Effectiveness of Autonomous Home Hazard Reduction on Fear of Falling in Community-dwelling Older Women

Ove Schroeder MD; Julia Schroeder MD; Stefanie Fitschen-Oestern MD; Lutz Besch MD; Andreas Seekamp PhD


J Am Geriatr Soc. 2022;70(6):1754-1763. 

In This Article

Abstract and Introduction


Background: Many falls in older people occur at home, and home hazards (HOHA) are often involved. Fear of falling (FOF) is a frequent and serious consequence of falls. This study aimed to analyze the effectiveness of an autonomous reduction of HOHA on FOF.

Methods: In this single-blinded, prospective cohort study design, the inclusion criteria were female sex, age ≥60 years, no known dementia, community-dwelling, and written informed consent. Using a 54-item room-by-room checklist, the participants identified and autonomously reduced as many HOHA as possible, within 14 days. The FOF was measured using a dichotomous scale (D-FOF) and the Falls Efficacy Scale International (FES-I). Logistic regression models were used to identify the predictors of a substantial reduction of HOHA (≥50%) and FOF (≥25%).

Results: A total of 782 women fulfilled the inclusion criteria, and 431 (60.5%) returned the complete checklist on time. The mean age was 72.5 [SD 7.1] years. 43.8% of participants reduced ≥50% of the HOHA. The D-FOF (odds ratio 22.4 [95% confidence interval 11.0–45.3]), age ≥ 75 years (14.1 [7.5–26.4]), polypharmacy (3.0 [1.4–6.5]), and assumed improvability of housing conditions (2.4 [1.3–4.3]) were identified as predictors for substantially reducing HOHA with an area under the curve of 0.91. The initial FES-I score decreased from 24.5 to 19.5. Prior to the intervention, 53.1% showed a high FOF (>22 FES-I scores). Of these, 70.7% participants reduced their high FOF to low FOF. 29.2% of all participants reduced FOF ≥25% postinterventionally, associated with a substantial reduction in HOHA (3.5 [2.2–5.7]) as the strongest independent factor in the multiple logistic regression analysis.

Conclusion: The use of a self-administered checklist led to a substantial reduction of HOHA and subsequently to a clinically relevant reduction of FOF in older community-dwelling women. Autonomous competence of older people should be considered when developing fall prevention strategies.


Over the past three decades, falls in older people have become a focus of research owing to their frequency and far-reaching individual and socioeconomic consequences.[3] Approximately, one in three people older than 65 years of age fall once a year.[2] Most of these falls occur at home.[14,32] Women have a higher risk of falling than men.[3] Physiological aging processes and comorbidities can worsen the outcome of falls.[37] For instance, after a fall-related hip fracture, 60% do not regain their previous mobility; several people become dependent on nursing care, and 30% die within the first year after the fall.[31] Women are 2.2 times more likely to suffer a fall-related fracture and display a hospitalization rate 1.8 times higher than men,[33] resulting in higher costs.[3] Still, even minor injuries or near-falls can affect a person's confidence in his/her own abilities. A long-term consequence is fear of falling (FOF). FOF is defined as "a lasting concern about falling that leads to an individual avoiding activities that she/he remains capable of performing."[34] More than half of the older population suffers from FOF,[27,30,41] which can be both a consequence of a previous fall[5,19] and a risk factor for future falls[27] or can occur independently of falls.[27,41] Therefore, falls and FOF mutually reinforce each other and can lead to frailty through activity avoidance,[9,41] mobility restriction,[9] limitations in the living space,[1] and a severe reduction in the quality of life.[20,29,30]

Many risk factors for falls also apply to FOF, such as older age, female sex, gait and balance impairments, functional impairments, and polypharmacy.[10,29,41] However, the home environment also plays a significant role in the risk of falls, especially for people with disabilities.[15] Home hazards (HOHA) are defined as "aspects of the physical environment, including objects, space, and the elements in and about the house that pose a risk or danger of causing the person to fall and, therefore, risk injury."[6] They are common among older people,[14] but several HOHA are modifiable.[24]

Based on known risk factors, fall prevention concepts[12] and methods for reducing FOF[18,21,28,42] have been developed.[3] Many prevention strategies focus on multilevel interventions using external resources, such as home checks by occupational therapists.[11] Gillespie et al. demonstrated in a meta-analysis that HOHA adjustment significantly reduced both the fall risk and the fall rate, especially in high-risk groups concurrent with occupational therapy monitoring.[11] Other studies demonstrated that home safety improvement reduced fall-related injuries in older people by 39%[16] and in people with visual impairment by 41%.[15] Furthermore, demographic developments strengthen the need for simple, individualized, and effective fall prevention strategies. However, the effectiveness of self-administered checklists for the autonomous reduction of HOHA and their influence on FOF is unknown.