CDC Fall Prevention Activities
Translating Research into Programs
Dissemination
Studies of AoA-funded Fall Prevention Programs
In June 2007, CDC developed an interagency agreement with the Administration on Aging (AoA). AoA currently provides 24 states with three-year grants that are designed to mobilize the aging, public health, and non-profit networks at the state and local level. The purpose of these grants is to accelerate translation of research into practice by introducing evidence-based disease and disability prevention programs at the community level. Of the 24 AoA grants, four evidence-based fall prevention models are being implemented: Matter of Balance (10 states and increasing); Stepping On (one state); Tai Chi (one state); and Step by Step (one state). It seems likely that other grantees will add fall prevention programs during the next three years.
Under this interagency agreement, CDC is conducting three activities related to older adult falls:
- Supporting the collaborative initiative by the National Council on Aging (NCOA), the Archstone Foundation, the Home Safety Council, and other partners to address the growing problem of falls and fall-related injuries among adults aged 65 years and older. The Falls Free Coalition, formed in 2004 as a result of this initiative, includes more than 55 organizations and employs a collective approach to promoting a national fall prevention action plan.
- Assessing the long-term impact of Matter of Balance, a program designed to reduce fear of falling; increase self efficacy and a sense of control in relation to fall risk; increase physical and social activity and consequently prevent older adult falls.
- Estimating the average implementation and maintenance costs and comparing these costs across three AoA-funded fall prevention programs: Matter of Balance, Moving for Better Balance, and Stepping On.
Dane County Safety Assessment for Elders (SAFE) study research project
From October 2002 to September 2005, CDC funded the Wisconsin Department of Health, in collaboration with the University of Wisconsin, to conduct a randomized controlled trial to assess the effectiveness of a comprehensive fall intervention among community-dwelling older adults (i.e.: adults living independently rather than in an assisted living facility or in a nursing home) aged 65 years and older and at high risk of falling. The intervention included:
- Conducting individualized health assessments in participants’ homes to identify fall risk factors.
- Reducing risk through changes in medical conditions, vision, medication use, behavior, physical functioning, home environment, and social support.
- Facilitating sustained fall prevention efforts through follow-up, social support, and links to existing medical care and human service networks.
- Educating physicians throughout the community about fall prevention.
The goal was to decrease fall rates by 35 percent. The key outcome measures were falls and related hospitalizations, and length of nursing home stays.
The study found that, compared to physician and therapist education alone, a multi-factorial individualized intervention in addition to physician and therapist education did not reduce the rate of falls among this population.
No More Falls!
From October 2001 to September 2004, CDC funded the California Department of Health Services to evaluate a multifaceted fall prevention intervention that was integrated into a public health program already established for older adults in the community. Study participants were 552 seniors attending Preventive Health Care for the Aging (PHCA) clinics in urban San Diego county and rural Humboldt county.
The intervention included four elements:
- Education about fall risk factors
- Referrals to community exercise programs to increase strength and balance
- Medication review, and
- Home modifications to reduce fall hazards.
The goal was to reduce the incidence of falls requiring hospitalization by 10 percent. Results showed that this intervention did not reduce falls in this population. Reducing falls among older adults by adding a fall intervention to an existing health promotion program remains challenging. Further research is needed on effective methods to deliver multifaceted fall interventions to healthy older adults in community settings.
Washington State older adults fall prevention study
The State of Washington Department of Community Health was funded in October 2002 for three years to evaluate the effectiveness of a best practices model for senior fall prevention in a community setting. The study was a 12-month, randomized controlled trial of a fall prevention intervention among community-dwelling seniors aged 65 years and older and was tailored for each individual. It was implemented in senior centers and housing through a partnership between a local YMCA and the Northwest Orthopedic Institute, and in a community hospital. The study population included 453 participants.
Participants in the intervention group received an exercise program to improve strength, balance, and mobility; an education program on how to avoid falls and reduce fall risk factors; medication review and modification; referral for medical care management for selected fall risk factors; and a home hazard assessment and reduction of environmental hazards. Outcome measures were falls, balance and gait, and functional status.
Falls among the intervention group were reduced 25% although this was not statistically significant. However, the intervention group showed significant improvement in measures of physical functioning.
Effect of medication changes on the short-term risk of falls in long-term care
In October 2004, researchers at Johns Hopkins University were funded to study the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. The study used a case-crossover design to capture medication changes that occurred one to 9 days before the fall. The measure of effect was the odds ratio of falling after a start, stop, or dose change in medication in the case time period compared to the control time period.
The results indicated that the short-term risk of single and recurring falls was three times higher in the two days following a medication change (odds ratio = 3.0, 95% CI=1.1, 25.9). The study outcomes may be used to develop similar fall risk studies in other clinical settings; identify high-risk times for falls related to medication changes; and to develop intensive, short-term interventions for vulnerable residents after medication changes.
Preventing falls through enhanced pharmaceutical care
Researchers at the University of North Carolina, Chapel Hill are conducting a randomized, controlled clinical trial to evaluate the effectiveness of a fall prevention program delivered by community pharmacists. The study focuses on community-dwelling older adults aged 65 years and older who have experienced a fall within the past year and are currently using either four or more prescription medications or at least one medication that acts on the central nervous system.
A community pharmacist will conduct an in-depth consultation with those in the intervention group about their current medications. The control group will receive a series of monthly informational materials about preventing and treating health problems associated with aging and on lifestyle behaviors important for maintaining health. Data on falls will be collected through monthly falls calendars. All participants will be followed for one year.
Translating Research into Programs
Dissemination of a community Tai Chi fall prevention program
Previous research findings have demonstrated that Tai Chi exercise can improve balance and decrease falls among older adults. However, it is not clear whether the general community can readily implement or adopt this type of training.
CDC funded a researcher at Oregon Research Institute in October 2005 for three years to translate his evidence-based Tai Chi intervention into a user-friendly resource package for communities to be used with adults 60 years and older who are physically mobile, with or without assistive devices.
A 12-week Tai Chi program for adults aged 60 and over, Moving for Better Balance, was developed and has been implemented in six local senior centers (140 people). The program consists of one-hour classes given twice a week. Participants are contacted 12 weeks after program ends to find out whether they’re continuing to practice Tai Chi. Dr. Li and his colleagues are evaluating the program’s feasibility and acceptability.
Based on feedback from senior service providers and seniors in the program, a user-friendly program package is being developed that includes:
- Instructor’s manual
- Instructor supplements, and
- Participant’s course book.
The results of this translation and dissemination research will provide an effective, evidence-based fall prevention package for older adults that can be implemented in a community setting. This research will also provide important public health information about the most effective dissemination strategies for program reach, adoption, feasibility, and acceptability.
Resulting publication:
Li F, Peter Harmer P, Mack KA, Sleet D, Fisher KJ, Kohn MA, Lisa M. Millet LM, Xu J, Yang T, Sutton B, Tompkins Y. Tai Chi: Moving for Better Balance—Development of a Community-Based Falls Prevention Program. Journal of Physical Activity and Health 2008;5:445-455.
Understanding factors that influence hip protector use among community-dwelling older adults
In February 2004, CDC funded researchers at the University of North Carolina Injury Control Research Center to evaluate the acceptability of hip protectors among community-dwelling seniors. The goal of this project was to identify perceived barriers to hip protector use and to develop methods to promote their acceptability and use among community-dwelling older adults.
Using focus groups and interviews, the researchers explored reactions to and attitudes about hip protectors among community-dwelling older adults. A different group of participants was interviewed and then given four pairs of hip protectors, instructed in their use, and asked to wear each one for a week. Participants were interviewed again after one week to determine their attitudes toward various aspects of the hip protectors including ease of use and care, comfort and fit, and physical difficulties and/or illnesses.
The study found that participants initially felt that comfort, convenience and protection were all important factors. However, after trying the different hip protectors, seniors were more likely to say that protection was most important. Seniors’ perceptions of their own fall risk also influenced their views on wearing hip protectors. CDC will use these findings to develop ways to make hip protectors more acceptable to community-dwelling older adults.
Resulting publication:
Blalock SJ, Demby KB, Karen L. McCulloch KL, Stevens JA. Seniors' Perceptions of Using Hip Protectors to Reduce Fracture Risk [Letter to the Editor] JAGS 2008 (in press).
Fall risk perception and risk assessment project
Researchers at the Veterans Affairs Greater Los Angeles Healthcare System are conducting a study to learn about older people’s perceptions of their own risk for falls. They also want to understand whether older people are willing and able to implement specific strategies to reduce their fall risk. This project was funded in 2005 through a grant to the VA Greater Los Angeles Healthcare System, a partner in the
Fall Prevention Center of Excellence.
In Phase I of the project, researchers conducted focus groups of 8 to 10 older adults at senior centers in Los Angeles County to learn about their knowledge of and beliefs about fall risk and fall prevention. The groups discussed perceived risk factors for falls, prevention efforts, barriers to performing recommended protective behaviors, and how to increase the chances that older adults would adopt changes to reduce their risk.
In Phase II, a second set of focus groups discussed whether a newly developed self-assessment brochure was easy for older people to use. The goal was to create a user-friendly education tool and to test its validity as a risk predictor by comparing the risk scores from the brochure with an independent physician’s risk evaluation carried out on the same day.
In Phase III, researchers will revise the brochure, test its validity among a large group of community seniors, and then test its predictive accuracy by conducting follow-up phone interviews after 3 and 6 months to determine if the self-assessment tool was both useful and accurate.
Dissemination research on fall prevention: Stepping On in a Wisconsin community In Sept 2007, CDC funded a researcher at the University of Wisconsin for four years to adapt the Australian program, Stepping On, for the U.S. while at the same time maintaining fidelity to the original program. Dr. Mahoney and her colleagues will be evaluating uptake, reach, feasibility, fidelity, adherence, and outcomes related to implementation.
In this project, the research team will examine issues such as:
- The feasibility of implementing this program in rural compared to urban settings;
- Uptake of the program by different community organizations in different settings, such as parish nurses, senior housing and senior centers;
- How effective this program is when delivered by a professional without a health degree.
Evaluating dissemination of a fall prevention program for older adults
The 11,500 senior centers throughout the United States serve as gathering places for older adults and offer both information and support for their clientele. As such, they are potentially powerful mechanisms for delivering injury control interventions to community-dwelling older adults.
This project, begun in October 2005 by the Injury Control Research Center at the University of North Carolina, will assess the perceived needs for, and barriers to, adopting and implementing Safe Steps, a fall prevention program in senior centers. It will also compare the effectiveness of two enhanced dissemination strategies with a mail-out strategy to promote senior center and older adult adoption and implementation of Safe Steps; identify organizational-level factors that predict increased adoption and implementation of Safe Steps by senior centers; and identify individual-level factors that predict increased adoption and implementation by older adults.
The aims of the project will be examined by conducting a needs assessment with a national sample of 510 senior centers. Researchers will also use a randomized, controlled trial of 180 senior centers equally randomized as Safe Steps via a mail-out; Safe Steps with a training component aimed at assisting senior center staff in program delivery; or Safe Steps with a dissemination strategy to address the barriers identified in the needs assessment.
Successful project outcomes will lead to more effective dissemination and increased adoption and implementation of the Safe Steps program to prevent older adult falls. Learning about factors that contribute to successful dissemination of an injury program will also prove useful for other interventions targeting this population.
Estimating the health care costs of older adult fall-related injuries
In 2003, economists at the Research Triangle Institute in North Carolina worked with CDC to estimate the direct medical costs of falls among adults ages 65 years and older in the United States. The study found that, in 2000, direct medical costs totaled $0.2 billion for fatal falls and $19 billion for nonfatal fall-related injuries. Of the nonfatal injury costs, 63% ($12 billion) were for hospitalizations, 21% ($4 billion) were for emergency department visits, and 16% ($3 billion) were for treatment in outpatient settings.
Medical expenditures for women, who made up 58% of the older adult population in 2000, were two to three times higher than for men for all medical treatment settings. Fractures accounted for just 35% of nonfatal injuries, but 61% of costs. Fall-related injuries among older adults, especially among older women, are associated with substantial economic costs. The magnitude of this economic burden underscores the critical need to implement cost-effective fall interventions.
Resulting publications:
Finkelstein EA, Chen H, Miller TR, Corso PS, Stevens JA. A comparison of the case-control and case-crossover designs for estimating medical costs of non-fatal fall-related injuries among older Americans. Medical Care 2005;43:1087–91.
Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5.
Page last modified: June 10, 2008