Fall Hazards Within Senior Independent Living: A Case-Control Study

Abstract

Aim:

The main purpose of this research was to identify significant relationships between environmental hazards and older adults’ falling.

Background:

Falls can present a major health risk to older persons. Identifying potential environmental hazards that increase fall risks can be effective for developing fall prevention strategies that can create safer residential environments for older adults.

Methods:

The research included a retrospective analysis of 449 fall incident reports in two case-control buildings. In the homes of 88 older adults residing in independent living, an observational study was conducted to identify environmental hazards using two assessment tools including Westmead Home Safety Assessment (WeHSA) and resident interviews.

Results:

A fall history analysis indicated that falls occurred in the bathroom were significantly associated with hospitalization. The observational study revealed that the bathroom was the most common place for environmental hazards. The research showed, with increasing age and use of mobility assistive aids, there was a corresponding increase in the total number of environmental hazards. Home hazards were significantly and independently associated with the incidence rate of falls. In other words, the high fall rate building included more environmental hazards compared to the low fall rate building while controlling for residents’ age and mobility.

Conclusion:

The current study provides empirical evidence of the link between environmental hazards and older adults’ falling, which is useful for developing effective fall intervention design strategies.

Keywords

fall hazards long-term care facilities environment of care case-control study

Introduction

Falls can present a major health risk to older persons. For adults age 65 and above, falls can be life altering with the most serious consquences of falls leading to disability or even death (Costello & Edelstein, 2008). Approximately one third of older adults fall each year and half of this group will have repeat falls (Tromp et al., 2001). Older adults are especially vulnerable to severe injuries from fall accidents in their homes due to prevalent physical and cognitive limitations typically associated with aging (Iwarsson, Horstmann, Carlsson, Oswald, & Wahl, 2009).

Older adults are especially vulnerable to severe injuries from fall accidents in their homes due to prevalent physical and cognitive limitations typically associated with aging

To examine the triggers of falls within older adults’ immediate living spaces, both intrinsic factors and extrinsic factors come into play. Intrinsic factors consider person-centered risk factors including age, physical limitations, or chronic diseases. Extrinsic factors examine physical environmental factors within living spaces such as the flooring surface or lighting (Pynoos, Steinman, Do Nguyen, & Bressette, 2012). Research into these intrinsic and extrinsic factors can suggest fall prevention strategies and help create safer residential environments for older adults.

Existing research has examined the role of extrinsic factors on older adults’ falling because environmental hazards are relatively easy to address in a short time (Feldman & Chaudhury, 2008; Lord, Menz, & Sherrington, 2006; Wood-Nartker, Guerin, & Beuschel, 2014). Many research studies developed various home assessment tools and identified a falling risk factor by knowledgeable observers or informants (Clemson, Bundy, Cumming, Kay, & Luclett, 2008; Tomita, Saharan, Rajendran, Nochajski, & Schweitzer, 2014). However, environmental hazards also may be identified by older adults’ perceived aspects of the environment. As Lawton and Nahemow (1973) argued, people with low mental or physical capacity are much more sensitive to environmental press than people with higher competence. The residents’ self-perception about environmental hazards could reflect their experiences and behaviors related to falling, which provide new insight about fall prevention strategy (Iwarsson et al., 2009). Thus, examining the perceived aspects could also be play an essential role in identifying environmental hazards. Therefore, this study represents one of the few comprehensive attempts at integrating both approaches (i.e., identifying environmental hazards by both researchers and elderly residents). However, fewer studies have attempted to examine environmental hazards with this comprehensive approach.

The main purpose of this research was to identify any significant relationships between environmental hazards and older adults’ falling. As a pilot study, the aims of the study were as follows: (1) to explore consequences of falls in two residential units that have been identified as having the highest and lowest fall rates within a senior living community; (2) to examine the relationship between age, mobility, and environmental hazards; and (3) to compare and contrast the fall hazards between highest and lowest fall rate buildings.

Environmental Hazards as a Falling Factor of Older Adults

Various research studies have delineated the relationship between the environmental hazards and falling of older adults. They showed inconsistent results, but a stable relationship appears between environmental hazards and falling injuries of frail older adults.

Previous research verified that home environmental hazards are a significant factor contributing to falls in the homes of older adults through a systematic review and meta-analysis (Clemson et al., 2004; Letts et al., 2010). Their results showed that reducing environmental hazards is effective for fall prevention. The most common environmental hazards increasing falling risk include poor lighting, slippery floor surface, steps and stairs, inappropriate furniture, lack of grab bars, and high cabinets. When controlling for intrinsic factors including age, gender, gait and balance, and the medications of 937 older residents, home hazards were significantly associated with the incidence rate of falls (Leclerc et al., 2010).

However, in another systematic review article, Feldman and Chaudhury (2008) argued that a strong link between environmental hazards and fall accidents has yet to be established. Carter, Campbell, Sanson-Fisher, Redman, and Gillespie (1997) failed to find a causal relationship between the presence of environmental hazards and falls after a cross-sectional survey of 425 older adults. Some researchers have suggested the inconsistent relationship between environmental hazards and fall accidents because of time-varying covariates of conventional cohort studies. In other words, environmental hazards at the time the research conducts may be different from those at the time a fall occurs, thereby weakening a true association (van Bemmel, Vandenbroucke, Westendorp, & Gussekloo, 2005). Also, the weak relationship may occur because homes of older adults in previous research have different characteristics (e.g., floor layout, building materials, and furniture types).

Despite the lack of consensus among research findings, a targeted high-risk group is more likely to benefit from reducing environmental hazards. Environmental modification programs were effective in reducing falls of older people with severe visual impairment and poor physical condition (La Grow, Robertson, Campbell, Clarke, & Kerse, 2006; Nikolaus & Bach, 2003). Clemson, Cumming, and Roland (1996) similarly concluded that home hazards might increase the risk of falls of older adults with cognitive impairment.

Method

Design

This research study occurred in a senior living community located in North Central Florida. The tripartile methodology consisted of historical resident fall data, resident self-reports of fall hazards, and assessments of environmental hazards in residents’ living units.

Sampling and Setting

The fall incident reports obtained from all five independent living buildings in the senior living community were used to select case-control study sample buildings as well as explore consequences of falls. Unlike assisted living community, residents in independent living buildings did not require assistance with daily activities or 24/7 nursing, but they could access to various services and amenities which the senior living community offer (e.g., meals, housekeeping, and social club). Five independent living buildings reflect 17 types of floor plans from 420 sq. ft. to 1,506 sq. ft. The retrospective data¹ included 670 falls that the center’s registered nurses reported using a standardized reporting format from January 2012 through December 2015. These incident reports included fall location, building name, age and gender of resident, the severity of the incident injury,² and the time of the incident. In order to select two case-control buildings, this research computed fall rate averages (the total number of fall accidents over 4 years divided by the average number of residents over 4 years) of five independent living buildings. As a result, two buildings were selected; one has the highest reported fall rates (345 falls with 154.8 residents: 2.23 fall rate average) and the other has the lowest reported fall rate (104 falls with 122.2 residents: 0.85 fall rate average).

The high fall rate building was built in 1990s and contains 180 apartments with units representing five types of floor plans. In contrast, the low fall rate building was built in 2000s and has 96 apartments with three floor plan options. Both buildings have similar amenities (e.g., housekeeping, scheduled transportation, flexible meal plans, and fitness center and wellness programs); however, the square footage and layout differed between the low and high fall buildings. At the time of the data collection in 2016, the number of residents totaled 284 in two buildings (high fall rate building—158 and low fall rate building—126).

After gaining approval from the director of the retirement community and the institutional review board at the University of Florida, invitation letters were sent to recruit potential research participants. Those residents who were interested in participating in the study were asked to fill out their contact information and leave it in the secured entry box in the lobby of their buildings. Potential research participants were also contacted by phone to schedule an interview and home assessment.

Instruments and Assessments

This research employed the Westmead Home Safety Assessment (WeHSA) that has been validated for identifying most common fall hazards and widely cited in peer-reviewed journals. The assessment tool demonstrated the high content validity and interrater reliability (Clemson, Fitzgerald, & Heard, 1999). To ensure validity in use, this assessment tool recommends completing the online training workshop where provides specific information how to conduct a comprehensive home assessment. The first author completed the online education training before home assessment.

The WeHSA was revised to enhance the suitability of specific items for the target homes in this study because this research focuses on environmental hazards inside the homes of older adults. An abbreviated version of the WeHSA contained 34 items rated as hazards or not hazards inside of older adults’ residences, defined as the low fall or high fall buildings.

Other locally developed assessments of perceptions of fall risks in the resident home units were gathered during on-site questionnaires and in face-to-face interviews. A semistructured questionnaire collected residents’ age, gender, habitation status, that is, residing with spouse, living with a roommate or living alone, and use of any mobility assistive aids (e.g., cane, walker, or wheelchair). Residents’ self-reported mobility level was measured using a 5-point Likert-type scale from 1 (very poor) to 5 (very good). During the interviews, residents gave their insights on any environmental hazards they thought increased the risk of falling within each space of their units and specific spaces they had the most concerns about falling.

Data Collection

The research team, consisting of the first author and a student assistant majoring in health science, collected the data within the residents’ homes. Upon arrival at their homes, the first author conducted a home assessment to identify potential environmental hazards using the WeHSA. After that, the research team interviewed the residents and audio recorded the interviews that were then transcribed and anonymized. All participants (N = 88) gave permission to be audiotaped and also agreed to have a few photographs taken of their home features during the visit. The team spent between 40 and 60 minutes during the on-site assessment. Data collection occurred between March and July 2016.

Data Analysis

The transcribed interview data were coded by phrases or words to identify environmental hazards using the keyword-in-context analysis (Onwuegbuzie, Leech, & Collins, 2012). Two steps were considered for the data analysis: (1) the researchers reviewed all transcribed transcripts independently to create categories based on predefined environmental hazards from the WeHSA to increase the reliability of data coding. For example, if residents described that the floor in the bathroom as slippery which may increase fall-related injuries, the slippery floor in the bathroom is coded; (2) the researchers reviewed all transcriptions and coding data again, then made data counts using Microsoft Excel (2016). Identified environmental hazards from both assessment approaches were individually categorized within six design features: accessibility, floor, furniture, lighting, mobility, and safety bar. The number of environmental hazards was also coded by the type of space within the unit: living/dining, kitchen, bedroom, and bathroom. Fall history and categorical interview data were analyzed using SPSS 22.0. χ² statistical analyses explored relationships between the fall incident occurrence and sociodemographic variables as well as time of fall, fall location, and severity of the injury resulting from the fall. An independent sample t test was conducted to compare mean difference in the number of environmental hazards according to residents’ age and mobility level. Analysis of covariance (ANCOVA) was computed to determine whether there was a significant mean difference in environmental hazards between the two buildings while controlling for covariate variables: residents’ age and mobility.

Results

Environment and Person Characteristics

The final sample consisted of 88 residents, 48 residents represented the high fall rate building and 40 residents occupied the low fall rate building (Appendix A). The sample ranged in age from 71 to 98 years with a mean age of 85.06 years (SD = 6.55). These residents fell into “young-old” and “old-old” age ranges, with being under 85 years old (46, 52.3%) and 85 years old and older (42, 47.7%). The sample consisted of 26 males (29.5%) and 62 females (70.5%). A total of 53 residents (60.2%) used a walker. About two thirds (60, 68.2%) were living alone, 24 residents were living with a spouse and 4 residents lived with their son or daughter. The average perceived mobility level was 3.70 (SD = .97): high fall rate building (M = 3.42, SD = 0.96) and low fall rate building (M = 4.05, SD = 0.88). The profile showed that the residents in the high fall rate building were more likely to be older and less mobile as well as they were more likely rely on a walker.

Creating a Composite Picture of Fall Risks

To overview larger trends relating to falls, this study examined the pattern of falls that occurred in the two buildings. From January 2012 to December 2015, 182 residents suffered falls that resulted in 449 recorded incidents. Some residents fell repeatedly, while others reported just one incident: 97 persons (53.3%) fell once; 39 (21.4%) fell twice; 17 (9.3%) fell 3 times; and 29 (15.9%) fell four or more times. Appendix B shows the baseline data of fall history by building type. Most fall incidents were reported by women (72.6%) and the majority were 85 years old or older (80.8%). Nearly 57% of falls were documented as “no injury,” and most fall incidents (73.5%) occurred inside the unit homes. The remainder of the falls took place in the common areas of buildings (e.g., social spaces or restaurants). A χ² test of independence examined any potentially confounding factors between two buildings but did not find any difference in the residents’ age, gender, time of the fall, or severity of the injury. However, a statistically significant relationship validated the fall location, χ² = 13.75, df = 3, p = .003. Falls in the common areas in the low fall rate building were more likely to happen as compared to the high fall rate building.

Table 1 shows the results of the χ² test of independence that examined relationships between the locations of the fall and age, gender, time, and severity level. The location of the fall did not differ by age or gender. The results did reveal relationships between the location of the fall and time of the fall incident, χ² = 58.31, df = 6, p < .001, and the falls’ severity level, χ² = 12.05, df = 6, p = .042. These statistically significant findings showed falls occurred in the bathroom were significantly associated with hospitalization. Also, falls in the bedroom and bathroom were more likely to happen between 12 a.m. and 8 a.m. than any other time.

These statistically significant findings showed falls occurred in the bathroom were significantly associated with hospitalization. Also, falls in the bedroom and bathroom were more likely to happen between 12 a.m. and 8 a.m. than any other time.

Table 1.

The Location of Falls by Age, Gender, Time, and Severity Level.

Characteristics	Living/kitchen, f (%)	Bedroom, f (%)	Bathroom, f (%)	Common Area, f (%)	χ²
Age
Under 85	30 (15.3)	15 (19.2)	11 (19.6)	30 (25.2)	4.702
85 and over	166 (84.7)	63 (80.8)	45 (80.4)	89 (74.8)	4.702
Gender
Male	57 (29.1)	13 (16.7)	20 (35.7)	33 (27.7)	6.464
Female	139 (70.9)	65 (83.3)	36 (64.3)	86 (72.3)	6.464
Time
08:01–16:00	89 (45.4)	30 (38.5)	17 (30.4)	68 (57.1)	58.314***
16:01–24:00	70 (35.7)	15 (19.2)	16 (28.6)	47 (39.5)
24:01–08:00	37 (18.9)	33 (42.3)	23 (41.1)	4 (3.4)
Severity levels
No injury	119 (60.7)	51 (65.4)	26 (46.4)	62 (52.1)	12.053*
Minor injury	39 (19.9)	13 (16.7)	10 (17.9)	32 (26.9)
Hospitalization	38 (19.4)	14 (17.9)	20 (35.7)	25 (21.0)

Note. N = 449.

*p < .05, **p < .01, ***p < .001.

Fear of Falling Concerns and Location Specificity

To better understand the resident perspective, participants were asked to identify any specific locations that seemed to pose a fall risk as shown in Table 2. Of the four spaces, residents’ perceived the bathroom (79.5%) as causing concern, followed by the kitchen (30.7%), living/dining room (27.3%), and bedroom (18.2%). A χ² test of independence indicated that residents in the high fall rate building were more likely to be afraid of falling in the bathroom, χ² = 4.107, df = 1, p = .043 and bedroom, χ² = 8.566, df = 1, p = .003, while residents in the low-rate building were more likely to be concerned about falls in the living/dining room, χ² = 11.619, df = 1, p = .001.

Table 2.

Concern About Place and Fear of Falling.

Concerned Place of Fear of Falling	High Fall Rate Building (n = 48)		Low Fall Rate Building (n = 40)		Total (N = 88)		χ²
Concerned Place of Fear of Falling	Yes, f (%)	No, f (%)	Yes, f (%)	No, f (%)	Yes, f (%)	No, f (%)	χ²
Bathroom	42 (87.5)	6 (12.5)	28 (70.0)	12 (30.0)	70 (79.5)	18 (20.5)	4.107*
Bedroom	14 (29.2)	34 (70.8)	2 (5.0)	38 (95.9)	16 (18.2)	72 (81.8)	8.566**
Kitchen	16 (33.3)	32 (66.7)	11 (27.5)	29 (72.5)	27 (30.7)	61 (69.3)	0.349
Living/dining	6 (12.5)	42 (87.5)	18 (45.0)	22 (55.0)	24 (27.3)	64 (72.7)	11.619**

Note. N = 88.

*p < .05, **p < .01, ***p < .001.

Environmental Fall Hazards From WeHSA and the Resident Perspective

Using the WeHSA, the research team identified 1,149 different fall hazards (high fall rate building: 734, low fall rate building: 415). The residents from the two building recognized 550 different fall hazards (high fall rate building: 324, low fall rate building: 226). Appendix C indicates identified environmental hazards based on six design elements and locations.

Across both buildings, the WeHSA described the most common hazards as accessibility (454, 39.5%), flooring surfaces (268, 23.3%), and lighting (193, 16.8%). Likewise, the resident interviews also showed that they saw the most common fall risks as accessibility (156, 28.4%), followed by flooring surfaces (134, 24.4%), and lighting (107, 19.5%). In terms of specific space of identified environmental hazards, the WeHSA shows the bathroom (466, 40.6%) was the most common space for falls followed by the living/dining room (304, 26.5%), bedroom (222, 19.3%), and kitchen (157, 13.7%). Likewise, the residents identified the bathroom (235, 42.7%) as the most common space for falling dangers. They also reported several potential environmental hazards in different spaces in their unit: the living/dining room (134, 24.4%), kitchen (110, 20.0%), and bedroom (71, 12.9%).

As Figure 1 indicates, prevalent hazards included poor access to shower, difficulty reaching high shelves, inadequate night lighting, slippery and uneven floor surfaces. Residents in the high fall rate building were more likely to be concerned about dim lighting, lack of storage for a walker, lack of grab bars, and lack of space for maneuverability in the kitchen area. Other high fall risk areas in the high fall buildings focused on the bathroom design including lack of grab bars and slippery flooring materials as well as the poor proximity to the bathroom from the bedroom. That is, the master bedroom did not have an adjacent bathroom; in these units, residents needed to walk down a short corridor to get from the bedroom to the bathroom.

Figure 1.

Common environmental hazards in the high fall rate building.

Differences in Environmental Hazards Based on Age and Mobility

An independent samples t test was conducted to compare mean difference in environmental hazards from two assessment approaches according to residents’ age (old-old and young-old) and mobility level (walker user and nonwalker user). The correlation test found a weak correlation between the user of walker and age (r = .265, p = .013).

Old-old (85 years old and more) versus young-old (under 85 years old)

As shown in Table 3, there were significant differences emerging between the relatively younger and older residents in terms of environmental risks of falling. The WeHSA indicated that signifiantly more environmental hazards existed in the homes of old-old (M = 14.14, SD = 2.98) compared to the homes of young-old (M = 12.07, SD = 2.61), t(92) = 3.483, p = .001. Three of the six design features including accessibility, flooring, and safety bars were significantly identified in the homes of old-old compared to young-old. The resident interviews also showed that old-old (M = 6.98, SD = 2.45) were more likely to perceive environmental hazards in their homes than the young-old did (M = 5.59, SD = 1.73), t(92) = 3.088, p = .003. No other significant differences in the six types of design features appeared between the age groups.

Table 3.

Environmental Hazards According to Residents’ Age.

Environmental Hazards		WeHSA					Resident’s Interview
		Old-Old		Young-Old		t	Old-Old		Young-Old		t
		(n = 42)		(n = 46)			(n = 42)		(n = 46)
		M	SD	M	SD		M	SD	M	SD
	Total	14.14	2.98	12.07	2.61	3.48***	6.98	2.45	5.59	1.73	3.09**
Features	Accessibility	5.40	0.94	4.93	1.08	2.17**	2.00	1.25	1.57	0.86	1.92
	Floor	3.38	0.94	2.74	0.61	3.84***	1.71	1.33	1.35	1.18	1.37
	Furniture	0.55	0.50	0.57	0.83	−0.12	0.50	0.59	0.37	0.64	0.98
	Lighting	2.19	0.77	2.20	0.78	−0.03	1.26	0.96	1.17	1.00	0.42
	Mobility	1.10	0.91	0.93	0.95	0.81	0.43	0.50	0.28	0.46	1.43
	Safety bar	1.52	0.86	0.70	0.96	4.23***	1.07	1.00	0.85	0.94	1.08
Locations	Living/dining	3.50	1.254	3.41	1.326	0.315	1.60	0.94	1.46	1.03	0.66
	Kitchen	1.86	0.417	1.72	0.455	1.496	1.26	0.89	1.24	0.67	0.14
	Bedroom	2.71	0.708	2.35	0.674	2.487*	1.05	0.91	0.54	0.69	2.95**
	Bathroom	6.07	1.827	4.59	1.857	3.775***	3.07	1.49	2.35	1.54	2.24*

Note. N = 88. WeHSA = Westmead Home Safety Assessment.

*p < .05, **p < .01, ***p < .001.

Walker user versus nonwalker user residents

Table 4 revealed that the total number of environmental hazards between two groups was significatly different. For example, the WeHSA indicated that environmental hazards were greater in the homes of walker users (M = 13.98, SD = 2.55) compared to the homes of nonwalker users (M = 11.66, SD = 3.04), t(92) = 3.873, p < .001. Likewise, environmental hazards associated with accessibility and safety bars were significantly identified more in the homes of walker users compared to nonwalker users. Environmental hazards in the kitchen and bathroom of walker users were identified. The resident interviews also indicated that walker users (M = 6.98, SD = 2.16) were more likely to perceive environmental hazards in their homes rather than their counterparts who were not using walkers (M = 5.14, SD = 1.80), t(92) = 4.16, p = .000. Walker users were more likely to perceive environmental hazards associated with accessibility and mobility rather than nonwalker users. Specifically, walker users were more likely to perceive environmental hazards in their kitchens and bathrooms compared to nonwalker users.

Table 4.

Environmental Hazards According to Residents’ Use of Walker.

Environmental Hazards		WeHSA					Resident’s Interview
		Walker User (n = 53)		Nonwalker user (n = 35)		t	Walker User (n = 53)		Nonwalker user (n = 35)		t
		M	SD	M	SD	t	M	SD	M	SD	t
	Total	13.98	2.55	11.66	3.04	3.87***	6.98	2.16	5.14	1.80	4.16***
Features	Accessibility	5.43	1.07	4.74	0.85	3.22***	2.19	1.04	1.14	0.81	5.03***
	Floor	3.09	0.71	2.97	1.01	0.67	1.53	1.40	1.51	1.04	0.05
	Furniture	0.58	0.80	0.51	0.51	0.47	0.53	0.64	0.29	0.57	1.82
	Lighting	2.30	0.72	2.03	0.82	1.64	1.15	0.91	1.31	1.08	−0.77
	Mobility	1.09	0.88	0.89	0.99	1.03	0.47	0.50	0.17	0.38	3.00*
	Safety bar	1.47	0.89	0.51	0.89	4.95***	1.11	0.95	0.71	0.96	1.92
Locations	Living/dining	3.58	1.13	3.26	1.48	1.17	1.66	1.07	1.31	0.80	1.63
	Kitchen	1.85	0.41	1.69	0.47	1.72**	1.47	0.70	0.91	0.78	3.50**
	Bedroom	2.49	0.70	2.57	0.74	−0.52	0.75	0.83	0.83	0.86	−0.40
	Bathroom	6.06	1.67	4.14	1.87	5.02***	3.09	1.63	2.09	1.20	3.14*

Note. N = 88. WeHSA = Westmead Home Safety Assessment.

*p < .05, **p < .01, ***p < .001.

Uncovering Environmental Hazards Within High and Low Fall Rate Buildings

A Pearson correlation coefficient showed significant relationships between the number of environmental hazards and residents’ age and perceived mobility from both assessment approaches, WeHSA r _age = .352, p = .001, r _mobility = −.343, p = .001; residents interview r _age = .386, p < .001, r _mobility = −.227, p = .033. That is, residents who are older and less mobile may have more environmental hazards in their homes, which may cause more falling accidents. Thus, while controlling for age and perceived mobility level on different falls as covariate variables, ANCOVA was computed to examine whether there was a significant mean difference in observed environmental hazards between the two buildings.

WeHSA

As shown in Table 5, a mean of 15.29 (SD = 1.58) environmental hazards was observed in the high fall rate building, compared with a mean of 10.38 (SD = 1.76) environmental hazards in the low fall rate building. The results of ANCOVA suggest that there is a significant mean difference in the total number of environmental hazards between the two buildings while controlling for covariate variables (age and perceived mobility level), F(1, 92) = 147.136, p < .001. Also, among the six design features, residents in the high fall rate building identified a higher number of environmental hazards associated with accessibility, flooring surfaces, lighting, and safety bars compared to residents in the low fall rate building. In terms of locations, the result of ANCOVA suggests the number of environmental hazards in the living/dining room and bathroom of the high fall rate building was greater than that of the low fall rate building.

Table 5.

Number of Environmental Hazards From WeHSA Between Two Buildings.

Environmental Hazards		High Fall Rate Building (n = 48)		Low Fall Rate Building (n = 40)		Total (N = 88)		ANCOVA^a
Environmental Hazards		M	SD	M	SD	M	SD	F	p	η²
	Total	15.29	1.58	10.38	1.76	13.06	2.97	147.136	.000	0.637
Features	Accessibility	5.75	0.91	4.45	0.68	4.45	0.68	36.732	.000	0.304
	Floor	3.35	0.84	2.68	0.69	3.05	0.84	12.539	.001	0.130
	Furniture	0.56	0.58	0.55	0.81	0.56	0.69	0.510	.477	0.006
	Lighting	2.60	0.57	1.70	0.69	2.19	0.77	44.359	.000	0.346
	Mobility	1.02	0.89	1.00	0.99	1.01	0.93	0.257	.613	0.003
	Safety bar	2.00	0.00	0.00	0.00	1.09	1.00	9.281E+31	.000	1.000
Locations	Living/dining	3.81	1.07	3.03	1.40	3.45	1.29	9.278	.003	0.099
	Kitchen	1.90	0.37	1.65	0.48	1.78	0.44	3.093	.082	0.036
	Bedroom	2.60	0.79	2.43	0.59	2.52	0.71	0.167	.684	0.002
	Bathroom	6.98	0.60	3.28	0.78	5.30	1.98	501.001	.000	0.856

Note. N = 88. ANCOVA = analysis of covariance.

^aCovariate variables: age and perceived mobility level.

Resident interviews

Comparing the total number of environmental hazards between the two buildings from the residents’ point of view, a mean of 6.75 (SD = 2.26) risks was identified in the high fall rate building, compared with a mean of 5.65 (SD = 2.02) hazards in the low fall rate building (Table 6). But, the result of ANCOVA suggests that there is no significant mean difference in the total number of environmental hazards between the two buildings while controlling for covariates (age and perceived mobility level). However, the results of ANCOVA suggest that there were significant mean differences in the number of fall risks associated with flooring, furniture, mobility, and safety bars. Residents in the high fall rate building were more likely to perceive mobility and safety bar hazards while residents in the low fall rate building were more likely to consider fall risks associated with floor and furniture. Also, the results of ANCOVA suggest the number of environmental hazards was significantly greater in the bathroom of the high fall rate building compared to the low fall rate building.

Table 6.

Number of Environmental Hazards From the Resident Interview Between Two Buildings.

Environmental Hazards		High Fall Rate Building (n = 48)		Low Fall Rate Building (n = 40)		Total (N = 88)		ANCOVA^a
Environmental Hazards		M	SD	M	SD	M	SD	F	p	η²
	Total	6.75	2.26	5.65	2.02	6.25	2.21	0.174	.678	0.002
Features	Accessibility	2.02	1.19	1.48	0.85	1.77	1.08	0.936	.336	0.011
	Floor	1.23	1.21	1.88	1.24	1.52	1.26	7.807	.006	0.085
	Furniture	0.25	0.44	0.65	0.74	0.43	0.62	21.034	.000	0.200
	Lighting	1.44	0.94	0.95	0.96	1.22	0.98	3.276	.074	0.038
	Mobility	0.52	0.50	0.15	0.36	0.35	0.48	7.742	.007	0.084
	Safety bar	1.29	0.90	0.55	0.90	0.95	0.97	10.003	.002	0.106
Locations	Living/dining	1.42	0.74	1.65	1.21	1.52	0.98	2.543	.115	0.029
	Kitchen	1.42	0.82	1.05	0.68	1.25	0.78	1.038	.311	0.012
	Bedroom	0.79	0.85	0.78	0.83	0.78	0.84	3.535	.064	0.040
	Bathroom	3.13	1.33	2.18	1.65	2.69	1.55	4.207	.043	0.048

Note. N = 88. ANCOVA = analysis of covariance.

^aCovariate variables: age and perceived mobility level.

Discussion

Using a comprehensive assessment approach, the core contribution of this research was to identify the effect of environmental hazards on falling accidents of older adults based on fall history analysis. The analysis revealed that environmental hazards contributed to significant differences in the incidence rate of falls between the two buildings and the impact of environmental hazards is different according to residents’ age and mobility level.

First, we see an alignment between a more objective environmental assessment of fall risks and the elderly residents’ perceptions of those risks. However, the resident interviews did not identify as many risks as the WeHSA recognized. Residents may be underestimating the prevalence of the risks within their home units where they spend a great deal of time (e.g., this floor is slippery, but it is okay because I’m always careful) or finding alternative ways to compensate from an environmental challenge (e.g., using a towel rack instead of installing a grab bar). This underscores the important role in using assessment measures such as the WeHSA when identifying environmental hazards and designing and renovating resident living spaces. Yet it is important to recognize that tapping into residents’ preferences and experiences expanded the understanding of fall risks in a way that was not obtained from a review of the WeHSA alone. For example, some residents described that they did not have adequate space to turn around with a walker in their kitchens. A number of residents shared that they wanted more handrail access on the way to their bathrooms and others voiced the need for dedicated space to store their mobility assistive aids. The structure of the WeHSA as an objective evaluation tool was not able to elicit these insights.

Second, this study found a significant relationship between environmental hazards and residents’ age and mobility condition. Both assessment tools showed, with increasing age and use of mobility assistive aids, there was a corresponding increase in the total number of environmental hazards. In other words, residents who are at high fall risk due to their age and poor mobility were more likely to have environmental hazards in their homes. However, identified environmental hazards were different between old-old and walker user. Both groups (old-old and walker user) have more environmental hazards associated with accessibility and safety bar compared to young-old and nonwalker user while walker users were more likely to describe mobility-related hazards. Previous studies this finding. Eshkoor, Hamid, Nudin, and Mun (2013) revealed that older people become more susceptible to environmental hazards, and age can increase fall-related injuries. Studenski et al. (1994) showed that people with limited mobility are at greater fall risk than people with low mobility.

… with increasing age and use of mobility assistive aids, there was a corresponding increase in the total number of environmental hazards.

Third, the research findings from WeHSA identified home hazards were significantly and independently associated with the incidence rate of falls. In other words, the high fall rate building included more environmental hazards compared to the low fall rate building while controlling for residents’ age and mobility. Even though resident interview showed no significant difference in the total number of environmental hazards between the two buildings, they revealed residents in the high fall rate building were more susceptible to several environmental hazards associated with the floor, furniture, mobility, and safety bars. Important considerations included lack of storage for their walker and housinghold items, lack of handrails, lack of space for mobility and maneuverability were identified by residents as common environmental hazards in the high fall rate building.

Fourth, fall history analysis indicated that falls occurring in the bathroom were more likely to cause severe injury. Resident interviews also revealed that most of the residents had a fear of falling in the bathroom. Previous research reported a consistent pattern demonstrating that falls in the bathroom were more likely to lead to serious injury (Stevens, Mahoney, & Ehrenreich, 2014). The research findings from the WeHSA and resident interviews showed that the bathroom was the most common place for environmental hazards, which may result in severe injury from falls and increase residents’ fear of falling. Also, in both buildings, the most common environmental hazards in the bathroom were poor access to the shower, slippery floor, and the lack of a night-light. The major environmental hazards in the bathroom of the high fall rate building included a lack of grab bars and a slippery floor in the shower. In particular, the serious problem in the high fall rate building was that there was no appropriate place to install a grab bar in the bathroom due to the small space and poor layout.

The significant relationship between the location and time indicates that falls in the bedroom and bathroom were more likely to happen between 12 a.m. and 8 a.m. This finding discloses that fall risk behavior frequently occurs when residents go to the bathroom from the bedroom at night. That is, walking becomes a risk-taking behavior which may lead to tripping and slipping at that time (Kim & Ahrentzen, 2017). Design solutions which support older adults’ walking behaviors at night, as well as behaviors occuring in the bathroom, is essential for reducing the risk of falling. In other words, the residential environment should be designed to support residents’ walking without their walker. For example, providing handrails from the bedroom to bathroom and providing an appropriate night-light supports residents’ mobility and balance as well as helping reduce the risk of falling.

Design solutions which support older adults’ walking behaviors at night, as well as behaviors occuring in the bathroom, is essential for reducing the risk of falling.

Strength and Weakness

This research study has several limitations and contributions that should be acknowledged. The study did not weight the relative risk of the hazards identified. Certain hazards could be more likely to contribute to falling than others. While the incidence report data does show that bathroom falls were more associated with hospitalization, environmental hazards influencing the severe injuries occurring within the bathroom were not examined. Second, this study did not follow a resident group over time; therefore, the findings were not able to reveal how fall risks and patterns may change. Further, the findings could reflect certain biases limited to this particular cohort of older adults. Third, this research defined high and low fall building based on fall incident rates. Even though the fall history analysis showed that there was no significantly different in the number of fall incidents based on residents’ age between two buildings, the high falls building might compound the risks of falling due to residents’ intrinsic factors including vision, balance and gait, or medical conditions. Fourth, this research measured residents’ mobility level using a self-rate instrument with one question even if an objective assessment tool such as Barthel index may provide more valid information. However, the length of a survey is a definitive factor in the respondent dropout rate (Quinn, 2010). For example, when the length of the survey is too long for older respondent, their response rate will be decreased immediately. Given that this comprehensive assessment with adults aged over 85 years old lasts more than 40 min, this research limited to increase the length of the survey by adding more questionnaires. Lastly, since the research sample of this research was small, research findings may not be generalizable.

A strength of this research was its use of the comprehensive assessment approach to identify primary risk factors in a senior retirement community and notably the use of fall incidents. Fall history data provide critical information for data interpretation in a large group of older adults. This data created the sampling structure for the study and enriched the findings of the environmental assessment and residents’ perceptions. Using a case-control study demonstrated a broader relationship between environmental hazards and older adults’ falling.

Conclusions and Future Research

Creating a fall prevention design strategy is a critical health priority within congregate living facilities for older adults. Investing in evidence-based design when creating new facilities as well as renovating existing spaces can impact safety and quality of life. The current study provides empirical evidence of environmental hazards as a significant environmental falling risk, which is useful for developing effective fall intervention design strategies.

This research suggests that a supportive space includes better lighting and grab bars adjacent to toilets or handrails from the bedroom to bathroom. A supportive spatial layout is also critical to reduce fall-related injuries. That is, the physical environment provides easy access to the bathroom within the unit, especially, bedroom and bathroom should be close together. However, some older adults do not want to install these grab bars in their homes because they are not viewed as necessary for their activity of daily living or as one resident commented, “Makes me feel old.” A challenge for healthcare designers is to create spaces that support both young-old and old-old and facilitate aging in place. For example, could a wall niche be used to feature a mural and as the residents age offer a discrete space to store walkers, if needed. Maintaining perceived and actual safety of residents should play an essential role in designing flexible environments that can be easily modified to support changing needs. These findings are of interest to designers and healthcare administrators in long-term care settings and to aging adults who desire to age in place in independent housing.

To create a tailored fall prevention strategy, it is recommended that future research examine a significant difference in environmental hazards according to residents’ chronic diseases, behavioral, or cognitive challenges. Future research also should pursue an examination with a longitudinal design to explore how environmental hazards interact with older adults over time. Implications for investing in such inquiry will only grow in significance as the population of older adults swells. Another opportunity is to investigate the interaction of intrinsic and extrinsic factors and its role on fall risks with objective measurement assessment. Also, in order to increase external validity, the future research will be applied to a larger sample and/or multiple buildings.

Implications for Practice

Falls in the bathroom were more likely to result in severe injuries compared to falls in other rooms. Also, there is a need to consider effective interventions for new and more creative bathroom designs to minimize fall risks (e.g., energy-absorbing flooring).

A design solution which supports older adults’ specific behaviors including mobility and transfer in the bathroom is essential for reducing the risk of falling (e.g., appropriate grab bars and handrails, easy access to the bathroom from the bedroom, nonslip floor surfaces, and appropriate night-light).

Creative design ideas might include handrails with a night-light or pathway lighting to support night mobility.

Footnotes

Appendix A

Table A1.

Profiling Participants Between Two Buildings.

	High Fall Rate Building		Low Fall Rate Building		Total		χ²
	f	%	f	%	f	%	χ²
Age-group
Young-old (under 85)	16	33.3	30	75.0	46	52.3	16.130***
Old-old (85 and over)	32	66.7	10	25.0	42	47.7	16.130***
Gender
Male	16	33.3	10	25.0	26	29.5	1.297
Female	32	66.6	30	75.0	62	70.5	1.297
Using walker
No	9	18.8	26	65.0	35	39.8	19.825***
Yes	39	81.3	14	35.0	53	60.2	19.825***
Living status
Alone	35	72.9	25	62.5	60	68.2	.298
With family	13	27.1	15	37.5	28	31.8	.298
	M	SD	M	SD	M	SD	t
Age	87.13	5.901	82.50	6.463	85.06	6.548	3.628***
^aPerceived mobility	3.42	0.964	4.05	0.876	3.70	0.973	−3.271**

Note. N = 88. ^aResponse: 1 = very poor; 2 = poor; 3= fair; 4 = good; 5 = very good.

**p < .01, ***p < .001.

Appendix B

Table B1.

Fall Incident Reports from Two Buildings.

	High Fall rate Building	Low Fall Rate Building	Total	χ²
	f (%)	f %	f %	χ²
Age
Young-old (under 85)	64 (18.6)	22 (21.2)	86 (19.2)	0.925
Old-old (85 and over)	281 (81.4)	82 (78.8)	363 (80.8)	0.925
Gender
Male	82 (23.8)	41 (39.4)	123 (27.4)	4.013
Female	263 (76.2)	63 (60.6)	326 (72.6)	4.013
Time
08:01–16:00	150 (43.5)	54 (51.9)	204 (45.4)	5.121
16:01–24:00	112 (32.5)	36 (34.6)	148 (33.0)
24:01–08:00	83 (24.1)	14 (13.5)	97 (21.6)
Injury severity
No injury	208 (60.3)	50 (48.1)	258 (57.5)	5.985
Minor injury	70 (20.3)	24 (23.1)	94 (20.9)
Hospitalization	67 (19.4)	30 (28.8)	97 (21.6)
Fall location
Living/kitchen	157 (45.5)	39 (37.5)	196 (43.7)	13.749**
Bedroom	65 (18.8)	13 (12.5)	78 (17.4)
Bathroom	46 (13.3)	10 (9.6)	56 (12.5)
Common	77 (22.3)	42 (40.4)	119 (26.5)

Note. N = 449.

*p < .05, **p < .01, ***p < .001.

Appendix C

Table C1.

Identified Environmental Hazards With Two Assessment Approaches.

Hazards		WeHSA			Interview
Hazards		High Fall (n = 48)	Low Fall (n = 40)	Total (N = 88)	High Fall (n = 48)	Low Fall (n = 40)	Total (N = 88)
Accessibility	Poor access to shower^a	48	40	88	25	12	37
	Reaching for high places^b	44	40	84	38	29	67
	Reaching for high places^c	44	40	84	3	6	9
	Poor proximity to eating area from kitchen^b	47	26	73	0	2	2
	Reaching for high places^d	44	16	60	9	1	10
	Poor proximity to bathroom from bedroom^a	42	0	42	15	6	21
	Poor access to bathtub^a	0	14	14	0	3	3
	Narrowed doorway^c	5	0	5	4	0	4
	Poor access to lamp^d	2	2	4	2	0	2
	Narrowed doorway^d	0	0	0	1	0	1
	Total	276	178	454	97	59	156
Floor	Flooring change^d	48	37	85	10	14	24
	Slippery floor^a	44	40	84	10	12	22
	Slippery surfaces in shower^a	48	0	48	19	11	30
	Throw and small rugs or floor mats^d	6	20	26	4	20	24
	Unsecure bath mats^a	11	10	21	8	0	8
	Floors and floor coverings Hazard^c	4	0	4	2	2	4
	Slippery floor^b	0	0	0	3	7	10
	Uneven floor surface^a	0	0	0	2	7	9
	Unsecure kitchen mats^b	0	0	0	1	2	3
	Total	161	107	268	59	75	134
Furniture	High chair^d	8	8	16	0	3	3
	Bed cover (trailing in traffic ways)^c	12	4	16	0	1	1
	Bed (Inappropriate height of bed)^c	5	8	13	2	4	6
	Unstable furniture^d	2	2	4	0	0	0
	Lack of storage^d	0	0	0	8	14	22
	Lack of storage^b	0	0	0	0	0	0
	Lack of storage^c	0	0	0	2	2	4
	Lack of storage^a	0	0	0	0	2	2
	Total	27	22	49	12	26	38
Lighting	Inadequate night lighting^c	46	37	83	15	12	27
	Inadequate night lighting^a	46	27	73	15	19	34
	Dim or inadequate lighting^d	31	0	31	31	3	34
	Poor lighting switch^c	2	4	6	4	2	6
	Dim or inadequate lighting^c	0	0	0	4	2	6
	Total	125	68	193	69	38	107
Mobility	Lack of space for mobility and maneuverability^d	22	22	44	0	0	0
	Obstacles to walking^d	20	14	34	3	6	9
	Obstacles to walking^c	7	4	11	0	0	0
	Lack of space for mobility and maneuverability^b	0	0	0	20	0	20
	Lack of space for mobility and maneuverability^c	0	0	0	2	0	2
	Total	49	40	89	25	6	31
Safety bar	Inappropriately installed grab bars in shower^a	48	0	48	11	3	14
	Nonexistent or slippery grab bars near toilet^a	48	0	48	32	4	36
	Handrail^a	0	0	0	13	8	21
	Handrail^b	0	0	0	6	2	8
	Handrail^d	0	0	0	0	5	5
	Total	96	0	96	62	22	84

Note. N = 88. ^aBathroom. ^bKitchen. ^cBedroom. ^dLiving/dining.

Author’s Note

He was a graduate student at the time this paper was written at University of Florida.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Daejin Kim, PhD

Notes

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