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Invited Commentary
Geriatrics
August 31, 2021

The Effect of Tailored Home Hazard Removal on Falls Among Community-Dwelling Older Adults

Author Affiliations
  • 1Johns Hopkins School of Nursing, Baltimore, Maryland
  • 2Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Netw Open. 2021;4(8):e2122325. doi:10.1001/jamanetworkopen.2021.22325

In a randomized clinical trial, Stark and colleagues1 found that removal of home hazards and tailored self-management strategies decreased fall rate among older adults at risk for falls. There were no differences in time to first fall or other prespecified outcomes of daily activity performance, falls efficacy, or self-reported quality of life.

Interventions to reduce fall rates are important because falls are hard to prevent and can be deadly. Even adjusting for population aging, mortality from falls has increased 30% from 2007 to 2016.2 The preventable and multifactorial causes for falls are well known but challenging to change. Most fall prevention programs are group exercise and education classes. Exercise, such as strength and balance training, is effective in preventing falls, but only 20% of individuals with fall risks consistently participate in these programs. For those who do participate, results diminish when participation ends.3

Even multifactorial approaches to fall prevention have had mixed results. A 2020 landmark null trial of a multicomponent fall prevention program, the STRIDE trial,4 found that medication assessment, referrals for exercise, recommendations for home modification, and visual assessment did not affect falls. Of note, home modifications were only recommended rather than provided and, similarly, the intervention referred older adults to exercise classes rather than working the classes into participants’ daily routine. Other multicomponent fall programs have used a person- and purpose-directed approach to setting goals with the expertise of an occupational therapist, nurse, and maintenance and repair professional to intervene on the person and their lived environment, resulting in reduced disability and increased falls efficacy.5,6 The study by Stark et al1 adds to this body of evidence that intervening with the home and the person could be an important strategy and the actual provision of services seems to have a stronger impact on falls than referral alone for services.

However, the home hazard removal intervention used by Stark et al1 focused on reducing risk for falls based on how an older adult uses their environment and did not include other individual-level risks. For example, the occupational therapist may discover that an older adult is grabbing onto the soap dish climbing into the tub without addressing the dizziness or leg weakness that might also cause a fall. Therefore, the multifactorial nature of this intervention is constrained.

That said, there are many innovative features of this study.1 In addition to the home environment intervention, Stark and colleagues1 enhanced the criterion standard falls calendar method of fall measurement by deploying a personalized calendar that includes each participant’s birthday, anniversaries, and holidays they celebrate. This can enhance recall accuracy and actual use of the calendar.

The study by Stark et al1 is important not only because it documents reduced fall rate but also because it was offered in the context of Area Agencies on Aging (AAA). AAAs are public or nonprofit agencies in every US county that offer services to help older adults age in their community. AAAs vary in scale and ability to partner, but many are strong partners to scale interventions.7 Having a real-world partner implement the intervention with significant findings is impressive.

In addition to reducing fall rate, Stark et al1 examined health care costs and found that the intervention saved more than it cost to implement. Being a pragmatic trial, the measures consisted of asking the older adult about health care utilization for each fall. As in many nonpharmacological and nondevice interventions, there is the question of who pays for the intervention and who reaps the savings. Commonly called the wrong pocket problem, if AAAs offer this program in a widespread fashion, most will not recoup savings because they do not pay for hospitalization. A few AAAs are in value-based contracts with insurers, but this is not widespread; the money spent by an AAA on the occupational therapist and the home modification required for this intervention would be mainly saved by the insurer. This leaves us, as a nation, with the issue of how to scale effective programs. As the US moves toward more value-based care arrangements, this may become less of a problem.

There is still much to be done to reduce falls and to scale successful interventions as the US population ages. To mitigate harm and death from falls, it will be important to deepen our understanding of intervening on the person and environment fit, determine the optimal amount of home modifications and support to provide the participant to offer long-lasting prevention, explore the role of person-directed goals in falls intervention design, and understand the potential synergy and parsimony of multicomponent falls interventions.

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Article Information

Published: August 31, 2021. doi:10.1001/jamanetworkopen.2021.22325

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Szanton SL et al. JAMA Network Open.

Corresponding Author: Sarah L. Szanton, PhD, ANP, Johns Hopkins School of Nursing, 525 N Wolfe St No. 424, Baltimore, MD 21205 (sarah.szanton@jhu.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Stark  S, Keglovits  M, Somerville  E,  et al.  Home hazard removal to reduce falls among community-dwelling older adults: a randomized clinical trial.   JAMA Netw Open. 2021;4(8):e2122044. doi:10.1001/jamanetworkopen.2021.22044Google Scholar
2.
Burns  E, Kakara  R.  Deaths from falls among persons aged ≥65 years—United States, 2007-2016.   MMWR Morb Mortal Wkly Rep. 2018;67(18):509-514. doi:10.15585/mmwr.mm6718a1 PubMedGoogle ScholarCrossref
3.
Nyman  SR, Victor  CR.  Older people’s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review.   Age Ageing. 2012;41(1):16-23. doi:10.1093/ageing/afr103 PubMedGoogle ScholarCrossref
4.
Bhasin  S, Gill  TM, Reuben  DB,  et al; STRIDE Trial Investigators.  A randomized trial of a multifactorial strategy to prevent serious fall injuries.   N Engl J Med. 2020;383(2):129-140. doi:10.1056/NEJMoa2002183 PubMedGoogle ScholarCrossref
5.
Szanton  SL, Xue  Q-L, Leff  B,  et al.  Effect of a biobehavioral environmental approach on disability among low-income older adults: a randomized clinical trial.   JAMA Intern Med. 2019;179(2):204-211. doi:10.1001/jamainternmed.2018.6026 PubMedGoogle ScholarCrossref
6.
Liu  M, Xue  QL, Gitlin  LN,  et al.  Disability prevention program improves life-space and falls efficacy: a randomized controlled trial.   J Am Geriatr Soc. 2021;69(1):85-90. doi:10.1111/jgs.16808PubMedGoogle ScholarCrossref
7.
Brewster  AL, Wilson  TL, Frehn  J, Berish  D, Kunkel  SR.  Linking health and social services through area agencies on aging is associated with lower health care use and spending.   Health Aff (Millwood). 2020;39(4):587-594. doi:10.1377/hlthaff.2019.01515 PubMedGoogle ScholarCrossref
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