ENVIRONMENTAL MODIFICATIONS AND FALL PREVENTION IN OLDER ADULTS Presented by: Sara Samuelson, OTS and Valerie Maeker, OTR/L, MS, Neuro-IFRAH Certified, C/NDT

Article 1  Title: Systematic Review of the Effect of Home Modification and Fall Prevention Programs on Falls and the Performance of Community- Dwelling Older Adults  Authors: Carla A. Chase, Kathryn Mann, Sarah Wasek, Marian Arbesman  Journal: The American Journal of Occupational Therapy, Volume 66, Number 3, May/June 2012.

Article 1 Purpose  Falls are the leading cause of injury and deaths in people over age 65 (Centers for Disease Control and Prevention[CDC], 2011).  One in 3 adults age 65 and older fall each year (Hausdorff, Rios, & Edelber, 2001; Hornbrook et al., 1994)  The objective of this systematic review was to synthesize existing literature to answer the following focused question: “What is the evidence for the effect of home modification and fall prevention programs on the performance of community- dwelling older adults?” (p. 284)

Multifactorial Approaches  The evidence that multifactorial approaches reduce falls and difficulties with ADLs and IADLs in older adults is strong.  The multifactorial approaches included:  home modifications  education on health and safety  medication management  vision management  gait and balance training  Exercise  Some of the professionals working together included:  occupational therapy  physical therapy  internal medicine  nursing  social work

Physical Activity  Studies of physical activity interventions in the systematic review included:  group and individual sessions that incorporated balance retraining  walking  general exercise in sitting and standing  lower-extremity strengthening  use of a workstation format  tai chi  Mixed but overall positive results were found in studies that measured the impact of physical activity programs on the performance of community-dwelling older adults.

Home Assessment and Home Modification  The home assessment and home modification interventions in this section of the systematic review included:  hazard identification  structural changes to the inside and outside of the home  provision of assistive technology and assistive devices

Overall Findings  This review provided strong evidence that when used in combination, these interventions play a role in successfully reducing the number of falls, limiting fear of falling, and preserving independence in community- dwelling older adults.  When physical activity and home modifications are provided individually, the evidence that these interventions reduce falls and maintain and promote ADL and IADL performance is moderate.  The evidence also indicates that the subgroup of frequent fallers show the greatest benefits from individual and multifactorial interventions.

Strengths  The methodology included a large time frame (since 1990) and incorporated several bibliographic databases, thus ensuring that relevant literature was captured.  In addition, a wide range of interventions was studied in the articles included in the review.  Of the 33 articles included in the review, 31, or 94%, were Level I RCTs, and 100% were Level II or Level I.

Weaknesses  Several studies were not blinded, had high dropout rates, and had small sample sizes.  Many of the studies used self-report, and the methods for recording falls and injuries varied among the studies.  The studies were conducted in several countries, and whether differences in health care systems had an impact on the design and implementation of the interventions is unknown.

Article 2  Title: Environmental Assessment and Modification as Fall-Prevention Strategies for Older Adults  Authors: Jon Pynoos, PhD, Bernard A. Steinman, MS, Anna Q.D. Nguyen, OTD, OTR/L  Journal: Clinical Geriatrics Medicine, 2010, Volume 26, page 633–644.

Article 2 Purpose  To discuss / summarize some literature relating to fall risk factors, effects of home modifications, home assessments, home modification programs and reimbursement, locating skilled installers and finding products

Article 2 Background Information  Older people’s home environment  Many older people want to live in their home environment  Some homes may have potential problems that could result in negative outcomes (falls, injuries and even death)  If the home is well designed and modifications are made, the environment could support the older person’s physical abilities, help physical health, promote a sense of security, and enhance social engagement  Statistics of older adult falls (Kochera, A.S., 2002)  55% occur inside the home (i.e. stairs in the home)  23 occur outside but near the home ( i.e. sidewalk or curb)  22% occur in the community

Article 2 Background Information Continued  According to Li, W. et al. (2006) the risk profile are different for indoor & outdoor falls:  Outdoor falls are more prevalent for the individual who is engaged in higher leisure-time physical activities  Indoor falls are more like to occur if the individual has more physical difficulties and indicators of poor health  These researchers reported that between 35% and 40% of falls result from factors that are related to the environment

Article 2 Key Findings  Fall Risk Factors  Extrinsic factors May result in trips, splits, or missteps Environmental factors are one of the more 400 fall risk factors identified in literature Approximately 80% of homes contain at least 1 identifiable hazard & 39% contain 5 or more (NEED FOR HOME ASSESSMENT AND MODIFICTION)  Intrinsic factors May include health conditions, degrees of functional loss, muscle weakness, gait or balance disorders, reduced metal status, sensory losses, drug interaction & history of falls (NEED FOR MULTIFACTORIAL FALL-PREVENT PORGMA INDICATED TO IDENTIFY HELAHT AND FUNCTIONAL PROBLEMS THAT LEAD TO FALLS)  Behavior Risk Factors Reflects the choices that the person makes in regards to their environment Behaviors that could increase fall risk (i.e. standing on unstable object) Not performing behaviors that could reduce fall (turning on light at night) Selecting unsafe clothing, footwear, or eyewear

Article 2 Key Findings  Effects of Home Modifications  Three key concepts: Lawton and Nahemow’s Theory of Environmental Press Universal design (UD) “Home modifications refers to the converting or adapting of environments to make everyday tasks easier, increase comfort, reduce the number of accidents and support independent living” (p. 635)  Home modifications can range from low-cost to expensive  Fall-prevention strategies must be individualized to the individuals need the client’s environment, health status and behavior patterns  Home Assessment  For individuals who have fallen or have multiple factors for falling, home assessments are indicated  Identify potential problems & offer solutions  Examples: checklists, functional fall risk assessment  Solutions to problems: get input from the older adult  Not a single event; dynamic in nature  *NO MENTION OF OCCUPATIONAL THERAPY SERVICES WITH REGARDS TO COMPLETING HOME ASSESSMENTS IN THIS SECTION OF THE ARTICLE!

Article 2 Key Findings  Home Modification Programs and Reimbursement  More than ¾ of older person pay for home accessibility features out of pocket (LaPlante, M.P. Hendershot, G.E. & Moss, A.J., 1992)  Countries such as Great Britain, the Netherlands, & Canada have launched home-repair-and-modification programs  Major reason people do not carry out home modifications= cost involved (AARP, 2000)  No federal programs that solely pays for or finances home modification  Public and Private Financing Sources Loans Home Improvement Structural Alterations program (for Veterans) Special Housing Adaptation Benefit (for Veterans) US Department of Housing and Urban Development Community Development Block Grand funds, Administration on Aging Title III funds Medicaid waiver programs  Locating Skilled Installers  Few specialists with training specifically in home modification  Older adults may rely on professionals such as OT who know of reputable installers  Training & Education is available for individuals that want to received extra training in home modifications The National Association of Home Builders Certified Aging-in-Place Specialists University of Southern California’s online Executive Certification Program in Home Modification

Article 2 Key Findings  Finding Products  No single place to locate them  Building supply stores Grab bars Comfort-height toilets Hand-held showers Hand rails  Medical supply & drug stores assistive devices such as reachers and RTS)  Specialized home modification firms Grab bars in different colors Chair lifts Walk-in showers  Website  Occupational therapists

Article 2 Summary  “Home assessment and environmental modification play an important role in reducing the risk of falling and helping older adults and persons with disability to remain living in their communities.” (p. 641)  Multiple considerations when trying to reduce falls include assessing home environment, community environment, exploring specific health & function consideration as well as patterns of behavior  “Practitioners, such as occupational therapists, who are knowledgeable about the places where older persons live and carry out activities, are especially well situated to assist in reducing fall risk through assessments, analyses, and provision of recommendations regarding home environments.” (p. 641).

Implications for Occupational Therapy Practice  “In general, a client-centered intervention plan that includes a mix of exercise, education, home modifications, and assistive technology is supported by the best evidence for fall prevention and occupational performance in community- dwelling older adults” (Chase, Mann, Wasek, & Arbesman, p. 289)  “Regardless of the setting in which one practices, occupational therapy practitioners can incorporate fall prevention and home modification strategies throughout the occupational therapy process, from evaluation to intervention planning and implementation and outcome review” (Chase, Mann, Wasek, & Arbesman, p. 289).

Discussion Questions  Has anyone seen or incorporated fall prevention interventions while out in their clinical rotations? If you have do you know which interventions were the most successful?  How do we help other professionals and clients know that occupational therapists are an excellent fit for completing home assessments and working with individuals on fall prevent?

References  Chase, C. A., Mann, K., Wasek, S., & Arbesman, M. (2012). Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. American Journal of Occupational Therapy, 66, 284–291.  Pynoos, J., Steinman, B. A., & Nguyen, Anna. (2010). Environmental assessment and modification as fall- prevention strategies for older adults. Clinics in Geriatric Medicine, 26(4)