Occupational Therapy and the Use of Technology on Older Adult Fall Prevention: A Scoping Review

Introduction: Falls are the second leading cause of accidental or non-intentional deaths worldwide and are the most common problem as people age. The primary purpose of addressing falls is to detect, prevent, treat, and reduce their incidence and consequences. Previous studies identified that multifactorial programs, an interprofessional team, and assistive technology are required to address falls in older adults effectively. Accordingly, the research question is as follows: what are the scope, type of studies, and approaches and strategies to fall risk using technology in the existing occupational therapy literature regarding interventions to address the effects of falls in older adults on daily living? Methods: This scoping review was carried out in January 2020 through Biblioteca Virtual de Salud España, C.I.N.A.H.L., Cochrane Plus, OTSeeker, PubMed, Scopus, and Web of Science. Results: Twelve papers were included. We analyzed the year and journal of publication, authors’ affiliation, and design of the study, and thematic categories. There were three themes: participants’ characteristics, type of intervention, and fall approach and type of technology used. Discussion and Conclusions: The literature obtained is scarce. It is considered to still be an emerging theme, especially when considering the use of technology for occupational therapy.


Introduction
The progressive aging of the population is a well-documented and projected theme of the 21st century, particularly in Europe and Japan [1][2][3]. Certain health conditions associated with the aging process lead to geriatric syndromes, including falls [4]. Current and past scientific evidence has identified falls as the second leading cause of accidental or non-intentional deaths worldwide and the most common and severe problem as people age [5][6][7][8][9][10][11]. Studies have shown that thirty percent of older adults suffer a fall annually, increasing to fifty percent for people aged eighty years and over, and this one of the primary causes of their hospitalization [5][6][7][8][9][10][11]. As people get older, they are more likely to fall. A recent study by Burton and colleagues [12] showed that the prevalence of falls has not changed in the last ten years.
Thus, the primary purpose of addressing falls, identified as a public health challenge, is to detect, prevent, treat, and reduce their incidence and consequences. There is a range of consequences from falls including a reduction in quality of life and increased socioeconomic costs. The consequences on quality of life can include decreased functional mobility, a decreased independence level, social restrictions, depression, loneliness, fear of falling and repeated falls [13][14][15][16][17][18][19]. Table 1. Summary of occupational therapy interventions for falls in older adults.

Summary of Occupational Therapy Interventions for Falls in Older Adults
Single component (includes only one of the following components)

Exercise
Home safety assessment Education about falls' prevention Example: Lifestyle Integrated Functional Exercise study [37] Multicomponent intervention (includes exercise and one of the following options) 1st option: educational components as: Feet or footwear risk Energy conservation strategies Safe assistive device use, home modification Fall recovery Table 1. Cont.

Medication routines
Nutrition and hydration Relaxation stress management 2nd option: home modification with other fall prevention intervention Example: Minimally Supervised Multimodal Exercise to Reduce Falls Risk in Economically and Educationally Disadvantaged Older Adults [38] Multifactorial intervention (include the complex assessment of different components) Fall risk Environment, education, and group activities Activities of daily living Assistive devices Self-efficacy or fear of falling Example: A single home visit by an occupational therapist reduces the risk of falling after hip fracture in elderly women: A quasi-randomized controlled trial [39] Population-based fall prevention (includes strategies implemented across whole communities, two different types) Existing effective population-based fall prevention programs Other population-based multicomponent interventions Example: Stepping On -Translating a Fall Prevention Intervention Into Practice: A Randomized Community Trial [40] In addition to multifactorial programs and the interprofessional team, more emphasis is being placed on technology use. Technology has been integrated into some of the interventions for, or approaches to, fall reduction [18]. Assistive technology has been used to enable and promote inclusion and participation, maintain or improve functioning and independence, and promote well-being and active living [41][42][43].
According to the WHO [41], around the world, there are one billion people who require assistive products today. More than two billion people worldwide are expected to need at least one assistive product by 2030 [41]. Some examples of using assistive technology in older adults' falls interventions may include, video monitoring, health monitoring, electronic sensors, and equipment such as fall detectors, door monitors, bed alerts, pressure mats, and smoke and heat alarms, according to Miskelly and colleagues [42].
Also, remembering that exercise is the most common approach to falls, previous European projects such as the iStoppFalls [44], Farseeing [45] and Prevent IT [46] project were focused on using technology to improve older adults' physical functioning.
Accordingly, this study's primary goal is to explore the scope of occupational therapy literature regarding interventions to address the effects of falls in older adults on daily living with technology. Specifically, we intend to:

•
Describe the types of studies on this topic and where they are usually published; • Describe proposed occupational therapy approaches and strategies to fall risk using technology.

Materials and Methods
The authors conducted a scoping review in January 2020. The research questions that we aimed to answer were the following: what are the scope, type of studies, and approaches and strategies to fall risk using technology in the existing occupational therapy literature regarding interventions to address the effects of falls in older adults on daily living? Two approaches guided the present scoping review. On the one hand, the Arksey and O'Malley [47] five-stage framework was used, which includes stage 1 establishment of the research question; stage 2 identification of pertinent studies and choice of studies, stage 3 study selection as explained in Figure 1; and, as shown in the Results section, the stage 4 charting the data and stage 5 mapping the data and collating, summarizing, and reporting the findings. On the other hand, this scoping review also follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (see Table S1 [48]. In accordance with the aim of a scoping review, a quality appraisal is not required, as opposed to Systematic reviews and Meta-Analyses [49]. type and design of the study. A thematic analysis was also conducted as a "method for identifying, analyzing, and reporting patterns (themes) within data" ([58], p. 79). According to Braun and Clarke "a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set" ( [58], p. 80). For this reason, the authors identified the following three themes: a description of the type of participants in study, types of intervention and approach to falls, and type of technology used.

Results
A total of 12 papers met the eligibility criteria and were included in the present Scoping Review. Figure 1 gives an explanation of the selection process for choosing these papers. Tables 2 and 3 summarizes the papers.

Bibliometric Characteristics
In total, we screened 74 documents, with 12 studies meeting the eligibility criteria (see Figure 1). The selected literature was published between 2012 and 2020. The first study to report the use of technology in an occupational therapy falls approach was published in 2012 [58].
The criteria used were flexible due to this being a current topic. The eligibility criteria were papers written in English, Portuguese, and/or Spanish; there was no limit on the year of publication; studies could only involve humans; and all types of documents (i.e., original articles, reviews, conference papers) were considered. Individual search strategies (see supplementary Table S2 in the supplementary materials) were used for each database using a combination of the operators "AND" and "OR," jointly with the criteria defined and the following descriptors:

Study Selection and Data Extraction
After searching, in accordance with the PRISMA-ScR guidelines [48], the first step was to identify all of the records, which were imported into the bibliographic manager Mendeley [57]. The second step was screening, whereby duplications were removed through Mendeley [57]. In the eligibility step, the results were assessed by title, abstract, or full text, following the eligibility criteria defined and in accordance with the topic of interest-occupational therapy interventions based on technology to address falls in older adults (see supplementary Table S3 on supplementary materials). Thus, the studies had to involve falls, the older adult population, an occupational therapy perspective, and the use of technology. In total, 12 papers met the defined criteria. See the details of these processes in the Figure 1 in the Section 3.

Data Analysis
Data were compiled in Microsoft Excel ® (Redmond, DC, USA) for validation, coding, and analysis. Bibliometric and thematic variables were used to analyze the characteristics of the studies. Frequencies and/or percentages were used to show the following bibliometric characteristics: year of publication, authors' affiliation, journal of publication, and type and design of the study. A thematic analysis was also conducted as a "method for identifying, analyzing, and reporting patterns (themes) within data" ( [58], p. 79). According to Braun and Clarke "a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set" ([58], p. 80). For this reason, the authors identified the following three themes: a description of the type of participants in study, types of intervention and approach to falls, and type of technology used.

Results
A total of 12 papers met the eligibility criteria and were included in the present Scoping Review. Figure 1 gives an explanation of the selection process for choosing these papers. Tables 2 and 3 summarizes the papers.

Bibliometric Characteristics
In total, we screened 74 documents, with 12 studies meeting the eligibility criteria (see Figure 1). The selected literature was published between 2012 and 2020. The first study to report the use of technology in an occupational therapy falls approach was published in 2012 [58].
1st phase: The Obstacle tool is a digitalized version using the mind maps and the paper version results for tablets. It has a version that can be used by health professionals or informal caregivers too. The digital version includes (1) the possibility of structuring the screening by adding the rooms in the order of preference for occupational therapists, (2) registration of problems/scores, the addition of photos to the screening, (4) a better overview than in the paper version, (5) the option to store and save data and make a back-up, and (6) connection with the application H-OPP (a digital coach for occupational therapists).
The Obstacle tool was developed and judged to be very useful by occupational therapists. It was highlighted that the Obstacle is adapted for use for persons with dementia and a mini-obstacle tool is under construction and will be digitalized to be available for clients and their informal caregivers. The next step is to make the tool accessible to everybody.  This mixed-method study aimed to present a 3D mobile application to enable older adults to carry out self-assessment measurement tasks in accordance to two different treatment conditions, using a 3D guidetomeasure tool or a 2D paper-based guide.

n = 37 participants
The application 3D guidetomeasure-3D was developed by the Unity3D game engine, which supports multi-platform deployment, including Android, IOS, desktops, and Web. The unity3D engine includes an avatar model, 3D furniture models, and arrow prompts of the application.
An empirical mixed-methods assessment of the performance of the guidetomeasure-3D application revealed that, in terms of accuracy, consistency, task completion time, and usability, significant performance gains were achieved over the art's current state paper-based 2D measurement guide equivalent.

A Description of the Type of Participants in Study
This theme was about the types of participants included in the studies (i.e., older adult(s) or occupational therapist(s)), the age of the participants, the percentage of females in the sample, the environment in which the study was conducted (i.e., communitydwelling or an institution), and other interesting details mentioned.
The reviews included in this study did not provide some of the participants' characteristics (see Table 3 details of the participants). In a review by Chase and colleagues [58], a total of thirty-three studies were included, all randomized controlled trials, while in the review by Stewart and colleagues study [62], ten studies were included and these were different types of studies.
All participants volunteered to participate in the different studies, but in the study by Hamm and colleagues, the occupational therapists received a ten pound voucher [64].

Type of Intervention and Approach to Falls
This theme included the type of intervention if the study was about a specific risk factor related to falls (extrinsic, alien to the individual, or intrinsic, related to the person and the aging process) and the type of approach to falls (detection, prevention, or treatment).
Four types of intervention were identified: "home modifications" (n = 5) [59,[64][65][66]69], "assistive technology" (n = 4) [58,[60][61][62], "exercise" (n = 2) [63,68], and "educational" (n = 2) [59,67]. We considered single-component interventions and focused on fall detection, prevention, and treatment. Interventions that focused on home modification addressed extrinsic factors such as bathroom modifications (i.e., bath, toilet, shower), appropriate chair height, and indications to include space to move, among others. Assistive technology interventions addressed extrinsic factors that can affect the safety of the person in the home. This included the use of telecare, emergency alarms, and fall detectors (i.e., pendant alarms). Exercise was used as a strategy to address intrinsic factors related to physical condition and the use of educational interventions in these studies was based on extrinsic factors, which consisted of the types of modification the person has to do to be safe at home.

Type of Technology Used
This theme was about the types of technology addressed in the studies. The technologies used in the studies were classified as software developments, telehealth, multimedia materials, and commercial and technological devices. Software developments (n = 5) included augmented reality applications [69], 3D measurement aid prototype applications [64,66], a digital version of the Obstacle Tool [61], and a Falls Sensei 3D game [67]. The use of telehealth was integrated into telecare to reduce the fear of falling [62], and the system was integrated into a watch to provide a factor sensor system to monitor temperature with an analog display, an emergency button, and an accelerometer [60]. The multimedia materials included different videos to identify environmental fall factors [59]. The commercial and technological devices included smart home technology to operate lights, appliances, doors, and windows [58], and these included the use of Kinect [68] and Nintendo Wii [63]. Table 3 shows the relationships between Section 3.2.2 (Type of intervention and approach to falls) and Section 3.2.3 (Type of technology used, and the compatibility of the technology used with the technological devices: Tablet, iPad, computer, laptop, Xbox, Nintendo Wii, and mobile phone).

Discussion
This study presents the first scoping review of occupational therapy interventions to address older adults' falls using technology. The objectives defined focused on exploring the literature about the topic to determine the type of studies conducted, where these studies have usually been published, and the approaches and strategies used to reduce fall risk by occupational therapists using technology.
The results show that this is an emerging area, which began to be researched in the year 2012 [58]. In a review by Chase and colleagues on home modification, only telecare was mentioned as a possible strategy by occupational therapists, but occupational therapists did not specifically develop that study. However, previous studies focused on the use of technology. For example, the iStoppFalls project focused on the use of exergames to reduce falls in older adults; this project was conducted from 2011 to 2014 to motivate and enhance the use of physical activity by community-dwelling adults aged more than sixty-five years by engaging with three purpose-built exergames to reduce falls [43,70].
The present review shows a trend toward carrying out studies with a qualitative approach [63,69] and mixed-methods studies [65,66], reinforcing the idea that is important to understand the perceptions and opinions of the older adults or occupational therapists and other health professionals under study to find out about their experiences with using the technology. This type of research helps us to understand the acceptance or not of technology and to determine how to improve or adapt it to make it useful in older people's day-to-day lives [71].
Regarding the place of publication, similar numbers of studies have been carried out in the USA [58][59][60][61] and Europe [62][63][64][65][66][67], even though progressive aging of the population is more apparent in Europe, and considering that previous European projects such as Prevent IT, Farseeing, and iStoppFalls, which are an essential background to fall prevention and the use of technology, were developed in Europe [43][44][45].
Compared with other reviews about falls and occupational therapy [41,69], the present scoping review results are of a lower research quality, because it was not possible to find any controlled trials to demonstrate the effectiveness of the interventions developed alongside technology. The types of studies included descriptive studies [61], case studies [59,60], experimental studies [68], and qualitative studies [63,69], which are not considered to give a high level of evidence. Instead, some controlled trials were carried out in the field of falls and occupational therapy, for example, the one by Monaco and colleagues [39].
As for the participant sample sizes and characteristics, the samples used were relatively small, except for one case [61]. This is linked to the level of evidence mentioned above and the types of study used. The types of participant included older adults, occupational therapists, and/or informal caregivers.
Only one of the types of software developed, obstacle tool digitalization [65], was tested in older adults, occupational therapists, and informal caregivers. The aim was to make it accessible for everybody, which is an essential factor to keep in mind in software development, according to the accessible software development model [72], the philosophy of design for all [73], and the inclusive perspective of the occupational therapy [74], as this helps to break the digital divide, particularly among older adults [74].
The studies included an extensive range of ages from 50 [67] to 98 years old [63], although older persons are classified as those aged 65 or more years. This reflects the perspective of preventing falls in people nearing retirement and the importance of active, healthy aging throughout life [75,76]. The life expectancy in Europe and USA, the main places of publication, is approximately 82 years old [74]. Life expectancy at age sixty is higher in women than men [77], and as can be seen in the results, females made up the highest percentage of participants in the studies, with 60-68% of participants being older women [67,69].
Regarding the type of intervention used to address falls in older adults through occupational therapy, only single-component interventions were used [36], even though different authors have suggested that multifactorial programs help to prevent and reduce falls because of their complexity [30]. None of the studies included an interprofessional team, despite its importance. The effectiveness of the multifactorial programs is also due to the use of an interprofessional team for fall prevention and treatment [33].
In terms of multifactorial programs [30], these involved exercise, as was done in two studies included in this review [63,68]; individualized and comprehensive fall risk assessment about the environment of an older adult, as done in a few studies mentioned in this review [59,[64][65][66]69]; and education on fall prevention, as done in two studies [60,68]. Furthermore, any intervention includes occupational therapy home visits [78], which can be an essential aspect to include, especially in the cases of home modification [59,[64][65][66]69] and assistive technology [58,[60][61][62]. The studies that integrated aging in place focused on assistive technology and home modifications because these factors are widely acknowledged as being the primary and preferred interventions during ageing [79,80]. Understanding how older people's needs contribute to improving their quality of life, which is affected after a fall, is necessary [13][14][15][16]18,19].
A previous systematic review explored the cost-effectiveness of several occupational therapy interventions for older people, concluding that they are useful and cost-effective compared with standard care or other therapies [81]. In this way, socioeconomic impact is one of the consequences of falls [28]. However, the results were not focused on aspects related to socioeconomic impact.
Our results reinforce the idea that home modifications, assistive technology, and educational interventions can address extrinsic factors, particularly environmental factors, and exercise can address intrinsic factors. This is in accordance with previous studies about the use of occupational therapy interventions to address fall risk [24,[82][83][84][85].
Although, as mentioned above, some examples of assistive technology used to prevent falls in older adults include video-monitoring, health monitoring, electronic sensors, and fall detectors [42] these were not included in the studies mentioned in this review. Moreover, regarding fall interventions globally, there is more focus on exercise options and an extensive range of technologies from virtual reality [86] to wearables [87] that were not included in these studies. Primarily, virtual reality interventions are used in occupational therapy, for example, in children [86].
As a result of this review, it is suggested that researchers in this field perform more studies that include the latest technology in the field of falls, so that more studies with a higher level of evidence exist. Interprofessional and multifactorial interventions should be integrated.

Limitations
The present scoping review has few limitations since all those publications related to the topic have been included; regarding the language were included articles in English, Spanish, and Portuguese; and regarding the type of study, any of them were included. The first limitation maybe not including other languages or other databases in the search process. However, we included databases of occupational therapy and socio-health care. Regarding the searches and the inclusion and exclusion of studies, it was carried out by one of the authors, which may be a limitation. In spite that the researcher used a structured process, some data may have been omitted or excluded. As future research, it would be important to integrate more researchers into this process.

Conclusions
Although falls have been identified as a public health challenge and the importance of technology in our lives is well known, the literature available on the prevention of falls in older adults using technology is scarce. It is considered to be an emerging area, especially when considering the use of technology in occupational therapy.
The studies in this area have mainly been conducted in the USA and Europe and have been published in occupational therapy and informatics journals. The target population is those over 50 years of age. The risk factors that have most frequently been evaluated and considered are extrinsic factors, particularly environmental factors. Interventions on occupational therapy using technology to address falls in older adults have been single component methods, including home modifications, assistive technology, educational intervention, and exercise. The technology used in the studies can be classified as software developments, telehealth, multimedia material, and commercial technological devices. Lastly, the authors conclude that the prevention of falls in older adults is an essential part of interventions against the risk of falls, and occupational therapy and the use of technology may contribute greatly to interprofessional fall prevention programs.
Supplementary Materials: The following are available online at https://www.mdpi.com/1660-4 601/18/2/702/s1, Table S1: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Table S2: Search strategies from each database, Table S3: Removed from eligibility criteria. Funding: The authors disclosed the receipt of the following financial support for the research, authorship, and/or publication of this article: The research team will bear all the economic costs involved in the study, with the support of the CITIC, as Research Center accredited by Galician University System that is funded by "Consellería de Cultura, Educación e Universidades from Xunta de Galicia," which provided 80% of funds through ERDF Funds, ERDF Operational Programme Galicia 2014-2020, and the remaining 20% was provided by "Secretaría Xeral de Universidades

Conflicts of Interest:
The authors declare no conflict of interest.