A Process Evaluation of a Fall Prevention Intervention Using the RE-AIM Framework

BACKGROUND

Home hazard removal programs are effective in reducing falls among older adults, but delivery in the United States is limited.

OBJECTIVES

We completed a process evaluation of the Home Hazard Removal Program (HARP), an intervention delivered by occupational therapists.

METHODS

Using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), we examined outcomes using descriptive statistics and frequency distribution. We examined differences between covariates using Pearson correlation coefficients and two-sample t tests.

RESULTS

79.1% of eligible older adults participated (reach); they experienced a 38% reduction in fall rates (effectiveness). Ninety percent of recommended strategies were completed (adoption), 99% of intervention elements were delivered (implementation), and 91% of strategies were still used at 12 months (maintenance). Participants received an average of 258.6 minutes of occupational therapy. An average of US$765.83 was spent per participant to deliver the intervention.

CONCLUSIONS

HARP has good reach, effectiveness, adherence, implementation, and maintenance and is a low-cost intervention.

Removing home hazards for older adults living in affordable housing: A stepped-wedge cluster-randomized trial

BACKGROUND

Falls are the leading cause of injury, disability, premature institutionalization, and injury-related mortality among older adults. Home hazard removal can effectively reduce falls in this population but is not implemented as standard practice. This study translated an evidence-based home hazard removal program (HARP) for delivery in low-income senior apartments to test whether the intervention would work in the "real world."

METHODS

From May 1, 2019 to December 31, 2020, a stepped-wedge cluster-randomized trial was used to implement the evidence-based HARP among residents with high fall risk in 11 low-income senior apartment buildings. Five clusters of buildings were randomly assigned an intervention allocation sequence. Three-level negative-binomial models (repeated measures nested within individuals, individuals nested within buildings) were used to compare fall rates between treatment and control conditions (excluding a crossover period), controlling for demographic characteristics, fall risk, and time period.

RESULTS

Among 656 residents, 548 agreed to screening, 435 were eligible (high fall risk), and 291 agreed to participate and received HARP. Participants were, on average, 72 years, 67% female, and 76% Black. Approximately 95.4% of fall prevention strategies and modifications implemented were still used 3 months later. The fall rate (per 1000 participant-days) was 4.87 during the control period and 4.31 during the posttreatment period. After adjusting for covariates and secular trend, there was no significant difference in fall rate (incidence rate ratio [IRR] 0.97, 95% CI 0.66-1.42). After excluding data collected during a hiatus in the intervention due to COVID-19, the reduction in fall rate was not significant (IRR 0.93, 95% CI 0.62-1.40).

CONCLUSIONS

Although HARP did not significantly reduce the rate of falls, this pragmatic study showed that the program was feasible to deliver in low-income senior housing and was acceptable among residents. There was effective collaboration between researchers and community agency staff.

Examining the impact of a health report card on follow through with fall risk recommendations: an observational study

BACKGROUND

Increasing older adults' awareness of their personal fall risk factors may increase their engagement in fall prevention. The purpose of this study was to explore the impact of and participant satisfaction with a comprehensive occupational therapy fall risk screening and recommendations for evidence-based fall prevention strategies based on personalized fall risk results for community-dwelling older adults.

METHODS

Cognitively normal participants (Clinical Dementia Rating = 0) were recruited from an ongoing longitudinal study of memory and aging. Participants completed 2 annual in-home visits, fall risk questionnaires, and 12 months of fall monitoring between visits. Participants received a health report card with their fall risks and tailored recommendations in 6 domains. Participants completed follow-up questions at their next annual in-home visit about the fall risk recommendations and their satisfaction with receiving their fall risk results.

RESULTS

Two hundred five participants completed 2 annual visits and 12 months of fall monitoring. Of the 6 domains of recommendations provided, participants were most likely to follow through with getting an annual eye exam and reviewing their medications with their doctor or pharmacist. Older adults who fell were significantly more likely to receive recommendations for finding fall prevention classes (p = 0.01) and having a doctor or pharmacist review their medications (p = 0.004). The majority of participants were satisfied receiving their fall risk results (92%) and believed it to be beneficial (90%), though few participants shared their results with their doctor (20%).

CONCLUSIONS

An occupational therapy fall risk screening and tailored recommendations were not sufficient to encourage follow through with fall risk recommendations. Older adults may benefit from additional support and encouragement to reduce their fall risk. Additional research is needed to examine awareness of fall risks and follow through with fall risk recommendations among community-dwelling older adults.

The Relationship Between Physical Housing Characteristics, Housing Accessibility and Different Aspects of Health Among Community-Dwelling Older People: A Systematic Review

Objectives: To synthesize the evidence on the relationships between physical housing characteristics or housing accessibility and different aspects of health among community-dwelling people 60 years and older. Methods: A systematic review of recent evidence with a narrative synthesis was conducted. Results: We included 15 studies and found three themes covering physical housing characteristics or housing accessibility that are associated with aspects of health among community-dwelling older adults: (1) interventions by home modifications targeting housing features both at entrances and indoors; (2) non-interventions targeting indoor features; (3) non-interventions targeting entrance features, that is, the presence of an elevator or stairs at the entrance. The overall quality of evidence across studies was assessed as very low. Discussion: The findings highlight the need for studies with a stronger research design and higher methodological quality that address the physical housing environment in relation to health among older adults to strengthen the body of evidence.

Home hazard modification programs for reducing falls in older adults: a systematic review and meta-analysis

Objective

This study aims to assess the effect of home modification in preventing falls in older adults.

Methods

A systematic review and meta-analysis of randomized studies were performed. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively. Five electronic databases were systematically searched for related articles. The titles and abstracts of the articles found using the key search phrases-home modification and falling-were screened using inclusion and exclusion criteria. The Cochrane risk of bias tool was used to evaluate the studies' methodology.

Results

A total of 12 trials were included. A meta-analysis was conducted using 10 studies with n = 1, 960 participants showing a clinically meaningful 7% reduction in falls (risk ratio = 0.93; 0.87-1).

Conclusions

Falls can be significantly reduced with the use of home modification interventions that are thorough, well-focused, have an environmental-fit perspective, and have adequate follow-up.

Development of the home environment risk rating scale and investigation of the psychometric properties in the elderly and adult individuals

Aim

To reduce home accidents, which is one of the critical public health problems, it is necessary to evaluate the home environment first. The aim of this study was to develop the Home Environment Risk Rating Scale (HERRS) and examine its psychometric properties in elderly and adult individuals.

Subject and methods

This study was conducted on 220 elderly and adult individuals (63.68±10.31 years old, 68.2% female, 31.8% male) living in their homes. The participants completed the Sociodemographic Information Form, Home Environment Conditions Evaluation Form for Falls, and Home and Environment Risk Rating Scale. In addition, psychometric measurement results for horizontal and vertical measurements were analyzed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) methods.

Results

It was found that the Kaiser-Mayer-Olkin (KMO) value for horizontal and vertical measurements were 0.613 and 0.704, respectively. Results of EFA for horizontal and vertical measurements revealed that five factors together explain 72.033% and three factors together explain 68.368% of the total variance, respectively. The result of CFA for horizontal and vertical measurements demonstrate that the 5-sub-dimension horizontal scale structure and the 3-sub-dimension vertical measurement structure generally fit acceptable in this scale. Cronbach's alpha was satisfactory in all of the measurements (0.73 and 0.80 respectively); the ICCs were good/excellent in all of the measurements (0.99 and 0.90, respectively).

Conclusion

The results show that HERRS has the potential to examine the risks of the home environment adequately for the home structure of Turkish society in detail and is a valid and reliable test that health professionals can use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01885-6.

Content validity of the comprehensive home fall hazard checklist, an observational study

One strategy to reduce the number of falls in older adults is through home hazards assessment checklists. The comprehensive home fall hazard checklist (CHFHC) was designed to guide individuals through their home, assessing fall hazards. The checklist systematically prompts the individuals to check 10 general locations in the house The purpose of this study was to assess the content validity of the comprehensive home fall hazard checklist. A 4-point ordinal Likert rating scale was used to evaluate the content validity of each of the 74 items on the checklist. The relevance and clarity of each item was assessed. Nine experts rated the content validity of each test in relation to the 5 tasks in the rating protocol. The item content validity index, and the scale content validity index were determined, and a kappa rating was calculated. Three of the 74 items on the CHFHC were determined to be not relevant receiving a content validity index of 0.78 or less. All of the items were ranked as being quite clear or highly clear, with all items receiving at least 0.78 on the content validity index. The Kappa score indicates expert agreement. The content validity index was determined to be excellent, with high ratings for both relevance and clarity for 71 of 74 items on the CHFHC.

Self-assessment of the home environment to plan for successful ageing: Report from a digital health co-design workshop

Many middle aged and older people will need to adapt or modify their home in order to age in place. Arming older people and their families with the knowledge and tools to assess their home and plan simple modifications ahead of time will decrease reliance on professional assessment. The objective of this project was to co-design a tool which enables people to assess their own home environment and make future plans for ageing in the home. We recruited members of the public who were aged 60 or older to attend a series of two co-design workshops. Thirteen participants worked through a series of discussions and activities including appraising different types of tools available and mapping what a digital health tool might look like. Participants had a good understanding of the main types of home hazards in their own homes and the types of modifications which may be useful. Participants believed the concept of the tool would be worthwhile and identified a number of features which were important including a checklist, examples of good design which was both accessible and aesthetically pleasing and links to other resources such as websites which provide advice about to make basic home improvements. Some also wanted to share the results of their assessment with family or friends. Participants highlighted that features of the neighbourhood, such as safety and proximity to shops and cafes, were also important when considering the suitability of their home for ageing in place. Findings will be used to develop a prototype for usability testing.

Examining Older Adults' Home Functioning Using the American Housing Survey

Identifying individuals at risk of experiencing functional difficulty at home would support timely home safety assessment and modification services, which could lead to reducing home incidents such as falls. The objective of this study was to calculate older adults’ functional difficulty at home scores using the 12 physical function items in the American Housing Survey National and Metropolitan Data (AHS). Among the 28,474 older adults selected for this study, we used 19,932 for measurement model development and 8542 for model testing. Confirmatory factor analysis confirmed an adequate fit of the one-dimensional model with all AHS 12 items loading on one latent construct (functional difficulty at home) (RMSEA: 0.034, CFI: 0.990, and TLI: 0.988). Based on our model selection process, we determined that the Graded Response Model was an optimal model for our analysis and separated two detected differential functioning items for each sex. Using the testing dataset, we validated that the estimated functional difficulty scores showed an expected item hierarchy and statistically significant differences in their association with housing and demographic conditions (p < 0.001). Our results demonstrated the process of using the 12 AHS physical function at home items to produce validated scores of older adults’ functional difficulty at home.

Association of a Perioperative Multicomponent Fall Prevention Intervention With Falls and Quality of Life After Elective Inpatient Surgical Procedures

Importance

Falls after elective inpatient surgical procedures are common and have physical, emotional, and financial consequences. Close interactions between patients and health care teams before and after surgical procedures may offer opportunities to address modifiable risk factors associated with falls.

Objective

To assess whether a multicomponent intervention that incorporates education, home medication review, and home safety assessment is associated with reductions in the incidence of falls after elective inpatient surgical procedures.

Design, Setting, and Participants

This prospective propensity score-matched cohort study was a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial, which was conducted at a single academic medical center between January 16, 2015, and May 7, 2018. Patients in the intervention group of the present study were enrolled in either arm of the ENGAGES clinical trial. Patients in the control group were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center. The propensity score-matched cohort in the present study included 1396 patients (698 pairs) selected from a pool of 2013 eligible patients. All patients underwent elective surgical procedures with general anesthesia and had a hospital stay of 2 or more days. Data were analyzed from January 2, 2020, to January 11, 2022.

Interventions

The multicomponent safety intervention (offered to all patients in the ENGAGES clinical trial) included patient education on fall prevention techniques, home medication review by a geriatric psychiatrist (with communication of recommended changes to the surgeon), a self-administered home safety assessment, and targeted occupational therapy home visits with home hazard removal (offered to patients with a preoperative history of falls).

Main Outcomes and Measures

The primary outcome was patient-reported falls within 1 year after an elective inpatient surgical procedure. The secondary outcome was quality of life 1 year after an elective surgical procedure, which was measured using the physical and mental composite summary scores on the Veterans RAND 12-item health survey (score range, 0-100 points, with 0 indicating lowest quality of life and 100 indicating highest quality of life).

Results

Among 1396 patients, the median age was 69 years (IQR, 64-75 years), and 739 patients (52.9%) were male. With regard to race, 5 patients (0.4%) were Asian, 97 (6.9%) were Black or African American, 2 (0.1%) were Native Hawaiian or Pacific Islander, 1237 (88.6%) were White, 3 (0.2%) were of other race, and 52 (3.7%) were of unknown race; with regard to ethnicity, 12 patients (0.9%) were Hispanic or Latino, 1335 (95.6%) were non-Hispanic or non-Latino, and 49 (3.5%) were of unknown ethnicity. Adherence to individual intervention components was modest (from 22.9% for completion of the self-administered home safety assessment to 28.2% for implementation of the geriatric psychiatrist's recommended medication changes). Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group. No significant difference was found in falls between the 2 groups (standardized risk difference, 0.4%; 95% CI, -4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group.

Conclusions and Relevance

In this cohort study, a multicomponent safety intervention was not associated with reductions in falls within the first year after an elective surgical procedure; however, an increase in quality of life at 1 year was observed. These results suggest a need for other interventions, such as those designed to increase adherence, to lower the incidence of falls after surgical procedures.

A protocol for Removing Environmental Barriers to Independent Living (REBIL): An adapted evidence-based occupational therapy intervention to increase community participation for individuals aging with long-term physical disabilities

Background

People aging with long-term physical disabilities (PAwLTPD) are living longer and experiencing the challenges of aging, including the onset of secondary and age-related health conditions. PAwLTPD are at high risk of falls, fall injuries, diminished functional abilities, and compromised participation. However, no available programs support PAwLTPD to participate safely at home and in the community. The proposed study is to examine the feasibility and efficacy of an adapted intervention: Removing Environmental Barriers to Independent Living (REBIL).

Method/Design

A single-blinded randomized controlled trial (RCT) will be conducted. Participants who are 45-65 years old; self-report difficulty with ≥2 daily activities; have had a physical disability for ≥5 years; and live within 60 miles of the research lab are eligible. All participants will receive an initial in-home evaluation before randomization. The treatment group will receive REBIL (total five visits), which is tailored. The waitlist control group will be offered the same intervention after 6-month follow-up. Expected outcomes are high acceptability, fidelity, and adherence; low safety risk; improved community participation and daily activities performance; and fewer environmental barriers and fall hazards.

Discussion

Findings will serve as preliminary evidence for occupational therapy community practice. Outcomes will also inform future large, pragmatic trials.

Trial Registration

ClinicalTrials.gov identifier NCT04589988.

Environmental Features Contributing to Falls in Persons With Vision Impairment: The Role of Home Lighting and Home Hazards

PURPOSE

To evaluate whether home hazards and lighting levels are associated with higher fall rates in adults with varying degrees of visual field (VF) damage from glaucoma.

METHODS

Participants with diagnosed or suspected glaucoma provided three years of prospective falls data via monthly falls diaries. A post-fall telephone questionnaire determined fall locations. Seven home areas were evaluated for hazards and lighting via an in-home assessment. Multivariate models adjusting for relevant confounders, including age, sex, comorbidity, and severity of VF damage, evaluated the influence of hazards and lighting on fall rates in each home region.

RESULTS

Mean baseline age for the 170 participants was 71.0 (7.6) years and 78 (46%) of participants were female. Fifty-nine participants experienced a total of 83 home falls, with the greatest number of falls occurring on the indoor stairs (n = 24, 29%) and bedroom (n = 17, 21%). Neither the number nor the percentage of hazardous items graded as hazardous was associated with the rate of falls (P > .26). Each 10-fold increase in room lighting was associated with 35% fewer falls in that home region (P = .02). The relation between lighting and the rate of falls did not differ with the degree of visual field damage (P > .3), and a lower fall rate was noted with better lighting even in participants with mild or no VF damage (rate ratio = 0.52/10-fold better lighting; P = 0.01).

CONCLUSIONS

Fewer home falls were found with better lighting, but not with fewer home hazards. Lighting improvements at home may reduce fall rates in older adults. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Home-based, tailored intervention for reducing falls after stroke (FAST): Protocol for a randomized trial

RATIONALE

People with stroke experience falls at more than twice the rate of the general older population resulting in high fall-related injuries. However, there are currently no effective interventions that prevent falls after stroke.

AIMS

To determine the effect and cost-benefit of an innovative, home-based, tailored intervention to reduce falls after stroke.

SAMPLE SIZE ESTIMATE

A total of 370 participants will be recruited in order to be able to detect a clinically important between-group difference of a 30% lower rate of falls with 80% power at a two-tailed significance level of 0.05.

METHODS AND DESIGN

Falls after stroke trial (FAST) is a multistate, Phase III randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis. Ambulatory stroke survivors within five years of stroke who have been discharged from formal rehabilitation to the community and who have no significant language impairment will be randomly allocated to receive habit-forming exercise, home safety, and community mobility training or usual care.

STUDY OUTCOMES

The primary outcome is the rate of falls over the previous 12 months. Secondary outcomes are the risk of falling (proportion of fallers), community participation, self-efficacy, balance, mobility, physical activity, depression, and health-related quality of life. Health care utilization will be collected retrospectively at baseline and prospectively to 6 and 12 months.

DISCUSSION

The results of FAST are anticipated to directly influence intervention for stroke survivors in the community.Trial Registration: ANZCTR 12619001114134.

The Efficacy of Fall Hazards Identification on Fall Outcomes: A Systematic Review With Meta-analysis

Objective

To investigate the efficacy of fall hazards identification programs when compared to no intervention or other fall prevention programs on number of falls, falls incidence, and identifying fall hazards in community-dwelling adults.

Data Sources

CINAHL, PubMed, EMBASE, Scopus, and PsychINFO were used to identify articles.

Study Selection

Studies were selected to compare fall hazards identification programs to a control group. Studies were eligible if they were randomized controlled trials and enrolled adults older than 50 years with the incidence rate of falls as an outcome.

Data Extraction

Study or authors, year, sample characteristics, intervention or comparison groups, number of falls, and number of hazards identified in the intervention and control groups, and follow-up were extracted. The risk of bias assessment was performed using the Cochrane Risk of Bias tool. Quality was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach per outcome.

Data Synthesis

A total of 8 studies (N=8) and 5177 participants were included. There was a high risk of bias across the studies mostly due to improper blinding of personnel of the outcome assessor. Pooled estimate effects from 5 studies assessing the incidence rate of falls from 3019 individuals indicated no difference between fall hazards identification programs and control (incidence rate ratio=0.98; 95% confidence interval, 0.87-1.10).

Conclusions

The current study suggests that there may be a benefit for fall hazards programs in reducing incident falls. However, because of a moderate GRADE rating, more large-scale studies with a higher number of falls events and more consistent control groups are required to determine the true effect.

Tailored Exercise and Home Hazard Reduction Program for Fall Prevention in Older People With Cognitive Impairment: The i-FOCIS Randomized Controlled Trial

Background

The evidence to support effective fall prevention strategies in older people with cognitive impairment (CI) is limited. The aim of this randomized controlled trial (RCT) was to determine the efficacy of a fall prevention intervention in older people with CI.

Method

RCT involving 309 community-dwelling older people with CI. The intervention group (n = 153) received an individually prescribed home hazard reduction and home-based exercise program during the 12-month study period. The control group (n = 156) received usual care. The primary outcome was rate of falls. Secondary outcomes included faller/multiple faller status, physical function, and quality of life.

Results

Participants’ average age was 82 years (95% CI 82–83) and 49% were female. There was no significant difference in the rate of falls (incidence rate ratio [IRR] 1.05; 95% confidence interval [95% CI] 0.73–1.51). A sensitivity analysis, controlling for baseline differences and capping the number of falls at 12 (4 participants), revealed a nonsignificant reduction in fall rate in the intervention group (IRR 0.78; 95% CI 0.57–1.07). Analyses of secondary outcomes indicated the intervention significantly reduced the number of multiple fallers by 26% (RR 0.74; 95% CI 0.54–0.99) when adjusting for baseline differences. There was a differential impact on falls in relation to physical function (interaction term p-value = .023) with a significant reduction in fall rate in intervention group participants with better baseline physical function (IRR 0.60; 95% CI 0.37–0.98). There were no significant between-group differences for other secondary outcomes.

Conclusions

This intervention did not significantly reduce the fall rate in community-dwelling older people with CI. The intervention did reduce the fall rate in participants with better baseline physical function.

Clinical Trials Registration Number

Australian and New Zealand Trials Registry ACTRN12614000603617.

Development and Psychometrics Test of Home Environment Assessment Checklist for Community-Dwelling Older Adults with Dementia

BACKGROUND

Home environment is a core domain in the care of community-dwelling older adults with dementia, but there is no suitable instrument to measure it in China.

OBJECTIVE

To develop and psychometrically test the home environment assessment checklist for community-dwelling older adults with dementia.

METHODS

A three-step process was performed to develop and test this instrument: 1) based on the evidence-based theory, the checklist was summarized as the main points of evidence from living environment settings among older adults with dementia, 2) the draft tool was assigned to an iterative process of evaluation by a panel of examiners consisting of experts from treatment, nursing and caring, people with dementia and their caregivers, 3) inter-rater reliability and internal consistency were calculated with a sample of 348 caregivers of the older adults with dementia.

RESULTS

The HEAC consisted of 71 items in domains addressing safety, stability and familiarity, visual cues, and sensory stimulation. Psychometric evaluation showed that this tool demonstrated sound reliability and validity. Content validity was 0.969 which was established by a panel of experts (n = 10). Inter-rater reliability of two researchers was 0.978, and 0.848 for researchers and caregivers. Test-retest reliability was excellent (ICC = 0.757-0.877) in community-dwelling older adults with dementia 2 week apart.

CONCLUSION

The HEAC is a new tool to help collect the reliable information on the barriers and facilitators of home environment for community-dwelling older adults with dementia and to precipitate the home modification process to improve the quality of care for people with dementia and their caregivers in daily life.

A scoping review of fall hazards in the homes of older adults and development of a framework for assessment and intervention

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.

Fall prevention in primary care using chronic disease management plans: A process evaluation of provider and consumer perspectives

INTRODUCTION

Falls are an important issue in primary care. General practitioners (GPs) are in a key position to identify older people at risk of falls on their caseload and put preventative plans into action. Chronic Disease Management (CDM) plans allow GPs to refer to allied health practitioners (AHPs) for evidence-based falls interventions. A previous pilot study reduced falls risk factors using CDM pans with older people at risk of falls. This study aimed to conduct a process evaluation of how the intervention worked in the pilot study for providers and consumers.

METHODS

This process evaluation used qualitative descriptive methods by interviewing the GPs, AHPs and older people involved in the intervention study. An independent researcher conducted interviews. These were audiotaped, transcribed and analysed using thematic analysis. Data were also collected about the implementation of the programme.

RESULTS

Two GPs, three occupational therapists, three physiotherapists and eight older people were interviewed. Key themes emerged from the perspectives of providers and consumers. The programme was implemented as intended, adherence to the exercise diaries was variable and the falls calendars were fully completed for three months of follow-up. The programme was implemented as intended.

CONCLUSION

The pilot CDM falls prevention programme did not identify common barriers attributed to GPs. Older people were amenable to the programme and participated freely. Private AHPs needed to make the CDM items work for their business model. This approach can be rolled out in a larger study and integrated pathways are needed to identify and intervene with older people at risk of falls in primary care.

Environmental interventions for preventing falls in older people living in the community

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.

A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review

BACKGROUND

Falls occurring on stairs or in bathrooms are associated with a high risk of injuries among older adults. Home environmental assessments are frequently used to guide fall-prevention interventions. The aims of this review were to describe how, where, by whom, and for whom environmental hazard checklists are used, and to examine the characteristics of environmental hazard assessment checklists with specific attention to features of bathrooms and stairs/steps assessed in them.

METHODS

Studies published before January 5, 2018, were identified using several databases. Publications reporting the use and/or evaluation of environmental hazard checklists were eligible if they assessed bathrooms or stairs/steps in homes of older adults (≥65 years). Content analysis was conducted on publications that provided a complete list of specific environmental hazards assessed. Checklist items related to bathrooms and stairs/steps were extracted and categorized as structural or non-structural and as objective or subjective.

RESULTS

1119 studies were appraised. A pool of 136 published articles and 4 checklists from the grey literature were included in this scoping review. Content analysis was conducted on 42 unique checklists. There was no widely used checklist and no obvious consensus definition of either environmental hazards overall or of single hazards listed in checklists. Checklists varied greatly with respect to what rooms were assessed, whether or not outdoor stair/steps hazards were assessed, and how responses were coded. Few checklists examined person-environment fit. The majority of checklists were not oriented towards structural hazards in bathrooms. Although the majority of checklists assessing stair/steps hazards evaluated structural hazards, most features assessed were not related to the construction geometry of stairs/steps. Objective features of bathrooms and stairs/steps that would deem them safe were rarely specified. Rather, adequacy of their characteristics was mostly subjectively determined by the evaluator with little or no guidance or training.

CONCLUSION

The lack of standard definitions and objective criteria for assessing environmental hazards for falls is limiting meaningful cross-study comparisons and slowing advances in this field. To inform population health interventions aimed at preventing falls, such as building code regulations or municipal housing by-laws, it is essential to include objectively-assessed structural hazards in environmental checklists.

Falls Among Wheelchair and Scooter Users with Multiple Sclerosis—A Review

Falls are increasingly recognized as a threat to the safety, health and well-being of people with multiple sclerosis (MS), and emerging evidence suggests that full time wheelchair and scooter users with MS have unique fall prevention needs. This review is comprised of three parts. Part 1 summarizes findings describing influences on falls among full time wheelchair and scooter users with MS and associated clinical implications. Although further studies are needed, early findings regarding influences on fall risk operating in this specific population highlight the importance of addressing falls that occur during activities of daily living, the high frequency of falls occurring in the bathroom, and both extrinsic (e.g., wet/slippery surfaces) and intrinsic (e.g., muscle spasticity/weakness) contributors to falls. Part 2 of this review describes available evidence regarding interventions to prevent falls in full time wheelchair and scooter users with MS. Because intervention work in this area is limited to one pilot study, Part 3 presents priorities for future research and identifies the need for randomized trials evaluating fall prevention programs that address diverse fall risk factors and allow for development and attainment of individualized fall prevention goals.

Development and validation of a remote home safety protocol

AIM

Environmental assessments and subsequent modifications conducted by healthcare professionals can enhance home safety and promote independent living. However, travel time, expense and the availability of qualified professionals can limit the broad application of this intervention. Remote technology has the potential to increase access to home safety evaluations.

PURPOSE

This study describes the development and validation of a remote home safety protocol that can be used by a caregiver of an elderly person to video-record their home environment for later viewing and evaluation by a trained professional.

METHODS

The protocol was developed based on literature reviews and evaluations from clinical and content experts. Cognitive interviews were conducted with a group of six caregivers to validate the protocol.

RESULTS

The final protocol included step-by-step directions to record indoor and outdoor areas of the home. The validation process resulted in modifications related to safety, clarity of the protocol, readability, visual appearance, technical descriptions and usability.

CONCLUSIONS

Our final protocol includes detailed instructions that a caregiver should be able to follow to record a home environment for subsequent evaluation by a home safety professional. Implications for Rehabilitation The results of this study have several implications for rehabilitation practice The remote home safety evaluation protocol can potentially improve access to rehabilitation services for clients in remote areas and prevent unnecessary delays for needed care. Using our protocol, a patient's caregiver can partner with therapists to quickly and efficiently evaluate a patient's home before they are released from the hospital. Caregiver narration, which reflects a caregiver's own perspective, is critical to evaluating home safety. In-home safety evaluations, currently not available to all who need them due to access barriers, can enhance a patient's independence and provide a safer home environment.

Modified Delphi Consensus to Suggest Key Elements of Stepping On Falls Prevention Program

Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers.

METHODS

Older adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists.

RESULTS

The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score -0.1, Outfit MnSQ 0.96, Z score -0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader's role, and all of the home visits, booster sessions, group leader's role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them.

DISCUSSION

The Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad US dissemination.

The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

Quantifying Fall-Related Hazards in the Homes of Persons with Glaucoma

OBJECTIVE

To characterize fall-related hazards in the homes of persons with suspected or diagnosed glaucoma, and to determine whether those with worse visual field (VF) damage have fewer home hazards.

DESIGN

Cross-sectional study using baseline (2013-2015) data from the ongoing Falls in Glaucoma Study (FIGS).

PARTICIPANTS

One-hundred seventy-four of 245 (71.0%) FIGS participants agreeing to the home assessment.

METHODS

Participants' homes were assessed using the Home Environment Assessment for the Visually Impaired (HEAVI). A single evaluator assessed up to 127 potential hazards in 8 home regions. In the clinic, binocular contrast sensitivity (CS) and better-eye visual acuity (VA) were evaluated, and 24-2 VFs were obtained to calculate average integrated VF (IVF) sensitivity.

MAIN OUTCOME MEASURES

Total number of home hazards.

RESULTS

No significant visual or demographic differences were noted between participants who did and did not complete the home assessment (P > 0.09 for all measures). Mean age among those completing the home assessment (n = 174) was 71.1 years, and IVF sensitivity ranged from 5.6 to 33.4 dB (mean = 27.2 dB, standard deviation [SD] = 4.0 dB). The mean number of items graded per home was 85.2 (SD = 13.2), and an average of 32.7 (38.3%) were identified as hazards. IVF sensitivity, CS, and VA were not associated with total home hazards or the number of hazards in any given room (P > 0.06 for all visual measures and rooms). The bathroom contained the greatest number of hazards (mean = 7.9; 54.2% of graded items classified as hazardous), and the most common hazards identified in at least 1 room were ambient lighting <300 lux and exposed light bulbs. Only 27.9% of graded rooms had adequate lighting. IVF sensitivity, CS, and VA were not associated with home lighting levels (P > 0.18 for all), but brighter room lighting was noted in the homes of participants with higher median income (P < 0.001).

CONCLUSIONS

Multiple home fall hazards were identified in the study population, and hazard numbers were not lower for persons with worse VF damage, suggesting that individuals with more advanced glaucoma do not adapt their homes for safety. Further work should investigate whether addressing home hazards is an effective intervention for preventing falls in this high-risk group.

Evaluation of the Home Environment Assessment for the Visually Impaired (HEAVI): an instrument designed to quantify fall-related hazards in the visually impaired

BACKGROUND

To (1) develop and refine the Home Environment Assessment for the Visually Impaired (HEAVI), and (2) determine the interrater reliability of this instrument, which was designed to quantify the number of fall-related hazards in the homes of individuals with visual impairment.

METHODS

Twenty homes of community-dwelling adults were included in this study. Each home was graded by an occupational therapist (OT) and two non-expert (NE) graders. Seventy-three HEAVI items were evaluated in eight rooms, for a total of 185 potential hazards per home (some items were assessed in multiple rooms). Pairwise and three-way agreement between graders was evaluated at the item, room, and home level using Krippendorff's alpha and intraclass correlation coefficients (ICC). Additionally, the most hazardous home locations and items were determined by comparing the mean and standard deviation of the number of hazards by room and grader.

RESULTS

Of the 73 items, 45 (62%) demonstrated at least moderate agreement overall and for each OT/NE pair (Krippendorff's alpha >0.4), and remained in the final instrument (a total of 119 potential hazards per home as some items were assessed in multiple rooms). Of these 119 potential hazards, an average of 35.7, 33.2, and 33.3 hazards per home were identified by the OT and NE graders, respectively. Moderate to almost perfect agreement on the number of hazards per home and number of hazards per room, except the dining room, was found (ICCs of 0.58 to 0.93). Bathroom items were most often classified as hazards (>40% of items for all graders). The item classes most commonly graded as hazardous were handrails and lighting (>30% of items).

CONCLUSION

Our results indicate that NE graders can accurately administer the HEAVI tool to identify fall-related hazards. Items in the bathroom and those related to handrails and lighting were most often identified as hazards, making these areas and items important targets for interventions when addressing falls.

Determining the Effectiveness of a Falls Prevention Programme to Enhance Quality of Life: An Occupational Therapy Perspective

Falls are common in older people and become more frequent with advancing age. Falling in older people is associated with mortality, decreased mobility, premature nursing home admissions and a reduced ability to perform activities of daily living. In an attempt to reduce the incidence of falls, the National Service Framework for Older People has emphasised the need to develop falls services that provide support for older people who have fallen and use health promotion initiatives. While there is evidence to suggest that home modifications can reduce falls in older people, there has been little research to evaluate the effectiveness of occupational therapy falls prevention programmes.

This paper reports the findings of an evaluation of a multifaceted falls prevention programme, which aimed to determine whether occupational therapy could enhance quality of life by educating people aged 65 years and over about the risk of falls. A pre-intervention and post-intervention non-standardised self-administered questionnaire was completed at week 1 and at week 14. Of the 172 older people attending the falls prevention programme, 78 (45%) completed both questionnaires.

The findings from this study suggest that an occupational therapy falls prevention programme can reduce the impact of falls on older people by enhancing confidence to perform activities, which in turn can increase quality of life. However, further research is needed to determine the effectiveness of anxiety management techniques.

Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the Items

The Home Falls and Accidents Screening Tool (HOME FAST) was developed as a screening instrument for use in a community preventive care trial for older people. This paper describes the first stage of the development of this screening tool. The objectives of the study were (i) to review existing home safety measures, (ii) to field test an instrument containing a pool of home safety items with the goal of identifying those hazards associated with falls in the home and (iii) to select the items for inclusion in a 25-item tool using an expert panel.

The field testing took place in a rural area of Australia, where the pooled checklist was used to evaluate hazards within the homes of 83 older people. No individual hazards were associated with the risk of falls at home and, although participants who had experienced falls had a higher mean number of home hazards (mean = 13.7, SD 8.2), the differences between fallers and non-fallers was not significant. Items relevant to a rural population were indicated through field testing. Further psychometric testing of the HOME FAST and a meaningful method of scoring the checklist are now warranted.

Social Isolation and Physical Barriers in the Houses of Stroke Survivors in Rural China

OBJECTIVE

To describe the home barriers and social isolation of stroke survivors in the rural areas of China and to explore which home barriers are associated with social isolation.

DESIGN

Cross-sectional survey.

SETTING

Structured interviews and observation in the participants' homes.

PARTICIPANTS

Community-dwelling stroke survivors in the rural areas of China (N=818).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical barriers in rural homes were surveyed using a home fall hazards assessment. Social isolation was identified if ≥2 of the following indicators were observed: low frequency of getting out of the home, lacking leisure activities, and living alone in the previous 3 months.

RESULTS

The prevalence rates of 18 among 30 home barriers were >20%, and the highest was 93% (lack of handrails in the bathroom). The prevalence of social isolation was 30%. Three home barriers were independently related to social isolation. These were a distant toilet (odds ratio [OR], 2.363; 95% confidence interval [CI], 1.527-3.658; P<.001), unsuitable seating (OR, 1.571; 95% CI, 1.026-2.404; P=.038), and inaccessible light switches (OR, 1.572; 95% CI, 1.064-2.324; P=.023).

CONCLUSIONS

Many barriers exist in the houses of stroke survivors in rural China. Some of them are related to social isolation. Eliminating or decreasing home barriers could be a feasible and effective approach to reducing social isolation.

Upper limb spasticity management for patients who have received Botulinum Toxin A injection: Australian therapy practice

BACKGROUND/AIM

To describe Australian physiotherapy and occupational therapy practice for patients who receive upper-limb Botulinum Toxin-A (BoNT-A).

METHOD

Anonymous online survey asking about practice experience. Convenience sample of 128 BoNT-A experienced occupational therapists and physiotherapists.

RESULTS

The primary work setting was multidisciplinary inpatient or outpatient rehabilitation services where therapists had automatic referral to BoNT-A patients. Patients expected BoNT-A to improve functional movement, reduce hypertonicity, increase passive range, reduce pain, improve appearance and hand hygiene. Most patients were injected in multidisciplinary public hospital clinics and had median 2 pre-injection (range 0-30) and 8 post-injection (range 0-50) therapy sessions. Biceps, flexor digitorum profundus/superficialis and brachoradialis were most frequently injected. Injectors used therapist assessment information to select sites 68% of the time; only 44% of services had assessment protocols. Standardised therapy assessments examined motor performance, pain and function in that order of frequency. The greater the awareness and perceived relevance of an assessment the more often therapists used it. All therapists set goals, most collaboratively, and these mirrored patient expectations. The most common treatments were stretch, task-specific functional training, strength training and home programmes.

CONCLUSION

While trends in Australian assessment, goals and treatment practice were observed, greater consistency could be achieved if therapy practice guidelines existed. The gap is exacerbated by the absence of Australian BoNT-A organisation and process of care spasticity management guidelines. This creates an environment where practice variability is inevitable. Recommendations to improve local service quality are made.

Non-therapist identification of falling hazards in older adult homes using digital photography

Evaluation and removal of home hazards is an invaluable method for preventing in-home falls and preserving independent living. Current processes for conducting home hazard assessments are impractical from a whole population standpoint given the substantial resources required for implementation. Digital photography offers an opportunity to remotely evaluate an environment for falling hazards. However, reliability of this method has only been tested under the direction of skilled therapists. Ten community dwelling adults over the age of 65 were recruited from local primary care practices between July, 2009 and February, 2010. In-home (IH) assessments were completed immediately after a photographer, blinded to the assessment form, took digital photographs (DP) of the participant home. A different non-therapist assessor then reviewed the photographs and completed a second assessment of the home. Kappa statistic was used to analyze the reliability between the two independent assessments. Home assessments completed by a non-therapist using digital photographs had a substantial agreement (Kappa = 0.61, p < 0.001) with in-home assessments completed by another non-therapist. Additionally, the DP assessments agreed with the IH assessments on the presence or absence of items 96.8% of the time. This study showed that non-therapists can reliably conduct home hazard evaluations using digital photographs.

[Home safety and severe mental disorders: Developing an evaluation tool]

BACKGROUND

Home safety evaluation is an important issue within the context of current perspectives on accommodation for people with a serious mental illness who favour a more independent way of life.

PURPOSE

This paper describes the development and content validation of the Evaluation de la sécurité a domicile et de la gestion des risques (ESGR), an occupational therapy assessment tool for people with a serious mental illness.

METHOD

The ESGR was developed from scientific knowledge and clinical experience. Assessing content validity was done in two phases and involved the consultation of 11 experts.

FINDINGS

In its current form, the ESGR includes 67 items organized into three categories (environment, occupation, person).

IMPLICATIONS

According to the experts consulted, there is a clinical interest in using the ESGR to support occupational therapists in the assessment of home safety for people with serious mental illness. The statements are clear and representative of the concept and the target audience.

Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia

Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.

Can a tailored exercise and home hazard reduction program reduce the rate of falls in community dwelling older people with cognitive impairment: protocol paper for the i-FOCIS randomised controlled trial

BACKGROUND

The rate of falls in community dwelling older people with cognitive impairment (CI) is twice that of a cognitively intact population, with almost two thirds of people with CI falling annually. Studies indicate that exercise involving balance and/or a home hazard reduction program are effective in preventing falls in cognitively intact older people. However the potential benefit of these interventions in reducing falls in people with CI has not been established.This randomised controlled trial will determine whether a tailored exercise and home hazard reduction program can reduce the rate of falls in community dwelling older people with CI. We will determine whether the intervention has beneficial effects on a range of physical and psychological outcome measures as well as quality of life of participants and their carers. A health economic analysis examining the cost and potential benefits of the program will also be undertaken.

METHODS AND DESIGN

Three hundred and sixty people aged 65 years or older living in the community with CI will be recruited to participate in the trial. Each will have an identifiable carer with a minimum of 3.5 hours of face to face contact each week.Participants will undergo an assessment at baseline with retests at 6 and 12 months. Participants allocated to the intervention group will participate in an exercise and home hazard reduction program tailored to their cognitive and physical abilities.The primary outcome measure will be the rate of falls which will be measured using monthly falls calendars. Secondary outcome measures will include the risk of falling, quality of life, measures of physical and cognitive function, fear of falling and planned and unplanned use of health services. Carers will be followed up to determine carer burden, coping strategies and quality of life.

DISCUSSION

The study will determine the impact of this tailored intervention in reducing the rate of falls in community dwelling older people with CI as well as the cost-effectiveness and adherence to the program. The results will have direct implications for the design and implementation of interventions for this high-risk group of older people.

TRIAL REGISTRATION

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry - ACTRN12614000603617.

Implementing person-environment approaches to prevent falls: a qualitative inquiry in applying the Westmead approach to occupational therapy home visits

BACKGROUND/AIMS

Despite 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.

RESULTS

Investment 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.

Avatar-mediated home safety assessments: piloting a virtual objective structured clinical examination station

BACKGROUND

Avatars and virtual worlds offer medical educators new approaches to assess learners' competency in home-safety assessments that are less time-consuming and more flexible than traditional home visits. We sought to evaluate the feasibility and acceptability of implementing an avatar-mediated, 3-dimensional (3-D) home simulation as a virtual objective structured clinical examination station for geriatric medicine fellows.

METHODS

We developed a 3-D home simulation in the virtual world Second Life (Linden Lab, San Francisco, CA) containing 50 safety hazards that could affect the safety of an elderly person at home. Eight geriatric medicine fellows participated in a 16-station objective structured clinical examination, with one station assigned to the 15-minute 3-D virtual world simulation, where the fellow's "home visit" was performed by navigating his or her avatar in the virtual world simulation. The fellows were instructed to find the home safety hazards in the simulated environment and then provide specific written recommendations. Two reviewers independently scored the fellows' written findings against an inventory-based checklist.

RESULTS

The geriatric medicine fellows scored a mean of 43% ± SD 9 on the inventory-based checklist. The scoring of the 2 reviewers showed a high interrater reliability (88%). Six of the 8 participants (75%) rated the simulation as "excellent." Four of the 5 women (80%) and none of the 3 men (20%) participating in the virtual objective structured clinical examination needed navigation assistance in the 3-D virtual house.

CONCLUSION

The 3-D, avatar-based, virtual geriatric home safety objective structured clinical examination is a practical and acceptable alternative to the traditional home safety visits in an objective structured clinical examination setting.

Environmental assessment and modification as fall-prevention strategies for older adults

This article discusses the role of home assessment and environmental modification in reducing the risk of falls and helping older adults and persons with disabilities live in the community. This article reviews the research on the efficacy of home environmental assessment and modification. Researchers agree that integrated risk-management programs that emphasize on multiple interventions, including professional home-hazard assessment, along with home modifications are most effective for improving function and reducing falls. Important steps for implementing home modifications for persons at risk of falling are discussed, including exploring fall-risk factors and the effects of home modifications, identifying what changes are needed through home assessments, identifying sources of payment, and finding qualified installers and products.

Person--environment fit predicts falls in older adults better than the consideration of environmental hazards only

OBJECTIVE

To test the hypotheses that the empirical consideration of objective person-environment fit in the home environment is a stronger predictor of indoor falls among older adults than the assessment of environmental barriers only, and that perceived aspects of home play a role as predictors for falls.

DESIGN

Survey study with data collection at home visits, followed up by self-reports about falls at home visits one year later.

SETTING

Urban districts in Sweden, Germany, Latvia.

PARTICIPANTS

Eight hundred and thirty-four single-living, older adults (75-89 years), in ordinary housing.

MEASUREMENTS

An assessment of objective person-environment fit in the home environment (housing enabler), a self-rating of the perceived home environment (usability in my home) and retrospective self-reports on indoor falls.

RESULTS

The participants reporting falls tended to be frailer than the non-fallers. The number of environmental barriers in the home was similar for the fallers and non-fallers; the magnitude of person-environment fit problems was higher among the fallers. The person-environment fit problem variable was a stronger fall predictor (odds ratio (OR) = 1.025; P=0.037) than number of environmental barriers (n.s.), even after controlling for confounders. Fallers also experienced lower usability of their home.

CONCLUSION

The results suggest that much of the inconclusiveness of the data in the relationship between environmental hazards and falls in the previous falls literature could be due to the neglect of person-environment fit assessment. The effectiveness of environmental interventions based on the notion of person-environment fit compared with traditional home hazard checklists remains to be tested.

Environmental interventions to prevent falls in community-dwelling older people: a meta-analysis of randomized trials

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.

Development and psychometric testing of the Clinician Readiness for Measuring Outcomes Scale

BACKGROUND

If allied health professionals are to begin measuring outcomes routinely, a change in attitudes and behaviour is necessary. However, individuals need to be ready to change and often move through several stages before practice change is observed.

AIM

To develop and test the psychometric properties of a questionnaire that determines clinicians' readiness to measure outcomes.

METHODS

A study of instrument development, validation and reliability. Ten expert allied health professionals were involved in content validity testing. A further 396 allied health professionals completed the questionnaire to establish content and construct validity, internal consistency and temporal reliability (or stability). Of these 396 allied health professionals, 70 participated in the temporal reliability assessment. Content validity was established using the Content Validity Index (CVI). Construct validity was determined using confirmatory factor analysis (CFA) and internal consistency was ascertained using Cronbach's alpha. Temporal reliability was confirmed using intraclass correlation coefficients (ICC 3,1).

RESULTS

A 30-item questionnaire was developed, reflecting the five stages of change from the Transtheoretical Model of Change, and commonly cited barriers to outcome measurement. Content validity was excellent (CVI = 0.96). Using CFA, a two-factor model provided best fit. Based on CFA results, four items were dropped resulting in a 26-item questionnaire (range 26-156). Internal consistency reliability was excellent (alpha = 0.94). Temporal (stability) reliability ICC (3,1) was very good (r = 0.86, P = 0.0001).

CONCLUSIONS

The final 26-item questionnaire takes 10 minutes to complete and 5 minutes to score. The Clinician Readiness for Measuring Outcomes Scale provides educators with useful information about clinician readiness and helps identify strategies for affecting behaviour change.