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Michael YL, Lin JS, Whitlock EP, et al. Interventions to Prevent Falls in Older Adults: An Updated Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Dec. (Evidence Syntheses, No. 80.)

Cover of Interventions to Prevent Falls in Older Adults

Interventions to Prevent Falls in Older Adults: An Updated Systematic Review [Internet].

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1Introduction

Scope and Purpose

This systematic review was undertaken to support the U.S Preventive Services Task Force (USPSTF) in updating its 1996 recommendation on prevention of falls in older adults, which was part of its general review on household and recreational injuries.

The 1996 USPSTF review found sufficient evidence that certain interventions (e.g., individualized and repeated home-based multifactorial interventions, exercise) reduce the risk for falls. This review found insufficient evidence, however, that counseling could be generalized to the primary care setting or that counseling reduced fall risk factors or the incidence of falls.1 The USPSTF also found insufficient evidence to recommend for or against the routine use of external hip protectors to prevent fall injuries. Issues requiring rectification for the USPSTF to change its recommendations include evidence showing that: primary care feasible interventions reduce the risk for falls or fall-related injuries in high-risk older adults; the general population benefits from these interventions; primary care counseling reduces the incidence of falling or fall-related injuries; primary care counseling is effective in encouraging older adults to increase their physical activity levels; and screening (balance and gait, visual acuity, ophthalmoscopic exam, dementia or altered mental status) reduces incidence of falls or fall-related injuries.

Condition Definition

A fall is “an unexpected event in which the participant comes to rest on the ground, floor, or lower level.”2 The operationalization and measurement of this definition varies considerably across studies, with some studies using no explicit definition.3 Fall data may be collected through retrospective reporting systems using telephone interviews, face-to-face interviews, or postal questionnaires; prospective reporting systems using postcards, calendars, and diaries; or routine surveillance systems using health care records. Because no single definition for a fall was consistently used across studies, we use the definition of a fall used by each reviewed study to maximize the number of included studies in the current review.

Prevalence and Burden of Disease/Illness

People aged 65 years and older represent the fastest-growing segment of the U.S. population, in part due to the increased average U.S. life expectancy and the aging of baby boomers. The U.S. Census Bureau projects that the number of persons aged 65 years and older will more than double by 2030, and the number of persons aged 85 years and older will increase by more than a factor of five by 2050.4

Falls are associated with many adverse health outcomes, including injury and death.5–14 In 2003, the Centers for Disease Control and Prevention (CDC) reported that falls were the leading cause of injury deaths, and the ninth leading cause of death from all causes, among those 65 years of age and older.15 Between 30 and 40% of community-dwelling persons aged 65 years and older fall at least once per year.5,16 This is complicated by the fact that the risk for falling and fall-related injuries increases with age.5,16 The 2006 Behavioral Risk Factor Surveillance System reported that 13% of adults aged 65–69 years, 14% of those aged 70–74 years, 16% of those aged 75–79 years, and 21% of those aged 80 years and older fell during the 3 months preceding the survey.16 Population-based studies of community-dwelling elderly persons have estimated annual total injurious fall rates from 84–229/1,000 persons6,17 and fall injury hospitalization rates of 14/1,000.7 Falls and fall-related injuries increase with age.5,16 Hip fractures are an especially grave complication of falls in older adults, resulting in more hospital admissions than any other injury; the age-adjusted hospitalization rate for hip fractures was 775.7 per 100,000 population in 2003.18 The death rate due to falls is 10/100,000 for those aged 65–74 and 147/100,000 for persons aged 85 and older.19 There is a 10% to 20% reduction in expected survival during the first year following a hip fracture,20–23 and roughly half of the survivors never recover normal function.21

Falls also predict quality of life and disability.11,13 Twenty to 30% of those who fall suffer injuries that result in decreased mobility that limits subsequent independence.8 Even falls that do not result in injury can lead to negative outcomes. In particular, experiencing a fall can increase an older person’s fear of falling,24,25 an important psychological outcome correlated with future falls.26 Fear of falling leads older adults with and without a history of falling to limit activities, which eventually increases fall risk through functional decline, deterioration in perceived health status, and increased risk for admission to institutional care.24,25

Falls represent a significant burden on the U.S. health care system. In 2004, the mean inpatient hospitalization cost for falls in older adults was $17,483. The mean reimbursement costs for an emergency department and outpatient clinic were $236 and $412, respectively.27 The estimated direct medical costs for fatal and nonfatal fall-related injuries for community-dwelling people aged 65 or older was $19.2 billion in 2000,28 with one study estimating that this cost could reach $43.8 billion by 2020.29

Etiology and Risk Factors

Falls are caused by complex interactions between multiple risk factors, including long-term or short-term predisposing factors.30–32 Interactions between these factors may be modified by age, disease, and environment.31 Risk factors are often characterized as intrinsic (i.e., patient related) or extrinsic (i.e., external to the patient). Studies of intrinsic and extrinsic factors that could lead to falls have reported the following major risk factors: increasing age, muscle weakness, gait and balance impairment, postural hypotension, medication use, low body mass index, history of recurrent falls, vision impairment, special toileting needs, urinary incontinence, comorbid illness, depression, and cognitive impairment.30,33–40 Repeated falls can each have a different etiology.11,30,33,41

At a population level, increasing age is the most important risk factor for falls. As people age, they may develop more than one risk factor for falls. Functional capacity may decrease with age due to physical and mental changes that lead to impairments in balance, gait, and strength.

People may develop impairments in vision and cognition with advancing age that may contribute to the risk for falls. Numerous medical conditions that are associated with age contribute to falls risks, including Parkinson’s disease, stroke, history of diabetes mellitus, and arthritis. Increased medication use is also associated with disease and aging. Use of certain psychoactive and cardiac medications, and use of four of more medications, has been associated with an increased risk for falls.42–44

Rationale and Current Practice

Falls among older adults are prevalent and preventable. Falls may have a significant impact on subsequent morbidity, disability, and mortality risk. Various falls-prevention interventions targeting a number of fall risk factors have been evaluated. Falls prevention approaches aim to increase older adults’ strength and balance, identify and remove hazards in their environment, increase awareness of falls and associated risk factors, correct clinical conditions that may increase fall risk, or some combination of these approaches.

Since 1996, two published evidence-based clinical guidelines for prevention of falls in older adults recommended routine assessment of falls history during the past year along with brief tests of gait and balance during primary care visits to identify older adults appropriate for further assessment and management to prevent falls.28,45 The CDC recommends that an annual check-up for chronic medical conditions include a review of medications and a vision screening.46 The American Geriatrics Society, British Geriatrics Society, and the American Academy of Orthopaedic Surgeons jointly recommend asking all older persons about falls at least once per year and endorse several falls-prevention interventions, including gait and exercise training, home visits, and medical management.28 The National Institute for Clinical Excellence (NICE) recommends that older people’s health care providers routinely ask about recent falls; that those reporting falls be observed for balance and gait deficits and considered for interventions to improve strength and balance; and that older adults appearing to be at high risk for falls be offered an individualized, multifactorial intervention including strength and balance training, home hazard assessment and intervention, vision assessment and referral, and/or medication review and modification.45

Despite these professional organizations’ recommendations for routine falls risk assessment and intervention in older persons, physicians may under-detect falls risk.47 A survey conducted in several regions of the United States found that most older adults are not asked about falls by their primary care physician.48 Complexities due to the interaction and probable synergism among multiple risk factors for falling present barriers to physicians’ risk assessment.12 Among primary care providers, barriers to intervening to prevent falls include lack of awareness and appropriate knowledge, competing risks, availability of appropriate providers for referrals, transportation and time barriers, patient compliance, and lack of Medicare reimbursement.49–51

Since 2000, several published systematic reviews for prevention of falls in older adults have concluded that fall prevention interventions are likely to be beneficial. All of these reviews except two52,53 included institutionalized and hospitalized populations in addition to community-dwelling older adults. A 2003 Cochrane review concluded that fall-prevention programs including multifactorial assessment and management, muscle strengthening and balance training, more intensive home hazard assessment and modification, withdrawal of psychotropic medication, cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity, and some types of group exercise are likely to reduce falls.54 Interventions including certain group exercise approaches, lower-limb strength training, nutritional or vitamin D supplementation, some home hazard modification approaches, pharmacological therapy, interventions using a cognitive/behavioral approach alone, hormone replacement therapy, and correction of visual deficiency were found to be of uncertain benefit. Brisk walking among women with recent upper-limb fractures was found to be of unlikely benefit. Chang and colleagues55 concluded that a multifactorial assessment and management intervention was the most effective for reducing falls risk and that exercise interventions also had a beneficial effect. A systematic review of randomized or controlled clinical trials comparing the use of hip protectors with a control group found no evidence of reduced hip fracture incidence from hip protectors among community-dwelling participants.56 A systematic review of multifactorial assessment and management found limited evidence that multifactorial fall prevention programs in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall-related injuries.57 Another systematic review of exercise programs for preventing falls found that exercise prevented falls in older people and reported that greater relative effects were seen in programs that included exercises that challenge balance, used a higher dose of exercise, and did not include a walking program.58 A 2009 Cochrane review focused specifically on community-dwelling older adults, the focus of the current report. This review concluded that Tai Chi and group- or home-based exercise with multiple components reduced the risk for falling; multifactorial assessment and management reduced the rate of falls but not the risk for falling; and vitamin D did not reduce falls, but may do so in people with lower vitamin D levels.53 Another review of complex interventions to improve physical function and maintain independent living in general, community-dwelling older adults concluded that fall-prevention interventions in general, and multifactorial assessment and management interventions specifically, successfully reduced the risk for falling.52

Previous USPSTF Recommendation

The 1996 USPSTF review focused on the effectiveness of counseling to prevent household and recreational injuries by age group, which included falls. The review focused on adults aged 65 years or older. The 1996 USPSTF recommendations related to falls are provided below.1

Counseling elderly patients on measures to reduce the risk for falling, including exercise (particularly training to improve balance), safety-related skills and behaviors, and environmental hazard reduction, along with monitoring and adjusting medications, is recommended based on evidence that these measures reduce risk for falls (B recommendation), although the effectiveness of routinely counseling older adults to prevent falls has not been adequately evaluated (C* recommendation).

Recommendations for regular physical activity in elderly patients without contraindications can also be made based on other proven benefits. Intensive individualized home-based multifactorial intervention to reduce the risk for falls is recommended for high-risk elderly patients in settings where adequate resources are available to deliver such services. Elderly persons at high risk for falls include those aged 75 years and older or aged 70–74 with one or more additional risk factors including: use of certain psychoactive and cardiac medications (e.g., benzodiazepines, antihypertensives); use of 4 or more prescription medications; impaired cognition, strength, balance, or gait. (B recommendation)

There is insufficient evidence for or against the routine use of external hip protectors to prevent fall injuries. Once these devices become generally available, recommendations for their use in institutionalized elderly may be made on other grounds, including the large potential benefit and limited adverse effects. (C* recommendation)

There is insufficient evidence for or against post-fall assessment and intervention in institutionalized elderly persons in order to prevent falls. Recommendations for such interventions may be made on the basis of other benefits, including reduced hospitalizations and hospital days unrelated to falls. (C* recommendation)

Since the 1996 recommendations, the USPSTF has adopted a different methodology and rating system to evaluate evidence. The 1996 recommendations of the letter “C” are annotated as “C*” if the current USPSTF grading criteria would warrant a recommendation of “I.”59

The 1996 recommendations included hospitalized patients and nursing home residents. The current focus of the USPSTF is preventive services provided by health care providers in an outpatient/ambulatory primary care setting.

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