4. Evidence-Based Best Practices for the Prevention of Falls

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• 4.1 Existing practice guidelines
• 4.2 Best practices for fall prevention
• 4.3 Selecting appropriate approaches according to setting
• 4.4 Recovery from a fall
• 4.5 Factors influencing client compliance in fall prevention

Information provided in this chapter on evidence-based best practices for the prevention of falls and fall-related injuries is taken from the guidelines and systematic reviews described in detail in Chapter 3. Additional evidence, highlighting Canadian interventions, is included here from studies carried out after the reviews were published.

4.1 Existing practice guidelines

In Canada and internationally, professional organizations and governments have established fall prevention guidelines based on systematic reviews of research evidence on best practices when working with seniors.

Guidelines prepared by professional organizations are generally considered prescriptive for professional practice. Professional organizations in Canada are beginning to develop practice guidelines on falls and seniors' falls. The Registered Nurses Association of Ontario recently published their professional guideline, RNAO: Prevention of falls and injuries in the older adult,⁸³ including best practices that address patient education and post-fall prevention.

Internationally, one of the most widely adopted guidelines is the Guideline for the prevention of falls in older persons of the American Geriatrics Society (AGS), described in the previous chapter, prepared in collaboration with the British Geriatrics Society and the American Academy of Orthopaedic Surgeons.

In the UK, the National Institute for Clinical Excellence (NICE) has published Clinical guideline 21: The assessment and prevention of falls in older people 2004.⁸⁴ The guideline outlines good practice based on the best available evidence of clinical and cost effectiveness. It encourages the participation of older people in fall prevention programs and supports fall prevention education for professionals working with seniors known to be at risk for falling.

Governments are developing comprehensive guidelines and strategies for reducing falls. The UK has established a National Health Service Framework for Older People with an entire section devoted to preventing falls.⁸⁵ In Australia, the Department of Health and Aging has developed a national fall prevention initiative for older people and the Australian states of Queensland and New South Wales have developed guidelines and initiatives to reduce falls. The Queensland government has produced comprehensive setting-specific guidelines for public hospitals and state government residential aged care facilities, incorporating community integration.⁸⁶ A 2004 Australian review of research on preventing falls and fall injuries in older people distinguishes between approaches for community-based, hospital-based and facility-based seniors.⁸⁷

4.2 Best Practices for Fall Prevention

Brief risk assessment to screen for high risk

Since it is impractical to think that all older people can be given a comprehensive fall-related assessment and treatment plan, a brief risk assessment is often the first step in identifying who may benefit most from this approach. The American Geriatrics Society's evidence-based guideline⁸⁸ suggests that a brief risk assessment would identify those who should be referred for a comprehensive fall evaluation. The three groups that such an assessment should identify are: older persons presenting for medical attention with one or more falls; older persons who report recurrent falls; and older persons with abnormalities of gait and/or balance.

Such an assessment may vary for seniors in different settings such as the community, a hospital or a nursing home. Assessments may be self-administered or used by first responders including paramedics; primary care personnel such as family physicians or nurse practitioners; physiotherapists; occupational therapists; and paraprofessionals, such as home support workers.

A Canadian study of veterans and caregivers supported the inclusion of the following factors in a brief risk assessment: lower limb disability, lower extremity weakness, worse memory than peers, one or more family doctor visits in the past month, and taking four or more medications. Physical inactivity and serious foot problems are other factors receiving some support for inclusion in a brief risk assessment.⁸⁹

Due to the multifactorial nature of falls, any one test cannot identify individuals who are at risk for falls.⁹⁰

Comprehensive clinical assessment

A comprehensive clinical risk assessment usually consists of:

• a review of falls history and circumstances; and
• an assessment of gait, balance, mobility and muscle weakness, osteoporosis risk, perceived functional ability and fear of falling, visual impairment and effects of corrective eyewear, urinary incontinence, home hazards, cardiovascular exam and medication review.⁹¹

The AGS Guideline advises that the assessment should be performed by a clinician with appropriate skills and experience. In addition to the factors identified above, the Guideline recommends including factors related to acute and chronic health problems; lower extremity joint function; and basic neurological function.

Multifactorial Interventions

The Rand Report, the Cochrane reviews and the Federal/Provincial/Territorial best practices guide all conclude that there is compelling evidence to support the use of multidisciplinary, multifactorial, health and environmental approaches to fall prevention. A comprehensive approach to fall prevention among seniors typically includes a combination of assessment and interventions such as exercise programs, behaviour change, medication review and modification, treatment of contributing health conditions, assistive and protective devices, environmental modifications, and education.

Excellent models of multifactorial interventions have been developed in Canada and elsewhere, although few have been tested empirically.

• A study conducted in Edmonton has shown promise in reducing falls using a multifactorial, risk-abatement approach, as well as a cognitive-behavioural and environmental focus. The target population was relatively healthy and mobile, community-dwelling older adults. The older adults who had completed the program made significant reductions in eight out of nine risk factors addressed in the program. Over a four-month follow-up period, the proportion of older adults who fell was lower in the treatment group (17%) than in the control group (35%). In addition, a significantly lower proportion (20%) of members of the treatment group, who had reported a fall in the year before the program, experienced a fall in the follow-up period compared to similar persons in the control group (35%).⁹²

• A study in which nurse practitioners and a physical therapist were trained to conduct comprehensive assessments and three months of focused interventions demonstrated significantly fewer 'fallers' and fewer total falls compared to the control group.⁹³

Exercise Programs

Evidence is growing concerning the benefits of exercise in reducing the risk of falls and related injuries. Exercise can improve balance, mobility and reaction time. It can increase bone mineral density in post-menopausal women and in people age 70 and over. The Rand Report concluded that exercise interventions reduced the risk of falls by 15% and the number of falls by 22%. The falls exercise programs typically involved cardiovascular endurance, muscle strength, flexibility and balance. The research supports general activity such as walking outside or mall walking indoors, cycling, mild aerobic movements or other endurance activities, and specific regimes geared toward balance, strength or flexibility.⁹⁴

Specific exercise regimes are associated with reduced falls and/or injuries. Overall, the Cochrane Review concluded that evidence from three randomized control trials proved that falls can be reduced through individually prescribed programs involving muscle strengthening and balance retraining. Group Tai Chi was also shown to be particularly effective.⁹⁵

Another review reported that 10 to 12 weeks of gentle exercise that focused on balance, strength and flexibility, produced a trend toward reduced multiple falls among high compliers. The review also reported on the benefits of an 80-minute exercise program, follow-up visits, and telephone encouragement. Participants reported fewer falls than persons in a control group. A combined strength and endurance training program, three times a week for six months, reduced the risk of falling by nearly half, when compared with either strength or endurance training alone.⁹⁶

Studies of the benefits of walking show mixed results. The Nurses' Health Study found walking to be preventive among the 61,200 women studied.⁹⁷ However, one researcher has reported increased falls from brisk walking among post-menopausal women.⁹⁸ Overall, Rand reviewers concluded that the data clearly point to the benefits of exercise in general, but they were not conclusive in recommending particular fall prevention exercises.⁹⁹

linical Management of Chronic and Acute Illness

Chronic illnesses that are frequently implicated in falls risk include arthritis, Parkinson's disease, stroke, urinary incontinence, sudden reductions in blood pressure on rising, and cardiovascular conditions including arrhythmias. Unfortunately, the increased risk of falls associated with chronic illnesses may be compounded by additional risks related to adverse reactions to medications used to treat them. Similarly, the medications used to treat sleep disturbances and acute illnesses may compound the fall risk.

Medication Review and Modification

Suggestions for improving medication management have been identified by a variety of sources. An Australian guideline reported that programs aimed at reducing the use of sedatives and tranquillizers have resulted in fewer hip fractures in nursing homes.¹⁰⁰

They recommended the following:

• use the lowest effective dosage of a medication specific to the symptoms;
• urge supervision and the use of walking aids while such medications are being taken;
• decrease chronic use of medications;
• limit multiple medication use; and
• conduct regular reviews of all patients' medications with a view to withdrawing those that are not absolutely necessary.

The use of post-menopausal hormone replacement therapy (HRT) is a controversial one. Some research has shown that fractures of the wrist and hip may be reduced with HRT and that bone loss may be prevented for up to 15 years with as much as a 50% reduction in fracture risk. However, other risks associated with HRT have yet to be resolved before informed decisions can be made about its usefulness in fracture prevention. Pending further research, decisions on the use of HRT should be made based on the risk profile of individual seniors. Other bone enhancing drugs are proving useful in reducing vertebral and hip fractures. These include biophosphonates (etidronate, alendronate, pamidronate) and selective estrogen receptor modulators (raloxifene).¹⁰¹

The B.C. Provincial Health Officer's report highlights the need for pharmacists to communicate clearly with both clients and physicians concerning the interplay of drugs and falls. It also recommends that pharmacists promote the use of assistive devices such as hip protectors and walking aids, apply stickers to drugs known to increase the risk of falls, and ensure that drug instructions are in large typeface and are readily understood by the client.¹⁰² Non-pharmacological approaches for patients can also be considered, including chiropractic and massage therapy.

Vision Referral and Correction

While vision problems are a known risk for falls, no research evidence yet exists to show that treating visual problems can prevent falls. However, many vision problems can be corrected with a proper exam and corrective lenses. Progressive lenses may give better quality vision of surroundings; however, it is not recommended that older patients be switched from bifocal to progressive lenses or vice versa.¹⁰³

Opticians can warn older persons that it takes time to adjust to new lenses - particularly multi-focal lenses - and that during this period they may be at high risk for a fall or associated injury, particularly on stairs. Simple suggestions include making sure the environment is well-lit, avoiding neutral colours, avoiding clutter and remembering to remove reading glasses when moving about.¹⁰⁴ Some older people may refrain from having regular eye exams and purchasing appropriate corrective lenses because of the cost.

Assistive Devices and Other Protective Equipment

Assistive and protective devices such as canes, walkers, safety poles or bathroom grab bars are often recommended to reduce the risk of falling, although empirical research to prove their effectiveness is lacking. While there is no clear evidence that assistive devices cause or prevent falls, their use can play an important role in increasing seniors' confidence and mobility and encouraging independence.¹⁰⁵

A recent review of the literature highlighting the demands and problems associated with mobility aids suggests that there may be a need for more cautious prescription of mobility aids and improved training to use the prescribed device safely.¹⁰⁶ Safer mobility aids are currently being developed, such as novel handrail systems designed to promote safe stair use among seniors, and new types of footwear designed to improve balance by facilitating pressure sensation from the sole of the foot.¹⁰⁷

A national project of the Health Canada/Veterans Affairs Canada Falls Prevention Initiative held focus groups with older adults, service providers and assistive device stakeholders. They found that, for many older persons, assistive devices, in particular mobility aids, can be viewed as stigmatizing and symbolic of aging and inevitable decline. These perceptions can influence an individual's decisions about whether or not to use aids.¹⁰⁸ Other researchers identified factors affecting the use of adaptive equipment, including age, gender, living environment, and health condition. Their findings indicated that device use is greater for persons with acute orthopaedic conditions and multiple impairments. The strongest predictor of use is a client's perceived need for the device.¹⁰⁹

Hip protectors are designed to reduce hip fractures with falls. This protective underwear-type garment has a soft or hard shell over the hip area. Researchers have reported that these garments may be 80% to 95% protective for hip fractures. A review commissioned by Health Canada and Veterans Affairs Canada reported that five studies showed reduced fractures among people wearing hip protectors; however, only one of these results was statistically significant. The authors note that the non-significant results may be due to different hip protectors being studied, small sample sizes and poor compliance for wear.¹¹⁰ One study reported that no one who was wearing hip protectors at the time of a fall suffered a hip fracture.¹¹¹

Personal emergency call devices are designed to enable prompt assistance to someone who has fallen and needs help. While they do not prevent people from falling, they can reduce the seriousness of injury complications by ensuring prompt treatment and reduced harm. Many residential care settings have such call devices installed as alarm buttons near the floor. Alerting systems, which alert care providers when an individual becomes ambulatory, may reduce falls. An ambulatory alarm secured to the thigh of hospitalized seniors, was shown to reduce falls by 45% in a general ward and 33% in an orthopaedic ward in less than a year¹¹² but these results have not been replicated and may not be applicable to a community-dwelling population.

Nutrition and Supplements

Limited but promising research evidence exists for the benefits of altered nutrition and supplements. One review has suggested that increasing dietary calcium has the greatest effect in improving bone mass among persons with low bone density and in those who have low calcium intake (<400 mg/day).¹¹³ It is currently advised that calcium supplements (1,500 mg/day) be used with vitamin D (800 IU/day) or other active agents. Institutionalized seniors may benefit in particular, as they have been shown to suffer vitamin D deficiency due to lack of exposure to sunlight.¹¹⁴ A more recent review from the United States combined data from five randomized clinical trials and concluded that 37% of people in control groups had a fall compared with 30% taking vitamin D.¹¹⁵

It is also reasonable to assume that underweight or malnourished persons would have a greater risk of fracture due to limited adipose (fat) tissue to protect bones during a fall, muscle weakness or poor reaction time. Improving oral health and dentures may enhance nutrition as well. These issues need to be addressed population-wide as well as on a case-by-case basis.

Environmental Assessment and Modification

In and around the home

Most falls occur in and around the home and research indicates that home modifications may be effective in reducing the risk of falls.¹¹⁶ An assessment of the home environment aims to enhance accessibility, safety, and performance of daily living activities. The Public Health Agency of Canada's Safe living guide¹¹⁷ includes a validated home safety checklist, which can be completed by seniors themselves or together with volunteers or health care workers. Modifications include removing clutter and securing electrical cords and loose carpets to prevent tripping; installing grab bars and handrails; improving lighting and keeping a working flashlight nearby; and improving shower and tub safety.

An important aspect of successful home modifications is ensuring that the identified hazards are actually corrected. Programs that not only identified the hazards and the needed modifications, but also carried out the modifications, were more successful than programs that left the modifications up to the seniors.¹¹⁸ Studies which have explored adherence to home modifications recommended by an occupational therapist indicate that factors such as the perceived need for the modification and lower cognitive or functional status are related to adherence. The older person's involvement in making the decision regarding the options for modifications may also influence adherence.¹¹⁹

In public spaces

There are many factors contributing to falls in public spaces and it is difficult to determine the impact of a specific intervention. However, a project in British Columbia called STEPS (Study to Promote Environmental Safety) produced an interesting model for reducing public fall hazards. This project pulled together government officials, seniors, city maintenance workers, and building owners to examine and reduce fall hazards in the community. A telephone hotline enabled people to report falls and hazards, leading to a repair or spray-painting of the hazard until the repair could be done.¹²⁰ Public awareness campaigns can also educate the community about fall hazards - municipal workers, seniors, caregivers, letter carriers, and others are well situated to observe and report on fall hazards in need of repair.

Building codes and standards can play an important role in the prevention of falls. The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) reports that stairs, floors and steps are implicated in seniors' falls more often than any other household areas or items.¹²¹

The Canadian Standards Association has undertaken several initiatives to improve safety and security for seniors. A key initiative has been the development of B659-01: Design for Aging, a guideline that outlines principles for the development of products, services and environments for an aging society.¹²²

Education

It is generally agreed that as a stand-alone intervention, education does not produce a measurable decline in falls or injuries. However, educational efforts with individuals, family caregivers, professionals and entire communities are recommended as an adjunct to other interventions. Effective education may take many forms including pamphlets or other printed materials, public talks or discussion groups and use of the media. More intense education can take place with individual counselling. A form of skills education is being studied in Canada to determine whether people can learn to fall more safely. A researcher has found that during a sideways fall, individuals can learn to avoid impact to the hip by changing the position of their body before they land on the floor, thereby lowering their risk of a hip fracture.¹²³

Educating care providers is another approach to fall prevention. An innovative educational program equipped community health workers to do first level assessments of older community-based clients receiving home care services. Following a one-day training session, the workers implemented a risk screen and intervention tool with selective clients. The total number of reported falls dropped by 44% and the study is now being replicated as a randomized control trial to establish the relationship between a decline in falls and the benefits of the program more clearly.¹²⁴

Addressing Fear of Falling

Existing education programs are tailored to prevent falls; however, a need also exists for post-fall interventions to prevent subsequent falls and to address fear of falling.¹²⁵ Many fall prevention programs target fear and self-efficacy but there is limited evidence of their effectiveness in reducing fear. One study reported a modest short-term effect in improving self-efficacy and increasing level of activity using a cognitive-behavioural intervention. No effect remained after six months.¹²⁶ An intervention involving participation in Tai Chi classes resulted in a reduction in fear of falling and risk of falling. Use of hip protectors did not appear to reduce fear of falling, but was associated with improved self-efficacy.¹²⁷

A recent study concluded that an intervention to reduce fear of falling through group sessions was most effective for participants who were less physically impaired, had greater concern about falling and had greater self-efficacy in making changes.¹²⁸ There is evidence to suggest that interventions for people being treated for fall-related injuries should try to lessen fear arousal. Also, increased social support is needed as a means to lessening fear.¹²⁹ A multi-faceted intervention strategy showed significant improvements in the capacity of community-dwelling seniors to address fall risks.¹³⁰

Programs seem to be more effective when they target remediable individual and environmental risk factors for falls, and when they are integrated into a range of services including prevention and management, acute care, rehabilitation, home care, and long-term support.

4.3 Selecting Appropriate Approaches According to Setting

Community-based Settings

Many of the fall prevention approaches described above are appropriate to community-based settings. Among seniors in the community, interventions need to be tailored to an individual's level of frailty - approaches suited to healthy, active seniors will be different from those for seniors who are more frail. In 2004, Health Canada conducted a survey to determine seniors' attitudes to falls and concluded that younger, healthy seniors tend to focus on healthy eating and exercise, and do not tend to think of this as preventing falls. Those who are frail and more vulnerable tend to focus on maintaining independence, and while they are at a higher risk for falls, they have a tendency to deny their risk. However, given the right information by the right professional, many will change their environments and behaviour to minimize their risk. Frail seniors who depend on others for their care, along with their professional and family caregivers, are often very concerned about falling and can benefit from education and interventions.

Institutionalized Seniors

A number of researchers have studied fall prevention approaches in long-term care facilities. Two promising examples are as follows:

• A randomized control trial in nursing homes combined individualized assessment with interventions. Interventions were in the areas of environmental and personal safety (i.e., improvement in room lighting, flooring, footwear, etc.), wheelchair use and maintenance (i.e., assessment by an occupational therapist), psychotropic drug prescriptions (i.e., assessment and recommendations for change), transfer and ambulation (i.e., evaluation and recommendations for change), and facility-wide interventions (e.g., educational programs for staff). The 'intervention' facilities had 19% fewer recurrent falls compared with the 'control' facilities, and a 31% reduction in the rate of injurious falls.¹³¹

• A project funded by PHAC's Population Health Fund developed a falls surveillance tool for long-term care facilities, based on a review of the literature on fall prevention for residents in such facilities. This project developed several collaborative protocols for recording, implementing and monitoring effective prevention strategies for falls and fall-related injuries.¹³²

Hospitalized Seniors

Many prevention practices are in place to protect hospitalized seniors from falls including educational activities for nursing and support staff, patient orientation activities, reviews of prior falls, and modifications to the environment. Environmental modifications include reducing ward or room obstacles, adding extra lighting and grab bars in bathrooms, and lowering bedrails and bed height. Other approaches address transfer and mobility issues with scheduled ambulatory and physical therapy activities and attention to footwear (e.g., non-skid socks). In addition, hospitals have incorporated strategies to assist cognitively impaired patients by: educating family members to deal with confused patients; minimizing sedating medications; and moving confused patients closer to nursing staff.¹³³

A recent systematic review reported a pooled effect of a 25% reduction in the fall rate in the studies that examined prospective interventions compared to fall risk in historical controls. Minimizing bed rest is a practical intervention that has implications for the prevention of a number of serious hospital-acquired complications.¹³⁴

4.4 Recovery From a Fall

This section summarizes the evidence presented in systematic reviews, guidelines and other studies concerning best practices for recovery from a fall and post-fall prevention of another fall.

Although there is information on the management of specific injuries, most notably hip fractures, the concept of fall recovery is not well recognized. Comprehensive fall injury management needs to go beyond care for the injury sustained to include assessment and reduction of the risk of future falls (i.e., medication review, exercise, and education) and the maintenance of a healthy lifestyle, not prescribed by the fear of falling and being injured again.

A number of factors play a role in a senior's recovery from a fall. Two studies have reported that almost half of those who fell required help getting up and that 10% of falls resulted in a wait of over one hour for help to arrive.¹³⁵ Compared with those who were able to get up, those who could not were more likely to suffer lasting decline in activities of daily living. A key recommendation from the studies reviewed is that older adults presenting for medical care with a fall injury should be assessed for risk of falling and that remediable risk factors should be addressed.¹³⁶

One worrisome complication for older adults after hip fracture surgery is delirium, which occurs in 35% to 65% of patients and can adversely affect rehabilitation outcomes.¹³⁷ Depression is another factor that has implications for practice as it may affect recovery from fall injuries. One study found that depression prior to a fall-related injury was not predictive of disability after the injury. However, symptoms of depression present two months after the injury were linked to significantly higher rates of disability over the short and long term.¹³⁸ Clearly, depression may be triggered by a fall-related injury and may affect recovery from such injuries.

Across Canada, services for seniors who have fallen vary, especially in relation to preventing future falls. The greatest variability appears to be in home care, home supports and physical therapy services. A step to consider is the addition of evidence-based fall prevention guidelines for the professionals who see patients presenting with a complaint of falls or with a fall-related injury. These professionals can include physicians, nurses, health workers in community and long-term care, physical and occupational therapists, etc.

4.5 Factors Influencing Client Compliance in Fall Prevention

A person's need for autonomy, dignity and independence, as well as the tendency to minimize the seriousness of a fall or displace blame may pose challenges to successful implementation of fall prevention initiatives. One study interviewed older women who had not followed through on recommendations to modify their environment to reduce their risk of falling. The study found that the women made decisions about whether or not to implement changes in their home based on their own perception of the level of risk, according to their own experience and knowledge, rather than on those of the person recommending the changes. The women tended to modify their behaviour rather than change their environment, opting to accept a level of environmental risk.¹³⁹

Varying attitudes have been observed in people who have fallen. One study found four patterns of response: overall lack of concern; a perception of the fall as part of the natural aging process; viewing the incident as a learning opportunity; and experiencing the event as dramatic and life-changing.¹⁴⁰ Those who had little or no concern tended to place great value on maintaining their independence and made no changes to reduce their risk of falling in the future. Those who saw falling as part of the aging process or as a learning opportunity took actions to reduce risk. Those who experienced the event as 'dramatic' were more fearful of falling in the future and perceived themselves as very vulnerable to falling. The latter group made the most changes to reduce their risk of falling but had a reduced sense of personal mastery. Thus, it is important for clinicians to determine a client's interpretations of a fall event as it may affect the senior's readiness to make changes.

Communicating to a client about falling and related fear is important both in treating fall-related medical conditions and in preventing future falls. Communications need to take into account the tendencies of people to dissociate from the likelihood of a future fall, displace blame for falls, and maintain a sense of personal control and independence. Also, understanding the complexity of fear of falling is important for effective communication. Communications should emphasize 'healthy fear' that results in risk reduction rather than 'unhealthy fear' that may lead to increased risk of falls.

A study of ten women living in a nursing home explored the women's experiences and feelings after having fallen.¹⁴¹ The women described feelings of helplessness, annoyance and frustration as a result of falling. Most expressed a fear of falling in the future and had opted to use assistive devices for mobility. They were reluctant to participate in organized physical activity programs, in part because they had never been involved in physical activities for pleasure at any stage in their life, but also due to their fear of falling again.

Clearly, falls are an emotionally loaded topic for older people. A study examining perceptions of falls found that the language used by older people to describe their falls avoided connotations of personal vulnerability.¹⁴² Similarly, there is a tendency for people to dissociate themselves from the likelihood of falling and to consider others at greater risk.¹⁴³ Many individuals are strongly motivated to underplay their personal susceptibility.¹⁴⁴

This tendency to avoid being perceived as vulnerable may relate to the need for personal control or autonomy. For seniors who have experienced a fall, there may be residual fear about possible loss of freedom. One researcher found that, although older nursing home residents were falling regularly, many were baffled as to why they were included in a group of 'frequent fallers' as they did not see themselves as persons who repeatedly fell. The residents described the falls as having been caused by an external factor. The authors conclude that the defense mechanism of displaced blame allowed frequent fallers to continue to view themselves as intact.¹⁴⁵ Interventions should take into account the tendencies of frequent fallers toward denial, as well as their need to preserve personal esteem and independence. It is important to respect the rights of seniors to live at risk.

Summary

There is compelling evidence for the effectiveness of combining comprehensive falls assessments with multidisciplinary and multifactorial interventions that address health and environmental factors to prevent falls among seniors.

Some interventions focus on the combination of factors that put a senior at risk while others address broader population-based efforts, such as education and reducing public hazards. These approaches are complementary and can be adapted to the community or the institutional environment. A comprehensive approach typically includes exercise programs, behavioural changes, review and possible modification of medications, treatment of health conditions contributing to risk, safety and protective aids, environmental modifications and the education of seniors and caregivers. With seniors who have experienced a fall injury, recovery, fear of falling and attitude need to be addressed to prevent further falls. Interventions need to support seniors' personal esteem and independence.

83. Registered Nurses Association of Ontario. Prevention of falls and fall injuries in the older adult. 2002 (revised in 2005).

84.  National Institute for Clinical Excellence. Clinical guideline 21: The assessment and prevention of falls in older people. 2004.

85.  National Electronic Library for Health (as viewed July 2005).

86. Queensland State Government, Australia. Falls prevention: Best practice guidelines for public hospitals and state government residential aged care facilities. Queensland Health, 2003.

87. Australian Government. An analysis of research on preventing falls and falls injury in older people: Community, residential care and hospital settings. Department of Health and Ageing, 2004.

88. American Geriatrics Society; British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. "Guideline for the prevention of falls in older persons." Journal of the American geriatrics society, Vol. 49, 2001, pp. 664-72.

89. Speechley, M. "Risk factors for falling among Canadian veterans and their caregivers." Canadian journal on aging, 2005. (Publication pending)

90. Hotchkiss, A. et al. "Convergent and predictive validity of three scales related to falls in the elderly." American journal of occupational therapy, Vol. 58, No. 1, 2004, pp. 100-3.

91.  National Institute for Clinical Excellence. Clinical guideline 21: The assessment and prevention of falls in older people. 2004.

92. Robson, E.; J. Edwards, E. Gallagher and D. Baker. "Steady As You Go (SAYGO): A falls-prevention program for seniors living in the community." Canadian journal on aging, Vol. 22, No. 2, 2003, pp. 207-16.

93. Tinetti, M. E.; M. Speechley and S. F. Ginter. "Fear of falling and fall-related efficacy in relationship to functioning among community-living elders." Journal of gerontology, Vol. 49, No. 3, 1994, pp. M140-M147.

94. Chang, J. T. et al. "Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomized clinical trials." British medical journal, Vol. 328, No. 7441, 2004, p. 680.

95. Gillespie, L. D. et al. "Interventions for preventing falls in elderly people." (Cochrane Review) The Cochrane library, Vol. 3, 2001.

96.  New South Wales Health Department . Preventing injuries from falls in older people: Background information to assist in the planning and evaluation of local area-based strategies in New South Wales. 2001.

97. Feskanich D.; W. Willett and G. Colditz. "Walking and leisure time activity and risk of hip fracture in post menopausal women." Journal of the American medical association, Vol. 288, 2002, pp. 2300-6.

98. Ebrahim, S. et al. "Randomized placebo-controlled trial of brisk walking in prevention of post-menopausal osteoporosis." Age and ageing, Vol. 26, 1997, pp. 253-60.

99. Chang, J. T. et al. "Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomized clinical trials." British medical journal, Vol. 328, No. 7441, 2004, p. 680.

100.  New South Wales Health Department. Preventing injuries from falls in older people: Background information to assist in the planning and evaluation of local area-based strategies in New South Wales. 2001.

101. Ibid.

102. Scott V.; S. Peck and P. Kendall. Prevention of falls and injuries among the elderly: A special report from the Office of the Provincial Health Officer. Victoria, B.C.: Ministry of Health Planning, 2004.

103. Eisenberg, J. "Your role in fall prevention." Review of optometry, 15 Dec. 2004, pp. 46-50.

104. Ibid.

105. Health Canada/Veterans Affairs Canada Falls Prevention Initiative. Assistive device use by seniors and injuries: A recent literature review. Prepared by J. Watzke, 2001.

106. Speechley, M. "Risk factors for falling among Canadian veterans and their caregivers." Canadian journal on aging, 2005. (Publication pending)

107. Maki, B. E. et al. "Effect of facilitation of sensation from plantar foot-surface boundaries on postural stabilization in young and older adults." Journal of gerontololgy, Vol. 54A, 1999, pp. M281-M287.

108. Aminzadeh, F. and N. Edwards. "Exploring seniors' views on the use of assistive devices in fall prevention." Public health nursing, Vol. 15, No. 4, 2001, pp. 297-304.

109. Kraskowsky, L. H. and M. Finlayson. "Factors affecting older adults use of adapted equipment: Review of the literature." American journal of occupational therapy, Vol. 55, No. 3, 2001, pp. 303-10.

110. Health Canada/Veterans Affairs Canada Falls Prevention Initiative. Hip protectors and community-living seniors: A review of the literature. Prepared by H. Sveistrup and D. Lockett, 2003.

111. Van Schoor, N. et al. "Prevention of hip fractures by external hip protectors: A randomized controlled trial." Journal of American medical association, Vol. 289, 2003, pp. 1957-62.

112. Widder, B. "A new device to decrease falls." Geriatric nursing, Vol. 6, 1985, pp. 287-88.

113.  New South Wales Health Department. Preventing injuries from falls in older people: Background information to assist in the planning and evaluation of local area-based strategies in New South Wales. 2001.

114. Ibid.

115. Birschoff-Ferrari, H. "Effect of Vitamin D on falls: A meta-analysis." Journal of the American medical association, Vol. 291, 2004, pp. 1999-2006.

116. Health Canada/Veterans Affairs Canada Falls Prevention Initiative. Evaluating the safe living guide. Prepared by L. Shaw; A. Freeman and K. Cooper, University of Western Ontario, 2004.

117.  Public Health Agency of Canada. The safe living guide: A guide to home safety for seniors. 2005.

118. F/P/T Ministers Responsible for Seniors. A best practices guide for the prevention of falls among seniors living in the community. 2001.

119. Cumming, R. G. et al. "Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention." Journal of the American geriatrics society, Vol. 47, No. 12, 1999, pp. 1398-1402.

120. Gallagher, E. and V. Scott. "The STEPS project: A collaborative study to reduce falls in public places among seniors and persons with disabilities." Canadian journal of public health, Vol. 88, No. 2, 1997, pp. 129-33.

121. F/P/T Ministers Responsible for Seniors. Enhancing safety and security for Canadian seniors: Setting the stage for action. 1999.

122.  Canadian Standards Association. B659-01: Design for aging. Edmonton: 2001. Available for purchase online.

123. Robinovitch, S. et al. "Strategies for avoiding hip impact during sideways falls." Journal of bone and mineral research, Vol. 18, 2003, pp. 1267-73.

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126. Gagnon, N. and A. Flint. "Fear of falling in the elderly." Geriatrics and aging, Vol. 6, No. 7, 2003, p. 15-17.

127. Ibid.

128. Tennstedt, S.; R. Lawrence and L. Kasten. "Intervention to reduce fear of falling and enhance activity: Who is most likely to benefit?" Educational gerontology, Vol. 27, No. 3, 2001, pp. 227-40.

129. Howland, J. et al. "Covariates of fear of falling and associated activity curtailment." Gerontologist, Vol. 38, No. 5, 1998, pp. 549-55.

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131. Ray, W. et al. "A randomized trial of a consultation service to reduce falls in nursing homes." Journal of the American medical association, Vol. 278, 1997, pp. 557-62.

132. Gallagher, E. et al. Stepping in: Long-term care collaborative falls prevention project. Unpublished final report and manual. 2005.

133. Agostini, J.; D. Baker and S. Bogardus. "Prevention of falls in hospitalized and institutionalized older people." Agency for healthcare research and quality: HRQ evidence reports, No. 1-60, 2004.

134. Ibid.

135. Nevitt, M.; S. Cummings and E. Hudes. "Risk factors for injurious falls." Journal of gerontology, Vol. 46, 1991, pp. M164-M170.
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137. Marcantonio, E. R. et al. "Reducing delirium after hip fracture: A randomized trial." Journal of the American geriatric society, Vol. 49, 2001, pp. 516-22.

138. Kempen, G. et al. "The role of depressive symptoms in recovery from injuries to the extremities in older persons: A prospective study." International journal of geriatric psychiatry, Vol. 18, 2003, pp. 14-22.

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140. Miller, J. "Perception and psychological effects of falling of elderly people living in the community." PhD dissertation. University of Illinois at Chicago, Health Sciences Center, 1995.

141. Davis, N. "Elderly women's narratives of falling, fear of falling, the role of physical activity and their impact on autonomy and quality of life." MA Dissertation. University of Ottawa, April 2001.

142. Martin, M. "The construction of the risks of falling in older people: Lay and professional perspectives final report." Scottish health feedback. Edinburgh: 1999.

143. Braun, B. "Knowledge and perception of fall-related risk factors and fall reduction techniques among community-dwelling elderly individuals." Physical therapy, Vol. 78, 1998, pp. 1262-76.

144. Ballinger, C. and S. Payne. "The construction of the risk of falling among and by older people." Ageing and society, Vol. 22, 2002, pp. 305-24.

145. Wright, B. et al. "Frequent fallers: Leading groups to identify psychological factors." Journal of gerontological nursing, Vol. 16, No. 4, 1990, pp. 15-19.

 

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