Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: Systematic review and meta-analysis

Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL.
BMJ (online) (Impact Factor: 17.45). 02/2008; 336(7636):130-3. DOI: 10.1136/bmj.39412.525243.BE
Source: PubMed


To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings.
Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis.
Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews.
Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors.
Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement.
19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral.
Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

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    • "It has been reported that, in older people ≥65 years of age, 1 in 3 falls at least once a year. Injuries from falls can also lead to reduced physical function [2] [3] [4]. In Japan, the nation with the highest proportion of older citizens [5], falls and fractures are one of 10 cases requiring long-term care among older people aged ≥65. "
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    ABSTRACT: Objective: Promoting participation in sport organizations may be a population strategy for preventing falls in older people. In this study, we examined whether participation in sport organizations is associated with fewer falls in older people even after adjusting for multiple individual and environmental factors. Methods: We used the Japan Gerontological Evaluation Study data of 90,610 people (31 municipalities) who were not eligible for public long-term care. Logistic regression analysis was performed, with multiple falls over the past year as the dependent variable and participation in a sport organization as the independent variable, controlling for 13 factors. These included individual factors related to falls, such as age and sex, and environmental factors such as population density of the habitable area. Results: A total of 6,391 subjects (7.1%) had a history of multiple falls. Despite controlling for 13 variables, those who participated in a sport organization at least once a week were approximately ≥ 20% less likely to fall than those who did not participate at all (once a week; odds ratio = 0.82 and 95% confidence interval = 0.72-0.95). Conclusion: Participation in a sport organization at least once per week might help prevent falls in the community-dwelling older people.
    Full-text · Article · May 2014 · BioMed Research International
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    • "Whilst combining interventions that are effective on their own might therefore seem intuitive, the evidence for combined interventions (multifactorial and multiple component as described above) is less clear. Multifactorial interventions, which require an individually tailored approach, have been shown in a meta-analysis to reduce the rate of falls [4] but there remains uncertainty in relation to reducing the number of those that fall [8]. Indeed, this is supported by a recently updated Cochrane review, including more than 13,000 participants which observed no benefit in a reduction in the number that fell [4]. "
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    ABSTRACT: Limited attention has been paid in the literature to multiple component fall prevention interventions that comprise two or more fixed combinations of fall prevention interventions that are not individually tailored following a risk assessment. The study objective was to determine the effect of multiple component interventions on fall rates, number of fallers and fall-related injuries among older people and to establish effect sizes of particular intervention combinations. Medline, EMBASE, CINAHL, PsychInfo, Cochrane, AMED, UK Clinical Research Network Study Portfolio, Current Controlled Trials register and Australian and New Zealand Clinical Trials register were systematically searched to August 2013 for randomised controlled trials targeting those aged 60 years and older with any medical condition or in any setting that compared multiple component interventions with no intervention, placebo or usual clinical care on the outcomes reported falls, number that fall or fall-related injuries. Included studies were appraised using the Cochrane risk of bias tool. Estimates of fall rate ratio and risk ratio were pooled across studies using random effects meta-analysis. Data synthesis took place in 2013. Eighteen papers reporting 17 trials were included (5034 participants). There was a reduction in the number of people that fell (pooled risk ratio = 0.85, 95% confidence interval (95% CI) 0.80 to 0.91) and the fall rate (pooled rate ratio = 0.80, 95% CI 0.72 to 0.89) in favour of multiple component interventions when compared with controls. There was a small amount of statistical heterogeneity (I2 = 20%) across studies for fall rate and no heterogeneity across studies examining number of people that fell. This systematic review and meta-analysis of randomised controlled trials found evidence that multiple component interventions that are not tailored to individually assessed risk factors are effective at reducing both the number of people that fall and the fall rate. This approach should be considered as a service delivery option.
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    • "These include counseling and guidance in fall prevention, home hazards assessment, group exercise, psychosocial support (Salminen et al. 2009), referral to community falls prevention services (Logan et al. 2010), or a combination depending on an individual's particular risk profile. The efficacy of these interventions has been assessed in a number of meta-analyses and systematic reviews (Gates et al. 2008; Sherrington et al. 2011; Chase et al. 2012), but recommendations for optimal falls prevention are still evolving (Moyer and US Preventive Task Force 2012; American Geriatrics Society 2010). An updated Cochrane Review reported that exercise and home safety programs reduce the rate of falls and risk of falling, but did not find benefit for interventions that increased knowledge about falls prevention without additional components (Gillespie et al. 2012). "
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    ABSTRACT: Current approaches to falls prevention mostly rely on secondary and tertiary prevention and target individuals at high risk of falls. An alternative is primary prevention, in which all seniors are screened, referred as appropriate, and educated regarding falls risk. Little information is available on research designs that allow investigation of this approach in the setting of aging services delivery, where randomization may not be possible. Healthy Steps for Older Adults, a statewide program of the Pennsylvania (PA) Department of Aging, involves a combination of education about falls and screening for balance problems, with referral to personal physicians and home safety assessments. We developed a non-randomized statewide trial, Falls Free PA, to assess its effectiveness in reducing falls incidence over 12 months. We recruited 814 seniors who completed the program (503 first-time participants, 311 people repeating the program) and 1,020 who did not participate in the program, from the same sites. We assessed the quality of this non-randomized design by examining recruitment, follow-up across study groups, and comparability at baseline. Of older adults approached in senior centers, 90.5 % (n = 2,219) signed informed consent, and 1,834 (82.4 %) completed baseline assessments and were eligible for follow-up. Attrition in the three groups over 12 months was low and non-differential (<10 % for withdrawal and <2 % for other loss to follow-up). Median follow-up, which involved standardized monthly assessment of falls, was 10 months in all study groups. At baseline, the groups did not differ in measures of health or falls risk factors. Comparable status at baseline, recruitment from common sites, and similar experience with retention suggest that the non-randomized design will be effective for assessment of this approach to primary prevention of falls.
    No preview · Article · Feb 2014 · Prevention Science
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