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• W2023183049 abstract "Home safety assessments, which identify environmental hazards to be eliminated, have high face validity as a fall prevention strategy.1 After all, environmental hazards are highly prevalent in the homes of community-living older persons, regardless of the level of disability or housing type.2 Moreover, when interviewed after a fall, older persons often identify an environmental hazard as a contributing factor.3,4 Contrary to conventional wisdom, however, there is little evidence from observation studies to support a causal association between environmental hazards and falls and no evidence from clinical trials to demonstrate the benefit of home safety assessments. In this issue of JAGS, Cumming and colleagues5 report the results of a randomized controlled trial designed to test whether home visits by an occupational therapist can reduce the risk of falls among community-living older persons. The intervention, which emphasized the identification and removal of potential hazards in the home, was found to reduce the risk of falls for a 12-month period, but only among a small subgroup (39%) of participants, each of whom had reported a fall in the previous year. Overall, the study was well executed, and the authors adhered to published standards for reporting randomized controlled trials.6 Treatment and control groups were well matched on important prognostic characteristics. The ascertainment of falls was nearly 100% complete, and there were relatively few losses to follow-up. The results were analyzed and reported using the intention-to-treat principle and were remarkably consistent regardless of whether the outcome was defined as one or more falls, time to the first fall, or mean number of falls. Despite these important strengths, the results of this study need to be interpreted cautiously, in light of several potential limitations, many of which were readily acknowledged by the authors in their discussion. First, in contrast to most successful fall prevention programs,7,8 the occupational therapy intervention was not suitably targeted to a group of older persons at high risk for falling. The vast majority of participants (84%) were recruited during an admission to either an acute care or rehabilitation hospital, but were not otherwise selected based on their level of frailty or risk of falls. The inclusion of persons at low risk for falls likely explains the intervention's overall lack of efficacy. Second, because the authors do not provide information on the number and characteristics of persons who were eligible for the study but not randomized, the generalizability of the results are uncertain. Third, the receipt of physical therapy and other effective fall prevention measures7,9 outside the study was not reported. Bias can occur when potent cointerventions are distributed unequally between the treatment and control groups. Fourth, the reliability of the occupational therapy assessment and intervention was not assessed. Consequently, we can not be sure that the success of the program was not a result of the unique skills and personal characteristics of the study's sole occupational therapist. Finally, the control group did not receive a home visit or other type of intervention, raising the possibility that the ascertainment of falls, which was based on participants' self-report, may have been biased. This problem arises when the incentive or motivation for reporting an outcome differs systematically between participants in the treatment group and those in the control group. In the current study, participants who were randomized to the occupational therapy group may have underreported, relative to participants in the control group, their falls in an attempt to please the therapist. The possibility of biased ascertainment is difficult to discount in the absence of other objective evidence demonstrating an intervention benefit. Even if the results are accepted at face value, exactly how the occupational therapy intervention produced its protective effect is difficult to determine. Removal or modification of potential hazards in the home was the central feature of the intervention. Yet, among participants who had fallen within the past year, the intervention was equally effective in reducing falls at home and away from home. This lack of specificity suggests that other aspects of the intervention must have been responsible for the reduction in falls. See also p 1397 What else was done? The occupational therapist recommended changes regarding unsafe behaviors and improper footwear, but only to a small subset of participants (19% and 13%, respectively), who were only partially compliant with these recommendations. Is it biologically plausible, then, that a single home visit by an occupational therapist, followed by a telephone call, could reduce the risk of falls by up to 36%? A much more intensive, multifactorial intervention, implemented by a physical therapist and nurse practitioner, reduced the fall rate by only 31%.7 Further operational details would help. For example, how were unsafe behaviors defined and subsequently assessed? And what specific recommendations did the occupational therapist provide about doing things more safely around the home? Although probably unintended, the study by Cumming et al. raises a fundamental and yet unanswered question regarding fall prevention: is it more effective to modify the environment or the individual? There are several reasons to suspect that identifying and eliminating environmental hazards in the home may be the less effective strategy. First, in contrast to the strong and consistent association found between intrinsic risk factors and falls,3,4,10,11 the epidemiological evidence linking environmental hazards to falls is weak. Two recent case control studies, for example, failed to find an association between an array of environmental hazards and the occurrence of injurious or repeated falls.12,13 Moreover, the results from several longitudinal studies have shown only small (or no) elevations in fall risk based on the presence of environmental hazards.3,4,14–17 Each of these longitudinal studies, however, had significant methodological limitations, including: the absence of a control group of nonfallers,14,15 the identification of environmental hazards through self-report rather than through direct observation,4,16 the use of a composite scale to analyze environmental hazards,3,16,17 and the failure to exclude syncopal falls, which are unlikely to be related to environmental hazards.3,14,16,17 Nonetheless, a recently completed longitudinal study, which addressed each of these limitations, found no consistent association between 17 trip or slip hazards and the time to a first nonsyncopal fall.18 Second, the opportunity to prevent falls by identifying and eliminating environmental hazards in the home is constrained, in part, by the large number of falls that occur outside the home.5,15,18 Even within the home, the inherent specificity between the intervention (i.e., removal of a specific hazard in a specific room) and the outcome (i.e., prevention of a fall that would otherwise be caused by this hazard) substantially limits the potential effectiveness of environmental interventions to prevent falls. Most interventions directed at the individual, on the other hand, are applicable to fall prevention inside and outside the home. Moreover, strong evidence already exists to support the effectiveness of several “intrinsic” interventions, including exercise to reverse impairments in muscle strength, balance, and gait, provision of behavioral instructions, and adjustment of medications.7,9,19 Third, older persons may adapt to the presence of environmental hazards and, indeed, may even use these purported hazards to enhance their indoor mobility. Rubenstein,20 for example, has noted that a carefully laid out series of chairs, which might otherwise be judged as obstructing the pathway, may instead provide support for walking from one room to another. Finally, older persons are often reluctant to make changes to their home environment, even when these changes are highly recommended, as evidenced by the relatively modest compliance rates reported in the current and other studies.5,7 How, then, should limited resources be allocated for fall prevention? At present, it would be prudent to focus on intrinsic risk factors in which the evidence of a causal association is the strongest and targeted interventions have been shown to be effective and even cost-effective.21 Further research is warranted, however, to determine whether interventions directed at modifying the environment can complement those directed at modifying the individual." @default.
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• W2023183049 title "Preventing Falls: To Modify the Environment or the Individual?" @default.
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