Letters to the Editor. Reinsch and colleagues reply
I commend the authors of "Attempts to Prevent Falls and Injury: A Prospective Community Study" (Reinsch et al., 1992) for their ambitious and greatly needed intervention study. But these authors should consider additional reasons for lack of differences in outcome among the programs offered and midcourse modifications to the intervention that may reduce numbers and frequency of falls. Some possible explanations are: 1. Monitoring falls weekly in person or with phone calls may reduce underreporting of falls, but it also provides negative reinforcement regarding fall expectations. This method could neutralize or negate cognitive-behavioral approaches to reducing fear of falling in the actual fall risk situation. 2. The low-intensity exercise program, which the authors acknowledge may not have been of sufficient intensity, could be graded for each participant to increase strength within individual tolerance levels so that at no time is the exercise regime experienced as "too strenuous" or "too low intensity." Consultation from an occupational therapist or physical therapist, with medical guidelines on a case-by-case basis to match exercise level with strength, would enhance this intervention in its second year. 3. The weekly cognitive-behavioral intervention might have been frequent enough if it were designed to accomplish its intended goals. It is not clear how an increase in visual eyehand reaction time in performing video games relates to an increase in lower extremity reaction time in preventing falls. 4. When, where, and how the falls occurred were not included in this outcome study. This information is particularly valuable in developing an individual or group cognitivebehavioral approach for preventing falls. Confidence in preventing falls needs to be increased, but learning about one's capabilities and limitations, while maintaining feelings of selfworth, remains the challenge. Identifying personal risks and knowing when to ask for help should be incorporated as goals of a cognitive-behavioral fall prevention program. A geriatric occupational therapist might be helpful to train the trainers on such individualized assessment and treatment approaches. 5. The authors did not include information about the qualifications of the group leaders or how they were trained. As a secondary prevention model, the group leaders should have training in group process with the elderly, cognitive-behavioral theory and techniques specifically, and geriatric rehabilitation, especially environmental assessment and adaptation. Without this base of knowledge and skills for leaders, the groups are more likely to follow a primary prevention model (which does not adapt the intervention to individual needs) and, therefore, despite the different group names and objectives, may differ little from the discussion control group. If the group leaders lack the requisite skills, the investigators might consider reducing the number of sessions per group and deploy resources to train the trainers to achieve their objectives of reducing falls based on one or more of the group interventions.
We appreciate the thoughtful analysis of our article. Below are some specific responses. 1. Participants at senior centers expressed little fear of falling at the beginning of the study or throughout the intervention year in all four groups. Thus, asking about falls in an interview about health and present activities does not seem to raise a fear of falling. 2. The major component of the low-intensity exercise program was a series of alternating step-up and stand-up exercises. Based on the overload principle of training, the number of repetitions for each individual was increased over time, with some participants progressing from 5 stand-ups/step-ups to as many as 50 in one exercise session. The group leader encouraged participants to exercise as much as they "comfortably could," and trained them to recognize the warning signs indicating rest periods. Such a self-monitored exercise program shows usually better adherence over time than a demanding exercise regime; however, there is a possibility that its participants may not challenge themselves enough to gain in strength and balance. 3. Video game playing can improve the reaction times of older adults. Because reaction/movement times of the upper and lower extremities are highly correlated, we hypothesized that it could improve response quickness and thereby prevent a fall. In addition, breaking a fall requires good reaction time in the upper extremities. 4. People fell more often outside and in transition areas, such as the patio or garage, than inside their homes. Many falls were associated with reduced attention, such as tripping over a sizable object, and with unnecessary risk-taking, such as balancing on an overturned clothes hamper. Thus, we endorse Miller's suggestion for education on risk-taking, safety awareness, and acknowledgement of one's limitations. 5. An exercise physiologist trained group leaders on the exercise component and a health psychologist trained them on the cognitive-behavioral component and on discussion control topics. Random checks of classroom activities and regular meetings were held to monitor specificity of treatment. Regarding secondary prevention, a subproject of this study evaluated a home safety intervention. After 6 months, participants in the treatment group did not implement suggested safety changes any more often than controls. Cost, lack of help, and concerns about the stigma of frailty and aging were some of the reasons mentioned for this inaction. Thus, we agree that programs to prevent falls must incorporate a wider range of issues, from emotions to the environment.
Patricia A. Miller, MA, MEd, OTR Assistant Professor in Clinical Occupational Therapy and Public Health Columbia University New York, NY
Good Photo, Poor Choice of Cane
Sibylle Reinsch and colleagues University of California, Irvine
I always enjoy the covers on The Gerontologist. However, the one on the August 1992 (Volume 32 Number 4), shows an elderly gentleman carrying a cane which is obviously several inches too long.
Reference
Reinsch, S., MacRae, P., Lachenbruch, P. A., & Tobis,). S. (1992). Attempts to prevent falls and injury: A prospective community study. The Gerontologist, 32, 450-456.
Vol.32, No. 6,1992
859
G. M. Rosenberg, MD St. Mary's of the Lake Hospital Kingston, Ontario, Canada
Downloaded from http://gerontologist.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Suggestions for Improving a Falls Prevention Program
I commend the authors of "Attempts to Prevent Falls and Injury: A Prospective Community Study" (Reinsch et al., 1992) for their ambitious and greatly needed intervention study. But these authors should consider additional reasons for lack of differences in outcome among the programs offered and midcourse modifications to the intervention that may reduce numbers and frequency of falls. Some possible explanations are: 1. Monitoring falls weekly in person or with phone calls may reduce underreporting of falls, but it also provides negative reinforcement regarding fall expectations. This method could neutralize or negate cognitive-behavioral approaches to reducing fear of falling in the actual fall risk situation. 2. The low-intensity exercise program, which the authors acknowledge may not have been of sufficient intensity, could be graded for each participant to increase strength within individual tolerance levels so that at no time is the exercise regime experienced as "too strenuous" or "too low intensity." Consultation from an occupational therapist or physical therapist, with medical guidelines on a case-by-case basis to match exercise level with strength, would enhance this intervention in its second year. 3. The weekly cognitive-behavioral intervention might have been frequent enough if it were designed to accomplish its intended goals. It is not clear how an increase in visual eyehand reaction time in performing video games relates to an increase in lower extremity reaction time in preventing falls. 4. When, where, and how the falls occurred were not included in this outcome study. This information is particularly valuable in developing an individual or group cognitivebehavioral approach for preventing falls. Confidence in preventing falls needs to be increased, but learning about one's capabilities and limitations, while maintaining feelings of selfworth, remains the challenge. Identifying personal risks and knowing when to ask for help should be incorporated as goals of a cognitive-behavioral fall prevention program. A geriatric occupational therapist might be helpful to train the trainers on such individualized assessment and treatment approaches. 5. The authors did not include information about the qualifications of the group leaders or how they were trained. As a secondary prevention model, the group leaders should have training in group process with the elderly, cognitive-behavioral theory and techniques specifically, and geriatric rehabilitation, especially environmental assessment and adaptation. Without this base of knowledge and skills for leaders, the groups are more likely to follow a primary prevention model (which does not adapt the intervention to individual needs) and, therefore, despite the different group names and objectives, may differ little from the discussion control group. If the group leaders lack the requisite skills, the investigators might consider reducing the number of sessions per group and deploy resources to train the trainers to achieve their objectives of reducing falls based on one or more of the group interventions.
We appreciate the thoughtful analysis of our article. Below are some specific responses. 1. Participants at senior centers expressed little fear of falling at the beginning of the study or throughout the intervention year in all four groups. Thus, asking about falls in an interview about health and present activities does not seem to raise a fear of falling. 2. The major component of the low-intensity exercise program was a series of alternating step-up and stand-up exercises. Based on the overload principle of training, the number of repetitions for each individual was increased over time, with some participants progressing from 5 stand-ups/step-ups to as many as 50 in one exercise session. The group leader encouraged participants to exercise as much as they "comfortably could," and trained them to recognize the warning signs indicating rest periods. Such a self-monitored exercise program shows usually better adherence over time than a demanding exercise regime; however, there is a possibility that its participants may not challenge themselves enough to gain in strength and balance. 3. Video game playing can improve the reaction times of older adults. Because reaction/movement times of the upper and lower extremities are highly correlated, we hypothesized that it could improve response quickness and thereby prevent a fall. In addition, breaking a fall requires good reaction time in the upper extremities. 4. People fell more often outside and in transition areas, such as the patio or garage, than inside their homes. Many falls were associated with reduced attention, such as tripping over a sizable object, and with unnecessary risk-taking, such as balancing on an overturned clothes hamper. Thus, we endorse Miller's suggestion for education on risk-taking, safety awareness, and acknowledgement of one's limitations. 5. An exercise physiologist trained group leaders on the exercise component and a health psychologist trained them on the cognitive-behavioral component and on discussion control topics. Random checks of classroom activities and regular meetings were held to monitor specificity of treatment. Regarding secondary prevention, a subproject of this study evaluated a home safety intervention. After 6 months, participants in the treatment group did not implement suggested safety changes any more often than controls. Cost, lack of help, and concerns about the stigma of frailty and aging were some of the reasons mentioned for this inaction. Thus, we agree that programs to prevent falls must incorporate a wider range of issues, from emotions to the environment.
Patricia A. Miller, MA, MEd, OTR Assistant Professor in Clinical Occupational Therapy and Public Health Columbia University New York, NY
Good Photo, Poor Choice of Cane
Sibylle Reinsch and colleagues University of California, Irvine
I always enjoy the covers on The Gerontologist. However, the one on the August 1992 (Volume 32 Number 4), shows an elderly gentleman carrying a cane which is obviously several inches too long.
Reference
Reinsch, S., MacRae, P., Lachenbruch, P. A., & Tobis,). S. (1992). Attempts to prevent falls and injury: A prospective community study. The Gerontologist, 32, 450-456.
Vol.32, No. 6,1992
859
G. M. Rosenberg, MD St. Mary's of the Lake Hospital Kingston, Ontario, Canada
Downloaded from http://gerontologist.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Suggestions for Improving a Falls Prevention Program
