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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 1  |  Page : 3-7

Implementation of environmental modifications in reducing fear of falling and studying its relationship with activity level and activity restriction among older adults living in old-age home: A one-arm interventional study


Department of Occupational Therapy, JKKMMRF College of OT, Namakkal, Tamil Nadu, India

Date of Submission07-Feb-2020
Date of Decision25-Feb-2020
Date of Acceptance28-Feb-2020
Date of Web Publication30-Mar-2020

Correspondence Address:
Dr. Hansa Varshneya
Associate Professor, JKKMMRF College of OT, Ethirmedu, Komarapalayam, Namakkal - 638 183, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_3_20

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  Abstract 


Background: Falls in older adults can cause severe physical injuries leading to activity restriction and subsequently adding to financial burden. Objectives: The objectives of our study were to assess the fear of falling in older adults living in old-age home, to implement cost-effective environmental modifications in old-age home, and to assess the relationship of fear of falling with activity level and activity restriction in older adults. Study Design: A one-arm interventional study design was chosen for the research. Methods: In this one-arm interventional study, 32 older adults, both males and females, were recruited from an old-age home, after their written informed consent. All the 32 older adults were assessed on the Survey of Activities and Fear of Falling in the Elderly (SAFFE) at baseline (preintervention), postintervention at 2 months, and at follow-up of 12 months. The architectural barriers in the old-age home were identified, and cost-effective environmental modifications were implemented. Statistical analyses of the SAFFE scores from baseline to follow-up were done. Results: The results revealed that fear of falling significantly reduced with the implementation of environmental modifications at postintervention at 2 months and at follow-up of 12 months. Fear of falling was positively correlated with the activity restriction (P = 0.0001, 95% confidence interval [CI] = 0.88-0.97) and fear of falling was negatively correlated with activity level (P = 0.0001, 95% CI = −0.97-−0.88) at baseline, postintervention, and follow-up. Conclusion: Our study showed that with the implementation of cost-effective environmental modifications, there was a significant reduction of fear of falling among older adults.

Keywords: Architectural Barriers, Falls, Geriatrics, Occupational Therapy, Old-Age Home


How to cite this article:
Varshneya H, Sonawane JV. Implementation of environmental modifications in reducing fear of falling and studying its relationship with activity level and activity restriction among older adults living in old-age home: A one-arm interventional study. Indian J Occup Ther 2020;52:3-7

How to cite this URL:
Varshneya H, Sonawane JV. Implementation of environmental modifications in reducing fear of falling and studying its relationship with activity level and activity restriction among older adults living in old-age home: A one-arm interventional study. Indian J Occup Ther [serial online] 2020 [cited 2020 May 25];52:3-7. Available from: http://www.ijotonweb.org/text.asp?2020/52/1/3/281639




  Introduction Top


Fear of falling is defined as an exaggerated concern about falling or the belief that one cannot prevent a fall. Fear of falling, a psychological symptom, is prevalent in 35%-55% of community-dwelling older adults regardless of whether they have experienced a fall. Falls in older adults are common due to aging because of muscle deconditioning, reduced muscle strength, deteriorating balance, and proprioception. Injuries in older adults due to falls can be fatal, which, in turn, can lead to increased medical finances. In case of older adults residing in old-age home, medical financial burden can be substantially exhausting. Due to their declining age, social isolation from family members can lead to psychological distress, which, in turn, leads to fear of falling.[1],[2]

Fall prevention strategies should be employed in order to reduce falls. Fall prevention should include clinical screening of older adults for various risk factors such as blood pressure, visual impairment, Vitamin D, and bone density and reviewing and modifying the medication protocol. Other strategies are aimed for safety in home, identifying architectural barriers and providing environmental modification for those with known risk factors or a history of fall, prescription of appropriate assistive devices to address physical and sensory impairments, muscle strengthening and balance retraining prescribed by a trained professional, and community-based group programs which may incorporate fall prevention education.[3]

Occupational therapy practitioners possess the critical skills needed to address fall prevention with older adults. Occupational therapy practitioners are skilled at evaluating and addressing influences from the person, their activity roles and routines, and the environment to maximize independence for older adults. Occupational therapy practitioners work with the client and caregivers to review the home environment for hazards and evaluate the individual for limitations that contribute to falls. A combination of interventions is often recommended that targets improving physical abilities, to safely perform daily tasks, modifying the home, and changing activity patterns and behaviors.[1],[3]

The aims and objectives of our study were to assess the fear of falling in older adults living in old-age home, to implement cost-effective environmental modifications in old-age home, and to assess the relationship of fear of falling with activity level and activity restriction in older adults.


  Methods Top


A one-arm interventional study design was chosen for the research. The study was carried out in Anbalaya Old-Age Home, Komarapalayam, Tamil Nadu, India. The research was conducted adhering to the principles of “Declaration of Helsinki,” and the necessary permissions were sought from the in charge of the old-age home through proper channel from our institution. A convenient sample of 32 older adults, both males and females, aged 58 years or more, with or without a history of fall, residing in the old-age home, were recruited after their written informed consent. Older adults with any psychiatric illness, hearing impairment, or visual loss were excluded from the study. The Survey of Activities and Fear of Falling in the Elderly (SAFFE) was used as the outcome measure for assessing fear of falling, activity restriction, and activity level. The SAFFE has six subgroups namely section A (activity level), section B (fear of falling), section C (level of worriedness), section D (reason of worriedness), section E (reasons for reduced activity level), and section F (activity restriction).[4] Older adults were evaluated on SAFFE sections A, B, and F only because sections C, D, and F assessed reasons for worriedness and reasons for reduced activity level, which would yield psychological aspect of qualitative data. Whereas the focus of the present study was primarily on the physical aspects of older adults and performing quantitative analysis. At baseline, older adults were evaluated on SAFFE, subsequently the architectural barriers were identified in the old age home and cost effective environmental modifications were provided. After two months of implementing the modifications post-intervention evaluation was done on SAFFE and follow-up evaluation was done after twelve months.

Environmental modifications that were given in the old-age home were as follows: placing a nonskid rubber mat at the entrance gate, installation of a small ramp at the entrance of the old-age home with grab rails, nonslip contrast stripping on the steps, making extra step in the place of big obstacle at the entrance, and making zigzag projection in the sloping surface floor and steps. In bathroom, nonskid footwears, nonskid bath mat, and small chairs and in toilets, grab rails with commode were installed. In laundry area, a raised platform was made for washing clothes as well as chairs were provided. Bleaching powder was sprinkled for better foot grip, trailing cords was removed and hangers were suggested to put wet clothes for drying. For sitting purpose, the placement of ferrule under the legs of chairs for slip resistance with a firm cushioned back support was done. Adequate spacing between the beds for making it easy to get in and out of bed was provided. Illumination was done with bright light in the pathways and installation of night-lights typically used in bathrooms or hallways. Scatter or throw rugs were removed, or double-sided tape was used to stick the edges of the rug or mat to the floor. General information about wearing properly fitted shoes with good grip and low heels was prescribed keeping the objects within their reach, so as to avoid excessive sideway, overhead, and backward reaches, sitting on the bed while dressing and undressing.

We recommended the above modifications which were implemented by the public work department of the institute which comprised of civil engineers, electricians, plumbers, etc., Within 1 week of time, the modifications were implemented, and all expenses were beared by Annai JKK Sampoorani Ammal Charitable Trust.

The data were analyzed in terms of their mean, standard deviation, standard error of mean, lower and upper 95% confidence interval, t-test, and Pearson's correlational test using GraphPad InStat 2 software. The level of statistical significancewas set at P < 0.05 at the outset of the study.


  Results Top


All the 32 older adults completed the evaluation on SAFFE at baseline (preintervention), postintervention (2 months), and follow-up (12 months), and there were no dropouts. The demographic characteristics of the older adults were analyzed, and the mean age of the older adults was 62.18 years, which comprised of 14 males and 18 females.

The mean value of SAFFE section A (activity level) (8.21 ± 2.02) remained unchanged from baseline to postintervention to follow-up [Table 1], which implied that the activity level was not improved.
Table 1: Baseline, Postintervention, and Follow-up Scores on Subtests of Survey of Activities and Fear of Falling in the Elderly A, B, and F

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The mean value of SAFFE section B (fear of falling) decreased from 23.68 ± 8.56 to 20.75 ± 7.92 from baseline to postintervention, which clearly implied that there was reduction in fear of falling. Although at follow-up, the mean increased from 20.75 ± 7.92 to 22.03 ± 8.26, still less as compared to the mean at baseline which was 23.68 ± 8.56, which implied sustained reduction in fear of falling [Table 1] and [Figure 1].
Figure 1: Comparison of Mean SAFFE Section B Scores at Baseline, Postintervention, and Follow-up (Fear of Falling)

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The mean value of SAFFE section F (activity restriction) decreased from 20.21 ± 6.93 to 18.12 ± 6.19 from baseline to postintervention, which clearly implied that there was a reduction in activity restriction. Although at follow-up, the mean value showed a slight increase from 18.12 ± 6.19 to 18.53 ± 6.47, still less as compared to the mean at baseline which was 20.21 ± 6.93, reduction of activity restriction was sustained [Table 1] and [Figure 2].
Figure 2: Comparison of Mean SAFFE Section F at Baseline, Postintervention, and Follow-up (Activity Restriction)

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There was a significant reduction of fear of falling (SAFFE section B) at baseline (P = 0.0001), postintervention (P = 0.0001), and follow-up (P = 0.0001). Furthermore, there was a significant reduction in activity restriction (SAFFE section F) at baseline (P = 0.0001), postintervention (P = 0.0001), and follow-up (P = 0.0001). However, activity level (SAFFE section A) remained unchanged at baseline (P = 1), postintervention (P = 1), and follow-up (P = 1) [Table 2].
Table 2: Paired t-Test between the Variables

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It was observed that there was a negative correlation between SAFFE section A and SAFFE section B, i.e., between activity level and fear of falling at postintervention, which clearly stated that the better the activity level, lesser was the fear of falling [Table 3] and [Figure 3]. Furthermore, it was seen that there was a positive correlation between SAFFE section B and SAFFE section F, i.e., between fear of falling and activity restriction at postintervention, which implied that the more the fear of falling, the more would be activity restriction [Table 3] and [Figure 4].
Table 3: Pearson Correlation between the Variables

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Figure 3: Correlation between SAFFE Section A and SAFFE Section B at Postintervention

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Figure 4: Correlation between SAFFE B and SAFFE F at Postintervention

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  Discussion Top


In the present study, cost-effective environmental modifications were implemented in an old-age home, and it was found that there was a significant reduction in fear of falling. Furthermore, the relationship of fear of falling was established with activity level and activity restriction in community-dwelling older adults living in old-age home.

The implementation of environmental modifications significantly reduced the fear of falling over a period of 12 months. Various studies in the past have suggested improvement in fear of falling through environmental modifications at home or workplace.[2] In urban areas, most of the buildings are barrier free whereas in rural areas barrier free buildings are seldom seen.

Despite the study setting being in rural setup, environmental modifications done were readily accepted by the community-dwelling old adults living in the old-age home. Environmental modifications done were followed as implemented by the occupational therapist.

In the process of this study, occupational therapist assessed the old-age home for architectural barriers, and cost-effective modifications were suggested, which the old-age management readily implemented. Whole process was evaluated and re-evaluated at different intervals of time when constructing the modifications by the occupational therapist. Fear of falling has a multi-factorial aspect i. e. declining physical health, deteriorating mental abilities, declining balance and coordination, and psychological reactions due to aging. Therefore for reducing fear of falling a holistic approach is warranted. Occupational therapist should target overall body conditioning exercises, use of assistive technology, fall prevention program, environmental modifications, as well as therapeutic use of self in order to improve their quality of life. There was reduction in activity level with increasing fear of falling. The present study was supported by the work of previous researchers (Delbaere et al., Deshpande et al., Hadjistavropoulos et al., Gagnon et al., and Jang et al.).[5],[6],[7],[8],[9]

Falls are the leading cause of fatal and nonfatal injuries among older adults even those who fall and are not injured often suffer negative health and mental consequences. Older adults who fall were more likely to fall again within a year and were at an increased risk of developing a fear of falling that can lead to mobility restrictions. Due to the fear of falling, older adults stop participating in activities of daily living (ADL) and instrumental ADL, thereby causing reduction in activity levels.

When people withdraw from ADL and outdoor social contact, they become more susceptible to the negative effects of social isolation and physical inactivity. Avoidance of activities leads to deterioration of muscle strength and postural control. Due to declining age, older adults have reduced physical performance, reduced muscle strength, deterioration in balance, and postural performance; in addition, fear of falling further leads to avoidance of activities.

However, it can be possible that community living for elderly still had sufficient functions to manage basic ADL and social activities with fear of falling.[10]

Due to nonavailability of family support and care in the old age home, these older adults refrain themselves from participating in the activities in order to prevent fall. Because of this psychological impact of being away from family members add to depression, anxiety and in turn can lead to less participation in activities.

Fear of falling leads to cessation of activities, i.e., activity restriction. This was supported by previous studies by Arfken et al., Van Haastregt et al., and Boyd and Stevens.[1],[3],[11] Fear of falling can lead to increased fall risk, decreased motivation, and decreased perception of capabilities, all of which can lead to self-imposed activity restriction. Thus, simultaneously, over a period of time, they further restrict themselves from doing that particular activity. Since the older adults were living in an old age home, there were other factors as well which may further lead to activity restriction like loneliness, lack of family support and care, and no motivation in carrying out the activities.

Although there was reduction in fear of falling and activity restriction, but activity level of older adults remained unchanged, it might be because of shorter duration of intervention, may be within a period of 3-5 years activity level of the older adults can be improved through occupational therapy interventions.

Further future studies could be conducted which can include objective measures to better understand the multifaceted construct of fear of falling. Furthermore, this study can be done in any community-dwelling older adults rather than taken only from an old age home.

The limitation of our study was that the data collected were self-reported and depended on older adults' memories of past event for the estimation of fear of falling, activity level, and activity restriction, which can lead to bias, and since it was a convenient sampling method and small sample size, it is insufficient to generalize the findings.


  Conclusion Top


Our study shows that there was a significant reduction of fear of falling after the implementation of cost-effective environmental modifications in the old-age home. There was a significant negative relationship of fear of falling with activity level and positive relationship with activity restriction.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Boyd R, Stevens JA. Falls and fear of falling: Burden, beliefs and behaviours. Age Ageing 2009;38:423-428.  Back to cited text no. 1
    
2.
Chase CA, Mann K, Wasek S, Arbesman M. Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. Am J Occup Ther 2012;66:284-291.  Back to cited text no. 2
    
3.
Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health 1994;84:565-570.  Back to cited text no. 3
    
4.
Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling and activity restriction: The survey of activities and fear of falling in the elderly (SAFE). J Gerontol B Psychol Sci Soc Sci 1998;53:P43-50.  Back to cited text no. 4
    
5.
Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing 2004;33:368-373.  Back to cited text no. 5
    
6.
Deshpande N, Metter EJ, Lauretani F, Bandinelli S, Guralnik J, Ferrucci L. Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study. J Am Geriatr Soc 2008;56:615-620.  Back to cited text no. 6
    
7.
Gagnon N, Flint AJ, Naglie G, Devins GM. Affective correlates of fear of falling in elderly persons. Am J Geriatr Psychiatry 2005;13:7-14.  Back to cited text no. 7
    
8.
Hadjistavropoulos T, Martin RR, Sharpe D, Lints AC, McCreary DR, Asmundson GJ. A longitudinal investigation of fear of falling, fear of pain, and activity avoidance in community-dwelling older adults. J Aging Health 2007;19:965-984.  Back to cited text no. 8
    
9.
Jang SN, Cho SI, Oh SW, Lee ES, Baik HW. Time since falling and fear of falling among community-dwelling elderly. Int Psychogeriatr 2007;19:1072-1083.  Back to cited text no. 9
    
10.
Delbaere K, Crombez G, Van Den Noortgate N, Willems T, Cambier D. The risk of being fearful or fearless of falls in older people: An empirical validation. Disabil Rehabil 2006;28:751-756.  Back to cited text no. 10
    
11.
Van Haastregt JC, Zijlstru GA, Van Rossum E, Van Ejik JTM, Kempen GI. Feelings of anxiety and symptoms of depression in 31 community living older adults. Am J Geriatr Psychiatry 2008;16:186-193.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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