Fall Prevention Education for Community-Dwelling Older Adults

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 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 of 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 on 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).

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, and 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, 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 aged 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, decreased 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 visual loss (Blaylock & Vogtle, 2017). As a result of visual deficits with aging, some fall intervention programs may include visual deficit 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, low-vision individuals 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 using 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 their home.

An older adult's footwear can increase their 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 shoe type to decrease fall risk. In their review, Ambrose et al. (2013). noted that 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 healthcare 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 as 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.