Which Interventions Help to Prevent Falls in the Elderly?

JASMINE CHEN GATTI, M.D., Johns Hopkins Medical Institutions, Baltimore, Maryland

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Jasmine Chen Gatti, M.D., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

An 80-year-old woman with osteoporosis complains of left hip pain after slipping with her cane on an area rug. Scarcely able to bear weight, with an asymmetric-appearing hip, she is found to have a trochanteric fracture.

Clinical Question

What effective interventions can clinicians use to adequately prevent falls in community-dwelling and institutionalized elderly patients?

Evidence-Based Answer

Beneficial interventions include individually prescribed programs of muscle strengthening, balance retraining, tai chi exercise, and home hazard assessment, limiting use of psychotropic medications, and team-approach multiple health and environmental risk factor reduction programs.

Cochrane Abstract Background. Approximately 30 percent of people older than 65 years and living in the community fall each year; the number is higher in institutions. Although fewer than one in 10 falls result in a fracture, one fifth of falls require medical attention. Objectives. To evaluate interventions designed to reduce the incidence of falls in elderly persons (living in the community or in institutions, including hospitals). Search Strategy. The authors searched the Cochrane Musculoskeletal Group specialized register (January 2001), Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2001), MEDLINE, EMBASE, CINAHL, The National Research Register, Current Controlled Trials, and reference lists of articles. They also contacted researchers in the field. Selection Criteria. Randomized trials of interventions designed to minimize the effect of, or exposure to, risk factors for falling in elderly persons. Main outcomes were the numbers of elderly persons who fell, or the number of falls. Trials reporting only intermediate outcomes were excluded. Data Collection and Analysis. Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate. Primary Results. The following interventions were likely to be beneficial: a program of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (three trials, 566 participants, pooled relative risk [RR], 0.80, 95 percent confidence interval [CI], 0.66 to 0.98); a 15-week tai chi group-exercise intervention (one trial, 200 participants, risk ratio, 0.51; 95 percent CI, 0.36 to 0.73); home hazard assessment and modification that is professionally prescribed for older people with a history of falling (one trial, 530 participants, RR, 0.64; 95 percent CI, 0.49 to 0.84; a reduction in falls was seen inside and outside the home); withdrawal of psychotropic medication (one trial, 93 participants, RR, 0.34; 95 percent CI, 0.16 to 0.74); and multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programs for unselected community-dwelling older people (data pooled from three trials, 1,973 participants, pooled RR, 0.73; 95 percent CI, 0.63 to 0.86) and older people with a history of falling, or selected because of known risk factors (data pooled from two trials, 713 participants, pooled RR, 0.79, 95 percent CI, 0.67 to 0.94). Interventions of unknown effectiveness include the following: group-delivered exercise interventions (nine trials, 2,177 participants); nutritional supplementation (one trial, 50 participants); vitamin D supplementation, with or without calcium (three trials, 679 participants); home hazard modification in association with advice on optimizing medications (one trial, 658 participants) or in association with an education package on exercise and reducing fall risk (one trial, 3,182 participants); pharmacologic therapy (one trial, 95 participants); and fall prevention programs in institutional settings; interventions using a cognitive/behavior approach alone (two trials, 145 participants); home hazard modification for older people without a history of falling (one trial, 530 participants); and hormone replacement therapy (one trial, 116 participants). Interventions unlikely to be beneficial include brisk walking in women with an upper limb fracture in the previous two years (one trial, 165 participants). Reviewer's Conclusions. Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing injuries related to falls. Costs per fall prevented have been established for four of the interventions, and careful economic modeling in the context of the local health care system is important. Some potential interventions are of unknown effectiveness, and further research is indicated. These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in The Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (www.cochrane.org).

Cochrane Critique

Did the authors address a focused clinical question? Yes.

Were the criteria used to select articles for inclusion appropriate? Yes.

Is it likely that important relevant articles were missed? No. Because this review was substantially updated on May 19, 2001, and ongoing trials are included in the update, recent searches do not reveal any major exclusion of important relevant articles.

Was the validity of the individual articles appraised? Elements of methodologic quality were assigned a point system. For example, three points were given if the method did not allow disclosure of assignment; two points were given if a small but possible chance of disclosure existed; one point was given if the study was quasi-randomized or undefined. Level of concealment of allocation or the process used to prevent foreknowledge of treatment/intervention assignment was also assessed.

Were the assessments of studies reproducible? Were the results similar from study to study? The authors acknowledge the difficulty in obtaining uniformity of participants, the wide variability in the definition of "fall" (resulting in some patients being included in some trials and not in others), and various settings--underlying illnesses, some patients with a history of falls and other patients without. In addition, there was a lack of blinding in some trials because of self-reporting, variability of duration of follow-up, and a range of intervention combinations as well as a range of extent of intervention by individual provider or team.

Despite the difficulties inherent in the populations studied, similar beneficial results were found in three studies each for the programs of muscle strengthening and balance retraining by prescription, and in team-approach multiple risk factor screening and interventions trials. Other modalities, such as the benefit of home hazard assessment, tai chi group exercise, and withdrawal of psychotropic medication, showed benefit in only one trial each.

How precise were the results? With the exception of the trial on withdrawal of psychotropic medication, all other trials had confidence intervals with acceptable precision--ranges were reasonable, and point estimates were good.

Can the results be applied to patient care? Yes.

Do the conclusions make biologic and clinical sense? Yes.

Are the benefits worth the harms and the costs? Yes.

Practice Pointers

The tremendous health care burden of an injured elderly person, especially one who sustains a fracture, is increasing as life expectancy increases. In elderly persons, falls remain the number one cause of injury-related emergency department visits.¹ Among those who are hospitalized for a fall (one of 40 persons), only about one half are alive one year later. Complications of falls include soft-tissue injury; fractures of the hip, femur, humerus, wrist, and ribs; subdural hematoma; hospitalization with associated iatrogenic and immobilization risks; disability resulting from fear of falling; restricted mobility during and after recovery; risk of institutionalization; and death.²

In geriatric assessment of the elderly, evaluation of the physical and social environment that includes the Instrumental Activities of Daily Living and Activities of Daily Living must also include a more detailed assessment of the home environment. Questions about lighting, footwear, uneven flooring, and access to assistive devices should be addressed. The problem of polypharmacy must always be addressed, and psychotropic medications should be withdrawn, if possible.

In addition to routine evaluation of hearing, vision, and neurologic status, clinicians also should include balance and gait testing with a timed "Up and Go" test or the simpler "Get-up and Go" test,² or a one-leg balance test (standing unassisted on one leg for 5 seconds).¹ If a problem is detected, the physician can set up a prescription for training in balance and strength that includes the preferences and limitations of the patient.

If a patient is at high risk for falls or has a history of falling, a team approach with multiple modifications in environment, medications, gait and balance retraining, education, and careful follow-up has been shown to be effective prevention.

Jasmine Chen Gatti, M.D., has worked as a fellow at the Cochrane Collaboration and is currently a consultant, medical writer, geriatrician, and family physician at the Johns Hopkins Community Physicians Department of Family Medicine of Johns Hopkins Medical Institutions in Baltimore, Md.

Address correspondence to Jasmine Chen Gatti, M.D., JHCP at Montgomery Grove, 15201 Shady Grove Rd., Rockville, MD 20850 (e-mail: jgatti@jhmi.edu). Reprints are not available from the author.

REFERENCES

1. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Intervention for preventing falls in elderly people (Cochrane Review). Cochrane Database Syst Rev 2001;3):CD000340.
2. Fuller GF. Falls in the elderly. Am Fam Physician 2000;61:2159-68,2173-4.