Acceptability of Online Yoga Among Individuals With Chronic Conditions and Their Caregivers: Qualitative Study

BACKGROUND

The online delivery of yoga interventions rapidly expanded during the COVID-19 pandemic, and preliminary studies indicate that online yoga is feasible across multiple chronic conditions. However, few yoga studies provide synchronous online yoga sessions and rarely target the caregiving dyad. Online chronic disease management interventions have been evaluated across conditions, life spans, and diverse samples. However, the perceived acceptability of online yoga, including self-reported satisfaction and online delivery preferences, is underexplored among individuals with chronic conditions and their caregivers. Understanding user preferences is essential for successful and safe online yoga implementation.

OBJECTIVE

We aimed to qualitatively examine the perceived acceptability of online yoga among individuals with chronic conditions and their caregivers who participated in an online dyadic intervention that merged yoga and self-management education to develop skills (MY-Skills) to manage persistent pain.

METHODS

We conducted a qualitative study among 9 dyads (>18 years of age; individuals experiencing persistent moderate pain) who participated in MY-Skills online during the COVID-19 pandemic. The intervention consisted of 16 online, synchronous yoga sessions over 8 weeks for both dyad members. After the completion of the intervention, participants (N=18) participated in semistructured telephone interviews for around 20 minutes, discussing their preferences, challenges, and recommendations for improved online delivery. Interviews were analyzed by using a rapid analytic approach.

RESULTS

MY-Skills participants were, on average, aged 62.7 (SD 19) years; were primarily women; were primarily White; and had a mean of 5.5 (SD 3) chronic conditions. Both participants and caregivers reported moderate pain severity scores (mean 6.02, SD 1.3) on the Brief Pain Inventory. The following three themes were identified related to online delivery: (1) participants indicated a preference for the intervention to be in person rather than online because they were distracted in the home setting, because they felt that in-person yoga would be more engaging, because the yoga therapist could physically correct positions, and because of safety concerns (eg, fear of falling); (2) participants indicated good acceptability of online MY-Skills delivery due to convenience, access, and comfort with being in their home; and (3) recommendations for improving online delivery highlighted a need for additional and accessible technical support.

CONCLUSIONS

Both individuals with chronic conditions and their caregivers find online yoga to be an acceptable intervention. Participants who preferred in-person yoga did so due to distractions in the home and group dynamics. Some participants preferred in-person corrections to ensure correct positioning, while others felt safe with verbal modifications in their homes. Convenience and access were the primary reasons for preferring online delivery. To improve online delivery, future yoga studies should include specific activities for fostering group engagement, enhancing safety protocols, and increasing technical support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03440320; https://clinicaltrials.gov/ct2/show/NCT03440320.

EXPERIENCING PAIN TOGETHER: CARE PARTNERS REFLECT ON A DYADIC INTERVENTION FOR PAIN SELF-MANAGEMENT

When caregivers and care receivers (caregiving dyad) both experience persistent pain, there is increased risk for shared adverse health outcomes, including social isolation and decreased relationship satisfaction. Yet, there are few non-pharmacological pain interventions for the caregiving dyad. The purpose of this study was to understand changes in the caregiving dyad after participating in a dyadic, multi-modal intervention for pain self-management. Fifteen caregiving dyads with pain (N=30) participated in the Merging Yoga and self-management to develop Skills (MY-Skills) intervention. Open-ended questions were included in the post-intervention evaluation tool to discuss changes in the dyadic relationship. Qualitative methods were used to analyze data, develop a coding scheme, and identify themes. Findings suggest the intervention strengthened relationships by improving communication, enhancing emotional connection, and increasing physical activity. This study demonstrates the importance of dyadic approaches to interventions for care partners with pain.

STARS AND WISHES: INSIGHTS AND SUGGESTIONS FOR ACADEMICS IN GERONTOLOGY AND GERIATRICS EDUCATION

In 2002, I presented a student paper at the annual meeting and educational leadership conference of the Association for Gerontology in Higher Education (AGHE) about co-teaching with my mentor an undergraduate adult development and aging course. Little did I know then, presenting about collaborative teaching methods and proven student assessment of learning such as, ‘Stars and Wishes’, that the AGHE presentation would lead me on a rewarding career path resulting in receiving the 2022 AGHE Distinguished Faculty Award. The purpose of this presentation is to discuss seven ‘Stars’ that I believe were pivotal points in my career whereby gerontological education and students studying gerontology benefited, and my ‘Wishes’ for gerontology and geriatrics education to inspire future academics as they navigate the next 20 years.

EXPLORING THE ASSOCIATION BETWEEN FAMILY DYNAMICS AND PREPAREDNESS FOR FAMILY CAREGIVING AT THE END OF LIFE

The transition to providing end-of-life (EOL) care to a family member can be challenging for family caregivers as they face difficult decisions regarding medical course of treatment, increasing caregiving responsibilities, and anticipatory grief. Low preparedness for EOL caregiving is associated with higher levels of caregiver strain, increased levels of depression and anxiety, and complicated and prolonged grief after the death of the family member. Despite the breadth of caregiving research, little is known about how family relationships and interactions relate to caregiver preparedness for EOL caregiving. Thus, the purpose of this study was to explore the association between family caregivers’ family dynamics and their perceived preparedness for the transition to EOL caregiving. A sample of 173 family caregivers were recruited to complete an online, self-report survey. A structural equation model was used to analyze the association between family dynamics and caregiving preparedness. Most caregivers reported balanced family cohesion (75.1%) and family flexibility (75.7%), but low family communication and low family satisfaction. In addition, 20.2% of caregivers reported being not at all prepared for the transition to EOL caregiving. Although there was a lack of meaningful association between family dynamics and preparedness for EOL caregiving, it may be that family relationships and interactions grow more complex as families age and individuals take on new and different roles (such as family caregiving) within the family system. This study demonstrates the need for future research to develop new measures to explore how aging family dynamics relate to family caregiver experiences and outcomes.

INDIVIDUALS AND THEIR CAREGIVERS WITH PERSISTENT PAIN: A FEASIBILITY AND ACCEPTABILITY STUDY

Persistent pain interventions targeting the caregiving dyad (i.e., caregivers and care receivers) are scarce. Thus, the purpose of this pilot study was to assess the feasibility and acceptability of the Merging Yoga and self-management to develop Skills (MY-Skills) intervention for caregiving dyads experiencing persistent pain. MY-Skills is a group intervention and was delivered in-person or online (due to COVID-19) twice a week for eight weeks, with each two-hour session including self-management education followed by yoga. Benchmarks for feasibility were set a prioi and included: recruitment, attrition, attendance, safety, acceptability/satisfaction, and study completion. Thirteen participants (caregivers n=7, care-receivers n=6) completed the in-person intervention and 18 individuals (9 dyads) completed the online version. Feasibility benchmarks were met, except for recruitment, where >1000 individuals were screened for eligibility. Interventions may lead to improved wellbeing, yet further research is needed to establish efficacy of health-related outcomes for the caregiving dyad experiencing persistent pain.

Testing Predictive Factors of Depressive Symptoms among Grandparents under the COVID-19 Pandemic

An estimated 69.5 million Americans are reported to be grandparents. Among them, about 10% are raising grandchildren and the number of grandparents who are raising grandchildren (GRG) is increasing. Previous research on GRG suggests that the unexpected caregiving duties may lead to negative physical and mental health including more depressive symptoms when compared to non-caregiving grandparents (NGRG). Additionally, grandparent-grandchild relationships determined by emotional availability (EA) of the grandparent may be impacted. These factors might further be complicated, especially as it relates to the health and well-being of GRG, as a result of the COVID-19 pandemic. Thus, the overarching goal of this presentation is to use the biopsychosocial model to present a conceptual framework to test the mental well-being of GRG during the COVID-19 pandemic. In this presentation, we will 1) summarize appropriate literature on GRG; 2) share a COVID-19 health and well-being assessment survey designated for GRG in order to assess their health before and since the COVID pandemic; and 3) propose a conceptual model to investigate and test the protective role of physical activity and GRG’s EA in the grandparent-grandchild relationship for the mental health of GRG. In our model, we argue that GRG experience more COVID-19 pandemic-related stress and more depressive symptoms when compared to NGRG. This proposed conceptual model offers one way to test the predictors of depressive symptoms on GRG. Future testing has the potential to shed new light on the development of appropriate intervention programs tailored to maintain the mental health of GRG.

Development of a Multi-Modal, Dyadic Intervention for Persistent Pain: A Qualitative Study

People who experience persistent pain often require help from a family member, partner, or friend. These caregivers frequently have pain, but are often not included in interventions. Caregivers and care-receivers who both experience pain are more likely to be socially isolated, experience communication conflict, and have decreased quality of life. Interventions should target caregiving dyads to help them manage their pain together. Feasibility studies that include manual development, intervention evaluation, and refinement of intervention manuals support randomized controlled trials and help move interventions from research to practice. Thus, the purpose of this qualitative study was to explore (a) the needs of caregiving dyads, (b) input from medical and allied health experts, and (c) feedback from intervention facilitators and evaluators, informing the development and refinement of an intervention manual for people with persistent pain. A total of 16 caregiving dyads and one individual (caregiver couldn’t participate) experiencing pain participated in focus groups. Eight experts then participated in a focus group or one-on-one interview. Lastly, after the intervention ended, 15 intervention facilitators and fidelity evaluators participated in one focus group. Data were uploaded into NVivo software and analyzed using constant comparison. Findings identified the importance of interventions to focus on pain interference, novel and modifiable approaches to managing pain as a dyad, and addressing the emotional and psychological effects of experiencing pain. Using qualitative approaches to develop, test, and refine an intervention manual enhances the relevancy, acceptability, and translation of our intervention to meet the needs of caregiving dyads experiencing pain.

Family Caregivers' Feelings of Preparedness for the Transition to End-Of-Life Caregiving

The high levels of stress experienced by family caregivers may affect their physical and psychological health, including their sleep quality. However, there are few population-based studies comparing sleep between family caregivers and carefully-matched controls. We evaluated differences in sleep and identified predictors of poorer sleep among the caregivers, in a comparison of 251 incident caregivers and carefully matched non-caregiving controls, recruited from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Incident caregivers and controls were matched on up to seven demographic and health factors (age, sex, race, education level, marital status, self-rated health, and self-reported serious cardiovascular disease history). Sleep characteristics were self-reported and included total sleep time, sleep onset latency, wake after sleep onset, time in bed, and sleep efficiency. Family caregivers reported significantly longer sleep onset latency, before and after adjusting for potential confounders, compared to non-caregiving controls (ps < 0.05). Depressive symptoms in caregivers predicted longer sleep onset latency, greater wake after sleep onset, and lower sleep efficiency. Longer total sleep time in caregivers was predicted by employment status, living with the care recipient, and number of caregiver hours. Employed caregivers and caregivers who did not live with the care recipient had shorter total sleep time and spent less time in bed than non-employed caregivers. Additional research is needed to evaluate whether sleep disturbances contributes to health problems among caregivers.

Grandparent Resilience: Improving Self-Efficacy in Grandparents Raising Grandchildren

Grandparents often protect against childhood trauma and promote resilience through their nurturance, love, and support when raising grandchildren. Despite the beneficial role grandparents have on their grandchildren, grandparents may experience challenges of their own, including physical, mental, and emotional health issues, lack of resources, and social isolation. Few interventions exist to help grandparents successfully adapt to the challenges they face as primary parenting figures. The purpose of this study was to test preliminary efficacy of a strengths-based intervention for grandparents raising grandchildren aimed at increasing self-care behaviors, managing emotions, and connecting to community resources. Grandparents (N = 137) providing primary care to grandchildren were recruited to participate in a single-group, pre- and post-test design, 6-week intervention. Self-efficacy was assessed at baseline, post-intervention, and at a 6-month follow-up. To evaluate who the intervention might be most beneficial for, grandparents’ service knowledge, perceived support from others, and length of care provided, measured at baseline, were analyzed for moderating effects. Results of paired-samples t-tests reveal significant increases in self-efficacy (p = .013) from baseline to post-test, which were maintained at the 6-month follow-up (p = .010). Hierarchical multiple regression showed interaction effects of the hypothesized moderators were not significant, indicating improvements in self-efficacy regardless of individual variability at baseline. As demonstrated, interventions can be effective at increasing self-efficacy in grandparents raising grandchildren and strengths-based approaches have the potential to provide universal benefits to grandparents, thus improving functioning in grandfamilies and promoting the health and well-being of grandparents and their grandchildren.

Why Engagement Matters to Gerontological Student Learning

Learning opportunities beyond the classroom create lasting and positive effects on students’ academic and professional growth. When faculty members participate in engaged scholarship in their local communities, out-of-classroom learning opportunities for students likewise expand. In the context of aging, the array of opportunities for students to engage with community partners is vast, from interactive course assignments to research opportunities, clinical experience, local policy efforts, and more. This paper builds on previous theoretical and empirical work from scholars (including AGHE and GSA Fellows) in the science of engagement, and integrates case examples of campus-community relationships from our collective years in the academy. Examples will showcase how engaged teaching, engaged research, and engaged service collectively informs and enriches our students’ experiences. In the spirit of the 2020 conference theme, we will discuss opportunities for university-community engagement as a way to strengthen and inspire current and future gerontological pedagogy.

Moderation of Physical Health on Emotional Health Among Grandparents Raising Grandchildren

An estimated 69.5 million older adults in the United States report being grandparents. It is also evident that the number of grandparents raising grandchildren among them is increasing. Although caring for their grandchildren often provides grandparents a sense of purpose and increased life satisfaction, unexpected responsibilities of parenting worsen the already challenging experience of aging (e.g., potential for poor physical and mental health). Thus, it is essential to study the well-being of grandparents raising grandchildren. Links between depressive symptoms and emotional health have been widely studied in previous research. However, limited research has focused on physical health as a potential moderator, despite indirect evidence shown that more depressive symptoms may be observed among those with worse physical health conditions. To address this, we used Optum® SF-36v2® Health Survey to collect physical- and mental-health data and Center for Epidemiological Studies Depression Scale (CES-D-10) to collect information on depressive symptoms in 137 grandparents raising grandchildren (age 40-83) before, immediately after, and six months after a six-week intervention focused on self-care practices. The presence of more depressive symptoms indicated worse emotional health. Physical health moderated these associations at all three time points, such that depressive symptoms were less strongly related to emotional health if grandparents self-reported better physical-health scores. These findings have important implications for future intervention studies. The importance of good physical health practices for grandparents raising grandchildren is evident, including increased physical engagement and better pain management.

Challenges of Recruiting Caregiver and Care Receiver Dyads for a Randomized Clinical Trial

The recruitment of participants for chronic disease clinical trial research is often challenging. Further complicating participant recruitment occurs when the intervention is dyadic (i.e., simultaneously includes both care receivers and caregivers or recruiting pairs of people). Despite the strong support in favor of dyadic interventions for certain chronic diseases (e.g., among cancer and stroke survivors and their caregivers), researchers have not systematically shared challenges and opportunities for dyadic recruitment. During the recruitment for a yoga and self-management education intervention for people with chronic pain and their caregivers, several steps were taken to recruit and screen potential participants for the study. In this presentation, we will provide an overview of common recruitment challenges for physical activity and chronic disease self-management studies as well as the actual challenges encountered and our procedures for overcoming these obstacles. We will present our consort figure with attention toward inclusion and exclusion criteria of both care receivers and caregivers. Additional discussion will include specific challenges encountered when recruiting and screening caregivers (i.e., after the care receiver has been screened). The need for innovative clinical trial research with caregivers and care recipient dyads is essential as new care practices continue to evolve and demands on health care utilization increase. Lessons learned from this study may prove useful for future researchers as they embark on developing and testing dyadic interventions among adults with chronic disease and their caregivers.

Merging Yoga and OT for Parkinson’s Disease: Preliminary Outcomes

Date Presented 03/26/20

We completed a pilot study of an eight-week Merging Yoga and OT for Parkinson’s Disease program (MY-OT for PD). MY-OT for PD was a fall-risk self-management program that merged community-based yoga and group OT. Participants served as their own controls during the pilot study. During the intervention period (as compared to the control period), participants experienced reduced self-reported falls, improved fall management and prevention, and improved balance.

Primary Author and Speaker: Karen Atler

Additional Authors and Speakers: Arlene Schmid

Contributing Authors: Brett Fling, Julia Sharp, Christine Fruhauf

INTEREST GROUP SESSION—GRANDPARENTS AS CAREGIVERS: GERONTOLOGICAL INTERVENTION SCIENCE: FOUR DIFFERENT APPROACHES TO GRANDFAMILY RESEARCH

For nearly three decades, the interest in custodial grandparents and their grandchildren has resulted in empirical studies from scholars addressing both the challenges and strengths often experienced by grandfamilies (i.e., grandparents and the grandchildren in their home). As the scholarship of intervention science increases in interest and as scholars continue to advance the field of knowledge with grandfamilies, it is important to share best-practices as we plan the future of gerontological intervention science. In this symposium, investigators with extensive experience researching custodial grandparents and in creating, testing, and refining interventions with grandfamilies will present theoretical, methodological, and practical lessons learned and empirical findings from their interventions. The first paper, by Musil and colleagues, will address a current online training program addressing resourcefulness with grandmothers. Second, Montoro-Rodriguez and Hayslip will discuss the use of the selective optimization with compensation model as applied to a goal-setting intervention with grandparents. The third paper by Fruhauf, Yancura and colleagues will address the progress and impact from the first two years of their intervention with grandparents, grandchildren, and service providers. The final paper, presented by Webster, Smith, and Infurna will focus on a dyadic intervention with grandparents and adolescent grandchildren as they seek to build social intelligence. Hayslip, the discussant, will integrate key points from these interventions while addressing considerations for future research as scholars embark on refining and testing their interventions related to grandparents raising grandchildren.

GRANDPARENT CAREGIVERS: THE RELATION BETWEEN SOCIAL NETWORKS AND RESILIENCE

Grandparents raising grandchildren experience multiple challenges as they take on the unexpected role of caring for their grandchildren, which usually occurs under stressful and stigmatizing conditions. Many of the challenges grandparents experience are well documented in the research. Less attention is given to understanding how a grandparent caregiver’s social network changes when s/he becomes a caregiver and how her/his social network influences resilience. Thus, the purpose of this study was to use social network analysis (SNA) to examine the relation between social networks and resilience in grandparents raising their grandchildren. This was done by conducting face-to-face interviews with twenty grandparents raising grandchildren after they completed a survey measuring social support, social isolation, and resilience. The interview protocol included questions related to participants’ social network, social support, and services. Prior to the interviews, using data from the surveys participants were identified as representing one of four resilience quadrants: resilient, maladaptive, competent, and vulnerable. Qualitative analysis of grandparent’s social networks across groups indicated resilient grandparent caregivers’ networks were structured in a way that provided more opportunities for the inflow of new information and resources. Whereas the proportion of professionals in maladaptive grandparent caregivers’ networks tended to be less than for other networks. This could suggest that for grandparent caregivers, having professionals in one’s network can be beneficial. Findings from the current study provide opportunities for future research such as identifying ways to help grandparent caregivers structure their social networks to promote resilience.

CALL A TEENAGER . . . THAT’S WHAT I DO!: GRANDCHILDREN HELP OLDER ADULTS USE NEW TECHNOLOGIES

As older adults increasingly show interest in technology for their well-being, families will play an important role in promoting the adoption and use of beneficial health technologies. The purpose of this study was to conduct a sub-analysis of data collected from a large-scale qualitative project regarding older adults’ experiences using health information technology. Specifically, the sub-analysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adult engagement with new health technologies. While the primary analysis of the original study was theoretically driven, this paper reports results from the inductive, open-coding analysis. Twenty-four older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index &gt; 2) participated in a focus group conducted at patients’ primary clinic. While conducting the primary theoretically-driven analysis, coders also utilized an open-coding approach to ensure important ideas not reflected in the theoretical code-book were captured. Open-coding resulted in a primary theme, “family support”, that was furthered categorized by who and how the tech-support was provided. Participants were not specifically asked about family support, yet family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children for help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process. Family support, specifically via grandchildren, may have a key role in the successful adoption and use of emerging health technologies.

IMPROVING HEALTH AND WELL-BEING OF GRANDPARENTS RAISING GRANDCHILDREN: A STRENGTHS-BASED INTERVENTION

Many grandparents raising grandchildren experience depression. Few interventions take a strengths-based approach to improve their mental health. To address this gap, this study utilized an adapted version of Powerful Tools for Caregivers (PTC) for grandparents (PTC-G) to improve their self-care, communication, and self-efficacy. Grandparents completed self-assessments including the CES-D short form prior to the intervention, immediately after the 6-week program, and at 6-months. Focus groups were also conducted during the 6-month follow-up to further explore positive behavior change. Data from all sources were analyzed to show that the PTC-G program significantly lowered depressive symptoms of grandparents raising grandchildren. Qualitative data shows that grandparents report increased awareness and use of self-care practices and community services. By improving the health and well-being of grandparents raising grandchildren, the PTC-G intervention shows promise in reducing depression and improving long-term mental health outcomes in vulnerable grandfamilies.

THE ROLE OF ENGAGEMENT IN SUPPORTING AND LEVERAGING GERONTOLOGY AND GERIATRIC PROGRAMS

For nearly 20 years, gerontology and geriatric administrators and faculty have been challenged by managing “tough times” related to low enrollment and reduced or limited funding for their programs. At the same time, the aging population continues to increase and the need for highly trained individuals to work with and on behalf of older adults are needed in all sectors of the workforce. In this paper, I will build on previous empirical and theoretical work from AGHE and GSA Fellows as I integrate personal experience from my fifteen years at a land-grant university, whereby I serve as the coordinator of our undergraduate gerontology minor. In particular, in an effort to uplift the 2019 conference theme, I will organize my thoughts from the lens of university-community engagement, as I describe how to best harness networks to support and leverage gerontology and geriatrics programs.

Meeting the Needs of People with Parkinson Disease Through the Adaptation of a Fall Risk Program: Merging Yoga and OT for Parkinson Disease

Date Presented 04/05/19

Primary Author and Speaker: Laura Swink

Contributing Authors: Karen Atler, Tara Klinedinst, Christine Fruhauf, Brett Fling, Arlene Schmid

"Call a Teenager… That's What I Do!" - Grandchildren Help Older Adults Use New Technologies: Qualitative Study

Background

Although family technical support seems intuitive, there is very little research exploring this topic.

Objective

The objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults’ experiences in using health information technology. Specifically, the subanalysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adults’ engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis.

Methods

This is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults’ use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients’ primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support.

Results

The participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process.

Conclusions

The results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients.

Fall-prevention pilot: hazard survey and responses to recommendations

This work reports a partial inventory of fall hazards for community-dwelling elders and characterizes older adult responses to fall prevention. Thirty-five seniors living in their homes participated in a fall-prevention initiative designed to identify hazards and make recommendations. Fifteen external hazards were identified and operationalized, and between one and four changes were reported per home in 18 of 22 homes, consistent with recommendations; however, most of the recommendations were unrelated to the cause of later participant falls. Considering the varied circumstances of falls in the community, we question the wisdom of designating specific risk posed by individual hazards and encourage future investigation on the merits of multifaceted evaluation and intervention including the consideration of combinations and interactions of hazards as well as raising caution and awareness.