Fall-Prevention Programs Take Tumble

By Judith Groch
WARWICK, England, Dec. 18 -- Fall-prevention programs in primary care, community, or emergency care settings have been a bust, according to an analysis here.
A review of 19 trials including 6,397 participants found no clear reduction in the number of people having at least one fall, the number having fall-related injuries, or the use of health services, Simon Gates, Ph.D., of the University of Warwick here, and colleagues reported in BMJ Online First.
The findings came from a systematic review of the randomized and quasi-randomized controlled trials, and meta-analyses from databases (Medline, Embase, CENTRAL, etc.) referenced by the Cochrane review last March 22.
The review dashed cold water on such interventions as strength and balance training, modification of home hazards, and withdrawal of psychotropic drugs, the researchers wrote. All these approaches had won previous plaudits.
The studies, variable in methodological quality, were carried out in eight countries (including six in the U.S. and four in Britain), the researchers said.
In addition to such multifactorial risk assessment, other reviews found that interventions targeted to an individual's risk factors were found more effective, and this practice is now recommended in guidelines published by the American Geriatrics Society and the British Geriatrics Society, they said.
In Britain, the National Health Service recommended that such interventions, namely fall clinics, should be undertaken, but the clinics have varied in configuration, location, skill mix, and interventions offered.
In view of the recent proliferation of these services, the researchers decided to re-examine their effectiveness.
The eligible trials evaluated fall-prevention programs that assessed multiple risks for falling and provided or arranged for treatment to address these risks.
Control groups in these studies could receive standard care or no intervention for fall prevention.
Most of the studies included assessments of gait and balance, drug review, and assessment of the home environment.
However, the interventions to tackle these risk factors were more variable, the researchers said. Some studies provided only limited treatment options, such as referral to a patient's doctor or to hospital consultants, supplemented by information. Others included a wide range of potential interventions, including exercise, drugs, and surgery, as well as referral.
The combined risk ratio during follow-up for the number of fallers given the intervention (18 trials) was 0.91 (95% confidence interval: 0.82 to 1.02) and for fall-related injuries (eight trials), the RR was 0.90 (95% CI: 0.68 to 1.20).
Follow-up varied from 12 months to less than 12 months, for which the researchers used the longest duration reported.
No clear reduction was found in the number of people having at least one fall, the number of fall-related injuries, or use of health services (ER visit or hospital admission), the researchers said.
However, accurate data on the number of falls per person-year of follow-up could be extracted from only one study. For the most part, data were insufficient to assess fall and injury rates, they said.
No differences were found in hospital admissions, ER attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected or unselected for high fall risk, or multidisciplinary teams including a doctor.
One subgroup analysis suggested that interventions that actively provide treatments -- exercise, drugs, and surgery, for example -- aimed at reducing risk factors may be more effective than those that provide only knowledge and referral. This seemed plausible, the investigators said, but noted that this finding should be treated with caution and requires testing in more studies.
No studies reported quantitative data on health-related quality of life or physical activity.
This review included more trials and more participants than earlier reviews, but there was little evidence that multifactorial fall-prevention programs are effective in reducing the number of fallers or fall-related injuries.
Study limitations included the fact that the quality of the evidence was not high. Most trials were small, and many had methodological drawbacks opening them to bias.
A major limitation of the existing evidence is the lack of data on important outcomes, such as fractures or other serious injuries, the researchers said.
Reviewing the implications for clinical practice, Dr. Gates and colleagues pointed out that the interventions that provide treatment to address risk factors may be more effective than information and referral, although the cost of such programs is likely to be high and has not been extensively studied.
There is urgent need for a large-scale definitive evaluation to resolve the uncertainty about the clinical effectiveness and the cost of this type of intervention, the researchers concluded.
This study was funded by the National Institute for Health Research service delivery and organization program.
No competing interests were declared.
Primary source: BMJ Online FirstSource reference:Gates S, et al "Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis" BMJ Online First 2007; DOI: 10.1136/bmj.39412.525243.BE.