Am Fam Physician. 2017;95(3):152-153
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Are interventions for preventing falls effective for older adults living in the community?
Structured exercise programs and home safety interventions reduce both the rate and the risk of falling among community-dwelling adults 65 years and older, whereas multifactorial assessment and intervention programs reduce the rate of falls but not the risk of falling. Vitamin D supplementation does not reduce the rate of falls or risk of falling in all patients. Education about fall prevention does not significantly reduce the rate or risk of falling.1 (Strength of Recommendation: B, based on inconsistent or limited quality patient-oriented evidence.)
One out of every three persons 65 years and older falls each year, and falling once doubles a person's chances of falling again.2 One out of every five such falls causes a serious injury, such as broken bones or a head injury.3 In addition, falls have a large economic impact on society. The average cost of hospitalization for a fall-related injury among persons older than 65 years is more than $17,000, not including indirect costs such as loss of productivity.4 Identified risks include lower body weakness, poor balance, home hazards, vitamin D deficiency, and medication use.3
This updated systematic review included 159 randomized controlled trials with 79,193 participants, all of whom were older adults (generally defined as age 65 years and older) living in the community.1 In this review, the risk of falling refers to the likelihood that a person will experience a fall within one year, whereas the rate of falls is the mean number of falls per year. Group exercise programs, consisting of two or more components of exercise, significantly reduced the rate of falls (rate ratio [RaR] = 0.71; 95% confidence interval [CI], 0.63 to 0.82), as did multicomponent home exercise programs (RaR = 0.68; 95% CI, 0.58 to 0.80). The components of the group and home-based exercise programs included balance training, strength and resistance training, walking, and tai chi. Overall, exercise interventions also significantly reduced the risk of fracture (relative risk [RR] = 0.34; 95% CI, 0.18 to 0.63). Multifactorial interventions, which assess an individual's risk of falling and then develop a treatment plan to reduce the identified risks, were also shown to reduce the rate of falls (RaR = 0.76; 95% CI, 0.67 to 0.86).
Home safety assessment and modification interventions were effective in reducing the rate of falls (RaR = 0.81; 95% CI, 0.68 to 0.97). These home safety interventions were more effective in persons at higher risk of falling and when delivered by an occupational therapist. An intensive educational program for family physicians that included face-to-face education by a pharmacist on how to conduct medication reviews and feedback on prescribing, along with incorporating active patient involvement, significantly reduced the risk of falling (RR = 0.61; 95% CI, 0.41 to 0.91).
Vitamin D supplementation did not reduce the rate of falls or risk of falling in all patients. However, subgroup analysis showed that it was effective when administered to those participants who began the study with low vitamin D levels (RaR = 0.57; 95% CI, 0.37 to 0.89). Similarly, trials testing interventions that only provided education about fall prevention did not significantly reduce the rate or risk of falling.
Potential sources of bias included under- or overreporting of fall events, lack of blinding to intervention, and attrition bias. In a large number of trials included in the review, the impact of the risk of bias was found to be mostly low or unclear. It is important to note that the findings are not generalizable to older persons with dementia, because most of the trials excluded those with cognitive impairment. Two of the trials testing resistance training reported adverse effects. One included musculoskeletal injuries, which improved within three weeks, and the other showed a higher risk of injury involving back or knee pain related to exercise (RR = 3.6; 95% CI, 1.5 to 8.0).
Current guidelines by the American Geriatrics Society recommend a multifactorial fall risk assessment followed by interventions tailored to each patient's risk factors coupled with an appropriate exercise program.2 This systematic review supports those recommendations.
The practice recommendations in this activity are available at http://www.cochrane.org.