Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 9:CD007146

Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand. .
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 09/2012; 9(9):CD007146. DOI: 10.1002/14651858.CD007146.pub3
Source: PubMed


Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.
To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.
Randomised trials of interventions to reduce falls in community-dwelling older people.
Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.
We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.
Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

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Available from: Lindy Clemson, Jul 31, 2015
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    • ". From the identified fall risk factors, some strategies appear to be effective in reducing the occurrence of falls among elderly persons living in the community [33] [92] [94] [107]. These authors reported beneficial effects of reduction of psychotropic medication and exercise promotion on the occurrence of falls. "
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    • "As a result, and due to global ageing trends [2], fall prevention is considered vital. Various forms of fall prevention have been shown to be effective in the community, from home/group exercise, to multi-faceted programmes that address a range of fall risk factors [3]. These costly interventions can handle only limited patient volumes, as is also the case with dedicated fall clinics and their specialised equipment and personnel. "
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    ABSTRACT: The field of fall risk testing using wearable sensors is bustling with activity. In this Letter, the authors review publications which incorporated features extracted from sensor signals into statistical models intended to estimate fall risk or predict falls in older people. A review of these studies raises concerns that this body of literature is presenting over-optimistic results in light of small sample sizes, questionable modelling decisions and problematic validation methodologies (e.g. inherent problems with the overly-popular cross-validation technique, lack of external validation). There seem to be substantial issues in the feature selection process, whereby researchers select features before modelling begins based on their relation to the target, and either perform no validation or test the models on the same data used for their training. This, together with potential issues related to the large number of features and their correlations, inevitably leads to models with inflated accuracy that are unlikely to maintain their reported performance during everyday use in relevant populations. Indeed, the availability of rich sensor data and many analytical options provides intellectual and creative freedom for researchers, but should be treated with caution, and such pitfalls must be avoided if we desire to create generalisable prognostic tools of any clinical value.
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    • "While a Cochrane review on interventions for preventing falls in older people suggested that interventions to improve home safety when carried out by therapists on high-risk individuals appear to be effective for reducing falls (a 19% reduction of falls, relative rate 0.81, 95% CI 0.68e0.97; six studies with 4208 total participants), another specific review on the home environment modification for the reduction of injuries in older people was unable to draw a similar conclusion due to the relatively few published studies [14] [15]. However, in the most recent clusterrandomized controlled study involving 842 households, a 26% reduction in the rate of injuries caused by falls was observed in the group provided with low-cost home modifications and repairs, including handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, edging for outside steps, and slipresistant surfacing for outside areas such as decks and porches [16]. "
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