Fall Prevention for Community-Living Older Adults: A Tale of Two Systematic Reviews

Falls, a significant public health issue, have been associated with many adverse health outcomes leading to increased morbidity, mortality, and institutionalization.1 Occupational therapy practitioners can play a pivotal role in addressing the multifactorial nature of falls.2 Home safety assessments and environmental modifications are areas in which occupational therapy practitioners can integrate the context and environment with the values and goals of the client to support engagement in desired occupations and minimize fall risk. Two recent systematic reviews examining fall prevention interventions for community-living older adults came to different conclusions about home safety assessments and environmental modifications. This article summarizes the home safety intervention results of these two high-quality systematic reviews, identifies the reasons for the different conclusions, and discusses the implications for occupational therapy practice. The 2012 Cochrane Review evaluated the effects of interventions designed to reduce the incidence of falls among community-living older people.3 Nine studies (randomized control trials [RCTs] or quasi-randomized trials) meeting the study's home safety assessment and environmental intervention inclusion criteria were conducted in more than 21 countries (some studies were carried out in multiple countries), using various health care models to reduce falls. The review concluded that home assessment and modification interventions were effective in reducing the rate of falls and the risk of falling.3 Older adults with a history of falling or multiple fall risk factors (i.e., high-risk fallers) benefited more from the intervention than those with a lower risk of falling. When stratifying the analysis by the profession delivering the care, there was evidence that occupational therapy– led home safety interventions were more effective than non-occupational therapy–led interventions (e.g., those led by nurses or public health workers). The U.S. Preventive Services Task Force (USPSTF) systematic review examined the benefits and harms of primary care fall prevention interventions for community-dwelling older adults.4 This systematic review used a more narrow inclusion criterion than the Cochrane Review, focusing solely on the primary care setting. As a result, only three RCTs conducted in settings generalizable to U.S. primary care met the inclusion criteria,5 one of which restricted the study population to healthy older adults.6 The systematic review concluded that there was limited evidence supporting home-hazard modification as an intervention to reduce the risk of falling. Although both studies evaluated the efficacy of home programs designed to prevent falls in community-dwelling older adults, differences in the aims of the research questions dictated the exclusion and inclusion criteria, thereby yielding dissimilar study samples and divergent conclusions. The USPSTF singularly examined studies generalizable to the U.S. primary care system, whereas the Cochrane Review used a more expansive health care context definition, to include studies that were conducted in a variety of health care contexts (e.g., acute-care hospital before discharge) and types of health care systems (e.g., socialized medicine). The definition of community living in the USPSTF study was also more focused, referring only to individuals residing in the community for the duration of the study, whereas the Cochrane Review used a broader classification, including studies that recruited participants prior to community discharge from an acute medical stay. Similarly, the Cochrane Review was more inclusive in the methodology of the intervention studies evaluated, including effectiveness trials that compared interventions with usual care, placebo control, or other fall-prevention interventions. Alternatively, the USPSTF exclusively evaluated interventions that were compared with a true control group. Due to these valid, yet different, methodological approaches, these two studies came to alternate conclusions about the effectiveness of home safety assessments for community-living older adults.