Fall Prevention Education for Community-Dwelling Older Adults.

Intrinsic fall risk factors include (Karlsson et al., 2013; Li et al., 2023).

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

Extrinsic fall factors include (Karlsson et al., 2013):

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

Frailty has been demonstrated to increase the risk of falls, disability, and death (Park & Ko, 2021). In community-dwelling older adults, frailty is more common in women than men and most common among older women (Park & Ko, 2021). Frailty is characterized by decreased physiological reserve, making older adults more vulnerable and increasing the likelihood of poor health outcomes when exposed to stressors (Won, 2019). Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic tool that evaluates functional, medical, psychological, and social abilities to assess frailty status and other geriatric conditions (Lee et al., 2020). The Frailty phenotype (FP) and the Clinical Frailty Scale (CSF) are two assessments commonly used to assess frailty (Montero-Odasso et al., 2022). The FP includes five categories: slow gait, unintentional weight loss, low physical activity, muscle weakness, and exhaustion. Individuals are categorized as frail if they fit three or more criteria (Montero-Odasso et al., 2022). The CSF uses a scale from 1 to 9, with 1 indicating someone is very fit and 9 indicating terminal illness. Scores of 4 or more indicate frailty.

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 (Kojima et al., 2015). All participants were 65 or older and had no history of more than three falls (Kojima 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 (Kojima 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 (Kojima et al., 2015).

A 2021 systematic review and meta-analysis explored the stages of frailty in middle-aged and older adults. The review, which included 29 studies, found individuals considered frail had a higher risk of adverse health effects, including falls, bone fractures, disability, dementia, and death (Chu et al., 2021). Their study confirms that frailty is linked to an increased risk of falls and hip fractures (Montero-Odasso et al., 2022). Assessing frailty among middle-aged and older adult clients may reduce the adverse effects of frailty in these populations (Chu et al., 2021). Therefore, it may be advantageous to begin assessing frailty in middle-aged populations to reduce the adverse effects of frailty as individuals age.

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 also noted that exercise also had a fall-prevention effect in community-dwelling adults with Parkinson's disease. Additionally, the USPSTF’s 2024 recommendation statement concluded with moderate certainty that exercise interventions offer a moderate net benefit in preventing falls and fall-related morbidity in older adults at increased risk for falls.

In their recommendation statement, USPSTF noted that effective exercise interventions included supervised individual physical therapy and group exercise classes. Gait, balance, and functional training were the most commonly studied components, followed by strength, resistance, flexibility, and endurance training. Exercise interventions typically occurred 2 to 3 times per week over 12 months (Guirguis-Blake et al., 2018). Of note, however, is that pain, musculoskeletal discomfort, and wrist and hip fractures were noted as hazards of exercise-only interventions(USPSTF, 2024).

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). 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 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, 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.

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 stress (Horowitz et al., 2016). In their review, Karlsson et al. (2013) found that home safety programs significantly reduced fall rates in high-risk, community-based older adults with a history of falls or multiple fall risk factors.

Occupational therapists, physical therapists, and nurses can perform home assessments and modifications. Home modification interventions should include an assessment of the individual’s flooring, furniture including bed/chair height, access to their bedroom and bathrooms, lighting, and home layout, including their ability to maneuver within their home free from clutter(WHO, 2017). The evidence supporting the effects of home modification in preventing falls in older adults was further demonstrated by a 2023 systematic review and meta-analysis that included 12 trials that demonstrated that falls could be significantly reduced with home modification interventions (Lektip et al., 2023).

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. 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, fall 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 Lavedan et al., a meta-analytic review by Schepens, Sen, Painter, and Murphy (2012) on fall-related efficacy and activity in community-dwelling older adults. In their longitudinal study, Lavedan 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.

A systematic review of multifactorial programs for older adults to reduce falls found a significant decrease in the fear of falling when participants were part of a multifactorial program that included exercise with health education and a home-based program (Loureiro et al., 2021). Further research supports the need for clinicians to assess the fear of falling as part of their comprehensive treatment planning. In their scoping review, Whipple, Hamel, and Talley (2018) 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., 2018). Non-effective treatments also included one-time assessments without resources for participants to implement the recommended improvements. Clinicians should address their client’s fear of falling because it can significantly impact their overall function, including their willingness and comfort level in daily functional activities. Clinicians should address the fear of falling throughout client sessions, as the research indicates that one-time education is insufficient.

Polypharmacy, the regular use of five or more drugs, increases fall risks (Varghese et al., 2024). 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. 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 falls resulting in injury. Their results were confirmed in a 2021 study by Ie et al. (2021) on low-income community-dwelling older adults who found that using two or more FRIDs was a predictor of fall risks, regardless of the total number of medications the individual was taking. The authors also noted that little evidence is available regarding the effects of reducing FRIDs (Ie et al., 2021). The Panel on Prevention of Falls in Older Persons, AGS & BGS (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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 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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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) of daily vitamin D supplements are recommended for older adults with Vitamin D deficiency. They should be considered for individuals suspected of having the deficiency or at high risk for falling (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011).

A 2022 study that included 38 RCTs and 350 participants reviewed the relationship between the effects of vitamin D with or without calcium supplements and those of a placebo or no treatment on fall incidences in adults 50 and older (Wei et al., 2022). The research found doses of 700 IU to 200 IU of supplemental daily vitamin D were associated with a lower risk of falls among ambulatory and institutionalized older adults( Wei et al., 2022). Of relevance, in their 2024 recommendation, the USPSTF found insufficient evidence to assess the benefits and harms of vitamin D and calcium supplementation alone or in combination for the prevention of fractures in men and premenopausal women.

Older adults’ nutritional and hydration status has also been linked to falls (Lindner et al., 2015). Polypharmacy, physiological changes in satiety, dysphagia, food access, and poorly fitting dentures contribute to malnutrition (Esquivel, 2017). In their prospective analysis, Sandoval-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. Dehydration occurs when the body loses too much water and fluids. It is associated with increased morbidity and mortality and can often be unidentified in community-based populations (Lacey et al., 2019). Dehydration places older adults at increased risk of urinary tract infections, renal failure, confusion, and falls (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). The Panel on Prevention of Falls in Older Persons, AGS & BGS (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011) includes hydration as a strategy for fall prevention among older adults.

Malnutrition in older adults can increase the development of geriatric syndromes that contribute to higher risks of falls, osteoporotic fractures, and increased mortality and morbidity (Kupisz-Urbanska & Suchowierska, 2022). Nutritional status in older adults is linked to the musculoskeletal system, bone density, strength, fall risk, postural instability, and immobility (Kupisz & Suchowierska, 2022). Malnutrition increases functional decline and an older adult’s overall health status (Kupisz & Suchowierska, 2022). It is linked to declines in mobility, instrumental activities of daily living, and quality of life (Kupisz & Suchwoeirska, 2022).

A 2020 study of 10,675 adults aged 65 and older in Korea examined the nutritional status of participants and found that participants who fell had poor nutritional status compared to non-fallers (Jo et al., 2020). The study also found that the link between nutritional status and the likelihood of falls was statistically more significant in women than men (Jo et al., 2020).

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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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 affects 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 (Davis 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.

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 unbuckled or untied shoes 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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). However, there is debate about the appropriate heel height and shoe type to decrease fall risk. In their review, Ambrose et al. (2013). Note 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). A 2018 systematic review that included 15 papers about foot problems in community-based older adults found that hallux valgus, lesser toe deformity and foot pain were linked to falls in older adults (Menz et al., 2018).

Wingood et al. (2022) developed the Screening Tool for Feet/Footwear-Related Influences on Fall Risk as an interprofessional healthcare tool to support clinicians in screening for footwear and foot problems that impact fall risk among community-dwelling older adults at risk for falls. The tool screens for items and asses areas including:

• Footwear and Footwear habits
• Nail or Skin changes
• Foot and Ankle Deformities
• Foot and Ankle Strength
• Foot Pain
• Foot Sensation 

The AGS and BGS also recommended that older adults be aware that shoes with low heels and high surface contact can reduce fall risks (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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 Menz et al. systematic review also supported this, recommending that documented foot problems and referrals to foot care specialists be part of fall risk assessments and prevention.

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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 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 cautiously introduced as it can increase falls in individuals with limited mobility who are not used to physical activity (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011).

A 2020 systematic review and meta-analysis of 41 trials that assessed the long-term effects of multifactorial interventions in preventing falls in community-dwelling older adults found exercise to be the most commonly prescribed component of multifactorial fall intervention programs (Hopewell et al., 2020). Twenty trials found evidence supporting that multifactorial interventions reduced the rate of falls and slightly lowered the risk of people having one or more falls and recurrent falls (Hopewell et al., 2020). 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. It may increase falls in older adults with limited mobility (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011).

The World Guideline for Falls Prevention and Management for Older Adults recommends that an older adult without a history of falls or who had one non-severe fall and has no gait problems is considered Low Risk, with the recommendation being that they are educated on fall prevention, engage in physical activity and are reassessed annually. Older adults with one non-severe fall but also have balance or gait problems are considered Intermediate Risk. They should be educated about falls, participate in balance and strength training exercises, and receive a referral to physical therapy to reduce their fall risk.

High-risk individuals are those who (Montero-Odasso et al., 2022):

• Have had multiple falls in the past year
• Have an injury
• Are frail
• Unable to bet up after a fall without help after an hour
• Have a suspected loss of consciousness

These individuals should be recommended for a multifactorial fall risk assessment, receive individualized interventions to address their needs and have a 30-90 day follow-up.

Poor lighting, cluttered walkways, and unsecured rugs are common household dangers that can increase the risk of falling. 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 (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). In their 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).

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 program component 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.

In their study, Horowitz et al. (2013) noted home modifications and assistive technology that assisted mobility, increased independence and safety with self-care tasks, and reduced caregiver assistance hours. An assistive technology 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, n.d.).” Assistive technology devices can be placed on a continuum that includes no-tech, low-tech, mid-tech, and high-tech solutions (ATIA, n.d.). The continuum is based on the device’s complexity and the level of training needed to operate it. No-tech solutions do not require assistive technology (Georgia Institute of Technology, n.d.). 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 assistive technology devices are inexpensive, easy to use and maintain, and have simple features (Georgia Institute of Technology, n.d.). Examples of low-tech solutions include motion-sensor lights and bath mats. Mid-tech assistive technology devices/solutions may be operated electronically or by a battery, have some complex features, and require some training (Georgia Institute of Technology, n.d.). Examples of mid-tech devices include medication management systems and apps under $100 (Georgia Institute of Technology, n.d). High-tech assistive technology devices are often computerized, require more extensive maintenance training, and might be expensive (Georgia Institute of Technology, n.d.). Examples of high-tech devices include stair lift systems and environmental control devices.

Occupational therapists can recommend assistive technology in the home for community-based older adults as part of a fall prevention program. 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.

Technology solutions can support community-dwelling older adults throughout the aging process with solutions to address chronic disease management, greater independence, and fall prevention (Verloo et al., 2020). A 2020 European study examined the perceptions and use of technology among community-dwelling older adults 65 and older and their professional and informal caregivers. All participants were living in France or the French-speaking part of Switzerland had prescriptions or indications for medical home care and were considered independent or had cognitive and physical limitations impacting their level of independence. Informal caregivers included spouses, siblings, and friends, while formal caregivers included nurses, occupational therapists, social workers, and care assistants. The community-dwelling adults found the technology useful, especially those with health problems; however, they rarely saw the need to use it themselves unless they had difficulties with ADLs. Many of the participants preferred help provided by humans over technology. Overall, the participants had positive attitudes toward technologies that supported continued mobility at lower costs and with advanced functions. They had negative attitudes toward some technology due to fear of becoming dependent, decreased interactions with caregivers, concerns about disturbing caregivers with alarms, and financial costs. The study also noted that informal caregivers had more positive attitudes and acceptance toward technology than community-dwelling caregivers but also noted feelings of being overwhelmed by the technology. The professional caregivers had mixed attitudes toward technology, but many showed interest in everyday use solutions such as solutions to support ADLs. They noted barriers related to a need for training, costs, and fears of being replaced by technology solutions (Verloo et al., 2020).

The 2020 Verloo et al. study highlights the importance of incorporating technology solutions into caring for community-dwelling adults with physical and cognitive deficits. Community-dwelling adults and their informal and formal caregivers still have limited knowledge about how technology can assist with daily living activities. The results also suggest that most solutions do not require technological advancements but specific adaptations to meet the users (Verloo et al., 2020). Clinicians should educate themselves about the latest and research-based assistive technology solutions to address areas that may prevent them from remaining safely in their homes and address deficits that occur as part of aging.