Fall-Prevention Program May Be Ineffective in High-Risk, Cognitively Intact Elderly

Laurie Barclay, MD

July 19, 2010

July 19, 2010 — A fall-prevention program is not shown to be effective in reducing falls among high-risk, cognitively intact older persons, according to the results of a randomized controlled trial reported in the July 12 issue of the Archives of Internal Medicine.

"Falls occur frequently in older people and strongly affect quality of life," write Oscar J. de Vries, MD, from VU University Medical Center in Amsterdam, the Netherlands, and colleagues. "Guidelines recommend multifactorial, targeted fall prevention. We evaluated the effectiveness of a multifactorial intervention in older persons with a high risk of recurrent falls."

At geriatric outpatient clinics of a Dutch university hospital and regional general practices in the Netherlands, 2015 persons who experienced a fall were identified, and 217 persons 65 years or older were recruited and studied from April 3, 2005, to July 21, 2008. Selection criteria were patients who visited the emergency department or their family physician after a fall, without cognitive impairment but with high risk for recurrent falls.

Reducing fall risk factors was the goal of geriatric evaluation and intervention, and main study endpoints were time after randomization to first and second falls. Secondary endpoints were fractures, activities of daily living (ADLs), quality of life (QOL), and physical performance.

At least 1 fall within 1 year occurred in 55 (51.9%) of the 106 intervention participants vs 62 (55.9%) of the 111 participants in the usual-care (control) group; this difference was not significant (P > .55). Times to first fall or second fall were not significantly different between groups (hazard ratio [HR], 0.96, 95% confidence interval [CI], 0.67 - 1.37; and HR, 0.15; 95% CI, 0.02 - 1.21, respectively). Secondary outcome measures and per-protocol analysis yielded similar findings between groups. There was 1 death in the intervention group and 7 in the control group; the authors report that this difference was not statistically significant.

"This multifactorial fall-prevention program does not reduce falls in high-risk, cognitively intact older persons," the study authors write.

Limitations of this study include the effect of recall bias when falls are recorded retrospectively, impact of screening and telling patients about the aim of the study and their estimated fall risk, small study sample, and lack of generalizability to other participants. In addition, the dose of cholecalciferol supplements prescribed may have been too low to lower the fall risk in this very high-risk group.

"New intervention programs and strategies to further increase adherence should be developed and tested in this target group," the study authors conclude. "Until then, we recommend closely monitoring the effects of the current multifactorial intervention in high-risk patients to allow intervention when an individually increased fall risk becomes apparent."

In an accompanying invited commentary, Jane E. Mahoney, MD, from the University of Wisconsin School of Medicine and Public Health in Madison, recommends using caution regarding relying on falls assessment clinics as a strategy for reducing falls.

"However, much depends on the extent to which primary care physicians follow through on recommendations, referral sources provide appropriate content for fall prevention, and medical providers are able to implement multifactorial fall-prevention content on their own as part of 'usual care,'" Dr. Mahoney writes. "For researchers and clinicians alike, the conundrum of conflicting multifactorial intervention studies should prompt careful attention to the aspects of the study (content, process, and choice of target group) that, if varied, have the potential to turn success into failure."

The study authors and Dr. Mahoney have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:1110-1117, 1117-1119. Abstract

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