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Preventing Falls: Which Intervention Is Most Effective?



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Am Fam Physician. 2002 Nov 15;66(10):1967-1971.

Several interventions have successfully reduced the incidence of falls among elderly people living at home, but little information is available on the comparative effectiveness of, or potential for, synergy between different interventions. Day and colleagues studied eight interventions in elderly people living in Melbourne, Australia.

More than 1,000 patients who were at least 70 years old and lived at home participated in the study. Patients were identified from electoral rolls. All were able to walk 10 to 20 m (9.14 to 18.28 yards) without resting, had no severe physical or mental condition that would limit participation in the study, and obtained approval from their family doctor. Persons who had previously participated in balance training or who had recent home modifications were excluded from the study.

Effect on Falls Outcome from Single and Combined Interventions

Rate ratio
Intervention Number having at least one fall (%) Estimate (95% CI) P value Estimated % reduction in annual fall rate (95% CI) Number needed to treat to prevent one fall

No intervention*

87/137 (63.5)

Reference (1.00)

Exercise

76/135 (56.3)

0.82 (0.70 to 0.97)

0.02

6.9 (1.1 to 12.8)

14

Vision

84/139 (60.4)

0.89 (0.75 to 1.04)

0.13

4.4 (− 1.5 to 10.2)

23

Home hazard management

78/136 (57.4)

0.92 (0.78 to 1.08)

0.29

3.1 (− 2.0 to 9.7)

32

Exercise plus vision

66/136 (48.5)

0.73 (0.58 to 0.91)

0.01

11.1 (2.2 to 18.5)

9

Exercise plus home hazard management

72/135 (53.3)

0.76 (0.60 to 0.95)

0.02

9.9 (2.4 to 17.9)

10

Vision plus home hazard management

78/137 (56.9)

0.81 (0.65 to 1.02)

0.07

7.4 (− 0.9 to 15.2)

14

Exercise plus vision plus home hazard management

65/135 (48.1)

0.67 (0.51 to 0.88)

0.004

14.0 (3.7 to 22.6)

7


CI = confidence interval.

*—No intervention until after the study had ended.

Reprinted with permission from Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:130.

Effect on Falls Outcome from Single and Combined Interventions

View Table

Effect on Falls Outcome from Single and Combined Interventions

Rate ratio
Intervention Number having at least one fall (%) Estimate (95% CI) P value Estimated % reduction in annual fall rate (95% CI) Number needed to treat to prevent one fall

No intervention*

87/137 (63.5)

Reference (1.00)

Exercise

76/135 (56.3)

0.82 (0.70 to 0.97)

0.02

6.9 (1.1 to 12.8)

14

Vision

84/139 (60.4)

0.89 (0.75 to 1.04)

0.13

4.4 (− 1.5 to 10.2)

23

Home hazard management

78/136 (57.4)

0.92 (0.78 to 1.08)

0.29

3.1 (− 2.0 to 9.7)

32

Exercise plus vision

66/136 (48.5)

0.73 (0.58 to 0.91)

0.01

11.1 (2.2 to 18.5)

9

Exercise plus home hazard management

72/135 (53.3)

0.76 (0.60 to 0.95)

0.02

9.9 (2.4 to 17.9)

10

Vision plus home hazard management

78/137 (56.9)

0.81 (0.65 to 1.02)

0.07

7.4 (− 0.9 to 15.2)

14

Exercise plus vision plus home hazard management

65/135 (48.1)

0.67 (0.51 to 0.88)

0.004

14.0 (3.7 to 22.6)

7


CI = confidence interval.

*—No intervention until after the study had ended.

Reprinted with permission from Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:130.

The baseline assessment included a home visit to obtain a medical and social history, to document the patient's ability to perform daily activities, and to conduct a risk assessment. During this visit, information also was collected on medications, self-rated health, and demographic characteristics. The patient's vision, balance and strength, and home hazards were assessed. After this assessment, patients were randomly assigned to one of eight intervention groups. The principal outcome was time to the first fall during the following 18 months. Patients used diaries to record falls and other events, and were contacted monthly by investigators. Other outcomes included change in balance and strength, vision, and home hazards.

The eight groups comprised three single-intervention subgroups (targeting exercise, home hazards, and vision), three subgroups in which two interventions were combined (exercise/home hazards, exercise/vision, vision/home hazards), one subgroup receiving all three interventions, and a control group that did not receive any intervention. Approximately 135 patients were assigned to each group, and 34 to 52 percent of each group completed the study.

Demographic and baseline risk factors were comparable across groups at the beginning of the study. Participants who took exercise classes showed significant gains in strength and some aspects of balance. The maximal balance range decreased only slightly in the exercise groups and declined in other groups, suggesting that exercise slowed age-related deterioration. The average number of home hazards decreased in all groups that received hazard interventions and in the control group. Visual acuity improved marginally in the control group compared with intervention groups.

In the control group, 63.5 percent of participants reported at least one fall during the 18-month study. All interventions reduced falls, but the effect was significant only for interventions that included exercise (see the accompanying table). Interventions appeared to be additive; the greatest estimated annual reduction in falls (14 percent) was obtained with exercise plus vision intervention plus hazard management. The authors estimate that only seven elderly persons need to be treated with this combination to prevent one fall. As shown in the table, exercise alone required 14 persons to receive the intervention to prevent one fall and was associated with an annual reduction of 6.9 percent.

The authors conclude that an exercise program averaging two classes per week can provide the basis for fall prevention in healthy elderly persons living at home. Other interventions have limited benefit but can contribute to a significantly reduced risk of falls.

Day L, et al. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ. July 20, 2002;325:128–31.

editor's note: We frequently do not think of recommending exercise to our elderly patients, or we hesitate for fear of embarrassing them or not knowing what to suggest. This study shows that even modest exercise can dramatically reduce the risk of falls. Other studies show that even 90-year-old patients in nursing homes benefit from appropriate exercise! The havoc that can follow a bad fall is worth avoiding at all costs, and the gains reported by this study are significant. Should we add discussion of exercise and balance training to the routine areas covered when treating elderly patients? Throughout the country, area agencies on aging can provide information about exercise programs. If these programs don't exist, maybe family physicians should take the lead in starting them in their own communities.—a.d.w.

 


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