Debra J. Rose, Ph.D. Co-Director, Fall Prevention Center of Excellence California State University, Fullerton Evidence-Based Multifactorial

Debra J. Rose, Ph.D.Co-Director, Fall Prevention Center of Excellence

California State University, Fullertonwww.stopfalls.org

Evidence-Based Evidence-Based Multifactorial Multifactorial InterventionsInterventions to Prevent Fallsto Prevent Falls

“C4A Fall Prevention Conference”, San Jose, CA. April 14, 2008

The Fall Prevention Center of Excellence is supported by the Archstone Foundation

Components of Components of Multifactorial Fall Multifactorial Fall

Prevention ProgramsPrevention Programs• Screening and/or Assessment (with

or without medical exam)

• Physical Activity (Exercise)

• Home Assessment and Modification

• Medical Management– Vision Assessment and/or correction;

postural hypotension; medication; assistive device, etc

• Fall Risk Education/ Behavior Change


Evidence-Based Evidence-Based ResearchResearch

Evidence-Based Evidence-Based ResearchResearch

Single vs Multiple Intervention Strategies

General vs Tailored Approaches

Different Target Audiences (Or Not)

Different Methods of Delivery Different Intervention Settings Different Providers


Physical Activity Physical Activity (Exercise)(Exercise)

Physical Activity Physical Activity (Exercise)(Exercise)

Effective as a Stand-Alone Strategy

Core component of most successful multifactorial approaches

Exercise strategy differs as function of fall risk


Stand-Alone Intervention Stand-Alone Intervention StrategiesStrategies

• Single modes of exercise include tai chi, strength training, walking.

• Multiple modes may include aerobic endurance, strength, flexibility, balance, and mobility.

• Fall risk and/or fall incidence rates lowered irrespective of type BUT not to same extent.

• Few head-to-head comparisons to date.


Home ModificationsHome Modifications

Successful programs:Successful programs: Include financial or manual assistanceHire trained health care professionals

(OTs) to perform initial assessmentsTarget older adults who are ready for

change (e.g., Fall history, increased understanding of risk)

Are combined with education and counseling about how to decrease risk


Fall Risk Education/ Behavior Change

• Insufficient evidence to evaluate as a stand-alone intervention.

• Often included as part of a multi-component strategy.

• Accurate perception of fall risk not always evident.

• Timing of program is important.

• Education of consumer and service provider important.


Fall Risk Education/ Fall Risk Education/ Behavior ChangeBehavior Change

• Can take many forms.

• Trained peer volunteers are well received by seniors.

• First step in continuum of injury prevention.

• Must raise awareness about importance of preventing falls.

• Must change notions that falls cannot be prevented and change behavior to increase long-term adherence.


Multifactorial ApproachesMultifactorial Approaches

• Require a multidisciplinary team approach

• Can be labor and resource intensive depending on complexity

• Most effective when targeted to high risk older adults at individual vs community level

• Intervention strategies need to specifically target identified risk factors


““There is There is NO NO

One-Size-Fits-All One-Size-Fits-All Fall Prevention Program”Fall Prevention Program”


Low-Risk Fall Prevention Low-Risk Fall Prevention ProgramsPrograms

Primary goal is to prevent onset of pathology and/or disabilityMany activity choices available (single vs multimodal exercise; less structured lifestyle activity)Fall risk education component may be helpful addition for purpose of raising awareness.Self-assessment of home desirable


Examples of Examples of ProgramsPrograms1,21,2

• Low- Moderate Risk– Enhance Fitness (Community-

based; Group; SS)*– Tai Chi – Moving for Better

Balance (Community-based; Group; SS)*

– Matter of Balance (Community-based; Group; MF)*

– Osteofit (Community-based; Group; MF)*


Moderate Risk Fall Prevention Moderate Risk Fall Prevention ProgramsPrograms

• Comprehensive assessment of fall risk factors desirable.

• Benefit from programs that specifically target identified physical risk factors.

• Specific balance and gait activities selected on basis of comprehensive evaluation of system impairments


Examples of Examples of ProgramsPrograms

• Moderate – High Risk– Fallproof™ (Community-

based; Group plus home-based program; MF)*

– Stepping On (Community-based; Group; MF – US replication in progress)*

– Step-By-Step (Community-based; Group; MF – Pilot phase of development)


High Risk Fall Prevention High Risk Fall Prevention ProgramsPrograms

• Carefully tailored and prioritized exercise program, usually as part of an individualized or staged multifactorial intervention strategy.

• Individually designed program that progresses from low to moderate intensity over longer duration.

• Couple exercise program with behavior skills training component and monitoring.


Examples of Examples of ProgramsPrograms

• High-Risk– FaME (Falls Management

Exercise – Group plus home-based program; SS)

– Otago Programme (Home-based exercise; SS)*

– SAIL (Strategies and Actions for Independent Living – Home-based; MF)

– InSTEP (Increasing Stability through Evaluation and Practice – Community-based, Group; MF – Pilot phase of development)


Changing Changing BehaviorBehavior33

• Recommended Strategies:– Secure social support from family and friends– Promote participant’s self-efficacy and perceived

competence– Providing older adults with active choices that are tailored

to their personal needs and preferences– Negotiate realistic and measurable goals, action plans, and

health contracts to promote adherence– Educate participants about actual risks of intervention– Provide regular and accurate performance feedback.


Marketing Strategies4

• ProFANE Network recommends the following:– Promote benefits of intervention relative to improving

balance and reducing fall risk

– Foster self-management skills (active vs passive role)

– Match intervention to needs, preferences, and capabilities

– Market program in a manner that is highly valued by older adults.


Sustainability5

• What is sustainability?• Why is it important?• What is the best pathway to

follow to ensure sustainability?– Pathway #1 – Redefine scope of

FP activities or program

– Pathway #2 – Creative use available resources


Selected Selected ReferencesReferences

1. Multifactorial and Physical Activity Programs for Fall Prevention Fact Sheet (2008). Available at: http://www.stopfalls.org/grantees_info/index.shtml

2. Preventing Falls: What Works (2008). Available at: www.cdc.gov/ncipc/preventingfalls

3. WHO Global Report on Falls Prevention in Older Age (2007). Available at: http://www.who.int/ageing/projects/falls_prevention_older_age/en/index.html

4. Yardley L et al. (2007). J Active Aging; Sept/Oct: 46-52.5. Basner E. et al. (2008). Pathways to sustaining fall prevention activities.

Available at: http://www.stopfalls.org/grantees_info/files/SustainabilityTA_Brief.pdf

Documents

Debra J. Rose, Ph.D. Co-Director, Fall Prevention Center of Excellence California State University, Fullerton Evidence-Based Multifactorial