities. Clinicians should address the fear of falling throughout various sessions with clients as the research indicates one-time education is insufficient.

Medication Management

Polypharmacy is defined as "the regular use of five or more drugs" and has been shown to increase fall risks among older adults.21(p463) However, current research indicates that the types of medication, as well as the number of medications taken, can increase an individual's risk of falling.21 In their literature review, Ambrose et al6 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 al6 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 al22 found antihypertensive medications resulted in an increased risk of a serious fall, especially among individuals with previous fall injuries. Zia et al.21 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 & BGS18 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 Guo23 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 al6 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 & BGS18 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, the use of 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.18

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.24 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.

Diet and Hydration

Older adults' nutritional and hydration status has also been linked to falls.25,26 polypharmacy, physiological changes in satiety, dysphagia, food access, and poorly fitting dentures can all contribute to malnutrition.26 Malnutrition in older adults can result in decreased bone mass and muscle strength and reduced cognitive abilities.23 Research indicates that malnutrition is a predictor of falls.23 In their longitudinal study, Chien and Guo23 found 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 poor nutritional status was associated with a higher risk of both falling and fractures in elderly French community-dwellers.27 In their prospective analysis, Insausti et al28 performed a prospective cohort study of 2,464 men and women ages 60 years or older who were 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.27 The results found 21.2% of participants experienced at least one fall at the end of the study.27 The results of the study 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.27

Dehydration occurs when there is a loss of body mass of at least 1%.25 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 an increase in body fat, can put older adults at greater risk for dehydration.25 In turn, dehydration places older adults at increased risk of urinary tract infections, renal failure, confusion, and falls.18, 25 The Panel on Prevention of Falls in Older Persons, AGS & BGS18 includes hydration as a strategy for fall prevention among older adults.

Vision Interventions

Older adults may experience visual deficits such as spatial and depth perception deficits as they age.6 Older adults with low vision are twice as likely to experience a fall compared to individuals without visual loss.29 As a result of visual deficits with aging, some fall intervention programs may include visual deficits management.

In their scoping review, Blaylock and Vogtle29 examined 17 publications for evidence of community-based fall prevention interventions that "appear inclusive of or accessible to individuals with low vision."29(p140) Blaylock and Vogtle29 found interventions to address individuals with low vision may not be effective with individuals 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.18 Blaylock and Vogtle29 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. Individuals with low vision in a fall prevention program may be unable to see written materials or visual demonstrations such as exercises.29 Therefore, specialized accommodations may be required for these individuals to participate in a fall prevention program.

Cognition and Vision

Impaired cognition also plays a role in falls among community-dwelling older adults.30 Executive dysfunction is a cognitive factor that predicts falls.30 In a 12-month cohort study with community-dwelling older adults 70 and older in Canada, Davis et al.31 found that among participants with a history of falls, processing speed was the most consistent predictor of falls. The study found poorer processing predicted the most indoor, outdoor, and non-injurious falls.31 The Davis et al31 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, referred to as visual cognition, has been shown to affect falls.32 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.32

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 programs with a caregiver. A caregiver's attendance may provide needed social and emotional support and assist the individual in implementing strategies in his or her home.

Appropriate Footwear

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.6,18 Shoes with a low heel height reduce the risk of falling.18 However, there is debate about the appropriate heel height and type of shoe to wear to decrease fall risk. In their review, Ambrose et al6 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, which affects balance and places individuals at increased risk of falling.33 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.33 The AGS and BGS also recommended that older adults be made aware that shoes with low heels and high surface contact can reduce fall risks.18 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.

Exercise Components

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 & BGS18 noted that most positive trials included exercise programs that were 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 & BGS18 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.18

There is research to support exercise as part of an effective multifactorial fall prevention program. However, the use of exercise as a program component should be carefully considered as it may increase falls in older adults with limited mobility.18 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.

Environmental and Home Safety

Home hazards such as poor lighting and loose rugs also place individuals at increased risk for falls.6 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.18 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.34 They analyzed 50 articles published between 2008 to 2015.34 Of those 50 articles, 37 articles provided Level I; 5, Level II; and 8, Level III evidence.34 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.34 Another study mentioned in the Chase et al8 review found interventions involving five sessions provided by an OT who assessed home environmental hazards, and a PT who addressed strengthening and balance, resulted in program participants having less difficulty with ADLs and IADLs and reduced fear of falling and home hazards.

In their systematic review, Stark et al16 found substantial evidence supporting home modifications by OTs as a component of a multifactorial fall intervention plan. In their review, Karlsson et al10 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.10

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. The use of the HSSAT as a component of a program to identify home hazards proved beneficial for community-based older adults who attended a senior center.15 Additional research could determine if the HSSAT would be beneficial to community-based older adults as part of a multifactorial intervention program.

Assistive Technology/Assistive Devices and Strategies

An AT device is "any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.35" AT devices can be placed on a continuum that includes no-tech, low-tech, mid-tech, and high-tech solutions.36 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.36 An example of a no-tech solution is placing frequently used items near users to prevent them from having to use a step ladder to retrieve items. Low-tech AT devices are relatively inexpensive, easy to use and maintain, and have simple features.37 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, may have some complex features, and require some training to use.37 Examples of mid-tech devices include some types of medication management systems and apps under $100.37 High-tech AT devices are often computerized, require higher maintenance, extensive training, and might be expensive.37 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.8 Older adults' use of AT aligns with occupational therapy's focus on health promotion and wellness by improving overall health and preventing or reducing further illnesses, injuries, or disabilities.

In their study, Horowitz et al13 noted home modifications and AT that assisted with 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.38 AT, like fall prevention and medication management tools, automatic home lighting, and smart home innovations, have been shown to positively impact health outcomes and the quality of life of older adults living independently in their communities.38 Clinicians should consider using AT with clients to address areas that may prevent clients from remaining safely in their home and also to 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 & BGS18 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.39 The Peek et al39 study also surmised community-based older adults were not aware technology could be beneficial to them, and interventions need to consider the adults' social, personal, and physical environment.

Fall Risk Categories

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.

In their article, 2006, Gondo et al. categorized older adults according to their functional status based on their sensory, cognitive, and physical functions. Gondo et al. categorized 304 Centenarians in Tokyo, Japan, 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 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.40(p655)" Frailty can be assessed using the components of the Fried Frailty Phenotype criteria that includes41:

  1. Self-reported unintentional weight loss of at least 10 pounds in the previous year
  2. Weakness based on grip strength testing
  3. Slow walking speed
  4. Self-reported exhaustion and low energy expenditure

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.41 In his article, Kojima42 conducted a systematic review of literature and meta-analysis from articles published 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 found to be a significant predictor of future fall risks, and frailty appeared to be higher in men than in women.30

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:

  1. Not fallen
  2. Experienced one fall
  3. Experienced two falls
  4. Experienced more than two falls

Of the 1066 participants, 37.1% were fallers, while 27.3% experienced one fall, and 9.8% were recurrent fallers (two or more). That study found that institutionalization, age, taking several medications, and muscle weakness were related to falls, but not to the recurrence of falls. 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.43 All participants were 65 years old or older and did not have a history of more than three falls.43 Frailty was found to be a significant and independent predictor of short-term future falls among community-dwelling older people who had volunteered for a physical activity study.43

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.43

Case Study A

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 home. 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 throw 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 there is anything that can be done to increase her independence and safety. What are some of the areas a clinician could assess and address regarding Linda's overall health and home safety concerns?

Discussion:

The clinician would complete a thorough home safety and fall assessment using a standardized or non-standardized assessment. However, it is important to consider the intrinsic and extrinsic factors that cause falls, as well as 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 are affecting her home safety and encourage Linda to speak with her physician/pharmacist about altering her medications if possible. As part of a thorough 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 the removal of 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, the use of 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 her 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.

Case Study B

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?

Discussion:

A thorough home safety and fall assessment that can be standardized or non-standardized should be completed. Luke and his wife’s occupational performance, as well as their safety concerns, interest, medication needs, current environmental supports, and financial resources should be considered. Options should be discussed with Luke and his wife that include strategies that range from low to high-tech solutions that promote aging in place.

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. This can include making recommendations regarding having handrails on both sides of the staircase, appropriate lighting on the staircase, as well as 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 the use of 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 types of smart home technologies available that control devices such as light switches, thermostats, and appliances. If medication management is a concern, medication management apps that provide options for 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.

Resources

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 has a plethora of 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 was developed by the Occupational Therapy Geriatric Group at the University of Buffalo as a means 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.

medhelper

Image obtained from Google Play website

 

pill_reminder_by_medsafe

Image obtained from Medisafe.com

 

my_medschedule_plus

Image obtained from Medicationactionplan.com

 

my_meds

Image obtained from My-meds.com

Conclusion

Falls can have a devastating impact on an older adult's life, potentially affecting independence, self-confidence, and their ability to remain safely in their home. Thus, clinicians must educate their clients and remain up to date on the most available evidence for fall prevention for community-based older adults. Single focus fall intervention programs often include exercise interventions and may also include home hazard interventions. Research supports multifactorial fall prevention approaches to prevent falls in older adults. Multifactorial fall prevention interventions often include education about:

  1. The fear of falling
  2. Medication management
  3. Diet and hydration
  4. Vision interventions
  5. The role cognition plays in falls and how cognition and visual deficits increase an individuals' risk for falling
  6. Appropriate footwear
  7. Exercise components
  8. Environmental and home safety education and
  9. Assistive technology/ assistive devices and strategies

AOTA, the CDC, AARP, and the University at Buffalo all maintain valuable resources about fall prevention and aging in place for community-dwelling older adults. Being able to provide 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 most older adults want to remain in their homes as they age. However, falls can prevent older adults from remaining safely in their homes and being active participants in their communities. Clinicians need to remain updated regarding the evidence supporting fall prevention programs.

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