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Occupational Therapy in Fall Prevention: Current

Evidence and Future Directions

Natalie E. Leland, Sharon J. Elliott, Lisa OMalley, Susan L. Murphy

KEY WORDS Falls are a serious public health concern among older adults in the United States. Although many fall pre-
 accident prevention vention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the
British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear.
 accidental falls
This article presents a scoping review of current published research documenting the role of occupational
 evidence-based practice therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and
 occupational therapy BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in
 professional role environmental modifications, exercise, and multifactorial and multicomponent interventions. Although re-
search documenting the efficacy of occupational therapy interventions is identified as part of the Occupa-
tional Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy
Association, 2008), we identified little or no such research examining interventions to modify behaviors
(e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage med-
ications. Although occupational therapy is represented in the fall prevention research, the evidence for the
professions role in many areas is still lacking.

Leland, N. E., Elliott, S. J., OMalley, L., & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence
and future directions. American Journal of Occupational Therapy, 66, 149160. http://dx.doi.org/10.5014/
ajot.2012.002733

Natalie E. Leland, PhD, OTR/L, BCG, is Assistant hirty percent of community-dwelling older adults 65 yr old fall each year;
Professor, Division of Occupational Science and
Occupational Therapy, Herman Ostrow School of Dentistry,
T of that group, 10% suffer a severe injury (Anderson, Minino, Fingerhut,
Warner, & Heinen, 2006). Falls are associated with limitations in activity, loss
and Davis School of Gerontology, University of Southern
California, 1540 Alcazar Street, CHP 133, Los Angeles, CA of independence, and institutionalization (Stevens, Corso, Finkelstein, &
90089-9003; nleland@usc.edu Miller, 2006; Tinetti, Inouye, Gill, & Doucette, 1995) often caused by
Sharon J. Elliott, DHS, GCG, OTR/L, BCG, FAOTA,
a combination of medical, social, and environmental factors (Chang & Ganz,
is Adult Therapy Services Coordinator, Therapeutic Life 2007). Occupational therapy practitioners are uniquely qualified to address the
Center, Greenville, NC. multifactorial nature of falls, given their knowledge of factors that influence
occupational performance (Peterson & Clemson, 2008). The specific role of
Lisa OMalley, PhD, is Lecturer, Department of Social
Policy and Social Work, University of York, Heslington, occupational therapy in fall prevention, however, is unclear.
York, England. Fall prevention research, in general, has been synthesized and translated into
clinical practice recommendations such as the guidelines updated in 2010 by the
Susan L. Murphy, ScD, OTR/L, is Assistant Professor,
American Geriatrics Society (AGS) in collaboration with the British Geriatrics
Physical Medicine and Rehabilitation, University of
Michigan, and Research Health Science Specialist, Society (BGS). These evidence-based guidelines outline strategies for fall risk
Geriatric Research, Education and Clinical Center, VA screening and highlight areas of risk for which research evidence supports in-
Ann Arbor Healthcare System, Ann Arbor, MI. tervention. Recommended intervention areas include modifying the environment;
using exercise to improve strength, balance, and gait; managing and minimizing
medications; managing postural hypotension; recommending appropriate foot-
wear and managing existing foot problems; and modifying behavior, such as
reducing the fear of falling. According to the Occupational Therapy Practice
Framework: Domain and Process (2nd ed.; American Occupational Therapy As-
sociation [AOTA], 2008), occupational therapy has a role in supporting each
intervention area. Although modifying the environment has been a traditional
occupational therapy role in fall prevention, given the occupational therapy
perspective of treating people within context, occupational therapy practitioners

The American Journal of Occupational Therapy 149


can address other fall risk factors as part of a multidisci- (e.g., Tinetti, Speechley, & Ginter, 1988) rather than on
plinary team. For instance, exercise interventions that examining occupational therapyled interventions to de-
improve strength, range of motion, balance, coordination, crease fall risk. We therefore felt that 1990 was an ap-
and endurance address the motor and praxis skills needed propriate starting point for this study. To be included,
to support occupational performance. In addition, behav- articles had to be written in English, include a sample of
ioral factors, such as fear of falling, can negatively affect community-dwelling older adults 65 yr old, include an
activity performance, thereby increasing fall risk (Walker intervention that involved occupational therapy (e.g., oc-
& Howland, 1991; Zijlstra et al., 2009). Occupational cupational therapy practitioners conducted and/or de-
therapists can use education to change behavior and im- signed the intervention), and evaluate falls or a fall-related
prove older adults falls self-efficacythat is, their confi- outcome. We included only articles that were published in
dence in performing activities without falling (Cheal & peer-reviewed journals, as opposed to clinical practice
Clemson, 2001; Peterson & Murphy, 2002). journals (e.g., OT Practice) or newsletters (e.g., Gerontology
As part of a multidisciplinary team, occupational Special Interest Section Newsletter), and that described
therapy practitioners potentially have a role in the other a quantitative research study that evaluated a fall-related
recommended areas listed in the AGS and BGS (2010) intervention. Articles that examined solely the cost-
guidelines, including medication management, postural effectiveness or the structure and process of implementing
hypotension management, and recommendation of ap- a fall prevention program were excluded. Systematic re-
propriate footwear, because those areas also affect occu- views and meta-analyses were also excluded; however, we
pational performance. For example, occupational therapy reviewed the reference lists of included articles to identify
practitioners can provide interventions to address per- any relevant articles not already captured by the initial
formance skills and performance patterns associated with search. In addition, we excluded articles focusing on
older adults ability to take their medications in a timely specialized populations (e.g., multiple sclerosis, low vi-
manner or reduce the effects of postural hypotension, sion, diabetes, arthritis, Parkinsons disease, stroke); our
which, unaddressed, may decrease participation in desired rationale was that such populations may have unique fall
occupations and increase fall risk. prevention intervention needs that may not be pertinent
The purpose of the literature review described in this to most community-dwelling older adults.
article is to summarize the existing occupational therapy The initial search used the terms occupational therapy
related fall prevention literature to elucidate information on and fall prevention and each of the AGS and BGS (2010)
occupational therapys current involvement in these efforts intervention areas (i.e., environmental modification, exer-
and offer suggestions for future opportunities for occupa- cise, medication management, managing postural hypoten-
tional therapy in fall prevention for community-dwelling sion, managing existing foot problems and recommending
older adults. An initial search of the literature did not reveal appropriate footwear, and behavior modification). This
sufficient occupational therapy evidence within the targeted search resulted in an initial sample of 198 articles. We
AGS and BGS intervention areas to support a systematic reviewed article abstracts to determine whether our initial
review or meta-analysis. Therefore, we undertook a scoping inclusion criteria were met and to categorize each article
review. Whereas a systematic review evaluates the quality of into one of the mutually exclusive intervention areas;
the literature, a scoping review informs future research needs multifactorial or multicomponent interventions (i.e., in-
by summarizing the current evidence on a given topic and terventions that address multiple fall risk factors) were
identifying gaps in the literature (Arksey & OMalley, grouped into their own intervention area. The AGS and
2005). Our research question was, What is known from BGS guidelines distinguish between these two terms;
the existing literature about the role of occupational ther- specifically, multifactorial interventions are those admin-
apy in evidence-based fall prevention interventions for istered to one person targeting his or her specific fall risk
community-dwelling adults age 65 and older? factors, and multicomponent interventions are group-
based interventions that incorporate multiple in-
tervention areas into one fall prevention program. We
Method then summarized the resulting sample of articles.
We conducted a bibliographic search of the Medline/
Pubmed, CINAHL, Google Scholar, and Cochrane data-
bases. The search was limited to articles published between Results
January 1990 and October 2010. Most research before We identified 15 articles that addressed the seven in-
1990 focused on identifying risk factors associated with falls tervention areas, which we divided into three categories:

150 March/April 2012, Volume 66, Number 2


environmental modifications, exercise, and multifactorial methodologies and types of exercise examined. For ex-
and multicomponent interventions. Most of the studies ample, one study determined that functional exercise
were randomized controlled trials (80%, n 5 12). Forty embedded in daily routines was effective in decreasing fall
percent (n 5 6) were conducted in Australia; other risk (Clemson et al., 2010), whereas another study (Luu-
countries represented included Finland, France, Ger- kinen et al., 2007) determined that functional exercises
many, the Netherlands, New Zealand, the United such as walking, self-care, or home or group exercise were
Kingdom, and the United States. ineffective in decreasing fall risk. A third study (Mihay
et al., 2006) determined that strengthening exercises and
Environmental Modification Interventions tai chiinspired exercise improved balance, which might in
The initial search for environmental modification inter- turn have lessened fall risk. Additionally, the methodo-
ventions resulted in 45 articles. We excluded articles that logical descriptions of these studies did not make clear the
were not intervention studies (n 5 18), were not falls-related details of occupational therapys specific role in the in-
(n 5 12), were published in practice journals (n 5 4), did tervention. None of the studies compared rote exercises to
not incorporate occupational therapy (n 5 3), or involved occupation-based exercise in decreasing the number of falls
a specialized population (significant visual impairment; n 5 or fall risk.
1). The final sample (n 5 7) is summarized in Table 1.
The study interventions involved home modification Multifactorial and Multicomponent Interventions
recommendations and had differing effects on fall incidence We identified 22 articles categorized as multifactorial or
and other fall-related outcomes and varying success rates multicomponent interventions. Articles excluded were
with participants (see Table 1 for details). In addition, nonresearch articles (n 5 3), did not meet the age min-
home assessment interventions varied among studies, and imum (n 5 2), involved a specialized population (adult
some articles did not report adequate detail on the in- day center participant, n 5 1; psychiatric ward resident,
tervention itself. Some studies (e.g., Di Monaco et al., n 5 1; significant vision impairment, n 5 2), had no fall-
2008; Peel, Steinberg, & Williams, 2000) outlined an related outcome (n 5 3), did not incorporate an occu-
approach that addressed multiple factors in the home as- pational therapy practitioner (n 5 3), or were process or
sessment, such as performance of activities of daily living evaluation studies (n 5 2). The five remaining articles
and education. In other studies, financial assistance was (see Table 3) were classified into two categories: those in
provided for home modifications (Peel et al., 2000); not all which an occupational therapist was part of a multidisci-
studies identified the financial aspect of home modifica- plinary multifactorial intervention team (n 5 4) and
tion, however. In addition, the studies had various control those that examined the efficacy of an occupational
groups that, for example, received education only, a mini- therapyled multicomponent intervention (n 5 1).
mal home hazard assessment, or no intervention. Two of the four multidisciplinary team intervention
articles used an occupational therapist as the home as-
Exercise Interventions sessment and modification interventionist (Davison, Bond,
During the initial article search, we identified 47 exercise- Dawson, Steen, & Kenny, 2005; Nikolaus & Bach, 2003).
related articles. We excluded 44 because they were unrelated In the other two multidisciplinary team articles, an occu-
to falls (n 5 30), did not have occupational therapy in- pational therapist addressed environmental modifications
volvement (n 5 1), were not research based (n 5 7), or and completed a functional assessment (Close et al., 1999;
were systematic reviews or meta-analyses (n 5 6). Table 2 Hendriks et al., 2008). Only one study examined the role
summarizes the final sample of articles (n 5 3). of occupational therapy in a multicomponent in-
The exercise interventions were classified into two tervention. The occupational therapy group intervention
different categories: (1) functional exercises (Clemson et al., involved fall risk identification; environmental mod-
2010; Luukinen et al., 2007) and (2) complementary or ifications; use of exercises to improve strength, balance,
alternative exercises (Mihay, Boggs, Breck, Dokken, & and gait; medication management; improvement of com-
Nathalang, 2006). The administration of exercises varied munity safety; recommendations to address footwear and
among the studies and included individualized exercise foot problems, management of vision deficits; and im-
interventions with older adults (Clemson et al., 2010), provement in mobility (Clemson et al., 2004). The role of
group interventions (Mihay et al., 2006), and individual the occupational therapy practitioner in these five studies
and group exercise interventions (Luukinen et al., 2007). varied; only one intervention was not efficacious in de-
These studies showed varying effectiveness in reducing fall creasing fall risk (Hendriks et al., 2008). None were
risk but were difficult to compare because of the different conducted in the United States. The four multidisciplinary

The American Journal of Occupational Therapy 151


Table 1. Environmental Modification Interventions to Decrease Fall Risk (N 5 7)

152
Author Study Purpose Study Type Sample Intervention Conclusions
Cumming Determine whether occupational RCT N 5 530 Intervention group: An occupational Participants in the intervention group
et al. (1999) therapist home visits targeted at therapist completed an assessment had a reduced likelihood of falling
addressing environmental hazards Mean age 5 77 yr of environmental hazards, facilitated in the 12-mo follow-up period. It
reduce the risk of falls Australia necessary home modifications is not clear, however, how much
(approximately 1 hr duration), and this result can be attributed to the
followed up via phone call at 2 wk intervention because falls were reduced
to check that the modifications had both in and out of the home environment.
been made and to encourage compliance
with recommendations.
Control group: No home visit was provided.

Cumming Examine adherence to home RCT (secondary N 5 178 participants from Same intervention as for Cumming 65% of participants adhered to 50% of
et al. (2001) modification recommendations analysis) the intervention arm of et al. (1999) study. recommendations. Those who adhered to
made by an occupational therapist the Cumming et al. recommendations were more likely than
in Cumming et al. (1999) study (1999) study those who did not to believe that home
modifications can reduce the risk of falling.
Mean age 5 76 yr
Australia

Di Monaco Assess the effectiveness of a Quasi-RCT N 5 95 women admitted Intervention group: Participants completed No significant difference was found
et al. (2008) single home visit by an to a rehabilitation hospital a home safety checklist in the hospital in fall rate between the intervention
occupational therapist in reducing after sustaining a fall-related with an occupational therapist and and control groups. However, participants
fall risk after hip fracture in hip fracture received a 1-hr home visit after who complied with the intervention (i.e.,
older adult women discharge that focused on hazard followed 50% of recommendations) were
Mean age 5 80 yr assessment, behaviors during ADLs, significantly less likely to experience one
Italy and recommendations. or more falls than control participants.
Control group: Participants completed
only a home safety checklist in the
hospital with an occupational therapist.

Greene, Sample, & Report a partial inventory of fall Pretestposttest N 5 35 community-dwelling All participants received a home visit in One or more modifications were made
Fruhauf (2009) hazards for community-dwelling design older adults which fall risks were evaluated and in 81% of homes. Seven participants
older adults and characterize older recommendations for home modifications fell in the follow-up period. Only one
Mean age of those with a
adult responses to fall prevention were made. Follow-up interviews were fall was related to recommended
history of a fall 5 79.3; conducted 6 mo later. modifications. The authors suggest
mean age of those with that it is important to address unique
no fall history 5 75.3 fall situations by addressing behavior,
United States raising awareness, and improving
problem solving among older adults.

March/April 2012, Volume 66, Number 2


Lannin et al. (2007) Investigate the feasibility of an RCT in RCT N 5 18 patients admitted to a Intervention group: Participants received Observed performance of functional abilities
a clinical setting and the effect of metropolitan rehabilitation a predischarge home visit that involved did not differ between groups.
predischarge home visits on functional unit who were referred to an assessment of their function Patient-perceived functional performance
performance in older people occupational therapist and and environment. on ADLs was higher at follow-up in the
undergoing rehabilitation who planned to return to the intervention group than in the control group,
same community dwelling Control group: Participants received routine although both groups experienced
care that included a hospital-based
on discharge improvement on this measure at 3-mo
interview and provision of information follow-up.
Mean age 5 81 yr on community access and use of
adaptive equipment.
Australia

Pardessus Investigate whether home visits by an RCT N 5 60 participants who Intervention group: Participants received No significant difference was found in the
et al. (2002) occupational therapist reduce fall risk were hospitalized for one 2-hr visit from several members number of falls between the intervention
and improve autonomy of older patients falling and were able of the physical medicine team who and control groups. Autonomy (measured
to return home after assessed ADLs, functional mobility, by ADL independence indexes) was better

The American Journal of Occupational Therapy


being hospitalized and home hazards. preserved in intervention vs. control
participants at 6- and 12-mo follow-up.
Mean age 5 84 yr Control group: Participants received
routine care.
France

Peel, Steinberg, Examine the effectiveness of a RCT N 5 252 people in 4 groups, Intervention groups: Participants received 59% of participants in the home assessment
& Williams (2000) home safety assessment as 2 that received a home one home visit to address home group made at least one home modification,
part of a randomized trial of assessment and 2 that modifications, financial assistance to compared with 32% of control participants.
fall prevention interventions did not make modifications, and the same A trend was found toward reduced fall
among older community dwellers education and exercise components as incidence in the home assessment group
Mean age 5 69 yr the control group. Half of the home compared with the control group during
Australia assessment group also received a the follow-up period, although the result
clinical assessment addressing was nonsignificant.
fall risk factors.
Control groups: All received education
(an oral presentation and video on
home safety and modifications), and
half were offered a monthly
exercise class.
Note. ADLs 5 activities of daily living; RCT5 randomized controlled trial.

153
Table 2. Exercise Interventions to Decrease Fall Risk (n 5 3)

154
Author Study Purpose Study Type Sample Intervention Conclusions
Clemson Examine whether LiFE RCT with single N 5 34 participants who Intervention groups: Participants LiFE exercises were effective
et al. (2010) intervention methods blinding of assessors had had 2 falls or one engaged in exercises during in reducing the number of falls.
(balance and strength fall-related injury in the everyday activities to improve
exercises within daily previous year balance (e.g., standing on one
activities) were pragmatic foot while working at the kitchen
and effective in reducing Intervention group mean age 5 81 counter) and strength (e.g.,
yr; control group mean age 5 82 yr
falls in older adults crouching to pick up a dropped item).
Australia Control group: No exercise
intervention was offered.

Luukinen Investigate the effectiveness RCT N 5 555 Intervention groups: Participants The intervention was
et al. (2007) of a fall prevention intervention engaged in walking exercises, ineffective in lowering fall
planned and conducted Mean age 5 88 yr group exercises, self-care risk but did slow the
by a geriatric team Finland exercises, or home exercises. deterioration of balance skills.
Control group: Participants
received routine care.

Mihay, Boggs, Compare tai chiInspired Pilot study using N 5 22 TCIE group: Participants engaged Both interventions were beneficial.
Breck, Dokken, Exercise (TCIE) with strengthening a quantitative in TCIE that incorporated The strength-training group showed
& Nathalang (2006) for reducing fall risk in quasi-experimental Tai chi group: n 5 12, balance, shifting weight, and greater improvements in movement
community-dwelling older adults design mean age 5 80.3 yr fall reduction principles 2/weekly and directional control for repetitive
Strength-training group: for 18 mo. movements. The TCIE group showed
n 5 10, mean age 5 78 yr a higher level of performance during
Strength-training group: Participants functional tasks.
United States did strengthening exercises that
emphasized repetitive target
movement while distributing
weight evenly through both legs
(p. 23) 3/weekly for 18 mo.

Note. LiFE 5 Lifestyle approach to reducing Falls through Exercise; RCT5 randomized controlled trial.

March/April 2012, Volume 66, Number 2


Table 3. Multifactorial and Multicomponent Interventions to Decrease Fall Risk (n 5 5)
Author Study Purpose Study Type Sample Intervention Conclusion
Clemson Evaluate the effectiveness of RCT N 5 310 older adults age 701 yr Intervention group: An occupational The Stepping On participants
et al. (2004) Stepping On, a community-based with history of falling in the therapist facilitated a 7-wk experienced decreased fall risk.
multicomponent fall prevention program past 12 mo or concern multicomponent intervention
about falling program incorporating risk
identification, exercise, home
Intervention group mean
hazards identification, community
age 5 78.3 yr; control safety, footwear management,
group mean age 5 78.5 yr vision, medication management,
Australia mobility, and a home assessment.
Control group: Participants received
social visits.

The American Journal of Occupational Therapy


Close Evaluate the effectiveness of a RCT N 5 397 participants who Intervention group: Participants The intervention group
et al. (1999) structured interdisciplinary presented to the ER received a multidisciplinary, experienced decreased fall risk.
assessment for people with multifactorial intervention that included
Mean age 5 78.2
a history of falling in limiting a comprehensive medical assessment
further falls United Kingdom (assessment of vision, balance,
cognition, affect, medications, and
hypotension) followed by an
occupational therapy assessment
(home and functional assessment,
recommendations and education
on safety in the home and
modifications). Referral to further
services was made as needed.
Control group: Participants received
usual care.

Davison, Bond, Examine the effectiveness of a RCT N 5 313 older adults age Intervention group: Participants received The intervention group experienced
Dawson, Steen, multifactorial fall prevention 651 yr who visited the a multidisciplinary, multifactorial reduced recurrent falls.
& Kenny (2005) program for cognitively intact ER after a fall or intervention incorporating a medical
community-dwelling older adults fall-related injury assessment (medication, vision,
cardiovascular, blood, EKG), physical
Mean age 5 77 yr therapy assessment (gait balance
United Kingdom assessment [POMA]; assessment of
feet, footwear, and assistive devices),
and occupational therapy assessment
(home safety checklist).
Control group: Participants received
usual care.

(Continued)

155
Table 3. Multifactorial and Multicomponent Interventions to Decrease Fall Risk (n 5 5) (cont. )

156
Author Study Purpose Study Type Sample Intervention Conclusion
Hendriks Examine the efficacy of a multifactorial RCT N 5 335 older adults age Intervention group: Participants received The intervention was not
et al. (2008) intervention vs. usual care 651 yr seen in a multidisciplinary, multifactorial effective in decreasing falls.
ER after a fall intervention, including medical and
occupational therapy assessments,
Intervention group mean to assess and address potential risk
age 5 74.5 yr; control factors for new falls (i.e., assessment
group mean age 5 75.2 yr of vision, sense of hearing, locomotor
Netherlands apparatus, feet and footwear, peripheral
nervous system, balance and mobility,
anthropometry, cognition, affect,
blood tests, and medication use).
Control group: Participants received
usual care.

Nikolaus Examine the effect of a multidisciplinary RCT N 5 360 older adults admitted Intervention group: Participants received The intervention group
& Bach (2003) team intervention aimed at reducing falls from community to geriatric a multidisciplinary, multifactorial experienced decreased
hospital intervention that included a comprehensive fall risk.
geriatric assessment; a home evaluation
Intervention group mean completed by an occupational therapist,
age 5 81.2 yr; control nurse, or physiotherapist; a follow-up
group mean age 5 81.9 yr
home visit to educate on fall risk and
Germany adaptive equipment use; and suggestions
for home modifications.
Control group: Participants received a
geriatric assessment with usual care.
Note. EKG 5 electrocardiogram; ER 5 emergency room; POMA 5 Performance Oriented Mobility Assessment; RCT 5 randomized controlled trial.

March/April 2012, Volume 66, Number 2


team interventions were administered individually to older supporting occupational therapy interventions to decrease
adults, whereas the occupational therapyled intervention falls among community-living older adults. Specifically,
was a small-group intervention. there is a dearth of research documenting interventions
focusing on modifying fall risk behaviors (e.g., reducing
Other Intervention Areas fear of falling), managing postural hypotension, managing
During the initial search for interventions examining medications, and recommending appropriate footwear to
management of medications to reduce fall risk, we decrease fall risk among community-dwelling older adults.
identified 23 articles. We excluded all articles because they Little of the research documenting occupational therapys
did not pertain to falls (n 5 14) or were population based role in intervention areas identified by the AGS and BGS
(n 5 9; Parkinsons disease, psychiatric disorders). The (2010; i.e., environmental modifications, exercise, and
two articles we initially identified in the intervention area multifactorial and multicomponent interventions) was
addressing postural hypotension were later eliminated conducted in the United States. More research is needed
because they did not relate to falls. Of the 16 studies we to document occupational therapy evidence-based in-
identified in the footwear area, 7 pertained to foot care in terventions in the United States across fall prevention
diabetes, 5 were published in practice journals, 3 were intervention areas. Additionally, translational studies are
nonresearch articles, and 1 was a nonintervention study. needed to ensure that programs such as Stepping On (an
We found no studies of occupational therapy inter- Australian occupational therapyled, multicomponent
ventions that linked footwear to falls. intervention program; Clemson et al., 2004) can be ef-
In the behavioral intervention area, we identified 24 ficaciously carried out among community-dwelling older
articles (7 behavioral interventions, 17 fear-of-falling adults in the United States.
interventions). All behavioral intervention articles were
excluded because they did not examine falls (n 5 2), were
Implications for Occupational
population based (n 5 1), did not meet the age re-
quirement (n 5 1), were not published in a peer-reviewed
Therapy Research
journal (n 5 2), or were not research based (n 5 1). All Of the current evidence documenting the role of occu-
fear-of-falling articles were excluded because they did not pational therapy in three fall prevention intervention
examine falls or did not have fear of falling as an outcome areasenvironmental modifications, exercise, and
measure (n 5 2), did not involve occupational therapy multifactorial and multicomponent interventionsonly
(n 5 3), were population based (n 5 5), were not quan- 15 articles met the criteria for this study, highlighting
titative (n 5 2), involved a special population (n 5 1), or the need for further occupational therapy research in
were not published in a peer-reviewed journal (n 5 4). these areas. In addition, this evidence comes largely from
international studies; this review underscores the dearth
Limitations of research conducted in the United States among
community-living older adults. Cross-national differ-
Studies included in this scoping review were limited to
ences in health care systems may influence the ability to
intervention studies that examined an outcome related to
translate successful fall prevention programs to practice
falls and that involved an occupational therapy practi-
in the United States. The limited occupational therapy
tioner. We excluded studies evaluating the effectiveness of
research we identified addressing the efficacy of fall risk
an occupational therapy intervention (e.g., environmental
interventions among U.S. community-dwelling older
modification) that did not include the number of falls or
adults also highlights the paucity of such research pub-
fall risk as an outcome. We identified studies for this
lished in peer-reviewed journals. Further research is
review through bibliographic searches; alternate search
needed to identify the efficacy of occupational therapy
terms may have resulted in additional articles. Addi-
led multicomponent group interventions versus in-
tionally, we may have inadvertently excluded articles
dividualized multifactorial interventions to decrease fall
because we did not identify occupational therapy or fall
risk.
prevention intervention terms in our examination of key
Although fall prevention interventions are within the
words, titles, and abstracts.
occupational therapy scope of practice as identified in the
Framework (AOTA, 2008), important gaps were evident
Conclusion in the literature documenting the occupational therapy
This scoping review highlights seven fall intervention areas practitioners role in fall-related interventions addressing
in which further research is needed to provide evidence managing medications, managing postural hypotension,

The American Journal of Occupational Therapy 157


recommending appropriate footwear and managing ex- Making Behavioral Changes and Reducing Fear
isting foot problems, and modifying behaviors such as of Falling
fear of falling among community-dwelling older adults. Occupational therapy practitioners have promising pre-
For example, Clemson and colleagues (2004) in- liminary evidence supporting the effectiveness of facilitating
corporated footwear management and medication man- behavior change (Peterson & Murphy, 2002; Walker &
agement into their randomized controlled trial of Howland, 1991). The limitation in this area of research
a multicomponent intervention; however, they did not involves the use of fall risk as the identified outcome.
test the efficacy of these interventions independently.
Occupational therapy practitioners can facilitate behavioral
Although the profession has begun to outline occupa-
changes by addressing changes in a persons routines to
tional therapys role in targeting the minimization of fall
decrease fall risk and fear of falling (e.g., instructing
risk in community-dwelling older adults in these areas
older adults to use stair railings consistently; Peterson &
(e.g., Juarbe & Bondoc, 2009; Peterson & Clemson,
Clemson, 2008). Additionally, behavioral interventions
2008), research is needed that clearly demonstrates the
may be incorporated into multifactorial interventions
contribution of occupational therapy and efficacy of oc-
such as home modifications and home safety education
cupational therapyled interventions. Guided by the
(AGS & BGS, 2010; Walker & Howland, 1991), exercises
Framework, we outline in the sections that follow the
(Harling & Simpson, 2008), assertiveness training (Walker
potential contributions occupational therapy practitioners
can make to fall prevention intervention in the areas & Howland, 1991; Zijlstra et al., 2009), self-efficacy
outlined in the AGS and BGS (2010) guidelines in training (e.g., Cheal & Clemson, 2001; Zijlstra et al.,
which, at present, no occupational therapy research on 2009), and multicomponent interventions that address
efficacy exists. fear of falling such as A Matter of Balance (Peterson &
Clemson, 2008) and Stepping On (Clemson et al., 2004;
Managing Medications Peterson & Clemson, 2008). Occupational therapy prac-
There is no research examining the efficacy of occupational titioners can also reduce fear of falling in older adults by
therapy interventions targeting medication management having them practice fear-provoking daily tasks to increase
to reduce fall risk. Studies are needed that evaluate confidence, assisting them with cognitive restructuring
teaching older adults compensatory strategies to open (Peterson & Murphy, 2002; Zijlstra et al., 2009), and
medication containers; ensuring the timeliness with which using guided imagery (Juarbe & Bondoc, 2009).
they take medications by using visual cueing, checklists,
medication boxes, or automatic pill dispensers; simpli- Implications for Occupational
fying medication routines; or integrating the medication Therapy Practice
routine into established performance patterns (e.g., taking
medications at meals or bedtime) as interventions to This scoping review elucidates the contribution of occupa-
decrease fall risk. tional therapy interventions in the pursuit of fall prevention,
specifically, environmental modification interventions,
Managing Postural Hypotension and Recommending exercise, and multifactorial and multicomponent inter-
Appropriate Footwear ventions. Occupational therapy practitioners working
Occupational therapy practitioners have the knowledge to with community-living older adults should be cognizant
understand how joint deformities, blood pressure changes, of these trends within fall prevention research and mindful
and the presence of wounds affect occupational perfor- of the need for further research demonstrating the efficacy
mance (AOTA, 2008). Using this knowledge, fall pre- of occupational therapy interventions addressing fall
vention research is needed to examine the efficacy of prevention in the areas of medication and postural hy-
interventions focusing on gradually accommodating to potension management, behavior modification, and rec-
postural changes, establishing routines to facilitate consis- ommendations of appropriate footwear. To summarize,
tent blood pressure medications consumption, and com- Occupational therapy contributes to fall prevention
pensatory strategies for donning and doffing footwear to among community-living older adults through envi-
limit risk of skin breakdown and fall risk. The evidence base ronmental modification interventions, exercise, and
to support the occupational therapy practitioners role in multicomponent or multifactorial interventions.
providing interventions for older adults that include edu- Clinicians should be cognizant of the evidence sup-
cation on appropriate footwear to support balance, mo- porting the efficacy of fall interventions. Much of this
bility, and skin integrity needs to be developed. research has not been carried out in the United States,

158 March/April 2012, Volume 66, Number 2


and barriers to carrying out these programs may exist the American Geriatrics Society, 52, 14871494. http://dx.
in the U.S. context. doi.org/10.1111/j.1532-5415.2004.52411.x
Occupational therapy research examining the efficacy of pClemson, L., Singh, M. F., Bundy, A., Cumming, R. G.,
Weissel, E., Munro, J., et al. (2010). LiFE Pilot Study:
fall prevention interventions targeting the modification
A randomised trial of balance and strength training
of fall risk behaviors (e.g., reducing the fear of falling), embedded in daily life activity to reduce falls in older
management of postural hypotension, medication man- adults. Australian Occupational Therapy Journal, 57, 4250.
agement, and recommendation of appropriate footwear http://dx.doi.org/10.1111/j.1440-1630.2009.00848.x
among community-dwelling older adults is needed. pClose, J., Ellis, M., Hooper, R., Glucksman, E., Jackson, S.,
The Framework supports the role of occupational & Swift, C. (1999). Prevention of Falls in the Elderly
Trial (PROFET): A randomised controlled trial. Lancet,
therapy in the intervention areas identified in the AGS
353, 9397. http://dx.doi.org/10.1016/S0140-6736(98)
and BGS (2010) intervention guidelines, and occupa- 06119-4
tional therapy is represented in fall prevention research. pCumming, R. G., Thomas, M., Szonyi, G., Frampton, G.,
Nevertheless, the evidence for occupational therapys role Salkeld, G., & Clemson, L. (2001). Adherence to occupa-
in many areas is still limited, and research targeting the tional therapist recommendations for home modifications
effectiveness of occupational therapy interventions in for falls prevention. American Journal of Occupational Ther-
apy, 55, 641648. http://dx.doi.org/10.5014/ajot.55.6.641
addressing fall-related outcomes is needed. s
pCumming, R. G., Thomas, M., Szonyi, G., Salkeld, G., ONeill,
E., Westbury, C., et al. (1999). Home visits by an occupa-
Acknowledgments tional therapist for assessment and modification of environ-
mental hazards: A randomized trial of falls prevention.
During the time this article was written, Natalie Leland was Journal of the American Geriatrics Society, 47, 13971402.
the recipient of a postdoctoral fellowship training grant pDavison, J., Bond, J., Dawson, P., Steen, I. N., & Kenny,
(5T32HS000011-24) from the Agency for Healthcare R. A. (2005). Patients with recurrent falls attending accident
Research and Quality. and emergency benefit from multifactorial interventionA
randomised controlled trial. Age and Ageing, 34, 162168.
http://dx.doi.org/10.1093/ageing/afi053
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