Author
CHANG John T.; et al.;
Title
Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials.
Journal citation/publication details
British Medical Journal, 328(7441), 20 March 2004, pp.680-683.
Summary
Various interventions have been used to prevent falls in older adults but there is no clear indication of the most effective strategies. This meta-analysis aims to identify and assess the relative effectiveness of different interventions using results from 40 randomised controlled trials, comprising 56 intervention groups. Meta-regression analysis of the different interventions showed that a multifactorial falls risk assessment and management programme was the most effective component in reducing both risk of falling and monthly fall rate. Exercise programmes were also beneficial.
Context
Falls are a major health problem among older adults, leading to fractures, head injuries and anxiety, which can contribute to a loss of independence through disability and fear of further falls. A range of prevention strategies has been used, including risk assessment and management, exercise, environmental modifications and education. However, as yet there is no clear evidence as to which are the most effective.
Methods
What sources were used?
Medline, AgeLine, Embase (Excerpta Medica), CINAHL (Cumulated Index to Nursing and Allied Health Literature), PsycINFO and the Cochrane Library were searched from 1992-2002. In addition, the reference lists from 82 reviews, and those obtained through the American Physical Therapy Association and American Geriatrics Society, were examined.
What search terms/strategies were used?
The search strategy was ‘accidental falls' or ‘falling' or ‘fall' AND ‘aged' or ‘elder care' or ‘elderly' or ‘elderly care' or ‘geriatric assessment' or ‘elder' or ‘senior' AND ‘clinical trial' or ‘randomised controlled trial'. No language limitations were imposed.
What criteria were used to decide on which studies to include?
To be included studies had to be randomised controlled trials with a major focus on falls prevention, include data on participants aged 60 or more, and employ a ‘usual care' or control group.
Who decided on their relevance and quality?
The initial searches identified 830 studies, of which 90 appeared to meet the inclusion criteria. Fifty of these were subsequently excluded. Two authors independently reviewed the selected articles and extracted general information on objectives, design, participants' ages and outcomes. Data were collected on study design and study quality was assessed using the Jadad score. Studies were then assessed in detail independently by different authors for content and methods.
How many studies were included and where were they from?
Forty studies were used in the meta-analyses. Geographical origins are not indicated.
How were the study findings combined?
Two outcomes were considered: falling at least once during a specified follow-up period; and the monthly risk of falling. Each outcome had an analysis plan.
To analyse the risk of falling during follow-up, a risk ratio was estimated using studies that provided the number of patients in each group (intervention, control or usual care) who fell at least once during follow-up of six to 18 months. Adjustments were made for heterogeneity across interventions.
The second analysis included studies that provided data on the total number of falls and the average follow-up period in each group. For each group the monthly incidence rate of falling and the incidence rate ratio for each comparison between an intervention group and usual care or control group were calculated.
As none of the studies directly addressed the relative effectiveness of different intervention components, this was assessed by meta-regression, comparing the magnitude of the effect of each component to a control group that received usual care.
Findings of the review
Full details of the references and analyses are given on the journal website ( www.bmj.com ). Overall findings show that interventions to prevent falls in older adults are effective. Combined data from 26 intervention groups in 22 studies showed a significant reduction in the risk of falling. Meta-analysis of data from 30 intervention groups in 27 studies also showed a reduction in monthly rate of falling. Meta regression analysis examined the relative effectiveness of the four different interventions categories.
Multifactorial falls risk assessment and management programmes
These programmes were post-fall assessments of systematic risk factor screening programmes among individuals at risk, tied to intervention recommendations and follow-up. Ten studies included assessment of falls during the follow-up period, and seven assessed the monthly rate of falling. These programmes had a statistically beneficial effect on both outcomes. The most commonly assessed risks were drugs, vision, environmental hazards and orthostatic blood pressure. There were some trends in the relative effectiveness of the major components of the programmes, but there was little difference between the most or least effective. There were no significant differences in the effectiveness of the interventions by population studied.
Exercise
Exercise programmes included both general and specific physical activities, such as walking, cycling, and aerobic movement. Thirteen exercise studies assessed falls during the follow-up period and 19 assessed the monthly rate of falling. Exercise had a statistically beneficial effect on the risk of falls but not on monthly rate of falling. It was not possible to detect statistically significant differences between different types of exercise.
Environmental modification and education programmes
Environmental modification programmes involved home visits to check for environmental hazards, with recommendations for modifications. These programmes were used in five studies where falls during follow-up period were included, and five which assessed the monthly rate of falling. Three studies involved education interventions targeting individuals, groups or communities with posters, pamphlets or counselling. Pooled estimates for these interventions were not statistically significant.
Authors' conclusions
The review found a multifactorial falls risk assessment and management programme to be the most effective at reducing falls. Exercise was also effective, but there was no clear evidence for the effectiveness of environmental modification or educational programmes.
Implications for policy or practice
The authors suggest ‘a two pronged approach' to falls prevention: a multifactorial falls risk assessment and management programme targeted at selected people, such as those with a history of falls; and exercise programmes directed at a general population of older adults.