Perspectives: How to Apply Motivational Interviewing for Older Adult Fall Prevention

Abstract

More than one in three adults age ≥65 fall each year, and fall-related deaths are increasing in the United States. Falls risks can be reduced when older adults are able to engage in series of behavior changes to reduce their high fall risk factors. However, older adults perceive their fall risks to be lower than clinically indicated and adherence rates for fall prevention recommendations are suboptimal. Motivational interviewing (MI), a validated patient-centered behavior change communication approach, is ideal for addressing these gaps and facilitating older adults’ engagement in fall prevention. The goal of this paper is to present practical tips to apply MI for fall prevention for clinicians who may not be familiar with MI. We draw on our experience from providing MI sessions to high fall risk older adults within a randomized controlled trial. We describe how we delivered MI sessions and practical lessons learned from this experience. We present how basic MI skills can be used for fall prevention using a case study, how an older adult may move through Stages of Change for fall prevention, and how to address strongly held beliefs about fall prevention.

“Physiologic and behavioral fall risks such as loss of balance control and strength, orthostatic hypotension, vision impairment, or tendencies to hurry are developed over time.”

Introduction

Falls lead to significant negative physical and emotional trauma. One in three adults age ≥65 fall every year, and falls are the number one reason older adults lose their independence. ¹ Falls are caused by biologic, behavioral, and environmental factors. Although biologic factors for fall prevention are well studied, there is a lack of effort and knowledge to improve behavioral fall risk factors. The Centers for Disease Control and Prevention (CDC) recommends talking to providers to identify fall prevention strategies and to implement balance exercises, environmental modifications for safety, and adjustment of high fall risk medication. ¹ However, only half of older adults report their falls to their providers, ¹ and only 18-50% of older adults adhere to these fall prevention recommendations.^2,3 Older adults do not perceive fall prevention as relevant to them ⁴ and view fall prevention strategies as too intensive or inconvenient. ⁵ Strategies to overcome older adults’ resistance with fall prevention are necessary to enhance their engagement in fall prevention behaviors.

Motivational interviewing (MI) has immense potential to be applied to fall prevention. MI is a validated communication strategy to promote individual health behavior change.^6–8 MI can be delivered in-person, virtually, and in brief formats (i.e., 15-30 minutes). There is emerging evidence to support the use of MI to address fall prevention.^9,10 However, there is limited literature on practical application of MI with older adults in healthcare settings to address fall prevention.

In this paper, we draw on our experience from providing MI sessions to high fall risk older adults within a randomized controlled trial. We describe how we delivered MI sessions and practical lessons learned from this experience. We present how basic MI skills can be used for fall prevention using a case study, how an older adult may move through Stages of Change for fall prevention, and how to address strongly held beliefs about fall prevention.

Overview of Motivational Interviewing

Abundance of literature exists for MI.^6–8 With clinicians who may not be familiar with MI in mind, we briefly describe elements of MI that pertains to facilitating patient-centered conversations for fall prevention. The fundamental elements of MI include: (1) MI specialist’s core communication skills; (2) a distinctive way of being called Spirit of MI ⁶ and (3) the four processes of MI. We use the term MI specialist as someone who utilizes MI. The core communication skills of MI include utilizing open-ended questions, affirmations, reflections and summary statements (OARS) to effectively move client’s behaviors toward change in conversations. ⁶ These skills are built on the MI specialist’s Spirit of MI, meaning that there’s constant recognition that each patient has absolute worth and autonomy in their life choices, and this unwavering respect is expressed through collaboration, evocation, compassion, and acceptance. ⁶

Equipped with these fundamental elements of MI, the MI specialist will facilitate MI conversations through four processes of MI known as engagement, focusing, eliciting (evoking), and planning. ⁶ Engagement refers to building trust and safety. As the MI specialist and the patient build a trusting relationship (engagement), the MI specialist will facilitate the conversation to provide clarity in a target behavior for change and potential outcomes (focusing). The MI practitioner will also facilitate forward movement in behavior change (elicit), meaning developing the momentum to shift the client toward change talk, commitment statement to adopt new behavior, rather than sustain talk, statements to indicate desire to remain at status quo. Finally, the MI specialist will facilitate conversations around planning next steps when the client is ready to adopt new behaviors (planning). Application of four processes of MI to fall prevention is illustrated in Table 2.

In order for these MI processes to take place, it is helpful for the MI specialist to understand where the patient is at for behavior change using the Stages of Change model ¹¹ to facilitate behavior change. Stages of Change is a helpful conceptualization of how individuals move through series of stages—precontemplation, contemplation, preparation, action, and maintenance—as they adopt various health behaviors for fall prevention. Centers for Disease Control and Prevention (CDC) has been successful exemplifying how providers may respond to patients at various Stages of Change. ¹² However, comprehensive description on how Stages of Change may shift toward change for fall prevention does not exist.

Motivational Interviewing for Fall Prevention (MI-FP) Study

As a study intervention for a federally funded study, Motivational Interviewing for Fall Prevention (MI-FP) was developed. In the MI-FP study, MI sessions were provided to older adult participants recruited from an internal medicine clinic at an academic medical center. Patients were eligible if they are age 65 or older, at high fall risk using the CDC’s Stopping Elderly Accidents, Death, and Injuries (STEADI) fall risk assessment questionnaire in which a score of ≥4 is considered high fall risk, ¹³ and received fall prevention recommendations from their providers. We conducted chart reviews and excluded patients with diagnosis of dementia or low scores on cognitive screening tests (Montreal Cognitive Assessment [MOCA] < 16; Saint Louis University Mental Status [SLUMS] <19.5 no high school education, <21.5 with high school education; Mini-Mental Status Exam [MMSE] <26.5 no high school education, <27.5 with high school education). Details are described elsewhere (in review).

Once participants were consented and randomly assigned to the intervention group, older adults received eight strike monthly MI sessions over 6-months over phone or video call (baseline, 1-week booster session, then monthly for 6 months). The study was approved by Oregon Health and Science University Institutional Review Board (IRB #8993) and registered as Clinical Trial # NCT04612842.

Delivery and Fidelity of Motivational Interviewing Sessions

Five MI specialists with basic or proficient skills of MI provided the MI sessions. These MI specialists have attended an MI workshop or one-to-one MI training prior to joining the study. The proficiency levels of MI skills were identified using Motivational Interviewing Training Integrity (MITI) 4.2.1 coding manual. ¹⁴ MI specialists included a mental health counselor, three nurses (two were inducted to Motivational Interviewing Network of Trainers [MINT] during the study), and a nursing student who was a health navigator at a primary care clinic. Overall quality of MI sessions was supervised by the consultant to the study, a MINT member (KNS). The MITI coding scheme was used by individual MI specialists to code individual MI sessions and during the monthly MI specialist meeting for ongoing MI training throughout this project. A random selection of MI sessions was quarterly assessed by four MITI coding experts external to the study who were Motivational Interviewing Network of Trainers (MINT) members who had completed MITI training program.

Description of Motivational Interviewing Sessions

The MI sessions were semi-structured to capture participants’ response to specific open-ended questions for research purposes. For example, the Menu of Options for Fall Prevention, ⁴ one-page document outlining potential topics for fall prevention (e.g., goals, risks, prevention strategies), was introduced during the first three sessions to engage and guide older adults’ fall prevention conversations. The first session started with the specialist describing the nature of MI sessions and asking “What do you think about the meeting today to talk about fall prevention?” and “What comes to your mind when you hear ‘fall prevention?’” to gauge older adults’ level of engagement with fall prevention. Typically, while the first session was aimed at building rapport and an engaged relationship with the participant, the second session was aimed at identifying the focus of fall prevention behavior change. In later sessions, MI specialists elicited health behavior change using OARS skills to reduce sustain talk and to encourage change talk.

Key Lessons Learned

All MI specialists participated in the monthly MI specialist meeting led by the MINT trainer (KNS) and the principal investigator (HKT) from September 2020 to July 2022. Total of 74 participants had completed at least two MI sessions. Thirty-nine participants had completed all eight MI sessions. Participants were mean age of 80, 32% male, 91.5% White, 92.5% Non-Hispanic, and 76.5% had Medicare insurance. During these meetings, MI specialists exchanged ideas about how to incorporate geriatric fall prevention strategies in 15-30 minute phone or video MI sessions, use Menu of Options for Fall Prevention, how to effectively move participants through four processes of MI, and how to address older adults’ sustain talk about fall prevention, and what worked to facilitate change talk.

Using the meetings notes, and further discussion among the MI specialists, we identified three key lessons to skillfully navigate brief, repeated, phone or video MI sessions about fall prevention with older adults. These lessons were about: how basic MI skills can be used for fall prevention, how an older adult may move through Stages of Change for fall prevention, and how to address strongly held beliefs about fall prevention.

Lesson 1: Application of Basic MI Skills for Fall Prevention

Basic MI skills (i.e., OARS) were critical to facilitating conversations about fall prevention and sharing information in 15-30 minute conversations. Table 1 offers a case study with examples of how MI skills can be applied in a fall prevention conversation, which MI process is being addressed, and an explanation about how the MI language can reduce sustain talk or encourage change talk. This example illustrates how basic MI skills can move fall prevention conversations toward positive behavior change despite participants’ reluctance to do so.

Table 1.

Fall prevention case study using motivational interviewing skills.

Case. Peggy, 75-year-old female, is identified as high fall risk. Balance exercise and use of cane are recommended by her provider to enhance stability. 6 months later, she is back at the clinic, and you (as provider or clinician) have 10 minutes to talk about fall prevention. You observe that she walks slow and use the wall more often to stabilize herself. However, she reports that she does not need to use the cane and does not have a cane with her. What do you think is going through Peggy’s head? How would you respond to the situation?

Example MI Language	MI Process (MI Skills Applied)	Explanation
“Is it OK that we talk about how you are getting around these days?”	• Engagement (asks for permission and uses OQ)	• Asking for permission to show respect for the individual
If OK, “Many people do not want to talk about falls, what do you think about having a conversation about fall prevention?” -A		• Rather than closed-ended questions about fall history and injury level, opening the conversation with a framing question is useful. This question can help understand the SOC for a fall prevention behavior
“It seems like you thought balance exercises can help and tried it, and found that time is an issue. a What else have you tried or have thought of to keep yourself steady? What would you be most interested in talking about?” -B	• Engagement (Uses reflective statements). Focusing (Uses OQ)	• Once an engaging relationship is established, agenda setting is helpful to identify the focus of the conversation. For balance exercises, this individual is in contemplation SOC. The OQ explores other relevant balance activities and encourages change talk as well as reducing sustain talk
“I am curious, can you tell me more about what you mean by being careful? a ” -C	• Eliciting (Uses OQ)	• Example of addressing resistance to engage in additional fall prevention measures. Many older adults identify “being careful” as their primary and only fall prevention strategy. Gathering more information about what this phrase means to an individual may offer clarity in identifying the SOC for a fall prevention behavior
“Thank you for telling me about your fall. a It shows that you really care about keeping yourself safe and independent. How has the fall impacted you?” -D	• Engaging (Uses affirmation)	• After a fall event, OQ can be a powerful way to gain insights about how the individual is engaged in fall prevention. Experiences of falls can be a window of opportunity to enhance fall prevention practices. The affirmation can reduce sustain talk while the exploratory OQ can help identify SOC for a fall prevention behavior
	• Evoking (Uses OQ)
Potential follow-up questions	• Eliciting (Uses OQ)
• “What are you doing differently now?”
• “What other fall prevention strategies are you using now or might be interested in exploring?” -E
Potential reflective statements: a	• Engaging (Uses affirmation)	• Identifying and affirming individual’s strengths related to being safe, healthy, and happy (e.g., being creative, trying, motivated to improve) deepen their desire to be to improve. Confidence building in this format can shift an individual toward the next SOC by encouraging change talk
• “You are trying to be creative about using different ways to be safe.”	• Eliciting (Uses affirmations and reflective statements)
• “You know yourself well and you are able to notice and make changes as needed when necessary.” -F
“Balance exercises and a cane were recommended and you didn’t think that was a good fit for you.” a -G	• Engaging (Emphasize autonomy)	• Acknowledging individual’s autonomy builds trust and collaboration. After exploring why, then explore what would work better. Useful for those in Precontemplation SOC to build trust and create reflection to reduce sustain talk
	• Eliciting (Uses reflective statements)
“You’ve provided some great ideas on how you prevent falls. Would you be interested in additional ideas?” a -H	• (Provides information in MI-aligned way)	• Examples of MI-aligned way to provide information
	• (Uses OQ)
“What do you think about these fall prevention ideas? How might any of them fit your life?” -I	• Eliciting (Uses OQ)	• It is important to elicit strategies from the individual, yet some education may be useful. After providing information or recommendations, explore the usefulness of the ideas. This reinforces the importance of their perspectives. Seeking permission reduces sustain talk
“Peggy, you indicated you were having more difficulty finding your balance and limited some activities to feel safe. It has been really hard to transition to this phase of your life. We explored some ideas you could add including X, Y, and Z. You sound interested in applying one or two of these." a -J	• Eliciting (Uses summary statements)	Strategically using several reflections summarizes and clarifies ideas toward change. Although some initial sustain talk is captured, the “explored some ideas” should include areas of change talk and interest to shift a person toward preparation or action SOC. Menu of options can be used here
Potential follow-up questions	• (Uses OQ)	Consider what is important for the individual to make positive changes. Determine future plans when the individual is ready to try new ideas. Pushing for a plan before at least preparation stage, can induce sustain talk and resistance
• “Is there anything you want to add?”
• “What do you think will be your next step?” -K

Notes. SOC: Stages of Change. OQ is Open-ended Questions.

^aSome MI examples assume a certain response from Peggy.

MI Spirit is demonstrated throughout, and is highlighted by how the request for permission is embedded in the conversation (Table 1-A) and how information is shared about fall prevention (Table 1-H). MI adherent way of information giving includes asking permission to share information and exploring the individual’s thoughts after the information is shared. ⁶ This approach allows participants to gain knowledge while retaining their autonomy to choose.

Open-Ended Questions.

• Explore the common strategy of “being careful” by asking, “I am curious, can you tell me more about what you mean by being careful?” (Table 1-C)

• After a fall event, exploring with “How has the fall impacted you?” or “What are you doing differently now?” can be powerful ways to gain insights about how the individual is engaged in fall prevention. Not all individuals see experiencing a fall as a window of opportunity to enhance fall prevention practices. (Table 1-D)

• Explore the usefulness of information or recommendations by asking “What do you think about these fall prevention ideas?” This will reinforce the importance of their perspectives. (Table 1-I)

• Open-ended questions aimed to elicit meaning and value were essential to move the conversation forward in 15-30 minute conversations. (Table 1-C, E-J)

• The Menu of Options for Fall Prevention can be used for focusing the conversation, finding the goal behavior to explore, or open the discussion possibilities. This tool is useful for covering various risk factors for falls in limited time. Examples include: “We have X, Y, Z options to focus on today, which do you see as the priority?” Or to explore next steps: “There are many options for preventing falls including ___, which do you believe you can work on for now?” (Table 1-J)

Affirmations

Because many older adults believe that they are not at risk for falling or are defensive about fall risk, affirming their abilities and skills to stay independent and capable are critical to gain their trust in early stages of MI sessions. (Table 1-D, F)

• Recognizing that older adults “know themselves” or “are intuitive about what works” supports desires to try new strategies.

Reflections

Reflections to capture older adult’s inner thoughts and feelings and to empathize with uncertainty, ambivalence, and grief were crucial. Meaningful reflective statements lead to building engaging relationships in a short amount of time. Reflective statements may also be valuable to demonstrate that you are actively listening when participants cannot see your facial or body expressions over the phone. (Table 1-B, F,G)

• Accepting an older adults’ autonomy builds trust and collaboration: “Your doctor recommended you do X, and you didn’t think that was necessary for you.” From here one can explore why or what would work better for the older adult. (Table 1-G)

Summary

Providing balanced or change talk focused summary is an effective way to tie in key elements of the conversation or redirect the conversation to focus on “potential” for change. (Table 1-J)

Lesson 2: Stages of Change Varies for Fall Prevention Topics and Health Behaviors

Under the umbrella of fall prevention, there are multiple topics and health behaviors to address. Participants were in different Stages of Change for each behavior. Each MI session covered one to three fall prevention topics and behaviors. Fall prevention topics discussed in MI sessions can be categorized in nine fall prevention behaviors and topics (Table 2). They were: adapting to aging, body awareness, assistive mobility devices, balance exercises, talking to clinicians, vision, environment, medication, and blood pressure management. Understanding Stages of Change for common fall prevention topics and behaviors helped MI specialists set the focus of each of the sessions.

Table 2.

Examples of fall prevention topics and behaviors and Stages of Change.

Fall prevention topics and behaviors	Stages of Change
	Pre-contemplation	Contemplation	Preparation	Action	Maintenance
Adapting to aging	I don’t see myself as old. Falling is not a problem for me yet. I get around just fine.	I realize that preventing falls might be important. I'm starting to think about it, but I still feel fine.	It is hard to make changes. At this stage of life, I really need to slow down and be careful. I’m working with my doctor on a plan.	I have started to take control of my risk of falling. I am making changes and seeing the benefits.	I think about fall prevention every day and explore ways to adapt. I want the next 10 years to be the best yet.
Body awareness	I don’t know why but I’ve fallen twice while walking it was just a chance happening.	I realized that I am walking off balance. I don't want to have an injury. I wish things were easy like they used to be.	I looked at the Youtubes and found a Better Bones and Balance video I really want to start.	I am in a class that has rails to hold onto while I exercise, it is starting to get easier.	I go to my balance classes every week. I wouldn't miss it for anything.
Assistive mobility devices	I don’t want to look like other people I see using a cane or walker. I am doing just fine. No problems.	I’m not ready, but it would probably be safer to use a cane or walker.	I found my cane, I'm going to start using it more regularly when walking.	I started keeping my cane by the front door so I don’t forget it. I am also using my walker outdoors more, it makes me feel safe.	I always use my cane or walker when I go out of my apartment. I hardly have to think about remembering anymore.
Balance exercises	I'm doing everything to prevent falls already. I am fine holding onto the furniture when I walk around the house.	I've noticed my balance is off and I almost fell the other day. I am thinking about starting a balance class, but I am just so busy.	I heard of a community Tai Chi class starting up. I'm going to sign up and give it a try.	I started going to the Tai Chi class on Tuesdays and Thursdays, it is not easy but I see some benefits already.	I've been going to Tai Chi twice a week for a while now. The moves are getting easy now and I feel stronger.
Talking to clinicians	I already talk to doctors about my health. No need to bring up something new.	I want to prevent falls, I'll consider talking to my doctor if they bring it up.	I have an appointment coming up and I'll ask about what more I can do to prevent falls.	I started seeing physical therapy (PT) and am learning some new exercises.	I learned some home exercises from PT and am doing them every day.
Vision	I don't have glasses but I hold onto walls to get around the house, I've been doing that for years and its just fine.	I should go get my vision checked out but I have a lot going on right now and don't have the money.	I need to make a vision appointment. After my last fall I think it is time.	I had my eye exam and have an appointment for a new glasses fitting.	I had the cataract surgery in both eyes and am using the eye medicine and sorting out new vision
Environment	I know my way around the house, even if there are some things in the way.	I tripped over a rug the last time I fell and I should move them, but I like the rugs where they are.	I need to move the rugs and fix the lighting so I don't fall	I’ve gotten rid of throw rugs and am turning on the hall light at dinner time every day	I’ve been using a nightlight and low wall light strips to help me get to the bathroom for a while now.
Medication	I take whatever they tell me. I need all of my medications and do not want to change them.	I know some of my medications are on the list for high fall risk. I'll consider talking to my PCP.	I am planning to see my PCP next week and will talk about my fall risk and medications	My doctor is adjusting some of my medications to help prevent falls.	I've been taking the alternate medications for 2 months now, my doctor says this should help my fall risk.
Blood pressure management	I don't have problems with blood pressure. It's just been the dizziness, especially when I stand up quickly.	My blood pressure was low at my last visit, but I'm fine most of the time. Maybe I should check it more.	I've noticed my blood pressure is low when I'm dizzy, I plan to talk to my doctor about this next week.	I have a blood pressure cuff and am checking it daily and staying hydrated.	I've been checking my BP for a while now, I am getting up slowly these days, drinking more water and staying in touch with my doctor.

Notes: Quotes are actual or slightly modified to succinctly exemplify Stages of Change for fall prevention.

Lesson 3: MI Spirit is Essential to Find Common Ground

MI specialists found that participants make choices that may not line up with provider recommendations, reflecting their autonomy. Participants had strong opinions about how they prefer to engage with fall prevention. For example, participants have stated “I’m not there yet to use the walker” or “I’ve tried Tai Chi and I don’t like it,” referring to what they had been recommended to do by their provider. In addition, many participants verbalized that “being careful” was sufficient to reduce their chances of falling. Fall prevention recommendations from their providers such as balance exercise, vision checks, and maintaining ideal blood pressure were often mentioned as afterthoughts or not at all when asked about what they are interested in discussing during MI sessions. Clinicians must be well prepared for these opinions that may not align with evidence-based practices. There may even be some emotional response from the clinician to correct the patient if they are deviating from evidence-based practice (e.g., righting reflex ⁸ ); however, it may not be the right approach for behavior change. An alternative to correcting the patient is to embrace the MI Spirit. Stepping back to realize that this conversation is for the patient helps to tame this reflex. Shifting the focus from correcting to being genuinely curious about participant’s experience may ultimately help identify fall prevention strategies that align with participants’ priority.

Discussion

This manuscript described how we structured and implemented MI sessions to facilitate older adults’ engagement in fall prevention, and to share our learning about MI for fall prevention. We presented examples of how open-ended questions, affirmations, reflections, and summaries helped navigate MI sessions on fall prevention in a short amount of time and by phone or video call. We illustrated how older adults may be at different Stages of Change for a specific fall prevention topic or behavior and that MI Spirit is essential when working with strongly held beliefs.

As we write this manuscript, we understand that conversations about fall prevention may not be a common practice for clinicians. In this context, we would like to offer ideas so that behavior change approaches like MI can be utilized with high fall risk individuals. First, reframing fall prevention as a chronic condition with multiple risk factors can strongly impact the supports that older adults may receive. Physiologic and behavioral fall risks such as loss of balance control and strength, orthostatic hypotension, vision impairment, or tendencies to hurry are developed over time. Once fall prevention is viewed as a chronic health condition, clinicians, public health professionals, healthcare and social systems can approach fall prevention as something that needs lifestyle and behavior change. It takes time and multiple opportunities to reduce each of the fall risks. Lastly, reframing fall prevention as a chronic condition will help encourage a team-based approach for fall prevention, which may include MI-trained personnel in a care manager or community health navigator role.

MI is a learned communication skill ideally suited to address multiple factors to address chronic risks, used within a clinical setting, and can applied by any team member. ¹⁵ The topic of focus for MI will differ depending on the clinical role of the individual using MI. It will be most suited for prescribing clinicians and pharmacists to discuss high fall risk medication. Conversely, many fall risks can be addressed by non-licensed personnel to address health promoting activities such as exercise or behavior tendencies. MI can be viewed as a foundational skill to promote behavior change and to have satisfying conversations. ¹⁶ We support that all clinicians be equipped with MI skill, starting with small communication changes, and taking another step as described in this manuscript to explore new skills while conversing with older adults to address fall risks. These first-hand experiences, and the immediate results one may receive from patients will encourage the continuation of an MI approach, as many of us in the authorship team have done.

We hope that sharing real-world experiences of organizing and conducting MI sessions would help clinicians to trial and implement aspects of MI in their clinical practice to address fall prevention. Case study examples were provided so that elements of MI can be applied to clinical practice if the whole package of MI seems daunting. Asking open-ended questions to assess older adults’ Stages of Change is a great place to start patient-centered conversations about fall prevention. If resistance is met, which is not uncommon, embrace the MI spirit and explore why. We hope these lessons offer practical MI strategies to move beyond patients’ resistance, and to stimulate older adults’ interest in fall prevention.