Interventions for preventing falls in older people in care facilities and hospitals: Cochrane systematic review

Abstract

Background

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012.

Objectives

To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017.

Selection criteria

Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals.

Data collection and analysis

One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence.

Main results

Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.

Care facilities

Seventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).

There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).

There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.

Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).

Hospitals

Three trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).

We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).

Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence).

Authors' conclusions

In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.

In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.

Author(s)

Cameron Ian D, Dyer Suzanne M, Panagoda Claire E, Murray Geoffrey R, Hill Keith D, Cumming Robert G, Kerse Ngaire

Summary

Interventions for preventing falls in older people in care facilities and hospitals

Review question
How effective are interventions designed to reduce falls in older people in care facilities and hospitals?

Background
Falls by older people in care facilities, such as nursing homes, and hospitals are common events that may cause loss of independence, injuries, and sometimes death as a result of injury. Effective interventions to prevent falls are therefore important. Many types of interventions are in use. These include exercise, medication interventions that include vitamin D supplementation and reviews of the drugs that people are taking, environment or assistive technologies including bed or chair alarms or the use of special (low/low) beds, social environment interventions that target staff members and changes in the organisational system, and knowledge interventions. A special type of intervention is the multifactorial intervention, where the selection of single interventions such as exercise and vitamin D supplementation is based on an assessment of a person's risk factors for falling. Falls are reported in two ways in our review. One outcome is rate of falls, which is the number of falls. The other outcome is risk of falling, which is the number of people who had one or more falls.

Search date

We searched the healthcare literature for reports of randomised controlled trials relevant to this review up to August 2017.

Study characteristics
This review included 95 randomised controlled trials involving 138,164 participants. Seventy-one trials (40,374 participants) were in care facilities, and 24 (97,790 participants) in hospitals. On average, participants were 84 years old in care facilities and 78 years old in hospitals. In care facilities, 75% were women and in hospitals, 52% were women.

Quality of the evidence
The majority of trials were at high risk of bias, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low quality, which means that we are uncertain of the estimates.

Key results

There was evidence, often from single studies, for a wide range of interventions used for preventing falls in both settings. However, in the following we summarise only the falls outcomes for four key interventions in care facilities and three key interventions in hospitals.

Care facilities
We are uncertain of the effect of exercise on the rate of falls (very low-quality evidence) and it may make little or no difference to the risk of falling (low-quality evidence).
General medication review may make little or no difference to the rate of falls (low-quality evidence) or the risk of falling (low-quality evidence).
Prescription of vitamin D probably reduces the rate of falls (moderate-quality evidence) but probably makes little or no difference to the risk of falling (moderate-quality evidence). The population included in these studies appeared to have low vitamin D levels.
We are uncertain of the effect of multifactorial interventions on the rate of falls (very low-quality evidence). They may make little or no difference to the risk of falling (low-quality evidence).

Hospitals
We are uncertain whether physiotherapy aimed specifically at reducing falls in addition to usual rehabilitation in the ward has an effect on the rate of falls or reduces the risk of falling (very low-quality evidence).
We are uncertain of the effect of bed alarms on the rate of falls or risk of falling (very low-quality evidence).
Multifactorial interventions may reduce the rate of falls, although this is more likely in a rehabilitation or geriatric ward setting (low-quality evidence). We are uncertain of the effect of these interventions on risk of falling.

Reviewer's Conclusions

Implications for practice

We found evidence of effectiveness for some fall-prevention interventions in care facilities and hospitals, although for many the quality of the evidence was considered low or very low. For all interventions, we are uncertain of their effects on fractures and on adverse events as the quality of the evidence for both outcomes was assessed as very low. For each setting, the summary is structured by the main categories of interventions evaluated in at least one setting in the review: exercise, medication (medication review; vitamin D supplementation); psychological interventions, environment/assistive technology, social environment, interventions to increase knowledge, other interventions, multiple interventions and multifactorial interventions. There was a lack of evidence on surgery, management of urinary incontinence, or fluid or nutrition therapy in both settings.

Care facilities:

  • Exercise
  • Medication
  • Environment/assistive technology
  • Social environment
  • Knowledge/education
  • Psychological interventions
  • Other single interventions
  • Multiple interventions
  • Multifactorial

Hospitals:

  • Exercise.
  • Medication
  • Environment/assistive technology
  • Social environment
  • Knowledge or education
  • Psychological interventions
  • Other single interventions
  • Multiple interventions
  • Multifactorial intervention

Implications for research

Further research, primarily randomised controlled trials, is warranted to help inform decisions in this key area. We suggest the following guide to help discussions on future priorities.

  • Further research into supervised exercise programmes in both settings. There is a particular need for larger trials in care facilities and trials that clearly describe the care needs of the participants.
  • Further research to strengthen the evidence for multifactorial interventions in both settings. Of note is that there are some substantial individual trials that have shown an important effect in reducing the rate of falls. A key feature of these multifactorial interventions is the individualised nature of the interventions delivered. This implies that further research with emphasis on an individualised, standardised approach to delivery of interventions with consistent description and application within further trials is warranted, including as a clear description of existing falls prevention practices in the control arm of any trials and the interaction of the intervention arm of the trial with usual care. A mixed methods approach may be necessary to achieve this.
  • Further trials of patient-directed interventions, especially in care facilities; for example, with a psychological and educational focus.
  • Trials with interventions incorporating approaches based on the circumstances of falls in addition to individual risk factors, e.g. regular assisted toileting in both care facilities and hospitals (Lohse 2012; Schnelle 2003).
  • Further trials testing the routine use of validated falls risk-assessment tools.
  • Further research is required testing interventions targeting staff, and changes to the organisational system in which an intervention is delivered or the introduction of new healthcare models.
  • In care facilities, additional trials on medication review, vitamin D plus calcium supplementation, environmental/assistive technologies and social environment interventions are required. There should be an emphasis on large trials.
  • In hospitals, more trials of additional exercise, social environment and knowledge interventions are needed.
  • Further research focusing on participants with dementia.

Other aspects, including research methods, that need to be adopted in all future studies are as follows.

  • Classification of the components of the fall-prevention intervention using the taxonomy developed by the Prevention of Falls Network Europe (ProFaNE) (Lamb 2007; Lamb 2011). This will produce consistency between trials allowing for more effective pooling of data.
  • Consideration is needed of the nature of 'usual care' and its potential interaction with the intervention group.
  • For multifactorial trials, clear descriptions are needed of the components and the proportion of the participants receiving the different interventions.
  • Falls data should be collated by a researcher blind to group allocation.
  • Fall events should be reported by group as total number of falls, fallers, and people sustaining a fall-related fracture or brain injury; rate of falls (falls per person year or per 1000 patient days); multiple fallers and number in each analysis.
  • Results should be analysed using appropriate, pre-specified methodology (e.g. negative binomial regression, survival analysis) (Robertson 2005). Group comparisons should be expressed as incidence rate ratios and risk ratios with 95% confidence intervals.
  • Authors of trials not excluding people with cognitive impairment should plan to report the results by level of cognitive impairment to indicate whether degree of impairment is an effect modifier.
  • Design and reporting of trials should meet the contemporary standards of the extended CONSORT statement including those relating to randomised sequence generation and allocation concealment prior to randomisation (Schulz 2010). Pragmatic trials and those testing non-pharmacological interventions should incorporate the requirements defined in Zwarenstein 2008 and Boutron 2008.
  • Clear description of usual care in the control arms of trials and discussion of the interaction of the intervention with this is needed.
  • Design and reporting of cluster randomised trials should follow contemporary guidance (Campbell 2004) including the reporting of intra-class correlation coefficients.
  • Where factorial designs are employed, data for each treatment cell should be reported to allow interpretation of possible interactions between different intervention components (McAlister 2003).
  • There is a clear need for further research clearly reporting on the cognitive status of the included participants and including those with cognitive impairment.
  • Economic evaluations should be conducted alongside randomised controlled trials to establish the cost-effectiveness of each intervention being tested. This involves measuring health-related quality of life as an outcome, defining the perspective and timeframe for costs, collecting data on healthcare use, costing healthcare resources, calculating cost-effectiveness ratios (if the intervention is effective in reducing falls), and evaluating uncertainty. Guidelines for carrying out and reporting economic evaluations in falls prevention trials have been published (Davis 2011).

Get full text at The Cochrane Library

Interventions for preventing falls in older people in care facilities and hospitals: Cochrane systematic review is a sample topic from the Cochrane Abstracts.

To view other topics, please or purchase a subscription.

Evidence Central is an integrated web and mobile solution that helps clinicians quickly answer etiology, diagnosis, treatment, and prognosis questions using the latest evidence-based research. Complete Product Information.