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June 2004

By Debra J. Rose, PhD

Over the course of the past 10 years, there has been a dramatic increase in the scientific knowledge base related to preventing falls in the elderly. Several intervention strategies have been shown to reduce multiple risk factors associated with falls and fall-related disability, as well as fall incidence rates among older adults at different levels of fall risk.^1-3

The evidence also suggests that effective intervention strategies provided to older adults at high risk for falls have the potential to be cost saving, with the costs of operating these types of programs being favorably offset by savings in reduced acute and long-term care expenses. The most effective intervention strategies include those that combine fall risk assessment with specific interventions such as exercise, home inspection and modification, and medication adjustment.⁴ Health promotion and education programs have also been shown to be effective in motivating older adults to change their behavior or immediate living environment as a means of reducing their fall risk.

It is important to note, however, that this type of intervention strategy has not been proven to be effective as a stand-alone intervention strategy.⁴ The development of clinical guidelines for fall assessment by health care professionals⁵ and Quality of Care Indicators⁶ further attests to the advanced state of knowledge regarding the prevention of falls. Given how much we know about how to prevent falls, it is time to put that knowledge into practice.

FALL PREVENTION IN CALIFORNIA
California has the largest elderly population of any state in the United States, with over 3.5 million Californians age 65 and older. On average, two older Californians die every day from fall-related injuries. This statistic alone suggests that falls pose a very real threat to the well-being of older Californians. Each year, more than 1,300,000 Californians in the 65+ age group suffer serious injuries from falls, with an estimated 1.2 million older adults needing to visit an emergency department for a fall-related injury and 60,000 being hospitalized as a result of fall-related injuries. The medical costs associated with a fall-related injury are also extremely high in California. The average medical bill for a hip fracture is $12,500 in California, or a total of $375 million per year. This figure does not include the costs associated with long-term disability and premature mortality. Beyond the high economic costs of serious falls in this population is the human cost: disability, loss of independence, and premature mortality.

The state of California already has in place a blossoming infrastructure designed to address the prevention of falls among older Californians. Many intervention programs that are based on best practice models described in the research literature are already being implemented in medical and community-based settings throughout California. These programs include one or more of the following intervention strategies: health promotion and education, home safety assessments and modification, targeted exercise programs, and multifactorial fall risk assessment and management programs.

The California Fall and Injury Prevention Public Awareness Campaign and StayWell program are examples of two statewide media education programs initiated by the California Department on Aging. The California Fall and Injury Prevention Public Awareness Campaign is designed to make the public aware of simple steps that consumers and caregivers can take to reduce the risk of fall-related injuries and targets older Californians at various levels of risk. The StayWell program promotes healthy lifestyles among older Californians by addressing a number of wellness factors such as exercise, proper nutrition, and injury prevention.

One additional demonstration project currently in progress is the No More Falls! Senior Injury Prevention Project being coordinated by the Epidemiology and Prevention for Injury Control (EPIC) branch of the Chronic Disease and Injury Prevention Division within the California Department of Health Services. The No More Falls! project is a multifaceted fall risk screening and health promotion project being implemented in selected communities within two counties in California. Although the results of the federally funded 3-year demonstration are not yet available, the results of an earlier pilot program were promising with a 20% reduction in the likelihood that older adults would fall 1 year after completing the program. If the demonstration project proves to be as effective as the earlier pilot program, the No More Falls! Program will be adopted in 14 additional counties.

At a regional level, the Community and Home Injury Prevention Program for Seniors CHIPPS) initiated by the San Francisco Health Department combines education of seniors and caregivers with training of health professionals in fall prevention, and home safety assessments and modification. In Alameda County, the Public Health Department, in collaboration with as many as 30 nonprofit and public sector agencies, administers the Senior Injury Prevention Program (SIPP). In addition to fall prevention discussion groups being held regularly throughout the county, an annual Senior Injury Prevention Conference aims to further educate older Californians about injury prevention.

A number of fall prevention programs with exercise as the primary component have also been implemented in community settings throughout California. Aging and Independent Services of San Diego County, in collaboration with San Diego State University faculty, developed an exercise program focused on fall prevention in 25 community sites throughout San Diego county. A similar number of sites in Orange, San Bernardino, and Los Angeles counties currently operate the FallProof balance and mobility program developed at the Center for Successful Aging at California State University, Fullerton.⁷ The FallProof program provides a multidimensional balance and mobility program that targets community-residing older adults identified as moderate-to-high risk. Both outcomes-based programs have demonstrated significant improvements in multiple components of functional fitness, balance and mobility, and balance-related self-confidence.

Although fall prevention programming is not well developed in hospital settings throughout California, some noteworthy programs have been initiated. The Veterans Administration Greater Los Angeles Healthcare System has implemented a fall prevention screening clinic to address risk factors among a moderate to high-risk outpatient population. An interdisciplinary team approach is used to review clinical information, identify medical risk factors (eg, vision deficits, imbalance), assess underlying disease management, design tailored interventions, and provide follow-up monitoring. In addition to high patient satisfaction ratings, fall incidence rates were significantly lower at a 3-month follow-up assessment.

While some initial efforts have been made to initiate fall prevention programs in Adult Day Health Care (ADHC) and Adult Day Care (ADC) programs, as well as residential care facilities within California, these two settings have been identified as ones in need of sustainable fall prevention programming. Very few fall prevention programs and services for the hard-to-reach older adult populations (eg, frail, homebound, culturally or geographically isolated) currently exist in California.

CREATING A STATEWIDE BLUEPRINT
In April 2002, recognizing the need to address fall prevention issues in a statewide forum, the Archstone Foundation, with the assistance of a steering committee comprising fall prevention experts and other interested health care professionals, invited key stakeholders within California to strategize on implementation of a statewide fall prevention blueprint. A planning committee developed guiding principles and set objectives and outcomes for a statewide leadership conference. The conference was held in Sacramento, Calif, on February 5-6, 2003, with the goals of being able to describe the state of the art in fall prevention and the existing infrastructure for fall prevention services that currently exists in California, and suggest future directions for a California Blueprint for Fall Prevention.

In preparation for the conference, advanced reading material summarizing current knowledge and best practice models in fall prevention in the elderly was distributed to invited conference attendees in the form of a series of white papers that served as the background document for the conference. These white papers are currently available on the Archstone Foundation Web site. The 2-day conference consisted of keynote presentations by fall prevention experts interspersed with focused breakout sessions on key fall prevention issues.

IDENTIFICATION OF KEY ISSUES
A number of common themes and key issues emerged from the conference and will clearly shape the Fall Prevention Blueprint that is being implemented in California. These are briefly outlined below:

California already has an infrastructure in place with services and programs that can address prevention of falls among seniors and advocates. The primary goal will therefore be one primarily of expansion rather than creation. Identifying the existing gaps in services and programs and developing effective strategies for their closure will be the highest priority.

There is a well-developed knowledge base related to fall prevention. Fall risks and appropriate prevention activities have been well documented and quality indicators established.

The training of professionals is a primary issue. While the knowledge base in fall prevention is now extensive, it is clear that it is not yet widely utilized. Regulations and licensing requirements that incorporate fall prevention guidelines are in place for institutions and similar requirements are needed for community-based practice. In addition, professional training that integrates fall prevention into existing curricula for physicians and associated health professionals needs to be extended.

Multi-agency strategies are needed to encourage the integration of multiple agencies and multiple disciplines beyond traditional work-group boundaries. In addition, while some resources for fall prevention exist, funding is often unstable, fragmented, and/or difficult to access. The general public also lacks awareness that falls can be prevented, and prevention efforts should address the racial and cultural diversity of California populations, as well as urban-rural differences. Finally, a central clearing house/coordinating body is needed to share information, facilitate networking, and encourage training.

THE NEXT STEPS
The first step in the construction and implementation of a statewide blueprint began with the formation of a consortium comprising fall prevention experts from the University of Southern California Andrus Gerontology Center, California State University, Fullerton, the Greater Los Angeles Veterans Administration Geriatric Research Education Clinical Center, and the EPIC branch of the California Department of Health Services. Working in close collaboration with the Archstone Foundation, this group is currently finalizing the blueprint document that will establish the strategic priorities for the statewide initiative.

A Fall Prevention Center of Excellence is also being created at this time and will provide the administrative focus and leadership needed to build a broad constituency base among partners and consumers and coordinate activities related to the statewide initiative. The overarching mission of the new center will be to provide leadership, create new knowledge, and develop strategies and programs to prevent falls. The major objectives of the center are outlined below:

Create and disseminate information about fall prevention to targeted audiences.
Conduct training and education for professionals, service providers, and students through online training, workshops, and conferences.
Develop new programs and improve existing programs in fall prevention.
Create systems change through networking, advocacy, and policy analysis.
Better understand and identify the causes of falls among older adults at various levels of fall risk and the types of intervention strategies that are effective in reducing fall incidence rates and fall-related disability.

SUMMARY
Many falls and injuries related to falls can be prevented with existing knowledge and technology. But effective fall prevention will require the collaborative efforts of many organizations as well as changes in the behavior of older adults and providers, and systematic changes in organizations. Many effective interventions currently exist, but improved access, additional resources, and coordination and commitment across systems are needed. In summary, we know how to prevent falls and reduce injuries, using proven intervention strategies aimed at both low-risk and high-risk older adults. There is a wide spectrum of screening and assessment tools available and effective intervention practices. The challenge now is to put into practice throughout California the state-of-the art knowledge that has already been compiled through innovative programs and rigorous research.

Debra J. Rose, PhD, is a professor in the Division of Kinesiology and Health Science and codirector of the Center for Successful Aging at California State University, Fullerton.

REFERENCES

Scott VJ, Dukeshire S, Gallagher E, Scanlan A. A best practices guide for the prevention of falls among seniors living in the community. Report prepared on behalf of the Federal/Provincial/Territorial Committee of Officials Seniors) for the Ministers Responsible for Seniors, Ottawa (2001). Available at: www.hc-sc.gc.ca/seniorsaines/pubs/best_practices/intro_e.htm. Accessed May 11, 2004.
Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2001;(3):CD000340.
Rose DJ. Results of intervention research: implications for practice. Generations. 2003;4:60-65.
Shekelle P, Maglione M, Chang J, et al. Falls Prevention Interventions in the Medicare Population. RAND-HCFA Evidence Report Monograph. Baltimore: HCFA;2002. Publication #HCFA-500-98-0281.
American Geriatrics Society, British Geriatrics Society, Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664-772.
Rubenstein L, Powers CM, MacLean CH. Quality indicators for management and prevention of falls and mobility problems in vulnerable elders. Ann Intern Med. 2001;135:686-693.
Rose DJ. Fallproof. A Comprehensive Balance and Mobility Training Program. Champaign, Ill: Human Kinetics; 2003.

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