© Springer International Publishing Switzerland 2015Ingrid Söderback (ed.)International Handbook of Occupational Therapy Interventions10.1007/978-3-319-08141-0_63
63. Preventing Falls in the Elderly: Opportunities and Alternatives
Faculty of Health Sciences, University of Sydney, East St Lidcombe, Sydney, NSW, 1825, Australia
About 30 % of older people who fall lose their self-confidence and start to go out less often. Inactivity leads to social isolation and further loss of muscle strength and balance, increasing the risk of falling again. The causes of falls can be multiple, and there are several successful preventive programs that occupational therapists (OTs) have had a key role in developing and implementing. These include (a) home environmental adaptations conducted on home visits—the Westmead approach, (b) a multifaceted group educational program based on cognitive learning techniques—the Stepping On program, and (c) a nontraditional approach to balance and strength training embedded in daily routines—the LiFE program. All three are evidence based with randomized trial evidence and are manualized to enable therapists to implement them.
KeywordsAccidental fallsFalls preventionHabit reframingHome and community safetySelf-efficacy
It’s made me more aware, just so much more aware. Of the buses, of my place. Of making it brighter inside, getting rid of leaves outside, of everything.
What you have done is focus on our abilities. No one else has done that.
I feel more confident and I’m going out more.
Home safety audits have consistently proven to be effective in reducing the risk and rate of falls when conducted by occupational therapists (OTs; Clemson et al. 2008b). The Westmead is an iterative approach to assessment and intervention whereby the OT moves through the home environment with the client jointly identifying hazards and risky behaviors, problem-solving solutions, and assisting to prioritize actions (Clemson 1997). In randomized trials of this intervention, falls have been reduced both at home and in the community (Campbell et al. 2005; Cumming et al. 1999), suggesting there is generalization of hazard awareness and safety behaviors beyond the home environment.
Stepping On is a multifaceted falls prevention program for the community-residing elderly (Clemson and Swann 2008). The program was developed by OTs in 2003. It evolved from a review of evidence-based interventions, contributions from content experts, and the views of older participants. It is different from a tailored approach where therapists assess risk factors and prescribe interventions based on risk assessment. In Stepping On, the older person is encouraged to have ownership of which strategies are relevant to them. Homework and follow-up support their engagement in relevant preventive strategies.
The LiFE program (Clemson et al. 2014) fills a gap for those older people who have struggled with maintaining regular exercise on a set time each week and provides another choice of an evidence-based program that reduces falls risk. Taught on home visits, movements which improve balance or increase hip, knee, and ankle strength are embedded in routine daily activities and done multiple times each day. LiFE activities or movements are closely aligned to functional activity. The participant learns the principles behind the program and engages with the therapist in planning weekly activities and upgrades. The LiFE program demonstrated significant improvements in balance and also resulted in improved functional capacity and more energy (Clemson et al. 2012).
A fall is defined as an event, including a slip or a trip where the person loses their balance and inadvertently lands on the ground or floor or other lower level. It is important to understand people’s perception of their fall, what they think could have caused the fall, and what they think could be done to stop a future fall.
The programs aim to reduce falls and fulfill one or more of the following:
Manage personal fall risk.
Maintain safety at home and in the community.
Build confidence in negotiating the environment and in other fall risk situations.
Improve balance and lower limb strength to protect from falling.
Candidates for the Intervention
The home safety intervention is best targeted to at-risk older people and works best with people who have had a fall in the past year. At-risk groups include frail older people, those recently hospitalized, and people with severe vision impairment.
Stepping On and LiFE are also suited to community-residing elderly people who are around 70 years of age and over and who have had a fall. Stepping On is also offered to people who have concerns about falling but is not suitable for people with a cognitive impairment or homebound as the focus includes community mobility. Typically, there are more women in the Stepping On groups than men, but the research supports specific benefit for men who have fallen, so inclusion of both genders are encouraging. The LiFE program’s randomized trial recruited people who had two falls or an injurious fall (Clemson et al. 2012), and a translational project successfully implemented the LiFE program in a post-hospital reablement program (Burton et al. 2013).
Falls are a common and serious problem for older people . Some 30–35 % of persons who are age 70 or older fall each year (O’Loughlin et al. 1993). Injurious falls are a leading cause of hospitalization and can lead to social isolation and premature institutionalization (Tinetti and Williams 1997). Risk factors for falls include poor balance, reduced lower leg strength, poor vision, chronic disorders, depression, and sleep disturbances (Deandrea et al. 2010). Fear of falling is also a common occurrence, with reported incidence of 30–70 % and increasing with age (Vellas et al. 1997). It is more prevalent in those who report multiple falls, poorer health, or unsteady balance (Lack 2005). Core interventions known to have an impact supported by meta-analyses are exercise, environmental adaptation, and medication management (Gillespie et al. 2012).
The prevention intervention is performed by home visits or group based in community venues. Venues chosen should be in an accessible place in the community, situated near public transportation.
Clinical Application of Preventing Strategies
It is important that theory underpins each of these programs and from which these specific preventive strategies are derived. Each has a different conceptual model, but overlap in that they use principles of self-efficacy , personal control, and enable a sense of ownership of solutions or strategies.
The following criteria define what should be included in a quality home safety intervention (Clemson et al. 2008a):
Formal and observational evaluation of the functional capacity of the person within the context of their environment. This includes physical capacity, behavior, functional vision, habits, and how the person uses and moves within home spaces. What is a hazard for one person may not be a hazard for another. For example, tripping hazards and clutter may be more of an issue for someone who is frailer with mobility problems, where as an active person may need to reconsider how they change a light globe or climb to reach high cupboards. For someone with a vision impairment, lighting and contrast at changes of level are particularly pertinent in all areas of the home.
A comprehensive evaluation process of hazard identification and priority setting taking into account both personal fall risk and environmental audit. Hazards can be trip or slip hazards, situations that could lead to loss of balance, or habitual behaviors that place the person at risk of falling.
Use of an assessment tool validated for the broad range of potential fall hazards.
Actively involving the older person in identifying the hazards, priority setting, and problem-solving. This collaborative process is critical to raise awareness of environmental and behavior risk, identify safer strategies, and plan ways of prompting to change the environment or embed more protective behaviors into habitual routines. For example, a range of strategies could be considered to prevent rushing to answer the telephone.
Provision of adequate follow-up by the health professional and support for adaptations and modifications.
The following assessment tools are recommended for use in a quality home safety intervention:
The Westmead Resource (Clemson 1997) includes a manual that provides background information to falls and environment–person assessment and a comprehensive assessment tool to assist in identifying hazards.
The Falls Behavioral Scale (Clemson et al. 2008a) is sometimes sent to a client prior to a home visit. It provides a useful checklist that (a) provides a profile of risk-taking, (b) provides protective behaviors currently in place, and (c) can act as an awareness-raising tool for the older person, showing of the wider range of potential contributing factors to their falls. It would be recommended that safe mobility practices in public places and when using transport be included.
The Stepping On manual (Clemson and Swann 2008) provides a range of handy hints and strategies that can be used as a resource, for example, safe walking strategies to compensate for low vision and handy hints when catching trains or busses.
Stepping On, led by a therapist as group facilitator, runs for seven 2-h sessions with a follow-up home visit (or telephone) contact and a booster 3-month session. Key content areas include home-based balance and strength exercises, home and community safety , coping with visual loss and regular visual screening, medication management, footwear audits, mobility mastery, and sleep hygiene. Content experts who are skilled in relevant aspects of falls prevention introduce some of the key content areas. For example, we include a physiotherapist to teach the exercises in the initial stages of the program and a mobility officer from the Guide Dogs Association to introduce the strategies for coping with low vision . Information is shared and reinforced within the context of the group by the OT facilitator. Each session provides time for reflection and sharing accomplishments and ends in planning action and homework for the next week. The balance and strength training is practiced or reviewed each week, and one session includes a community mastery experience (usually just outside the venue) during which community mobility and discrete skills (e.g., negotiating grass or curb ramps) are practiced.
The conceptual basis of Stepping On are as follows:
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