Falls are a serious threat to the lives and occupational well-being of older adults. More than one-third of community-living adults ages 65 yr or older fall each year (Centers for Disease Control and Prevention [CDC], 2008; Rubenstein & Josephson, 2002), and 20%–30% of falls result in moderate to severe injuries, such as traumatic brain injuries and fractures (Sterling, O’Connor, & Bonadies, 2001). Over the past 20 years, an explosion of research across disciplines has deepened our understanding of fall risk factors and effective interventions. This special issue of AJOT on fall prevention provides examples of how occupational therapy practitioners are contributing to this body of knowledge.
Cumulative fall research knowledge to date has informed three major evidence-based initiatives that are currently underway to support practice in fall prevention: (1) publication of the Clinical Practice Guideline: Prevention of Falls in Older Persons (American Geriatrics Society [AGS] & British Geriatrics Society [BGS], 2010), (2) the CDC’s efforts to disseminate four specific fall prevention programs with documented effectiveness, and (3) the emergence of state fall prevention coalitions. It is critically important for occupational therapy practitioners to be aware of these initiatives. Each offers occupational therapy practitioners unprecedented opportunities to extend and strengthen their active role in fall prevention efforts at the national, state, and local levels. This editorial highlights these three initiatives and discusses how occupational therapy clinicians and researchers can contribute to each of them and build on their success to further develop fall prevention research and practice.
Initiative 1: Clinical Practice Guideline: Prevention of Falls in Older Persons
The 2010 Clinical Practice Guideline: Prevention of Falls in Older Persons was a joint endeavor of the AGS and the BGS. The 2010 publication updates an earlier guideline (AGS, BGS, & American Academy of Orthopaedic Surgeons, 2001) by evaluating evidence and analyses that have become available since 2001 and providing revised recommendations on the basis of these evaluations (AGS & BGS, 2010). The Guideline, which was developed by an invited panel of fall prevention experts, is intended for use by health care providers across diverse disciplines and settings, and occupational therapists can use it to screen community-residing older adults (≥65 yr old) for risk of falls. In addition to outlining a screening process, the Guideline details key components of a multifactorial assessment process intended to lead to tailored interventions.
The Guideline highlights the centrality of environmental and functional assessments in comprehensive fall risk assessment, which further increases its salience to occupational therapists. Observing a client’s performance during activities relevant to desired occupations and identifying factors that act as supports or barriers to participation in daily occupations are hallmarks of the occupational therapy evaluation process (American Occupational Therapy Association [AOTA], 2008). Occupational therapy practitioners’ attention to diverse factors influencing occupational performance (e.g., activity demands, the environment, and client factors) and the transactional relationships among these factors are increasingly recognized as being important to the assessment of fall risk.
Identifying subjective influences on functional capacity and participation is also central to the occupational therapy evaluation process and directly relevant to the AGS and BGS (2010) recommendations. Specifically, the Guideline recommends assessments of current activity levels that attend to and differentiate between concerns about falling that are protective (i.e., realistic and relevant to abilities) and those that contribute to deconditioning or compromised quality of life (i.e., by causing the person to curtail involvement in activities he or she could potentially perform safely). This issue of AJOT features two articles that highlight the importance of screening older adults for fear of falling and recognizing its strong contribution to activity curtailment (Painter, Allison, Dhingra, Daughtery, & Cogdill, 2012; Schepens, Sen, Painter, & Murphy, 2012).
One outcome of a functional assessment administered by an occupational therapist (and the occupational therapy assessment process in general) is the identification of risk factors influencing occupational performance that can and cannot be changed. In the context of fall prevention, the importance of developing, using, and evaluating diverse approaches to intervention (e.g., remediation, maintenance, compensation, disability prevention) described in the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) cannot be overstated. The Guideline emphasizes the importance of identifying modifiable fall risk factors and implementing tailored interventions to address those risk factors.
Although evidence supports this remediative approach to fall intervention and efforts should indeed be made to correct modifiable fall risk factors (Panel on Prevention of Falls in Older Persons, AGS, & BGS, 2011), additional approaches to intervention are often warranted. For example, many older adults live with chronic conditions (e.g., stroke, multiple sclerosis) and experience condition-specific symptoms that increase their fall risk. The article in this issue by Elliott et al. (2012) presents research conducted during interdisciplinary fall prevention screenings and describes an excellent example of the application of disability prevention and compensatory approaches to fall prevention efforts.
Initiative 2: CDC Efforts to Disseminate Evidence-Based Fall Prevention Programs
The CDC has made dissemination of evidence-based fall prevention programs a priority and has focused its efforts on four specific interventions: the Otago Exercise Programme (Gardner, Buchner, Robertson, & Campbell, 2001; Robertson, Campbell, Gardner, & Devlin, 2002; Thomas, Mackintosh, & Halbert, 2010), Stepping On (Clemson et al., 2004), Tai Chi: Moving for Better Balance (Li et al., 2008), and a clinical care risk assessment treatment and referral intervention (Tinetti et al., 1994). Occupational therapists can take lead roles in facilitating the first three of these intervention programs and can make valuable contributions to the latter one together with other members of the interdisciplinary team (for more information about these interventions, see Stevens, 2010).
In addition to contributing to efforts to deliver and disseminate CDC-endorsed programs, occupational therapists are encouraged to think carefully about gaps in current evidence-based fall prevention practice and to develop diverse and innovative ways to minimize them. Leland, Elliott, O’Malley, and Murphy (2012) conducted a scoping review of the research on occupational therapy fall prevention interventions for community-dwelling older adults, which is included in this issue. Their results document the contribution of occupational therapy in environmental modifications, a variety of exercise programs, and multifactorial and multicomponent fall prevention intervention programs. Home safety interventions delivered to high-risk groups represent a very important example of occupational therapy’s contribution to fall prevention. Such interventions are clearly supported by the evidence (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008; Pighills, Torgerson, Sheldon, Drummond, & Bland, 2011), and recognition is growing that environmental and behavioral changes must be considered in concert with the stressors exerted by the environment and a person’s capacity (Wahl, Fänge, Oswald, Gitlin, & Iwarsson, 2009).
Several additional practice and research opportunities in fall prevention exist. Because available evidence-based interventions have focused primarily on community-dwelling older adults without significant disability, interventions for high-risk subgroups are urgently needed (e.g., people living with dementia, intellectual disability, multiple sclerosis, Parkinson’s disease, stroke; people transitioning to or residing in long-term care facilities; hospital inpatients). These groups experience falls at a much higher rate than the general population and often at a much earlier age. Occupational therapists can use their knowledge, skills, and theoretical perspectives to participate in the delivery, modification or development, and testing of programs that can address the needs of specific patient populations.
Finally, and perhaps most important, occupational therapists’ use of everyday occupation as means remains the cornerstone of our client-centered interventions. Studies are needed to show how this approach supports fall prevention goals. Studies are also needed to develop and test additional strategies that occupational therapists and their clients can use collaboratively to appraise fall risks and generate solutions. To this end, both empirical and qualitative research opportunities abound. Development of client-centered approaches to fall prevention can be informed by studies exploring influences on an older adult’s motivation and activity engagement and the meaning and lived experience of “living life to its fullest.”
Initiative 3: State Fall Prevention Coalitions
Thirty-eight state fall prevention coalitions are in existence, and several new state coalitions are in the process of forming. The National Council on Aging (NCOA) strongly supports these coalitions, which are in various stages of development. The NCOA provides technical assistance and facilitates collaboration among states through quarterly conference calls, committee activity, an online community, an electronic mailing list, and many other resources (NCOA, 2011). Within coalitions, leadership comes from multiple sources (e.g., health care professionals including occupational therapists, representatives of state aging and public health departments, academics). Although each coalition sets its own priorities for fall prevention initiatives, success depends on the efforts of people who are in regular contact with older adults and their advocates. Thus, occupational therapy practitioners can play important roles ranging from participating in annual Falls Awareness Day activities to delivering evidence-based programs such as Matter of Balance (Healy et al., 2008; Tennstedt et al., 1998), which is now being offered in most states, and Stepping On (Clemson et al., 2004). CDC funding now supports U.S.-based Stepping On training as a core component of its efforts to disseminate the program. To find out whether your state has a coalition, see NCOA (2011) or e-mail email@example.com.
For many state coalitions, educating health care providers about fall prevention strategies and resources is a major goal. Occupational therapy researchers are encouraged to use state coalitions to translate research findings into practice changes. Many state coalitions also focus on increasing older adults’ access to evidence-based fall prevention services for older adults. The Annual Wellness Visit, provided as part of the Patient Protection and Affordable Care Act (2010) and available to older adults as of September 2011, can help to make this vision a reality (AOTA, 2010). Occupational therapy practitioners working in tandem with state coalitions can learn more about the Annual Wellness Visit and educate older adults and their advocates about this new benefit. This education should include the major provisions of the benefit, which include a comprehensive health risk assessment and personalized prevention plan services (AOTA, 2010).
This editorial was written with the goal of highlighting practice and research opportunities in fall prevention for occupational therapy practitioners. Existing evidence supports occupational therapists in their efforts to manage community-dwelling older adults’ fall risk; however, there is still much work to do. The characteristics of a comprehensive multifactorial assessment and management intervention have not been clearly defined (Michael et al., 2010), and numerous other knowledge gaps remain. In other words, there is still time to establish the centrality of occupational therapy in clinical fall prevention efforts. The authors of the articles in this special AJOT issue encourage and challenge occupational therapy practitioners to lead fall prevention efforts in multiple arenas. Infusing fall prevention practice and research with occupational therapy expertise has tremendous potential to influence fall prevention policy and practice, increase customer demand for occupational therapy services, and foster older adults’ ability to prevent falls and engage in the activities they value.