Prevention of Falls at Home: Home Hazard and Safety Assessment and Management

Preventing falls and disability and maintaining older adults as valuable members of their communities is rapidly becoming a national priority. This major public healthcare concern not only encompasses the physical and psychological sequalae associated with the fall itself, but also the social and economic impact on the individual, family/caregivers, and the healthcare industry. Recently published guidelines include home hazard and safety assessment and home modification as part of fall prevention for adults over the age of 65 years.^1-4 The purposes of this article are to highlight findings from select research studies and identify components of a home hazard and safety assessment as part of a geriatric assessment for older adults living at home.

FALLS IN THE HOME

Approximately 20-55% of all unintentional falls and fall-related injuries in adults over the age of 60 years occurs inside the home.^5,6 Most falls (44%) occur on a level surface (eg, ground level), 16% occur on the stairs or from a height, and 4% occur in the bathroom. Approximately 75% of these falls happen during the performance of routine daily activities, 44% occur in the presence of one or more environmental hazards, and 2-5% during the performance of hazardous activities, such as climbing onto ladders. Only 20% of older adults who fall seek medical attention;⁶ therefore, the full extent of falls and injuries is unknown. The result of unintentional falls can have a negative effect on quality of life, including loss in days of work, increased healthcare expenditures, dependency, and early admission to an assisted living or long-term care facility.

Fall death rates in the home are highest among older adults; 48.8% of the death rate occurs in those over age 60 years, and 65.9% in those over age 70 years.⁷ Causes of fall death are rarely reported; however, when identified, falls from stairs were most frequently reported, followed by slipping or tripping, and falls from a bed or chair.

A fall is defined as “unintentionally coming to rest on the ground, floor or other lower level.” The question used to elicit a response from an older adult is: “In the past month, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?”⁸

HOME HAZARDS: ASSESSING THE EVIDENCE

Early research investigating the relationship between home hazards and falls are equivocal; however, recently published studies support the importance of reducing home hazards by modifying the home environment. Reasons for the disparity in the research include different methods used to define the home environment and to identify a home hazard. Furthermore, earlier studies did not include environmental modifications as part of their comprehensive falls reduction program.

The home environment is considered the areas inside the residence and immediately outside the residence (eg, entryway, driveway, walkway).

Several studies found minor to significant associations between documented home hazards and falls in older adults.^9,10 Evidence includes:

• Environmental hazards are not associated with increased risk of fall injury events in older adults who have fallen as compared with those who have not fallen.¹¹
• Homebound older adults who have fallen have a greater number of home hazards than homebound older adults who have not fallen.¹²
• Older adults without a history of falling have a 4-fold risk of falling in the presence of existing home hazards.¹³ One likely explanation is that older adults who have fallen may be more cautious of their surroundings and more aware of fall hazards because of their fall.

CONDUCTING A HOME SAFETY AND HAZARD ASSESSMENT:SUGGESTIONS FOR PRACTICE

Older adults receiving at-home medical care should receive a home safety and hazard assessment as part of their plan of care. Home assessments are recommended for those who have fallen, who are deemed at risk for a fall, and who are frail or have cognitive impairments. Home assessments may reduce the probability of a fall in a person who has not fallen. The assessment, prescribed by a physician, can be conducted by a nurse, physical therapist or occupational therapist.

A home safety assessment includes 3 parts: assessment of (1) commonly used areas inside and outside the home; (2) observation of the older person moving around the home environment; and, (3) fall risk and health status of the older person. The major outcome of the assessment is to maintain the person’s ability to function in a safe environment by developing and implementing effective strategies to reduce hazards and fall risk factors, and to improve the person’s accessibility.

Commonly used home safety checklists identify three basic types of problems: hazards, problem areas, and lack of supportive or safety features.^10,14-16 Several consumer checklists have been translated into Spanish and other languages.¹⁵ Potential hazards are grouped according to lighting, flooring, and obstacles.^8-15 These hazards can be documented by counting the number of rugs and uneven surfaces (eg, thresholds), piles of clutter, electrical cords, low tables or other furniture, and pets in the most frequently used path (eg, from the favorite chair to the bathroom). Intensity and location of lighting in the path are inspected for adequacy. Similarly, the outdoor area is scanned for railings, adequate lighting, and uneven surfaces along the most frequently used pathway.

Interaction of the person and the environment is observed by asking the person to rise from a favorite chair and walk the path, while paying particular attention as to whether the person is holding on to or touching furniture or walls to maintain balance.

Many older adults live in old homes, where the bed and bathroom may be located on the second level. The older adult’s ability to negotiate the stairs, as well as the location of handrails and lighting is documented. The bathroom is assessed for safety hazards and currently installed safety modifications (eg, grab bars, bathtub seat). In the bedroom, the distance of the side of the bed to the wall is measured to ensure that the person does not become “stuck” if he or she falls out of bed. More comprehensive home safety assessments use a room-by-room approach (Table I).

In addition to the home safety check, a geriatric examination includes the following: fall risk, fear of falling, physical and cognitive status, medication management, footwear, and use of assistive devices. Major risk factors associated with falls are located in Table II.^17-19 A balance and falls risk assessment addressing many of the most prevalent risk factors is located on the Internet.¹⁵ Frail older adults and those with cognitive impairments or those with multiple chronic conditions are at greater fall risk and have greater need for assessment of assistive and adaptive measures to function safely.¹³

Verbal responses of the person should be corroborated by observing the person performing routine activities of daily living, such as arising from a chair, climbing steps, and getting in and out of the bathtub. These observations provide a measure of the individual’s functionality in the home setting.

HOME HAZARD MODIFICATIONS: ASSESSING THE EVIDENCE

Reducing home hazards to reduce the probability of falling is an appealing strategy because it can be a relatively inexpensive intervention. Consensus from a meta-analysis from the RAND Corporation and other critical reviews indicate that home assessment should be included as part of a multicomponent fall prevention program rather than a stand-alone intervention.^1-3

Outcomes of select studies follow:
• One-month follow-up indicated that 9% of participants who received education and brochures made home safety changes. The findings suggest that a relatively inexpensive and targeted program may have benefit.²⁰
• Multifactor programs that include medication management, exercise, and home modification resulted in up to 30% reduction in falls.³
• One-year follow-up visit by occupational therapist indicated that approximately 52% of recommendations related to environmental modifications, medication management, and safer footwear were made by older persons and their families.²¹
• One-year follow-up documented an average reduction of five home hazards. Low- or no-cost changes and installation of grab bars were the most frequently made modifications.^10,22
• Home assessment, assistance with modifications, and training in the use of mobility aids were effective in frail older adults with recurrent falls.²³

HOME HAZARD MODIFICATIONS: SUGGESTIONS FOR PRACTICE

A three-part intervention includes: (1) home hazard and safety assessment (discussed above); (2) specific advice on removal or modification of the hazard; and (3) the use of assistive devices to maintain or increase mobility. Frequently made no- or low-cost recommendations include: placing a nightlight in the hallway to illuminate the path to the bathroom, removing throw rugs, marking the bottom of the step for easy identification, or removing unsafe chairs (too low or no arms). More costly structural modifications require a skilled professional (eg, installing grab bars, handrails on stairs, additional lighting [Table I]).

Because most falls result from the interaction of the individual with the environment, interventions should include maintaining or increasing activities of daily living (ADLs), provision of assistive devices, and an activity program (eg, exercise, walking). These recommendations and modifications are made in light of the functional and cognitive abilities of the individual.^10,24

Considerations for designing an intervention program follow:
• Home assessment and modification is most effective when recommended by a healthcare professional (nurse, occupational therapist, physical therapist). The older person or family members may identify and make home modifications; however, they may not be able to determine the best corrective solution.
• The older adult may not recognize the problem as a safety hazard and may not make the safety modification, or may not perceive the modification as a benefit.
• Approximately 46% of home modifications are made by the individual.²¹ The older adult needs to agree that the home modification is necessary to ensure compliance with the recommendations.
• Multiple recommendations are overwhelming; therefore, fewer recommendations are more likely to be made.
• Environmental modifications need to be custom designed for persons with visual impairments, cognitive deficits, frailty, or who are wheelchair-bound or homebound. • Recommendations need to consider convenience, safety, aesthetics, and cultural sensitivity. • Assure older adult that modifications can be made in rent-controlled housing.

Payment Mechanisms for Home Assessments and Safety Modifications
A home assessment may be included as part of a plan of care from a home health nurse, physical therapist, or occupational therapist. Some recommendations are covered by Medicare/Medicaid.²⁵ Part of the healthcare professional’s responsibility is to identify resources to make the home modifications and resources to cover costs. Resources for help with modifications include Social Services, Area Agencies on Aging (AAA), community and civic organizations, and vocational schools. Costs for assistive devices and modifications may be covered by private insurers, Medicare, Medicaid, welfare, or Emergency Departments.

REDUCING HOME HAZARDS: IMPLICATIONS FOR PREVENTION

The evidence for home assessment and safety modification is a relatively new component of fall intervention and prevention programs. Based on the current evidence and public health concern to keep older adults living in a safe home environment, the following suggestions can be posited:

• Increase public awareness of home hazards and their remediation.
• Provide annual fall assessment for all older adults. Recommend a home safety and hazard assessment.
• Initiate a fall risk assessment at the entry point into the medical system. Recommend a home safety and hazard assessment.
• Promote revision of building codes to include construction to reduce fall hazards. Older dwellings may need to be retrofitted with protective and safety devices, and new construction needs to include safety devices.²²

CONCLUSION

Falls and subsequent injury are a health and financial burden on older persons and their families, as well as a financial burden on the healthcare system. Home safety assessments with relatively low-cost recommendations to ensure home safety may abate falls and fall injury in older adults.