Correction of environmental hazards All three fall prevention guidelines that have been discussed in previous sections recommend a home hazard assessment, followed by home modifications to remove the hazards, and follow-up assessments to inspect the modifications. The CDC/ STEADI program has a detailed educational handout that addresses potential safety hazards in the home (see https://www. cdc.gov/steadi/pdf/STEADI-Brochure-CheckForSafety-508.pdf). Examples of what to look for include, scatter rugs, loose carpet, lack of handrails, exposed electrical cords, uneven floors, small pets, clutter on walkways, poor lighting, and wet surfaces. This is an important aspect of a fall prevention program and should be carried out by a clinician or caregiver if the older adult is unable to assess their own living environment for fall hazards. Correction of footwear or structural impairments of the feet Many older adults discover the need to wear shoes with a low heel height and high surface contact area to help with balance during gait. The AGS/BGS guideline supports this practice (AGS/ BGS, 2010). Proper footwear can be described as having non- slip soles (rather than socks or slippers), low heel height, high surface contact area, and a full back or collar (no sling backs or flip flops), and a wide opening to get the foot in and out of the shoe. Foot conditions that can contribute to increased fall risk include bunions, claw toes, ingrown toe nails, and foot pain. A study published in the British Medical Journal found that a multifaceted foot care program can reduce falls by as much as 36% (Vernon, 2011). Older adults should wear proper shoes, be examined for foot conditions that affect fall risk, and practice good foot care. A good foot hygiene routine should include washing and drying feet daily, applying moisturizer, cutting toenails regularly, and seeing a podiatrist if foot conditions exist. Older adults with diabetes also should be aware of sensory deficits that could lead to the need for foot orthoses, painful neuropathy, foot ulcers, or even amputation if regular medical attention is ignored (Migliarese, 2017). Recommended interventions will be discussed based on the four living environments, beginning with community-dwelling, fit older adults. Community-dwelling, fit older adults For community-dwelling, fit older adults good evidence exists that supports multifactorial programs that include activities aimed at addressing all fall risk factors with special attention paid to improving balance, gait, strength, endurance and correcting home safety hazards, footwear, and possibly flexibility (although the evidence is not as strong for flexibility; Gillespie et al., 2012). Several exercise programs incorporate exercises and education proven to decrease future falls. The frequency of most programs is at least two to three times per week with recommended daily home exercise for more active adults. The AGS/BGS clinical practice guideline also recommends that any exercise program for fall prevention should take into account the physical capabilities and health profile of the individual and should be prescribed by qualified health professionals. The AGS/ BGS also recommends that the exercise program be reviewed, progressed, and adjusted as appropriate. These programs should be recommended if they are available in the more fit older adults’ community. Fair evidence exists to support group or individual exercise programs including the following formally organized programs, which are described below: ● Stepping On. ● A Matter of Balance. ● Tai chi. ● Fall Proof. ● SAIL (Stay Active and Independent for Life). ● NoFalls. ● FallsTalk/FallsScape. ● Enhance Fitness. ● YMCA Moving for Better Balance.
speed, the elevation, attention demands, postural transitions between different surfaces, dual-tasking demands, and amount of support. Once any existing etiologies are addressed and the activity of gait is safe for longer distances indoors or outdoors, the older adult can begin walking for longer distances and at faster speeds. Remember that the functional community ambulatory gait speed for adults is 3.3 ft/s (Table 3). Working to improve gait speed to that functional velocity should be a goal for older adults who desire that level of independence in the community. The Otago Exercise Program also includes guidelines for general walking, preferably outdoors if that is safe for the individual. The program recommends walking at a normal pace, with a friend, while wearing appropriate clothing and shoes for the climate, in well-lit areas, while avoiding multitasking. It also recommends that a walking program only be initiated after a clinician determines that it is safe to do so and has evaluated the need for an assistive device for safety. More fit older adults should strive for gait speeds closer to 3.3 ft/s, for more functional distances, and with a good quality gait pattern. Several of the balance activities included in the Otago program also involve dynamic gait and can be emphasized in a gait training program and include the following: ● Backward walking with hand support, then progressed to no support. ● Walking and turning in a figure-eight pattern. ● Walking sideways. ● Heel toe (tandem) standing with UE support, then progressed to no support. ● Tandem walking with UE support, then progressed to no support. ● Heel walking with support, then without support. ● Toe walking with support, then without support. Guidelines for interventions by living environment When designing interventions for older adults who are at risk for falls, physical therapists are called on to employ evidence-based practices to achieve effective results. Evidence-based medicine has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). In order to provide recommendations to physical therapists on fall risk identification and fall prevention, the Academy of Geriatric Physical Therapy developed a CGS for community-dwelling older adults. This guideline examined five existing practice guides that were broad in scope, geared toward community-based older adults, and not diagnosis specific. They developed a clinically useful summary of recommendations for physical therapists based on three of the guidelines that they recommended for use. The full description of the development of this guideline can be found in the Resources section (Avin et al., 2015). The three guidelines recommended includes the National Collaborative Centre for Nursing and Supportive Care, Prevention of Falls in Older Adults by the AGS/BGS, and evidence-based guidelines for the secondary prevention of falls in older adults by Moreland and colleagues (2003). Interventions were categorized as having evidence that was good, fair, no recommendation against, ineffective intervention, or insufficient evidence to recommend. Interventions were then categorized by fall history, including: 1. Fit older person who has not fallen. 2. Adults at risk for falls. 3. Those experiencing single or recurrent falls. Next, the interventions were assessed by living environment of the older adults to include: 1. Community-dwelling older adults. 2. Long-term care. 3. Hospital based care. 4. Homebound older adults.
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