education, and vitamin supplementation, there is insufficient evidence to support any single intervention. Multifactorial interventions in long-term care, including structured exercise, also have been explored, but there is insufficient evidence for or against any of these singular interventions. Clearly defined results are difficult to achieve in this setting due to the wide variety of functional levels and the presence of compounding factors such as dementia and frailty. The AGS/BGS guideline does consider (with caution) the use of exercise programs for long-term care residents, although there is no proof that they decrease falls (AGS/BGS, 2010). Vitamin D supplementation for this population has been useful in fall prevention for older adults with vitamin D insufficiency. Vitamin D insufficiency can result from inadequate nutritional intake of vitamin D, inadequate sunlight exposure, disorders limiting vitamin D absorption, and conditions impairing vitamin D conversion into active metabolites. This is a simple, low-cost intervention (Annweiler et al., 2010). Vitamin D insufficiency has been associated with muscle weakness in proximal muscle groups, such as leg extensors, which are crucial for sit to stand. Supplementation of this vitamin can decrease falls and increase bone density (Janssen, Samson, & Verhaar, 2002). Therapists should be aware of patient complaints that may signal presence of this problem. Patients may describe a feeling of heaviness in the legs, tiring easily, and difficulty in mounting stairs and rising from a chair (Janssen et al., 2002). Changing the environment in a long-term care facility has shown promise in reducing injuries from falls and incidence of falls (Quigley, 2015). Suggested environmental changes that can decrease extrinsic fall risk factors include the following: ● Eliminate slipping and tripping hazards. ● Keep the bed at the proper height during transfer and when the patient rises to a standing position. ● Don’t keep the bed in a low position at all times. ● Check chairs, toilets, and safety grab bars for potential safety problems. ● Use proper room lighting. ● Make sure the patient wears proper footwear (not just nonskid socks). (Quigley, 2015) Decreasing severity of injury secondary to a fall can be accomplished by using protective equipment (such as floor mats and hip protectors), video surveillance, chair alarms, and eliminating sharp edges (Quigley, 2015). Although there is little evidence to support fall prevention interventions for older adults with dementia, there is growing interest in attempting to decrease fall risk with cognitive therapy (Smith-Ray et al, 2013). In a 2013 study with 51 participants living in independent living communities, cognitive training provided over a 10-week period had a significant effect on gait and balance as measured by the TUG test, gait speed, and gait speed with a cognitive distraction (Smith-Ray et al, 2013). The training was comprised of a computer-based cognitive training programs instructed by gerontology researchers. The programs challenged visuospatial working memory, processing speed, and visual attention through the use of games. Although these participants were residents in independent living, this intervention may show promise in the long-term care population as well. A small number of studies have explored dual-tasking during activities such as treadmill walking and playing a gaming system programs. One study of 518 adults in a psychogeriatric ward did find promising findings on number of falls as a result of a multifactorial intervention with individually tailored therapy (Neyens et al., 2009). The study did not describe the details of the therapeutic interventions. More research is needed to determine which interventions can decrease fall risk in older adults with dementia in a variety of living environments. Frailty is another common geriatric syndrome that can potentially influence the effectiveness of interventions designed to decrease fall incidence in a long-term care setting. In a
wa.gov). More than 1,000 older adults in Washington State have completed this program. NoFalls NoFalls is a multifactorial fall prevention program developed in Australia that consists of 15 weeks of 1-hour balance and exercise classes. These classes are supplemented with daily home exercise. Along with exercise, this program removes home hazards and provides interventions for vision correction. Reduction in injurious falls has been greatest in participants who received exercise and vision correction, but fall reduction with NoFalls also has occurred with the exercise component alone (Fitzharris, Day, Lord, Gordon, & Fildes, 2010. FallsTalk/FallsScape These interventions are evidenced-based programs offered separately or in combination to anyone who has experienced a fall or loss of balance, regardless of mobility status or fitness level. The FallsTalk intervention involves a personal interview in- home or in the community to identify individual fall risk factors, then is followed up by an additional interview, daily personal reflections, and three brief weekly check-in calls. FallsScape uses each individual’s mobility, environment, and functional status to create personalized interactive multimedia training sessions and vignettes. Adding the multimedia training has been shown to improve program results (Schepens, Panzer, & Goldberg, 2011). Resources can be found at http://www.fallscape.org/ Enhance Fitness Enhance Fitness (EF) is an evidence-based group exercise program based in the community that helps older adults become more physically active (Belza, Snyder, Thompson, & LoGerfo, 2010). EF is taught three times a week in 1-hour sessions by certified trainers. Sessions involve exercises for cardiovascular endurance, strength training, dynamic and static balance, posture, and flexibility. Since 1999, EF has been taught in 41 states and has reached more than 59,000 adults (Petrescu- Prahova, Eagen, Fishleder, & Belza, 2017). YMCA Moving for Better Balance This YMCA program is an evidence-based 12-week program endorsed by the NCOA and CDC for fall prevention. Community-dwelling adults 60 years of age and older can participate in the small group setting of 10 to 15 adults for twice-a-week 1-hour sessions. Participants are asked to practice at home for 30-minutes once a week, also. Classes target social, mental, and physical well-being through tai chi-based exercise, education, and social support. A YMCA membership is not required, although local YMCA organizations should be checked for availability and whether they have a Y-certified Moving for Better Balance instructor (http://ymca.net). In addition to an evidence-based fall prevention program, the trained clinician also should address individual impairments or fall risk factors that are not specifically targeted by the prescribed program. Most proven programs include balance, gait, strengthening, and mobility activities, but older adults may have additional areas that need attention. These could include postural correction, fear of falling, poor balance strategies, dizziness, or avoidance behaviors. This may require physical and/ or occupational therapy in addition to the fall prevention classes that may be available. Clinicians should progress therapeutic goals as well as the types of exercise performed in the fall prevention exercise classes. This may require collaboration with the instructor of the fall prevention program in order to identify the most appropriate level of exercise difficulty and intensity. Long-term care setting Older adults who reside in long-term care facilities, who are at high risk for falls, or who have already fallen do not have as many evidence-based options for fall prevention as community- dwelling adults. This is unfortunate, as approximately half of ambulatory long-term care residents fall at least once a year (AGS/BGS, 2010). Although several studies have investigated single interventions, such as hip protectors, fall alarm devices, medication review, removal of physical restraints, fall prevention
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