Winter 2002-03
Featured Article

Results of Intervention Research: Implications for Practice

by Debra J. Rose

Over the course of the past twenty years, researchers have investigated the efficacy of a number of different intervention strategies designed to reduce the risk factors that contribute to falls, and the actual incidence of falls and fall-related injuries in the older adult population. These different types of strategies have been implemented with different target populations (e.g., healthy and frail community-residing older adults, frail nursing-home residents) and in a variety of settings (e.g., long-term-care facilities, community centers, hospitals, homes). Although the efficacy of a number of different intervention strategies has been investigated, this article will focus on three intervention strategies that have been proven to be the most effective in reducing fall incidence rates and fall-related injuries among the older adult population. These strategies are (1) exercise-based interventions (targeted and nontargeted), (2) environmental modifications, and (3) multifactorial risk-factor assessment and abatement strategies (e.g., Gillespie et al., 2002).

Other intervention strategies that have been investigated but will not be discussed here include injury minimalization aids such as hip protectors and assistive devices, health promotion and education, cognitive and behavioral interventions, medication withdrawal or adjustment, nutritional and vitamin supplementation, and hormonal and other pharmacological therapies.

Exercise Interventions

The role of exercise as a method of reducing fall risk and fall incidence rates in the older adult population has been well studied. Many different types of exercise interventions have been used, ranging from single exercise (e.g., resistance exercises, walking, t'ai chi) to multicomponent exercise programs (e.g., aerobic endurance, flexibility, strength, and balance training). While some exercise studies have adopted a more general or nontargeted approach, others have included exercises that specifically target balance and gait impairments and other physical factors known to be associated with heightened fall risk, such as muscle weakness or reduced flexibility (e.g., Buchner et al., 1997). In addition to the different exercise components investigated, the method of delivery has also differed across studies (i.e., group-based versus one-to-one). Finally, the type of provider (e.g., physical or occupational therapists, nurses, physical activity instructors) used to implement these interventions has also differed across studies.

The multicentered FICSIT (Frailty and Injuries: Cooperative Studies on Intervention Techniques) randomized, controlled trials represented the first systematic and large-scale attempt to investigate the efficacy of exercise (both targeted and nontargeted) on selected indexes of frailty and fall incidence rates among older adults. Five of the seven intervention sites involved community-residing older adults, while the two remaining sites involved frail nursing-home residents. Although the interventions varied with respect to the type of exercise used and the intensity, frequency, and duration of the intervention, the results of a preplanned meta-analysis that combined the multisite outcomes demonstrated a significant reduction in the risk of falling for the seven interventions that included exercise as a component of the intervention. Fall risk was further reduced, however, if the exercise intervention was more targeted by including specific balance activities (Province et al., 1995).

In recent years, individualized exercise programs that have targeted specific physical impairments identified during an initial assessment have also been shown to significantly lower fall incidence rates. These programs are generally designed and supervised by physical or occupational therapists in the home setting (Campbell et al., 1997; 1999).

In contrast to the significant findings emerging from a number of studies conducted on fall incidence rates among community-residing older adults, the results of a smaller number of randomized controlled trials conducted in long-term-care settings have been largely unimpressive (e.g., Fiatarone et al., 1994).

Why is it that exercise intervention strategies have failed to significantly reduce fall incidence rates when implemented in long-term-care facilities housing very frail older adults? Norwalk and colleagues (2001) attributed their nonsignificant findings to the fluctuating health status of their frail study participants and the low overall adherence rates for each of the two different exercise groups over the course of the two-year intervention phase of the study. The authors concluded that exercise programs conducted in long-term-care settings may need to be more individually tailored to better accommodate the fluctuations in health, interest levels, and physical and cognitive abilities typical of very frail older adults. Another contributing factor may be that the intervention was not of sufficient intensity, frequency, or duration. It is also likely that additional factors (e.g., type and number of medications, environmental hazards, multiple medical conditions) that cannot be resolved by exercise alone contributed to the nonsignificant findings.

Although fall incidence rates have not been positively affected in any of the exercise interventions conducted in long-term-care settings, the existing research does show that targeted exercise interventions do lead to significant improvements in overall function. For example, a number of studies focusing on resistance exercise training have reported significant improvements in physical function (e.g., improved sit-to-stand performance, increase in absolute strength) and mobility (e.g., change in ambulation status, improved gait speed) (e.g., Brill et al., 1998). Unfortunately, none of these studies recorded postintervention fall incidence rates. One problem that pervades all exercise intervention studies conducted with frail older adults is that the functional gains achieved are lost very quickly once the intervention ends. This finding suggests that every effort must be made to institute long-term exercise interventions that foster sustained adherence.

Future research recommendations. Based on the mixed findings emerging from a large number of studies that have included exercise as the primary intervention strategy, a number of important issues warrant further investigation. These include (a) identifying the minimum dosage (i.e., frequency, intensity, and duration) of exercise needed to significantly lower fall incidence rates and fall-related injuries among older adults at different levels of risk; (b) directly comparing the relative benefits of different types of exercise interventions; (c) investigating the cost effectiveness and cost savings associated with different types of intervention strategies; (d) identifying which type of intervention strategy is most effective for older adults with cognitive impairment and dementia; and (e) addressing how the effectiveness of a given exercise intervention is influenced by the ethnicity of the participants.

Practical implications. Although many issues remain to be addressed, the current research findings indicate that intervention strategies that include exercise have the potential to significantly reduce many of the risk factors that contribute to falls and, in the case of community-residing older adults, the actual number and rate of falls. What is less clear is how best to match the type and dose of exercise to the specific needs of older adults at different levels of risk. A set of six recommendations, some more speculative than others, follows:

1. Multicomponent exercise programs. These constitute an effective method for reducing fall risk in community-residing older adults at low-to-moderate risk for falls. Although these programs need not be individually prescribed, they should include exercises that specifically target known intrinsic risk factors for falls (e.g., strength, balance, flexibility, aerobic endurance).
2. Individually prescribed exercise interventions. If these interventions target specific physical impairments, they are likely to be more effective in reducing fall rates and fall-related injuries in older adults at high risk for falls or with a history of falls. Furthermore, these programs should be delivered, on a one-to-one basis, by providers trained in the assessment and treatment of fall-related risk factors, at least during the early stages of the intervention.
3. Longer duration and lower intensity. For optimal results, exercise interventions designed for the frail older adult, irrespective of setting, should be of longer duration and lower intensity, although not too low, and should be responsive to the fluctuating health status and interests of this population.
4. Dimensions of balance. While no definitive evidence exists in support of one type of exercise more than another, exercise interventions should include activities that target the multiple dimensions of balance (e.g., sensory and motor integration and coordination, reactive and anticipatory postural control) and are performed in variable practice environments. Although balance activities are often incorporated into exercise interventions, they tend to focus more on static postures or activities performed in an unchanging exercise environment.
5. T'ai chi. T'ai chi has emerged as a viable stand-alone exercise intervention for relatively healthy community-residing older adults, but more research is needed to determine its relative effectiveness when compared to other exercise interventions implemented with older adults of varying functional levels and ethnic backgrounds.
6. Resistance and seated balance training. In the case of very frail older adults, an early emphasis on resistance and seated balance training may be necessary before specific balance activities that require weight-bearing abilities and aerobic endurance training can be introduced.

Environmental Modifications

Environmental modification strategies are intended to address the extrinsic risk factors known to be associated with increased fall risk. Environmental hazards may be identified within the home or its immediate environs or in the community at large. Examples of potential home hazards include unsecured floor rugs, inadequate lighting, absence of support railings on stairs and in bathroom areas, and household clutter. Given that a growing number of older adults choose to remain in their homes rather than move into a long-term-care facility, it stands to reason that this type of intervention strategy would be considered an effective method by which to lower fall incidence rates and fall-related injuries among older adults.

Unfortunately, studies investigating this type of intervention strategy have yielded mixed results (e.g., Cumming et al., 1999). Significant reductions in actual fall rates or falls requiring subsequent medical attention were only observed in those studies in which technical and financial assistance was provided to complete the recommended changes. Without this type of assistance, residents were much less likely to implement the more substantive changes (e.g., installation of grab bars, stair railings, or additional lighting). While the major focus of these studies was improving the safety of the home, educational materials, counseling, and additional assessments conducted by an occupational therapist were also included in a number of the studies (Scott et al., 2001). It is therefore difficult to know the extent to which the environmental-modifications strategy alone contributed to the fall incidence and fall injury rates reported.

Although to date, no strong evidence exists for the implementation of environmental modification as a stand-alone fall prevention strategy, recent findings suggest that it is an effective strategy when combined with other strategies that target intrinsic risk factors. For example, Day and colleagues (2002) recently demonstrated that a home hazard-management strategy, when combined with group-based exercise and vision improvement, resulted in an estimated 14 percent reduction in the annual fall-incidence rate among a group of community-residing older adults. In contrast, no significant reduction in fall rates was estimated for the group receiving the home hazard-management intervention alone.

Future research recommendations. A number of the conclusions presented in the aforementined studies provide the basis for future research recommendations. These include the need to (1) determine the extent to which environmental modifications contribute to fall incidence rates and fall-related injuries when combined with other fall prevention strategies; (2) investigate whether environmental modification interventions administered by professionals trained in assessing both the older adults' home environment and their ability to safely function in that environment are more effective in reducing fall incidence rates; and (3) study the effectiveness of environmental modification strategies implemented on a community-wide basis, given that a high percentage of more active healthy adults are more likely to fall outside the home or while walking in familiar areas within their community (Reinsch et al., 1992; Gallagher and Brunt, 1994).

Practical implications. At a practical level, the available research evidence suggests that environmental modifications should be an important component of any fall risk-reduction program designed for older adults, whether they reside in the community or a long-term-care setting. Although the types of environmental modifications implemented will differ across settings, the primary goal of this type of intervention is to immediately improve the "balance" between daily task demands and older adults' balance abilities by modifying their living environment and behavior. One challenge will be convincing many older adults that modifying their home is important for lowering their fall risk. Older adults who have recently experienced a fall or are better educated about fall risk and prevention are more likely to make the necessary home modifications. Once these modifications have been made, the next step will be to address with an appropriate exercise intervention the intrinsic risk factors that may be limiting what an older adult is able to actually do within and around the home.

The success of any environmental modification strategy will also be dependent on the availability of trained personnel to conduct the initial home assessment and the availability of funding to hire qualified individuals to complete the modifications.

Multifactorial Risk-Factor Assessment and Abatement

Given that not all older adults fall for the same reason, and are in fact most likely to fall as a result of the presence of multiple fall risk factors, multifactorial intervention strategies designed to first identify and then minimize the intrinsic or extrinsic risk factors are likely to produce the most successful outcomes. The most common fall risk factors targeted in these studies include gait and balance impairments, muscle weakness, difficulties moving from bed to chair, number and type of medications, cardiovascular risk factors, and environmental hazards in the home. Multifactorial fall risk assessments and follow-up have been conducted with older adults identified to be at high risk for falls both prior to and immediately following falls. This type of intervention strategy generally requires a multidisciplinary team of providers comprising emergency room physicians and nurses, general practitioners, physical and occupational therapists, pharmacists, psychiatrists, and social workers. Once medical personnel identify the risk factors, the individual is then referred to the appropriate services for specific treatment and follow-up.

The results of an analysis of the results of a small number of randomized controlled trials using this multifactorial approach with community-residing older adults at high risk for falls demonstrated a significant reduction in fall risk and fall incidence rates (Gillespie et al., 2002). A frequently cited study conducted by Tinetti and colleagues (1994) reported that fewer subjects in the intervention group fell during the one-year follow-up period (31 percent) and the time to the first fall was also significantly longer for this same group. More recently, Close and colleagues (1999) also demonstrated a significant reduction in falls in the year following discharge in a group of older adults who received a multifactorial fall risk assessment and appropriate referral and follow-up when compared to a control group who had received usual care in a hospital emergency department following a fall. Only 32 percent of the intervention group versus 52 percent in the control group reported at least one fall.

Ray and colleagues (1997) also investigated the efficacy of a multifactorial approach in reducing fall rates in multiple nursing-home settings. Unlike the more individually prescribed interventions just described, however, the patient safety assessment conducted in this study targeted four specific safety domains: environmental and personal safety, wheelchairs, psychotropic medication use, and walking and moving from bed to chair. Based on the outcome of the initial assessment, an individualized treatment plan was then implemented by trained personnel. At follow-up, the mean proportion of recurrent fallers was significantly lower in the facilities where intervention was done.

Future research recommendations. In general terms, the research evidence suggests that multifactorial risk assessment and abatement strategies are most beneficial for older adults who have been identified at high risk for falls, but more research is needed before definitive conclusions can be made. According to the fall prevention guidelines jointly developed by the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopedic Surgeons (2001), older adults who have experienced repeated falls, who reside in a nursing home, who are prone to fall-related injuries, or who have just sustained a fall requiring medical attention should be considered to be in this category. One additional research issue that warrants further investigation is whether these more resource-intensive intervention strategies are both beneficial and cost-effective when implemented with older adults at various levels of risk. Data are currently insufficient to make any definitive conclusions in this area (e.g., Tinetti et al., 1994).

Practical implications. This type of intervention strategy holds promise for significantly lowering fall incidence rates and fall-related injuries among high-risk older adults residing in the community or long-term-care settings. The successful implementation of these programs will require allocation of sufficient time and the appropriate resources to identify the individual risk factors contributing to each older adult's heightened fall risk. Also necessary will be a clear set of operating procedures to ensure that the older adult receives the appropriate services and treatment in a timely manner and that progress is monitored over the long term. One potential barrier to effective implementation of this type of intervention strategy in a long-term-care facility would be the lack of sufficient resources such as educated staff and technical support to carry out the program as well as provide the ongoing staff training and follow-up critical to ensuring that the recommended changes are actually made in a timely manner. The high employee turnover rates that characterize these settings will also pose a formidable challenge to sustaining an intervention of this type over the long term.

Summary

One thing that is clear from a review of the existing research is that a "one size fits all" fall risk-reduction approach will meet with little success. Both the type and complexity of the intervention strategy will be determined by the older adult's existing fall risk and the availability of the resources needed to initiate and sustain programs. While the common denominator among most, if not all, intervention strategies will be the inclusion of exercise, the type of exercise and how it is implemented will differ across target populations. While community-residing older adults at low to moderate risk will lower their risk for falls by participating in a targeted exercise program that addresses the intrinsic risk factors known to heighten fall risk, older adults at high risk for falls are likely to derive greater fall protection from a multifactorial risk-factor assessment and abatement intervention strategy. The goal of this strategy is to identify the multiple intrinsic and extrinsic risk factors contributing to each individual's heightened fall risk and then prescribe the services and treatment necessary to abate the identified risks. Ideally, environmental modification should be a component of all intervention strategies designed to reduce fall incidence rates and fall-related injuries among older adults because it addresses the extrinsic risk factors that contribute to increased fall risk. The success of such interventions will probably depend on financial subsidies, and an understanding among older adults about the importance of modifying their home environment in order to lower their fall risk.

Debra J. Rose, Ph.D., is codirector, Center for Successful Aging, and professor, Division of Kinesiology and Health Promotion, California State University, Fullerton.

References

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Ray, W., et al. 1997. "A Randomised Trial of a Consultation Service to Reduce Falls in Nursing Homes." Journal of the American Medical Association 278: 557-62.

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Scott, V. J., et al. 2001. A Best Practices Guide for the Prevention of Falls Among Seniors Living in the Community. Report prepared on behalf of the Federal/Provincial/Territorial Committee of Officials (Seniors) for the Ministers Responsible for Seniors.

From Generations Winter 2002 issue, 26(4): 60-65. © 2002 American Society on Aging

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