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Japan Journal of Nursing Science (2015) 12, 184–197

doi:10.1111/jjns.12059

ORIGINAL ARTICLE

Effectiveness of a home hazard modification program for reducing falls in urban community-dwelling older adults: A randomized controlled trial Tomoko KAMEI,1 Fumiko KAJII,1 Yuko YAMAMOTO,1 Yukako IRIE,2 Rumi KOZAKAI,3 Tomoko SUGIMOTO,4 Ayako CHIGIRA1 and Naoakira NIINO5 1

College of Nursing, St. Luke’s International University, 5Faculty of Gerontology, Graduate School of J.F. Oberlin University, Tokyo, 2Takasaki University of Commerce Junior College, Gunma, 3School of Lifelong Sport, Hokusho University, Hokkaido and 4School of Nursing, Faculty of Health Care Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan

Abstract Aim: To evaluate the potential improvement of fall prevention awareness and home modification behaviors and to decrease indoor falls by applying a home hazard modification program (HHMP) in communitydwelling older adults followed up to 1 year in this randomized controlled trial. Methods: The present authors randomly assigned 130 older adults living in the Tokyo metropolitan region to either the HHMP intervention group (n = 67) or the control group (n = 63). Both groups received four, 2 h fall prevention multifactorial programs including education regarding fall risk factors, food and nutrition, foot self-care, and exercise sessions. However, only the HHMP group received education and practice regarding home safety by using a model mock-up of a typical Japanese home. Results: The mean age of the HHMP group was 75.7 years and the control group 75.8. The HHMP group showed a 10.9% reduction in overall falls, and falls indoors showed an 11.7% reduction at 52 weeks. Those aged 75 years and over showed a significant reduction in both overall falls and indoor falls at 12 weeks. Fall prevention awareness and home modifications were significantly improved in the HHMP group. Conclusion: HHMP has the potential to improve fall prevention awareness and home modification behaviors, and specifically decreased overall and indoor falls in 12 weeks in those aged 75 years and older in community-dwelling older adults. Key words: accidental falls, aged, home hazards, program evaluation, randomized controlled trial.

INTRODUCTION Falls among adults aged 65 years and older are a leading cause of disability, morbidity, and death, with sufferers occasionally requiring special medical or nursing care for injuries, resulting in a subsequent decrease in quality of life (Centers for Disease Control and Prevention, 2011; Costello & Edelstein, 2008; Lord, Ward, Williams, & Anstey, 1994; Mahoney et al., 2007; Correspondence: Tomoko Kamei, Gerontological Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan. Email: [email protected] Received 9 January 2014; accepted 16 July 2014.

Rubenstein & Josephson, 2002). In a single year, 20–30% of Japanese older adults and approximately one third of adults from other countries aged 65 years and over, and 50% of those aged 80 years and over, experienced falls (Berg, Alessio, Mills, & Tong, 1997; Campbell et al., 1990; Centers for Disease Control and Prevention, 2011; Kamei, Kajii, Itoi, Yamada, & Niino, 2009; Niino, Tsuzuku, Ando, & Shimokata, 2000; Rubenstein & Josephson, 2002; Yasumura et al., 1994; Yasumura & Hasegawa, 2009). Internal factors of older adults, as well as environmental factors such as residential safety, influence fall risk in community-dwelling older adults (Centers for Disease Control and Prevention, 2011). Falls at home

© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science

Japan Journal of Nursing Science (2015) 12, 184–197

often occur during daily activities with almost 50% of falls occurring indoors for community dwellers (Kamei et al., 2009; Pynoos, Steinman, & Nguyen, 2010). Of these, 65.3% result in injury and 20.4% in fractures (Kamei et al., 2009). Prevention of falls, particularly within the home, is a major issue for maintaining the functional life of community-dwelling older adults and has become a public health priority in super-aging societies such as Japan (Ministry of Health, Labor and Welfare, 2009). Multifactorial intervention programs for older adults have proved effective for preventing falls (American Geriatrics Society, British Geriatrics Society & American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001; Costello & Edelstein, 2008; Day et al., 2002; Gillespie et al., 2012; Mahoney et al., 2007; Tinetti et al., 1994). Recent studies have shown that multifactorial interventions including home hazard, safety assessments, and home modifications are beneficial for decreasing the rate of falls in the community elderly strongly supporting the importance of home hazard reduction (Costello & Edelstein, 2008; Gillespie et al., 2012; Kamei, Kajii, Itoi, Kozakai, & Niino, 2010; Newton, 2006). The presences of certain home hazards were more important in predicting falls at home among vigorous rather than the frail older adults (Northridge, Nevitt, Kelsey, & Bruce, 1995). Nevertheless, a metaanalysis provided insufficient evidence to show that interventions focused on the residential environment, including home hazard assessment and modification, medication reviews, health and bone assessment, and exercise decreases injuries in older adults (Turner et al., 2011). Thus, evidence for the effectiveness of home hazard self-assessment and self-modification for preventing falls is insufficient. Home hazard assessment and modification professionally prescribed for older adults with a history of falls has led to a reduction in falls both inside and outside the home (Gillespie et al., 2012); however, home hazards in each country are unique given the lifestyle differences among countries. In fact, Japanese residences have both Japanese-style and Western-style rooms, and floor level differences between these rooms often exist. Moreover, shoes are customarily not worn indoors and almost 50% of the Japanese population use floor-level sleeping mats (“futons” in Japanese) (Japan Industrial Society of Bed Manufactures, 2013). Nikolaus and Bach (2003) found in that in southern Germany 75.7% of elderly individuals implemented a minimum of one recommended change after being visited by a home intervention team. The same study

Home modification for fall reduction

showed that the most commonly recommended changes were elevation of the toilet seat, use of a rollator walker, and installing grab bars in the bathroom. At the 12 month follow up, older adults who had implemented at least one of the previous recommendations experienced a significant reduction in the rate of falls, especially those with a history of recurrent falls. Clearly, it is important for older adults to be aware of how to prevent falls in their own residence and to be able to modify the environmental hazards in their residence in order to maintain their daily residential safety. Kamei et al. (2010) presented multifactorial and people-centered fall prevention group classes in Japan consisting of fall risk awareness, food and nutrition, practice of foot self-care, and home hazard modification education as well as exercises to maintain strength, coordination, and balance with an outcome of short-term effects in fall reduction. This type of group home hazard educational intervention seemed to provide a low cost approach compared with professionals visiting homes and giving specific advice, however, the long-term effects for fall prevention were not clear.

PURPOSE The present study focused on the reduction of falls and promotes fall-preventing behaviors in urban community-dwelling older adults and provides multifactorial interventions including a home hazard modification education program (HHMP) using an original residential mock-up for inducing awareness of their surroundings. The study also presents a 3 month (12 week) and a 1 year (52 week) follow up to show the short- and long-term effects of HHMP in preventing overall falls as well as falls in the residences of older adults living in the urban community. The purpose of the study was to evaluate the effects of a HHMP with residential mock-up and home equipment. The hypothesis was that the incidence of overall and indoor falls in the HHMP group would be significantly lower than that in the control group. The primary outcome was overall and indoor fall reduction. The secondary outcome was promotion of knowledge of fall prevention awareness and behaviors of home modification of their residential environment in urban community-dwelling older adults.

DEFINITIONS For this study, a fall was defined as falling down to the ground, or to a lower level, against one’s will (Gibson,

© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science

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Japan Journal of Nursing Science (2015) 12, 184–197

1990), as well as slips and trips. Older adults included those aged 65 years and over. The definition of indoor residence, residential environment, and home all refer to the participants’ living space.

METHODS Design The present authors used a randomized controlled trial with a pretest and two post-tests, one at follow up at 12 weeks and the other at 52 weeks.

Interventions Research assistants allocated participants randomly into either the HHMP group or the control group and without the presence of the researchers. Both groups participated in equal 4 weekly fall prevention multifactorial programs each lasting 120 min. This included: (i) 5–15 min of physical and mental assessment interview by the nurse; (ii) blood pressure check; (iii) 30 min education regarding fall risk factors, food and nutrition, foot self-care; and (iv) 60 min exercise sessions designed to maintain strength, coordination, and balance. Moreover, the HHMP group was given education and practice regarding environmental safety for their indoor residence: (i) a residential safety selfassessment consisting of a 33 item self-checklist which was modified from both Northridge et al.’s (1995) eight factors and the Centers for Disease Control and Prevention (2005) home fall prevention checklist for older adults modified for Japanese settings with added items; and (ii) a home hazard awareness program and education as to how to modify and create safety in a residential environment using a displayed 60 cm × 60 cm residential mock-up (Fig. 1). Participants practiced interactively with the educator by removing obstacles in the mock-up to maintain floor and environmental safety for each area. Participants were also shown home equipment useful for rooms, bathroom, stairs, and hallways, such as automatic floor lighting; grab bars for the bathroom, restroom, and entrance hall; small ramps between rooms; and non-slip rug and non-slip tape on stairs. A collaborative interdisciplinary fall prevention team provided the intervention and control program. In the first week, both groups were informed about fall risks and safety by a physician researcher. In the second week, they were informed about food and nutrition by a nutritionist researcher. In the third week, only the HHMP group received a home hazard modification

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Figure 1 Education mock-up for fall prevention in the residence. Public health nurse researcher provides lectures and uses the mock-up to teach about home hazards and how to modify the home environment to prevent inside falls. Participants were asked to remove obstacles, put household equipment in the right places, and maintain safety throughout the residence, such as placing handrails, removing bumps/electrical cords, and installing foot lights near the stairs. (Size: 60 cm × 60 cm; Japan Patent Office registration no. 3148203.)

program by a public health nurse researcher. The first half of the program included a lecture about indoor fall prevention. The second half of the program was the interactive practice with the participants using the mock-up. The control group was given a short talk on health and aging by a physician researcher. The fourth week activity was a nurse researcher demonstrating foot self-care. The control program was implemented in the morning and the HHMP program in the afternoon to avoid contamination between the program participants. The same staff-educators were assigned to both morning and afternoon programs to ensure the same program consistency.

Subjects The subjects were older adults aged 65 years and over recruited through posters, flyers, and websites from the Tokyo metropolitan region. The inclusion criteria were: first time participation in the program; allowed by their primary physician to undergo physical exercise; living in their own residence; and aged of 65 years or older. The exclusion criteria were: low cognitive function; dementia; and/or poor physical condition such as inability

© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science

Japan Journal of Nursing Science (2015) 12, 184–197

Home modification for fall reduction

Figure 2 Time frame of the data collection in present study.

to walk by themselves. A trained nurse screened the subjects’ physical and cognitive status by telephone prior to commencement of the program to assess the inclusion/exclusion criteria.

Sample size Previous studies have shown that Japanese older adults in the community experience falls at a rate of approximately 25% in a single year (Yasumura et al., 1994); assuming this prevalence, this program aimed to obtain a 15% reduction in the fall rate. In order to obtain 80% power and 5% significance levels, and estimating a 10% dropout, a sample size of approximately 85 subjects in each group was required (Grobbee & Hoes, 2008).

dar and self-report. Data included the fall date, time, place, type of footwear, circumstances of the fall, injury, and treatment. The data were collected once a year at the fall prevention class provided by St Luke’s International University, Tokyo, with gerontological nursing researchers and co-researchers as the interdisciplinary fall prevention team. The number of participants was limited to 20 in each group session due to space constraints and participant safety; therefore, the class was given once a year in four class sessions with two follow-up sessions at 12 and 52 weeks. Thus, baseline data collection and the intervention program were conducted over four yearly cycles (September 2008– August 2011) without changes in the program contents, intervention, or educators.

Data collection The time frame of data collection is shown in Figure 2. After random allocation into the groups and before the beginning of the interventions, the participants received a questionnaire by mail to: (i) provide baseline information on demographics, medical history, risk of falls, and history of falls; (ii) assess their fall prevention awareness; and (iii) assess their perception of home hazards such as features of their home that may cause falls, slips, and trips. Participants of both groups were asked to keep a self-report falls calendar to record daily activities, exercise, food, and fall incidents. Participants were asked to bring their falls calendar to their 12 and 52 week follow up, and trained nurses discussed the details of any fall incident using a standard interview format and interview and according to the falls calen-

Outcome measured The primary outcome was the occurrence of overall and indoor fall events. The secondary outcomes were participants’ fall prevention awareness and modification of their home. Falls were monitored prospectively using a daily falls calendar and self-report. Moreover, participants were interviewed twice: once at the 12 week follow up as a mid-term evaluation and then again at 52 weeks for the 1 year evaluation. The fall prevention awareness in their home was assessed by a 10 item original questionnaire on falls. The questionnaire was empirically developed and used in another study (Kamei et al., 2010) by researchers to assess older adults’ fall prevention awareness. It comprised the following items: floor mat without any grips

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on the reverse side; floor level difference; floor lights; water spilled on the floor; chair in the bathroom; type of slippers; direction of grab bars; clutter; and sleep mat. Further, statements such as “A power cord across the floor is a kind of fall hazard” were given, and older adults were asked whether they considered the statement was correct (yes), incorrect (no), or if they did not know. These required an awareness of home safety. One point was given for a correct answer; therefore, the total score ranged 0–10 points. Alterations participants made to their indoor home environment were evaluated by a 33 item checklist, which was modified for the Japanese home according to the original report by Northridge et al.’s (1995) eight factors and a fall prevention checklist for older adults (Centers for Disease Control and Prevention, 2005). A 33 item checklist of home hazard assessment included the following items: storage; clutter; small rug problems; poor lighting; problems in transfer; bathroom; climbing aids; grab bars; footwear; pets; stairways; and bedroom. The location of hazards in Japanese homes and all essential major places for daily living for older adults were also covered. Participants responded to such items if they made a modification such as: “Adjusted the height of shelves to make them easier to reach”. Participants marked the appropriate items that they had actually modified during the 12 and 52 week period. The ratio of items modified : unmodified in each home was compared at the 12th and 52nd week after the intervention.

consent to participate. Compliance with the Declaration of Helsinki (World Medical Association, 2008) was maintained with regard to confidentiality of participants and data. In addition, all participants were assured that they could participate or withdraw at any time without repercussions. The ethics committee of St Luke’s International University, Tokyo, Japan, provided approval for the study (approval no. 08-006).

RESULTS Subjects and data completeness Out of 136 adults aged 65 years or older recruited from six locations in the Tokyo metropolitan area, six were excluded because one did not meet inclusion criteria and five refused to participate. Finally, 130 subjects were enrolled and randomly allocated to the HHMP (n = 67) and control (n = 63) groups. In the HHMP group, 11 did not attend sessions regularly and withdrew over the course of the study. From the control group, nine did not attend sessions regularly and withdrew over the course of the study. Per protocol analysis included 56 subjects in the HHMP group and 54 in the control group (Fig. 3). Table 1 shows the baseline characteristics of the subjects according to group. Participants’ mean age was 75 years and sex, physical status, fall risks, person who

Statistical analysis To evaluate the effectiveness of the HHMP, the time to first fall event and falls at indoor residence was compared between the groups using Kaplan–Meier survival analysis with the log–rank (Mantel–Cox) test undertaken on an intention-to-treat basis. The fall risk was analyzed by hazard risk. Total points for fall prevention awareness were analyzed by repeated-measures anova. Pearson’s χ2-test was used to analyze the home hazard modification ratio. If the expected frequencies were less than five, the present authors adopted Fisher’s exact test (two-tailed). The significance level was set at P < 0.05. The statistical analysis was carried out using the Japanese version of IBM SPSS Statistics version 19 (SPSS, Chicago, IL, USA).

Ethical considerations

N=136

Excluded

Randomized

Allocated to intervention (HHMP) group

n=67

Withdrew

n=11

52 weeks follow-up n=56

Analyzed

n=56

n=6

♦1

did not meet inclusion criteria

♦5

refused to participate

N=130

Allocated to control group n=63

Withdrew n=9

52 weeks follow- up

Analyzed

ITT n=67 Per protocol

The participants were given verbal and written explanations of the purpose and methods of the research. Return of the initial self-assessment was considered

188

Assessed for eligibility

n=54

ITT n=63 Per protocol

n=54

Figure 3 Flow diagram of the participants throughout the study. ITT, intention to treat.

© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science

Japan Journal of Nursing Science (2015) 12, 184–197

Home modification for fall reduction

Table 1 Baseline characteristics of the subjects by group

Age† (years) Sex Male Female No. of users with walking assistance devices Tinetti test†‡ BMI†‡ Fleming’s fall risks assessment† (0–17)‡ 10 m walking time† (s)‡ Performed housing repair in the past No. of falls over the previous year

HHMP group, N = 67

Control group, N = 63

75.7 (6.7)

75.8 (6.4)

11 (16.4) 56 (83.6) 8 (11.9) 27.1 (1.7) 22.8 (3.6) 4.1 (2.1) 7.2 (3.0) 14 (20.9) 19 (28.4)

9 (14.3) 54 (85.7) 7 (11.1) 26.8 (2.0) 22.6 (4.1) 4.4 (2.4) 6.9 (1.9) 17 (27.0) 18 (28.6)

† Values in parentheses indicate standard deviation. ‡HHMP, N = 66; control, N = 59. BMI, body mass index; HHMP, home hazard modification program.

10.9% reduction in overall falls compared with the control group (hazard ratio [HR] = 0.591, 95% confidence interval [CI] = 0.305–1.147; log–rank test, P = 0.116), and these results indicate that the HHMP group did not decrease overall fall risks, with a statistically significant difference at 52 weeks.

Fall events for indoor residence

Figure 4 Time to first fall stratified by the home hazard modification program (HHMP) and control group. CI, confidence , HHMP (overall); , control interval; HR, hazard ratio. , HHMP (indoors); , control (indoors). (overall);

performed housing repair in the past, and number of fallers over the previous year were similar in both the groups.

Overall fall events for both groups Figure 4 displays the Kaplan–Meier survival curves stratified by the HHMP and control groups for time to the first overall fall and indoor fall. At 52 weeks (∼365 days from baseline), the HHMP group achieved a

Falls occurring in the home at 52 weeks were reduced by 11.7% in the HHMP group compared with the control group (HR = 0.397, 95% CI = 0.151–1.045; log–rank test, P = 0.052), and showed no significantly reduced fall risks in the home (Fig. 4). In the HHMP group, six older adults fell accidentally in their home becoming injured and two sustained fractures by 52 weeks. In the control group, 13 older adults had fallen indoors and, of those, three were bruised, three were injured, and one sustained a fracture (Table 2).

Fall events by age group Overall and indoor falls occurring by 12 and 52 weeks in both groups by age (

Effectiveness of a home hazard modification program for reducing falls in urban community-dwelling older adults: A randomized controlled trial.

To evaluate the potential improvement of fall prevention awareness and home modification behaviors and to decrease indoor falls by applying a home haz...
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