Homebound setting Older adults who are homebound, at risk for falls, or have fallen have fewer evidence-based options for fall prevention than community-dwelling adults. The Centers for Medicare & Medicaid Services (CMS) defines “homebound” as the inability to leave home without considerable and taxing effort. A person who is homebound may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to attend religious services or a wedding (CMS, 2015). It is estimated that there are about 2 million homebound Americans, which is larger than the current nursing home population (Ornstein et al., 2015). In a 2015 study by Musich and colleagues (2015) factors associated with being homebound include self-reported memory loss, being older (>75 years), having multiple chronic conditions (three or more) resulting in multiple hospitalizations (two or more) in the past year and taking many prescription drugs (seven or more). Adults who never leave their home are three times more likely to become frail (Xue, 2011). Homebound older adults who have fallen or who are at risk for falls may be appropriate for the Otago exercise, which has been proven to reduce fall incidence in this population by up to 35% (Shubert, Smith, Jiang, & Ory, 2018; Thomas, MacKintosh, & Halbert, 2010). Developed and tested in New Zealand from 1997 to 2003, Otago was implemented more recently in the United States. Otago focuses on improving strength and balance with a simple, easy-to-implement, homebased exercise program (Shubert et al., 2018). The homebound older adult, who is typically frailer than non-homebound adults, receives a visit from a home health nurse or physical therapist, along with telephone calls to provide support and guidance throughout the program. The program’s original, evidence-based plan includes 12 months of strengthening and balance exercises with tapering of onsite clinician visits across the program and monthly calls. The first 8 weeks includes five to six visits in the home. A follow-up visit takes place, if possible, at 6 and 12 months. Walking for endurance is added when the person is deemed ready by a skilled clinician. Although not every adult who could benefit from Otago is homebound, the best results appear to be in older, more frail adults living at home (Shubert et al., 2018). An affordable, 3-hour online Otago training for therapists can be accessed at http://www.med.unc.edu/aging/cgec/ exercise-program. Although several thousand physical therapists have completed the training, implementing the program duration and billing has been difficult with many persons being discharged after 8 weeks without follow-up phone calls. Program delivery innovations are being studied to address these issues, including the use of virtual rehabilitation technologies (Shubert, Basnett, Chokshi, Barrett, & Komatireddy, 2015), with hopeful modifications to come.
20‑week multicenter study involving 15 homes for the elderly, a moderate-intensity group exercise class was able to decrease falling and increase physical performance in pre-frail older adults, but not in the frail cohort (Faber, Bosscher, Chin A Paw, & van Wieringen, 2006). The risk for falls increased as the degree of frailty increased. If older adults are considered frail, then clinicians who intend to implement a fall risk program should adjust exercise interventions to match the level of physical performance for these frail adults, but can expect better results in a pre-frail versus frail population. They may need closer supervision during balance and gait activities. Hospital-based setting For older adults in a hospital setting, there are no adequate randomized controlled trials of multifactorial interventions proven to decrease falls. For older adults who are hospital inpatients, a multifactorial approach, although unproven, is typically a clinically appropriate approach for physical or occupational therapists who may be treating this adult for an unrelated diagnosis. Any inpatient over 65 years of age should be asked about fall history, gait, and balance, as previously described, especially those who may have been admitted as a result of a fall. Most hospitals remove trip hazards from patient rooms and maintain dry surfaces. At a minimum, clinicians should ask every older adult about falls in the past 12 months, circumstances surrounding the falls, and if the older adult has difficulty with gait or balance. More research is needed for fall prevention in this setting. A common fall risk assessment form used by nursing in the hospital setting is the Schmid Fall Assessment Tool (Lee, Lee, & Khang, 2013). This tool includes evaluation of the patient’s mobility, mentation, toileting, fall history, and use of psychoactive medications. A score of 3 or more is considered as an increase in fall risk, triggering the use of the following interventions: ● Appropriate orientation strategies. ● Access to patient’s hearing aids or glasses. ● Call bell. ● Access to patient’s personal items. ● Use of patient’s walking aids. ● Frequent comfort rounds. ● Patient and family education about fall risk. ● Early and frequent mobilization. ● Nonslip footwear. ● Elimination of barriers to transfer or ambulation. In a systematic literature review by Cameron and colleagues (2012), the authors found evidence of reduced fall rates with multifactorial interventions, but only inconclusive evidence for decreasing risk for falls in the hospital setting. More evidence is needed. ● Minimization of use of restraints. ● Use of bed alarm when necessary.
BRINGING FALL PREVENTION PROGRAMS TO YOUR COMMUNITY
theme, fall prevention promotional materials, and a PowerPoint presentation, video contest, and media toolkit (http://www. ncoa.org). Both the STEADI and NCOA websites have extensive resources needed to get started. In addition to the existing screening protocols, many of the community-based programs described here can be implemented in any community. Collaborating with local senior services, YMCAs, or community centers can assist the clinician in implementation and execution of these vital programs. However, even before structured programs are in place, all physical therapists should ask their older patients the three basic screening questions: 1. Have you fallen in the past year? 2. Can you tell me the details surrounding the fall(s)? 3. Do you have difficulty walking or balancing? This is a great place to start for addressing the health emergency of falls.
By now, it should be clear why bringing fall risk screening and programs to the community is a crucial step in improving the health, function, and mortality rate of older adults at risk for falls. The STEADI program developed by the CDC offers a comprehensive program that is available online, in multiple languages, and free of charge (http://www.cdc.gov/steadi/). STEADI online resources include fall risk surveys, fall risk screening forms, educational handouts on a variety of fall risk factors, and a home safety checklist, just to name a few. The STEADI program can be easily disseminated to lay persons at local community centers, YMCAs, health departments, and hospital systems to reach as many older adults as possible. A link to STEADI resources can be found in the Resources section. Communities often choose to implement a fall risk screening on Falls Prevention Awareness Day, which is on the first day of fall in September every year, and is sponsored by NCOA. In 2018, NCOA will have promoted this event for 10 years with an annual
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