Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses.
ABSTRACT To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment.
Systematic review and meta-analyses of studies grouped by intervention and setting (hospital or care home). Meta-regression to investigate the effects of dementia and of study quality and design.
Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical Trials Register, and hand searching of references from reviews and guidelines to January 2005.
1207 references were identified, including 115 systematic reviews, expert reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Meta-analysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the number of fallers or fractures. For hip protectors in care homes (11 studies) the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and not enough studies on fallers. For all other interventions (multifaceted interventions in care homes; removal of physical restraints in either setting; fall alarm devices in either setting; exercise in care homes; calcium/vitamin D in care homes; changes in the physical environment in either setting; medication review in hospital) meta-analysis was either unsuitable because of insufficient studies or showed no significant effect on falls, fallers, or fractures, despite strongly positive results in some individual studies. Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment.
There is some evidence that multifaceted interventions in hospital reduce the number of falls and that use of hip protectors in care homes prevents hip fractures. There is insufficient evidence, however, for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes.
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ABSTRACT: Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk of fractures due to osteoporosis. INTRODUCTION: The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2008. This manuscript updates these in a European setting. METHODS: Systematic literature reviews. RESULTS: The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk, general and pharmacological management of osteoporosis, monitoring of treatment, assessment of fracture risk, case finding strategies, investigation of patients and health economics of treatment. CONCLUSIONS: A platform is provided on which specific guidelines can be developed for national use.Osteoporosis International 01/2013; 24(1):23-57. · 4.17 Impact Factor
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ABSTRACT: AimsTo determine the most accurate fall risk screening tools for predicting falls among patients aged 65 years or older admitted to acute care hospitals.Background Falls represent a serious problem in older inpatients due to the potential physical, social, psychological and economic consequences. Older inpatients present with risk factors associated with age-related physiological and psychological changes as well as multiple morbidities. Thus, fall risk screening tools for older adults should include these specific risk factors. There are no published recommendations addressing what tools are appropriate for older hospitalized adults.DesignSystematic review.Data sourcesMEDLINE, CINAHL and Cochrane electronic databases were searched between January 1981–April 2013. Only prospective validation studies reporting sensitivity and specificity values were included.Review methodsRecommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews have been followed.ResultsThree fall risk assessment tools were evaluated in seven articles. Due to the limited number of studies, meta-analysis was carried out only for the STRATIFY and Hendrich Fall Risk Model II. In the combined analysis, the Hendrich Fall Risk Model II demonstrated higher sensitivity than STRATIFY, while the STRATIFY showed higher specificity. In both tools, the Youden index showed low prognostic accuracy.Conclusion The identified tools do not demonstrate predictive values as high as needed for identifying older inpatients at risk for falls. For this reason, no tool can be recommended for fall detection. More research is needed to evaluate fall risk screening tools for older inpatients.Journal of Advanced Nursing 10/2014; · 1.69 Impact Factor
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ABSTRACT: Die Sturzprävention findet in der medizinischen und der Pflegeliteratur zunehmend Interesse. In die medizinische Literaturdatenbank PubMed wurden im heurigen Jahr bereits 236 Arbeiten aufgenommen, die sich detailliert mit dem Problem Sturz und seine Verhinderung auseinandersetzen. Es wurden 21 randomisierte kontrollierte Studien und 4 Metanalysen randomisierter Untersuchungen identifiziert. Trotz dieser regen Forschungs- und Publikationstätigkeit ist die Evidenz für viele Detailaspekte der Sturzprävention noch unklar. Evidenz gestützte Empfehlungen zur Sturzprävention sind zur Zeit nur eingeschränkt möglich SUMMARY The medical and nursing literature indicate a rising interest in prevention of falls. The medical database PubMed has included in this year already 236 papers, which discuss the topic falls and their prevention in detail. Reports of 21 randomised controlled trials (RCT)and 4 meta-analyses of RCTs were identified. Despite of these busy research and publication activities, the evidence of many details of fall prevention remain unclear and evidence based recommendations are scarce at the moment.ÖZPMR, Österreichische Zeitschrift für Physikalische Medizin & Rehabilitation. 11/2007; 17(2):70-79.
Strategies to prevent falls and fractures in hospitals and care homes
and effect of cognitive impairment: systematic review and
David Oliver, James B Connelly, Christina R Victor, Fiona E Shaw, Anne Whitehead, Yasemin Genc, Alessandra
Vanoli, Finbarr C Martin, Margot A Gosney
Objectives To evaluate the evidence for strategies to prevent
falls or fractures in residents in care homes and hospital
inpatients and to investigate the effect of dementia and
Design Systematic review and meta-analyses of studies grouped
by intervention and setting (hospital or care home).
Meta-regression to investigate the effects of dementia and of
study quality and design.
Data sources Medline, CINAHL, Embase, PsychInfo, Cochrane
Database, Clinical Trials Register, and hand searching of
references from reviews and guidelines to January 2005.
Results 1207 references were identified, including 115
systematic reviews, expert reviews, or guidelines. Of the 92 full
papers inspected, 43 were included. Meta-analysis for
multifaceted interventions in hospital (13 studies) showed a rate
ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but
no significant effect on the number of fallers or fractures. For
hip protectors in care homes (11 studies) the rate ratio for hip
fractures was 0.67 (0.46 to 0.98), but there was no significant
effect on falls and not enough studies on fallers. For all other
interventions (multifaceted interventions in care homes;
removal of physical restraints in either setting; fall alarm devices
in either setting; exercise in care homes; calcium/vitamin D in
care homes; changes in the physical environment in either
setting; medication review in hospital) meta-analysis was either
unsuitable because of insufficient studies or showed no
significant effect on falls, fallers, or fractures, despite strongly
positive results in some individual studies. Meta-regression
showed no significant association between effect size and
prevalence of dementia or cognitive impairment.
Conclusion There is some evidence that multifaceted
interventions in hospital reduce the number of falls and that
use of hip protectors in care homes prevents hip fractures.
There is insufficient evidence, however, for the effectiveness of
other single interventions in hospitals or care homes or
multifaceted interventions in care homes.
Falls are common in hospitals and care homes,1where rates vary
from three to 13 falls per 1000 bed days. In 2004-5, 275 000 falls
were reported in hospitals in the United Kingdom2—60% of all
reported incidents. Cohort studies in UK care homes have
shown that residents fall two to six times a year.3About 30% of
falls in hospitals and care homes result in physical injury and
3-5% in fracture.4 5Up to 20% of admissions to general hospitals
for hip fracture are from care homes.6Falls may also lead to loss
increased length of hospital stay, and inability to return to previ-
ous residence, thus contributing to additional health and social
care costs.7–9Falls in institutions may result in complaints or liti-
gation from families.10 11All of this leads to anxiety for staff and
proprietors,who require guidance on best practice in preventing
falls and injuries.
Falls often indicate underlying frailty or illness and thus
require a broad approach to assessment and management.12 13
Most evidence about successful prevention strategies, however, is
derived from less frail and more clinically stable people living in
their own homes.12 13Such evidence may not translate to
transient populations who are medically unstable with a high
prevalence of cognitive impairment, as is typical in hospitals or
care homes. We synthesised and evaluated the evidence for pre-
vention of falls and fractures in hospitals and care homes to
inform the development of guidance on best practice; to avoid
implementation of ineffective or harmful strategies; and to iden-
tify gaps and controversies in the evidence from research. We
also investigated the impact of cognitive impairment or demen-
tia on the effectiveness of the identified interventions.
Literature search strategy
In accordance with QUOROM14and Cochrane15we searched
Medline, CINAHL, Embase, PsychInfo, Cochrane Database of
Systematic Reviews, and the Register of Clinical Trials for guide-
lines and hand searched references from 115 guidelines, system-
bmj_falls.htm). Our core search terms were “accidental fall”,
“fracture”, “accident prevention”, “risk management”, “wounds
and injuries”, “hospital”, “hospitalisation”, “residential facilities”,
“care homes”, “institutionalisation”, “dementia”, “delirium”, “cog-
nitive disorders”, “clinical trials”, “restraint physical”, “protective
devices”(see www.reading.ac.uk/ihs/bmj_falls.htm for full search
strategy). When possible, we contacted authors of included stud-
ies to ascertain their knowledge of unpublished data or ongoing
References to the studies included in the systematic review (w1-w44) and
three tables showing key features, quality scores, and outcome measures
are on bmj.com.
BMJ Online First bmj.com
page 1 of 6
Cite this article as: BMJ, doi:10.1136/bmj.39049.706493.55 (published 8 December 2006)
Copyright 2006 BMJ Publishing Group Ltd
Identification of articles for inclusion
Our initial inclusion criteria were deliberately broad. We sought
studies of patients in hospitals or care homes that reported the
number or rate of falls or fractures or people who fell (“fallers”)
as a primary or secondary outcome. For inclusion, the data also
had to be reported in such a way that we could calculate log rate
ratios or log relative risks and their variances. We included trials
with individual or cluster randomisation, case-control studies,
and observational cohort studies, this variety reflecting the
methodological and logistical difficulties of performing ran-
domised controlled trials in these settings and with these popu-
Abstraction of data and outcomes
We used the quality score of Downs and Black to assess papers
because it enables assessment of studies of various design.16After
initial piloting on five papers to assess inter-rater reliability, we
determined that the statistical items on the score should be inde-
pendently scored by a statistician (AW). We also piloted and
refined a data extraction form summarising key features of trial
design, study population, and interventions on these five papers.
One of three pairs of peer assessors (DO/MG, JC/CV, FM/FS)
scored each included study and extracted data.Each pair worked
independently with a further assessor arbitrating if necessary.
Classification of studies for meta-analysis
For meta-analyses and presentation of results, we grouped stud-
ies into nine categories according to type and setting of the
intervention. The prevalence of dementia in study participants
was categorised by a “metric” where 0 was unknown, 1 was
< 40%, 2 was 40-69%, and 3 was ≥ 70%. If the study did not state
the prevalence of dementia but the environment was a specialist
setting for dementia care, then we assumed 3.
Extraction, analysis, and synthesis of quantitative outcome
Two statisticians (YG and AW) abstracted quantitative outcome
fractures/1000 person years, and percentage of people falling.
Measures of the effect of the intervention relative to the control
were the log rate ratio for falls and fractures and the log relative
risk of falling. We calculated estimates of these effect measures
and their variances for each study when data permitted.17 18
Where reports of cluster randomised trials had not reported any
adjustment for clustering (as stipulated by the CONSORT state-
ment19), we used the intracluster correlation coefficients of 0.1,
0.071, and 0.026 for falls, fractures, and fallers, respectively, pro-
vided by Dyer et al.w1We carried out a sensitivity analysis for the
effect of these coefficients for meta-analyses that included five or
more cluster randomised trials.
Heterogeneity between studies was quantified by the I2statis-
tic.20Fixed17and random18effects meta-analyses were performed
separately within each of the nine categories for each of the three
principal outcome measures (falls, fallers, and fractures),
provided there was a minimum of three studies. We created for-
est plots with studies ordered by quality score and calculated
95% confidence intervals for estimates. Because of heterogeneity
between studies, we have presented only random effects models.
We undertook random effects meta-regression using restricted
maximum likelihood (REML) methods21for the estimates of the
regression parameters and the heterogeneity variance to assess
the potential effect of dementia as an effect modifier. Dementia
was considered as a categorical variable with four levels, and all
studies were included in these meta-regressions. To allow for
possible confounding by the type of intervention, we repeated
meta-regressions adjusting for this factor. Finally, as we had
aggregated studies of varying design and quality, we performed
meta-regression to describe any association between effect size
and the type or quality of studies.
Figure 1 summarises the literature search, which resulted in the
final inclusion of 43 studies. The full list of rejected studies along
with reasons for rejection can be found on our website
The key features and quality scores for the 43 included stud-
ies are summarised in table A on bmj.com. Outcome measures
and 95% confidence intervals are summarised in tables B and C
on bmj.com. Individual elements of the Downs and Black score
by paper are listed on our website (www.reading.ac.uk/ihs/
bmj_falls.htm). Sixteen studies were individually randomised
controlled trials, 12 were cluster randomised, nine were prospec-
tive (historical control), two were retrospective observational
cohort, two were prospective observational cohort, one was a
prospective case-control study, and one was quasi-experimental
with a multiple interrupted time series.
Sufficient data were available for us to calculate estimates and
variances of log rate ratios for falls in 35 studies and fractures in
22 studies and for log relative risk for falling in 25 studies.
Although several study populations had a high prevalence of
dementia, only one study was exclusively in people with demen-
tia or cognitive impairmentw2(though in this case, only 70% were
from institutional settings).Jensen et al initially reported a cluster
randomised trial from care homes,w3but then reported subgroup
analysis based on levels of cognitive impairment.w4For this
review we treated the subgroups as separate datasets. Donald et
al reported a 2×2 factorial design with the interventions being
exercise and environmental changew5and so we included it
under two separate single intervention headings.
We present our results for each of the nine categories of
intervention and setting and forest plots only for three key inter-
ventions and four outcomes and only for random (not fixed)
effects. Other meta-analyses are available on our website
In hospital—We included 13 studiesw6-18: three were individually
randomised, two were cluster randomised trials, and eight were
prospective (historical control “before and after” studies), which
with one exceptionw8were of poor methodological quality. Com-
ponents of interventions were varied and included risk
Initial references identified (n=1207; Medline (289), Embase (722),
PsychInfo (5), CINAHL (44), National Research Register (34),
Medical Register of Controlled Trials (26),
Cochrane Database (77), clinicaltrials.gov (10))
Papers rejected (n=49; subjects not in institutions (10), people with
cognitive impairment excluded (1), insufficient data on any outcome
measure (35), unobtainable (1), duplication (1), intervention (1)
Studies accepted for inclusion, outcome data extracted
(n=43; one study reported twice)
Met criteria and were
Systematic/expert reviews or
guidelines used in this review
and hand searched (n=115)
Fig 1 QUOROM flow diagram of selection of studies
page 2 of 6
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assessment, risk factor assessment, care planning, medical/
diagnostic approaches, changes in the physical environment,
education programmes, medication review, hip protectors,
removal of physical restraints, and exercise (see table A on bmj-
.com). There was evidence of heterogeneity between the studies
(I2= 80% for falls,59% for fractures,and 58% for fallers) The rate
ratio was 0.82 (95% confidence interval 0.68 to 0.997) for falls
(fig 2) and 0.59 (0.22 to 1.58) for fractures. The relative risk for
fallers was 0.95 (0.71 to 1.27).
In care homes—We included eight studies,w1-w4
which yielded two datasets.w3
randomised and five were cluster randomised controlled trials.
The components of the interventions were varied and included
all those listed for hospital patients (see table A on bmj.com).
Quality scores were generally high. There was significant hetero-
geneity for falls (I2= 87%), although this was much less for fallers
(24%) and non-existent for fractures. The rate ratio was 0.80
(0.59 to 1.09) for falls (fig 3) and 0.91 (0.54 to 1.53) for fractures.
The relative risk for fallers was 0.92 (0.82 to 1.03) (fig 4).Sensitiv-
ity analyses performed for falls and fallers, varying the intraclass
correlation coefficient between 0 and 1, had little impact on the
conclusions; confidence intervals always included 1, though the
width of the random effects confidence intervals reduced with
Three were individually
All the single interventions described were also components of
one or more of the multifaceted interventions in care homes and
Hip protectors in care homes—We included 11 studiesw24-w34: five
were individually randomised controlled trials, five were cluster
randomised controlled trials, and one was a prospective histori-
cal control study. Quality scores were generally high. There was
significant heterogeneity for falls (I2= 90%), but less for hip frac-
tures (39%). Meta-analysis was not performed for fallers as only
two studies reported relevant data. The rate ratio was 0.67 (0.46
to 0.98) for hip fractures (fig 5) and 0.97 (0.77 to 1.22) for falls.
The results for hip fractures were sensitive to the magnitude of
the intraclass correlation coefficient:values of ≥ 0.05 gave results
that were not significant, whereas the value of 0.026 as reported
by Dyer and colleaguesw1and lower values gave significant
results. The conclusions regarding hip fractures are therefore
Removal of physical restraint in either setting—We included five
studiesw35-w39: two were prospective with historical controls and
three were observational cohort studies. Three were in care
homes, one was in an assessment and treatment unit for older
people, and one was in a hospital stroke ward. Studies were gen-
erally of moderate methodological quality. There was significant
heterogeneity for falls (I2= 99%) and fallers (91%). The rate ratio
was 0.59 (0.19 to 1.77) for falls,and the relative risk for fallers was
0.83 (0.42 to 1.66). Only one study provided data on fractures.
Fall alarm devices in either setting—We included only one study:
a small prospective historical control crossover study of moder-
ate methodological quality in a care home.w40This showed a sig-
nificant effect on falls, though not on fallers or fractures. It was a
small study, however, with a low quality score, making general
conclusions hard to draw.
rate ratio 0.82 (95% CI
0.68 to 1.00); I 2=80%
Fig 2 Meta-analysis for multifaceted interventions in hospital—falls (random
rate ratio 0.80 (95% CI
0.59 to 1.09); I 2=87%
0.1 0.2 0.51
Fig 3 Meta-analysis for multifaceted interventions in care homes for falls
(random effects model)
risk 0.92 (95% CI
0.82 to 1.03); I 2=24%
Fig 4 Meta-analysis for multifaceted interventions in care homes for fallers
(random effects model). Jensen et al carried out subgroup analyses according to
score on MMSE (mini-mental state examination) of <19 v >19
rate ratio 0.67 (95% CI
0.46 to 0.98); I 2=39%
Fig 5 Meta-analysis for hip protectors as a single intervention in care homes (no
hospital studies were identified)—hip fractures (random effects model)
BMJ Online First bmj.com
page 3 of 6
Exercise in either setting—We included two individually
randomised controlled trials.w5 w41Neither showed any effect on
falls, despite good adherence and a range of other benefits.
Changes or differences in the physical environment in either
setting—We included only one study, which compared carpeting
with vinyl flooring.w5There were few participants, and there was
no significant effect on the rate of falls. One review that we iden-
tified but excluded was a large observational cohort study in a
UK care home that compared rates of falls and fractures in resi-
dents’ rooms with concrete or wooden floors and carpeted or
uncarpeted.22They found that wooden carpeted floors were
associated with the lowest rate of fractures. Also a retrospective
observational cohort study of falls in a general hospital showed
that falls on wooden flooring were associated with a significantly
lower rate of injuries.23
Calcium and vitamin D in care homes—Only two published
studies were eligible for inclusion, both individually randomised
controlled trials.w42 w43Compared with placebo there was a signifi-
cant effect on the rate of hip fracture,w42and compared with cal-
cium alone there was a significant effect on the fall rate.w43Two
key studies have been published since our review. Both were
large randomised controlled trials from care homes in residents
with a high prevalence of vitamin D deficiency.24 25One showed a
significant effect on falls and fractures24and the other found no
evidence of prevention for either outcome.25
Medication review in either setting—Only one study reported
review of medication as a single intervention in preventing
falls.w44This small hospital based study reported a rate ratio for
falls of 0.53 (0.30 to 0.95).
The results of meta-regressions to assess the effect of prevalence
of dementia on effect size for each of the three reported
outcome measures were not significant: the P values were 0.72
for the rate ratio for falls, 0.87 for the relative risk for fallers, and
0.18 for the rate ratio for fractures. After adjustment for the type
of intervention, the corresponding P values were 0.37, 0.78, and
0.006 (see www.reading.ac.uk/ihs/bmj_falls.htm for further
details). Although this suggests an association between a smaller
intervention effect on fracture rate and increasing prevalence of
dementia, the significant effect seemed to be caused by a differ-
ence between the “unknown” category and the others. Therefore
there is no conclusive evidence that the effect size is modified by
the prevalence of dementia.
For meta-regressions on study type, they were categorised
into randomised controlled trials (including cluster randomised
controlled trials) versus the rest. Results were not significant for
falls (P = 0.19) or fallers (P = 0.11) but were for fractures
(P < 0.001). For fractures the randomised controlled trials had a
ratio closer to 1 than the other studies did. The conclusions were
not altered when we adjusted for type of intervention. For the
assessment of study quality on the results we placed quality
scores into one of three categories: < 15, 15-19, and ≥ 20. Meta-
regressions on study quality were not significant for falls
(P = 0.41) or fallers (P = 0.44) but were for fractures (P = 0.004).
For fractures, the lower the quality score the larger the effect of
the intervention. After adjustment for the type of intervention,
the conclusions did not change for fallers or fractures but
became significant for falls (P = 0.021). This effect with falls was
difficult to interpret as the largest treatment effect was found
with the middle category of study quality, with the lowest
category showing a slightly negative effect.
There have been two major approaches to interventions to
reduce falls in hospital and care homes: those based on a single
intervention and those that combine various interventions. In
this systematic review and meta-analysis we found some
evidence for modest reductions in rates of falls in hospital
patients with multifaceted interventions and in rates of hip frac-
tures with hip protectors in people in care homes. However, we
found insufficient evidence for any other interventions in these
Undertaking research on prevention of falls and fractures in
hospitals and care homes is problematic. There are inherent
logistic difficulties in performing or interpreting studies in care
homes or hospitals associated with population, setting, design,
and outcome measurement. Getting consent from or randomis-
ing frail, confused, unwell elderly people, who are often in the
institution for only a short stay, is challenging. For outcome
measures such as number of falls and fallers recorded by staff
there may be recording bias.
The wide range of studies is reflected in the quality scores,
which wepresent asa descriptive
interpretation of findings. Use of a cut-off score as an inclusion
criterion would have been arbitrary and led to exclusion of
results of interest in a specialty where there is still a lack of robust
evidence. For answering certain types of question (for example,
the effect of physical environment or restraint removal) conven-
tional randomised controlled trial design is neither feasible nor
suitable as individual randomisation within the same setting may
leadto “contamination” of
randomisation overcomes this,but the analysis needs adjustment
for intracluster correlation.
Studies may have high internal validity for the specific
setting, case mix, skill mix in staff, physical environment, and
medical or nursing culture in which they were performed.
Factors such as the degree of adherence to interventions or the
prevalence of cognitive impairment are likely to affect the
success of interventions. Finally, the content of multifaceted
interventions incorporating a range of approaches differs from
study to study, making the benefit of each individual component
hard to attribute.
The approach we took to the methodological challenges neces-
sarily affects the interpretation of our findings. Categorisation by
type of intervention has greater methodological validity than
aggregating results from disparate interventions. We aggregated
studies of different design (such as before and after and
randomised controlled trials) so as not to lose useful data from
studies where this design would not have been feasible. The
inclusion of study setting in deciding the type was intended to
enable the review’s findings to be applied operationally to
particular settings. Nevertheless, heterogeneity of case mix of
participants or clinical practice is still likely to exist across similar
settings and we could not account for this in our analyses.
With regard to the analysis of falls and fallers, differences
between the studies in terms of design and quality did not seem
to affect the results. With regard to fractures, however, there is
some evidence that randomised controlled trials (including clus-
ter randomised controlled trials) have smaller effects than other
types of design, and that effect size increases with lower quality.
When the original authors did not report intracluster correlation
coefficients, we used estimates from Dyer et alw1on the grounds
that imputation of the variances was preferable to excluding the
study from the meta-analysis. Sensitivity analyses undertaken for
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three of the meta-analyses heavily dependent on cluster
randomised trials showed that for falls and fallers in multifaceted
interventions in care homes the conclusions remained the same
over a wide range of correlation coefficients. For the analysis of
hip fractures and hip protectors, however, the results changed
coefficient rose above about 0.05. Finally, our insistence on
including only studies for which our three standardised outcome
measures could be calculated led to the exclusion of some high
quality studies with potentially useful information (such as Simp-
son et al22and Ray et al26). Standardisation of outcomes was an
operational necessity for the meta-analysis. Because of the small
number of studies in each intervention type, we performed
meta-regressions across all interventions. Interpretation of the
meta-regression to test effect size versus design and quality of
studies is difficult because of the association between study
design and intervention.Some interventions (such as hip protec-
tors) were almost exclusively carried out in high quality
randomised controlled trials whereas others (such as multifac-
eted interventions in hospital) were usually of non-randomised
design. The only clear association between quality score and
effect size was for fracture as an outcome.
once the correlation
Effect of dementia
The application of a “metric” to investigate the potential effect of
dementia as an effect modifier was a pragmatic solution to a dif-
ficult problem. Only one study included solely participants with
dementia,w2and only one reported subgroup analyses to
compare effects on those with or without dementia.w4Yet there
was often a high prevalence of dementia in participants, which
was defined in diverse ways (for example, various mental test
scores, clinical diagnosis, behavioural rating scales).
We identified 13 studies with multifaceted approaches to
preventing fallsin hospital.
heterogeneous, and the study design and quality highly variable.
Two high quality randomised controlled trialsw7 w10and one high
quality before and after studyw8described significant effects on
rates of falls, with meta-analysis showing a reduction of 18%,
which was just significant, though with no comparable effect on
fractures or fallers. Of eight studies reporting multifaceted inter-
ventions in care homes, all were described as randomised
controlled trials and were generally of good quality, though
adjustments for clustering were rarely undertaken in the original
analyses. While some individual trials showed a large effect size
onfalls (thoughnoton fractures
meta-analyses for multifaceted interventions in care homes did
not show any significant effects. There was insufficient power to
detect a difference in fracture rates in these studies so the results
We identified 11 studies on the use of hip protectors, 10 of
which were randomised controlled trials. There was evidence to
show an overall effect of hip protectors on rates of hip fracture.
Given the number of cluster randomised trials in this
meta-analysis and the sensitivity of the results to the magnitude
of the intraclass correlation coefficient, which necessarily had to
be imputed for most studies, we consider it unwise to draw defi-
nite conclusions about efficacy. There was no evidence for exer-
cise as a single intervention in preventing falls or fractures,
though it was a component of several successful multifaceted
interventions and conferred a range of other benefits. Five stud-
ies on removal of physical restraint (of necessity, largely with
observational cohort or case control designs) showed no
evidence of significant effect on falls or fractures in either direc-
tion. There were not enough trials of fall alarm devices, changes
in physical environment, or medication review as single
interventions. Oral calcium and vitamin D at appropriate doses
reduced rates of fallsw42, w43and fracturesw43for older people in
care homes in the two included studies. A recent randomised
controlled trial in care home residents in Australia24mirrored
these findings (though it was published too late for inclusion),
but a subsequent UK study25failed to replicate them, confusing
the picture. Many of the single interventions described were also
components of multifaceted interventions.
Our findings suggest that there is reasonable evidence that
using a structured multifaceted intervention for hospital
inpatients may have a modest effect on falls but not on fractures.
Replication of such studies would not be a high priority, but
closer investigation of specific components is required. A similar
approach in care homes has yielded significant reductions in
falls, fallers, and fractures in some large individual studies, but
this is not substantiated by meta-analysis so the case for effective-
ness is unproved. The use of high dose calcium and vitamin D
has proved effective in three studies in care homes but ineffective
in a more recent and larger study, suggesting that effects might
be setting and population specific. For all other interventions
listed, there is currently no evidence to support widespread
interventions except for hip protectors there was insufficient
power to detect a significant difference, so that the case remains
unproved rather than disproved.
Our review illustrates an increasingly prevalent view27that an
over-reliance on the primacy of the randomised controlled trial
as the main source of clinical evidence may not be suitable where
interventions are complex and individual consent is hard to
obtain. An approach of realistic evaluation,28where factors such
as context, case mix, adherence, quality of intervention, and
process are considered,may be more suitable in answering many
pragmatic questions around “real life” clinical practice.29 30
asan outcome,for all
We have identified many gaps in the evidence that merit further
investigation—for example, interventions specifically for those
with cognitive impairment or dementia; the reproducibility of
interventions within and between different types of service
setting; cost effectiveness of interventions; and the effect of a
range of single interventions, such as medication review, use of
alarms, or changes or differences in the physical environment.
Even for multifaceted interventions—with most studies and
participants—the results are inconclusive, and it may be that for
these interventions and for hip protectors there is insufficient
power to draw definitive conclusions about effects on fracture
rate, meaning that even these studies deserve further replication,
perhaps after further work on improving targeting and
adherence. Despite the pressing importance of preventing falls
and fractures in hospitals and care homes, the evidence is incon-
clusive for multifaceted interventions in care homes and single
interventions (except hip protectors) in either setting in reducing
fall rates, risk of falling, or fracture rates. Use of hip protectors in
care homes is associated with a small reduction in rates of hip
fracture, which despite borderline significance on meta-analysis
is inconclusive because of clustering effects. More encouragingly,
we found a modest reduction in the rate of falls with a multifac-
eted intervention in hospital settings (though we found no effect
on risk of falling or fracture rates). It therefore seems likely that
currently healthcare providers are incurring important opportu-
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page 5 of 6
nity and financial costs by using injury prevention strategies of
We thank Karen Stenner (collation and summary of papers) Jill Duncan,
(construction of literature search and retrieval of articles), and Jane Hardie
(secretarial and administrative work).
Contributors: DO was principal investigator, was responsible for design,
quality assessment,review of studies,and writing up,and is guarantor.MAG,
CRV, JBC, FCM, and FES were also responsible for design, quality
assessment, review of studies, and writing up. YG and AW were responsible
for design, numerical data abstraction, statistical analysis, meta-analysis, and
quality assessment for statistical components. AV was responsible for litera-
ture review and economic evaluation.
Funding: Department of Health Accidental Injury Prevention Programme.
Competing interests: None declared.
Ethical approval: Not required.
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(Accepted 20 October 2006)
University of Reading Institute of Health Sciences, Reading RG1 5AG
David Oliver senior lecturer
James B Connelly professor
Christina R Victor professor
Margot A Gosney professor
Institute for Ageing and Health, University of Newcastle upon Tyne, Newcastle
Fiona E Shaw honorary clinical senior lecturer
University of Reading Medical and Pharmaceutical Statistics Research Unit,
Reading RG6 6FN
Anne Whitehead professor
Department of Biostatistics, Faculty of Medicine, Ankara University, 06100 Ankara,
Yasemin Genc lecturer
Centre for Health Services Research, University of Newcastle upon Tyne,
Newcastle NE2 4AA
Alessandra Vanoli lecturer
Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust,
London SE1 7EH
Finbarr C Martin consultant geriatrician
Correspondence to: D Oliver firstname.lastname@example.org
What is already known on this topic
Falls are the most common adverse incident in hospitals
and care homes, nearly always affecting frail elderly people,
many of whom have dementia or delirium
Risk management must be balanced against the need to
promote functional independence and to respect autonomy
Previous reviews and guidelines have focused largely on
elderly people living in the community and those without
What this study adds
There is evidence for modest reductions in fall rates in
hospital patients from multifactorial interventions and on
hip fractures from hip protectors in care home residents
There is insufficient evidence for any other interventions in
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