October 20, 2020
Coauthored by Cheryl Ben-David
Over the last decade, multiple national health organizations and philanthropic organizations have addressed the concept of “Fall Prevention and Ageing In Place for the Elderly” with their attention focused on the rapidly growing problems of elderly falls. While extensive research on fall prevention strategies and their effectiveness exists, there still seems to be a significant gap on how to overcome the fall risk factors to effectively reduce elderly falls. The American Association of Retired Persons (AARP), a United States-based interest group whose stated mission is “to empower people to choose how they live as they age”, reports that 87 percent of seniors express a strong preference for “Ageing In Place for as long as possible….by remaining in their homes.” Alongside, the National Institutes of Health (NIH) reports that “more than half of senior falls occur at home, yet few homes have the features necessary to help older adults safely navigate in them.”
Recognizing the Growing Issue
Each year, an estimated 29 million adults ages 65 and older fall—meaning an older adult falls every second of every day. About one-third of the adults ageing 65 years or older fall each year, with most falls occurring inside the home. Every 11 seconds a senior is treated at an emergency department for fall related injuries that happened inside their home. Every 19 minutes an aged patient dies from fall related injuries. Based on data collected by the US Centers for Disease Control (CDC) and the National Council on Aging (NCOA), more than 2.8 million elderly fall injuries are treated in emergency departments annually, including over 800,000 hospitalizations and more than 27,000 deaths annually, or over 70 per day. This data does not consider unreported fall related injuries, or injuries not treated at an emergency department.
According to the CDC, the medical costs due to the injuries caused by falls ranks as one of the top 20 most expensive medical costs in the US. By end of Year 2020, expenditures related to injuries from falls to seniors are projected to cost nearly $60 billon (Figure 2).
Source: Adapted from Houry et al. 2016 / The CDC Injury Centers Response to the Growing Public Health Problem of Falls Among Older Adults
CDC estimates that the annual deaths from falls will triple to 100,000 by the year 2030 (Figure 1) as will the associated costs to up to $100 billion by the year 2030 (Figure 2). In summary, as the U.S. population ages, elderly falls are projected to increase.
Visibly, unintentional falls are the leading cause of injuries among adults age 65 years and older. Despite clinical and non-clinical programs to identify older adults at risk of falls; to assess the individual risk factors; and to intervene to reduce fall risks, the elderly fall rates continue to increase, and many national organizations within the public health community view elderly falls as a significant health concern. Along with the clinical approach, there is an equal and evolving opportunity to overcome the fall risk obstacles by modifying both the interior and exterior built environment of homes and buildings to reduce elderly falls.
Life Planning is the Prerequisite for “Ageing In Place”
It is apparent that most elderly and seniors prefer to remain in their own homes and “Age In Place”. In order to allow for “Ageing In Place“, a planning process for how to alter the built environment of a home in a manner that enhances active ageing and optimizes the time that one can remain in his / her home, should be understood and molded through intentional design. Therefore, “Ageing In Place“ concepts very often require modifications of the built environment to ensure safety and to offset the risk factors associated with falls and ageing. While the concept of “baby-proofing” a home is known to most, the concept of “elder-proofing” a home is not. The concept of “elder-proofing” should be the new prerequisite to home design, for both new and renovated residential spaces.
The U.S. Department of Housing and Urban Development (HUD) echoes this sentiment when it states, “housing is of particular importance to coordinated health and senior falls prevention because of the amount of time seniors spend at home and its potential as a centralized site to provide essential health and wellness to seniors.” It is expected and natural to overlook the imperceptible fall risk factors in the homes, either because they were not previously fall hazards or they are not construed as hazards because one has grown accustomed to an unchanging spatial setting. The functionality of an unchanged home and its design can morph into new barriers for the elderly over time as one ages, becoming evident only after serious injury, disability, or an associated nursing home placement is suggested, and therefore, preventing the ability to safely remain in the home.
Defining Elderly Falls
Falls are generally broadly categorized as either intrinsic or extrinsic. Falls caused by intrinsic factors are those directly related to the individual, while extrinsic falls are caused by external factors surrounding the individual. The extrinsic factors directly relate to the elderly’s physical environment including elements such as interior home hazards, exterior site elements like sidewalks, use of assistive devices like walkers and canes, and inappropriate footwear.
Although most falls result in minor injuries, per CDC up to 30 percent of seniors suffer moderate to severe injuries, some even resulting in death. In fact, falls are now the fifth leading cause of death for those over 65. Nearly any type of fall can adversely impact a senior’s ability to maintain their independence. Even if a fall causes no noticeable physical injury, it can instill a fear of falling that can lead a senior to limit physical activities and lessen social interactions.
Even though falls are classified along the lines of behavioral, medical, or biological factors for clinical programs, the built environment, both interior and exterior are equally instrumental to the causation and continuum of risk factors associated with falls and ultimately ensuring its mitigation. Therefore, the fall prevention and management strategies can be broken into two major categories:
- Clinical / Medical Evaluation related to intrinsic factors
- Built Environment Assessment and Modifications related to extrinsic factors
Intrinsic Causes and Predictors of Elderly Falls
Beyond the external signs of ageing, silent and subtle changes are also happening internally. Ageing dampens the ability to notice, interpret, and respond to environmental details while also raising the risk of falling. This profile helps to explain the rise in fall frequency and severity with advanced age in comparison to other age groups. The design of a home contributes to falls throughout all age groups but becomes an increasing risk as we age. The anatomy of ageing is highly dependent on the three critical senses that alert us to changes in our immediate environment and help to prevent falls: hearing, vision, and touch. All of which are dampened at varying rates with ageing.
Hearing, vision, and touch are core senses we rely on to remain upright while in motion. Functionally, these senses signal us about the conditions of our immediate environment, requiring some form of action to maintain our upright posture to avert a fall. Advancing age is directly related to losing acuity to notice, interpret, and/or respond to environmental risk factors, which when left unaddressed, will likely result in displacing our balance, often ending in a fall.
Hearing is related to maintaining physical balance. With ageing, the internal body structures used to maintain equilibrium change, contributing to problems with maintaining balance while walking, standing, and even sitting. Similarly, the vision of a 60-year-old is decreased due to physical eye functionality. With ageing, we react more slowly in response to darkness or bright light and visual acuity gradually declines over time making it more difficult to focus eyes on close-up objects. Additional limiting factors include:
- an intolerance for glare like walking into a very sunny room over shiny floors
- a decrease in visual adaption rates and lighting changes when exposed to darkness or a brightly lighted room
- changes to color perception – the aged eye can tell red from yellows, better than blues from greens; and
- a reduction in peripheral vision (side vision) which has also been linked with loss of balance and falls.
Just as with hearing and vision, the ability to sense and process touch, and vibration, is required to establish where the body is relative to the floor. The diminishment of this feedback loop has been linked to increasing fall-risk.
These overviews of the physical changes illustrate how a reasonably “healthy individual” can over the course of time, miss the cues that home adaptation is essential to maintain a safe haven for ageing. Unfortunately, only when the person’s conditions reach a tipping point, where makeshift strategies, succumb to unforgiving home design plans, it revealed that the injury may have been avoidable.
The need to adapt the home design is more apparent during times of illnesses or with physical conditions that directly affect strength and balance. Cognition changes caused by dementia or the side effects of medications used to manage chronic illnesses like depression, sleep problems, high blood pressure, pain and/or diuretics may reduce balance and mental acuity, both of which are linked to falls and will likely require degrees of home adaptation.
Many elderly falls are preventable and often result from predictable risk factors. Consequently, although the elderly fall more frequently than younger adults, falls should not be considered an inevitable consequence of ageing or lack of mobility. In fact, the most common activity connected to outdoor falls is walking. Understanding that the anatomy of ageing dampens one’s ability to easily adapt to the surrounding built environment, and becomes challenging with active ageing, helps to assure and substantiate that new design concepts and approach becomes necessary to enhance the function, safe use and spatial experience by removing fall risk factors and hazards.
Deploying Universal Design for mitigating extrinsic factors related to elderly Falls
Data published by various industry organizations promoting awareness of fall prevention, improving home and environmental safety in community, and public spaces, along with individual residential homes, is recognized as a critical tool to mitigate fall risks over the course of an occupant’s life. Environmental safety is the implementation of policies and procedures that are aimed at ensuring one’s surrounding environment is free of dangers that could cause harm to a person specifically in work areas. A safe place to work is the key element of environmental safety. Similarly, Universal Design works to improve the interior safety of homes, through design concepts aimed at achieving user friendly interiors for a wide array of evolving limitations to enable and embrace Ageing In Place.
Essentially, Universal Design is “Design for All” during the entirety of the life cycle of the design, building or product. The Center for Universal Design defines the concept as, “the design of products and environments to be able to be used by all people to the greatest extent possible without the need for adaptation or specialized design.” Universal Design is a proposed set of guidelines based on the fundamentals of user-friendliness, convenience, and safety, which facilitates individual assessment and modification of a residential setting during the initial design, or afterward during occupancy.
Many of the homes in communities across the U.S. were constructed before accessibility was a priority for many homeowners (and, hence, many homebuilders). The American’s With Disabilities Act (ADA) Standards were adopted by the U.S. Department of Justice (DOJ) and Department of Transportation (DOT) in 1990 for those with physical limitations. Its associated standard, the ADA Accessibility Guidelines for Buildings and Facilities (ADAAG) was also first published in 1991. Similarly, most, if not all, state accessibility laws and local adoptions of the current model building codes also do not address advanced age as part of their scopes. Even though it is widely accepted that advanced age often coincides with diminishing functional abilities, “Advanced Age” or “Ageing” is not a designated physical limitation regulated by the current building codes or state laws or by ADA criteria.
The American Housing Survey (AHS) has issued survey results identifying homes in the U.S. that have accessibility and/or safety features that can also assist with reducing fall risks. It is apparent from the AHS data below, that most U.S. homes have few design elements related to meeting the accessibility design criteria, and most are certainly missing design concepts and/or elements that can be instrumental in mitigating fall risks.
Source: Accessibility / Safety Features in U.S. Homes by American Housing Survey in 2011
The fact that falls are the leading cause of injury, long-term disability, premature institutionalization, and injury-related mortality for the elderly, lends credence to the urgency for adapting the Universal Design concepts as the new practice standard. It is reasonable to predict that removing the extrinsic factors contributing to elderly falls will directly reduce the number of falls, as well as the cost to manage the resulting injuries.
The implementation of Universal Design in the residential setting can significantly aid in mitigating fall risks and provide long-term benefits in sustaining independence and preventing fall induced disability. An effective fall prevention strategy within a community setting requires a comprehensive approach.
A. Building Age-Friendly Home and Spaces
Active ageing is a life-long process that warrants creating age-friendly spaces to improve safety, adaptation, mobility, and independence. The notion that physical structures are an integral component for sustaining the goal of “live-life” in one’s home and workplace has been slow in changing the way builders and designers create spaces, including what individual homeowners consider when selecting a home. The inclusion and creation of age-friendly spaces through implementation of Universal Design concepts can significantly enhance the function, safe use and spatial experience by removing fall risk factors and hazards and ultimately, embracing “Ageing In Place” by mitigating elderly falls.
B. Built Environment Hazards Assessment and Modifications
Numerous studies have revealed that nearly 77 percent of indoor falls occur within the home, while concurrently, additional studies also report that nearly 50 percent of all falls occur outdoors in residential community common spaces. These statistics demonstrate that the Universal Design concepts need to be implemented both within a home and building, and also need to be expanded to the exterior spaces of a home and building to mitigate the risks associated with falls. Of the 50 percent of outdoor falls that occur, nearly 14 percent of these outdoor falls happen in the senior’s own yard or garden. Most outdoor falls occur on sidewalks, curbs, streets, and outdoor stairs due to such exterior site elements with uneven surfaces causing tripping and slipping.
Home modifications are defined as adapting the home environment to make routine tasks easier, help reduce accidents, and support seniors’ ability to live independently in their community and workplace. While the interior of any home is understood to be a safe haven, there are multiple fall factors in the various spaces related to design, orientation, arrangement, layout, function, and use. Bathrooms in a home are most common areas where 70 percent of the indoor falls occur due to tripping, slipping and/or loss of balance. Tight spatial and maneuvering constraints can increase the risk of falls in a bathroom. Dysfunctional design and/or layout of the bedrooms, living room, den, kitchens, and hallways also contribute to fall risk factors within the home. Hallways and circulation open spaces are critical and must be designed such that they can allow for proper maneuvering of the devices intended to assist the elderly throughout their home.
Similarly, the design and functionality of the access pathways that lead to a home including the driveway, patio, decks, front entry porch and exterior stairs are critical to mitigate fall risks. The design and use of these exterior property elements present fall risk factors when dealing with rain, snow, and ice. The design of the transition between the interior and exterior spaces of a home is also crucial to avoid fall risks associated with tripping, loss of balance and slipping.
Enactment of the Universal Design concepts in a new home design and modification (renovation) of an existing home must be embraced to mitigate the unseen hazards throughout the built environment to overcome spatial obstacles for “Ageing In Place”. There are several illustrations of spatial modifications beyond that required by building codes and therefore, more than likely, not incorporated in a home’s design. The concepts of Universal Design at residential communities and homes include, but are not limited to, the spatial relationship and safety, circulation, flooring selections, bathroom layouts, stair design, lighting, kitchen layout, and cabinetry design.
Similar to the residential properties, several illustrations of spatial modifications beyond that required by building codes can be implemented using concepts of Universal Design at retail and commercial properties including but not limited to, the entry vestibule design, flooring selections, building entrances, restroom layouts, lighting, and interior elements design.
Challenges with Existing Properties
Existing residential and commercial properties may have design features that are outdated, but grandfathered in, essentially freeing them from the current building and accessibility code mandates and increasing the likelihood of falls resulting from dated construction.
Remnants of unsafe building elements such as exterior and/or interior stairs with either uneven and/or excessively high or narrow steps; slippery floor surfaces; unmarked edges at floor elevation changes or low ceilings; discontinuous or poorly-fitted handrails and guardrails; inadequate or excessive lighting; loose electrical wires; or inconvenient and unexpected steps at doorway entrances and exits can significantly contribute to avoidable falls and subsequent injuries sustained by the aged.
Deploying the Universal Design concepts to existing buildings in the absence of accessibility design remediation becomes even more necessary to mitigate fall risk factors for the occupants and visitors to such buildings.
Pro-active and Systematic Approach
Age-friendly built environments have been lauded as an essential component by individuals and organizations, working to reduce the number of falls and related injuries sustained by the elderly in their homes and other buildings frequented by the elderly.
A pro-active and systemic approach to identify the most common cause(s) and risk predictors of elderly falls can be initiated with the “Three P’s” review concept of Plan, Predict, and Prevent to create built environments that can mitigate fall risks. The Three P’s review concept is vital to create an age-friendly property and are applicable for any new or existing building project. Overcoming obstacles for preventing falls by the elderly in their own built environments and embracing “Ageing In Place” requires the three major reviews:
- PLAN – Accept that advanced age often coincides with diminishing functional abilities, which would benefit from assessment of the home interiors over a 10 to 15-year planning horizon to greatly help mitigate the likelihood and incidents of falls. Building owners, developers and design professionals must evaluate and provide design that mitigates risks associated with elderly falls and qualifies to support advanced ageing.
- PREDICT – Perform an interior and exterior built-environment assessment with consideration for fall risk mitigation, introduce concepts of Universal Design and review the built environment modifications.
- PREVENT – As a developer or a building owner, introduce the principles of Universal Design in the design development process of a new construction or renovation project, centered on building age-friendly homes and properties, and enhance the safe use and spatial experience to endorse active ageing.
Implementing fall risk assessment and mitigation
The implementation of Fall Risk Assessment and Mitigation Approach concepts is becoming a necessary design consideration for the built environment and our community, and can assist and protect the building owners, developers, property management companies, insurance companies, corporate entities and home owners who Plan, Predict, and Prevent fall-risk factors. These applied concepts can result in building and maintaining safer interior and exterior environments for their occupants and users, integrating Universal Design concepts to mitigate and reduce falls, and mitigating liability due to claims associated with falls and personal injury. Implementing fall prevention as a design initiative can result in a reduction of insurance premiums throughout the lift cycle of a building and property.
THE LIFE CYCLE OF A BUILDING
We are rapidly approaching a demographic phenomenon, linked to the ageing of Baby Boomers, where one in every five, or 20 percent of the U.S. residents will be at retirement age by the year 2030 according to the U.S. Census Bureau. Now consider how many homes that are adaptable or that require adaptions that will be needed to address the physical decline corresponding to active ageing. Recognizing the growing issue of elderly falls, professionals associated with the design and construction of all real property asst types, have an opportunity to provide built environments that can support healthy ageing and independence through accessibility and user-friendly design. We can minimize the role a home design has in contributing to avoidable falls and premature departure of the home dweller to an assisted-living residence. The Three P’s coupled with a collaborative fall risk assessment and mitigation approach can help achieve “Ageing In Place for as long as possible….by remaining in our own Homes.”
How Ankura Can help
World Health Organization (WHO) Ageing and Life Course Global Report on Falls Prevention in Older Age (February 2007)
U.S. National Library of Medicine Study on Preventing Falls Among Older Fallers collaborated with Center for Disease Control and Prevention (CDC) and information provided by John Hopkins University
Craven, Jackie. “Universal Design is Architecture for All.” ThoughtCo, Feb. 11, 2020, thoughtco.com/universal-design-architecture-for-all-175907
What is the difference between accessible, usable, and universal design?” DO-IT, University of Washington, April 30, 2019
Center for Disease Control and Prevention (CDC) STEADI Initiative for Health Care Providers – STEADI Stopping Elderly Accidents, Deaths and Injuries – STEADI Initiative: cdc.gov/steadi
Connell, Bettye Rose. “The Principles of Universal Design.” Version 2.0, The Center for Universal Design, NC State University, April 1, 1997
Centers for Disease Control and Prevention and The Merck Company Foundation: The State of Aging and Health in America 2007
American Housing Survey (AHS) National Surveys and Work Papers
U.S. Department of Housing and Urban Development (HUD) Report for Overcoming Obstacles to Policies for Preventing Falls by the Elderly, February 2017
National Council on Aging (NCOA) Fall Prevention Statistics and Program Initiatives for Fall Prevention: National Falls Prevention Resource Center
Cameron, K., Schneider, E., Childress, D., Gilchrist, C. (2015). National Council on Aging Falls Free® National Action Plan.
Beattie, BL and Peterson, EW. (2007). Exploring practice in home safety for fall prevention. National Council on Aging
National Aging in Place Council (NAIPC) Facts, Statistics, Cost Studies and Initiatives for Fall Prevention
National Center for Injury Prevention and Control. Preventing Falls: A Guide to Implementing Effective Community-based Fall Prevention Programs. 2nd ed. Atlanta, GA: Centers for Disease Control and Prevention, 2015.