Fall Prevention Strategies Depend on Indoor, Outdoor Risk Factors

Older adults have different risk factors when it comes to indoor and outdoor falls. This subtle variation is often ignored and should affect how fall prevention programs are structured, study says.

"Indoor and outdoor falls are both important, but people at high risk for indoor falls are different in many ways from those at high risk of outdoor falls," says Marian T. Hannan, lead author of the study by the Institute for Aging Research of Hebrew SeniorLife. "Failure to separate the two can mask important information on risk factors and may hamper the effectiveness of falls prevention programs."

The study, published in the Journal of the American Geriatrics Society, found that indoor falls are associated with an inactive lifestyle, disability, and poor health, while outdoor falls are associated with higher levels of activity and average or better-than-average health.

Older adults who fell outdoors were somewhat younger than those who fell indoors, more likely to be male and better educated, and had lifestyle characteristics indicative of better health. Those who fell indoors had more physical disabilities, took more medications, and had lower cognitive function than those who fell outdoors.

The study examined 765 men and women, age 70 and older, randomly selected in the Boston area, all of whom underwent a baseline falls assessment, including a home visit and clinic examination. Over a nearly two-year period, 598 indoor falls and 524 outdoor falls were reported, and study participants were interviewed to determine the causes.

Hannan said the study shows that falls are not necessarily a marker of poor health. Almost half of all falls occurred outdoors, and people who fell outdoors had the same or better health than those who did not fall at all. Hannan said epidemiological studies of risk factors for falls in older people may be hampered when falls are combined, with important associations between risk factors and indoor and outdoor falls potentially being missed.

Intervention programs need to be tailored differently for people more likely to fall outdoors than those who tend to fall indoors. "Most fall prevention programs emphasize the prevention of indoor falls, particularly through strength, balance and gait training; use of assistive devices; treatment of medical conditions; reduction in the use of certain medications; improvement in vision; and the elimination of home hazards," Hannan said in the study.

Many of these programs do not take into account the causes of outdoor falls, she said. Falls interventions for community-dwelling seniors should consider their health status, activity level, and other characteristics. Most seniors who fall outdoors do so on sidewalks, streets or curbs, or in parking lots.

"Healthy, active older people should be aware of their surroundings, especially when walking outdoors," said Hannan, an associate professor of medicine at Harvard Medical School. "More attention needs to be paid to the elimination of outdoor environmental hazards involving sidewalks, curbs and streets, such as repairing uneven surfaces, removing debris, installing ramps at intersections, and painting curbs."

According to the Centers for Disease Control and Prevention, nearly 40% of seniors who live in the community fall each year, with many suffering moderate to severe injuries, including hip fractures and traumatic brain injuries. At least half of these falls occur outdoors.

The study was funded by the National Institutes of Health.

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