Around 50 million people live with dementia worldwide, and this number is expected to double by 2030. It is anticipated that this condition will affect 152 million people by 2050 (Patterson, 2018). Dementia can impair balance, vision, attention and cognition, which can also lead to a greater risk of falls for the person living with this condition (Fernando et al, 2017). The risk of falling is 2–3 times higher in older adults with dementia in the community (Jørgensen et al, 2015; Meuleners and Hobday, 2017; Sharma et al, 2018). Older adults with dementia living at home had a 1.89–fold higher risk of falling (Petersen et al, 2018). Of the adults older than 65 years of age hospitalised due to falls, 58% had dementia (Harvey et al, 2016). The risk of hospitalisation due to injuries resulting from falls was 2.34 times higher in individuals with dementia (Jørgensen et al, 2015). Many older adults with dementia are living in the community and may not be offered environmental interventions to reduce falls. Memory loss also contributes to individuals forgetting measures that have been implemented to increase the safety of their home (van Hoof and Kort, 2009a).
There are many different types of interventions to prevent falls. These include exercises, medication support, assistive technologies, home safety assessment and modifications, and knowledge interventions (Hopewell et al, 2018). The most consistently effective strategy to prevent falls is reported to be home safety interventions and modification of home hazards, which create a safer home environment (Keall et al, 2015; Olij et al, 2018; Carnemolla and Bridge, 2018; Clemson et al, 2019; dos Santos and Baixinho, 2020). Home safety assessment and modification interventions have proven effective in reducing the rate of falls (rate ratio risk: 0.81) and the risk of falling (relative risk: 0.88) (Gillespie et al, 2012). Home modifications prevented falls in older adults by 19% (Gillespie et al, 2012), and a home safety modification programme achieved health gains of 2800 quality-adjusted life-years (Wilson et al, 2017). Interventions performed to identify domestic hazards for older adults are known to be cost effective (Gillespie et al, 2012; Olij et al, 2018).
Studies on falls in older adults with dementia have mostly been conducted to determine risk factors for residents receiving nursing care or staying in hospitals (Wu et al, 2013; Jørgensen et al, 2015; Uymaz and Nahcivan, 2016; Sharma et al, 2018). However, in one study, fall risk was determined to be twice as high in home-dwelling older adults with dementia as compared to those in residential care facilities (Petersen et al, 2018). The number of studies investigating older people with dementia living in their own home, which identify the risks and advise on suitable home modifications to reduce falls, is limited, and there are no recent studies (Gitlin and Corcoran, 1996; Gitlin et al, 2001; van Hoof et al, 2010; Guo et al, 2014). In the case of an older person with dementia, measures to improve home safety may need to be periodically reassessed by family members or caregivers as memory loss progresses. Therefore, increasing the knowledge and awareness of family members or caregivers about home safety becomes critical.
This quasi-experimental study aimed to investigate the effects of nurse-led home modification interventions on the family members of home-dwelling older adults with dementia. The study was carried out with older individuals and their family members living in Izmir, the third largest city in Turkey. Older adults with dementia in Turkey are often treated in hospitals where necessary. In cases that do not require treatment, these individuals mostly live in the community with their family members. Older adults with advanced dementia frequently reside in small care centres. These care centres are not covered by social security funding or health insurance, and are instead privately funded by the residents or their families. For this reason, many older adults with dementia live in their own home or that of a family member, which can increase the risk of falls and associated complications. The aim of this study was to raise awareness among nurses, other health workers and researchers about what can be done to reduce the risk of falls in older adults with dementia living with their family members or caregivers in the community.
Method
Design, setting and sample
This quasi-experimental study was carried out between November 2017 and July 2018 at the homes of older adults with dementia in Izmir, Turkey. The power analysis was performed based on the study conducted to determine the effect of education on risk reduction (Ness et al, 2003). The sample size was calculated using the post-hoc power analysis (effect size = 0.47, power = 80%, α = 0.05). Sample size was determined as 42 family members of older adults. The study was completed with 42 family members, as no older person or family member left during the study period.
The inclusion criteria for the older adults were as follows: being over 65 years of age with a diagnosis of dementia of at least 6 months' duration, not bedbound and living at home with family members. A number of different characteristics of the older people taking part in this study were collated, including: levels of consciousness and cognition; a 3-month falls history, ambulation and continence status; details relating to vision, gait and balance; orthostatic changes; medication and equipment availability; activities of daily living; and addiction levels.
The inclusion criteria for the family member participants were as follows: being over 18 years of age and being closely related to the person with dementia (eg spouse, child, etc), volunteering to participate in the study, being literate, agreeing to accept home visits and without previous education on falls. Of the older adults, those who had Parkinson's disease or any other neurological conditions, those with visual impairment but who did not wear glasses, those who used a wheelchair or who were bedbound were excluded from the study (Figure 1).
The main hypotheses of the present study are:
- There will be a difference in the number of older people who experience a fall between quarterly periods
- There will be a difference in the number of older people who make modifications in their homes between the first visit and the last visit of the study period.
Ethical issues
Ethical committee approval was received from the Non-Interventional Clinical Research Ethics Committee (October 4, 2017; number 212). The older adults in the study were accessed through a neurology outpatient clinic for home visits. It was observed that the majority of older participants (92.8%) were diagnosed with moderate Alzheimer's disease. Written and verbal informed consent was obtained from family members, and verbal consent was obtained from every older person able to communicate with the researcher during the study. Participants in the study were assured that all information, including the data collected, would be kept confidential and would not be disclosed to third parties.
Tools
Interview form
To determine the sociodemographic and health characteristics of older adults with dementia and family members, the Interview Form was used (Table 1). The researchers created this form based on background literature and received feedback from experts during its development, including a neurologist, nurse and home care nurse. No changes were required after expert review.
Table 1. Stages of study data collection
| Data collection stage | Type of data collected |
|---|---|
| First stage | Sociodemographic characteristics of participating older adults (age, gender, educational level, marital status, income) collected using interview formHealth characteristics of participating older adults (diagnosed diseases, date of the diagnosis, drug usage, assistive device use, smoking status, alcohol usage, comorbidities) collected using interview form |
| Second stage | Sociodemographic characteristics of the participating family members (age, gender, educational level, marital status, income) |
| Third stage | History and number of falls |
| Fourth stage | Recording falls that might occur during the 6-month follow-up period (includes items questioning whether falls occurred between the first home visit [at baseline] and the third visit paid at the final month of the study). If falls occurred, data regarding where, when and how these occurred were collected |
Note: To ensure accuracy, the data in this section were obtained from the relatives and caregivers of the older adults with dementia in order to eliminate any errors caused by cognitive impairment
Falls risk assessment
The DENN-Fall Risk Assessment Scale (Tekin et al, 2013), developed by the Delmarva Foundation and adapted into Turkish, was used to assess the falls risk in older adults. The form consists of nine main sections. These sections are: level of consciousness/mental status; history of falling in the previous 3 months; ambulation/toilet status; vision status; gait and balance; orthostatic changes; drugs; diseases; and equipment availability. The evaluation is made over the total score and the falls risk score of the individual is determined. After the assessment is made over the total score, an individual's fall risk score is determined (0–5 points: low risk, 6–9 points: medium risk, 10 and above points: high risk) (Tekin, et al, 2013).
Home environment risk factors for falls assessment form
This form was used to determine potential risks in the home environment in terms of falls. The form assesses physical characteristics of the home environment that may pose a risk for falls, dividing it into separate spaces and assigning a score to each: living room (5 items), kitchen (5 items), bedrooms (5 items), stairs (8 items) and corridor (3 items). The form consists of 39 observational items in total. Items are scored between 0 and 1. A score of 0 indicates that there is no risk of falling, while a score of 1 indicates that there is a risk. A high total score indicates that the domestic environment of the older person is putting the individual at higher risk of falling (Lök and Akin, 2013).
Activities of daily living functioning (ADLs) and instrumental activities of daily living (IADLs)
Activities of daily living affect older adults' likelihood of falls; therefore, older adults' dependence on others while performing these activities was investigated. To determine the older person's level of dependence, the Katz Index of Independence in Activities of Daily Living was used. The index addresses six items, which include bathing, dressing, toileting, transferring, continence and feeding, and assigns a score (0–6 points = dependent; 7–12 points = semi-dependent; and 13–18 points = independent) (Shelkey and Wallace, 1999).
Brody-Lawton Instrumental Activities of Daily Living (Brody-Lawton IADL)
This scale was also used to assess the older person's ability to perform instrumental activities of daily living (Shelkey and Wallace, 1999). The scale consists of eight questions. A score of 0–8 indicates dependence; a score of 9–16 indicates semi-dependence; and a score of 17–24 indicates independence (Aktaş and Erci, 2016).
Fall prevention training booklet
Every family member in this study was given the Fall Prevention Training Booklet prepared by the researchers to be used in this intervention. This booklet was prepared based on the pertinent literature (Aktaş and Erci, 2016; Uymaz and Nahcivan, 2016) and expert opinion. The booklet outlines the risks and conditions that lead to falls, provides interventions to prevent falls, stresses the importance of the physical environment, and suggests modifications, such as taking precautions for wet and slippery floors, installing grabrails in bathrooms and so on, which can be made to prevent older adults from falling.
Intervention
In order to reach older adults with dementia living in the community, a doctor in the neurology outpatient clinic of a local public hospital was interviewed. Older adults with dementia were identified from the neurology outpatient clinic for home visits. Family members were contacted by the first researcher via telephone. The contact numbers of family members were obtained from hospital records. The family members were informed of the purpose of the study, and appointments for home visits by a researcher were made. All family members were visited on three occasions: a first visit to establish a baseline, with the second and third visits taking place in the following 3 and 6 months, respectively.
During the first home visit, the information contained in the educational booklet was outlined to the family members through face-to-face interviews. The booklets were then given to the family members. Study data were collected using the aforementioned tools, which were applied by the researcher at each of the three home visits.
All of the older people with dementia included in the study lived with family members. The researcher gained permission to observe each room in the home environment to identify potential risks. These risks were determined in accordance with the Home Environment Risk Factors for Falls Assessment Form. The researcher then offered health education and counselling to the family members about the identified risks that could lead to the older person falling. During the second visit, this home safety information was reinforced, and the home environment was re-inspected. Any modifications that had been made were checked, including those most frequently suggested (recommendations regarding wet and slippery floors), and the participants were informed again of potential environmental risks that could pose a falls hazard for the older person. The first and second visits were between 1.5–2.5 hours' duration, while the third visit usually lasted between 30 minutes to 1 hour.
Data analysis
The Statistical Package for Social Sciences (SPSS), version 25, was used to analyse the data. In the descriptive analysis, percentages, arithmetic mean and standard deviation, parametric or non-parametric tests in dependent groups were used in the analysis of the data. P <0.05 was considered statistically significant at the 95% confidence interval.
Results
It was determined that 71.4% of the older adults were diagnosed with Alzheimer's and 28.6% were diagnosed with dementia, and 92.8% of the older people in this study were at the intermediate stage of this condition. Other sociodemographic and health characteristics of the participating older adults and family members are given in Table 2 and Table 3.
Table 2. Sociodemographic and health characteristics of the participating older adults
| Variables | Number of participants | Percentage of participants (%) |
|---|---|---|
| Age (79.04 ± 7.8) | ||
| 65–74 years | 12 | 28.6 |
| 75–84 years | 20 | 47.6 |
| ≥85 years | 10 | 23.8 |
| Gender | ||
| Female | 24 | 57.1 |
| Male | 18 | 42.9 |
| Education status | ||
| Illiterate | 9 | 21.4 |
| Primary education | 20 | 47.6 |
| High school | 5 | 11.9 |
| University | 8 | 19.0 |
| Marital status | ||
| Married | 19 | 45.2 |
| Single | 23 | 54.8 |
| Presence of a chronic condition | ||
| No | 10 | 23.8 |
| Yes | 32 | 76.2 |
| Severity of dementia | ||
| Mild | 3 | 7.2 |
| Moderate | 24 | 57.1 |
| Severe | 15 | 35.7 |
| Date of diagnosis | ||
| Within the last year | 3 | 7.1 |
| Within the last 2–5 years | 26 | 61.9 |
| Within the last ≥6 years | 14 | 33.3 |
| Income status | ||
| Income less than expenses | 3 | 7.1 |
| Income equal to expenses | 39 | 92.9 |
Table 3. Sociodemographic and health characteristics of the participating family members
| Variables | Number of participants | Percentage of participants (%) |
|---|---|---|
| Age (57.7 ±11.3) | ||
| ≤65 years | 32 | 76.2 |
| 65–74 years | 7 | 16.7 |
| 75–84 years | 3 | 7.1 |
| Gender | ||
| Female | 39 | 92.9 |
| Male | 3 | 7.1 |
| Education status | ||
| Illiterate | 2 | 4.8 |
| Primary education | 14 | 33.4 |
| High school | 11 | 26.2 |
| University | 15 | 35.7 |
| Marital status | ||
| Married | 33 | 78.6 |
| Single | 9 | 21.4 |
| Income status | ||
| Income less than expenses | 1 | 2.4 |
| Income equal to expenses | 41 | 97.6 |
| Degree of kinship between the older adult and family members | ||
| Spouse | 13 | 31.0 |
| Daughter/son | 25 | 59.5 |
| Daughter-in-law/son-in-law | 1 | 2.4 |
| Other (paid caregiver) | 3 | 7.1 |
Of the participating family members, 97.6% stated that they knew what the medication they administered to the person with dementia was for, and 97.6% said that they gave medication to the older adults on a regular basis. Of the older adults with dementia, 40.5% had fallen at least once, and 33.3% used an assistive device. The assistive device most commonly used was a walking stick (71.4%). Only three of the participating family members did not live in the same house with the older person with dementia (data were not presented in a table).
According to the Katz Index of ADL, three of the activities of daily living most independently performed by the older adults in this study were bathing (69%), dressing (54.8%) and toileting (33.3%). Three activities of daily living performed semi-independently included continence (31%), bathing (21.4%) and transferring (21.4%). Three activities of daily living performed with the most dependence by the participating older adults included eating (57.1%), transferring (47.6%) and continence (35.7%), respectively. Telephoning other parties, including social calls, was performed semi-independently by 23.8% of the older adults with dementia, while 16.7% were dependent on others for this activity. According to the DENN Fall Risk Assessment Scale scores, while 50% of the older adults in this sample were in the high-risk group during the first and second visit, by the third visit, 47.6% of older adults were in the high-risk group. In the first visit, it was determined that as the scores obtained from the Katz Index of ADL (r = 0.726, p <0.01) and Brody-Lawton IADL (r = 0.658, p <0.01) increased, as did the scores obtained from the DENN Fall Risk Assessment Scale (data not shown).
Table 4 demonstrates the decrease in the number of falls between visits. Some 17 of the older adults experienced falls during the study period. While 15 older adults experienced falls during the first 3-month period, only two experienced falls during the second 3-month period. Therefore, there was a marked decrease in the number of the falls in the second 3-month period between the second and third visit (p = 0.002) (Table 4).
Table 4. Distribution of falls occurring between home visits
| Falls status (number of adults) | First 3-month period | Second 3-month period | Test* |
|---|---|---|---|
| Non-fallers | 27 | 40 | p=0.002 |
| Fallers | 15 | 2 | |
| Total | 42 | 42 |
Note:
*McNemar test
Table 5. Distribution of the home modifications made during the 6-month follow-up period (n =18)
| Type of home modification | Number of homes implementing modifications* | Percentage of homes implementing modifications (%) |
|---|---|---|
| Installing a safety grab bar in the toilet | 13 | 30.9 |
| Installing a safety grab bar in the bathroom | 9 | 21.4 |
| Using anti-slip tape in the hallway | 5 | 11.9 |
| Using anti-slip tape in the bathtub | 2 | 5.6 |
| Replacing current light bulbs with ≥75 watt light bulbs | 1 | 2.4 |
| Anchoring furniture in the living room | 1 | 2.4 |
| Replacing armchairs with a more appropriate option | 1 | 2.4 |
| Anchoring furniture and using anti-slip tapes in the kitchen | 1 | 2.4 |
| Removing or rearranging furniture to have a clear walking path in the bedroom | 1 | 2.4 |
Note:
*More than one option was marked
Table 6. Distribution of the number of the falls experienced according to falls history and home modifications during the two 3-month follow-up periods
| Variables | First 3-month period | Second 3-month period | Total | ||
|---|---|---|---|---|---|
| Non-fallers* | Fallers* | Non-fallers* | Fallers* | ||
| Falls history in the last 6 months | |||||
| No falls | 19 | 6 | 24 | 1 | 25 |
| Fall | 8 | 9 | 16 | 1 | 17 |
| Total | 27 | 15 | 40 | 2 | 42 |
| Analysis* | p>0.05 | p=0.000 | |||
| Making home modifications | |||||
| No | 18 | 6 | 23 | 1 | 24 |
| Yes | 9 | 9 | 17 | 1 | 18 |
| Total | 27 | 15 | 40 | 2 | 42 |
| Analysis** | p>0.05 | p=0.000 | |||
Note:
*Number of older adults
**McNemar test
Of the falls, 41.2% occurred in the bathroom, and 23.6% in the toilet, which are typically located in separate rooms in Turkish houses. While the cause of falls was slipping in 70.6% of the older adults, loss of balance was also responsible in 23.5% of falls. Of the older adults who experienced falls, 17.6% presented to a hospital. While 52.9% of the older adults using an assistive device, such as a walking stick, experienced falls, 47.1% of the older adults not using an assistive device experienced a fall. The difference between the groups was not significant (p> 0.05).
The mean scores obtained from the DENN Fall Risk Assessment Scale by the older adults with dementia who experienced falls (11.6 ± 4.0) were higher than those obtained by the older adult with dementia who did not experience falls (7.9 ± 3.8) (MWU = 1301.6, p 0.05) (Table 4). In the second 3-month period, two older adults with dementia experienced falls. After follow-up visits and the educational intervention, a statistically significant decrease was observed in the number of older adults with dementia experiencing falls in the second 3-month period (p = 0.000). Age and gender did not affect falls frequency (p> 0.05).
In the first 3-month period, home modifications did not affect the number of falls experienced by the older adults with dementia, either positively or negatively (p = 0.791). In the second 3-month period, 18 families (43%) had made some modifications to the home based on interventions suggested in the home safety booklet, and two falls occurred in one family home. In the other homes, no falls occurred during this period. Those older adults who had their homes modified were among those who did not experience falls, and the number of falls decreased significantly in the second 3-month period (p = 0.000) (Table 4).
Discussion
In this study, the effects of nurse-led home modification interventions on the prevention of falls in the homes of older adults with dementia living with family members were investigated. The findings demonstrated that, after a range of interventions—including three home visits, on-site observation of the home environment and an educational intervention accompanied by a booklet—approximately one out of every two older adults with dementia took safety measures in their home, and the number of older adults with dementia who experienced falls decreased by the end of the total 6-month study period.
According to other studies in the literature that exclude older adults with dementia, the rates of falls in older people is estimated to range from 13–47.7% (Guner and Albayrak, 2016; Lök and Akin, 2013; Leszczyńska et al, 2016; Vitorino et al, 2017). However, home-dwelling older adults with dementia are at increased risk of falling when compared to older adults without dementia (Petersen et al, 2018). In this study, the number of older adults with dementia experiencing falls in the second 3-month period appeared to decrease, with fewer reported falls during this time than in the first 3 months of the study (p = 0.002). Furthermore, during the second 3-month period, the number of falls decreased in older adults with dementia with a previous history of falls. These results confirmed our prediction that the number of older adults with dementia experiencing falls in the second 3-month period would be lower than those in the first 3-month period. The decrease in the number of falls observed during the second 3-month period showed that the educational interventions given to family members during the first and second visits appeared to help reduce the number of falls reported in the older adults taking part in the study. In addition, home modifications may contribute to a decrease in the number of falls.
Home safety measures and assessment of risk factors have been found to be effective in preventing and decreasing the number of falls for older adults (Gillespie et al, 2012; Guo et al, 2014; Rimland et al, 2016). According to the results of studies investigating the cost-effectiveness of fall prevention programmes, in-home assessment programmes were reported to be the most cost-effective intervention (Pega et al, 2016; Olij et al, 2018). The older adults with dementia in this study had a moderate monthly income, which was self-reported as neither particularly high nor low (income higher than expenses vs income lower than expenses, respectively). Monthly income can be regarded as a variable, as cost may be a deterrent to the purchase and instalment of necessary modifications in the homes of older adults with dementia. Therefore, research findings that indicate that low-cost, at-home modifications can be effective in reducing the rate of falls among community-dwelling older adults (Gillespie et al, 2012; Keall et al, 2015) are welcome.
In the present study, it was demonstrated that, during the 6-month follow-up period, almost one out of every two homes made several environmental modifications in order to reduce the risk of falls and improve safety. The assessment of risk factors and provision of falls and risk management education for family members seemed to make an impact on the number of falls experienced by the participating older adults with dementia and their families. More home modifications were made during the second 3-month period, following the second visit by the researcher, which had a positive effect on the decrease in the number of falls. In the older adults with dementia whose homes were modified, the number of falls in the second 3-month period was lower than in the first 3-month period. This finding supports our hypothesis that the number of home modifications made in the second 3-month period will be higher than that in the first 3-month period.
In the current study, modifications made were low-cost and relatively easy to implement, such as the installation of a safety grab bar in the toilet and bathroom and usage of anti-slip tape in hallways. These simple home safety measures could be easily put into practice by many families and thereby reduce the falls risk for older adults with dementia. Most identified hazards were found in bathrooms, kitchens and stairways. Poorly installed or slippery flooring was the most commonly identified hazard (van Hoof et al, 2010). As in the literature (Lök and Akin, 2013; Aktaş and Erci, 2016; Guner and Albayrak, 2016), in the present study, almost half of the older people with dementia fell in the bathroom, and a quarter of this group fell in the toilet. Because most of the activities of daily living that older people with dementia performed semi-dependently or dependently were ‘toileting/bathing’ and ‘feeding/transferring/toileting’, respectively, it appears that the most frequent falls related to the older person slipping and losing their balance in the bathroom and toilet. Generally speaking, this is because separate toilets in Turkish homes mean that older adults are generally left alone in this space; additionally, even if an older adult is accompanied to the toilet by a family member, lack of education in safety measures can mean that a fall may still occur. After family training and home visits, the places most frequently modified in the homes of older adults with dementia were the bathroom and toilet.
Based on these findings, it can be said that the education provided and visits made by the research team actively contributed to the older adults with dementia and their families making changes in their homes, which, in turn, positively affected the rate of falls experienced.
Limitations
This study had some limitations. One of these was that this quasi-experimental study design was conducted with a single group. The lack of a control group led to a limitation in the interpretation of the efficacy of the interventions. The modifications that could be made at the participants' homes were also closely related to their financial status. The fact that the majority of the older people older adults with dementia had an income equal to their outgoing expenses may have adversely affected the number and extent of modifications made at their homes. The relatively limited study follow-up period of 6 months may have also limited the amount of modifications that could realistically be made in participants' homes. Therefore, future studies should implement more extensive follow-up periods, which can better track any progress and reflect the efficacy of any modifications made.
Conclusion
This study revealed that the family-centered, nurse-led home modification interventions could be effective in preventing and reducing falls in older adults living with dementia in the community. Nurses who care for older adults, with and without dementia, often carry out and advise on multiple interventions in the areas of clinical evaluation, home safety, monitoring of prescription drugs, environmental changes, transportation and ambulation, and assessment of behaviour. Within the scope of fall-prevention efforts, nurses could also play an active role in raising awareness among older adults and their families and caregivers. It is recommended that, during home visits, nurses and home care staff should assess the risk factors that may cause older adults to experience falls in the home environment, and provide advice on measures that could be taken to mitigate these. In the future, further research, possibly nurse-led and including randomised controlled studies, to assess the effect of home modifications can help in establishing an evidence base to develop best practice in falls prevention for this patient group.
With relevant and suitable modifications made in their homes, older adults with dementia should be able to more safely carry out their activities of daily living, which may enhance their independence. The present study aims to serve as a reminder for policymakers and healthcare workers of the importance of implementing effective fall-prevention interventions in the home environment. Policymakers and healthcare providers and professionals all play an important role in providing the older person living with dementia and their family with information and financial, physical and emotional support regarding the condition of dementia as a whole, its impact on quality of life and ability to carry out activities of daily living, and any modifications or interventions that could be implemented to make a positive impact.
Key points
- The risk of falling is 2-3 times higher in older adults with dementia. Home modification training is important in the prevention of falls
- During the 6-month follow-up period, almost one out of every two homes made several environmental modifications in order to reduce the risk of falls and improve safety
- The nurse–led home modification training given to the relatives of older adults with dementia was effective in the prevention of falls.
CPD reflective questions
- What role do community and district nurses have in preventing older people from falling at home?
- What are some effective fall prevention practices to prevent older people from falling at home?
- What are the challenges faced by older people and their relatives and caregivers in performing evidence-based practices in preventing falls at home?