Interventions May Reduce Falls in Elderly Living at Home

Laurie Barclay, MD

September 12, 2012

September 12, 2012 — Not all interventions to reduce falls in community dwellers aged 65 years and older are equally effective, according to an update of a systematic review first published in 2009. The new findings were published online September 11 in the Cochrane Review.

"Multiple-component exercises carried out either in groups or by individuals when prescribed in their homes significantly reduced the rate of falls and reduced an individual's risk of falling," lead author Lesley D. Gillespie, from the Department of Medicine of Dunedin School of Medicine, University of Otago in New Zealand, said in a news release.

Each year, according to the researchers, falls occur in about 30% of community dwellers at least 65 years of age. Approximately 20% of these falls necessitate medical attention, and fewer than 10% result in fracture.

The goal of this updated Cochrane review was to evaluate the effectiveness of interventions intended to lower fall risk in this population. The reviewers identified randomized trials of such interventions by searching the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register through February 2012, CENTRAL, MEDLINE from 1946 to March 2012, EMBASE from 1947 to March 2012, CINAHL from 1982 to February 2012, and online trial registers.

Two reviewers independently extracted data from retrieved articles and determined the risk for bias. Where appropriate, they pooled data, using a rate ratio (RaR) to compare the intervention and control groups in terms of falls per person-year. According to the number of people falling in each group, the reviewers used a risk ratio (RR) to calculate risk for falling.

The 159 trials meeting selection criteria and included in the analysis enrolled a total of 79,193 participants. Most of these trials compared an intervention designed to prevent falls with either no intervention or an intervention not anticipated to lower fall risk.

Of these 159 trials, 59 evaluated exercise as a single intervention and 40 evaluated multicomponent programs. Risk for bias was low for sequence generation in 62% of trials, for attrition bias for falls in 60%, for fallers in 73%, and for proper blinding in only 38%.

Other limitations of this review include the inability to evaluate interventions in demented elderly, as most trials excluded them. The reviewers recommend additional studies on improving implementation and compliance with effective programs.

Effective Interventions to Reduce Falls

  • Multiple-component group exercise was effective in reducing falls (RaR 0.71, 95% confidence interval [CI], 0.63 - 0.82 in 16 trials enrolling 3622 participants; RR, 0.85, 95% CI, 0.76 - 0.96 in 22 trials enrolling 5333 participants).

  • Multiple-component home-based exercise also was effective in reducing falls (RaR, 0.68; 95% CI, 0.58 - 0.80 in 7 trials enrolling 951 participants; RR, 0.78; 95% CI, 0.64 - 0.94 in 6 trials enrolling 714 participants).

  • Safety modifications and behavioral changes in the home were effective at reducing falls, particularly when based on an evaluation by a qualified occupational therapist and for people with severe visual impairments. For fall rate, RaR was 0.81 (95% CI, 0.68 - 0.97) in 6 trials enrolling 4208 participants, and for risk for falling, RR was 0.88 (95% CI, 0.80 - 0.96) in 7 trials enrolling 4051 participants.

  • Pacemaker implantation for people with carotid sinus hypersensitivity reduced fall rate (RaR, 0.73; 95% CI, 0.57 - 0.93 in 3 trials enrolling 349 participants), but not risk for falling.

  • Cataract surgery on the first affected eye in women also reduced falls (RaR, 0.66; 95% CI, 0.45 - 0.95 in 1 trial enrolling 306 participants). However, cataract removal from the second eye had no additional benefit.

  • Gradual withdrawal of psychotropic medication and patient-specific modification of drug prescription by general practitioners both reduced falls.

  • Use of an antislip shoe device for people needing to walk on icy streets also reduced falls.

  • Finally, tai chi significantly reduced fall risk (RR, 0.71; 95% CI, 0.57 - 0.87 in 6 trials enrolling 1625 participants), although the reduction in fall rate only bordered on statistical significance.

Interventions Ineffective in Reducing Falls

  • New use of multifocal eyeglasses did not reduce fall risk. In fact, fall risk actually increased when older people were adjusting to new glasses or to significant changes in prescriptions, but this risk declined with the substitution of single-focal lenses for activities outside the home.

  • Overall, vitamin D supplementation did not lower fall rate, but it trended in that direction for participants who were vitamin D deficient at trial enrollment.

  • Cognitive behavioral interventions and education regarding fall prevention also did not lower fall rate.

Cost-Effective Interventions to Reduce Falls

  • Home-based exercise in persons older than 80 years was a cost-effective method of reducing falls.

  • Home safety evaluation and modification after a fall also reduced falls inexpensively.

  • In addition, a multifactorial program directed at 8 specific risk factors was successful in reducing fall rate.

"There is now strong evidence of effect in preventing falls for some interventions and no evidence of effect for others," the review authors conclude.

"Programmes containing multiple categories of exercise were effective in reducing both rate of falls and risk of falling when delivered as group classes or when individually prescribed at home. The types of exercise commonly included were balance retraining and muscle strengthening."

The study was supported by the National Health and Medical Research Council, Australia; the University of Otago; the University of Sydney, Australia; the University of Warwick, Coventry, United Kingdom; and the National Institute of Health Research through a Department of Health Cochrane Review incentive award. Four review authors were investigators for 10 included studies.

Cochrane Library. Published online September 12, 2012. Abstract