Material throughout this chapter has been reproduced from Cockayne et al.1 © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Material throughout this chapter has been reproduced from Cockayne et al.2 © 2021 Cockayne S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Burden of falls and falling in the UK
Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and cost to individuals and society.3 Approximately one-third of people aged ≥ 65 years, and half of those aged > 80 years living in the community, will have a fall each year.4,5 Although not all falls will have an impact on the individual, approximately one-fifth of all falls will require medical attention and 5% will result in a fracture,6 often a hip fracture. A significant number of falls (85%) occur within the home.7 Older people who fall once are two to three times more likely to fall again within 1 year. Repeated falls tend to be experienced by frail older people aged ≥ 75 years.4 These falls may lead to a loss of independence, resulting in the need for institutional care. It is likely that this burden will further increase, given the ageing population in the UK, with projections that the proportion of people aged ≥ 65 years is set to rise from 18% to 24% between 2016 and 2042.8 The financial cost of treating injurious falls has been estimated at £2B per year, mainly as a result of the cost of treating hip fractures.9
Risk factors for falling
Falls occur as a result of a complex interaction of risk factors. These risk factors can be separated into three broad categories: intrinsic, extrinsic and behavioural. Intrinsic risk factors are person-related and include factors such as having had a previous fall or fracture, impaired vision or impaired balance/gait.10 Extrinsic risk factors are related to the environment, such as the presence of clutter, trip hazards or poor lighting. Behavioural risk factors include risk-taking activities, for example climbing on chairs, drinking alcohol, or having poor intake of nutrition or fluids.
Environmental hazards (extrinsic risk factors) are frequently attributed by older people as the primary causal factors in their fall and are also cited in the literature as a major contributor to falls. In a review by Rubenstein11 of 12 studies, environmental factors were identified as the primary cause of approximately one-third of falls (mean 31%, range 1–53%, n = 36,280). Similarly, in Talbot et al.’s12 retrospective study, environmental factors were perceived by older people as the second most common cause of falls, with key contributors identified as objects on the floor, external forces and wet, uneven and icy surfaces. The latest Cochrane review in this area13 reported that home safety assessment and modification was effective in reducing the risk of falling [relative risk of falling 0.88, 95% confidence interval (CI) 0.80 to 0.96]. It also concluded that the intervention was more effective in people at higher risk of falling, including those with visual impairment, and if it was delivered by an occupational therapist (OT).14
Environmental assessment and modification to reduce falls
The person–environment–occupation occupational therapy conceptual model of practice purports that the person, their environment and the activities in which they engage continually interact in ways that enhance or diminish the individual’s occupational performance. Environmental hazards constitute dynamic entities, which occur through the interaction between these three elements, and occupational therapy practice aims to restore a balance between these elements. Occupational therapy-led environmental interventions, therefore, comprise a comprehensive assessment of the older person, their environment and the tasks they perform, with intervention strategies focused on the person, their environment and their task performance.
At the time of applying for funding for this study, National Institute for Health and Care Excellence (NICE) guidance15 recommended the delivery of a home hazard assessment and safety intervention/modification for those receiving treatment in hospital as a result of a fall. It was recommended that the assessment should be undertaken by a ‘suitably trained professional’, in conjunction with follow-up and appropriate interventions. However, no such guidance existed for older people living in the community who had an elevated risk of falling but had not yet necessarily received hospital treatment as a result of falling. This was despite a pilot trial, undertaken by one of the authors,16 that assessed the effectiveness of a home hazard assessment and environmental modification in this population reporting a reduction in the number of falls as a secondary outcome in the study.
Consequently, the Occupational Therapist Intervention Study (OTIS) was undertaken to find out if these preliminary findings could be confirmed and to evaluate the cost-effectiveness of the intervention. If home hazard assessment and environmental modification were shown to be clinically effective and cost-effective, it would be likely that these would be implemented more widely, and could lead to important public health gains in preventing or delaying disability in the older population.
Research aims and objectives
OTIS was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme in response to a call for efficient study designs. The aim of OTIS was to establish the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification, delivered by OTs, on the number of falls among older, community-dwelling people at risk of falling.
The main objectives of OTIS were to:
investigate the clinical effectiveness of a home hazard assessment and environmental modification for falls prevention
investigate the cost-effectiveness of a home hazard assessment and environmental modification for falls prevention
explore the barriers to and facilitators of implementing the intervention among OTs and the wider community (e.g. commissioners of services).
