What type of environmental assessment and modification prevents falls in community dwelling older people?

Pighills, Alison; Drummond, Avril; Crossland, Shelley; Torgerson, David

doi:10.1136/bmj.l880

Cited by 16 publications

(16 citation statements)

References 20 publications

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“…RCTs have yielded inconsistent findings. 40 The evidence base for fall reduction in RCTs of home-safety assessment and modification and provision of adaptive equipment is strongest for high-intensity interventions and interventions targeted to high-risk groups. 40 Cognition and psychological health…”

Section: Home Modification; Adaptive Equipmentmentioning

confidence: 99%

Prevention of Falls in Community-Dwelling Older Adults

2020

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A 79-year-old woman presents for her annual wellness visit. She reports having fallen 9 months ago and again a few weeks ago. She does not remember the details of the first fall, but for the second fall, she notes having tripped over uneven pavement while walking outside of her home. Despite some difficulty, she was able to get up unassisted and did not seek medical attention; she recalls having taken an overthe-counter "sleep aid" the night before. She said she has no fear of falling, dizziness, or loss of consciousness. Office staff perform a Timed Up and Go test, and it takes her 15 seconds to complete the test (≥12 seconds indicates an increased risk of falls). How would you evaluate this patient and manage the risk of future falls? The Clinic a l Problem F alls, defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level," 1 occur at least once annually in 29% of community-dwelling adults 65 years or older-a rate of 0.67 falls per person per year. 2 Population-based studies suggest that 10% of older adults fall at least twice annually 3 ; patients regularly visiting clinician offices are presumed to be more likely to belong to this high-risk group, given the prevalence of diseases and impairments that increase the risk of falling. After falling, a quarter of older adults restrict their activity for at least a day or seek medical attention. 2 More serious injuries, such as fractures, joint dislocations, sprains or strains, and concussions, occur in approximately 10% of falls. 4 Rhabdomyolysis due to muscle ischemia can develop in persons who are unable to get up after a fall and are "found down" after a long period. After a fall, a fear of falling develops in 21 to 39% of those who previously had no such fear; persons who fear falling may restrict their activity and have a reduced quality of life. 5 In aggregate, fall injuries lead to 2.8 million emergency department visits and 800,000 hospital stays in the United States annually, 2 with total health care costs of $49.5 billion. 6 Most falls result from a combination of intrinsic risks (e.g., balance impairment) and extrinsic risks (e.g., trip or slip). Given the many contributors to the risk of falls, 7 focusing on the factors that are the final common pathways to falls and are those most commonly evaluated in randomized trials leads to a core set of risk factors (Table 1). 3,29 Deficits in gait and balance are the most prominent predisposing risk factors at the population level. Medications (including over-the-counter drugs), alcohol, visual deficits, impairments in cognition and mood, and environ-From the Geriatric Research, Education, and Clinical Center and the Center for the

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Section: Home Modification; Adaptive Equipmentmentioning

confidence: 99%

Prevention of Falls in Community-Dwelling Older Adults

2020

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“…Intrinsic risk factors are person-related and include factors such as having had a previous fall or fracture, impaired vision or impaired balance/ gait. 10 Extrinsic risk factors are related to the environment, such as the presence of clutter, trip hazards or poor lighting. Behavioural risk factors include risk-taking activities, for example climbing on chairs, drinking alcohol, or having poor intake of nutrition or fluids.…”

Section: Risk Factors For Fallingmentioning

confidence: 99%

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

Cockayne

Pighills

Adamson

et al. 2021

Health Technol Assess

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Background Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken. Objective To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care. Design This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study. Setting Eight NHS trusts in primary and secondary care in England. Participants In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible. Interventions All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist. Main outcome measures The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness. Results The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss –0.0042, 95% confidence interval –0.0041 to –0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree. Limitations Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data. Conclusions We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care. Future work An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified. Trial registration Current Controlled Trials ISRCTN22202133. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

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“…Improving home environments by reducing home hazards that cause tripping or slipping, and having home modifications (i.e., bathroom modifications) are essential to mitigate fall risks (Keall et al, 2015;Pighills et al, 2019;Pynoos et al, 2010;Rogers et al, 2004;Vieira et al, 2016). Additionally, home modifications have been shown to improve daily activities in older adults (Stark et al, 2009), which is vital for those who want to age-in-place.…”

Section: Statistics Released By the Centers For Disease Control And Preventionmentioning

confidence: 99%

Bathroom modifications among community‐dwelling older adults who experience falls in the United States: A cross‐sectional study

Lü

Tiu

et al. 2021

Health Soc Care Community

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Falls impose substantial health and economic burdens on older adults. Over half of falls in older adults occur at home, with many involving bathroom areas. Limited information is available on the presence of bathroom modifications for those who experience them. Therefore, we examined factors associated with bathroom modifications among older adults with at least one fall in the United States. We analysed the nationally representative 2016 Medicare Current Beneficiary Survey Public Use File of Medicare beneficiaries aged ≥65 years with ≥1 fall (n = 2,404

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What type of environmental assessment and modification prevents falls in community dwelling older people?

Cited by 16 publications

References 20 publications

Prevention of Falls in Community-Dwelling Older Adults

Prevention of Falls in Community-Dwelling Older Adults

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

Bathroom modifications among community‐dwelling older adults who experience falls in the United States: A cross‐sectional study

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