Abstract: Occupational therapy practitioners are uniquely prepared to contribute to fall prevention efforts because of their attention to diverse influences on occupational performance. This article is intended for occupational therapy practitioners who seek to deliver evidence-based fall prevention programs to community-dwelling older adults and features descriptions of best practice in fall risk assessment and intervention. Interventions to improve home safety and mobility skills are highlighted, as are shared features of two community-based programs: Matter of Balance and Stepping On. obJECtiVEs After reading this article, you should be able to: 1. Recognize the personal and societal consequences of falls. 2. Identify key fall risk factors among community-dwelling older adults. 3. Select evidence-based approaches to assessing fall risk. 4. Identify evidence-based approaches to fall prevention intervention for community-dwelling older adults. 5. Identify strategies to reduce falls and improve falls selfefficacy, drawing from the Matter of Balance and Stepping On programs. 6. Identify gaps in current fall prevention research. introdUCtion Fall-induced injuries are one of the most common causes of restricted activity, disability, and death in elderly populations (Gill, Allore, Holford, & Guo, 2004; Kannus, Niemi, Palvanen, Parkkari, & Järvinen, 2005). The problem of falls among older adults stems from a combination of high incidence and high susceptibility to trauma (Rubenstein, 2006). About one third of persons 65 years of age and older living in the community fall at least once a year (Tinetti, Speechley, & Ginter, 1988). Both the incidence and the severity of fall-related complications increase with age, level of disability, and extent of functional impairment (van Weel, Vermeulen, & van den Bosch, 1995). The high personal and societal cost of falls has been recognized at a national level. Fall-related deaths and injuries have been targeted for reduction in the Healthy People 2010 Objectives for Improving Health (U.S. Department of Health and Human Services, 2000). The National Council on Aging (2005) has led the development of a national action plan to reduce fall dangers for older adults. Fortunately, a surge in fall-related research has dramatically improved understanding of fall risk factors and effective intervention strategies. Current practice in fall prevention is now informed by findings from more than 60 randomized trials and meta-analyses of the most scientifically rigorous studies (Chang et al., 2004; Gillespie et al., 2003). Fall risk FaCtors Fall risk factors, which typically are classified as intrinsic or extrinsic, vary by disability group and by setting (e.g., community vs. nursing home) (Koski, Luukinen, Laippala, & Kivela, 1998). Because falls generally are the result of multiple, diverse, and interacting risk factors, a multifactorial approach to falls assessment and intervention is needed for most populations (Chang & Ganz, 2007). Intrinsic fall risk factors include impairments in muscle strength, balance, gait, cognition, and vision; depressive symptoms; fear of falling, postural hypotension; arthritis; and the use of four or more prescription medications or benzodiazepines (Bergland & Wyller, 2004; Campbell et al., 2005; Friedman, Munoz, West, Rubin, & Fried, 2004; Sattin, 1992; Tinetti, Doucette, Claus, & Marottoli, 1995; Tinetti et al., 1988). Extrinsic risks are environmental in nature. Because most falls occur in and around the home, consideration of environmental hazards in these areas is important. The top three home-based fall hazards identified through a content analysis of fall studies (Clemson, 1997) are slippery surfaces, obstacles in pathways, and poor illumination. Of note is that the existence of home hazards alone is insufficient to cause falls. Instead, the interaction between an older person’s physical abilities and his or her exposure to environmental stressors appears to be more important (Lord, Menz, & Sherrington, 2006). Thus, it is essential to consider older adults’ ability to make good decisions about which activities to Understanding the Role of Occupational Therapy in Fall Prevention for Community-Dwelling Older Adults AOTA Continuing Education Article NOW AVAILABLE! CE Article, exam, and certificate are now available ONLINE. Register at www.aota.org/cea or call toll-free 877-404-AOTA (2682). CE-2 FEBRUARY 2008 n OT PRACTICE, 3(3) ARTICLE CODE CEA0208 engage in. Also important is learning about an older adult’s fall history because older adults who have fallen once are at high risk of falling again (Rubenstein & Josephson, 2003). EValUation For Fall risk: an oCCUPational PErsPECtiVE Fall prevention guidelines emphasize the need for careful evaluation of an individual’s risks and deficits. In particular, consideration of the interaction and probable synergism between multiple risk factors is needed (American Geriatrics Society [AGS], British Geriatrics Society [BGS], and American Academy of Orthopaedic Surgeons [AAOS] Panel on Falls Prevention, 2001). The Person–Environment–Occupation (PEO) model (Stewart et al., 2003) is a useful framework to apply to fall risk evaluation. The model’s key assumption is that the person, environment, and occupation interact continuously across time and space in ways that increase or decrease their congruence: the closer the fit, the greater the overlap or occupational performance. Improving occupational performance in the context of fall prevention focuses on reducing fall risk and enhancing clients’ confidence in their ability to engage in valued activities without falling. PEO-based fall assessment considerations are highlighted in the section that follows. the Person: specific Considerations in Fall risk Evaluation Understanding Capacities, Past Fall Experiences, and Physical Risk Factors Occupational therapy practitioners must ask older adults about their recent fall experiences and listen carefully to their responses. Specifically, clients can be asked, “In the past month, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?” (Lamb, Jorstad-Stein, Hauer, & Becker, 2005, p. 1619). The AGS, BGS, and AAOS Panel on Falls Prevention (2001) recommended that fall evaluation be included as part of routine care provided to older adults who are at relatively low risk. Use of the Timed Up and Go (TUG) test (Podsiadlo & Richardson, 1991) is recommended by the panel. The TUG test requires the client to stand up from a chair without using the arms (if possible), walk several paces, and return. Persons who have difficulty performing the TUG or presenting with one or more falls or gait and balance abnormalities should be assessed further. This more detailed assessment of fall risk, involving clinicians and physicians with appropriate skills and experience, features measures of acute and chronic medical problems, neurological and cardiac status, medication, vision, and lower-extremity joint function. Understanding Falls Self-Efficacy Falls self-efficacy refers to the degree of confidence a person has in performing common activities of daily living without falling (Tinetti, Richman, & Powell, 1990). The Falls Efficacy Scale–International (FES–I), a 16-item instrument that assesses the intensity of concern about falling when performing easy and more-demanding physical and social activities, is the recognized standard for measuring falls self-efficacy (Zijlstra et al., 2007). The FES-I has excellent internal and test–retest reliability (Cronbach’s alpha = 0.96) (Kempen et al., 2007). Understanding Behavioral Fall Risk Factors A range of behaviors contribute to fall risk (Clemson, Manor, & Fitzgerald, 2003). Protective behaviors, as described by Clemson, Cumming, and Heard (2003), are presented in Table 1. Each dimension also could be described in terms of its opposing risk-taking behaviors. There are many ways that occupational therapy practitioners can support clients’ efforts to explore and use new fall prevention strategies. In addition to evaluating a client’s level of confidence in his or her ability to participate in daily activities without falling, it is helpful to explore whether the client thinks a particular strategy will be useful. If a client reports that he or she has doubts about the effectiveness of a fall prevention strategy, the practitioner should take time to understand the client’s reasoning and address concerns (Lachman et al., 1997). Because using new fall prevention strategies often requires changes in routine and habitual behaviors, practitioners can help clients to create new routines that dimension description Cognitive adaptations Behaviors associated with reflection, intention, and planning (paying attention to changes in balance, level of alertness, etc., when trying a new medication) Protective mobility Negotiating the environment in a supportive or protective way (using defensive walking strategies, e.g., walking away from crowds) Avoidance Avoiding risky situations (e.g., peak hour on the buses) Awareness and being observant Behaviors associated with noticing hazards, such as spills on the floor, or scanning ahead for potential hazards when walking table 1. dimensions of Protective behaviors (Clemson, Cumming, & heard, 2003). Pace Slow walking pace to cope with reduced physical functioning Practical strategies Anticipating problems and finding solutions (e.g., using a wide-based stepladder for climbing instead of reaching from a chair) Earn .1 AOTA CEU (one NBCOT PDU/one contact hour, see page CE-7 for details. CE-3 FEBRUARY 2008 n OT PRACTICE, 3(3) ARTICLE CODE CEA0208 work well for them and strategies to remember when to change the behavior. Lastly, clear, measurable objectives are essential to target the true behavior for change. Occupational therapy practitioners can identify the “just-right challenge” for older adults to develop detailed an

Abstract: Mental Health Services Administration (SAMHSA), an agency of the U.S. Department of Health and Human Services, recently launched two Web-based services to promote the implementation of evidencebased practice. The National Registry of Evidence-Based Programs and Practices (NREPP) (www.nrepp. samhsa.gov) is a searchable online database of mental health and substance abuse interventions that have been reviewed and rated by independent experts. The Guide to Evidence-Based Practices (EBP) on the Web (www. samhsa.gov/ebpWebguide) currently features 37 Web sites that contain evidencebased information about specific interventions or reviews of research findings. Marian Scheinholtz, MS, OT/L, former practice associate at the American Occupational Therapy Association (AOTA) and current public health adviser for the Community Support Program at SAMHSA’s Center for Mental Health Services, reminds us of the big picture—that “all areas of occupational therapy practice have a psychosocial component.” She continues, “the psychosocial interventions listed and evaluated in NREPP are especially valuable to occupational therapy practitioners who are interested in reflecting on the outcomes of their services and thinking about how to tailor these interventions to meet the preferences and needs of their own clients.” As of this writing, the NREPP featured 66 interventions, with more than 200 in the pipeline for review. The registry is expected to add 5 to 10 interventions each month; new interventions may be submitted for review each year in response to an annual notice in the Federal Register. NREPP’s review procedures were developed and refined according to recommendations from scientific communities, service providers, expert panels, and consumers. Two ratings are provided for each intervention: (1) the quality of research (summarizes and rates the strength of the evidence supporting the results of outcomes of the intervention); and (2) the intervention’s readiness for dissemination (summarizes and rates the quality of the resources available to support the use of the intervention). An important feature of the registry is that contact information for the developer of the intervention is provided, as is a set of questions to ask a developer while exploring the possible use of an intervention in clinical practice. The NREPP can be searched by a checklist format based on topic, area of practice, population characteristics, and setting. SAMHSA’s Guide to EBP on the Web also uses a checklist format for searches, based on age group and setting. Both Webbased resources are welcome additions to an occupational therapy practitioner’s collection of “EBP favorites.”