Abstract
Over the years, a number of strategies have been investigated to prevent falls in older people in a number of settings. Over 200 randomised controlled trials now exist, and the challenge for the discerning clinician is to read and interpret the existing literature so as to be able to implement effective strategies, targeting the right individual with the right intervention. This chapter reviews the current literature and attempts to simplify what has become an enormously complex area. Interventions are reviewed in three main settings – community, hospital and care facilities and based on the type of approach – single, multiple or multifactorial interventions. It also considers the reality in which we practise and provides some ‘best bets’ to consider at this point in time.
Introduction
A wealth of literature has emerged over the last three decades, which has greatly enhanced our understanding of the important contributors to risk of falls and fall-related injury in older people. Equally, a number of clinical trials of varying quality have been published, providing evidence of effective approaches to preventing falls with the first effective study published in 1994 . What has also become apparent is the complexity of the evidence upon which our practice is shaped with enormous challenges faced by those expected to implement research in knowing which intervention is likely to be most effective in which population.
A fall is an important event for an older person and should not simply be viewed as a surrogate marker of fracture risk. Most falls do not result in a fracture or serious injury, yet the functional consequences of a fall can be sufficient to necessitate hospitalisation and a period of restorative care. Data from New South Wales, Australia show that 17% of older people presenting to an emergency department do so as a result of a fall and of these, approximately 50% are admitted . Of those admitted, 60% have not sustained a fracture. There are also data that highlight the increasing rates of non-fracture fall-related hospitalisations ( Fig. 1 ) – something that pharmacological agents for osteoporosis will not address.
This chapter focusses on intervention and attempts to unravel the complex literature in a way that is helpful to clinicians working in this area. Consideration is given to the challenges associated with systematisation of models of care, addressing both bone health and falls risk. Of course, interventions are only successful in real life if they are demonstrated to be effective for and accepted by the intended recipients. Awareness of the preferences and priorities of older people as well as the ability to motivate, educate and negotiate are important and often under-recognised aspects of successful implementation in this area.
Screening and assessment
Screening offers the opportunity to identify a population potentially at risk of falls so as to streamline referrals to services and more effectively manage within limited resources. Whatever tool is used, it needs to be simple and quick to administer, but have adequate specificity and sensitivity to be fit for purpose. The Timed Up and Go Test (TUG) has frequently been recommended as a screening tool but a recent systematic review , which included 53 studies and 12,832 participants, found that the TUG is not useful for discriminating between fallers and non-fallers, particularly when applied to a healthy, high-functioning population ( Fig. 2 ). The article concludes that the predictive ability and diagnostic accuracy are at best moderate and that no cut-point could be recommended.
The current American Geriatrics Society/British Geriatrics Society (AGS/BGS) clinical practice guideline provides simple advice on opportunistic screening with three simple questions used to identify people requiring further assessment and intervention. The patient:
- 1.
has had two or more falls in the prior 12 months,
- 2.
presents with an acute fall and
- 3.
has difficulty with walking or balance.
In some populations, the value of screening is questionable and this includes people living in residential and nursing-care facilities where approximately 50% of residents will fall annually. However, limited resources may necessitate a more focussed assessment linked to intervention, and in such cases, a screening tool may be useful in this setting. A recently published paper by Whitney et al. provides a simple tool that quantifies the probability of a resident falling over a 6-month period (Care Home Falls Risk Screen – Fig. 3 ). The tool can also assist in guiding the approach to intervention.
Screening and assessment
Screening offers the opportunity to identify a population potentially at risk of falls so as to streamline referrals to services and more effectively manage within limited resources. Whatever tool is used, it needs to be simple and quick to administer, but have adequate specificity and sensitivity to be fit for purpose. The Timed Up and Go Test (TUG) has frequently been recommended as a screening tool but a recent systematic review , which included 53 studies and 12,832 participants, found that the TUG is not useful for discriminating between fallers and non-fallers, particularly when applied to a healthy, high-functioning population ( Fig. 2 ). The article concludes that the predictive ability and diagnostic accuracy are at best moderate and that no cut-point could be recommended.
The current American Geriatrics Society/British Geriatrics Society (AGS/BGS) clinical practice guideline provides simple advice on opportunistic screening with three simple questions used to identify people requiring further assessment and intervention. The patient:
- 1.
has had two or more falls in the prior 12 months,
- 2.
presents with an acute fall and
- 3.
has difficulty with walking or balance.
In some populations, the value of screening is questionable and this includes people living in residential and nursing-care facilities where approximately 50% of residents will fall annually. However, limited resources may necessitate a more focussed assessment linked to intervention, and in such cases, a screening tool may be useful in this setting. A recently published paper by Whitney et al. provides a simple tool that quantifies the probability of a resident falling over a 6-month period (Care Home Falls Risk Screen – Fig. 3 ). The tool can also assist in guiding the approach to intervention.
Intervention in the community setting
The majority of older people live in the community setting, and preventing falls in this population is important in relation to maintaining function and independence. It is in this setting where most is to be gained from implementation and systematisation of effective models of care, but it is also the setting that is associated with most complexity in terms of interpretation of the literature and developing a clear understanding of which intervention should be targeted at which population. The most recent Cochrane review of interventions to prevent falls in the community setting includes 159 trials and 79,193 participants and presents a comprehensive high-quality review of the literature in this area.
Exercise
Exercise has been the single most tested approach to falls prevention, and overall the evidence is supportive of exercise as a falls’ prevention strategy both as a single intervention and as part of a multifactorial intervention in the community setting. However, care is needed when interpreting the literature, as the type of exercise is important and not all populations will benefit from exercise with the potential of increasing falls in some. In a systematic review by Sherrington et al., designed to tease out the key components of an effective exercise intervention, three factors appear critical to success: 1) exercise that challenges balance (movement of centre of mass and reducing the base of support and need for upper limb support), 2) exercise undertaken for approximately 2 h a week over 6 months and 3) exercise that does not include walking as part of the programme. Table 1 highlights the effects of the various combinations of these factors with the most effective programmes offering a high-dose, high-balance challenge and no walking as part of the programme and producing a 42% reduction in rate of falls. However, programmes with a low-dose, low-balance challenge and including a walking programme produce a significant 20% increase in rate of falls.
| High balance challenge rate ratio (95% CIs) | Low balance challenge rate ratio (95% CIs) | |
|---|---|---|
| High dose + walking | 0.76 (0.66–0.88) | 0.96 (0.80–1.16) |
| High dose no walking | 0.58 (0.48–0.69) | 0.73 (0.60–0.88) |
| Low dose + walking | 0.95 (0.78–1.16) | 1.20 (1.00–1.44 ) |
| Low dose no walking | 0.72 (0.60–0.87) | 0.91 (0.79–1.05) |
The Cochrane review also provides evidence to support exercise in the prevention of falls. A total of 59 trials were identified in the latest update which tested exercise as a single intervention and a further 40 included exercise as part of a multifactorial intervention. Both group- and home-based multicomponent exercise can reduce the rate and risk of falls. Importantly, the data also point to exercise as an effective strategy in reducing the risk of fall-related fractures (relative risk (RR) 0.34, 95% confidence interval (95% CI) 0.18–0.63; six trials; 810 participants).
Emerging research suggests that not all populations stand to benefit from exercise as a single intervention. A study recently completed in Sydney, Australia looked at the impact of an individualised 12-month strength and balance, home-based exercise programme on 340 participants (mean age 81.2 years, standard deviation (SD) 8.0) recently discharged from hospital. The target population represents a frailer end of the spectrum as most participants came from geriatric medicine services. The intervention group had a higher fall rate (1.0 per person, SD 1.23) than that of the control group (0.73 falls per person, SD 1.22) and this difference was statistically significant (incidence-rate ratio (IRR) 1.43, 95%CI 1.07–1.93).
Interventions targeting vision
Visual impairment is an established risk factor for falls as is the use of bifocal and multifocal glasses ( Fig. 4 ). In cases where the cause of visual impairment is related to cataract formation, the first cataract extraction, leading to an average corrected binocular acuity improvement of 0.25 logMAR (logarithm of the minimum angle of resolution) units, has been shown to reduce the risk of falls . In cases where cataracts are bilateral, the removal of the second cataract does not confer any additional benefit in terms of falls risk reduction, but does of course have benefits in terms of enhanced vision and quality of life . The substitution of bifocal or multifocal glasses for single-lens glasses has been shown to reduce the rate of outdoor falls in people regularly undertaking outdoor activities as measured using the Adelaide Activities Profile . However, a significant increase in outdoor falls occurred in those who rarely went out, which again highlights the need to carefully consider which intervention is appropriate for which population . A separate visual intervention study targeting frail older people and undertaking detailed vision assessment linked to intervention showed that it was not only ineffective but also increased falls (rate ratio (RaR) 1.57 95%CI 1.20–2.05) and fractures (RR 1.74, 95%CI 0.97–3.11) .
Medication and medication management
Medication management involves ensuring that people are prescribed and able to take medications that are appropriate for their clinical condition(s) and are also not taking medications causing harm or for which there is no longer a clinical indication. Medication review linked with clinical education, feedback on prescribing practice and financial reward for general practitioners (GPs) has been shown to improve prescribing practice and reduce risk of falling (RR 0.61, 95%CI 0.41–0.91) . The financial rewards were in the form of incentive payments for completing medication review checklists and reimbursement for time with the pharmacist. However, simply sending recommendations to a GP following medication review by a pharmacist or a nurse has not been shown to be effective .
The evidence linking psychotropic medications with falls and injury is substantial and over the years, we have seen a change in clinician attitude and practice regarding use of drugs, such as sedative/hypnotics. One relatively small trial (93 participants) has shown the benefits of gradual withdrawal of psychotropic medications on the rate of falls (RaR 0.34, 95%CI 0.16–0.73) . However, there were challenges with this study in terms of both recruitment of willing participants and re-institution of withdrawn medications after conclusion of the study period. This study highlights the importance of not initiating a psychotropic medication in the first place unless there is a clear clinical indication and the benefits and risks of prescribing are considered.
Whilst it is important to stop medications that increase the risk of falls and for which there is no clear clinical benefit, it is also important to encourage people to take medications from which they stand to benefit. There are fairly robust data that support a range of pharmacological agents in the treatment of osteoporosis and this is beyond the scope of this chapter. The exception is vitamin D. This vitamin is essential for bone health, but there is evidence of direct benefit of vitamin D on muscle function, reaction time and overall falls risk in people with low levels of vitamin D . The Cochrane review of vitamin D in community-dwelling older people did not show an overall benefit of vitamin D in relation to reducing falls rate (RaR 1.00, 95%CI 0.90–1.11; seven trials; 9324 participants) or risk (RR 0.96, 95%CI 0.89–1.03; 13 trials; 26,747 participants), although a subgroup analysis does support the use of vitamin D in people with lower levels of vitamin D (the level is not defined but consensus would suggest levels <50 nMol l −1 would be indicative of insufficiency).
Footwear and foot care
A multifaceted podiatry intervention targeting older people with foot pain has been shown to reduce the rate of falls (RaR 0.64, 95%CI 0.45–0.91) . The intervention offered regular podiatry review over the period of the study, provision of appropriate orthoses, advice on footwear with a voucher towards recommended footwear and a series of ankle–foot exercises undertaken in the home environment for 30 min, three times a week.
An anti-slip shoe device applied to an outdoor shoe/boot (YakTrax) has also been shown to be effective in reducing rate of falls in icy conditions .
Occupational therapy assessment and intervention
Assessment of the home environment and a person’s safe interaction with that environment including the provision of technical aids and adaptations is largely but not exclusively the domain of the occupational therapist. A number of studies have looked at the benefit of home safety assessment and have demonstrated evidence of effectiveness in both reducing rate of falls (RaR 0.81, 95%CI 0.68–0.97) and risk of falling (RR 0.88, 95%CI 0.80–0.96) . Importantly, this approach to intervention appears to be more effective when targeted at those considered to be at high risk of falls, such as those being discharged from hospital with a history of falls and those with severe visual impairment .
Multiple and multifactorial interventions
Multiple interventions involve each participant receiving more than one intervention, but all participants receiving the same combination. However, multifactorial interventions involve assessment and individualised intervention based on identified need. Both approaches have been shown to be effective in preventing falls and most commonly when targeted at higher risk populations. The criticism commonly levelled at both multiple and multifactorial intervention is the inability to determine which components of the intervention are effective. The reality is more likely to reflect a complex interaction between the interventions rather than a simple additive model. Nonetheless, multiple and multifactorial interventions tend to be more expensive than single interventions and, as such, targeting high-risk populations, such as those people presenting to the Emergency Department with a fall , is probably the more effective use of these approaches to intervention.
What does not work in the community setting?
Learning from what does not work is as important as knowing what interventions are effective. Fear of falling is an independent predictor of falls risk, yet little, if any, evidence exists to support cognitive–behavioural therapy (CBT). The Cochrane review concludes that there is no evidence that supports the use of CBT to reduce the rate or risk of falls . Increasing awareness and improving knowledge about preventing falls has the potential to be a cost-effective, population-based approach to preventing falls. Unfortunately, the evidence to support it is lacking, with the Cochrane review concluding that interventions to increase knowledge/educate about falls prevention do not reduce rate of falls (RaR 0.33, 95%CI 0.09–1.20) or risk of falling (RR 0.88, 95%CI 0.75–1.03) .
Preventing falls in people with cognitive impairment
Dementia has consistently been shown to increase the risk of falls in older people, with fall rates twice that found in cognitively intact older people . A fall is the most common cause of hospitalisation in people with dementia – accounting for 26% of all admissions and older people with dementia have a fourfold increased risk of hip fracture and a threefold increased risk of 6-month mortality following a fracture when compared to older people without dementia . Ongoing work looks at developing a better understanding of the contributors to risk in this population , but at this point in time, we have no conclusive evidence that it is possible to prevent falls in this high-risk population.
Related posts:
Hip fracture as the tracer condition
Multi-disciplinary care of the patient with acute hip fracture: How to optimise the care for the elderly, traumatised patient at and around the time of the fracture to ensure the best short-term outcome as a foundation for the best long-term outcome
Principles of osteoporotic fracture treatment
Osteoporosis and fragility fractures: Vertebral fractures
Prevention of incident fractures in patients with prevalent fragility fractures: Current and future approaches
Secondary prevention and estimation of fracture risk
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