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November/December 2013
Home Remedy for Fall RiskBy Machiko R. Tomita, PhD, and Susan M. Nochajski, PhD, OTR/L A new educational and assessment tool identifies fall risk factors in the home and offers specific information about ways to prevent older adults’ falls. Older adults’ falls represent a serious public health concern. As the number of older adults increases, so does the incidence of falls and their associated costs. One in three older adults falls at least once in any given year, and almost one-half of those who have experienced a fall will fall again within a year. When older adults fall, 20% to 30% of them sustain injuries such as lacerations, hip fractures, or traumatic brain injuries; some falls result in death. In the past 15 years, there has been a sharp rise in the death rate from falls as well as the direct medical costs for treating fall-related injuries. In 2020, the costs are estimated to reach $54.9 billion.1 Many falls are preventable, especially in a familiar environment such as the home. For older adults, their own homes should be safe and free from environmental hazards in order to prevent falls. However, according to the National Institutes of Health, six of every 10 falls occur at home. The Centers for Disease Control and Prevention recommends a simple strategy for reducing in-home falls: remove the hazards that may cause a fall. This strategy may include modifications such as removing or securing throw rugs, increasing lighting, and improving bathroom safety by installing grab bars. Such modifications appear to be common sense. So why aren’t more older adults making these changes? One reason may be that elders adopt a “not me” attitude. Older people tend to have lived in their homes for a long time, and it’s not easy for them to recognize that their familiar environment may harbor fall risks. For elders who are experiencing gradual physical decline, such as weakened muscle strength and decreased flexibility caused by age-related illnesses, fall prevention is more essential. Some conditions can increase the likelihood of falls in older adults. Roughly 45% of older adults have a diagnosis of arthritis,2 and about one-half of women aged 50 and older break a bone because of osteoporosis.3 A patient’s gradual decline increases the difficulty of objectively assessing risk factors that exist in a home environment. Therefore, older adults who have not fallen tend to believe they are immune to falling in their own homes. Another reason may be that although older adults may be aware of their physical changes, old habits are difficult to alter. Elders tend to go about chores or routine activities without thinking about the way they are used to doing them. Suppose, for example, an older woman wakes up in the middle of the night to go to the bathroom, and the bedroom is dark. She has taken the same path hundreds of times and has never fallen before. She knows the exact path and can locate where a quad cane, a standing floor lamp, and a basket full of knitting yarn are located. What she does not know is that her grandchildren were playing with her purse, and the strap is on the floor near her bed. Unfortunately, as she begins to walk, the purse strap catches her foot and she falls. If there were a motion sensor nightlight attached to the bedroom wall, this could have been prevented. Researchers familiar with the potential catastrophic results of elders’ in-home falls have developed a practical tool that’s effective in preventing such falls. Members of the occupational therapy geriatric group in the department of rehabilitation science at the University at Buffalo in New York have designed an effective educational and assessment tool to identify fall risk factors for use among health care professionals and older adults. The Home Safety Self-Assessment Tool (HSSAT), which prevents falls through self-improvement of the home environment, offers specific information about ways to prevent falls in the home. Additionally, it cites helpful safety devices and products, providing names and contact information for area businesses and free services prepared to assist elders with structural and equipment issues. Such resource lists easily can be adapted to any locale. Health care providers can raise elders’ awareness of the risk of in-home falls and the environmental factors that can increase the risk, and home safety assessments can work effectively to help prevent older adults’ falls. Havoc in the Home Once an elder has experienced a fall, he or she may be even more vulnerable to a future fall, as the elder may fear falling again and subsequently lead a less active, more sedentary lifestyle. This inactivity, in turn, leads to further loss of muscle conditioning that contributes to falls. The fact that the elder doesn’t engage in activities like he or she once did, representing the onset of disability, often results in depression, which then can lead to further inactivity. Providers need to interrupt or prevent this downward spiral. Exercise offers an effective approach to head off the cascade of events that contribute to older adults’ falls. Health care professionals should encourage mobility inside the home, especially for older adults who are homebound and/or without transportation and for those who live in areas with severe weather where outdoor activities may not be possible. Home improvements can help increase elders’ mobility when the environment becomes safer. Older adults should be able to move around their homes free from worry about falling hazards. It’s important to create a safe environment with a balance between convenience and mobility. It’s better and less confusing when home environment improvements involve the fewest changes and moves possible. For example, it’s ideal to arrange frequently used items within elders’ reaching distance and determine whether new arrangements are actually helpful. When it’s practical and safe, activities should be built into routine situations. For example, residents in Albert Lea, Minnesota, who are participating in the well-known AARP/Blue Zones Vitality Project, are encouraged not to use a remote control to operate a television but to walk to the TV to change channels. Some nursing homes have adopted an Eden Alternative concept that allows residents to enjoy their meals in a homelike kitchen located close to their bedrooms. The setting provides residents with the opportunity to experience living in an inviting atmosphere rather than an institutional setting. The trade-off, however, is that residents experience decreased lower extremity strength from not having to walk long distances to reach community dining rooms. Caregivers often increase elders’ dependency and contribute to their muscle deterioration by providing too much help and doing everything for them. The caregiver may pick up mail, make doctor’s appointments, prepare meals, give medications, sweep floors, and walk the dog while the older adult sits on the couch and watches TV. Although the older adult may be happy with the caregiver’s assistance, he or she increases the risk of the older adult developing hypertension, obesity, weakened lower extremities and grip strength, and even cognitive decline, if these conditions are not already present. A better caregiver is one who encourages older adults to perform daily chores with minimal assistance, assuring their safety and pacing activities so that elders can accomplish what they need to do without fatigue. Older adults need to maintain and improve physical and cognitive strength for independent living. Caregivers should support independence and activity in the home to prevent the need for long term care. To make a home environment safer for older adults requires a similar approach. The strategy should be for older adults to be safely active in their own homes, allowing space where elders can move around and exercise. Providers must become actively engaged in identifying home hazards and taking the steps to effect modifications that ensure a safe living environment and reduce the risk of falls. A Practical Solution The HSSAT encompasses nine home area assessments: entrances to the front door and yard as well as to the back/side door, hallway or foyer, living room, kitchen, bedroom, bathroom, staircases, and laundry room/basement. The tool includes pictures of potential fall risks for each area along with a checklist. The list highlights four to 10 fall risks, and the accompanying page shows the solutions for each fall risk item. The numbers in each picture, potential fall risk items, and solutions coincide. Another section directs users to look at assistive devices and helpful products currently available in the market. It contains pictures, descriptions, the price range of each product, and the source of information. To identify reliable area home-modification service providers, the researchers recommend contacting local providers listed in a telephone book or on websites. When contacting a prospective vendor, inquire whether the company employs a certified aging-in-place specialist (CAPS), a designation that usually confirms qualifications for such a modification job. Regardless, determine whether vendors complete small-scale jobs under $1,000, whether they’re experienced in the necessary modifications for older adults and can provide two references, whether they are insured, and the length of the lead time. Word of mouth may be the best way to judge vendors’ reliability and quality. For the HSSAT, almost all of the service providers in Erie County, New York, listed in the yellow pages and on websites were contacted and then sent a small survey that included the four questions above. For vendors who were qualified, the researchers provided a seminar regarding how to work with a CAPS to make homes safe for older adults. Once they were committed to the goals and objectives, they were listed in the HSSAT. As mentioned, both health care providers and older adults can use the HSSAT action log. For example, an occupational therapist involved in overseeing modifications in an older adult’s home can use this action log by recording an observed problem or hazard, the intended course of action, actions completed and the associated timing, and the vendor contacted or strategy used and its cost. The log is for the user’s convenience and works especially well for older adults with memory loss. Using the log to record home modifications creates a written history of improvements. Since the HSSAT booklet was designed for residents in a particular county, the information related to vendors and home modification service providers and organizations that provide free services is specific to residents of that area. Therefore, the authors recommend modifying these sections to make the information pertinent to other areas or counties in which it is used. (The HSSAT is available free of charge at www.agingresearch.buffalo.edu.) The HSSAT’s reliability and validity have been established, and its effectiveness has been evidenced through several studies in individuals’ homes as well as in an institutional setting. Health care professionals’ use of the HSSAT to educate older adults can reduce the number of fall risk factors through actions subsequently taken by older adults. Elders’ use of the HSSAT without the involvement of an occupational therapist is effective for those who have experienced a previous fall and raises fall-risk awareness even among elders who can’t afford or don’t care to make home modifications. The HSSAT is routinely reviewed and updated, and information is added as appropriate. The authors are developing another section, how-to home improvements, which will be available in spring of 2014. — Machiko R. Tomita, PhD, is a gerontologist and researcher on the interaction between technology and health behavior in the department of rehabilitation science and the director of the Aging and Technology Research Center at the University at Buffalo, State University of New York. — Susan M. Nochajski, PhD, OTR/L, is director of the occupational therapy program in the department of rehabilitation science at the University at Buffalo.
Patient Tips for Home Fall Prevention • Remove small icicles within easy reach so that home entry and exit are safe. Do not try to remove bigger and dangerous icicles; have someone else remove them. • Always wear shoes that fit properly and have nonskid soles. • Install light switches at the top and bottom of all stairs. • Use lights with high-wattage bulbs to see more clearly. • Install automatic lighting in areas of frequent activity to make nighttime safer. • Keep emergency flashlights near the bed to help locate light switches and provide illumination in case of a power outage. • When climbing or descending stairs, never hurry to pick up a phone or answer the doorbell. • Remember the number of stairs and count each step when climbing or descending them. • When carrying items, always keep one hand empty to grab on to something if support is needed. • Remove electrical and phone cords from walkways. • Place regularly used kitchen items where they are easily accessible. • When using a ladder, always keep three points of contact with the ladder: two feet and a hand. • Use a handheld showerhead to make showering safer and easier. • Avoid carrying a heavy laundry basket or one with odd-shaped or large objects in it. • For emergency purposes, keep a phone in the bathroom, attic, and laundry room. • For emergency purposes, place a bag with a three-day supply of water and food, a contact list, a radio, a flashlight, a first aid kit, and medications near the home’s exit.
References 2. Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2010;59(39):1261-1265. 3. What women need to know. National Osteoporosis Foundation website. http://www.nof.org/articles/235. |
