Fall prevention in nursing homes

The incidence of falls and fall-related injuries such as hip fractures remains high in nursing homes (NHs) across the world. Randomized controlled trials have shown that interventions that combine multiple components such as progressive exercise, medication review, and improvements in the person-environment fit and delivered by multidisciplinary teams can effectively reduce the number of falls and fallers. Vitamin D supplementation in adequate dosage is another effective method to reduce the burden of injuries in NHs. Single interventions such as exercise alone or insufficient organizational support are reasons for failure or even harmful consequences. Large-scale efforts are needed and justified to translate these findings into meaningful results.     

Assessment and management of falls in older people

Falls remain a major cause of mortality and morbidity for older Australians, despite considerable growth in falls prevention activity in recent years. Risk factors for falls are well defined, and there is a growing evidence base from randomized controlled trials in community settings indicating a range of effective individual and multiple strategy interventions to reduce falls and falls injuries. These range from health promotion approaches, such as group exercise programmes, through to multidisciplinary, multifactorial interventions for high-risk populations. Practitioners need to utilize a range of strategies to enhance uptake and sustained participation in falls prevention activities. Future research needs to address important gaps, such as compliance issues, and interventions for people with cognitive impairment, dizziness and vision loss. Further research is also required in residential care and hospital settings, where there is relatively little research evidence to guide practice.     

Do continence management strategies reduce falls? A systematic review

Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls.     

Prevention of fall and fracture

Many programs to prevent falls were designed for intervention in fall risk factors. Several meta-analyses, based on many randomized, controlled trials and conducted for the purpose of evaluating the efficacy of these interventions, have been published recently. According to these studies, multifactorial fall risk assessment and management, as well as muscle strengthening and balance retraining, succeeded in reducing falls by approximately 10-38%. Only New Zealand trials were found to decrease even injurious falls, with reduction of moderate or serious injuries by 35% using fall prevention. However, there was no significant difference between the two groups when looking at only serious injuries such as fractures. Thus, fall prevention can prevent falls, but not fractures at present.     

Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus

The prevention of injury associated with falls in older people is a public health target in many countries around the world. Although there is good evidence that interventions such as multifactorial fall prevention and individually prescribed exercise are effective in reducing falls, the effect on serious injury rates is unclear. Historically, trials have not been adequately powered to detect injury endpoints, and variations in case definition across trials have hindered meta-analysis. It is possible that fall-prevention strategies have limited effect on falls that result in injuries or are ineffective in populations who are at a higher risk of injury. Further research is required to determine whether fall-prevention interventions can reduce serious injuries. Prevention of Falls Network Europe (ProFaNE) is a collaborative project to reduce the burden of fall injury in older people through excellence in research and promotion of best practice (www.profane.eu.org). The European Commission funds the network, which links clinicians, members of the public, and researchers worldwide. The aims are to identify major gaps in knowledge in fall injury prevention and to facilitate the collaboration necessary for large-scale clinical research activity, including clinical trials, comparative research, and prospective meta-analysis. Work is being undertaken in a 4-year program. As a first step, the development of a common set of outcome definitions and measures for future trials or meta-analysis was considered.     

How can you prevent falls and subsequent fractures?

Over the years, a number of strategies have been investigated to prevent falls in older people in a number of settings. Over 200 randomised controlled trials now exist, and the challenge for the discerning clinician is to read and interpret the existing literature so as to be able to implement effective strategies, targeting the right individual with the right intervention. This chapter reviews the current literature and attempts to simplify what has become an enormously complex area. Interventions are reviewed in three main settings – community, hospital and care facilities and based on the type of approach – single, multiple or multifactorial interventions. It also considers the reality in which we practise and provides some ‘best bets’ to consider at this point in time.     

Prevention of falls and fall-related fractures in community-dwelling older adults: a meta-analysis of estimates of effectiveness based on recent guidelines

Abstract Background: Two recent falls prevention guidelines have been published but did not include quantitative estimates of effectiveness based on the published reports that were reviewed to support their recommendations. Aim: To produce quantitative estimates of effectiveness of falls prevention programs from the randomised controlled trials cited in the guidelines together with an updated search of the available published reports to August 2002. Methods: A meta‐analysis of randomised controlled trials cited in falls guidelines and studies identified by an updated search of the available published reports was carried out. Randomised controlled trials were identified from the falls guidelines and a search, which met the following criteria: trials in community‐dwelling older people; 1‐year follow up; and outcome measures reported as the number of subjects with at least one fall or the number of subjects with a fracture. Results: The guidelines identified four studies of ‘exercise as a sole intervention’, which when combined with one further study identified in a search of the published reports, gave a fixed effects odds ratio (OR) favouring this strategy of 0.81 (95% confidence interval (CI) 0.58–1.14); the number of patients needed to be treated to prevent one person having a fall was 19.5. The guidelines identified seven studies of a ‘multiple intervention’ strategy that gave a random effects OR favouring this strategy of 0.64 (95% CI 0.47–0.88). Four further studies were identified by the search of the published reports. The updated OR favouring this intervention strategy was 0.65 (95% CI 0.52–0.81); the number of patients needed to be treated to prevent one person having a fall was 9.8. Only two studies had data for fracture and a fixed effects OR favouring falls interventions for fracture prevention was 0.50 (95% CI 0.18–1.40); the number of patients needed to be treated to prevent one person having a fracture was 45.5. Conclusion: Semiquantitative statements of evidence can both understate and overstate the effectiveness of falls prevention strategies. There is moderate evidence of efficacy for falls prevention particularly for multiple intervention strategies. (Intern Med J 2004; 34: 102–108)     

Implementation of multifactorial interventions for fall and fracture prevention

Over 60% of falls experienced by older people result from multiple aetiological factors. Preventing falls in individual patients requires the identification and treatment of these interacting factors. Multifactorial interventions have been successful in some, but not all, fall prevention trials. Preventing falls in populations requires selection of the population most likely to benefit, and selection of the particular interventions shown to have been effective in this group. The implementation of preventive measures has been low despite strong evidence that fall and fractures can be reduced. Misconceptions about the potential for prevention in old age, the time to effect improvement, resource issues and the nature of the interventions contribute to the low uptake. An improved system of delivery of proven preventive measures is needed.     

Methodology matters: what type of research is suitable for evaluating community treatment supporters for HIV and tuberculosis treatment?

The choice of research method relevant to the evaluation of delivery of a health intervention is not always straightforward. We use the evaluation of HIV and tuberculosis community treatment supporters in promoting adherence to treatment in Africa as a case study to illustrate the pros and cons of operational research and randomised controlled trials. The choice of this intervention for the case study reflects the importance of maximising the benefits of unprecedented efforts to scale-up treatments of these two epidemics. International policy supporting the role of community treatment supporters in tuberculosis is largely based on the findings of operational research studies. This reflects the advantages that operational research is less costly than randomised controlled trials, provides more rapid answers to policy questions, enables standard evaluation of the intervention in 'real life' conditions in several diverse settings and has in-built potential to influence policy and practice, because the research is conducted within health programmes. Recent evidence on the role of community treatment supporters in HIV is largely based on randomised trials. This reflects the advantages that randomised trials compared to operational research are more rigorous and generate a more convincing result. Operational research and randomised trials may be viewed as providing complementary findings to inform new policies and practice aimed at improving programme performance and patient outcomes. However, in practice, insufficient funds are likely to be made available for randomised trials to answer all the current research questions on delivery of programme interventions. In deciding on the type of research to evaluate a particular health intervention, dialogue is necessary with policy-makers to weigh up explicitly the trade-offs between research rigour and other factors such as cost, speed of implementation of research and speed of policy uptake and of change in programme practice.     

Efficacy of treatments for orthostatic hypotension: a systematic review

Background: orthostatic hypotension (OH) affects up to 30% of adults over 65 and frequently contributes to falls and syncopal episodes. Current guidelines suggest a wide range of treatments, but systematic reviews of the evidence base for such recommendations are lacking. Methods: we performed a systematic review to assess the evidence for all non-pharmacological and pharmacological interventions for OH. Our search included the following databases: MEDLINE; EMBASE; CINAHL; and the Cochrane library. We searched grey literature and references from included studies and other reviews. We included randomised, placebo-controlled trials, which measured postural drop as an outcome. Study quality was assessed using pre-specified measures of bias. Results: overall, 36 trials (21 interventions) were included. We identified a heterogeneous population and a wide variety of study methods, precluding meta-analysis. Most trials were of poor quality with high risk of bias. Changes in postural drop and symptoms were frequently inconsistent. Compression bandages, indomethacin, oxilofrine, potassium chloride and yohimbine improved the postural drop. Several vasoactive drugs-including midodrine and pyridostigmine-improved the standing blood pressure, but overall worsened the postural drop. Conclusions: many commonly recommended interventions for OH have a limited evidence base supporting their use. High quality, randomised, controlled trials are needed to underpin clinical practice for this condition.     

Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials

OBJECTIVE: to review systematically the range of case definitions and methods used to measure falls in randomised controlled trials. DESIGN/METHODS: a Cochrane review of fall prevention interventions was used to identify fall definitions in published trials. Secondary searches of various databases were used to identify additional methodological or theoretical papers. Two independent reviewers undertook data extraction, with adjudication by a third reviewer in cases of disagreement. SETTINGS: community-dwelling and institutionalised older persons. RESULTS: 90 publications met the predefined inclusion criteria. Of these, 44 provided no definition of the term fall. In the remainder, there were substantial variations in the definition and methods of measuring falls. Reporting periods ranged from 1 week to 4 years with only 41% using prospective data collection methods. CONCLUSION: the standard of reporting falls in published trials is poor and significantly impedes comparison between studies. The review has been used to inform an international consensus exercise to make recommendations for a core set of outcome measures for fall prevention trials.     

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data

OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) = 0.65, 95% confidence interval (CI) = 0.57-0.75; and, respectively IRR = 0.65, 95% CI = 0.53-0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64-3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.     

What is the role of falls?

There is now firm evidence to support interventions in the prevention of falls in older people, and emerging data support prevention of falls as a method of fracture prevention. This chapter discusses the epidemiology of falls, risk factors associated with an increased risk of falling, assessment of the older faller, and evidence-based approaches to the prevention of falls in the older person. Several randomized controlled trials have found that hip protectors, if worn, probably prevent hip fractures, but that poor compliance is a major issue limiting the effectiveness of this form of intervention. More data are needed to support the role of prevention of falls in preventing fractures, as well as comparative cost-effectiveness data with other evidence-based approaches to preventing fractures in an older population.     

Intervention strategies and risk-factor modification for falls prevention. A review of recent intervention studies

At least 21 randomized trials of falls-prevention interventions have been published in the past 10 years; thus, many falls clearly can be prevented. The most effective interventions are those that target community-dwelling people who are at high risk for falling. There is no doubt that for this group multifactor intervention is effective. Convincing evidence that exercise can prevent falls does exist, but the best type of exercise remains uncertain. Tai Chi, intensive strength and endurance training, and home-based exercises prescribed by a physiotherapist seem promising. Reducing the use of psychotropic medications does prevent falls, but the value of home modifications is still unclear.     

Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older Adults

OBJECTIVES: To model the incremental cost‐utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature. SETTING: Model represents population level interventions. PARTICIPANTS: No human subjects were involved in the study. MEASUREMENS: The last Cochrane database review and meta‐analyses of randomized controlled trials categorized effective fall‐prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high‐risk frail elderly people. Fall‐related hip fracture incidence was obtained from the literature. Salary figures for health professionals were based on Bureau of Labor Statistics data. Using an integrated healthcare system perspective, healthcare costs were estimated based on practice and studies on falls in older adults. Base case incremental cost utility ratios were calculated, and probabilistic sensitivity analyses were conducted. RESULTS: Medical management of psychotropics and group tai chi were the least‐costly, most‐effective options, but they were also the least studied. Excluding these interventions, the least‐expensive, most‐effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality‐adjusted life year (QALY) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more‐studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls.     

Prevention of sports injuries: systematic review of randomized controlled trials

Increased participation in sports has led to more sports injuries. Evidence-based methods to prevent sports injuries are needed. A systematic review was conducted of the effects of randomized controlled interventions to prevent sports injuries. A systematic search was performed of various databases and the reference lists of articles and reviews. Two reviewers independently extracted the data and assessed the methodological quality of the included trials. Thirty-two trials (24,931 participants) met the inclusion criteria. We found evidence of the preventive effect of 3 types of injury prevention interventions. In 5 trials including 6 different comparisons (2446 participants), custom-made or prefabricated insoles reduced lower limb injuries compared with no insoles in military recruits (risk reduction > or =50% in 4 comparisons). All 7 studies investigating external joint supports (10,300 participants) showed a tendency to prevent ankle, wrist, or knee injuries (risk reduction > or =50% in 5 studies). All 6 multi-intervention training programs (2809 participants) were effective in preventing sports injuries (risk reduction > or =50% in 5 studies). Various interventions may prevent sports injuries. A decreased risk of sports injuries was associated with the use of insoles, external joint supports, and multi-intervention training programs. More high-quality randomized controlled trials in different sports and populations are needed.     

Postprandial Hypotension

Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.     

Interventions to increase antiretroviral adherence in sub-Saharan Africa: a systematic review of evaluation studies

The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.