A Randomized Controlled Feasibility Trial of Tailored Home Modifications To Improve Activities of Daily Living

BACKGROUND: Approximately one in three community-dwelling adults age 65 and older fall each year; falls remain the leading cause of injury, long-term disability, injury-related mortality, and institutionalization. As the population ages, so will the number of persons at risk of falling. Unless prevention efforts are successful, annual costs associated with falls are projected to reach nearly $60 billion by 2020. A home modification program, delivered by occupational therapists, in Europe and Australia has demonstrated efficacy in preventing falls and has high adherence rates. It is unknown whether the intervention is feasible in the United States given the disparity in our housing policies.

OBJECTIVE: The purpose of this feasibility trial was to examine the efficacy of a home modification intervention program targeting activities of daily living (ADLs) on the primary outcome of risk of falls among community-dwelling older adults at high risk of a fall in the United States.

METHOD: We conducted a blinded, randomized sham-controlled feasibility trial to test the hypothesis that home modifications are efficacious in reducing falls and maintaining independence in daily activity performance for older adults at high risk of a fall. A sample of 115 community-dwelling older adults at high risk for a fall (history of recent fall, difficulty in two or more ADLs, age 65 or older) were randomized to receive either a sham ADL intervention or a tailored home modification intervention. All participants were blinded to the primary outcome of the trial. Six 90-min sessions were provided in the home by occupational therapists according to a manualized intervention.

Participants were followed for 12 mo to ascertain their fall status (fall/no fall). Fall covariates and daily activity performance were measured before randomization and at 12 mo by blinded raters. Time-to-event analysis was conducted to compare the risk of falling between the treatment and control groups.

RESULTS: Of the 115 participants randomized in the trial, 92 participated in the postintervention assessment: 45 participated in the treatment group, and 47 participated in the control group. This represented a total of 23 participants that were unavailable at posttest, or a 20% attrition rate for the total sample. The two groups were similar before intervention. The sample was 73% female, 71.3% White, 27.0% Black, and 1.7% other. The average reported age was 77.6 yr (SD = 7.14 yr). The 115 participants had a total of 222 falls over the 365-day monitoring period. The adjusted cumulative incidence of time to first fall for the entire monitoring period was not significant (hazard ratio = 1.29; 95% confidence interval [CI] [0.75, 0.212]; p = .3). The adjusted cumulative incidence of first fall in the home in the first 260 days was increased to more than twice the risk in the control group when controlled for demographics (age, race, sex), total falls in the previous year, daily activity performance, and amount of barriers in the home (hazard ratio = 2.37; 95% CI [1.02, 5.53]; p = .04).

DISCUSSION: Tailored home modification delivered in the home by an occupational therapy practitioner, targeting ADL performance was not superior to sham control at 12 mo. However, there was a significant reduction in the risk of falling in the first 260 days of monitoring. Further study of the effectiveness of home modifications to reduce fall risk is warranted.

IMPACT STATEMENT: Older adults who are at high risk for falls who receive a tailored home modification intervention have experienced a decrease in falls for the first 260 days after the intervention is completed. After this time, there was no significant difference between those who received the treatment and those who did not. Further study is warranted to explore why this crossover occurred and what can be done to prevent it from happening in the future.