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he incidence of falls increases with chronological age. Numerous research studies have shown that elderly adults aged 65 years or older are more prone to experiencing both single and multiple falls than younger adults.1–6 However, it should be noted that falls are not a normal part of the aging process.7 When falling occurs in the aged population, it should be seen as a signal that something has gone awry. Poor health, declining mobility, physical limitations, cognitive slippage, medication combinations and side effects, and behavioral factors, such as avoidance and awareness,8 have all been correlated with an increased risk for falling. It should also be noted that one of the single greatest risk factors for falling is a history of previous falls.9 Research has also shown that death often is preceded by an increased number of falls that cluster around common time points.10
       An increased prevalence of falls is also related to environmental factors in both the man-made and the natural world.11 Environmental hazards, such as glossy floors, improper bed position, cluttered rooms, and unstable furniture, place individuals at risk for falling. Uneven and slippery walking surfaces, lack of handrails, and curbs that are not well marked are common precipitators for falls.
       The literature is resplendent with research studies, such as those discussed above, about risk factors for falling and how rehabilitation personnel can prevent falls. One of the most common interventions to prevent falls is environmental adaptation. Removing the known causes of falls (for example, scatter rugs) or adding safety devices, such as handrails, grab bars, or additional lighting and contrast materials, is a common intervention strategy. Another common intervention is the prescription of an assistive device, such as a walker or cane, or handrails to the person’s home. However, despite these recommendations made in the rehabilitation literature for fall prevention, it has been the experience of the authors that all too frequently such recommendations made by well meaning professionals are not followed. How often we have recommended that an older person remove the scatter rugs from the floors only to find that on our next visit, the rugs are still there. We recommend that people “not hurry” to answer the phone, because we know that hurrying is a cause of falls, but when a child who lives far away calls home, that call may be the highlight of a person’s day or week. Additionally, research has shown that the prescription of assistive devices can be both beneficial and detrimental.12,13 In some cases, assistive devices have actually contributed to a fall because of improper prescription or use. Thus, the argument is made that the effects of these interventions on quality of life for elderly individuals at risk are less well studied. One question that should be asked is how a person’s quality of life is affected by his or her fear of falling.
       Velde14 states that “the rehabilitation literature contains over 100 definitions and models of quality of life.” She continues her discussion by defining quality of life as a global construct that encompasses both subjective and objective perspectives. In other words, some measures of quality of life are determined externally (social indicators like income, education, physical function, and housing), while others must be subjectively measured by each person. For example, even though an individual might live in a “state of poverty” as determined by the federal scale, he or she may feel that his or her quality of life is high because of others factors, such as closeness of family or a strong religious value system.
       Therefore, in asking the question about how fall prevention programs influence quality of life, we must examine whether what we add or subtract from an individual’s life leads to an improvement or a decrease in his or her quality of living. Does adding or subtracting in the course of service provision add up to an acceptable outcome, and if so, whose definition of acceptable is used?
       When we add assistive devices or protective garments, such as elbow pads, hip protectors, or devices, to the home are we negatively affecting quality of life? The intuitive answer as a therapist is no. However, as healthcare providers, we should challenge ourselves to look at these changes from our client’s perspective. Are we too quick to use labels, such as “noncompliant” or “nonadherent,” in measuring the response of our clients to the therapy that we prescribe or “impose” when in reality we have not contributed to a better quality of life?
       In analyzing the issue of “noncompliance” or “nonadherence” with regard to environmental modifications or adaptive equipment, Bottomley and Lewis7 argue that the aged person with a disability may view such aids as unattractive and demeaning. They also suggest that walkers and grab bars project an image of disability, one that is not easily modified or camouflaged. These issues are further acknowledged by Patterson15 who argues that physical living environment and the objects it contains, such as walkers or bedside commodes, can affect motivation to participate in health-related and other meaningful activities.
       It is then our challenge as healthcare providers to meet our client’s needs more effectively. We can do so by ending the “blame game” and looking for creative solutions. For example, if removing a throw rug is necessary, could it be replaced with a painted floor mural? Rather than the placement of stainless steel grab bars, could we add hand-painted ceramic bars that match the motif of the room? Would the use of a hand-carved and personalized cane increase the chance of it being used?
       Examination of the relationship between healthcare provider and client becomes paramount in the success of any intervention. To most effectively meet the needs of our clients, we must understand relationships and motivational strategies. It is being increasingly recognized that inclusion of the individual in the treatment planning process (i.e., person-centered planning) is prerequisite to successful intervention. The type of relationship described here is collaborative in nature and is referred to as “joining or creative rapport” in the psychological literature.16–18 By closely collaborating with the client, we have intimate access to his or her interests and needs. As a result, we are more aware of what motivates our clients and how to set goals that meet the rehabilitation needs of the person. Table 1 illustrates the formula for motivation that has been provided by Kemp.19
       Kemp’s work provides a strategy for addressing our client’s rehabilitation needs by thoroughly examining what is important to him or her. Wants are defined as desires, wishes, needs, and goals. Beliefs are assumptions and perceptions, and rewards are defined as reinforcements or benefits. These factors are all weighed in relationship to costs. Costs are the perceived negative outcomes. By using this formula and building on a strong collaborative relationship with our client, the therapist can design a fall prevention or treatment program that has a greater potential for success.