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Understanding the role of occupational therapy in fall prevention for community-dwelling older adults
Abstract
Occupational therapy practitioners are uniquely prepared to contribute to fall prevention efforts because of their attention to diverse influences on occupational performance. This article is intended for occupational therapy practitioners who seek to deliver evidence-based fall prevention programs to conununity-dwelling older adults and features descriptions of best practice in fall risk assessment and intervention. Interventions to improve home safety and mobility skills are highlighted, as are shared features of two community-based programs: Matter of Balance and Stepping On.
... The risk of falling is associated with external and internal risk factors (Peterson et al., 2008). Internal risk factors include impairments in balance, gait, muscle strength, visual acuity, cognition, chronic disease, postural hypotension, and use of psychotropic medication (de Vries et al., 2010;Johnson et al., 2009). ...
... External factors refer to environmental factors that increase the risk of individuals falling such as slippery surfaces, obstacles in pathways, and poor illumination. (Peterson et al., 2008). Interventions to reduce the risk of falling have shown mixed success (de Vries et al., 2010;Palvanen et al., 2014). ...
... It was noted that patients who were well and able to attend their appointment were 15 points higher on a modified FIM/FAM, compared to those who were unwell and unable to attend their appointment. Decreased activity engagement post-fall due to fear of falling has also been demonstrated in the literature (Peterson et al., 2008). To address this barrier to activity participation, evidence supports the use of psychosocial and cognitive-behavioral programs such as Matter of Balance and Stepping On (Peterson et al., 2008). ...
Aim: To determine whether a multifactorial intervention can decrease the frequency of secondary falls in older patients presenting to an emergency department with a fall. Methods: A randomized control design comparing multifactorial follow-up intervention to standard care. Risk assessments included Falls Risk for Older Persons—Community Setting Screening Tool (FROP Com Screen) and the Two Item Screening Tool, which were compared for sensitivity. Results: Eight patients (14%) in the control group and 11 patients (20.8%) in the intervention group experienced falls (p = 0.373). The proportion of those identified as high risk that fell was similar between the FROP Com Screen (17%) and the Two Item Screening Tool (17%). Patients on average waited 35 days in the control group and 40 days in the intervention group for an outpatient appointment. Conclusions: There was no significant benefit of the intervention. Our findings support interdisciplinary collaboration, multifactorial intervention, and risk management for falls prevention.
... Falls are associated with limitations in activity, loss of independence, and institutionalization (Stevens, Corso, Finkelstein, & Miller, 2006;Tinetti, Inouye, Gill, & Doucette, 1995) often caused by a combination of medical, social, and environmental factors (Chang & Ganz, 2007). Occupational therapy practitioners are uniquely qualified to address the multifactorial nature of falls, given their knowledge of factors that influence occupational performance (Peterson & Clemson, 2008). The specific role of occupational therapy in fall prevention, however, is unclear. ...
... Although the profession has begun to outline occupational therapy's role in targeting the minimization of fall risk in community-dwelling older adults in these areas (e.g., Juarbe & Bondoc, 2009;Peterson & Clemson, 2008), research is needed that clearly demonstrates the contribution of occupational therapy and efficacy of occupational therapy-led interventions. Guided by the Framework, we outline in the sections that follow the potential contributions occupational therapy practitioners can make to fall prevention intervention in the areas outlined in the AGS and BGS (2010) guidelines in which, at present, no occupational therapy research on efficacy exists. ...
... The limitation in this area of research involves the use of fall risk as the identified outcome. Occupational therapy practitioners can facilitate behavioral changes by addressing changes in a person's routines to decrease fall risk and fear of falling (e.g., instructing older adults to use stair railings consistently; Peterson & Clemson, 2008). Additionally, behavioral interventions may be incorporated into multifactorial interventions such as home modifications and home safety education (AGS & BGS, 2010;Walker & Howland, 1991), exercises (Harling & Simpson, 2008), assertiveness training (Walker & Howland, 1991;Zijlstra et al., 2009), self-efficacy training (e.g., Cheal & Clemson, 2001;Zijlstra et al., 2009), and multicomponent interventions that address fear of falling such as A Matter of Balance (Peterson & Clemson, 2008) and Stepping On (Clemson et al., 2004;Peterson & Clemson, 2008). ...
Falls are a serious public health concern among older adults in the United States. Although many fall prevention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear. This article presents a scoping review of current published research documenting the role of occupational therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in environmental modifications, exercise, and multifactorial and multicomponent interventions. Although research documenting the efficacy of occupational therapy interventions is identified as part of the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008), we identified little or no such research examining interventions to modify behaviors (e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage medications. Although occupational therapy is represented in the fall prevention research, the evidence for the profession's role in many areas is still lacking.
... Home safety fall prevention interventions are more effective when conducted by occupational therapists (Gillespie et al., 2012). Those shown to be most effective incorporate environment-person and problem-solving approaches and use validated, comprehensive tools for identifying fall hazards (Clemson, Mackenzie, et al., 2008;Peterson & Clemson, 2008). However, one implementation study incorporating a home safety component did not show an effect (Hendriks et al., 2008). ...
... Additional resources included community safety mobility strategies and limited information on hazard solutions. The Westmead approach encourages assessment of the persons functional capacity, vision and beliefs about falls, observation of home hazards jointly with clients using a comprehensive checklist of environmental features, jointly prioritising hazards and generating solutions, use of strategies such as targeting behaviours for change, and support with follow up (Clemson;Peterson & Clemson, 2008). ...
... Research indicates that the home safety fall prevention intervention used in this study is effective when conducted by an occupational therapist (Gillespie et al., 2012;Pighills, Torgerson, Sheldon, Drummond & Bland, 2011) but there is a gap in the understanding of what this approach specifically entails (Peterson & Clemson, 2008). Our participants acknowledged that the nature of the intervention enabled them to engage with their clients in ways they had not previously, raising clients' awareness of their risk and their environment, and encouraging ownership of solutions. ...
Background/aimsDespite evidence of the effectiveness of home safety interventions for preventing falls, there is limited uptake of such interventions within community services. Therefore, as part of a broader translational project, we explored issues underlying the implementation of an evidence-based home safety fall prevention intervention.Method
We conducted in-depth interviews with eight occupational therapists and two programme coordinators engaged to deliver a home safety fall prevention intervention. Six community health centres within two metropolitan regions of Melbourne, Australia participated. The RE-AIM framework and Diffusion of Innovations theory underpinned the interviews which examine the enablers and barriers to implementing a home safety fall prevention intervention and integrating it into routine community preventive practice. Analysis involved thematic and content analysis.ResultsInvestment in the home safety for fall prevention intervention was supported and valued by coordinators and therapists alike, and a number of themes emerged which influenced implementation of this intervention. These included issues of: compatibility with organisational processes, individual practitioner practices and skills, a prevention approach, and client expectations; relative advantage in terms of flexibility of the process, client engagement and regional capacity building; complexity of implementing the intervention; and observability related to the invisible nature of fall prevention outcomes.Conclusion
Implementation of this home safety fall prevention intervention was influenced by a range of interrelated organisational, practitioner and client related factors. The findings from this project provide insights into, and opportunities to increase the sustainable implementation of the home safety fall prevention intervention into practice.
... Risk factors typically act together to increase a person's fall risk. [6] There are many risk factors for falls, and only a few are variable ones that we can influence. The most important variable risk factors are balance disorder, gait disturbance, muscle weakness and medication use. ...
... It is, therefore, necessary to take into account the older person's ability to judge what activities he or she can perform. Also, it is essential to consider the history of a person with a previously reported fall as a positive history increases the risk of a fall [6]. Fall prevention activities are implemented through a range of health disciplines including occupational therapy, physiotherapy, general practice, patient care, geriatrics, gerontological health and social care [13]. ...
... FaB (The Falls Behavioral Scale for Older People) evaluates everyday behaviour, both accidental and deliberate, that provides the elderly with protection from falls [6]. ...
... Professional training was considered at a high level when it involved an occupational therapist, ergotherapist or equivalent, as these professions have specific expertise evaluating both the person and the environment. Trial interventions were classified as high or not high intensity using four criteria based on best practice (Peterson & Clemson, 2008) and agreed on a priori by the investigators. ...
... Such judgments are based on considering a range of factors. These include history of falls, patterns of usage of the home, protective and risk-taking behaviors, functional vision, physical and cognitive attributes that affect mobility and task performance, and fall risk in specific situations such as reaching, climbing, and transferring (Clemson, 1997;Peterson & Clemson, 2008). Case-control, cohort, and qualitative studies (Clemson, Manor, & Fitzgerald, 2003;Lord et al., 2006;Northbridge, Nevitt, & Kelsey, 1996) have suggested that hazards are riskier for people with balance and other conditions related to frailty and that behavior change strategies need to be employed. ...
Objective. This study seeks to determine the efficacy of environmental interventions in reducing falls in community-dwelling older people. Method. A systematic review and meta-analysis of randomized trials was performed. Results. Pooled analysis of six trials (N = 3,298) demonstrated a 21% reduction in falls risk (relative risk [RR] = 0.79; 0.65 to 0.97). Heterogeneity was attributable to the large treatment effect of one trial. Analysis of a subgroup of studies with participants at high risk of falls (four trials, n = 570) demonstrated a clinically significant 39% reduction of falls (RR = 0.61; 0.47 to 0.79), an absolute risk difference of 26% for a number needed to treat four people. Discussion. Home assessment interventions that are comprehensive, are well focused, and incorporate an environmental-fit perspective with adequate follow-up can be successful in reducing falls with significant effects. The highest effects are associated with interventions that are conducted with high-risk groups.
... Current best practice in fall prevention is multifactorial and includes: environmental adaptations in the home, balance training, gait training, strengthening exercises, adjustments to medication, management of vision problems, and management of cardiovascular issues (Peterson & Clemson, 2008). Clinical practice guidelines emphasize that interventions should be customized, based on assessment, and include an exercise program that targets balance, cardiovascular functions, and gait (Avin et al., 2015;Peterson & Clemson, 2008). ...
... Current best practice in fall prevention is multifactorial and includes: environmental adaptations in the home, balance training, gait training, strengthening exercises, adjustments to medication, management of vision problems, and management of cardiovascular issues (Peterson & Clemson, 2008). Clinical practice guidelines emphasize that interventions should be customized, based on assessment, and include an exercise program that targets balance, cardiovascular functions, and gait (Avin et al., 2015;Peterson & Clemson, 2008). These guidelines mention evidence that Tai Chi is effective as an intervention (Gillespie et al, 2012); swing dance involves a comparable range of motion, albeit at a faster pace. ...
This article describes using the Knowledge to Action Cycle (graham et al. 2006) to guide the development of a clinician handbook to assess feeding and swallowing issues in children with disabilities and the role of occupational therapy.
... Alltagsorientierte körperliche Trainingsprogramme zielen darauf ab, die Körperfunktionen zu verbessern und mobilitätsbezogene Risikofaktoren wie Stürze zu reduzieren (Jefferis et al., 2014). Sie können in monofaktorielle Trainingsprogramme (Cumming et al., 1999;Steultjens, Dekker, Bouter, Jellema, & Bakker, 2004;Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008;Costello, & Edelstein, 2008;Sherrington et al., 2008;Davis et al., 2010;Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011;Leland, Elliott, O'Malley, & Murphy, 2012) und in multifaktorielle Trainingsprogramme (Steultjens et al., 2004;Costello, & Edelstein, 2008;Peterson, & Clemson, 2008, Sherrington et al., 2008Davis et al., 2010;Sherrington et al., 2011;Leland, et al., 2012) eingeteilt werden. Beide Formen können entweder als Gruppen-oder Einzeltraining in der eigenen Häuslichkeit angeboten werden (Costello, & Edelstein, 2008). ...
... Gemäß der Meta-Analyse von Sherrington et al. (2011) entfalten körperliche Trainingsprogramme ihre Wirkung insbesondere unter folgenden Bedingungen: 1) Anforderungen an Gleichgewichtstrainings sollten moderat bis hoch sein, 2) Trainings sollten ausreichend dosiert werden und 3) kontinuierlich erfolgen, 4) Trainings sollten für Menschen mit einem hohen Sturzrisiko in der Häuslichkeit angeboten werden, 5) Trainings können als Einzel-oder Gruppenprogramm erfolgen, 6) Lauftrainings sollten ergänzend zu einem Gleichgewichtstraining erfolgen, 7) Krafttrainings sollten additiv zum Gleichgewichtstraining durchgeführt werden und 8) Therapeuten/-innen sollten Sturzrisikofaktoren umfassend erfassen. (Peterson, & Clemson, 2008). Der Durchführung von Wohnraumanpassungen durch Ergotherapeuten/-innen wird hohes Potenzial zugeschrieben (Costello, & Edelstein, 2008), da Ergotherapeuten/-innen über die notwendigen fachlichen Qualifikationen verfügen, insbesondere bei der Durchführung von Wohnraumassessments und -anpassungen (Steinmetz, & Hobson, 1994;Cumming et al., 1999;Lampiasi, & Jacobs, 2010). ...
Background
In Germany, four to five million community-dwelling people aged 65 years or older fall every year. The presented potential analysis evaluates the potential of occupational therapy-led physical exercise programs and home environment adaptations to reduce the frequency of falling and as well as intrinsic and extrinsic risk factors for falling of older people living at home.
Methods
The potential analysis was compiled according to a method guideline (p.11-22) available as follows: http://www.cochrane. de/news/leitfaden-f%C3%BCr-gesundheitsfachberufe-mai-2013 . The research question of fall prevention was considered as very relevant for health care and specified according to the PICOS-system. A Cochrane review was systematically searched and the body of evidence was assessed using the GRADE-system. In addition, studies after the search period of the Cochrane review were identified using the search strategy of this review. Both the studies within and after the review were assessed regarding their transferability to the German health care context.
Corpus of evidence
A Cochrane review from 2012 revealed that occupational therapy-led physical exercise programs reduced the frequency of falling of older people living at home (7 studies, 951 participants, 0.68 RaR; 95%-KI [0.58-0.80]), the number of fallers (6 studies, 714 participants, 0.78 RaR, 95%-KI [0.64-0.94]) and the fractures (6 studies, 810 participants, 0.34 RaR, 95%-KI [0.18-0.63]). Further studies showed that home environment adaptation programs significantly reduced the number of falls (4 studies, 1443 participants, 0.69 RaR, 95%-KI [0.55-0.86]) and the number of fallers (5 studies, 1153 participants, 0.79 RaR, 95%-KI [0.70-0.91]). However, direct implementation into the German healthcare context is not recommendable.
Implication for research
It is recommended (1) to manualise identified home environment adaptation programmes for the German healthcare context and (2) to pilot-test the physical exercise programmes ‘LiFE’ with regard to theoretical framework, acceptance, applicability and feasibility and to examine both interventions as part of a feasibility study. If this trial results in a feasible treatment programme well accepted by patients and their treating occupational therapists, a large-scaled randomized clinical trial in terms of comparative effectiveness research may follow.
... A randomized trial completed by Tennstedt et al. [18] and then repeated by Zijlstra et al. [18], showed that the MOB program increased fall self-efficacy, which is the confidence a person has in performing common tasks without falling, and activity levels in community-dwelling adults who have restricted activity due to fear of falling [37]. ...
This study compared the effect of Nintendo Wii Fit to the Matter of Balance program, a valid and reliable program, on improving balance, and well-being to decrease the risk of falls.
Residents of an independent living senior housing facility were recruited and thirty-two residents ages 63 to 90 participated. Participants were separated into three groups: (1) Wii Fit group (n=11) completed balance games on the Wii Fit in individual sessions twice a week and supplemental home exercises; (2) Matter of Balance Group (n=11) completed exercises from the Matter of Balance Program in a group setting twice a week; (3) Control group (n=10) received no intervention. Intervention lasted three weeks.
One-way ANOVA's were completed. Scores from the assessments were not statistically significant at post-test Berg Balance Scale (p=0.837); Tinetti Gait and Balance Assessment (p=0.913); SF-36 (p=0.256). Results from a self-report demonstrated that Wii Fit is an enjoyable form of exercise for an elderly population.
Although, the interventions failed to significantly increase balance, with an increase in intervention duration of Wii Fit or Matter of Balance balance may be improved. Although results were not significant this study adds to the growing body of evidence regarding the use of Wii Fit as a rehabilitation tool.
... A randomized trial completed by Tennstedt et al. [18] and then repeated by Zijlstra et al. [18], showed that the MOB program increased fall self-efficacy, which is the confidence a person has in performing common tasks without falling, and activity levels in community-dwelling adults who have restricted activity due to fear of falling [37]. ...
Objective
The aim of this preliminary study was to determine the effectiveness of the Nintendo Wii Fit as an occupation to promote weight loss in undergraduate students.
Participants
Five first-year female students living on campus at a northeastern university in the United States were recruited to participate in this study.
Method
An A-B single subject design was created where participants were separated into three groups: a typical activity group and two Wii conditions (Wii Fit individually and Wii Fit with another participant). In all conditions, participants recorded their daily food intake and daily number of steps using a pedometer. Body mass index (BMI) and weight were recorded at baseline, at 6 weeks and at 12 weeks (the conclusion of the intervention). At baseline and 12 weeks, motivation and activity level were measured.
Results
There was a significant change in BMI, weight and motivation for participants in the singles group.
Conclusion
Although the sample size was very small, the results of this preliminary study suggest that the Wii Fit should be considered by occupational therapists as a potential occupation of weight control in undergraduate students when performed individually.
... OTs elicit a falls history, individuals'beliefsabout causes of falls, their understanding of environmental risks and perceived ability to negotiate those risks, and patterns of home use and community access. 30 OTs help older adults change their behavior to prevent falls; for example, by helping them create new routines during daily activities and identifying adaptive behaviors (eg, scanning ahead for hazards when walking). Like outpatient PT services, outpatient OT services are a covered Medicare Part B benefit. ...
Falls among older adults are neither purely accidental nor inevitable; research has shown that many falls are preventable. Primary care providers play a key role in preventing falls. However, fall risk assessment and management is performed infrequently in primary care settings. This article provides an overview of a clinically relevant, evidence-based approach to fall risk screening and management. It describes resources, including the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit that can help providers integrate fall prevention into their practice.
Copyright © 2015 Elsevier Inc. All rights reserved.
... Subgroup analysis -intensity of intervention. The Clemson review included an additional step in which the intervention was rated as 'high intensity' or 'not high intensity' according to four pre-specified criteria reflecting best practice (Peterson and Clemson, 2008): (a) comprehensive assessment, taking into consideration both individual and environmental characteristics; (b) use of a validated assessment tool; (c) consideration of the functional performance of the individual within the context of their environment; and (d) provision of follow-up and support. An intervention was required to fulfil a minimum of three of these four criteria to be rated as 'high intensity'. ...
The potential of environmental assessment and modification to reduce falls has recently received attention within the gerontology literature. Research investigating the clinical effectiveness of this intervention in falls prevention reports conflicting results. Discrepancies are due to variation in the risk profile of study participants and the health care background of the person providing the environmental intervention or the intensity of the intervention provided.
Method: The purpose of this paper is to compare and contrast two systematic reviews, which include meta-analyses, of environmental interventions for falls prevention in community dwelling older people, using the critical appraisal skills programme tool for systematic reviews. Findings: Both reviews found that: environmental assessment and modification was effective in falls prevention; intervention was effective with high but not low risk participants; and that high intensity environmental assessment was effective, whereas low intensity intervention was not. Environmental interventions which were delivered by occupational therapists were deemed high intensity, probably because their underpinning theoretical frameworks focus on the impact of the environment on function.
Conclusion: We discuss possible reasons why occupational therapist led environmental assessment and modification is clinically effective in falls prevention, for people at high risk of falls, whereas non occupational therapist led intervention is not.
... These typically take the form of an OT and an OT assistant attending the patient's home, usually with family in attendance, to assess the person-environment fit, and ensure a safe discharge. These home visits have been shown to minimise the risk of falls and other adverse events (Cumming et al., 1999;Di Monaco et al., 2008;Peterson & Clemson, 2008;Pighills, Torgerson, Sheldon, Drummond, & Bland, 2011). A complex home assessment with a patient including driving and administrative tasks can take over five hours. ...
This article reports upon an initiative to improve the timeliness of occupational therapy home visits for discharge planning by implementing technology solutions while maintaining patient safety. A community hospital in Queensland, Australia, hosted a process evaluation that examined which aspects of home visiting could be replaced or augmented by alternative technologies. Strategies were trialled, implemented and assessed using the number of home visits completed and the time from referral to completion as outcomes. A technology-enhanced solution called “Home Quick” was developed using technology to facilitate pre-discharge home visits. The implementation of Home Quick resulted in an increase in the number of home visits conducted prior to discharge (50% increase from 145 to 223) and significantly increased the number of patients seen earlier following referral (X2=69.3; p<0.001). The substitution of direct home visits with technology-enabled remote visits is suitable for a variety of home visiting scenarios traditionally performed by occupational therapists.
... Falls are a prominent cause of injury and reduced quality of life among older individuals, an issue that is familiar to many health professionals. Occupational therapists are key providers of effective fall prevention interventions, especially in the community (Royal College of Occupational Therapists, 2015; Peterson and Clemson, 2008). Professionals in the primary care context, including general practitioners (GPs) and other allied health providers (AHP), are particularly well placed to offer primary prevention services to older people at risk of falls. ...
Introduction: Occupational therapy in primary care settings in Australia is developing. This study aimed to examine current practice in preventing falls among older people living in the community prior to attending a home safety workshop; explore the outcomes of the workshop on fall prevention practice; and investigate self-reported changes in practice 3 months after the workshop. Method: The 3-hour workshop was focused on evidence-based home safety interventions and was offered to occupational therapists providing community-based services in the Sydney North Primary Health Network area. Knowledge surveys were used immediately pre and post workshop, and practice surveys were collected data at baseline and at 3-month follow-up. Results: Three workshops were run in 2015–2016, with a total of 40 occupational therapists. At follow-up, a positive impact on confidence and knowledge was reported. Less impact was observed on identifying and reducing an older person’s fall risk, and on fall prevention services provided and referrals received. Changes in practice were reported by 48% (n = 16) of the 33 participants who returned surveys at 3 months. Conclusion: These findings provide support for the benefit of professional development workshops to improve confidence and knowledge, but challenges remain in facilitating change in fall prevention service delivery. Further study on screening for fall risk and collaboration between community service providers in the primary care context is recommended.
... A draft framework was constructed, drawing on the original WeHSA Home Fall Hazards manual (Clemson, 1997a) and emergent evidence (e.g., Peterson & Clemson, 2008;Pighills, Ballinger, Pickering, & Chari, 2015). The framework was developed to outline the key concepts underpinning how assessment should be conducted and the clinical reasoning for interventions to reduce fall risks. ...
Introduction
Comprehensive evaluation and intervention provided by occupational therapists is effective in reducing the presence of fall hazards in the homes of older adults. The purpose of this study was to document known environmental hazards and to update a previous content analysis. A secondary goal reviewed a framework for evaluation and practice.
Methods
A comprehensive scoping review of published academic articles was performed from 1996 to 2019 to answer: What environmental hazards have been associated with falls in the homes of community‐dwelling older adults? Data was extracted in a standardised critical appraisal worksheet and content analysis was conducted. A review of a conceptual framework for assessment and intervention was conducted by international experts (n = 6) in face‐to‐face interviews.
Results
Fourteen studies met the inclusion criteria for the scoping study. The studies reported 17 in‐home environmental hazards: throw rugs/carpets, clutter, cords/wires, poorly placed light switches, items placed too low, items placed too high, no grab bars, toilet seats too low, uneven floor surfaces, slippery/wet surfaces, snowy/icy surfaces, backless/unsupportive shoes, unsteady stairs, inadequate lighting, inadequate heating/cooling, step stools without railings, and pets.
Conclusion
A comprehensive list of specific fall hazards in and around the homes of older adults and a guiding framework offers occupational therapists an evidence‐based foundation for fall prevention efforts.
To evaluate the validity and feasibility of a novel photography-based home assessment (PhoHA) protocol, as a possible substitute for on-site home assessment (OsHA).
A total of 20 patients aged ≥65 years who were hospitalised in a rehabilitation centre for musculoskeletal disorders affecting mobility participated in this prospective validation study. For PhoHA, occupational therapists rated photographs and measurements of patients' homes provided by patients' confidants. For OsHA, occupational therapists conducted a conventional home visit.
Information obtained by PhoHA was 79.1% complete (1,120 environmental factors identified by PhoHA vs 1416 by OsHA). Of the 1,120 factors, 749 had dichotomous (potential hazards) and 371 continuous scores (measurements with tape measure). Validity of PhoHA to potential hazards was good (sensitivity 78.9%, specificity 84.9%), except for two subdomains (pathways, slippery surfaces). Pearson's correlation coefficient for the validity of measurements was 0.87 (95% confidence interval [CI 0.80-0.92, p <0.001). Agreement between methods was 0.52 (95%CI 0.34-0.67, p <0.001, Cohen's kappa coefficient) for dichotomous and 0.86 (95%CI 0.79-0.91, p <0.001, intraclass correlation coefficient) for continuous scores. Costs of PhoHA were 53.0% lower than those of OsHA (p <0.001).
PhoHA has good concurrent validity for environmental assessment if instructions for confidants are improved. PhoHA is potentially a cost-effective method for environmental assessment.
There are no standard criteria for an occupational therapy (OT) home assessment for patients about to be discharged from an acute rehabilitation facility. This has implications for benchmarking, quality improvement and research. The aim of this paper is to establish 'core/essential' and 'ideal world' elements of OT home assessments for patients about to be discharged from acute rehabilitation settings.
A piloted open-ended questionnaire initiated a Delphi study involving knowledgeable OTs working in Australian public and private acute rehabilitation settings. 'Core/essential' and 'ideal world' elements of OT home assessments were confirmed when 70% agreement was reached.
Of 242 facilities in two Australian states, 110 were invited to participate, and 81 OTs from 84 facilities did so. Four Delphi rounds were required to reach consensus on 30 'core/essential' and 25 'ideal world' elements.
Standard use of 'core/essential' pre-discharge home assessment elements should improve standards of care and the quality of discharge planning. OTs should consider including 'ideal world' criteria in pre-discharge assessments to optimize recently ill patients' community independence.
This article reviews fall prevention research using the Centers for Disease Control public health model and suggests several critical research questions at each step. Research topics include surveillance and data systems, fall risk factors, development, evaluation and implementation of fall interventions, translation of interventions into programs, and promotion, dissemination, and widespread adoption of fall prevention programs. These broad topics provide a framework for research that can guide future advances in older adult fall prevention.
To make an impact on the public's health, evidence-based interventions must be disseminated broadly, supported by training and technical assistance, adopted widely, and implemented as designed. Many effective older adult fall prevention interventions have been identified, but too few have gained wide community acceptance and little is known about the best ways to encourage their broader use. Therefore, as in many other fields, fall prevention suffers from a wide gap between scientific discoveries and their everyday use.
This article articulates the key activities embedded in Step 4 of the public health model-specifically translation and dissemination to ensure widespread adoption and use-in order to illuminate critical research needs in older adult fall prevention.
These needs, if addressed, will help close the gap between research and practice.
A large body of research has addressed the assessment and management of fall risk among community-dwelling older adults. Persons with dementia are at higher risk for falls and fall-related injuries, yet less is known about effective strategies for reducing falls and injuries among those with dementia. Falls and dementia are regularly considered to be discrete conditions and are often managed separately. Increasing evidence shows that these conditions frequently co-occur, and one may precede the other. This article explores the relationship between falls and dementia, including the importance of rehabilitation strategies for reducing fall risk in these individuals.
Stepping On is a multifaceted falls-prevention program for the community-residing elderly. The programs are held in local community venues and run for seven 2-hour weekly sessions, with a follow-up home visit contact and a 3- month booster session. About 30% of older people who fall lose their self-confidence and start to go out less often. Inactivity leads to social isolation and loss of muscle strength and balance, increasing the risk of falling. Stepping On aims to break that cycle, engaging people is a range of relevant fall preventive strategies. Stepping On content draws on current evidence for falls prevention. The program has been proven to reduce falls. A detailed manual is available to enable occupational therapists to run the program.
I feel more confident and I’m going out more.
—Marie, a client
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.
—Roleena, a client
What you have done is focus on our abilities. No one else has done that.
—Nancy, a client
I have had some near falls but you have a quicker recovery and your muscles don’t collapse.
—Herbert, a client
Rationale, aims and objective Pre-discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre-discharge home assessment and falls in the first month post-discharge from a rehabilitation hospital.
Methods 342 inpatients were recruited and followed up 1 month post-discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM™) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post-discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM™.
Results Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post-discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4–4.7, P = 0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7–33.2), 3.4 (1.4–8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non-neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM™ scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1–8.2, P < 0.001).
Conclusions Pre-discharge occupational therapy home assessments are sound post-discharge falls-prevention strategies in non-neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.
A keynote address given at the Council of Occupational Therapists for the European Countries' (COTEC's) 8th European Congress of Occupational Therapy, Hamburg, 22-25 May 2008, hosted by the Deutscher Verband der Ergotherapeuten e.V. (German Association of Occupational Therapists).
Falls in older adults are a major health concern, yet the “fear of falling”, a common psychosocial response that can occur post-fall, has seldom been investigated. A scoping review was conducted to identify and map interventions that occupational therapists can use to manage the fear of falling psychosocial response (FoFPR) among older adults. Thirteen electronic databases were searched and 22 studies were retrieved. Cognitive behavioral therapy, guided imagery, and Tai Chi were interventions found to help older adults deal with their FoFPRs. Occupational therapists assisting older adults in this area can play a significant role.
Objective:
Falls and fall-related injuries among older women constitute a major public health problem with huge costs for the society and personal suffering. The aim of this study was to describe and illustrate how a number of circumstances, conceptualized as a scenario, that were related to the individual, the environment, and the ongoing occupation contributed to a fall that led to a hip fracture among women. The sample included 48 women over 55 years old.
Methods:
Interviews were conducted during home visits and the analysis provided a descriptive picture of circumstances in the shape of a scenario related to the risk of falling. A number of scenarios were developed based on the data and named to provide an understanding of the interplay between the individual, the environment, and the ongoing occupation at the time of the fall.
Results:
By applying the concept of a scenario, occupational therapists can increase the awareness of fall risks among older people, and are relevant also for interior designers, architects, and town planners to consider when designing the local environment as well as furniture and other objects.
Strategies that address decreased vision are an important part of multifactorial interventions to prevent falls and facilitate safe participation in valued occupations.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects (benefits and harms) of environmental interventions (such as assistive devices, and reduction of fall hazards in home, outdoors, and public places) for preventing falls in older people living in the community. © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The purpose of this study was to assess feasibility and changes in outcome measures following the Merging Yoga and Occupational Therapy for Parkinson's Disease (MY-OT for PD) program: a 14-session program which combined community-based yoga for PD, and fall-risk focused group occupational therapy sessions. Seventeen participants completed an 8-week control period consisting of their normal participation, and an 8-week intervention period (14 MY-OT for PD sessions). There were fewer self-reported falls in the intervention (6) vs. control periods (10). One fall risk factor management scale (the Fall Prevention and Management Questionnaire, p=.02), and balance (p<.01) showed significant improvement between the control and intervention. The MY-OT for PD program is an encouraging occupational therapist-led program, which may improve balance and reduce self-reported falls.
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.
This third edition of a trusted resource brings together the latest literature across multiple fields to facilitate the understanding and prevention of falls in older adults. Thoroughly revised by a multidisciplinary team of authors, it features a new three-part structure covering epidemiology and risk factors for falls, strategies for prevention and implications for practice. The book reviews and incorporates new research in an additional thirteen chapters covering the biomechanics of balance and falling, fall risk screening and assessment with new technologies, volitional and reactive step training, cognitive-motor interventions, fall injury prevention, promoting uptake and adherence to fall prevention programs and translating fall prevention research into practice. This edition is an invaluable update for clinicians, physiotherapists, occupational therapists, nurses, researchers, and all those working in community, hospital and residential or rehabilitation aged care settings.
Although targets have been set for the establishment of falls prevention services, little is known about the views of older people in respect of such initiatives. The purpose of this study was to investigate the perspectives of the older participants in a community group falls prevention programme in Australia and to explore their views about the most and least useful aspects of the programme, using methods deriving from a grounded theory approach.
Semi-structured interviews were carried out with nine women and two men who had attended a falls prevention programme. The multifaceted intervention comprised seven weekly meetings of 2 hours each. The key principle underpinning the programme was enhancement of self-efficacy.
Four themes were identified through qualitative analysis: identity (focusing on participants as active elders); the salience of interventions (or the meaning attributed to different programme components); the social experience (the views about group interaction); and the consequences of participation. The participants were very positive about their experience of the programme and described a range of psychological and physical outcomes.
A decrease in the likelihood of a fall did not feature prominently in these interviews. It may be more meaningful to older people to embed falls prevention within a wider context of wellbeing and independence.
Activity recall, in-depth interviews, and reenactment of the fall were used to elucidate the behavior patterns, actions, and habits that contribute to older adults falling in public places. The aim was to improve older adults' capacity to understand behavioral risks associated with falls and develop safe adaptive strategies so they can play an active role in minimizing falls and maintaining meaningful activity. Ten major themes were identified: not attending to the route ahead, lack of familiarity, pace, mobility behaviors, environmental influences, eyesight behaviors, health factors affecting physical abilities, lack of confidence, overexertion, and unnoticed environmental hazards. The findings add to knowledge about the extent and nature of behavioral factors that contribute to falls in public places and provide guidelines for some specific areas of focus for falls prevention. A recommendation is that fall prevention interventions with older adults employ strategies that actively engage them in critical reflective thinking.
The Safety Assessment of Function and the Environment for Rehabilitation (SAFER Tool) was designed to evaluate seniors' abilities to manage safely within their home environments. This study evaluated the content validity, internal consistency and construct validity of the Tool. Content validity was established through the use of a review panel of seniors and clinical experts, and was supported by item analyses. Internal consistency was calculated and found to be high. Construct validity was evaluated by testing hypotheses about the SAFER Tool, which were not supported. These results provide support for the content validity and internal consistency of the instrument. Further psychometric testing of the SAFER Tool is needed.
This study focused on the relative utility of the model of human occupation for occupational therapy assessment of persons having mental disorders. The organizational status of the human system and its relationship to adaptive level of functioning and degree of symptomatology were examined in a sample of 30 adult psychiatric patients. We used a six-test assessment battery developed for this study, which was based on the model of human occupation, to measure the organizational status of the following components of the human system: locus of control, goals, temporal orientation, interests, roles, and skills. Subtests of the American Association on Mental Deficiency (AAMD) Adoptive Behavior Scale and the Modified Brief Psychiatric Rating Scale were used to measure adaptive level functioning and symptomatology, respectively. When we compared organizational status with psychiatric diagnosis and symptomatology, we found organizational status to be the more significant index of adaptive level of functioning.
The purpose of this study was to report the development of the Falls Behavioral (FaB) Scale for Older People, an assessment designed to evaluate behavioral factors that could potentially protect against falling. Instrument development included content analysis, expert review, and factor analysis. Ten behavioral dimensions were identified including Cognitive Adaptations, Protective Mobility, Avoidance, Awareness, Pace, Practical Strategies, Displacing Activities, Being Observant, Changes in Level, and Getting to the Phone. The final 30-item scale had a Content Validity Index of 0.93. Test-retest reliability was ICC = 0.94 (p < .01). Construct validity was established by showing that, as expected, scale scores were positively associated with increasing age (rs = 0.46, p < .01) and negatively associated with greater physical mobility (rs = -0.68, p < .01). People who had fallen utilized safer behaviors than those who had not reported a fall (p < .05) providing a benchmark for using the scale in future studies. The FaB is an easily completed, reliable, and valid tool for determining the presence or absence of protective behaviors. It has potential to assist in goal setting for falls prevention and to evaluate behavioral outcomes of fall prevention programs.
This study assessed the current secular trends in unintentional injury deaths among persons 15 years of age or older in Finland. For this purpose, we obtained from the Finnish Official Cause-of-Death Statistics (OCDS) the data for persons aged 15 years or older whose deaths occurred in 1971–2003 due to an unintentional injury.
Among Finnish men, the most drastic change occurred in road traffic crashes. The age-standardised death rate (per 100,000 person-years) of men's road traffic crashes was 47 in 1971 but only 11 in 2003. In contrast, the rate of fall-induced deaths among Finnish men gradually rose, from 18 in 1971 to 24 in 2003, by which time falls became the leading category of men's unintentional injury death. Also alcohol poisonings seemed to bypass road traffic crashes as the cause of men's injury death.
Among Finnish women, the age-standardised rate of fall-induced deaths decreased till 1975, after which the curve was rather flat. The death rate (per 100,000 person-years) of women's falls was 30 in 1971 and 18 in 2003. During the entire period of 1971–2003, traffic caused fewer deaths in women than men, but the declining trend in women's death rates was also clear, from 17 in 1971 to 5 in 2003. Other unintentional causes accounted for few deaths in women during 1971–2003, although it was of interest that the rate of women's deaths due to alcohol poisoning rose from 1 in 1971 to 4 in 2003.
In conclusion, during1971–2003 falls replaced road traffic crashes as the leading cause of unintentional injury death in adult Finns. The rise in men's fall-induced deaths occurred even with a rate that cannot be explained merely by demographic changes, and therefore, systematic fall prevention measures are needed to control the development. The rising incidence of women's deaths due to alcohol poisoning needs close follow-up.