[Effectiveness of falls prevention strategies for elderly subjects who live in the community with performance assessment of physical activities (before-after)]

Exercise for falls prevention in community-dwelling older adults: trial and participant characteristics, interventions and bias in clinical trials from a systematic review

INTRODUCTION

There is strong evidence that exercise prevents falls in community-dwelling older people. This review summarises trial and participant characteristics, intervention contents and study quality of 108 randomised trials evaluating exercise interventions for falls prevention in community-dwelling older adults.

METHODS

MEDLINE, EMBASE, CENTRAL and three other databases sourced randomised controlled trials of exercise as a single intervention to prevent falls in community-dwelling adults aged 60+ years to May 2018.

RESULTS

108 trials with 146 intervention arms and 23 407 participants were included. Trials were undertaken in 25 countries, 90% of trials had predominantly female participants and 56% had elevated falls risk as an inclusion criterion. In 72% of trial interventions attendance rates exceeded 50% and/or 75% of participants attended 50% or more sessions. Characteristics of the trials within the three types of intervention programme that reduced falls were: (1) balance and functional training interventions lasting on average 25 weeks (IQR 16-52), 39% group based, 63% individually tailored; (2) Tai Chi interventions lasting on average 20 weeks (IQR 15-43), 71% group based, 7% tailored; (3) programmes with multiple types of exercise lasting on average 26 weeks (IQR 12-52), 54% group based, 75% tailored. Only 35% of trials had low risk of bias for allocation concealment, and 53% for attrition bias.

CONCLUSIONS

The characteristics of effective exercise interventions can guide clinicians and programme providers in developing optimal interventions based on current best evidence. Future trials should minimise likely sources of bias and comply with reporting guidelines.

Exercise for preventing falls in older people living in the community

BACKGROUND

At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these people. An up-to-date synthesis of the evidence is important given the major long-term consequences associated with falls and fall-related injuries OBJECTIVES: To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.

MAIN RESULTS

We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster-RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here.Exercise (all types) versus control Eighty-one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high-certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high-certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not.The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall-related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low-certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low-certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low-certainty evidence). Exercise may make little important difference to health-related quality of life: conversion of the pooled result (standardised mean difference (SMD) -0.03, 95% CI -0.10 to 0.04; 3172 participants, 15 studies; low-certainty evidence) to the EQ-5D and SF-36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales.Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non-serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups.Different exercise types versus controlDifferent forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high-certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high-certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate-certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low-certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high-certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control.

AUTHORS' CONCLUSIONS

Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high-certainty evidence). The effects of such exercise programmes are uncertain for other non-falls outcomes. Where reported, adverse events were predominantly non-serious.Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.

Comparative Effectiveness of Published Interventions for Elderly Fall Prevention: A Systematic Review and Network Meta-Analysis

Background: Falls are a major threat to older adults worldwide. Although various effective interventions have been developed, their comparative effectiveness remains unreported. Methods: A systematic review and network meta-analysis was conducted to determine the most effective interventions to prevent falls in community-dwelling adults aged 60 and over. Combined odds ratio (OR) and 95% credible interval (95% CrI) were calculated. Results: A total of 49 trials involving 27,740 participants and 9271 fallers were included. Compared to usual care, multifactorial interventions (MFI) demonstrated the greatest efficacy (OR: 0.64, 95% CrI: 0.53 to 0.77) followed by interventions combining education and exercise (EDU + EXC) (OR: 0.65, 95% CrI: 0.38 to 1.00) and interventions combining exercise and hazard assessment and modification (EXC + HAM) (OR: 0.66, 95% CrI: 0.40 to 1.04). The effect of medical care performed the worst (OR: 1.02, 95% CrI: 0.78 to 1.34). Model fit was good, inconsistency was low, and publication bias was considered absent. The overall quality of included trials was high. The pooled odds ratios and ranking probabilities remained relatively stable across all sensitivity analyses. Conclusions: MFI and exercise appear to be effective to reduce falls among older adults, and should be considered first as service delivery options. Further investigation is necessary to verify effectiveness and suitableness of the strategies to at-risk populations.

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To determine whether, and to what extent, fall prevention exercise interventions for older community dwelling people are effective in preventing different types of fall related injuries.

DATA SOURCES

Electronic databases (PubMed, the Cochrane Library, Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July 2013.

STUDY SELECTION

Randomised controlled trials of fall prevention exercise interventions, targeting older (>60 years) community dwelling people and providing quantitative data on injurious falls, serious falls, or fall related fractures.

DATA SYNTHESIS

Based on a systematic review of the case definitions used in the selected studies, we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of results across studies and the pooling of data. For each study we extracted or calculated the rate ratio of injurious falls. Depending on the available data, a given study could contribute data relevant to one or more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls based on random effects models.

RESULTS

17 trials involving 4305 participants were eligible for meta-analysis. Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled estimates of the rate ratios of 0.63 (95% confidence interval 0.51 to 0.77, 10 trials) for all injurious falls, 0.70 (0.54 to 0.92, 8 trials) for falls resulting in medical care, 0.57 (0.36 to 0.90, 7 trials) for severe injurious falls, and 0.39 (0.22 to 0.66, 6 trials) for falls resulting in fractures, but significant heterogeneity was observed between studies of all injurious falls (I(2)=50%, P=0.04).

CONCLUSIONS

Exercise programmes designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.

Prevention of falls in old people – a review

Physical training, if including specific different training modalities, reduces the fall risk in healthy community-dwelling older people, as does a home hazards modification programme. Vitamin D supplementation in older individuals with low levels of vitamin D, adjustment of psychotropic medication, and structured modification of multi-pharmacy are all drug-focused programmes that reduce the number of falls. Anti-slip shoe devices during icy conditions for older people who walk outdoors and multifaceted podiatry in patients with specific foot disability reduce the fall risk. First eye cataract surgery and pacemakers in patients with cardio-inhibitory carotid sinus hypersensitivity are surgical interventions that reduce the fall risk. Multi-factorial preventive programmes that include training, both individually designed and generally prescribed, also reduce the fall frequency. With this in mind, we ought to initiate fall preventive programmes in older people, especially in high- risk groups, to reduce the number of falls and fallers in society.

Prevention of falls in the elderly: a review

AIMS

Falls often result in soft tissue injuries, dislocations, fractures, longstanding pain and reduced quality of life. Therefore, fall preventive programmes have been developed.

METHODS

In this review, we evaluate programmes that in randomized controlled trials (RCT) have been shown with fall reducing effect.

RESULTS

Physical exercise that includes several training modalities, especially balance and strength training, is the only intervention programme that reduces both the number of fallers and the number of falls in community dwellers. Home hazards modification reduces the fall risk in community-living elderly but has the best effects in high risk groups when the programme is led by occupational therapists. Vitamin D supplement in those with low levels of vitamin D, adjustment of psychotropic medication and modification of multi-pharmacy are drug-related programmes that reduce the fall risk. Anti-slip shoe devices in elderly who walk outdoors during icy conditions and multifaceted podiatry to patients with specific foot disability are interventions targeted at the lower extremities with a fall-reducing effect. First eye cataract surgery and pacemakers in patients with cardio-inhibitory carotid sinus hypersensitivity are surgical procedures with fall-reducing effect. Multifactorial standardized preventive programmes that include an exercise component and individually-designed subject-specific programmes also reduce the number of falls.

CONCLUSIONS

Fall preventive interventions should be provided to elderly by a structured approach, especially to high risk groups, as to reduce the number of falls and fallers.

Prevention of falls in the elderly--a review

The proportion of elderly in the society increases and fall frequency increases with advancing age. Many falls result in fractures and also soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, increased mortality, and excess in healthcare costs. Due to the magnitude of these negative effects, a variety of single- and multicomponent fall-preventive intervention programs has been initiated.This review identifies programs that, in randomized controlled trials (RCTs), have been shown with fall-reductive effects.The most effective strategies in community-dwelling elderly include regular physical training with program that includes several different training modalities. Modification of the overall or patient-specific risk factor profile in home hazard modification program has been proven to decrease fall risk in community-living elderly. The elderly in the community benefit also from wearing antislip shoe devices when walking in icy conditions, from adjustment of psychotropic medication, and from structured modification of multipharmacy. If vitamin D levels in blood are low, supplementation is beneficial as is the first eye cataract surgery and pacemaker implantation in patients with cardioinhibitory carotid sinus hypersensitivity. In addition to modification of specific risk factors, generalized and individualized multifactorial preventive programs, all including some sort of physical training, have been found to decrease the fall risk. In summary, there is now strong evidence in the literature that structured fall-preventive programs in the elderly, especially in high-risk groups, are beneficial in reducing both the number of fallers and the number of falls in community.

Interventions for preventing falls in older people living in the community

BACKGROUND

Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.

SELECTION CRITERIA

Randomised trials of interventions to reduce falls in community-dwelling older people.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.

MAIN RESULTS

We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.

AUTHORS' CONCLUSIONS

Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

Exercise for improving balance in older people

BACKGROUND

In older adults, diminished balance is associated with reduced physical functioning and an increased risk of falling. This is an update of a Cochrane review first published in 2007.

OBJECTIVES

To examine the effects of exercise interventions on balance in older people, aged 60 and over, living in the community or in institutional care.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE and EMBASE (to February 2011).

SELECTION CRITERIA

Randomised controlled studies testing the effects of exercise interventions on balance in older people. The primary outcomes of the review were clinical measures of balance.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed risk of bias and extracted data from studies. Data were pooled where appropriate.

MAIN RESULTS

This update included 94 studies (62 new) with 9,917 participants. Most participants were women living in their own home.Most trials were judged at unclear risk of selection bias, generally reflecting inadequate reporting of the randomisation methods, but at high risk of performance bias relating to lack of participant blinding, which is largely unavoidable for these trials. Most studies only reported outcome up to the end of the exercise programme.There were eight categories of exercise programmes. These are listed below together with primary measures of balance for which there was some evidence of a statistically significant effect at the end of the exercise programme. Some trials tested more than one type of exercise. Crucially, the evidence for each outcome was generally from only a few of the trials for each exercise category. 1. Gait, balance, co-ordination and functional tasks (19 studies of which 10 provided primary outcome data): Timed Up & Go test (mean difference (MD) -0.82 s; 95% CI -1.56 to -0.08 s, 114 participants, 4 studies); walking speed (standardised mean difference (SMD) 0.43; 95% CI 0.11 to 0.75, 156 participants, 4 studies), and the Berg Balance Scale (MD 3.48 points; 95% CI 2.01 to 4.95 points, 145 participants, 4 studies).2. Strengthening exercise (including resistance or power training) (21 studies of which 11 provided primary outcome data): Timed Up & Go Test (MD -4.30 s; 95% CI -7.60 to -1.00 s, 71 participants, 3 studies); standing on one leg for as long as possible with eyes closed (MD 1.64 s; 95% CI 0.97 to 2.31 s, 120 participants, 3 studies); and walking speed (SMD 0.25; 95% CI 0.05 to 0.46, 375 participants, 8 studies).3. 3D (3 dimensional) exercise (including Tai Chi, qi gong, dance, yoga) (15 studies of which seven provided primary outcome data): Timed Up & Go Test (MD -1.30 s; 95% CI -2.40 to -0.20 s, 44 participants, 1 study); standing on one leg for as long as possible with eyes open (MD 9.60 s; 95% CI 6.64 to 12.56 s, 47 participants, 1 study), and with eyes closed (MD 2.21 s; 95% CI 0.69 to 3.73 s, 48 participants, 1 study); and the Berg Balance Scale (MD 1.06 points; 95% CI 0.37 to 1.76 points, 150 participants, 2 studies).4. General physical activity (walking) (seven studies of which five provided primary outcome data). 5. General physical activity (cycling) (one study which provided data for walking speed). 6. Computerised balance training using visual feedback (two studies, neither of which provided primary outcome data). 7. Vibration platform used as intervention (three studies of which one provided primary outcome data).8. Multiple exercise types (combinations of the above) (43 studies of which 29 provided data for one or more primary outcomes): Timed Up & Go Test (MD -1.63 s; 95% CI -2.28 to -0.98 s, 635 participants, 12 studies); standing on one leg for as long as possible with eyes open (MD 5.03 s; 95% CI 1.19 to 8.87 s, 545 participants, 9 studies), and with eyes closed ((MD 1.60 s; 95% CI -0.01 to 3.20 s, 176 participants, 2 studies); walking speed (SMD 0.04; 95% CI -0.10 to 0.17, 818 participants, 15 studies); and the Berg Balance Scale ((MD 1.84 points; 95% CI 0.71 to 2.97 points, 80 participants, 2 studies).Few adverse events were reported but most studies did not monitor or report adverse events.In general, the more effective programmes ran three times a week for three months and involved dynamic exercise in standing.

AUTHORS' CONCLUSIONS

There is weak evidence that some types of exercise (gait, balance, co-ordination and functional tasks; strengthening exercise; 3D exercise and multiple exercise types) are moderately effective, immediately post intervention, in improving clinical balance outcomes in older people. Such interventions are probably safe. There is either no or insufficient evidence to draw any conclusions for general physical activity (walking or cycling) and exercise involving computerised balance programmes or vibration plates. Further high methodological quality research using core outcome measures and adequate surveillance is required.

Developing a Housing Adaptation Genome Project

Evidence about the effectiveness of housing adaptations is unsystematic, leaving large gaps in knowledge. The evidence that exists is not sufficiently compelling to attract substantial investment, and its weakness impedes evidence-based practice. In order to fill the gaps, a more systematic approach to adaptation research is needed. A housing adaptation genome project is proposed to address this problem by mapping, planning and coordinating future research.

This opinion piece sets out the rationale and potential value of developing a housing adaptation genome project. It invites all stakeholders to become involved and to help to shape a more powerful approach to housing adaptation research.

Community-based health efforts for the prevention of falls in the elderly

Falls are a major public health problem in the elderly population. The associated health care cost is great. It has therefore become an important public health matter to evaluate those interventions that might be effective in reducing the risk of falls. Risk factors that predict an increased risk of falling are described. We discuss interventions that can be employed in the community to reduce the risk of falls and associated injuries by discipline, including physiotherapy, occupational therapy, and physician-led interventions. We also discuss the cost-effectiveness of such interventions.

WITHDRAWN: Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or 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.

MAIN RESULTS

Sixty two trials involving 21,668 people were included.Interventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants).Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

AUTHORS' CONCLUSIONS

Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Interventions for preventing falls in older people living in the community

BACKGROUND

Approximately 30% of people over 65 years of age living in the community fall each year.

OBJECTIVES

To assess the effects of interventions to reduce the incidence of falls in older people living in the community.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).

SELECTION CRITERIA

Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

We included 111 trials (55,303 participants).Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03); RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).There is some evidence that falls prevention strategies can be cost saving.

AUTHORS' CONCLUSIONS

Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Role of physical activity in the prevention of falls and their consequences in the elderly

This work aims to provide an inventory of the risk factors and consequences of falling in the elderly, namely fractures, and to identify strategies to prevent falls and minimise their effects. Falls in elderly people are a major cause of injuries, leading to a general fear of falling, poorer quality of life and even death. The increase in life expectancy brought by developments in the medical and health sciences has not always brought enhanced quality of life. More elderly people live with reduced functional capacities resulting in a higher prevalence of falls and associated problems for themselves and for society. Risk factors for falling, commonly resulting from normal aging processes, have already been identified through multiple studies. Exercise may play an important role in fall prevention and their consequences. Although, effective strategies are usually multi-disciplinary and focus simultaneously on several risk factors. However, only large-scale prevention programmes can have significant effective social impact. To minimise occurrence and consequences of falls, policies to systematically implement prevention programmes should be established.

Exercise for improving balance in older people

BACKGROUND

Diminished ability to maintain balance may be associated with an increased risk of falling. In older adults, falls commonly lead to injury, loss of independence, associated illness and early death. Although some exercise interventions with balance and muscle strengthening components have been shown to reduce falls it is not known which elements, or combination of elements, of exercise interventions are most effective for improving balance in older people.

OBJECTIVES

To present the best evidence for effectiveness of exercise interventions designed to improve balance in older people living in the community or in institutional care.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (Feb 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), other databases and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials testing exercise interventions designed to improve balance in older people were included. We excluded trials of interventions targeting individuals with specific conditions in order not to broaden the scope of this review too widely. Trials were included where participants were randomised to receive the following: a single exercise intervention or a multiple exercise intervention and a control group (usual activities or attention or recreational activity). Trials comparing two or more exercise interventions and a control group were also included.

DATA COLLECTION AND ANALYSIS

Three pairs of members of the review team independently assessed trial quality and extracted data. For each trial, relative risk and 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals calculated for continuous outcomes. Where appropriate, results of comparable groups of trials were pooled and 95% confidence intervals calculated.

MAIN RESULTS

For the 34 included studies there were 2883 participants at entry. Statistically significant improvements in balance ability were observed for exercise interventions compared to usual activity. Interventions involving gait; balance; co-ordination and functional exercises; muscle strengthening; and multiple exercise types appear to have the greatest impact on indirect measures of balance. There was trend towards an improvement in balance with cycling on a static cycle. However, there was limited evidence that effects were long-lasting.

AUTHORS' CONCLUSIONS

Exercise appears to have statistically significant beneficial effects on balance ability in the short term but the strength of evidence contained within these trials is limited. Many of these mainly small studies demonstrated a range of methodological weaknesses. The failure across the included studies to apply a core set of standardised outcome measures to determine balance ability restricts the capacity to compare or pool different trials from which firm conclusions regarding efficacy can be made. Further standardisation in timing of outcome assessment is also required as is longer term follow-up of outcomes to determine any lasting effects.

Falls

In the context of an aging population, the importance of falls and their prevention has arguably never been greater. Both injurious and non-injurious falls are a frequent occurrence resulting in potentially devastating physical and social consequences. In recent years, there has been a marked expansion in falls research, meta-analysis, and local and national management guidelines, reflecting increased multidisciplinary professional and public awareness of falls.

Modification des performances au Timed « Up and Go » test et à l'appui monopodal par l'addition d'une charge cognitive : valeur discriminative des résultats

OBJECTIVE

This study aimed to determine whether ordinary clinical performance on the timed "up-and-go" and one-leg-balance tests varied with additional cognitive tasks and the predictive value of this combination for future falls.

METHODOLOGY

The sample comprised 95 women with osteoporosis who lived independently in the community and were older than 70 years (mean 73.4+/-1.7 years) who were randomized to perform the timed "up-and-go" (TUG) and one-leg-balance (OLB) tests. The tests were performed with or without an additional cognitive task (math task involving subtraction by 2 s or 5 s or addition by 3 s).

RESULTS

For both TUG and OLB, performance decreased in the dual-task condition (P<0.05) but did not differ in older women with and without a history of falling, whatever the test, and with or without an additional cognitive load.

CONCLUSION

Performance on the TUG and OLB tests was less efficient when patients simultaneously performed a cognitive task. Performance on these tests, without or with cognitive tasks, did not predict falls in a sample of women who lived independently.

Facteurs prédictifs de la chute chez l'hémiplégique vasculaire en centre de médecine physique

OBJECTIVES

To determine factors predicting falls by patients with vascular hemiplegia to establish a program aimed at preventing falls in this population.

METHODS

A comparative prospective study performed over 19 months with 44 patients older than 16 years who had had a cerebral vascular accident (CVA, stroke) and were consequently admitted to the Centre Richelie. The exclusion criteria were represented by CVA history, evidence of another form of encephalic lesion, and subsequent admission to hospital after hemiplegia or for follow-up. Assessment consisted of taking note of the mechanism of the fall, possible lesions, and number of falls and analyzing follow-up after the return home. Also included for all patients was information on 20 variables that could be risk factors for fall.

RESULTS

The patients' average age was 60.43+/-13.43 years and 20 had had at least one fall (mean 2.2), which allowed us to determine a "falling" group and a control group. Statistical analysis revealed the following factors considered to predict falls: large amount of time prior to hospitalization and lengthy hospitalization, low functional independence measure for entering and leaving, the existence of sensitivity disorders, spatial neglect, failed seated and standing equilibrium, and sedative treatment. In most cases, whatever their nature, falls occurred during transfers (68% of cases). Most often, the post-fall lesions were minor. However, in one case, a femur neck fracture necessitated osteosynthesis. One-third of the patients had a fall at home (as opposed to 5% of the control group).

CONCLUSION

Our results confirm those in the literature. The predictive factors for falls in patients with hemiplegia are therefore well established and essentially correlate with the CVA. This consideration must lead to implementation of a prevention program including material-based as well as human measures.

Évaluation posturale à domicile chez la personne âgée : comparaison chuteurs–non chuteurs

OBJECTIVES

To determine the main clinical and posturographic factors correlated with falls in elderly individuals and to specify the role of static posturography in this appraisal.

MATERIALS AND METHODS

The study involved 38 people living in an residential center who were autonomously ambulatory and had a Mini Mental Test score> or =24. Fallers (N = 15) had fallen within 1 month, and nonfallers (N = 23) had not fallen for at least a year. Assessment consisted of a series of questions, a complete clinical appraisal, specific independently validated tests, and static posturographic analysis different parameters of the stabilogram with the eyes first open and then closed, all carried out in the center.

RESULTS

From the clinical standpoint, spinal pathologic features and the scores on the Functional Reach Test were significantly different between the fallers and nonfallers. In static posturography, fallers' equilibrium was more precarious than that of nonfallers with eyes are closed: significant differences were observed in surface, X length and overall fast Fourier transform score. The comparison between results with open and closed eyes showed that the fallers had a pronounced tendency to retropulsion in the absence of visual participation: a significant difference as regards overall length, Y length, minimum Y and FFT Y (0.5-2 Hz).

CONCLUSIONS

To complement a satisfactorily conducted clinical examination, static posturography allows for rapid assessment of equilibrium and posture in elderly patients who fall? Performed at the place where an individual resides, this appraisal constitutes an original and pragmatic element. As an evaluation strategy, it can reveal nonnegligible information within the framework of an appraisal of such, and thereby allows for adjustment of the rehabilitation or compensatory strategy.

Preventing falls in older people: evaluating a peer education approach

Initiatives in falls prevention usually rely on the expertise of health professionals and are therefore limited in scope. In order to reach a wider audience, a peer education programme in Bradford gave one-off sessions to groups of older people providing information about falls prevention and demonstrating simple balance and strength building exercises. Although evaluation found the programme to be well received, it also revealed a high rate of undisclosed falls and a reluctance to inform, or seek advice from, health professionals. It was not clear how far this was to do with embarrassment or being seen as not coping, but suggests that a more appropriate role for health professionals may be one that is complementary and supportive within a broad educational and facilitative programme embodying peer education.

Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group specialised register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or 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.

MAIN RESULTS

Sixty two trials involving 21,668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness: Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants). Interventions unlikely to be beneficial: Brisk walking in women with an upper limb fracture in the previous two years (1 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 fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.