Strategies to implement multifactorial falls prevention interventions in community-dwelling older persons: a systematic review

BACKGROUND

One-third of the community-dwelling older persons fall annually. Guidelines recommend the use of multifactorial falls prevention interventions. However, these interventions are difficult to implement into the community. This systematic review aimed to explore strategies used to implement multifactorial falls prevention interventions into the community.

METHODS

A systematic search in PubMed (including MEDLINE), CINAHL (EBSCO), Embase, Web of Science (core collection), and Cochrane Library was performed and updated on the 25th of August, 2022. Studies reporting on the evaluation of implementation strategies for multifactorial falls prevention interventions in the community setting were included. Two reviewers independently performed the search, screening, data extraction, and synthesis process (PRISMA flow diagram). The quality of the included reports was appraised by means of a sensitivity analysis, assessing the relevance to the research question and the methodological quality (Mixed Method Appraisal Tool). Implementation strategies were reported according to Proctor et al.'s (2013) guideline for specifying and reporting implementation strategies and the Taxonomy of Behavioral Change Methods of Kok et al. (2016).

RESULTS

Twenty-three reports (eighteen studies) met the inclusion criteria, of which fourteen reports scored high and nine moderate on the sensitivity analysis. All studies combined implementation strategies, addressing different determinants. The most frequently used implementation strategies at individual level were "tailoring," "active learning," "personalize risk," "individualization," "consciousness raising," and "participation." At environmental level, the most often described strategies were "technical assistance," "use of lay health workers, peer education," "increasing stakeholder influence," and "forming coalitions." The included studies did not describe the implementation strategies in detail, and a variety of labels for implementation strategies were used. Twelve studies used implementation theories, models, and frameworks; no studies described neither the use of a determinant framework nor how the implementation strategy targeted influencing factors.

CONCLUSIONS

This review highlights gaps in the detailed description of implementation strategies and the effective use of implementation frameworks, models, and theories. The review found that studies mainly focused on implementation strategies at the level of the older person and healthcare professional, emphasizing the importance of "tailoring," "consciousness raising," and "participation" in the implementation process. Studies describing implementation strategies at the level of the organization, community, and policy/society show that "technical assistance," "actively involving stakeholders," and "forming coalitions" are important strategies.

TRIAL REGISTRATION

PROSPERO CRD42020187450.

Fall Prevention Program Characteristics and Experiences of Older Adults and Program Providers in Canada: A Thematic Content Analysis

Objectives: To document the characteristics of fall prevention programs in specific regions in two Canadian provinces and to explore older adults' and program providers' experiences with these programs. Methods: Semi-structured interviews were conducted with 16 program providers/managers from 12 different programs. Ten semi-structured focus groups were conducted with 59 older adults. Data were analyzed using thematic content analysis. Results: Older adults reported functional and social benefits. Program providers identified barriers to program success, including cognitive impairment, frailty, and lack of motivation. The need for general attitudinal changes toward older adults' needs and broader community changes were identified as important by the older adults. Discussion: Easily accessible information about fall prevention programs for older adults and no-cost, ongoing initiatives were critical. Health care providers play keys roles in disseminating information, facilitating referrals, and advocating for initiatives that best meet the needs of older adults in their communities.

Understanding the profile of Personal Alert Victoria clients who fall

Personal response systems are used to support frail, older people, and people with disabilities to live independently in their own homes. This paper describes the patterns, characteristics, and outcomes of Personal Alert Victoria (PAV) clients who experience a fall. It also examines the current falls prevention referral practices of assessors who determine whether an older person would benefit from a personal response system. Deidentified data on clients from the PAV service provider from 2012 to 2014 were linked to routine data maintained by the Department of Health and Human Services in Victoria. Falls prevention referral practices of assessors were examined using an online survey. Personal response systems were most frequently activated because of a fall in this group of older people (n = 16,822; 44%). No demographic or clinical factors differentiated PAV clients who activated the system because of a fall compared to those who did not, despite a significant increase in the rate of falls-related system activations (p = 0.001) and hospitalisation (p < 0.001) between 2012 and 2014. Assessors believed that PAV clients were at increased risk of falls and frequently recommended falls prevention interventions such as strength and balance interventions (n = 112; 93%) in order to address this risk. This study has provided an insight into the issue of falls among PAV clients, which can help guide the tailoring of falls prevention interventions that can be integrated within existing service models.

Evaluation of older people's knowledge, awareness, motivation and perceptions about falls and falls prevention in residential aged care homes: a tale of two cities

Falls prevention strategies can only be effective in reducing falls amongst older people if they are adopted and enacted in their daily lives. There is limited evidence identifying what older people in residential aged care (RAC) homes understand about falls and falls prevention, or what may limit or enable their adoption of strategies. This study was conducted in two countries and explored older people's knowledge and awareness of falls and their preferences, opportunities and motivation to undertake falls prevention strategies. A cross-sectional survey was administered to participants (N = 70) aged 65 years and over, living in six RAC homes in Perth, Australia and six RAC homes in Swansea, Wales, United Kingdom. Participants had limited knowledge about intrinsic falls risk factors and strategies to address these and frequently expressed self-blame regarding falling. Almost all (N = 67, 95.7%) participants felt highly motivated to maintain their current functional mobility and independence in everyday tasks. Key preferences for receiving falls prevention messages favoured a positive approach promoting wellness and independence (N = 41, 58.6%) via pictorial posters or brochures (N = 37, 52.9%) and small group discussions preferably with demonstrations (N = 18, 25.7%). Findings from this study may assist organisations and staff to more effectively engage with older people living in RAC about falls prevention and design targeted resources to address the motivations and preferences of this population.

Depressive symptomatology and fall risk among community-dwelling older adults

RATIONALE

Falls are common among older adults and may be related to depressive symptoms (DS). With advancing age, there is an onset of chronic conditions, sensory impairments, and activity limitations that are associated with falls and with depressive disorders. Prior cross-sectional studies have observed significant associations between DS and subsequent falls as well as between fractures and subsequent clinical depression and DS.

OBJECTIVE

The directionality of these observed relationship between falls and DS is in need of elaboration given that cross-sectional study designs can yield biased estimates of the DS-falls relationship.

METHODS

Using 2006-2010 Health and Retirement Study data, cross-lagged panel structural equation models were used to evaluate associations between falls and DS among 7233 community-dwelling adults ages ≥65. Structural coefficients between falls and DS (in 2006→2008, 2008→2010) were estimated.

RESULTS

A good-fitting model was found: Controlling for baseline (2006) physical functioning, vision, chronic conditions, and social support and neighborhood social cohesion, falls were not associated with subsequent DS, but a 0.5 standard deviation increase in 2006 DS was associated with a 30% increase in fall risk two years later. This DS-falls relationship was no longer significant when use of psychiatric medications, which was positively associated with falls, was included in the model.

CONCLUSION

Using sophisticated methods and a large U.S. sample, we found larger magnitudes of effect in the DS-falls relationship than in prior studies-highlighting the risk of falls for older adults with DS. Medical providers might assess older individuals for DS as well as use of psychotropic medications as part of a broadened falls prevention approach. National guidelines for fall risk assessments as well as quality indicators for fall prevention should include assessment for clinical depression.

Home or away? Choosing a setting for a falls-prevention program for people with multiple sclerosis

Evidence suggests that choice of setting may be important in influencing the outcomes of rehabilitation programs, as well as optimizing participant satisfaction and adherence. This article aims to examine the factors that may inform the choice of setting for a falls-prevention program tailored to the needs of people with multiple sclerosis, including the influence of setting on program effectiveness, participant engagement, cost, and sustainability. Any new program should ensure that the choice of setting is informed by the intended program outcomes as well as an awareness of the opportunities and challenges presented by each type of setting. Evaluations of falls programs for older people suggest that immediate outcomes are similar regardless of setting; however, long-term outcomes may differ by setting, possibly owing to differential effects on adherence. Programs based away from home may offer benefits in terms of maintaining motivation, providing peer-support opportunities, and allowing regular access to facilitator input, while home-based programs offer unique opportunities for context-based practice and the integration of falls-prevention activities into real life. Additionally, home-based programs may address some of the long-term feasibility issues associated with programs away from home. A "mixed" program incorporating elements of home- and community-based activity may be the most sustainable and effective choice to achieve both long- and short-term goals within a falls-prevention program. However, currently there are significant gaps in knowledge relating to comparative program outcomes, cost, and long-term sustainability.

Twelve month follow up of a falls prevention program in older adults from diverse populations in Australia: a qualitative study

Several randomised trials demonstrate that multi dimensional falls prevention programs are effective in reducing falls in older adults. There is a need to examine the impact of these programs in real life settings where diverse populations exist. The aim of this study was to examine the acceptability and impact on sustained participation in falls prevention activities of a combined exercise and education falls prevention program. A semi structured telephone interview was conducted with 23 participants 12 months following the completion of a 15 week falls prevention program tailored to diverse communities in Victoria, Australia and provided in both a group and home based format. Reported benefits of the falls prevention program included physical improvements in joint flexibility, mobility and balance and enjoyment derived from both the exercises and socialisation. Recall of the educational component was minimal as were ongoing behavioral changes to reduce the risk of falling other than exercise. Participation in sustained exercise for falls prevention following the completion of the program was also inconsistent. Future improvements of such programs could focus upon ensuring the exercises prescribed are sufficiently challenging for each individual in order to be of physical benefit, altering the educational style to be goal directed and more enjoyable, and integrating further strategies to support sustained participation in falls prevention behavioral changes. Linking participants with alternate ongoing exercise opportunities or potential sources of ongoing support may be advantageous in enhancing long term participation in exercise for falls prevention following cessation of the program.

Fear of Falling and the Use of Telecare by Older People

Introduction:

Since fear of falling has been linked to self-restriction of activity, a further decline in physical functioning and a greater risk of falling, interventions, such as use of telecare, to address a person's fear are essential to reduce the risk of further falls. The aim of this critical review was to evaluate the association between older people's fear of falling and the use of telecare, and whether telecare could reduce this fear.

Method:

A search of major databases (1980–2011) identified 424 results and, following screening, 10 articles were included in the review.

Findings:

Perceptions of older people about using telecare were mixed: some felt a greater sense of security and reassurance but, for others, confidence levels were not increased. Studies suggest that an automatic fall detector was useful for older people who were unable or reluctant to use a pendant alarm following a fall.

Conclusion:

The use of telecare including the wearing of an automatic fall detector, while improving confidence and reducing fear of falling in some, does not suit everyone. A careful assessment of a person's views on his or her falls risk and level of anxiety will determine how telecare can best meet the person's needs to remain supported at home.

Representations of Old Age in Falls Prevention Websites: Implications for Likely Uptake of Advice by Older People

Introduction:

The representations of old age in falls prevention websites were explored and considered for their potential impact on older people's uptake of the advice.

Method:

Websites were searched for using the strategy of a previous systematic-style review and evaluated using the principles of discourse analysis.

Findings:

In the analysis of 33 websites, three main subject positions afforded to older readers were identified: (1) Passive recipients: victims of the ageing process, ignorant, ill-informed and vulnerable; (2) Rational learners: responsive to information, rational problem solvers and compliant with prescriptive advice; and (3) Empowered decision makers: actively engaged with and evaluative of information, autonomous and responsible for their course of action.

Discussion:

Falls prevention websites were rarely designed according to evidence-based recommendations concerning fit with positive self-identity and empowerment of active self-management of health. Although the representation of older people as passive and inert was most evident, the image of empowered decision makers was most likely to engage older people in preventing falls.

Conclusion:

Occupational therapists should ensure that they represent older people in a positive and respectful manner in falls prevention information, both that available through the internet and in written form.

Psychosocial issues in Engaging Older People with Physical Activity Interventions for the Prevention of Falls

Dans cet article on présente une vue d’ensemble des facteurs psychosociaux ayant une influence sur la participation des personnes âgées aux interventions concernant l’activité physique et visant la prévention des chutes. On souligne l’importance des facteurs psychosociaux puisque les interventions seront rendues inutiles si elles ne réussissent pas à attirer la participation active des personnes âgées. La théorie du comportement planifié sert de cadre pour un examen de la façon dont les connaissances (un préalable), les attitudes, les normes subjectives (le contexte social) et la perception du contrôle comportemental (la confiance) encouragent ou entravent l’intention d’entre-prendre des activités pour la prévention des chutes. Cette étude est accompagnée de documents qui indiquent la manière dont la perception de soi influence l’intention. On termine par une discussion des recommendations recommendations du réseau européen Prevention of Falls Network Europe concernant l’implication des personnes âgées dans la prévention des chutes.

Older Adults' Experiences and Perceptions of Dual Tasking

There is no consensus on which dual task (DT) test best assesses mobility or balance deficits in older adults. This study aimed to explore older adults' experiences and perceptions of dual tasking to identify DTs relevant to their everyday life and that they perceive as difficult or risky.

Two gender-specific focus groups were conducted. Six males and nine females, aged 70 years or above, participated. The topics posed to the groups included structured and open questions designed to explore experiences of combining two activities and the consequences of that for balance. The results were subjected to content analysis to identify DT examples, task difficulty levels and balance-threatening tasks.

Most participants were able to identify DT examples and some identified a concurrent impact on balance. There were gender differences in the examples: the females focused more on household tasks and the males more on outdoor activities. Many tasks that were considered difficult or risky by the participants do not feature sufficiently in the literature, such as stair negotiation and avoiding moving obstacles accompanied by secondary tasks.

The views of older adults should be taken into consideration to help to develop tests that are more sensitive and have face validity.

A Review to Explore how Allied Health Professionals can Improve Uptake of and Adherence to Falls Prevention Interventions

A literature review was conducted to facilitate allied health professionals' implementation of the recommendations made by the Prevention of Falls Network Europe (ProFaNE) (Yardley et al 2007a) on promoting older people's engagement in activities to prevent falls. The falls prevention literature was searched for relevant papers to aid allied health professionals' choice of strategies and to inspire ideas about how to implement ProFaNE's recommendations in everyday practice. Suggestions for each of the six ProFaNE recommendations are made, which may in turn promote older people's adherence to falls prevention interventions.