Intervention strategies and risk-factor modification for falls prevention: A review of recent intervention studies

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Methodology of falls-prevention trials

Conducting a randomized trial of a falls-prevention intervention presents a number of challenges to investigators. Chief among these is that most falls do not result in seeking help from the health care system, making outcome ascertainment difficult. Another problem is that falls are recurrent events: people can and do fall more than once during the study follow-up period. The statistical analysis of recurrent event data is complex [6]. Offsetting these problems is the high frequency of falls.

Multifactorial interventions

The first falls-prevention randomized trials tended to involve multiple interventions and reflected the central tenet of geriatric medicine: The etiology of health problems in older people is often multifactorial, so treatment often requires a multidisciplinary approach. Several multifactorial intervention trials are summarized in Table 1.

In 1990, Rubenstein et al. [25] published the first falls-prevention randomized trial, which was conducted in a nursing home. Subjects who had a fall were

Exercise programs

People with weak lower-limb muscles or poor balance are at increased risk for falling. Exercise programs to strengthen muscles, improve balance, and thus prevent falls are clearly an attractive idea. There have been at least 11 published randomized trials of exercise for falls prevention, but they have yielded mixed findings (Table 2).

The most comprehensive evaluation of the effectiveness of exercise for falls prevention comes from the Frailty and Injuries: Cooperative Studies of Intervention

Home modifications

Although environmental hazards appear on everyone's list of risk factors for falls and home modifications have been included in most multifactorial falls prevention trials, there has been surprisingly little detailed research on the topic. Epidemiologic studies of risk factors for falls and fractures usually have ignored environmental hazards; those that included a hazard checklist have found only weak relationships, if any, between falls and the existence of hazards. These findings may result

Preventing falls in hospital

Many older patients fall while in the hospital, and checklists have been developed to identify those patients at the highest risk for falling. Few strategies for preventing falls in hospitals, however, have been evaluated in randomized trials. Tideiksaar et al. [27] studied a bed alarm system, the purpose of which is to warn nurses when certain patients were getting out of bed unassisted. Seventy patients were randomized; although there were fewer falls in the intervention group, the

Which falls-prevention interventions are effective?

Table 4 summarizes the findings of falls-prevention trials published over the past 10 years (1990–2000). Most tested interventions have proven effective in at least one study. Not surprisingly, the most consistent findings are for multifactorial interventions, with all trials findings at least a small, if not always statistically significant, effect.

A perceived problem with interpreting the findings of multifactorial interventions is that determining which component of the intervention package

Are falls-prevention interventions more effective in some groups of older people than in others?

In Table 4, study results have been placed into three categories according to the study population: nursing home residents, high-risk people living in the community, and the general population of older people. The categorization was sometimes difficult. For example, the 1997 study of home-based exercise by Campbell et al. [3] was placed in the high-risk category because subjects were substantially older (mean age 84 years) than in other community-based studies (mean age approximately 75 years).

Summary

At least 21 randomized trials of falls-prevention interventions have been published in the past 10 years; thus, many falls clearly can be prevented. The most effective interventions are those that target community-dwelling people who are at high risk for falling. There is no doubt that for this group multifactor intervention is effective. Convincing evidence that exercise can prevent falls does exist, but the best type of exercise remains uncertain. Tai Chi, intensive strength and endurance

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