Older Adult Fall Prevention
Subjects: Nursing

Falls are the second leading cause of accidental or non-intentional deaths worldwide and are the most common problem as people age. The primary purpose of addressing falls is to detect, prevent, treat, and reduce their incidence and consequences. Previous studies identified that multifactorial programs, an interprofessional team, and assistive technology are required to address falls in older adults effectively. Accordingly, the research question is as follows: what are the scope, type of studies, and approaches and strategies to fall risk using technology in the existing occupational therapy literature regarding interventions to address the effects of falls in older adults on daily living? 

  • older adults
  • falls
  • occupation
  • occupational therapy
  • scoping review
  • smart home technology
  • telehealth
  • exergames
  • 3D-application tool

1. Introduction

Fall prevention is focused on injuries or complications that occur because of falling [12,22]. Numerous studies [23] have demonstrated that many falls can be prevented through adequate assessment and intervention. Some of the most common and effective interventions include [23] gait stabilizing footwear, vitamin D, dietary supplements, medication adaptation, multiple interventions, multifactorial interventions, assistive device training, cognitive monitoring and intervention, environmental modification, and family and caregiver training [24,25,26,27,28,29].
Different authors have also suggested that multifactorial programs are useful for preventing and reducing falls because of the complexity in the types of falls [30]. According to the World Health Organization (WHO), the risk of falls increases when multiple risk factors are present [16]. These multifactorial programs [30] involve a combination of exercise (focus on strength, balance and mobility), and other options such as individualized and comprehensive fall risk assessment about the person and, their environment and education on fall prevention. The GeriaTIC project is an example of using multifactorial interventions for fall prevention [31]. A study by Close and colleagues highlighted that an interprofessional approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment [32].
The effectiveness of these multifactorial programs is also based on the need to have an interprofessional team for fall prevention and treatment and geriatric approaches [33]. This includes a physician, a neurologist, a nurse, a psychiatrist, a physical therapist, and an occupational therapist. The latter is part of the non-pharmacological intervention [34,35]. Elliot and colleagues [36], in a systematic review, classified occupational therapy interventions on older adults’ falls into three types of intervention that are shown in Table 1.
Table 1. Summary of occupational therapy interventions for falls in older adults.

2.Methodology

The authors conducted a scoping review in January 2020. The research questions that we aimed to answer were the following: what are the scope, type of studies, and approaches and strategies to fall risk using technology in the existing occupational therapy literature regarding interventions to address the effects of falls in older adults on daily living? Two approaches guided the present scoping review. On the one hand, the Arksey and O’Malley [47] five-stage framework was used, which includes stage 1 establishment of the research question; stage 2 identification of pertinent studies and choice of studies, stage 3 study selection as explained in Figure 1; and, as shown in the Results section, the stage 4 charting the data and stage 5 mapping the data and collating, summarizing, and reporting the findings. On the other hand, this scoping review also follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (see Table S1 [48]. In accordance with the aim of a scoping review, a quality appraisal is not required, as opposed to Systematic reviews and Meta-Analyses [49].
Figure 1. Flow diagram of the Scoping Review process.

3. Bibliometric Characteristics

In total, we screened 74 documents, with 12 studies meeting the eligibility criteria (see Figure 1). The selected literature was published between 2012 and 2020. The first study to report the use of technology in an occupational therapy falls approach was published in 2012 [58].
The studies were conducted in the USA (n = 4) [58,59,60,61]; Europe (n = 6) [62,63,64,65,66,67], specifically in Scotland (n = 1) [62], Sweden (n = 1) [63], the UK (n = 3) [64,66,67], and Belgium (n = 1) [65]; and other countries such as Tunisia (n = 1) [68] and Australia (n = 1) [69].
The journals in which the articles were published were mainly those focusing on occupational therapy (n = 6) [58,59,60,61,62], particularly for the first publications of studies on the topic, and informatics and technological journals (n = 6) [64,65,66,67,68,69], which contained more of the recent studies.
The types of study were reviews—a systematic review (n = 1) [58] and a critical review (n = 1) [59] and original articles (n = 10) [59,60,61,67,68]. Within the original articles, there were different research designs. Quantitative approaches were used, including a descriptive study (n = 1) [66], a case study (n = 2) [60,61], and an experimental study (n = 1) [68]. The qualitative approaches used were qualitative research (n = 2) [63,69] and a mixed-methods study (n = 2) [65,66].
Table 2. Summary of data extracted from the 12 selected studies.

4. Thematic Categories

4.1. A Description of the Type of Participants in Study

This theme was about the types of participants included in the studies (i.e., older adult(s) or occupational therapist(s)), the age of the participants, the percentage of females in the sample, the environment in which the study was conducted (i.e., community-dwelling or an institution), and other interesting details mentioned.
The reviews included in this study did not provide some of the participants’ characteristics (see Table 3 details of the participants). In a review by Chase and colleagues [58], a total of thirty-three studies were included, all randomized controlled trials, while in the review by Stewart and colleagues study [62], ten studies were included and these were different types of studies.
The original articles [59,60,61,63,64,65,67,68,69] included 614 older adults, 15 occupational therapists, and 5 informal caregivers. The samples size of the studies included 1 (n = 1) [68] to 445 (n = 1) older adults [61], 1 (n = 7) [59,60,61,63,66,67,69] to 10 (n = 1) types of occupational therapy [64], and 1 (n = 9) to 5 (n = 1) informal caregivers [65]. There was a large age range age of older adults from 50 years old (n = 1) [67] to a maximum of 98 years old (n = 1) [63]. These people were recruited from the community (n = 8) [59,60,61,65], an activity center for older adults (n = 1) [63], or people attending a gym group on a university campus (n = 1) [67]. Regarding the percentage of females, all studies included more females than males, with a percentage of females of between 60 (n = 2) [64,69] and 68% (n = 2) [59,61]. One hundred percent of the occupational therapists were female [64].
All participants volunteered to participate in the different studies, but in the study by Hamm and colleagues, the occupational therapists received a ten pound voucher [64].

4.2. Type of Intervention and Approach to Falls

This theme included the type of intervention if the study was about a specific risk factor related to falls (extrinsic, alien to the individual, or intrinsic, related to the person and the aging process) and the type of approach to falls (detection, prevention, or treatment).
Four types of intervention were identified: “home modifications” (n = 5) [59,64,65,66,69], “assistive technology” (n = 4) [58,60,61,62], “exercise” (n = 2) [63,68], and “educational” (n = 2) [59,67]. We considered single-component interventions and focused on fall detection, prevention, and treatment. Interventions that focused on home modification addressed extrinsic factors such as bathroom modifications (i.e., bath, toilet, shower), appropriate chair height, and indications to include space to move, among others. Assistive technology interventions addressed extrinsic factors that can affect the safety of the person in the home. This included the use of telecare, emergency alarms, and fall detectors (i.e., pendant alarms). Exercise was used as a strategy to address intrinsic factors related to physical condition and the use of educational interventions in these studies was based on extrinsic factors, which consisted of the types of modification the person has to do to be safe at home.

4.3. Type of Technology Used

This theme was about the types of technology addressed in the studies. The technologies used in the studies were classified as software developments, telehealth, multimedia materials, and commercial and technological devices. Software developments (n = 5) included augmented reality applications [69], 3D measurement aid prototype applications [64,66], a digital version of the Obstacle Tool [61], and a Falls Sensei 3D game [67]. The use of telehealth was integrated into telecare to reduce the fear of falling [62], and the system was integrated into a watch to provide a factor sensor system to monitor temperature with an analog display, an emergency button, and an accelerometer [60]. The multimedia materials included different videos to identify environmental fall factors [59]. The commercial and technological devices included smart home technology to operate lights, appliances, doors, and windows [58], and these included the use of Kinect [68] and Nintendo Wii [63].
Table 3 shows the relationships between Section 3.2.2 (Type of intervention and approach to falls) and Section 3.2.3 (Type of technology used, and the compatibility of the technology used with the technological devices: Tablet, iPad, computer, laptop, Xbox, Nintendo Wii, and mobile phone).
Table 3. Relationships between Section 3.2.2. and Section 3.2.3.
Types of Technology Technology Used Compatibility Intervention Falls Risk
Software developments Augmented reality application iPad Home modifications Extrinsic factors
3D measurement aid prototype application Tablet, mobile phone, or laptop
Digital version of Obstacle Tool Tablet
Falls Sensei 3D game Computer
Telehealth Telehealth system Not applied Assistive technology Extrinsic factors
Telecare  
Smart home technology  
Multimedia materials Videos Computer, laptop, mobile phone or Tablet Educational Extrinsic factors
Commercial and technological devices Kinect with Xbox and Nintendo Wii Kinect with Xbox and Nintendo Wii Exercise Intrinsic factors

5. Discussion

This study presents the first scoping review of occupational therapy interventions to address older adults’ falls using technology. The objectives defined focused on exploring the literature about the topic to determine the type of studies conducted, where these studies have usually been published, and the approaches and strategies used to reduce fall risk by occupational therapists using technology.
The results show that this is an emerging area, which began to be researched in the year 2012 [58]. In a review by Chase and colleagues on home modification, only telecare was mentioned as a possible strategy by occupational therapists, but occupational therapists did not specifically develop that study. However, previous studies focused on the use of technology. For example, the iStoppFalls project focused on the use of exergames to reduce falls in older adults; this project was conducted from 2011 to 2014 to motivate and enhance the use of physical activity by community-dwelling adults aged more than sixty-five years by engaging with three purpose-built exergames to reduce falls [43,70].
The present review shows a trend toward carrying out studies with a qualitative approach [63,69] and mixed-methods studies [65,66], reinforcing the idea that is important to understand the perceptions and opinions of the older adults or occupational therapists and other health professionals under study to find out about their experiences with using the technology. This type of research helps us to understand the acceptance or not of technology and to determine how to improve or adapt it to make it useful in older people’s day-to-day lives [71].
Regarding the place of publication, similar numbers of studies have been carried out in the USA [58,59,60,61] and Europe [62,63,64,65,66,67], even though progressive aging of the population is more apparent in Europe, and considering that previous European projects such as Prevent IT, Farseeing, and iStoppFalls, which are an essential background to fall prevention and the use of technology, were developed in Europe [43,44,45].
Compared with other reviews about falls and occupational therapy [41,69], the present scoping review results are of a lower research quality, because it was not possible to find any controlled trials to demonstrate the effectiveness of the interventions developed alongside technology. The types of studies included descriptive studies [61], case studies [59,60], experimental studies [68], and qualitative studies [63,69], which are not considered to give a high level of evidence. Instead, some controlled trials were carried out in the field of falls and occupational therapy, for example, the one by Monaco and colleagues [39].
As for the participant sample sizes and characteristics, the samples used were relatively small, except for one case [61]. This is linked to the level of evidence mentioned above and the types of study used. The types of participant included older adults, occupational therapists, and/or informal caregivers.
Only one of the types of software developed, obstacle tool digitalization [65], was tested in older adults, occupational therapists, and informal caregivers. The aim was to make it accessible for everybody, which is an essential factor to keep in mind in software development, according to the accessible software development model [72], the philosophy of design for all [73], and the inclusive perspective of the occupational therapy [74], as this helps to break the digital divide, particularly among older adults [74].
The studies included an extensive range of ages from 50 [67] to 98 years old [63], although older persons are classified as those aged 65 or more years. This reflects the perspective of preventing falls in people nearing retirement and the importance of active, healthy aging throughout life [75,76]. The life expectancy in Europe and USA, the main places of publication, is approximately 82 years old [74]. Life expectancy at age sixty is higher in women than men [77], and as can be seen in the results, females made up the highest percentage of participants in the studies, with 60–68% of participants being older women [67,69].
Regarding the type of intervention used to address falls in older adults through occupational therapy, only single-component interventions were used [36], even though different authors have suggested that multifactorial programs help to prevent and reduce falls because of their complexity [30]. None of the studies included an interprofessional team, despite its importance. The effectiveness of the multifactorial programs is also due to the use of an interprofessional team for fall prevention and treatment [33].
In terms of multifactorial programs [30], these involved exercise, as was done in two studies included in this review [63,68]; individualized and comprehensive fall risk assessment about the environment of an older adult, as done in a few studies mentioned in this review [59,64,65,66,69]; and education on fall prevention, as done in two studies [60,68]. Furthermore, any intervention includes occupational therapy home visits [78], which can be an essential aspect to include, especially in the cases of home modification [59,64,65,66,69] and assistive technology [58,60,61,62]. The studies that integrated aging in place focused on assistive technology and home modifications because these factors are widely acknowledged as being the primary and preferred interventions during ageing [79,80]. Understanding how older people’s needs contribute to improving their quality of life, which is affected after a fall, is necessary [13,14,15,16,18,19].
A previous systematic review explored the cost-effectiveness of several occupational therapy interventions for older people, concluding that they are useful and cost-effective compared with standard care or other therapies [81]. In this way, socioeconomic impact is one of the consequences of falls [28]. However, the results were not focused on aspects related to socioeconomic impact.
Our results reinforce the idea that home modifications, assistive technology, and educational interventions can address extrinsic factors, particularly environmental factors, and exercise can address intrinsic factors. This is in accordance with previous studies about the use of occupational therapy interventions to address fall risk [24,82,83,84,85].
Although, as mentioned above, some examples of assistive technology used to prevent falls in older adults include video-monitoring, health monitoring, electronic sensors, and fall detectors [42] these were not included in the studies mentioned in this review. Moreover, regarding fall interventions globally, there is more focus on exercise options and an extensive range of technologies from virtual reality [86] to wearables [87] that were not included in these studies. Primarily, virtual reality interventions are used in occupational therapy, for example, in children [86].
As a result of this review, it is suggested that researchers in this field perform more studies that include the latest technology in the field of falls, so that more studies with a higher level of evidence exist. Interprofessional and multifactorial interventions should be integrated.

Limitations

This entry is adapted from 10.3390/ijerph18020702

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