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Primary care
Editorial
by Gillespie and p 676
Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomised clinical trials
John T Chang, Sally C Morton, Laurence Z Rubenstein, Walter A Mojica, Margaret Maglione, Marika J Suttorp,
Elizabeth A Roth, Paul G Shekelle
Abstract
Objective
To assess the relative effectiveness of interventions to
prevent falls in older adults to either a usual care group or
control group.
Design
Systematic review and meta-analyses.
Data sources
Medline, HealthSTAR, Embase, the Cochrane
Library, other health related databases, and the reference lists
from review articles and systematic reviews.
Data extraction
Components of falls intervention:
multifactorial falls risk assessment with management
programme, exercise, environmental modifications, or
education.
Results
40 trials were identified. A random effects analysis
combining trials with risk ratio data showed a reduction in the
risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to
0.95), whereas combining trials with incidence rate data showed
a reduction in the monthly rate of falling (incidence rate ratio
0.80, 0.72 to 0.88). The effect of individual components was
assessed by meta-regression. A multifactorial falls risk
assessment and management programme was the most
effective component on risk of falling (0.82, 0.72 to 0.94,
number needed to treat 11) and monthly fall rate (0.63, 0.49 to
0.83; 11.8 fewer falls in treatment group per 100 patients per
month). Exercise interventions also had a beneficial effect on
the risk of falling (0.86, 0.75 to 0.99, number needed to treat 16)
and monthly fall rate (0.86, 0.73 to 1.01; 2.7).
Conclusions
Interventions to prevent falls in older adults are
effective in reducing both the risk of falling and the monthly
rate of falling. The most effective intervention was a
multifactorial falls risk assessment and management
programme. Exercise programmes were also effective in
reducing the risk of falling.
home or even premature death.
89
In the United States in 1994
the total cost of fall injuries for older people was around $20.2bn
and is projected to reach $32.4bn (in 1994 US dollars) by 2020.
10
Although the extensive literature on interventions to prevent
falls provides many insights, there is no clear message about how
best to prevent falls in older adults. To identify effective interven-
tions and their relative effectiveness in preventing such falls, we
conducted a meta-analysis of relevant randomised controlled
trials. This approach builds on earlier work, where beneficial
interventions are identified by using separate estimates of abso-
lute effectiveness in different study strata.
11
Our strategy provides
additional insight by applying a global multivariate model, allow-
ing for assessment of the relative effectiveness of each interven-
tion component while controlling for the effect of other
components in multifactorial interventions across all studies.
Methods
The categories we identified for intervention programmes to
prevent falls were multifactorial falls risk assessment and
management, exercise, environmental modifications, and educa-
tion. A multifactorial falls risk assessment and management pro-
gramme was defined as a focused post-fall assessment or
systematic risk factor screening among individuals at risk tied to
intervention recommendations and follow up for risks
uncovered. Review of drugs was an important component of
nearly all the programmes.
Exercise programmes included both general and specific
physical activities. Examples of general physical activity included
walking, cycling, aerobic movements, and other endurance exer-
cises. Specific physical activity included training targeted towards
balance, gait, and strength.
Environmental modification programmes often included a
home visit by a professional, who would check for environ-
mental hazards such as poor lighting or sliding carpets and
recommend modifications. Some programmes would also assist
with implementation of recommendations.
Educational interventions targeted individuals, groups, or
communities. This could vary from pamphlets and posters at
senior centres and nursing homes to more intensive interven-
tions such as one to one counselling about risk factors.
To identify relevant literature, we checked the reference lists
from 82 reviews (see bmj.com) and reference lists obtained from
the American Physical Therapy Association, American Geriat-
Introduction
Falls are a major health problem among older adults. In the
United States one in three people aged 65 or more living in the
community fall at least once a year. This proportion increases to
one in two for those over 80 years.
1–3
Worldwide, adults aged over
70 years, particularly females, have a significantly higher fall
related mortality than younger people.
4
The severity of fall
related complications also increases with age.
23
The primary sequelae of falls include fall related injuries,
such as fractures and head injuries, and post-fall anxiety.
5–7
These
lead to loss of independence through disability and fear of
falling. The reduction in mobility and independence are often
serious enough to result in admission to hospital or a nursing
Relevant articles, details of studies, and references in table 2 are on
bmj.com
BMJ
VOLUME 328 20 MARCH 2004 bmj.com
page 1 of 7
 Primary care
rics Society, and experts. The Cochrane Library was searched in
2002. We also searched Medline, Ageline, Embase, CINAHL, and
PsycINFO databases from 1992 to 2002 using the search terms
accidental falls, falling, or fall
and
aged, aging, elder care, elderly,
elderly care, geriatric, geriatric assessment, older, or senior
and
clinical trial or randomised controlled trial. There was no restric-
tion on language of publication.
Data collection
JTC and WAM independently reviewed the articles and extracted
general information on objectives, design, participants’ age, and
outcomes. Detailed information was extracted only from studies
that met the major inclusion criteria: focus on falls prevention,
data on participants aged 60 or more, randomised controlled
trial, and inclusion of a usual care or control group. Data were
collected on study design; study quality with the Jadad score
12 13
;
concealment of allocation; participants (number and characteris-
tics); type, duration, and intensity of interventions; outcomes
measured; time from intervention until outcome; and results,
including falls outcomes. Each study could contain one or more
intervention groups, and each intervention consisted of one or
more components. Disagreements were resolved by consensus,
and PGS resolved any remaining ones.
Each study intervention was classified independently by LZR
(for content) and by PGS (for methods) as including up to two of
the following components: multifactorial falls risk assessment
and management, exercise, environmental modification, or
education. If more than two components were described, each
investigator chose the two judged to contribute most to the
effectiveness of the intervention. Calculations were not
performed for inter-rater reliability, but there were essentially no
discrepancies in coding the interventions. To minimise detection
bias, each investigator received only the methods sections for
each article, retyped but with no identifiers. A debriefing showed
that PGS correctly matched none of the deidentified methods
sections to their respective article, whereas LZR correctly
matched only two articles. Exercise components were further
characterised as balance, endurance, flexibility, or strength, based
on the description of the intervention. Walking programmes
were classified as endurance exercise.
Statistical analyses
We considered two outcomes: falling at least once during a
specified follow up period and the monthly rate of falling. Other
clinically relevant outcomes were not reported sufficiently, often
to justify pooling data. Each of these outcomes had its own
analysis plan.
Our first analysis included studies that provided the number
of patients in each group (intervention, control, or usual care)
who fell at least once during follow up of six to 18 months. This
interval was selected on the basis that a treatment effect at any
time during this interval would be comparable. For studies with
more than one follow up data point during this interval, we
chose the one closest to 12 months. A risk ratio was estimated for
most of the studies that compared an intervention group with a
usual care or control group. For the few studies that contained
more than one intervention group, we estimated multiple risk
ratios, one for each intervention compared with the common
usual care or control group, and performed a sensitivity analysis
to assess the impact of correlation among these ratios. We
estimated the DerSimonian and Laird random effects pooled log
risk ratio of all studies, conducted a
2
test of heterogeneity, and
calculated the I
2
statistic and its 95% uncertainty interval; this was
also done for the second analysis of incidence rate ratios, includ-
ing a DerSimonian and Laird random effects pooled log
incidence rate ratio of all included studies.
14–16
To adjust for the
heterogeneity across interventions, we also fit in Stata two
random effects meta-regressions of the log risk ratio for falling at
least once as a function of different predictors.
17–19
The first
model contained the intervention components as predictors in a
main effects additive model, and the second contained exercise
components as predictors in a main effects additive model. We
also performed an exploratory analysis to determine the relative
effectiveness of the components of the multifactorial falls risk
assessment.
Our second analysis included studies that provided data on
the total number of falls and the average follow up period in
each group. For each group we calculated the monthly incidence
rate of falling and the incidence rate ratio for each comparison
between an intervention group and usual care or control group.
20
The same modelling approach was applied as that used for the
outcome of falling at least once.
17–19
We calculated the number needed to treat or number needed
to harm for the statistically significant adjusted risk ratios.
21
We
assumed the underlying risk of falling was equal to the simple
average fall rate across the control groups of the modelled trials.
Analogously for the incidence rate ratios, we calculated the
number of additional falls per 100 patients per month by assum-
ing the underlying monthly fall rate was equal to the simple
average fall rate across the modelled trials.
We assessed funnel plots of the log risk ratios and the log
incidence rate ratios for publication bias. Formal statistical
testing included an adjusted rank correlation test and a
regression asymmetry test.
22 23
Sensitivity analyses
To assess the robustness of our findings, we undertook several
sensitivity analyses. The first set of analyses included correcting
for randomisation at the cluster level because several studies
were randomised as such rather than at the individual patient
level. All models were re-estimated using an adjustment in sam-
ple size, from the observed number of clusters within each
group, and an intracluster correlation of 0.05 for those studies
that were randomised at the cluster level. To correct for correla-
tion across treatment arms within a single study, we performed a
second set of analyses to examine whether correlation across
multiple risk ratios or incidence rate ratios in the same study had
an effect on model estimation. A third set of sensitivity analyses
examined the effect on model estimation using data from the
sites included in a pooled meta-analysis—the FICSIT trial (Frailty
and Injuries: Cooperative Studies of Intervention Techniques).
24
In the last set of analyses we fit several additional meta-
regressions that examined patient risk, provider setting, intensity
level, Jadad score, and some limited interactions between these
variables and intervention components.
Results
Ninety nine of 830 articles met the inclusion criteria for detailed
data abstraction (fig 1). Sixty one were randomised controlled
trials that included outcomes on falls. These were reviewed for
potential inclusion in the meta-regression analyses. After exclud-
ing articles for being outside our specified follow up period,
using idiosyncratic interventions that could not be pooled (for
example, restraints, a bed alarm), or including duplicate study
populations (see bmj.com), 40 trials contributed data to the
meta-analyses (see table A on bmj.com). Using the Jadad tool for
study quality (scores from 0 to 5), four trials scored 1, 22 scored
2, and 14 scored 3.
12
As this scoring system gives up to two points
for double blinding, and double blinding is not conceptually
page 2 of 7
BMJ
VOLUME 328 20 MARCH 2004 bmj.com
Primary care
Articles requested (n=855)
Not found (n=25)
Articles obtained and screened (n=830)
Rejected (n=731):
Study design
Subject
Duplicate article
No outcomes
Age
Articles accepted after screening (n=99)
(n=628)
(n=73)
(n=16)
(n=13)
(n=1)
Articles accepted with falls outcomes (n=61)
Rejected (n=38):
Intermediate falls related outcomes
Non-comparable falls outcomes
Primary interventions other than
falls prevention
(n=24)
(n=7)
(n=7)
Articles contributed data to meta-analysis (n=40):
39 from those accepted with falls outcomes
and one with data from Frailty and Injuries:
Cooperative Studies of Intervention Techniques
Rejected (n=22):
Duplicate study population
Wrong intervention type for models
Insufficient statistics
Not our outcome of interest
Not our follow up time
(n=9)
(n=6)
(n=3)
(n=2)
(n=2)
Fig 1
Flowchart of articles
possible for falls intervention studies, the maximum possible
score for these studies is effectively 3. Nine studies described
concealment of intervention allocation.
Data for the meta-analysis of participants who fell at least once
came from 26 intervention groups in 22 studies. The combined
data showed a significant reduction in the risk of falling (risk ratio
0.88, 95% confidence interval 0.82 to 0.95; P = 0.03; I
2
= 31%, 95%
uncertainty interval, 0% to 61%; fig 2). Data for the meta-analysis
on monthly rate of falling came from 30 intervention groups in 27
studies. The combined data showed a significant reduction in the
monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88;
P < 0.001; I
2
= 81%, 74% to 86%; fig 3).
None of the studies directly assessed the relative effectiveness
of intervention components. To assess such effectiveness we
therefore compared the magnitude of the effect of each of the
components to a control group that received usual care. We
entered all studies in the meta-regression model that assessed
the effect of individual components while controlling for other
components (table 1). A multifactorial falls risk assessment and
management programme had a statistically significant beneficial
Risk ratio, log scale
Buchner 1997
w1
Campbell 1997
w2
Cerny 1998
w5
Close 1999
w6
Coleman 1999
w7
Cumming 1999
w9
Day 2002
w10
Day 2002
w10
Day 2002
w10
Ebrahim 1997
w11
Fabacher 1994
w13
Jenson 2002
w17
Lord 1995
w18
Mayo 1994
w19
McMurdo 2000
w21
McRae 1994
w22
Millar 1999
w24
Pardessus 2002
w26
Pereira 1998
w27
Reinsch 1992
w28
Reinsch 1992
w28
Reinsch 1992
w28
Rubenstein 1990
w30
Tinetti 1994
w37
Van Haastreg 2000
w18
Wagner 1994
w39
Combined
0.1
1
10
Favours control
Favours intervention
Fig 2
Pooled risk ratio of participants who fell at least once
BMJ
VOLUME 328 20 MARCH 2004 bmj.com
page 3 of 7
Primary care
Table 1
Meta-regression estimates of effect of individual intervention components controlling for other intervention components
Participants who fell at least once*
Monthly rate of falling†
Treatment component
No of studies
(comparison pairs) Adjusted risk ratio (95% CI)
Number needed
to treat
No of studies
(comparison pairs)
Adjusted incidence rate
ratio (95% CI)
Fewer falls in
treatment group‡
Multifactorial falls risk
assessment and
management programme
10 (10)
0.82 (0.72 to 0.94)
11
7 (7)
0.63 (0.49 to 0.83)
11.8
Exercise
13 (15)
0.86 (0.75 to 0.99)
16
19 (21)
0.86 (0.73 to 1.01)
2.7
Environmental modifications
5 (4)
0.90 (0.77 to 1.05)
NA
5 (6)
0.85 (0.65 to 1.11)
NA
Education
2 (3)
1.28 (0.95 to 1.72)
NA
1 (1)
0.33 (0.09 to 1.30)
NA
NA=not applicable.
*R
2
=0.29.
†R
2
=0.16.
‡Per 100 patients a month.
effect on both risk of falling (adjusted risk ratio 0.82, 0.72 to 0.94)
and monthly rate of falling (adjusted incidence rate ratio 0.63,
0.49 to 0.83). The two models fit relatively well, explaining 29%
and 16% of the variance, respectively. The risks assessed in mul-
tifactorial risk assessments varied among studies. The most com-
monly assessed risks were drugs, vision, environmental hazards,
and orthostatic blood pressure (table 2). Exercise was an
intervention in the largest number of studies. This also had a sta-
tistically significant beneficial effect on the risk of falls (adjusted
risk ratio 0.86, 0.75 to 0.99), but on monthly rate of falling
(adjusted incidence rate ratio 0.86, 0.73 to 1.01) did not reach
conventional statistical significance. Environmental modification
and education were primary components of a few studies, and
the pooled estimates were not statistically significant.
In the second meta-regression analysis, we were not able to
detect statistically significant differences or consistent trends in
the efficacy between different types of exercises (table 3). Colin-
earity between balance and both flexibility and strength was
problematic.
We observed some trends in the relative effectiveness of the
major components of a multifactorial falls risk assessment and
management programme, but no component was most or least
effective.
In a post hoc analysis we attempted to see if the greater effec-
tiveness of the multifactorial falls risk assessment and manage-
ment programme was due to the preferential enrolment of people
at higher risk. Therefore we classified each study according to
population (general, community dwelling, or higher than average
risk groups for falls—for example, living in a nursing home, recent
history of falls) and repeated our meta-regression analyses
stratified by population. No significant differences were found in
effectiveness of the interventions by population studied.
Incidence rate ratio, log scale
Buchner 1997
w1
Campbell 1997
w2
Campbell 1999
w2
Carpenter 1990
w4
Close 1999
w6
Crome 2000
w8
Day 2002
w10
Day 2002
w10
Day 2002
w10
Ebrahim 1997
w11
El-Faizy 1994
w12
Fiatrone 1993
w14
Gallagher 1996
w15
Hornbrook 1994
w16
Jenson 2002
w17
Lord 1995
w18
McMurdo 1997
w20
McMurdo 2000
w21
Means 1996
w23
Mulrow 1994
w25
Robertson 2001
w29
Rubenstein 2000
w30
Ryan 1996
w32
Salkeld 2000
w33
Schoenfelder 2000
w34
Steinberg 2000
w35
Stevens 2001
w36
Tinetti 1994
w37
Wolf 1996
w40
Wolf 1996
w40
Combined
0.1
1
10
Favours control
Favours intervention
Fig 3
Pooled incidence rate ratio of monthly rate of falling
page 4 of 7
BMJ
VOLUME 328 20 MARCH 2004 bmj.com
Primary care
Table 2
Components of multifactorial falls risk assessment
Trial
Orthostatic blood
pressure
Vision
Balance and
gait
Drug
review
Instrumental
activities of daily
living or activities of
daily living
Cognitive
evaluation
Environmental
hazards
Other
Carpenter 1990
w4
No
No
No
No
Yes
No
No
Fabacher 1994
w13
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Assessment of hearing and
depression
Rubenstein 1990
w30
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Neurological and
musculoskeletal examination,
laboratory tests, 24 hour heart
monitor
Tinetti 1994
w37
Yes
No
Yes
Yes
No
No
Yes
Muscle strength and range of
motion
Wagner 1994
w39
No
Yes
No
Yes
No
No
Yes
Hearing, assessment of
alcohol misuse, assessment of
physical activity
Gallagher 1996
w15
Yes
Yes
Yes
Yes
Yes
Yes
Yes
List of health problems
Coleman 1999
w7
No
No
No
Yes
No
No
No
Self management skills, health
assessment
Close 1999
w6
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Affect, carotid sinus studies (if
clinical suspicion)
McMurdo 2000
w21
Yes
Yes
No
Yes
No
No
No
Review of lighting in
environment
Van Haastregt 2000
w38
No
No
No
Yes
Yes
Yes
Yes
Physical health, psychosocial
functioning
Millar 1999
w24
Yes
Yes
No
Yes
No
No
No
Review of lighting in
environment
Crome 2000
w8
*
Jensen 2002
w17
No
Yes
Yes
Yes
Yes
Yes
Yes
Hearing, review of lighting in
environment, assistive device
(for example, cane, walker),
review of use of device, and
repair of device if needed
See table A on bmj.com for details of references.
*No specific components stated.
A visual inspection of the funnel plots indicated no evidence
of publication bias for all studies included in the meta-analyses
for the risk ratio of falling at least once and for the falls incidence
rate ratio. Although the adjusted rank correlation test indicated
no evidence of publication bias, the regression asymmetry test
did indicate some evidence for the falling at least once outcome.
None of the sensitivity analyses significantly changed the
estimates of the meta-regression models, nor did the additional
meta-regression models yield contrary conclusions.
Our results for exercise need to be put into context with
those from the FICSIT trials, a preplanned meta-analysis of ran-
domised controlled trials. FICSIT included seven trials that
assessed a variety of exercise interventions, including endurance,
flexibility, platform balance, t’ai chi, and resistance.
25–31
The meta-
analysis included data at the individual patient level, which we
did not have access to.
24
In one of our meta-analyses on partici-
pants who fell at least once we were only able to include data
from two of the FICSIT trials because these were the only
published results available on this outcome.
29 31
All but one FIC-
SIT trial contributed data on monthly falling rate to the second
meta-analysis. Despite this, our results on exercise agree with
those of the central FICSIT meta-analysis, that exercise
programmes help prevent falls (pooled effect for monthly rate of
falling: FICSIT, adjusted incidence rate ratio 0.9, 0.81 to 0.99
v
0.86, 0.73 to 1.01), and there were no differences between types
of exercise. Our meta-analysis goes beyond the FICSIT
meta-analysis by providing evidence about the effectiveness of
exercise relative to other falls prevention interventions.
Discussion
Interventions to prevent falls significantly reduce the proportion
of older people who fall at least once and the monthly rate of
falling. Among the interventions studied in our systematic review
and meta-analyses, a multifactorial falls risk assessment and
management programme was the most effective component.
Exercise was also effective at reducing falls. We found no clear
evidence for the independent effectiveness of environmental
modification or education programmes.
Table 3
Meta-regression estimates of effect of individual exercise components controlling for other exercise components
Participants who fell at least once*
Monthly rate of falling†
Exercise type
No of studies (comparison
pairs)
Adjusted risk ratio (95% CI)
No of studies (comparison
pairs)
Adjusted incidence rate ratio (95% CI)
Balance
8 (10)
1.16 (0.67 to 2.01)
14 (16)
0.78 (0.60 to 1.01)
Endurance
7 (7)
0.86 (0.70 to 1.05)
5 (5)
1.53 (1.04 to 2.25)
Flexibility
5 (6)
0.87 (0.60 to 1.25)
6 (7)
1.03 (0.68 to 1.54)
Strength
9 (11)
0.82 (0.48 to 1.41)
14 (15)
1.04 (0.76 to 1.42)
*R
2
=0.16.
†R
2
=0.38.
BMJ
VOLUME 328 20 MARCH 2004 bmj.com
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