Home hazard modification programs for reducing falls in older adults: a systematic review and meta-analysis

Introduction

Falls are a significant cause of injuries and death in older adults, leading to ∼36,000 deaths and $50 billion for yearly medical costs (Centers for Disease Control and Prevention, 2023). The older adults who fall can suffer terrible consequences. It might lead to persistent discomfort, and loss of independence. The problem of falls among older adults has grown as a result of the aging population and is projected to become epidemic in scope (Vaishya & Vaish, 2020). Moreover, older adults may develop a fear of falling, resulting in activity restriction and a decline in physical and cognitive functions, which may affect the quality of life (Schoene et al., 2019). Multifactorial therapies, such as exercise prescription, physical activity promotion, education, and home modification, are used by healthcare practitioners to reduce falls and the risk of falls among the older adult (Hopewell et al., 2020).

Environmental factors are the major cause of falls, particularly falls occurring at homes (Zhang et al., 2019; Sophonratanapokin, Sawangdee & Soonthorndhada, 2012). Home modification is a potential intervention to reduce fall risks in this population (Hill et al., 2018). The term “home modification” is used to describe the act of changing settings to reduce the number of accidents and promote independent living (McCullagh, 2006). Previous systematic reviews show evidence for both single- and multi-component treatments that included home modifications to reduce the number and risk of falls among older adults and to improve function for people with a variety of health conditions. (Stark et al., 2017). Cumming et al. (1999) designed randomized study found that among older adults living in the community who were at high risk for falling, a home hazard reduction program did not reduce their risk of falls. The intervention was successful in reducing the rate of falls as a secondary outcome. A specified secondary outcome of the intervention, a lower rate of falls, was achieved. Additionally, another systematic review reveals the positive outcomes of home modification interventions in enhancing participation for community-dwelling individuals and older adults (Chase et al., 2012). A meta-analysis of randomized trials on environmental interventions to prevent falls in community-dwelling older people showed a 21% decrease in the incidence of falls (relative risk (RR) = 0.79; 0.65 to 0.97). The significant treatment impact of one trial was the cause of the heterogeneity. An analysis by Clemson et al. (2008) found a clinically significant 39% reduction in falls (RR = 0.61; 0.47 to 0.79), representing an absolute risk difference of 26% for a number needed to treat four individuals (Clemson et al., 2008).

Although evidence suggest that home modification can enhance the performance and safety of older adults with functional impairments. Nevertheless, previous evidence showed some ambiguous results. A meta-analysis of current scientific evidence would be beneficial for fulfilling this knowledge gap of the effectiveness of home modification interventions. Thus, the goal of this systematic review and meta-analysis was to update prior reviews, investigate the evidence, and characterize the effectiveness of the evidence for the usefulness of environmental interventions in preventing falls, improving the precision of known results.

Results

Identifying eligible trials

Of the 2,108 identified articles (including duplicates), 31 articles were retrieved for the full-text review after the title and abstract screening. After full-text review, 20 articles were excluded because two were not randomized controlled trials, 8 showed the extent of the home modification program as <75%, 7 were not reported falling as the primary outcome, one article was not completely provided in the English language, and two were not related to aging population; 11 studies met the inclusion criteria. The updated search identified five additional articles; of these, one article met the inclusion criteria, and four articles were excluded because one was not a randomized controlled trial, two showed the extent of the home modification program as <75%, and one was not reported falling as primary outcome (Table S2—the detail of the articles excluded after full-text review). In total, the results of 12 trials were included in the final review (Fig. 1).

Risk of bias

Overall quality varied from low to moderate (Table 2; Fig. 2). Most studies had a minimal risk of bias due to appropriate sequence creation, incomplete outcome data, and selective outcome reporting. Five of 12 trials indicated a significant risk of allocation concealment bias, indicating the possibility of selection bias. Nine of 12 indicated a high risk of ascertainment bias from participant and personal blinding, whereas seven of 12 reported blinding outcome assessment, indicating the possibility of ascertainment bias. There was broad agreement among researchers (κ = 0.81, 95% CI [0.68–0.94]).

Table 2:

Risk of bias summary.

Authors	Adequate sequence generation	Allocation concealment	Blinding participant and personal	Blinding outcome assessment	Incomplete outcome data	Selective outcome report	Other source of bias
Stark et al. (2021)	L	L	L	U	L	L	L
Cockayne et al. (2021)	L	L	H	H	L	L	L
Chu et al. (2017)	L	L	L	L	L	U	H
Kamei et al. (2015)	L	H	H	H	L	L	H
Pighills et al. (2011)	L	H	H	L	L	L	H
La Grow et al. (2006)	U	L	U	H	H	H	H
Campbell et al. (2005)	U	L	U	H	H	H	H
Nikolaus & Bach (2003)	L	L	H	H	L	L	L
Pardessus et al. (2002)	U	H	H	H	U	U	L
Stevens et al. (2001)	L	L	H	L	L	L	H
Gerson, Camargo Jr & Wilber (2005)	H	H	H	H	L	U	L
Cumming et al. (1999)	L	U	H	L	U	L	H

DOI: 10.7717/peerj.15699/table-2

Completeness of reporting

Using the TIDieR checklist, the intervention group’s shown method (TIDieR item 3, T3) was best described in the presented information. Two of the least favorably reported elements were the modification of the intervention during the study (T10) and evaluation of intervention adherence (Table S3—the TIDier table). The intervention group trials were reported more thoroughly than those of the control group, as shown in Figs. 3 and 4. For the intervention group, the percentage of trials qualifying for each TIDieR item ranged from 0% to 100%, whereas for the control group, the percentage ranged from 0% to 66.67%. There was broad agreement among researchers (κ = 0.83, 95% CI [0.74–0.92]).

Effect of home modification on falls

After applying meta-analysis to 10 trials (1,960 participants), we obtained moderate-quality evidence that home modification was effective for reducing the number of falls compared with the usual care (Stark et al., 2021; Chu et al., 2017; Kamei et al., 2015; Pighills et al., 2011; La Grow et al., 2006; Campbell et al., 2005; Gerson, Camargo Jr & Wilber, 2005; Nikolaus & Bach, 2003; Pardessus et al., 2002; Cumming et al., 1999). Two other trials (Cockayne et al., 2021; Stevens et al., 2001) could not be included in this meta-analysis. Both trials measured home modification in the emergency department (ED) population. The risk ratio of the 10 trials was 0.93 [0.86, 1.00, I ² = 18%] (Fig. 5).

Discussion

This systematic review and meta-analysis showed the effects of home environmental intervention in preventing falls. Our findings indicated a 7% reduction in the risk of falls across all studies. Only two of 10 studies (Cockayne et al., 2021; Nikolaus & Bach, 2003) found that house modifications did not decrease falls. This may be due to the lack of intervention adherence in both studies. The findings of these studies have implications for policy, practices, and resource allocation, and a pragmatic recommendation is made that the older adults at risk be provided with environmental condition is diagnosed by experienced specialists. One or two visits to the house may be sufficient to lower the likelihood of a fall-prevention intervention, which may be cost-effective and advantageous. According to Campbell et al. (2005), the cost of the home safety program per fall averted was $432 (Campbell et al., 2005).

This study enhances prior literature reviews by giving current data for home modification methods for preventing falls in older adults. In accordance with prior studies, this study indicated that home modifications reduce falls among older persons at high risk (Chase et al., 2012; Clemson et al., 2008). Because of various methods for home modification, this study grouped all studies by the target population to evaluate the efficacy of home modifications. Additionally, this investigation was limited to studies that evaluated the efficacy of interventions for falling as the primary outcome. This study provides professionals with the most recent evidence-based practice in the field of environmental modifications considering specific outcomes and populations. Moreover, to enable standardized and comparable outcomes, guidelines must be set for home modification intervention study. These guidelines should include follow-up period, environment, and outcome measurements, reporting of results, and operational definitions of home modification treatments.

We developed a guidance for health professionals, older adults, and caregivers for what constitutes a high-quality home modification intervention for preventing falls in older adults. Despite its seeming convenience, identifying specific change-related risks represents just the beginning of the complexity. Hence, a full examination of home hazard tools is required. Numerous studies (Romli et al., 2018) have developed a home hazard assessment to reduce falls in the older adult. Each evaluation tool’s validity and reliability are reported so that it can be effectively implemented. The Westmead Home Safety Assessment was implemented by the majority of the studies in this investigation to investigate home hazards. This instrument’s content validity index was 0.80, and inter-rater reliability was fair to good (0.48–1.00). The assessment contained a checklist of 13 home hazards including external trafficways, general indoors, mobility aids, internal trafficways, living area, seating, bedroom, footwear, pets, bathroom, toilet area, kitchen, medication management, safety call system (Clemson, Fitzgerald & Heard, 1999a; Clemson et al., 1999b). The interaction between an individual and their environment consists of risk-taking behaviors, protective behaviors, functional vision, and physical and cognitive characteristics that influence falling. This study demonstrates the importance of interventions that manage these variables. Seldom have studies explicitly focused on these variables for preventing falls. Besides that, almost all studies’ findings support that good adherence produces positive outcomes to prevent falls.

Environmental interventions should be incorporated into predischarge planning for high-risk patients and postdischarge follow-up for those who have a history of falls, according to this study. We propose that older patients treated in emergency rooms following a fall should also be included in this high-risk group. Evidence supports a complete strategy for fallers who present to the emergency room, including home evaluations and occupational therapy intervention (Cockayne et al., 2021; Stevens et al., 2001).

Currently, there is evidence that home modification treatments that are comprehensive, well-targeted, and have an environmental-fit perspective can help reduce falls among the older adult high-risk groups. It seems likely that a compensatory approach consisting of raising awareness, enhancing safety measures, and reducing hazards in the home would be useful for older individuals who are at risk. Assessing the elders and their caregivers, making recommendations, and providing sufficient training, education, and follow-up for successful home modification interventions to promote involvement are the responsibilities of health professionals.

A possible limitation of this review is that the meta-analysis on home modification included a wide range of achievement measures, which could provide a problem for the homogeneity of the outcome measures used in this research. Nonetheless, we believed that falling was a primary outcome of home modification. Moreover, the I ² score of 18% indicated that the statistical heterogeneity in this meta-analysis was minimal. Specific outcomes examined in the many individual trials, such as daily activity performance, measured by specific measures, such as the Barthel Index, could not be applied to meta-analyses. The systematic review presented here has several strengths. This review’s ability to precisely adhere to the PRISMA standards is one of its strongest points. Additionally, the GRADE technique was used to assess the degree of evidence of the results between trials, as presented in a meta-analysis. All trials were evaluated for reporting completeness using the TIDieR checklist. Further, the methodology included a large time frame (since 1999) and covered several bibliographic databases, thereby guaranteeing that relevant literature was captured.

Conclusions

There is moderate-quality evidence from 10 randomized controlled trials that applied home modification to prevent falling in older adults. Across all studies showed a 7% reduction in the risk of falls. The home modification intervention should be:

• standardization

• well focused both person and environmental fit

• adequate follow up

• sufficient training and education for the older adults and their caregivers

• add the intervention to be part of the normal discharge procedure after referral from emergency department.

Supplemental Information