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Implementing environmental interventions to prevent falls

Dr Alison Pighills Principal Research Fellow

Queensland Health

Outline of presentation • Introduction • Literature

• Research trial

• Environmental risk factors

• Environmental assessment

• Implications for practice

• Video

Summary of the evidence • Observational studies have failed to find a strong

association between home hazards and falls1-5

•  5 RCTs evaluating environmental assessment in isolation6,7,8,9,10

•  2 significant effect6,7, 3 non significant effect8,9,10 (low risk)

•  Involved OTs in 3 trials and trained assessors in 2 • Pooled RR of OT led trials 0.75 (95% CI 0.68-0.84)

Research Question

Is environmental assessment and modification (EAM) clinically effective?

Is EAM as effective if delivered by an OT as compared with a trained assessor?

Recruitment

Recruited 238

Usual care control 78

TA led EAM 73

OT led EAM 87

15 OTs & 15 Trained Assessors (TA) participated

TA = rapid response & home helps OTs = acute & community physical, mental health & SS

Results

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Falls Risk Factors •  Intrinsic risk (person-related) – falls caused by balance, gait, or

mobility problems (due to disease or motor disorders), poly-pharmacy, postural hypertension, visual, or cognitive impairment (DoH, 2001).

•  Extrinsic risk (environment-related) – “falls caused by a hazard, a trip or slip over a particular item, or falls that occur on the stairs, steps or a change of level” (Northridge et al., 1995, p510)

•  Behavioural risk (activity-related) – falls caused by an individual’s self imposed exposure to risk as a consequence of their behaviour, for example, hurrying, failing to concentrate or intentionally moving outside their base of support.

Evidence Based Intrinsic Risk Factors • Age; History of falls; Previous fracture;

Gender; Ethnicity; Medication; Medical history of arthritis, stroke or Parkinson’s disease; Functional limitations; Poor self reported health status; Impaired mobility and gait; Muscle strength; Dizziness or impaired balance; Postural Hypertension; Fear of falling; Cognitive impairment; Low body weight; Visual impairment; Foot problems; Continence

Evidence Based Extrinsic Risk Factors •  Steps and stairs

•  Floor coverings •  Absence of carpeting

•  Loose rugs and mats •  Clutter and tripping hazards (such as cords and wires)

•  Poorly positioned bedroom light switches

•  High cabinets •  Absence of appropriate adaptations (such as grab-rails)

•  Poor lighting; glare and shadows •  Low furniture

Evidence Based Behavioural Risk Factors

• Activity level

• Alcohol intake • Choice of footwear and clothing

• Risk taking behaviour • Inappropriate assistive devices

Falls Risk Falls, the Environment and Behaviour

(Law et al., 1996, p18)

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Categorising those who fall

• Multiple falls : multiple risk factors • Active people : fall less/fall in the presence of

environmental hazards/sustain serious injury Action – education on avoidance of hazardous activity

• Less mobile : fall at home during routine ADL Action – removal of environmental hazards

When and Where? • Day time from 10 to 12 and 2 to 4 • Night time bathroom falls cause serious injury

(lighting and traffic ways)

• Around 70% occur in the home

• The majority of which happen whilst walking particularly changing level, climbing steps & carrying

• Falls during task performance

Mobility

• Walking on level ground is associated with most falls

• Falls are common during transfers and climbing steps and stairs

• Falls while carrying, hurrying or climbing on chairs are less common but associated with greater injury

Steps, obstacles, reaching, climbing, floors

Rails, mats, seating, bath, cords lighting, footwear

Wet floors, bed, pets, shower, mobility aid, garden

Bed light, unstable furniture, bathroom, toilet, kitchen, trafficways

Hazards Implicated in Falls

Top Ten Individual Hazards 1.  Slippery surfaces

2.  Obstacles in trafficways 3.  Poor lighting

4.  Mats 5.  Footwear

6.  Ladder/chair to climb

7.  Bath 8.  Pathways (uneven, broken, loose)

9.  Steps, stair rails, cords on floor 10.  Seating

Factors Affecting Visual Performance •  Lighting

•  Ability to detect contrast and edges •  Bifocals

•  Loss of stereocuity/depth perception •  Reduced colour perception

•  Dark/light adaptation

•  Sensitivity to glare •  Ocular disease

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Environmental Assessment •  Problem solving approach

•  Consider the nature of the person’s falls and the relationship of the person to their environment

•  Design and condition of objects (equipment, furniture)

•  Design and condition of fixed features (stairs, floors)

•  Use of space •  Impact of lighting/temperature/colour contrast

Environmental Assessments

• Westmead Home Safety Assessment (WeHSA) – valid & reliable

• Home Falls and Accidents Screening Tool (HomeFast) - valid & reliable - SCREEN

• Safety Assessment of Function and the Environment for Rehabilitation (SAFER) – NOT valid or reliable - SCREEN

Westmead Home Safety Assessment (WeHSA) Considers 72 items in 14 domains

•  External traffic ways •  General indoors •  Internal traffic ways •  Living area •  Seating •  Bedroom •  Footwear •  Bathroom •  Toilet area •  Grab rails in toilet / bathroom •  Kitchen •  Laundry •  Medication management •  Safety call system

The WeHSA • Tool to work through with the participant • Problem solving approach

• Participant’s view of risk is important

• Behavioural and environmental risks

• Follow through of recommendations – putting higher wattage bulbs on shopping list, working out where to store new step ladders

Adherence • Degree of action required - commitment •  Perception of need/risk of falling • Belief that the recommendation will reduce falls •  Involvement of the individual in decision making –

empowerment, ownership of problem and solution •  Perceived ability to exert control over home environment •  Involvement of carers/relatives •  Respect/generation differences •  Lower adherence rates for modifications than equipment

Clemson 1997, Cumming 2001

Pre-Assessment Interview 1.  History of falls 2.  Lifestyle

3.  Patterns of usage of areas in the home

4.  Risk taking behaviour

5.  Strategies adopted to reduce falls risk

6.  Vision

7.  Mobility

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Summary “Taking positive action to stay on your feet does not mean

you have to place restrictions on everything you do. In fact, it should allow you to be more active and give you greater freedom and confidence. Nobody wants to think of themselves or be seen by others as someone who might fall. But remember, the purpose of taking steps to stay steady and prevent falls is to protect and improve your health, mobility and independence – not to take it away.”

Staying Steady, Help the Aged, 2005

Implications for practice

• Environmental assessment, aiming to reduce falls, should be a specific targeted professionally prescribed intervention – not just a component of a generic home visit

http://www.hse.gov.uk/slips/step/launch_sector.htm

UK Health Services Executive Slips and Trips e-learning package

Contact Details

Alison Pighills

Email: alison_pighills@health.qld.gov.au

1.  Tinetti, M. E., Speechley, M. and Ginter, S. F. (1988). Risk factors for falls among elderly persons living in the community. The New England Journal of Medicine, 319, 1701-1707

2.  Campbell, A. J., Borrie, M. J., Spears, G. F. and Jackson, S. L. (1990). Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing, 19, 136-141

3.  Parker, M. J., Twemlow, T. R. and Pryor, G. A. (1996). Environmental hazards and hip fractures. Age and Ageing, 25, 322-325

4.  Sattin, R. W., Rodriguez, J. G., DeVito, C., A and Wingo, P. (1998). Home environmental hazards and the risk of fall injury events among community dwelling older people. Study to Assess Falls Among the Elderly (SAFE) Group. Journal of the American Geriatrics Society, 46, 669-676

References 5. Gill, T. M., Williams, C. S. and Tinetti, M. E. (2000). Environmental

hazards and the risk of non syncopal falls in the homes of community-living older persons. Medical Care, 30, 1174-1183

6. Campbell, A. J., Robertson, M. C., La Grow, S. J., Kerse, N. M., Sanderson, G. F., Jacobs, R. J., Sharp, D. M. and Hale, L. A. (2005). Randomised controlled trial of prevention of falls in people aged ≥75 with severe visual impairment: the VIP trial. British Medical Journal, 10, 1136-1143

7. Nikolaus, T. and Bach, M. (2003). Preventing falls in community dwelling frail older people using a home intervention team: Results from the randomised falls-HIT trial. Journal of the American Geriatrics Society, 51, 300-305

References

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References 8.  Cumming, R. G., Thomas, M., Szonyi, G., Salkeld, G., O'Neill, E.,

Westbury, C. and Frampton, G. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomised trial of falls prevention. Journal of the American Geriatrics Society, 47, 1397-1402

9.  Stevens, M., Holman, C., D'Arcy, J., Bennett, N. and de Klerk, N. (2001). Preventing falls in older people: outcome evaluation of a randomised controlled trial. Journal of the American Geriatrics Society, 49, 1448-1455

10.  Day, L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H. and Lord, S. (2002). Randomised factorial trial of falls prevention among older people living in their own homes. British Medical Journal, 325, 128

References 11. Clemson et al (2008). Environmental interventions to prevent falls

in community-dwelling older people A meta-analysis of randomized trials. Journal of Ageing and Health, 20, 954-971 doi: 10.1177/0898264308324672

12. Clemson, L. (1997). Home fall hazards: A guide to identifying fall hazards in the homes of elderly people and an accompaniment to the assessment tool, the Westmead Home Safety Assessment. West Brunswick, Victoria, Australia: Coordinates Publication

13. Mackenzie, L., Byles, J., & Higginbotham, (2000). Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the items. British Journal of Occupational Therapy, 63, (6), 260-269