Healthy Aging Column – Watch Your Step!

Research in the Department of Occupational Therapy at Colorado State University is looking at falls among older adults. Falls are the leading cause of death from injury among people 65 years and older in the United States, with more than a third of adults aged 65 years or older falling each year. In 2001, this was more than 1.6 million older adult emergency room visits with nearly 388,000 associated hospitalizations.

By 2020, the estimated cost of fall-related injuries may reach $32.4 billion. The majority of fall-related injuries occur in older adults living independently. In many cases, this leads to depression when their physical functioning does not improve after a fall. Most alarming is that some 70 percent of the fall injuries consist of falls indoors or within the housing area.

In Colorado, nearly 7,750 people are hospitalized for fall-related injuries annually, and about 197 older adults die as the result of falls. Colorado is among a block of states in the West and upper Midwest with age-adjusted, fall-related death rates that are significantly above the U.S. rate of 4.7 per 100,000 population.

Fall risks are generally due to one of two factors. They can occur due to intrinsic factors such as Parkinson’s disease and normal age-related changes in vision, joints, muscles, gait and balance. They can also occur due to extrinsic factors occurring in the environment – both indoors and outdoors – and can include low lighting and low-height seating.      

Conflicting information on predictors of falls and the role of home environmental hazards have been described including a number of observational studies indicating no difference in the rate of falls based on number and type of hazards in the home. Still others have linked low lighting and low seating with falls in the home.  

The aims of the occupational therapy fall research and prevention project are aligned with the first goal of Healthy People 2010, to help individuals of all ages increase life expectancy and improve their quality and years of healthy life, reacting to factors in the physical and social environments. Identifying and reducing physical hazards in the home is a major theme of this project.

In addition to doing home evaluations to identify extrinsic (or environmental) hazards in the home possibly leading to increased fall risk, the OT fall prevention study provides recommendations and minor home modifications aimed at reducing the risk. So far, the project

has worked with 12 participants, aged 59-83, living in nine homes in Northern Colorado.

Home evaluations have yielded the following information about environmental (extrinsic) hazards. On average, homes had 10 stairs inside, three stairs to the most frequent access into and out of the house, nine area rugs, seven thresholds (elevated areas in doorways or moving from smooth flooring to carpeting), and most households had one or more stepstools in use with an average height of 16 inches. The long-range plan is to gather similar information from a large number of homes and begin to look for relationships between environmental hazards in the home and fall rates.

The study also looks at attributing causes – why do people think they fall, or how do they perceive risk? Participants reported intrinsic fall factors such as pain associated with arthritis in the hips, knees and ankles as well as unsure balance, and extrinsic risks including edges of rugs and uneven ground.

While fear of falling is reported in the literature as an actual cause of more falls and a reason people limit their daily activities, only two participants reported being afraid of falling. Both participants had higher than average tub height, no adaptive equipment in use at the time of evaluation and a lower than average number rugs and thresholds – but we don’t know the meaning of these characteristics in terms of contributing to fear. All of the other participants expressed realistic concern and said they were cautious in their daily activities. None of the participants, including the two who reported being afraid of falling, limited their activities based on being fearful.

Recommendations and modifications provided in the study have included installation of stair railings (inside and outside), tub benches for sitting while showering and sitting to enter the tub instead of stepping over the tub wall, taping the edges of or removing throw rugs, using step stools with hand railings, tub grab bars, changing the swing direction of screen/storm doors to allow easier entrance, and raised toilet seats and toilet grab bars. The study has also tried to increase awareness of small pets in the house, using lights when walking into garages and up and down stairs, and reducing clutter of walking pathways in the home. We hope to find that the information gained in home evaluation and recommendations given based on this information will reduce the likelihood of falls in and around the home.

This study, as part of an ongoing effort to reduce falls, was funded through a grant by the Colorado Injury Control Research Center and was carried out by Amanda Cool, Krista Eaton, Sarah Golliher, Susan McCoy, Stella Murphy, Jill Savage, Arie Schwartzman, Jennifer Townsend, Sara Tuman as a degree requirement for the master of science degree in occupational therapy. Minor home modifications were carried out in conjunction with a Volunteers of America organization called Safety for Seniors Handyman Project, who volunteered their services for obtaining the supplies and actual building/installation.

Additional information on Healthy Aging is available on the Colorado State University Cooperative Extension Web site at under Family/Consumer.

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by David Greene, Ph.D., OTR, Associate Professor of Occupational Therapy, Colorado State University