Falls,Older Adults,and the Impact of the Neighborhood Environment

Falls and Fall Prevention

Falls are common in older adults, and they can produce fractures, limb or trunk soft-tissue injuries, and devastating head injuries. These injuries often alter the older adult’s quality of life and require an increased use of health care services, thereby contributing to the rise of health care costs. Fall-related injuries cost >$20 billion each year in the United States, and these costs are expected to rise (CDC, 2004, 2010). Falls and unstable balance can significantly affect both mortality and morbidity among older adults, and they are among the more serious clinical problems that older adults experience (Rubenstein, 2006). Intrinsic factors, including functional impairments stemming from chronic disease, weakness, unsteady gait, declining postural control, confusion, or side effects from medications, increase the risk of falls in older adults (Markle-Reid et al., 2010; Rubenstein, 2006). Substantial empirical evidence has shown that fall risk assessment and corresponding specified fall prevention interventions reduce the rates of falls and are cost-effective (Gillespie et al., 2009; Hektoen, Aas, & Lurås, 2009).

Fall prevention and management programs range from purely exercise-based intervention programs to multifactorial, multidisciplinary programs that, in addition to exercise, attend to cognitive assessments, monitor medical conditions, review responses to medication, assess the home for safety, and provide education sessions for clients and their caregivers (Petridou, Manti, Ntinapogias, Negri, & Szczerbinska, 2009). One example of a widely adopted fall prevention program that incorporates exercise, education, and home assessment is the Healthy Steps for Older Adults program offered throughout the state of Pennsylvania (Health Research for Action UC Berkeley, 2010).

Occupational therapists lead or serve as team members for fall prevention programs in both community-based and institutional settings. Occupational therapy interventions for fall prevention include cognitive assessment, in-home modifications, and education for safety with personal activities of daily living (ADLs), instrumental activities of daily living (IADLs), and leisure activities as well as physical conditioning programs (Lampiasi & Jacobs, 2010; Woodland & Hobson, 2003). Other team members addressing fall prevention come from medicine, nursing, public health, and physical therapy (Ciaschini et al., 2009; Greene, Sample, & Fruhauf, 2009). Although each clinical rehabilitation profession brings its own unique perspective and expertise to address the older adult’s needs, physical therapists are predominant in the fall prevention literature (Delaune & Ciolek, 2007). In the past decade (2000–2010), physical therapists have authored >100 refereed publications examining the effectiveness of prerequisite skills such as therapeutic exercise, gait training, and in-home safety modifications for fall prevention. Fall prevention is an integral component of physical therapy practice; it is noteworthy that the primary focus is on direct service delivery in the home, not outdoors in the neighborhood, and service is not yet population based (Peel, Brown, Lane, Milliken, & Patel, 2008).

Risk of falls is known to be reduced by participation in physical activity programs that also include at least two of the following additional programs: endurance training, balance training, and flexibility or strength training (Gillespie et al., 2009). Tai chi, a form of self-defense exercise developed in ancient China, is now used as a graceful form of exercise that seeks to integrate mind–body neural and physiological connections. It reduces stress and has been shown to help in fall prevention (Mayo Clinic, 2010; National Center for Complementary and Alternative Medicine, 2010). In addition to attention to intrinsic factors, environmental adaptation and modification in the home (e.g., removing scatter rugs, adjusting lighting conditions) have been found to improve safe mobility and to be effective in reducing falls among older adults at high risk for falling or who have visual impairments (Gillespie et al., 2009).

Although environmental review and modification are focused on the home, nearly half of the most recent falls reported among community-dwelling older adults occurred outdoors. Most outdoor falls are precipitated by environmental hazards in the neighborhood context, such as sidewalks, curbs, streets, gardens, patios, decks, parks, recreational areas, parking lots, or outdoor stairs (Li et al., 2006). Because 70% of older adults identify walking outdoors as their primary choice of physical activity, attention to the physical risk factors in the outdoor neighborhood environment is critical for successful fall and chronic disease prevention (Chakravarthy, Joyner, & Booth, 2002; Li et al., 2006). Only one study, a participatory community-based injury prevention program conducted >20 yr ago, examined the effects of modification of the outdoor environment on fall risk in older adults (Lindqvist, Timpka, & Schelp, 2001). Interventions that included improvements in winter road maintenance, reconstruction of pavements and walkways, and improved evening illumination resulted in a 26% reduction in falls for older adults ages 65–79 (Lindqvist et al., 2001).

The neighborhood physical environment is important in fall risk and fall prevention, but it has received less attention from occupational therapy and other health care professions (Li et al., 2006). Although occupational therapy practice has emphasized community mobility, including walking and attention to the built environment (American Occupational Therapy Association [AOTA], 2005; Weisser-Pike & Kaldenberg, 2010; Zahoransky, 2009), fall prevention programs are focused on the individual’s intrinsic status and in-home environment. Occupational therapists need to consider attending to the outdoor neighborhood environment to optimally implement fall prevention intervention programs.

Neighborhood and Physical Activity

Healthy aging is directly related to the opportunity to readily engage in safe walking outdoors. Critical to walking outdoors are accessible resources and services in safe proximity for engagement in physical activity and completion of routine and usual daily life tasks. Going outdoors daily correlates with and is a safeguard for optimal functional status among older adults (Jacobs et al., 2008). Adults age >70 who go outdoors daily are more likely to maintain their functional status, whereas those who do not tend to be at greater risk of joint pain, poor vision, and urinary incontinence (Jacobs et al., 2008). Older adults are more likely to experience a lowered activity level if they do not have the opportunity to walk outdoors regularly; this reduced activity in turn may put them at a greater risk for a fall. Decreased physical activity can adversely affect mobility, because fewer opportunities to walk increase the risk for mobility disability (walking ability, maneuverability, or decline in speed), which in turn increases functional decline (Clark et al., 2009). The relationship between impairment and disability with regard to the neighborhood environment is clear. Of older adults who have existing severe lower-extremity impairments, those living in neighborhoods with poor conditions are much more likely to report mobility disability than those living in neighborhoods with better street and sidewalk conditions (Clarke, Ailshire, Bader, Morenoff, & House, 2008).

A neighborhood’s sense of attractiveness encourages walking for exercise and use of the outdoor space for pleasure, including socialization (Michael, Green, & Farquhar, 2006). The physically built condition of the local neighborhood environment, such as the type and quality of paved surfaces, sidewalk width, presence and location of potholes and gratings, high curbs, garbage bins, advertising boards, pedestrian infrastructure, and traffic density, affects walkability and the degree to which older residents feel able and motivated to walk or spend time outdoors. Walkability is also affected by the availability of benches for resting and of key neighborhood services, including shops, post offices, and public toilets (Michael et al., 2006). Poor pedestrian safety, high crime rates, and impoverished esthetics often deter older adults from walking outdoors.

When the relationship between walkability and economic disparities was studied, high-poverty residential areas had poorer street-level walkability, including lower ratings for sidewalk and street maintenance (Zhu & Lee, 2008). The streets and sidewalks in lower-income neighborhoods are often not clear of debris and have more apparent signs of disrepair, excessive noise, lower tree density, and inadequate lighting. Cars tend to move at higher rates of speed through poorer neighborhoods, and the density of pedestrian–vehicular collisions and rates of felony and narcotic arrests are higher (Balfour & Kaplan, 2002; Neckerman et al., 2009). In one study, the blocks inhabited predominantly by African-Americans were 38 times more likely to have considerable sidewalk unevenness and 15 times more likely to have many sidewalk obstructions (Kelly, Schootman, Baker, Barnidge, & Lemes, 2007).

Walking is important for maintaining or increasing endurance, and it is an important component of an older adult’s physical activity program. It is optimal for the older adult to engage in additional forms of physical activity that specifically target strength, flexibility, and balance (Gillespie et al., 2009). Therefore, access to and availability to engage in physical activity in the neighborhood is paramount for fall prevention and, ultimately, for healthy aging. Low-income neighborhoods were 4.5 times more likely than higher-income areas not to have recreational facilities (Moore, Diez Roux, Evenson, McGinn, & Brines, 2008). Although parks are more equitably distributed, researchers have noted that 92% of the types of activities offered in parks are sports related, whereas only 4% of older adults report participating in any type of sporting activity. Parks offer resources for baseball, ice skating, and soccer, whereas recreational facilities offer weight training, mall walking, and tai chi classes (Moore et al., 2008).

Future Directions in Occupational Therapy Practice

Falls, whether they occur indoors or out, are a significant health problem for older adults. A neighborhood’s built and physical environment can affect fall risk, and low-income neighborhoods have disproportionately more risk factors that impede older adults from engaging in needed physical activity in the form of outdoor walking and fewer recreational resources for healthy aging. Given the growth of the aging population residing in the community and what is known to decrease the risk of falls in the health care delivery model, it is important that occupational therapists begin to understand what is required to prevent falls from a population model standpoint and in the neighborhood.

Improving physical and built neighborhood environments to reduce older adults’ risk of falls will require long-range urban planning and thus has civic policy implications. In the immediate term, our view is that occupational therapy needs to not only focus on indoor activities but also consider the full spectrum of older adults’ lives and address the outdoor neighborhood in fall prevention educational programs. At the individual direct-care level, in addition to ordering grab bars and tub benches and making other recommendations for in-home modifications to increase safety, occupational therapists need to provide information about safe community mobility and help older adult clients safely walk in their neighborhood by identifying potential outdoor tripping or safety hazards.

In addition, occupational therapists need to think beyond the indoor home environment and consider gathering data about the built environment or collaborating with people in the community who are skilled in public health and urban planning and zoning. Once occupational therapists become familiar with the community’s needs, population, and services, they will be capable of serving as advocates at the community level to help define the importance of the built and physical outdoor community environments and to show why changes are needed in the community for healthy aging and reduction of health care costs.

As a first step in the educational component of the fall prevention program, clients should be encouraged to observe the conditions of their outdoor neighborhood environment. In New York City, for example, residents can easily report problems with curbs, sidewalks, street lighting, signage, and street sanitation to the city government. Clients can be encouraged to become active at the community level in the form of participatory action research to identify problems and make needed neighborhood-level changes (Chippendale & Bear-Lehman, 2010).

To address the neighborhood environment, occupational therapists’ collaboration with urban planners, public health practitioners, and other health care researchers is needed to achieve fall prevention and to abate hazards in the environment. Specifically, occupational therapists can expand their role to serve as consultants to urban planning departments. They can help plan new communities that are friendly to older adults and help retrofit existing neighborhoods for healthy aging. Given their strong concentration of older adults, naturally occurring retirement communities could be a good place to begin making needed neighborhood-level changes. Collaboration with public health for planning and execution of neighborhood-level interventions is critical.

Why Occupational Therapy?

Health promotion and prevention have long been of concern to the profession of occupational therapy at the individual, community, and population levels (AOTA, 2008b; Hildenbrand & Froehlich, 2002). Occupational therapists’ expertise in human development and aging, activity analysis, low vision, and occupation in the context of daily living make them well suited to embrace the needs of the population in the neighborhood environment with team members including public health and urban planners. Although urban planners are well versed in zoning regulations, developing plans for land use, and recommending locations for infrastructure such as parks and roads (Bureau of Labor Statistics, 2010), public health professionals are skilled in epidemiology, injury prevention, and population-level health promotion initiatives (Albert & Freedman, 2010). With an appreciation of the impact of aging and chronic disease on function, occupational therapists are adept in assessing and helping older adults achieve and sustain independence in IADLs such as community mobility and shopping. Moreover, occupational therapy’s professional tenet is to maximize independence despite illness or chronic disease. These skills can be applied in the outdoor and neighborhood contexts to effect larger-scale community change.

The CDC has announced its goal to partner with organizations that share the common mission of preventing falls and reducing fall-related injuries (CDC, 2004). The profession of occupational therapy and its national organization, AOTA, share this goal and are ideally suited to form this partnership.

Challenges

Although disability prevention is an important part of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008a), and although empirical evidence of the benefits and cost-effectiveness of fall prevention is mounting, occupational therapy cannot bill for these services in the inpatient setting. Although “community/work reintegration training” is billable through Medicare in the inpatient setting, no Current Procedural Terminology (American Medical Association, 2011) codes are available for interventions that prevent falls. Therefore, Medicare does not cover fall prevention for hospitalized older adults. The lack of reimbursement for prevention services is not a new issue, but occupational therapists must continue to emphasize fall prevention, because it has been demonstrated to be an ethically sound and effective intervention that facilitates healthy aging and is cost-effective (Gillespie et al., 2009; Hektoen et al., 2009).

In home care, fall prevention is a reimbursable service, but only in the home, not in the neighborhood. Under home care guidelines, occupational therapists cannot implement an intervention program that requires the client to participate in activities outside of the home, such as practicing community mobility, because engagement in this type of therapeutic activity would indicate that the client is no longer homebound and therefore does not require home care services. For older adults to have access to the benefits of effective fall prevention programs that include community mobility and the neighborhood environment, occupational therapists need to work with the insurance industry, and with Medicare in particular, so that they can provide fall prevention programs in the health care delivery model to further promote healthy aging.

Summary

Outdoor falls account for almost half of those sustained by community-dwelling older adults, yet fall prevention programs focus on intrinsic factors and the in-home environment. Occupational therapists are best equipped to meet this unmet care need in conjunction with urban planners and public health professionals, including collaboration at the organizational level. Although immediate practice implications exist, policy changes are needed with regard to reimbursement for preventative and community-based services to effect change and promote healthy aging.