There are a large number of randomised controlled trials that have investigated the effectiveness of a range of interventions to reduce the risk and the rate of falling in older people living in the community. The most robust evidence is derived from large, well- conducted trials with methodology that limits bias, or from meta-analyses that have
conducted rigorous systematic reviews and then collated the data from the included trials. As the number of studies increased, the need for systematic reviews and meta-analyses
increased. A look at these systematic reviews is the best way to determine which
interventions have the strongest evidence of efficacy to prevent falls. The first Cochrane review of falls prevention interventions in older people living in the community was published in 2003, with an updated review published in 2009 and 2012. (80-82) A further review is in progress and has not been reported at this time. This review will focus on the information provided by the 2012 Cochrane review and will then examine some of the individual studies in more detail later. (80)
The objective of the 2012 Cochrane review by Gillespie et al. was to assess the efficacy of interventions designed to reduce the incidence of falls in older people living in the
community. Randomised controlled trials were included if the participants were 60 years or older (or mean age minus one standard deviation was more than 60 years), and if the majority of participants were living in the community in accommodation which was not residential care or a rehabilitation setting. If the study had a mixed population, it was suitable to be included in the review if there was a subgroup analysis based on place of residence. Trials involving patients with Parkinson’s disease or stroke were not included. The study outcomes
60
included rate of falls and/or number of fallers, while secondary outcomes included number of participants sustaining fall-related fractures, adverse effects of interventions and economic outcomes. The searches for all appropriate studies were conducted to include studies published up to March 2012 and included a range of databases including MEDLINE, EMBASE, CINAHL, and Cochrane Library registers. The details of the specific search strategy are beyond the scope of this review. Interventions were grouped using the fall prevention classification developed by the Prevention of Falls Network Europe (ProFaNE), based on single, multiple and multifactorial interventions and the type of intervention. (83) The pooled data were used in a series of meta-analyses to estimate pooled risk and rate ratios of falls for all the interventions. Additional subgroup analyses were also performed, for example to examine the effect of high and low falls risk on interventions, and whether active treatment was provided versus interventions which depended on referral to other services or primary care physicians for their provision.
This review will focus on the impact of multifactorial interventions on falls prevention. These interventions are most closely aligned to the development of falls prevention clinical services, and formed the basis for the study design reported in this thesis.
1.7.1.1 Multifactorial falls prevention interventions – Cochrane review
Multifactorial interventions are interventions which consist of more than one main category of intervention, with participants receiving different combinations of intervention based on their fall risk factor assessment. (80) The aim of the multifactorial intervention is to provide comprehensive and individualised interventions. Using data from 19 trials with 9,503 participants, the pooled analysis showed that multifactorial interventions significantly
61
reduced the rate of falls (RaR 0.76; 95% CI 0.67 – 0.86). That is multifactorial interventions reduce the number of falls. In contrast, the pooled data from 34 trials and 13,617 participants did not show a significant reduction in the number of fallers and therefore the risk of falling (RR 0.93; 95% CI 0.86 – 1.02). There was also no significant reduction in the risk of fractures using pooled data from 11 trials (RR 0.84; 95% CI 0.67 – 1.05). There was significant heterogeneity between the studies in the pooled analyses of the rate of falls (I² = 85%; p<0.00001) and the risk of falls (I² = 69%; p<0.00001). Additional analyses were performed to assess if baseline risk of falls or intensity of intervention affected the outcomes of rate of falls and risk of falls. It was hypothesised that high risk fallers may benefit more from these interventions than low risk fallers. The subgroup analysis by baseline risk of falls did not show evidence of difference in the rate of falling (p = 0.50; I² = 0%), or risk of falling (p = 0.88; I² = 0%). There was no evidence that the scope and intensity of interventions affected the rate of falls (p = 0.36; I² = 0%) however there was a suggestion that the risk of falling was affected (p = 0.05; I² = 74.3%). Interventions which provided advice only and depended upon the primary care physician to implement the specific treatment plans were less effective at reducing the risk of falling than those interventions which were provided directly and included direct organisation of any additional referrals. Table 1.4 shows details of the studies included in the Cochrane review and the outcomes from each study. (80)
62
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people.
Author Participants Follow-up
period Intervention Control Results
Carpenter 1990 (84) United Kingdom N = 539 Age ≥75 years (13% >85years old) 65% female.
Recruited from 2 GP practices Inclusion: ≥75 years, living in area Exclusion: living in residential aged care facility
3 years Trained volunteers administer the Winchester disability rating scale. Those with no disability assessed every 6 months.
Those with disability assessed every 3 months. Referral to GP if increase in disability score. Usual care. No disability surveillance between evaluations Number of falls Rate of falls RaR 0.34 (0.18 – 0.65)
Ciaschini 2009 (85)
Canada
N = 201
Mean age 72 years (SD 8.4) 94% female.
Recruited from community
Inclusion: >55 years, at risk of fracture due to falls, previous fragility fracture or high risk of falls TUGT >14sec
Exclusion: On treatment for Osteoporosis
6 months (12 months in total with cross- over for control group at 6 months)
Nurse led multifactorial risk assessment and counselling. Referral for PT, OT and interventions.
Recommendations for Osteoporosis therapy to physicians and patients.
Usual care for 6 months then offered same as intervention group Number of fallers Risk of falling RR 1.51 (0.87 – 2.61) Number of fractures Risk of fractures Close 1999 (64) United Kingdom N = 397
Mean age 78.2 years (SD 7.5). 68% female.
Recruited from A&E (after discharge). Inclusion: ≥65 years, history of falling, community dwelling.
Exclusion: cognitive impairment, no regular carer, limited English, not living locally.
1 year Comprehensive medical
assessment of multifactorial risks of falling.
Interventions and referrals as required.
OT assessment – functional and home environmental hazards. Funded minor modifications, equipment and advice.
Usual care. Number of falls Rate of falls RaR 0.41 (0.34 – 0.49) Number of fallers Risk of falling RR 0.39 (0.23 – 0.66)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department;
63
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Coleman 1999 (86)
United States
N = 169
Mean age 77 years. 49% female.
Recruited from 9 ambulatory care clinics – cluster randomised.
Inclusion: ≥65 years, community dwelling, high risk of hospitalisation or functional decline.
Exclusion: Living in residential aged care, terminal illness, moderate to severe dementia, and if physician determined “too ill”. 12 months (24 months complete collection of data)
Chronic care clinics every 3-4 months in 5 practices.
Physician and nurse led chronic disease management.
Pharmacist led medication review – polypharmacy and falls risk increasing drugs (FRID). Self-management and support group.
Usual care (4 practices) Number of fallers Risk of falling RR 1.14 (0.74 – 1.75) Conroy 2010 (87) United Kingdom N = 364
Mean age 78.6 years (SD 5.7). 60% female.
Recruited from General Practices.
Inclusion: community dwelling, >70 years, high risk of falling by postal questionnaire. Exclusion: living in residential aged care, receiving end of life care, already receiving falls prevention program, unable to consent.
12 months Screening questionnaire, information leaflets, invitation to attend day hospital for
multifactorial assessment and interventions.
Screening questionnaire, information leaflets, and usual care from primary care service. Offered day hospital intervention at the end of collection of outcome data.
Number of falls Rate of falls RaR 0.86 (0.74 – 1.01)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department;
64
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Davison 2005 (88)
United Kingdom
N = 313
Mean age 77 years (SD 7). 72% female.
Recruited from A&E
Inclusion: >65 years, community dwelling, presenting to A&E with fall or fall-related injury, ≥1 fall in prior 12 months. Exclusion: cognitive impairment (MMSE <24), >1 previous episode of syncope, immobile, not living locally, registered blind, aphasic, clear medical cause for fall, enrolled in another study.
12 months Hospital based medical multifactorial falls assessment and interventions.
Home based PT assessment and intervention – exercise, mobility aids, and footwear.
Home based OT home hazard assessment and intervention.
Usual care Number of falls Rate of falls RaR 0.64 (0.46 – 0.89) Number of fallers Risk of falling RR 0.95 (0.81 – 1.11) De Vries 2010 (89) Netherlands N = 217
Mean age 79.8 years (SD 7.35). 71% female.
Community based – following ED or GP attendance with fall.
Inclusion: ≥65 years, living independently or in assisted living facility, living near University Medical Centre, history of fall in the previous 3 months.
Exclusion: unable to consent, unable to provide a fall history, cognitive impairment (MMSE <24), fall due to traffic or
occupational accident, living in a nursing home, acute pathology requiring long-term rehabilitation.
1 year Hospital based multidisciplinary assessment and tailored treatment in collaboration with GP – psychotropic drug withdrawal, strength and balance exercises, home hazard reduction, and referral to specialists.
Usual care. Number of fallers Risk of falling RR 0.96 (0.68 – 1.37) Number sustaining fracture
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department; MMSE – Mini Mental Test Score;
65
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Elley 2008 (90) New Zealand
N = 312
Mean age 80.8 years (SD 5) 69% female.
Recruited from 19 primary care practises. Inclusion: ≥75 years, fallen in last year, living independently.
Exclusion: unable to consent, unstable or progressive medical condition, severe physical disability, dementia (<7 AMTS).
1 year Nurse-led community-based falls and fracture risk assessment, home hazard assessment, strength and balance exercises and appropriate referrals to community interventions.
Usual care and social
visits. Number of falls Rate of falls RaR 0.96 (0.69 – 1.34) Number of fallers Risk of falling RR 1.11 (0.94 – 1.29) Fabacher 1994 (91) United States N = 254
Mean age 73 years. 2% female.
Recruited from voter registration and service organisations.
Inclusion: ≥70 years, not receiving health care at Veterans Administration Medical Centre.
Exclusion: known terminal disease, dementia.
1 year Health professional home visit to screen for falls risks, with letter of targeted recommendations for participant’s physician.
Usual care. Phone contact for follow-up only.
Number of fallers Risk of falling RR 0.60 (0.33 – 1.10)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department; AMTS – Abbreviated Mental Test Score;
66
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Fox 2010 (92) United States
N = 552
Mean age 76.9 years (SD 6.8) 67% females
Recruited from ‘Preventive Health Care for the Aging’(PHCA) clients
Inclusion: ≥65 years, living in area for the following year, speaking English, Spanish, Cantonese or Vietnamese.
Exclusion: serious cognitive impairment, medical disorders that would affect participation.
1 year Usual PHCA care (community- based health promotion programme) and multifactorial fall prevention programme targeting 10 risk factors. Nurse led.
Usual PHCA care. Number of fallers Risk of falling RR 1.62 (0.88 – 2.97) Gallagher 1996 (93) Canada N = 100
Mean Age 74.6 years 80% female.
Recruited from community.
Inclusion: ≥60 years, fallen in previous 3 months.
Exclusion: not described.
6 months 2 risk assessment interviews (45mins).
1 counselling interview (60mins) – video, booklet, results of risk assessment.
Baseline interview and follow-up only.
Number of falls Rate of falls RaR 0.81 (0.60 – 1.09)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department;
67
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Hendriks 2008 (94)
Netherlands
N = 333
Mean age 74.8 years (SD 6.4) 68% female.
Recruited from ED or GP
Inclusion: ≥65 years, community living, history of fall requiring visit to ED or GP, living in local area.
Exclusion: not able to speak or understand Dutch, unable to complete questionnaires or interviews by telephone, cognitive
impairment (<4 on AMT4), long-term admission to hospital or other institution (>4 weeks from date of inclusion), permanently bedridden, fully dependent on a wheelchair.
1 year Detailed assessment by geriatrician, rehabilitation physician, geriatric nurse. Recommendations and indications for referral sent to GP. GP driven interventions. Home assessment by OT – recommendations to participant and GP, and referral also sent for technical aids and adaptations or additional support.
Usual care Number of fallers Risk of falling RR 1.08 (0.76 – 1.54)
Hogan 2001 (95) Canada
N = 163
Mean age 77.6 years (SD 6.8) 72% female
Recruited from community.
Inclusion: ≥65 years, fallen in previous 3 months, community living, ambulatory (with/without aid), able to provide consent. Exclusion: fall in previous 3 months resulting in lower extremity fracture, fall resulted from vigorous or high-risk activities, fall due to syncope or stroke, fall during active treatment in hospital.
1 year In-home multifactorial falls assessment by geriatric specialist (doctor, nurse, PT or OT) – 1 – 2 hours. Multidisciplinary case conference. Recommendations sent to GP for their
implementation. Referral to exercise class if problems with gait or balance and not attending an exercise programme. Instructions on home based exercises.
One home visit by
recreational therapist. Number of falls Rate of falls RaR 0.74 (0.62 – 0.88) Number of fallers Risk of falling RR 0.91 (0.77 – 1.09) Total number of fractures
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department; AMT – Abbreviated Mental Test Score;
68
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Hornbrook 1994 (96)
United States
N = 3182
Mean age 73 years (SD 6) 62% female
Recruited from HMO (Health Maintenance Organisation)
Inclusion: >65 years, ambulatory, living within 20 miles of study site, living independently, able to consent. Exclusion: blind, deaf, institutionalised, housebound, non-English speaking, severely mentally ill, terminally ill, unwilling to travel to research site.
23 months Home visit, safety inspection, hazards booklet, repair advice, fall prevention classes, financial and technical assistance.
Home visit, safety inspection, hazards booklet.
Rate of falls RaR 0.84 (0.80 – 0.89) Risk of falling RR 0.89 (0.82 – 0.96) Huang 2004 (97) Taiwan N = 120
Mean age 72 years (SD5.7) 46% female.
Recruited from community.
Inclusion: ≥65 years, community living, cognitively intact.
Exclusion: not stated.
4 months Nurse-led home visits: 1. Risk assessment. 2. 2 months later – fall
prevention brochure and individualised written and verbal instructions on falls risk factors.
3. Assessment and collection of falls data.
Nurse-led home visits: 1. Risk assessment. 2. Standard fall prevention brochure. 3. Assessment and collection of falls data. Number of fallers Risk of falling RR 0.12 (0.01 – 1.76)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department;
69
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Huang 2005 (98) Taiwan
N = 141
Mean age 77 years (SD 7.6) Recruited from hospital.
Inclusion: hospitalisation for fall-related hip fracture, ≥65 years, living in medical centre catchment area.
Exclusion: cognitive impairment, too ill.
3 months Nurse-led discharge planning intervention – review within 48 hours of admission, seen every 48 hours in hospital, home visit 3-7 days post-discharge, phone contact once per week with additional daily phone advice as required. 3 months follow-up post discharge.
Individualised discharge plan with home-care services, brochures on post hip fracture care and fall prevention.
Nurse directed care in terms of assistive devices and
rehabilitation.
Collaboration with physicians as required.
Nurse-led usual
discharge planning. Number of fallers Risk of falling RR 0.67 (0.22 – 2.01)
Jitapunkul 1998 (99)
Thailand
N = 160
Mean age 75.6 years (SD 5.8) 65% female.
Recruited from a previous study. Inclusion: ≥70 years, living at home. Exclusion: not stated.
3 months (measured at the end of 3 years) last 3 months falls
Home visit from researchers with structured questionnaire. 3 monthly visits for 3 years. Referral to nurse or geriatrician for review if decline in ADL score or ≥1 fall in the previous 3 months.
Nurse / geriatrician provided a comprehensive assessment, educate, prescribe drugs or aids, rehabilitation programme and make referrals.
Visit at the end of 3 years. No intervention.
Number of fallers Risk of falling RR 0.52 (0.14 – 1.94)
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department; ADL – activities of daily living;
70
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Kingston 2001 (100)
United Kingdom
N = 109
Mean age 71.9 years. 100% female. Recruited from A&E.
Inclusion: attended A&E with fall, female, 65 – 79 years, history of fall, discharged to own home.
Exclusion: admitted to hospital from A&E, institutional care.
12 weeks Rapid Health Visitor review within 5 working days of index fall – pain control, medications, how to get up after a fall, fall risk factor education, advice on diet, strength exercises.
Usual post fall care – letter to GP regarding A&E attendance, interventions and recommendations for follow-up. Number of fallers Risk of falling RR 0.64 (0.18 – 2.24) Lightbody 2002 (101) United Kingdom N = 348
Median age 75 (IQR 70-81) 74% female.
Recruited from A&E.
Inclusion: >65 years, attended A & E with a fall.
Exclusion: admitted to hospital with a fall, living in institutional care, unable to consent, living out of area.
6 months Nurse-led multifactorial falls risk assessment at home. Referral for specialist assessment or further action such as referral to community services or primary care.
No referrals to day hospital or hospital outpatients.
Home safety advice and simple modifications (mat removal etc.).
Usual care. Number of falls Rate of falls RaR 0.85 (0.69 – 1.06) Number of fallers Risk of falling RR 0.98 (0.68 – 1.42) Number sustaining a fracture
RaR – rate ratio; RR – relative risk; SD – standard deviation; GP – General Practice; TUGT – Timed Up and Go Test; PT – physiotherapy or physiotherapist; OT – occupational therapist or therapy; A&E – Accident and Emergency; E.D. – Emergency Department; IQR – interquartile range;
71
Table 1.4: Randomised controlled trials of multifactorial falls prevention interventions for community dwelling older people (Continued)
Author Participants Follow-up
period Intervention Control Results
Logan 2010 (102)
United Kingdom
N = 204
Median age 83 (IQR 77 – 86) 65% female.
Recruited from 4 primary care trusts. Inclusion: ≥60 years, living at home or in a care home, called for an ambulance after a fall and not taken to hospital, or taken to hospital and not admitted.
Exclusion: receiving fall prevention services.
1 year Referral to multidisciplinary falls prevention service for assessment and tailored interventions – balance training, strengthening exercises, environmental hazard assessment, education on how to get off the floor, provision of equipment.
Referral to GP for vision
assessment and medication review and if necessary community geriatrician.
Usual care – no intervention by fall prevention service.
Number of falls Rate of falls RaR