Home Safety Evaluation and Fall Risk Assessments for Community-Dwelling Older Adults: Reducing the Risk for Falls

Falls are defined as any unplanned descent to the ground. Although preventable and not an inevitable part of the aging process, falls have been reported to be one of the most significant causes of injuries and injury-related deaths in the older adult (65 years of age and above) population (Centers for Disease Control and Prevention [CDC], 2023). Notably, 85-year-old plus females of Alaskan Native or American Indian descent are at a higher risk for falls, and approximately one out of every four 65-year-old plus older adults will experience a minimum of one fall per year (Johnson et al., 2024). A descriptive study conducted by Moreland et al. (2020) stated that the majority of falls in older adults, leading to emergency room visits, occur at home. Accidental falls resulting from extrinsic fall risk factors, like environmental hazards in the home, are prevalent in the older adult population. However, intrinsic factors, such as age-related changes, can also place them at a higher risk for falls in the home (Johnson et al., 2024).

Before conducting a home health safety evaluation, it is necessary to distinguish between intrinsic and extrinsic risk factors for falls. Intrinsic risk factors are comprised of an individual’s unique personal characteristics/contexts, such as age-related physiological changes. Extrinsic risk factors are comprised of environmental characteristics, such as throw rugs, that affect fall-related safety in the home (American Occupational Therapy Association [AOTA], 2020a; Johnson et al., 2024).

Physicians highly consider intrinsic risk factors for falls in community-dwelling older adults to generate referrals for occupational and physical therapy services. Assessment tools like the Timed Up and Go (TUG) test or manual muscle testing are warranted to target intrinsic fall risk factors like a balance deficit or decreased muscle strength. Recommending and training community-dwelling older adults on the safe use of adaptive equipment (AE), inclusive of assistive devices (AD) and durable medical equipment (DME), can address intrinsic fall risk factors by compensating for deficits as part of the rehabilitation treatment approach. The biomechanical approach may be utilized in addition to rehabilitation approaches to address intrinsic fall risk factors by implementing interventions to remediate previously mentioned deficits (AOTA, 2020a).

Intrinsic factors for falls include the following (Nugraha, et al., 2022):

• Increased age
• History of falls in the past
• Presence of chronic diseases (Parkinson’s, dementia, stroke, arthritis, urinary incontinence, etc.)
• Balance deficits
• Functional ambulation/gait deficits
• Vision impairments
• Hearing impairments
• Decreased muscle 

Many older adults are under medical care to treat intrinsic factors such as chronic disease but are unaware of the role that medications or medication interactions may play in decreased balance and risk for falls.  Rehabilitation clinicians need to be aware of such risk factors and encourage their older adult patients to discuss these interrelations with their physicians. Similar encouragement needs to occur related to regular vision and hearing examinations. As movement specialists, the role of occupational and physical therapists cannot be undervalued in improving home safety for community-dwelling older adults. Clinicians can address extrinsic fall risk factors by conducting a home health safety evaluation using appropriate safety assessments in the patient’s home. Occupational therapists (OTs) and physical therapists (PTs) can employ rehabilitation treatment approaches to target extrinsic risk factors for falls by making environmental modifications in the home to improve fall-related safety (AOTA, 2020a).

Extrinsic factors for falls include the following (Nugraha, et al., 2022):

• Side Effects of drugs that cause drowsiness
• No handrails or grab bars in the bathroom
• Slippery floors
• Uneven floors
• Low toilets
• No stair handrails
• Poor lighting and glare
• Furniture walking and inappropriate use of assistive devices, adaptive equipment, or household items

When conducting a home health safety evaluation, OTs and PTs should incorporate evidence-based fall risk assessments and home safety assessments to address intrinsic and extrinsic fall risk factors, justify the need for skilled services, and create a comprehensive treatment plan.

To address the fall risk in a community-dwelling older adult’s home, rehabilitation clinicians must use evidence-based fall risk assessment tools as outcome measures to document justification for required skilled services and to track and measure progress. Such fall risk assessment tools are necessitated for reimbursement by health insurance companies, including Medicare and Medicaid. Frequently used home health fall risk assessment tools to address the popular intrinsic risk factor of decreased balance in community-dwelling older adults include the TUG, 30-Second Chair Stand test, Functional Reach test, Four Step Square test, 5 Times Sit-to-Stand test, and the Berg Balance Scale (Lusardi, 2017; Wang-Hsu, 2020). Each assessment tool takes approximately five minutes or less to administer, except for the Berg Balance Scale, which may take 15-20 minutes (Lusardi, 2017; Wang-Hsu, 2020).

In a systematic review conducted by Lusardi et al. (2017), the Berg Balance Scale, TUG, and the 5 Times Sit-to-Stand fall risk assessment tools are the most evidence-based outcome measures in determining the future fall risk of community-dwelling older adults. The Four Step Square and Functional Reach tests are also sufficient as evidence-based functional outcome measures for predicting fall risk (Lusardi, 2017; Wang-Hsu, 2020). Although widely used, the 30-Second Chair Stand test has limited evidence and is currently under review for its effectiveness in assessing fall risk (Wang-Hsu, 2020). In addition to using the suggested evidence-based fall risk assessments on community-dwelling older adults to address intrinsic fall risk factors, clinicians should familiarize themselves with the specific assessments preferred by their healthcare agency or organization.

Based on their findings during the fall risk assessment, the occupational or physical therapists can develop an appropriate treatment plan with specific interventions to meet the older adult’s needs. This may include strengthening exercises if specific areas of weakness were identified through manual muscle testing.  Balance exercises may be devised within the safety construct of the older adult, for example, standing with feet together on firm ground and eventually progressing to standing with feet together on a soft surface like a mat to replicate the balance needs of moving from hard flooring to carpeted flooring.  Many older adults think that decreased balance or loss of balance is just a normal part of getting older and are unaware that there are many exercises and training techniques that can be employed to improve their balance, reduce the risk of falls, and improve their safety.

Appropriate evidence-based home safety assessments to address environmental extrinsic risk factors, available to rehabilitation clinicians, include the Housing Enabler (HE), In-Home Occupational Performance Evaluation (I-HOPE), Home Safety Self-Assessment Tool (HSSAT), and Rebuilding Together At Home Safety Checklist (National Council on Aging, 2017).

The HE is unique because it assesses personal intrinsic fall risk factors like the functional capacity of the individual (P) as well as extrinsic factors like environmental barriers (EB) inside and outside the home (National Council on Aging, 2017; Pettersson et al., 2018). A scoring matrix calculates a score by combining P and EB components, allowing clinicians to assess the magnitude of accessibility issues (Pettersson et al., 2018). The HE is an internationally renowned instrument with good reliability and validity (Pettersson et al., 2018).

The HSSAT is a practical assessment that addresses extrinsic environmental risk factors for falls and includes a checklist of common fall hazards and solutions to common problems, inclusive of education on assistive devices and home modifications in nine areas of the home (Horowitz et al., 2016). The list of fall hazards accompanied by visual illustrations is especially useful in raising an individual’s awareness of fall risks within their home environment (National Council on Aging, 2017). The HSSAT can be used by community-dwelling older adults for home safety health, is available at no cost, and has robust test-retest reliability, interrater reliability, and content validity (Tomita et al., 2014 as cited in Horowitz et al., 2016). In an explorative study conducted to ascertain older adults’ views of the HSSAT, older adults indicated that the HSSAT assisted them in establishing a plan for home safety (Horowitz et al., 2016).

Trained rehabilitation clinicians can use the I-HOPE to evaluate personal intrinsic risk factors for falls and assess the client’s person-environment fit in the home, including environmental extrinsic factors such as size manageability, accessibility, and safety (National Council on Aging, 2017). Although a valuable tool, Australian OTs, who conducted a qualitative study on the clinical utility of the I-HOPE, suggested that a minimum of half a day of training, an improved instruction manual, and an online training resource (video) could enhance the utilization of I-HOPE (Aplin & Ainsworth, 2018).

Rebuilding Together Safe At Home Checklist is an AOTA-endorsed resource, created in partnership with the Administration on Aging, that homeowners and their family members can use to help identify extrinsic fall risk hazards and accessibility issues, covering twelve home area categories within their home (Grasso et al., 2023). This resource provides an adjacent list of solutions and modifications for listed hazards in each of the twelve home area categories (AOTA, 2023b). Rebuilding Together Safe At Home Checklist has national partnerships with stakeholders ranging from community to national levels, including but not limited to aging area agencies and the National Association of Home Builders (NAHB; AOTA, 2023b).

The HE, HSSAT, and Rebuilding Together Safe At Home Checklist are available at no cost for clinicians to obtain for utilization. However, the I-Hope Kit costs $75 and is available online (Washington University, 2023). Substantial evidence supports a multifactorial approach (including intrinsic and extrinsic factors) to address fall risk factors in community-dwelling older adults. However, evidence suggests that addressing extrinsic fall risk factors alone can help lower the incidence and prevalence of falls, especially for at-risk older adults (Steven & Burns, 2015, as cited in Horowitz et al., 2016). Again, in addition to using the suggested evidence-based home safety assessments for community-dwelling older adults, clinicians should familiarize themselves with the specific assessments preferred by their healthcare agency or organization.

Environmental fall hazards can differ amongst cultures, types of housing, and geographical locations (urban versus rural or north versus south), with regional climate also affecting extrinsic fall risk factors in the home (Kim et al., 2023). Several studies included in Kim and colleagues’ systematic review (2023) have confirmed that the most common home areas where falls have been reported amongst the older adult population are the bathroom and bedroom and that most falls in this population occur indoors versus outdoors. A scoping review by Keglovits et al. (2020) supports Kim et al.’s study by concluding that a higher percentage of falls in older adults occur in the bedroom and bathroom, where they spend the most time moving, changing positions, and performing activities of daily living (ADLs) (Keglovits et al., 2020). A list of common extrinsic fall risk hazards in the bathroom and bedroom and suggested modifications are depicted in the table below. Additional extrinsic fall risk hazards found in other areas of the home can be found in the HSSAT and Rebuilding Together Safe At Home Checklist.

Although DME, AE, and AD are used interchangeably, per the national government agency Medicare (Medicare.gov, 2023), DME is characterized by any equipment that can withstand repeated use, is prescribed by a Medicare-enrolled physician for a medical reason for use in the home, that is typically only helpful to someone who is ill or injured, and is expected to last three years. DME includes, but is not limited to, assistive devices (AD). ADs are typically mobility aids, such as canes, crutches, bedside commodes (BSC), walkers, wheelchairs, and scooters (Medicare.gov, 2023; National Institute of Child Health, 2018). AE includes safety equipment like shower chairs, grab bars, and mobility aids that limit task demand and help compensate for intrinsic fall risk factors (like balance impairment) to prevent injury in individuals with limited mobility. AE refers to any equipment that facilitates participation in instrumental activities of daily living, such as rest, sleep, play, leisure, social participation, health management, and work (Bergem, 2020). AE can include mobility devices, referred to as AD and DME.

Rehabilitation professionals training older adults in the safe use of AD, like canes and walkers, can help older adults compensate for intrinsic fall risk factors. However, rehabilitation professionals must exercise clinical reasoning and judgment to select the most appropriate type of AD for the older adult. When doing so, consideration of factors like available strength, endurance, balance, cognition, and the older adult's home environment must be included (Cruz et al., 2020).

BSC, placed on top of regular commodes, can be helpful as AE for assisting older adults with toilet transfers and can help compensate for intrinsic factors like decreased range of motion in lower extremities by raising the height of the regular commode. Please refer to Table 1 for alternative options that raise the height of the toilet. BSCs are also known as 3-in-1 commodes due to their versatility and multi-use features. For example, BSC can also be placed at the bedside to compensate for limited functional ambulation ability in older adults due to strength and endurance impairments, especially during nighttime when limited visibility can further increase the risk for falls. Using BSC as a shower chair can help mitigate intrinsic fall risk factors such as decreased balance, strength, and endurance. Please refer to Table 1 for shower chair options other than BSC.

Fixed grab bars in bathrooms can assist older adults with transfers on and off commodes and in and out of the shower, helping compensate for balance impairments and minimizing fatigue by allowing for weight distribution. The placement and orientation of grab bars have been described under bathroom suggested modifications in Table 1. For adults with somatosensory deficits, grab bars with a textured handle are recommended to compensate for insufficient tactile registration and provide a slip-resistant grip.

Adaptive strategies may address intrinsic factors such as vision impairments outside of DME, AD, and AE. For example, An older adult with contrast sensitivity impairment may be at higher risk for falls in the bathroom because they may be unable to distinguish between the white toilet seat and light-colored flooring. In this case, adapting the environment by replacing the toilet seat with a black one would improve their ability to distinguish between the toilet seat and the floor, making for a safer transfer onto the commode.

Rehabilitation professionals need to consider each individual's inherent worth and uniqueness and their medical profile when assessing for intrinsic and extrinsic fall risk factors, as this will determine tailored and comprehensive treatment plans inclusive of multi-treatment approach-based interventions, home modifications, and recommendations for DME, AD, and AE.

Mrs. Patel is a married 66-year-old female who is two days status post elective left total knee arthroplasty (LTKA), with weight-bearing as tolerated (WBAT) on her left lower extremity (LLE). She was discharged home with a front-wheeled walker (FWW) from the hospital on the same day she had the knee replacement surgery. One-week post-discharge, Mrs. Patel will start receiving outpatient physical therapy two times a week.

Following discharge, she and her husband chose to stay at her adult daughter’s home due to not having a bedroom on the first floor of their two-bedroom townhome and her inability to navigate a flight of stairs post-surgery safely. Her daughter is a licensed occupational therapist (OT) and a Certified Aging in Place Specialist (CAPS). The daughter recently moved into a new home with a ground-level bedroom and adjoining accessible bathroom.

Door widths throughout the home are 36 inches, 4 inches above the 32-inch standard per code, and sufficient for navigation with all types of walkers (Young et al., 1998). While recovering from the surgery in her daughter’s home, Mrs. Patel can functionally ambulate well using the FWW, requiring occasional supervision from family, more so if ambulating in areas of the home other than the bedroom or bathroom. The walk-in shower door of the bathroom is not wide enough for her to walk into with her walker; however, the zero-step entry into the shower lowers the risk of falls by eliminating a threshold she could not negotiate due to the limited range of motion in the left knee. There is a 45-degree angle grab bar installed into the wall across from the shower door that can assist with the transfer onto the built-in solid bench at the back wall of the shower. A vertical grab bar on the outside wall of the shower door and another grab bar in a horizontal orientation on the wall across the shower door need to be installed to enhance safety and compensate for Mrs. Patel’s decreased dynamic standing balance when stepping into the shower without the walker. The built-in bench in the walk-in shower does not have armrests to help facilitate transfers on and off the seat, and therefore, Mrs. Patel will need to have a shower chair with armrests or BSC placed in the walk-in shower. Luckily, there is enough space in the walk-in shower to accommodate this addition. Water does not leak through the zero-entry walk-in shower. A low-profile slip-resistant and water-absorbing mat has been placed outside the shower door to capture any water when exiting and minimize the risk of falls due to a slippery wet floor. Although Mrs. Patel does not have any visual impairments, when designing the home, her daughter incorporated a small round patterned mosaic tile, with many grout lines in a different color to the color of the bathroom floor tile to enhance the grip of feet on the shower floor, prevent slipping, and compensate for impaired contrast sensitivity. The toilet in the bathroom is two inches higher than the standard minimum of 15 inches per code, so although the height is appropriate for Mrs. Patel’s current level of function, no armrests can assist her with the transfer (Young et al., 1998). The addition of a toilet safety frame bolted into the toilet would provide sturdy and comfortable assistance during transfers.

The bedroom has an appropriate-height king-sized bed with clear pathways on both sides and adequate space for Mrs. Patel to use the FWW during functional ambulation. She requires occasional minimal assistance for her LLE to get into bed but can get out independently. Mrs. Patel and her family try to ensure she always has a water bottle on her nightstand because she often needs it to ingest her medicine and gets thirsty, especially at nighttime. There is a long desk/dresser combination on the opposite wall of the head of the bed, with plenty of walkway space in between. The lower dresser has a small refrigerator filled with water bottles. If Mrs. Patel runs out of water on her nightstand, she can use her FWW to ambulate to the dresser to obtain more water, but she cannot safely open the lower dresser and the small refrigerator to get a water bottle. To accommodate Mrs. Patel, her daughter has temporarily placed the small refrigerator on the top surface of the dresser, thereby eliminating the need for Mrs. Patel to bend her knees and squat down to access the water. As mentioned previously, Mrs. Patel gets thirsty often, especially at nighttime, meaning frequent nighttime visits to the bathroom. The clear walkways on the sides of the bed and between the bed and desk/dresser combination are ideal for functional ambulation with a FWW. However, with the light switch on the opposite side of the room, her daughter must incorporate stick-on battery-operated motion sensor lights along the pathway from her bedside down to the bathroom door. This will give her the light needed to safely ambulate to the bathroom with her FWW without disturbing her husband.

With Mrs. Patel’s daughter being a CAPS-certified OT, many features of the bathroom and bedroom made it ideal and safe for Mrs. Patel to continue participating in occupations that were meaningful to her post-LTKA. Some missing features mentioned as recommended additions to enhance safety could easily be implemented at a minimal cost (stick-on battery-operated motion sensor lights and the toilet safety frame). Installing additional grab bars in the bathroom would be more costly but, as permanent fixtures, would essentially increase the home's value by promoting comfort and usability. Without these features and suggested home modifications, Mrs. Patel would be at increased risk for falls and rehospitalization.

It is important to note that if Mrs. Patel’s daughter were not an OT, she would have needed a home health safety evaluation ordered by her physician and conducted by licensed OTs or PTs to address intrinsic and extrinsic risk factors for falls in the home upon discharge from the hospital.

More than 75% of falls in the elderly occur inside the home and due to age-associated functional decline. Older adults who wish to age in place are at substantial risk for falls (Trudeau, 2017). In 2014, 800,000 out of 2.8 million older adults were treated in emergency rooms for fall-related injuries; estimated medical costs in 2015 for fatal and nonfatal falls in older adults were $50 billion (Choi et al., 2019). Medicare and Medicaid shouldered 75% of the estimated $50 billion in medical costs related to falls (CDC, n.d.). With depleting Medicare and Medicaid funds, it becomes imperative that healthcare providers and allied health professionals think innovatively to find a way to reduce these costs in the interest of existing and future generations and to provide older adults with a quality of life that is often compromised with falls that lead to head injuries or hip fractures (CDC, n.d.).

Conducting home health safety evaluations for community-dwelling older adults wanting to age in place can improve safety, accessibility, and ability to function in their own homes. Age-associated functional decline and personal contexts (intrinsic fall risk factors) and environmental (extrinsic fall risk) factors necessitate implementing adaptive strategies, environmental adaptations, and home modifications in the homes of those who wish to age in place safely.

Rehabilitation professionals are responsible for selecting evidence-based fall risk assessments to support the need for home health safety evaluations and skilled services to address intrinsic fall risk factors but also need to identify the appropriate home safety assessments to justify the need for skilled interventions to address extrinsic fall risk factors. OT and PT practitioners should focus on the most frequently used areas of the home, common areas where falls occur, and hazards found in those areas as they conduct home health safety evaluations. Only then can they outline appropriate recommendations to address fall hazards found in the homes of older adults.

Appropriate home modification recommendations to address intrinsic and extrinsic fall risk factors may require rehabilitation professionals to suggest specific DME, AE, and AD to enable patients to age in place safely. Home health safety evaluations require the expertise of rehabilitation professionals such as occupational therapy or physical therapy practitioners. OTs or PTs with a CAPS designation are especially equipped to address incompatibilities between the person and the home environment that many elderly people experience. They can offer choices in addressing aging in place safely, decreasing the risk of falls, and promoting safety and accessibility within their homes.

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