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Final Evidence Summary

Other Supporting Document for Falls Prevention in Older Adults: Counseling and Preventive Medication

Preface

Primary Care–Relevant Interventions to Prevent Falling in Older Adults

A Systematic Evidence Review for the U.S. Preventive Services Task Force

Release Date: December 2010


By Yvonne L. Michael, ScD, SM; Evelyn P. Whitlock, MD, MPH; Jennifer S. Lin, MD, MCR; Rongwei Fu, PhD; Elizabeth A. O'Connor, PhD; and Rachel Gold, PhD, MPH


The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.

This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was first published in Annals of Internal Medicine on December 21, 2010 (Ann Intern Med 2010;153:815-825; http://www.annals.org).

Abstract

Background: Falls among older adults are both prevalent and preventable.

Purpose: To describe the benefits and harms of interventions that could be used by primary care practitioners to prevent falling among community-dwelling older adults.

Data Sources: The reviewers evaluated trials from a good-quality systematic review published in 2003 and searched MEDLINE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL from the end of that review's search date to February 2010 to identify additional English-language trials.

Study Selection: Two reviewers independently screened 3423 abstracts and 638 articles to identify randomized, controlled trials (RCTs) of primary care-relevant interventions among community-dwelling older adults that reported falls or fallers as an outcome. Trials were independently critically appraised to include only good- or fair-quality trials; discrepancies were resolved by a third reviewer.

Data Extraction: One reviewer abstracted data from 61 articles into standardized evidence tables that were verified by a second reviewer.

Data Synthesis: Overall, the included evidence was of fair quality. In 16 RCTs evaluating exercise or physical therapy, interventions reduced falling (risk ratio, 0.87 [95% CI, 0.81 to 0.94]). In 9 RCTs of vitamin D supplementation, interventions reduced falling (risk ratio, 0.83 [CI, 0.77 to 0.89]). In 19 trials involving multifactorial assessment and management, interventions with comprehensive management seemed to reduce falling, although overall pooled estimates were not statistically significant (risk ratio, 0.94 [CI, 0.87 to 1.02]). Limited evidence suggested that serious clinical harms were no more common for older adults in intervention groups than for those in control groups.

Limitation: Interventions and methods of fall ascertainment were heterogeneous. Data on potential harms of interventions were scant and often not reported.

Conclusion: Primary care-relevant interventions exist that can reduce falling among community-dwelling older adults.

Primary Funding Source: Agency for Healthcare Research and Quality.

Introduction

Falls are a serious threat to the lives, health, and independence of older adults. Falls are caused by complex interactions among multiple risk factors, which are characterized as intrinsic (patient related) or extrinsic (external to the patient) 1-3. Between 30% and 40% of community-dwelling persons 65 years or older fall at least once per year 4-5. Falls were the leading cause of fatal and nonfatal injuries among persons 65 years or older 6. The death rate due to falls is 10 per 100,000 persons for those aged 65 to 74 years and 147 per 100,000 persons for those aged 85 years or older 7. The estimated direct medical costs for fatal and nonfatal fall-related injuries among community-dwelling persons 65 years or older in 2000 was $19.2 billion 8, with one study estimating that this cost could reach $43.8 billion by 2020 9.

Falls among older adults are preventable 8, 10. In 2006, the American Geriatrics Society and the British Geriatrics Society published an updated evidence-based practice guideline recommending that older adults at high risk for falls receive a multifactorial fall-risk assessment and individualized, targeted interventions to address the risks and deficiencies identified in the assessment 8. Physicians face significant barriers to intervening to prevent falls, however, including lack of awareness and appropriate knowledge, competing risks, and difficulty assessing risk 11-13. Therefore, we conducted a systematic review of outpatient interventions available to primary care clinicians to prevent falls in older adults to support the U.S. Preventive Services Task Force (USPSTF) recommendation process.

Methods

We followed a standard protocol for this review. The USPSTF gave guidance on formulating 4 key questions (Appendix Figure 1, 2 of which are addressed in this review: Do primary care interventions reduce risk or rate of falls or fallers among community-dwelling older adults? What are the adverse effects associated with interventions to reduce falls or fallers? We grouped these interventions into 5 main categories: multifactorial assessment and management; single clinical treatment (vitamin D, vision correction, and medication management); clinical education or behavioral counseling; home-hazard modification; and exercise or physical therapy. Expanded definitions for the categories are provided in Appendix Table 1, and a more detailed description of our methods is available in our full report 14.

Searches and Selection Process

We searched multiple databases (MEDLINE, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and Health Technology Assessments) and Web sites (Institute of Medicine, the Agency for Healthcare Quality and Research [AHRQ], and National Institute for Health and Clinical Excellence) to identify relevant, good-quality systematic reviews published between January 1991 and October 2007. We found 13 existing systematic reviews for interventions to prevent falls. Using guidelines for integrating systematic reviews 15, 2 independent reviewers assessed relevancy (research questions and scope) and quality of identified reviews. We used citations from 1 recent good-quality review of fall interventions 16 and then searched MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from the end of the previous review's search date of January 2002 to February 2010 to identify additional trials. We searched MEDLINE and CINAHL from 1992 (the earliest publication date of the included trials) through February 2010 to locate studies of harms for the included interventions. Our review of harms of vitamin D supplementation and vision screening or early treatment was limited to previously synthesized evidence 17-18. We included randomized, controlled trials (RCTs) of community-dwelling older adults (average age ≥65 years) in settings generalizable to U.S. primary care populations. We included trials if they were designed to assess fall prevention based on assessment of falling or falls as a primary or secondary outcome. We excluded trials not conducted in primary care or other settings with a primary care-comparable population (for example, hospitals, nursing homes, rehabilitation centers, or other long-term care facilities) and trials without a true control group. Inclusion and exclusion criteria and search strategies are available in the full report 14.

Quality Assessment and Data Abstraction

Two investigators independently screened all abstracts for inclusion. We screened 3423 abstracts and 638 full-text articles (Appendix Figure 2. Two investigators independently critically appraised all articles by using the USPSTF quality criteria 19. In brief, the USPSTF quality criteria for RCTs includes consideration of assembly and maintenance of comparable groups; differential loss to follow-up or overall high loss to follow-up; a clear definition of the intervention; equal, reliable, and valid outcome measurement; and intention-to-treat analysis. Good-quality and fair-quality articles meeting the inclusion criteria were retained, and studies with fatal flaws were rated poor quality and not included. Discrepancies were resolved through consultation with a third investigator. One reviewer abstracted relevant information into standardized evidence tables for each included article, and a second reviewer checked the abstraction.

Data Synthesis and Statistical Analysis

We qualitatively synthesized the included trials and summarized the results in tables, stratifying the discussion of evidence by similar intervention groupings (for example, physical activity, vitamin D, vision correction, and multifactorial assessment and management). When possible, we also quantitatively pooled fall-related outcomes to estimate the effect size of these intervention groupings. Falling was assessed in a variety of ways (number of fallers, fall rate, time to first fall, and number of frequent fallers). Number of fallers was the most consistently assessed measure of falling; the other measures were used more selectively. Thus, primary analyses estimated relative risk for falling by using random-effects models 20-21.

We conducted separate analyses for each intervention category. For single clinical treatments, the analyses were further stratified by treatment type. For trials with multiple intervention groups in which the interventions were variations of the same intervention type (for example, 2 exercise programs), we calculated estimates for the more intense groups. We assessed the presence of statistical heterogeneity among the studies by using standard chi-square tests and estimated the magnitude of heterogeneity by using the I2 statistic 22. A series of random-effects meta-regression models were used to examine potential sources of heterogeneity in fall risks; such sources include mean age, average age of 80 years or older, proportion of women, proportion of participants with a history of falling in the previous year, comprehensiveness or intensity of the intervention, and whether the sample comprised high-risk participants. All meta-analyses were done by using Stata software, version 10.1 (StataCorp, College Station, Texas).

Role of the Funding Source

AHRQ funded this work, provided project oversight, and assisted with internal and external review of the draft evidence synthesis. The authors worked with 3 members of the USPSTF to develop the analytic framework and resolve issues involving the scope of the review. The draft systematic review was reviewed by 8 external peer reviewers, then revised for the final version. Agency approval was required before this manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for publication.

Results

We included 54 RCTs (with a total of 26,102 participants) that tested primary care interventions to prevent falling. Only 41 of the 111 trials from the Cochrane review16 were included in our review, owing to differences in inclusion criteria. The most common reasons for exclusion from our review were that a true control group was lacking, the population studied was institutionalized or recruited from inpatient settings, and interventions could not be conducted in primary care or be referred to from primary care. Evidence tables and tables of excluded studies for each key question are available in the full report 14. Details of each included study are summarized in Appendix Tables 2, 3, 4, 5, 6. The Table shows a summary of evidence by intervention category.

Multifactorial Assessment and Management

We evaluated 19 multifactorial assessment and management trials (7099 participants) with 21 active intervention groups 23-41. All trials except 1 were limited to populations at high risk for falling 36. Most interventions assessed primary risk factors for falls that were identifiable during clinical evaluation: medication use, visual acuity, home environment, and gait and balance. On the basis of evidence that multifactorial assessment interventions that incorporate comprehensive management strategies are more successful in preventing falls 13, interventions were categorized during the abstraction phase by 2 independent investigators as comprehensive (complete and active management of fall risk factors and conditions identified in the multifactorial assessment, including provision of case managers or home nurses) or noncomprehensive (provide only partial or limited management of identified fall-related risk factors). Control groups primarily received usual care, although 2 trials used "attention control groups"30, 32 and 1 trial provided "a minimal intervention of mainly education" as a control group 42.

The majority of studies were rated as fair quality. Most studies did not report whether treatment allocation was blinded or whether the persons who conducted follow-up assessments were blinded to the treatment condition. Most trials used prospective methods to assess falling; 4 noncomprehensive trials assessed falling retrospectively by using a questionnaire 23, 25, 29, 40. Studies made different assumptions in their analyses, including assumptions about loss to follow-up and falls that may have resulted in outcome misclassification. For example, 1 study counted all lost participants (including those who died) as fallers 24, but another included falls that occurred before loss to follow-up 30. The remaining studies excluded participants who were lost to follow-up or were dead from the analyses or did not report the analyses assumptions.

Efficacy

Pooled estimates involving all 19 multifactorial assessment and management trials suggested a possible reduction in falls with some of these interventions (risk ratio, 0.94 [95% CI, 0.87 to 1.02]), although this finding was not statistically significant. Pooled estimates for the 6 comprehensive trials also suggested a protective effect (risk ratio, 0.89 [CI, 0.76 to 1.03]), although this finding was not statistically significant either (Figure 1. Multifactorial and management interventions were clinically heterogeneous, and the pooled statistical heterogeneity, particularly for the comprehensive trials, was high (I2 = 73.1%). Meta-regression models did not identify any study-level variable, including the comprehensiveness of the intervention, that clearly explained the heterogeneity in the effect estimate. Of note, however, the 4 trials with retrospective assessment of falls more often reported greater reduction in the number of fallers in the intervention group than the control group, compared with trials that used prospective assessment methods. Removing these trials, all of which involved noncomprehensive interventions, further attenuated the observed effects of the noncomprehensive interventions toward the null.

Harms

We found no additional studies beyond the trials included in the efficacy section. Overall, there was limited evidence for clinically significant harms from multifactorial assessments. One good-quality trial conducted in New Zealand (312 participants) had a higher proportion of fallers and frequent fallers at 12 months in the intervention group than in the control group 27. Only 5 fair-quality trials explicitly reported additional adverse effects. Adverse effects in these trials were minor and included minor musculoskeletal symptoms or increases in nonurgent outpatient visits to primary care 28, 30, 33, 38, 40.

Exercise or Physical Therapy

We evaluated 18 trials of exercise or physical therapy interventions (3986 participants) that had 21 active intervention groups 43-60. Trials of exercise or physical therapy tested a variety of interventions in 3 major categories: gait, balance, or functional training (exercises designed to develop dynamic strength, flexibility, and agility needed for everyday activities); strength or resistance exercise; and general exercise (including walking, cycling, aerobic activity, and endurance exercise). All but 1 trial 45 included some type of gait, balance, or functional training, and all but 6 trials 50-52, 58-60 used strategies in more than 1 category. Control groups received no intervention or education. Three trials evaluated interventions that lasted 12 months or longer 44, 48, 56. The duration of intervention in the remaining trials ranged from 6 to 26 weeks (median, 12.5 weeks). Treatment intensity (total hours of contact) ranged from 2 to 243 hours (median, 28 hours). Several trials assessed falling retrospectively by using questionnaires 44, 50, 53, 54, 57.

Efficacy

In pooled analysis, exercise or physical therapy interventions reduced the risk for falling by 13% (CI, 6% to 19%), although most trials showed non-statistically significant differences (Figure 2. In meta-regression models, the effect size of the pooled estimate was not influenced by age, sex, history of falling, or risk status of the participants. Meta-regression of the number of hours of physical activity, however, suggested that more intensive physical activity interventions produced a small but statistically significant reduction in the risk for being a faller.

Harms

We found no evidence of an increase in falls or fallers in 18 fair-quality or good-quality trials. These trials examined exercise or physical therapy interventions to prevent falls 43-60; in addition, 2 additional fair-quality trials (496 participants) were identified in our harms search 61-62. Three of these trials reported other adverse effects. Two trials reported falls while exercising as instructed, although there was no increase in the number of fallers in the intervention group 56, 61. One fair-quality trial (424 participants) that explicitly evaluated for adverse effects found that persons in the exercise group had more physician visits for abnormal heart rhythm than did persons in the control group, but it reported no statistically significant differences for serious harms, including clinically significant abnormal laboratory or other diagnostic testing, hospitalization, or life-threatening events 62.

Single Clinical Treatments

Vitamin D

We evaluated 9 trials of vitamin D supplementation (5809 participants) 63-71. Five of the trials included only women 66-67, 69-71; the proportion of women in the other trials ranged from 51% to 80% 63-65, 68. Five trials were conducted in populations defined as high risk because of recent falls or vitamin D deficiency 64, 67-70. The remaining 4 studies used populations that were unselected except for age 65 years or older 63, 65, 66, 71. All studies were rated as fair quality. Only 3 trials assessed self-reported falls prospectively by using a diary or questionnaire 64, 66, 68. The remaining trials assessed self-reported falls retrospectively with periods of recall ranging from 6 weeks to 12 months 60, 62, 64, 66-68.

The daily oral doses of vitamin D in the intervention ranged from 10 IU 66 to 1000 IU 70 (median, 800 IU). One study provided a single intramuscular injection of 600,000 IU of vitamin D 64. The duration of active intervention ranged from 8 weeks 67 to 3 years 63, 66, 71 (median, 12 months). Two studies evaluated ergocalciferol (vitamin D2) 64, 70, and the remaining studies evaluated cholecalciferol (vitamin D3). Six trials included calcium supplements with vitamin D 63, 67-71. The control groups ranged from no intervention 69, 71 to placebo 63-66 or calcium supplements only 67-68, 70.

Efficacy. Vitamin D with or without calcium was associated with a 17% (CI, 11% to 23%) reduced risk for falling during 6 to 36 months of follow-up (Figure 3. Trials of vitamin D with calcium compared with no treatment or placebo did not support any added benefit of calcium 63, 69, 71. Age, sex distribution, history of falling, or risk status of the participants did not affect the pooled estimate.

Harms. On the basis of the 9 fair-quality trials included in our review, we found no increase in falls, fallers, or other major adverse events. Only 3 trials (926 participants) specifically reported adverse effects—transient and asymptomatic hypercalciuria or hypercalcemia in the intervention group—but no differences in adverse effects or clinically significant harms, such as incident kidney stones, cancer, ischemic heart disease, or stroke 65-66, 70.

Vision Correction

Four fair-quality or good-quality trials (1437 participants) evaluated the effect of surgical and nonsurgical vision correction (after screening for visual impairment) on risk for falling 49, 72-74. All of the trials included high-risk populations that were selected for frailty or presence of cataracts. Two trials evaluated expedited cataract surgery compared with routine wait-list controls 73-74. The other 2 studies compared vision screening and referral or treatment with wait-list control or usual care 49, 72.

Efficacy. Vision correction did not reduce the proportion of fallers.

Harms. Although evidence on harms of vision screening or treatment of early impairment of visual acuity in older adults is sparse, 1 study suggested a possible harm 72. In a fair-quality trial conducted in Australia (616 participants), frail older adults received a comprehensive eye examination and approximately 44% received subsequent treatment of identified vision problems 72. Compared with control participants, persons in the intervention group had a higher proportion of fallers (65.0% vs. 49.8%; P < 0.001) and frequent fallers (37.9% vs. 30.6%; P = 0.003) 72. There was also a non-statistically significant increase in fall-related fractures. Trial investigators hypothesized that corrected vision may have increased the level of activity of these frail older adults, thereby increasing their risk for falling 72.

Medication Assessment and Withdrawal

We evaluated 1 small trial (48 participants) of medication assessment and withdrawal in older adults taking psychotropic medications compared with usual care 47. An additional 10 studies with multifactorial assessment and management interventions also included medication assessment and withdrawal 23-25, 31-32, 37-41.

Efficacy. Medication assessment and withdrawal of therapy with medication alone were not associated with a reduced fall rate 47.

Harms. No harms were reported in the trials evaluating withdrawal of therapy with medication.

Home-Hazard Modification

We evaluated 3 trials of home-hazard modification (2348 participants) 48-49, 75. All 3 trials evaluated an in-home assessment with modification of any identified hazards (for example, adding nonslip tape to rugs and steps) or provision of free safety devices (such as grab bars), compared with usual care or a social control. Two of these interventions also included behavioral counseling of intervention participants 48, 75.

Efficacy

Risk for falling was reduced by 7% to 41%, although only 1 home-hazard modification trial (196 participants) reported a statistically significant beneficial effect on risk for falling compared with control participants 48.

Harms

There was no evidence of increased falls or fallers, based on the 3 fair-quality trials that included home-hazard modification interventions. None of these trials reported additional adverse events.

Clinical Education or Behavioral Counseling

We evaluated 1 trial of behavioral counseling (310 participants) in high-risk older adults 76. The intervention group received seven 2-hour weekly group sessions conducted by an occupational therapist and one booster session held 3 months after the final group session. The control group received 2 social visits conducted by an occupational therapist. An additional 13 trials incorporated educational components into a multifactorial clinical assessment, clinical management, or home-hazard modification intervention 23-25, 30-31, 33-38, 46, 75.

Efficacy

Education alone was not associated with a reduction in fall risk.

Harms

There was no increase in falls or fallers, and no additional adverse effects were reported.

Discussion

Although we conclude that exercise or physical therapy interventions and vitamin D supplementation reduce the risk for falling among community-dwelling older adults, it is unclear whether comprehensive multifactorial assessment and management interventions reduce the number of fallers. Overall, we found no major clinical harms for these effective interventions to prevent falls in older adults.

Most trials of vitamin D were not adequately designed to assess long-term adverse effects. On the basis of a recent AHRQ evidence report, we found limited evidence (based on 19 vitamin D trials in adults) that vitamin D intake above the current dietary reference amount may be harmful 17. The Women's Health Initiative reported a 17% increased risk for kidney stones in postmenopausal women aged 50 to 79 years whose daily vitamin D3 supplementation was 400 IU combined with 1000 mg of calcium 17. In most trials, reports of hypercalcemia and hypercalciuria were not associated with clinically relevant events.

We found evidence of possible minor harms for vision correction, an intervention without evidence of effectiveness. In a recent USPSTF report evaluating the harms of vision screening and early vision correction in older adults, a single small observational study showed an association between multifocal lens use and an increased risk for falls (adjusted odds ratio, 2.09 [CI, 1.06 to 4.92]) 18. Other treatments for uncorrected refractive errors showed limited evidence of harm.

Our results are similar to those of previous systematic evidence reviews and meta-analyses 16, 77-79, but they differ in some ways. Relevant recent systematic evidence reviews evaluating specific types of interventions (for example, multifactorial assessment and exercise) also included institutional and hospitalized populations 79-80. The purpose of our review was to evaluate outpatient approaches to falls prevention that are relevant to primary care to support the USPSTF recommendation process; thus, our review has a narrower focus than other reviews have had.

The most current review before ours, and the one that is most similar to ours, is a 2009 Cochrane Collaboration review 78. Like that review and meta-analyses, we found no statistically significant reduction in fall risk when all of the multifactorial assessment and management trials were pooled. Another recent systematic review and meta-analysis of multifactorial clinical assessment programs addressing fall risk also reported a lack of overall benefit 79, and a review addressing a broader grouping of complex interventions and outcomes reported a reduction in fall risk associated with these interventions 81. Although the lack of a consistent finding for an overall benefit may result from analyses combining studies that provide direct intervention with those studies that primarily provide referral 82-83, comprehensiveness did not seem to be a predictor of successful interventions in our analysis or in the 2009 Cochrane review 78. However, the current body of literature is sensitive to changes as new trials are published. For example, a recent good-quality trial from the United Kingdom (204 participants) that was published after our review search period ended evaluated comprehensive multifactorial falls assessment and management among community-dwelling older adults who called an ambulance after a fall but were not taken to the emergency department 84. After 12 months, the relative risk for falling between the intervention group and usual care was 0.86 (CI, 0.78 to 0.94). Although the addition of this trial does not affect the pooled estimate of risk for falling, it does affect the overall statistical significance for comprehensive interventions (relative risk, 0.88 [CI, 0.78 to 0.98]; number of active study groups, 7; I2 = 70.2%). The characteristics of a comprehensive multifactorial assessment and management intervention have not been clearly defined, and different approaches to classification may also lead to different results, although our coding of level of comprehensiveness was internally valid.

We conclude that exercise programs are effective overall, as did other reviews 77-78, 80. Like the 2009 Cochrane review 78, we did not find any evidence for differences in the results of fall prevention interventions on the basis of fall risk at baseline, although the intensity of the physical activity interventions was associated with greater reductions in the risk for falling 78, 80.

Unlike the recent Cochrane review and meta-analyses, we found that vitamin D supplementation was consistent with a reduced risk for falling. Our review, however, included data from 4 trials that were not included in the Cochrane review 65-66, 68, 71; these data were generally protective. One large null study85 included in the Cochrane review was excluded from our review owing to problems with the outcome reporting. After our search period ended, a good-quality trial evaluating a single large oral dose of vitamin D (500,000 IU) showed a paradoxical effect, in which the intervention group had an increase in fallers compared with the placebo control group at 12 months (74% vs. 68%; P = 0.003) 86. After we included this study in the meta-analysis, the relative risk reduction was attenuated but remained statistically significant (relative risk, 0.83 [CI, 0.71 to 0.97]). It was hypothesized that the mega-dose of oral vitamin D in the trial conducted by Sanders and colleagues 86 may have up-regulated CYP24, the enzyme that catabolizes 1,25-dihydroxyvitamin D, leading to decreased levels of vitamin D and increased falling in the intervention group 87. Only 1 other small trial included in this review administered a single mega-dose of vitamin D to vitamin D-deficient participants and reported no difference in risk for falling over 6 months 64.

Our review has limitations. First, we included only English-language RCTs with a true control group that were conducted in community-dwelling older adults and tested outpatient interventions most applicable to primary care clinicians. Second, the heterogeneity of interventions to prevent falling—from the identification of an at-risk population to intervention approaches to the different methods of assessing relevant outcomes—is an inherent limitation in the conduct and interpretation of statistical syntheses of this research. Third, among the intervention trials, we identified no consistent method of identifying people at increased risk for falls. Most studies (68%) enrolled participants who were preselected for increased risk factors for falls, including history of falls, gait and balance impairment, clinical history (for example, stroke, Parkinson disease, recent hospitalization, or medication use), and clinical examination findings (for example, frailty). Fourth, the interventions are heterogeneous even within intervention categories. In particular, the exercise intervention and the multifactorial assessment and management interventions vary considerably in terms of focus and components of care. Fifth, published studies use diverse terms to describe trial components, creating difficulty in categorizing studies. Sixth, very few trials replicated the same intervention, and none of the study-level characteristics helped to explain study effects or reduce heterogeneity. This makes providing clear clinical recommendations with regard to details of successful interventions difficult. Seventh, measurement of outcomes was variable in terms of the method of data collection (prospective vs. retrospective) and the specific measures that were collected (fallers vs. falls). Finally, we report here the proportion of fallers as our primary outcome, but in the full report, we describe other outcomes, including the rate of fallers and health outcomes (injury and fractures, quality of life, disability, and mortality). However, these outcomes were much less commonly reported: only 20 of the included trials reported outcomes of fall-related fractures. In general, we found scant and inconclusive evidence on changing true health outcomes.

Recently, the Prevention of Falls Network Europe published a consensus document describing a common data set for fall prevention interventions; the routine use of these assessment instruments and procedures will enhance the quality and comparability of future trials and expand the available data on health outcomes and other positive outcomes 88. Although the consensus document does not address harms reporting, this is a critical need, particularly because harms were not systematically evaluated in the majority of fall prevention interventions in this review.

In conclusion, current research suggests that clinical interventions, such as vitamin D supplementation, exercise or physical therapy programs, and some comprehensive multifactorial fall assessment and management interventions, can reduce falls and are safe for community-dwelling older adults.

Copyright and Source Information

Source: This article was first published in Annals of Internal Medicine (Ann Intern Med 2010;153:815-825).

Requests for Single Reprints: Yvonne L. Michael, ScD, SM, Epidemiology and Biostatistics, Drexel University School of Public Health, 1505 Race Street, 6th Floor, MS 1033, Philadelphia, PA 19102; e-mail, michaely@drexel.edu.

Current author addresses and author contributions are available at http://www.annals.org

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Figure 1. Pooled risk for falling for multifactorial assessment and management interventions.

Figure 1. Pooled risk for falling for multifactorial assessment and management interventions. Figure 1 displays a forest plot of all multifactorial assessment and management trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in the noncomprehensive subgroup (n=4,312) was 0.98 (95% CI, 0.88 to 1.08), with moderate statistical heterogeneity (chi-square=52.5%). The pooled relative risk for falling in the comprehensive subgroup (n=2,010) was 0.89 (95% CI, 0.76 to 1.03), with high statistical heterogeneity (chi-square=73.1%). The overall pooled relative risk for falling (n=6,322) was 0.94 (95% CI, 0.87 to 1.02), with moderate to high statistical heterogeneity (chi-square=61.5%).

CG = control group; IG = intervention group.

Text Description.

Figure 1. Pooled risk for falling for multifactorial assessment and management interventions. Figure 1 displays a forest plot of all multifactorial assessment and management trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in the noncomprehensive subgroup (n=4,312) was 0.98 (95% CI, 0.88 to 1.08), with moderate statistical heterogeneity (chi-square=52.5%). The pooled relative risk for falling in the comprehensive subgroup (n=2,010) was 0.89 (95% CI, 0.76 to 1.03), with high statistical heterogeneity (chi-square=73.1%). The overall pooled relative risk for falling (n=6,322) was 0.94 (95% CI, 0.87 to 1.02), with moderate to high statistical heterogeneity (chi-square=61.5%).

Figure 2. Pooled risk for falling for exercise or physical therapy interventions.

Figure 2. Pooled risk for falling for exercise or physical therapy interventions. Figure 2 displays a forest plot of all exercise or physical therapy trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in all trials (n=3,568) was 0.87 (95% CI, 0.81 to 0.94), with low statistical heterogeneity (chi-square=4.2%).

CG = control group; IG = intervention group.

Text Description.

Figure 2. Pooled risk for falling for exercise or physical therapy interventions. Figure 2 displays a forest plot of all exercise or physical therapy trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in all trials (n=3,568) was 0.87 (95% CI, 0.81 to 0.94), with low statistical heterogeneity (chi-square=4.2%).

Figure 3. Pooled risk for falling for single clinical treatment interventions: Vitamin D.

Figure 3. Pooled risk for falling for single clinical treatment interventions: Vitamin D. Figure 3 displays a forest plot of all vitamin D trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in all trials (n=5,780) was 0.83 (95% CI, 0.77 to 0.89), with low statistical heterogeneity (chi-square=3.2%).

CG = control group; IG = intervention group.

Text Description.

Figure 3. Pooled risk for falling for single clinical treatment interventions: vitamin D. Figure 3 displays a forest plot of all vitamin D trials reporting between-group differences in risk for falling. Data for the figure are presented alongside the forest plot. The pooled relative risk for falling in all trials (n=5,780) was 0.83 (95% CI, 0.77 to 0.89), with low statistical heterogeneity (chi-square=3.2%).

Table. Summary of Evidence, by Intervention Category

Intervention Studies, n (Reference) Limitations Consistency Applicability Overall
Quality
Summary of Findings Comments
Multifactorial assessment and management 1923-41 Majority of trials were conducted outside of the United States and may vary from usual care in the United States Heterogeneity in many dimensions, including age of participants, baseline risk for falling, intervention approach, country, treatment intensity, and duration of follow-up; high attrition in many trials; failure to blind assessors Trial participants were primarily non-Hispanic white adults selected for being at high risk for falls Fair Pooled RR for comprehensive interventions, 0.89 (95% CI, 0.76-1.03); I2 = 73.1%
Pooled RR for noncomprehensive interventions, 0.98 (CI, 0.88-1.08); I2 = 52.5%
Paradoxical increase in falling in 1 trial
No significant clinical harms
Pooled estimate was sensitive to the addition of new trial data
Exercise or physical therapy 1843-60 Majority of trials did not include an intention control or report whether follow-up assessments were blinded Heterogeneity in many dimensions, including age and sex of participants, baseline risk for falling, intervention approach, country, treatment intensity, and duration of follow-up; high attrition in many trials; failure to blind assessors Trial participants were primarily non-Hispanic white adults Fair Pooled RR, 0.85 (CI, 0.78-0.92); I2 = 21%
No significant clinical harms
Meta-regression results indicate that more intensive exercise trials had a greater effect on risk for falling
Single clinical treatment:
Vitamin D
963-71 Majority of trials were not powered to observe a significant reduction in fall risk and assessed falls retrospectively Heterogeneity in dosing and duration of follow-up Trial participants were primarily non-Hispanic white women Fair Pooled RR, 0.83 (CI, 0.77-0.89); I2 = 3.2%
Potential increase in kidney stones with high levels of supplementation
Trials of vitamin D with calcium that were compared with no treatment or placebo did not support any added benefit of calcium
Single clinical treatment:
Vision correction
449, 72-74 No serious limitations Heterogeneity of intervention approach; all trials included high-risk populations because of selection for frailty or presence of cataract Trial participants were primarily non-Hispanic white women selected for being at high risk for falls Fair No reduction in risk for falling; potential increase in falling Fall rate was reduced in 1 trial of first cataract surgery
Single clinical treatment:
Medication assessment and withdrawal
147 Small sample size (48 participants) NA NA Fair Limited evidence of no benefit Fall risk was not reported
Home-hazard modification 348, 49, 75 Assessment of outcomes not blinded; studies were conducted outside the United States Heterogeneity in intervention approach and approach to selecting a high-risk population Trial participants were primarily female Fair Limited evidence of benefit Results from the trial groups that combined other interventions with home-hazard modification were generally similar
Clinical education or behavioral counseling 176 No serious limitations NA NA Good Limited evidence of no benefit -

NA = not applicable; RR = relative risk.

Appendix Figure 1. Key questions.

Appendix Figure 1. Key questions. Go to [D] Text Description for details.

[D]. Select for Text Description.

Appendix Figure 1 is an analytic framework that depicts the events that older adults experience while undergoing primary care interventions to prevent falling. The framework includes six groupings: Risk Evaluation, Intervention, Intermediate Outcomes, Health Outcomes, Other Positive Outcomes, and Adverse Effects. The patient population undergoing risk evaluation is adults aged 65 years and older; the subpopulation for key question 4 is those who are considered at high risk for falling. The intervention is one of the following (alone or in combination): multifactorial assessment and management; single clinical treatment, with or without screening; clinical education or behavioral counseling; home hazard modification; and exercise or physical therapy. The intermediate outcome, which is used to determine if the intervention is effective, is number of falls/fallers. The health outcomes include a reduction in fall-related fractures and serious injuries, improvement in quality of life, and reduction in disability or mortality. Other positive outcomes include a reduction in fear of falling and improvement in balance, gait, and mobility measures. Minor adverse outcomes associated with specific interventions include: increased fall-related outpatient visits after comprehensive falls assessment; self-reported musculoskeletal complaints (but not outpatient visits or hospitalizations) with exercise interventions; increased outpatient visits for abnormal heart rhythm with exercise intervention; minor local skin irritation or infection with use of hip protectors; gastrointestinal side effects with liquid protein-energy supplementation; and transient or asymptomatic hypercalcemia and hypercalciuria with vitamin D supplementation.

Key Questions
KQ1: Is there direct evidence that primary care interventions reduce fall-related injury, improve quality of life, reduce disability, or reduce mortality when used alone or in combination to reduce falls in community-dwelling older adults?
KQ1a: Do these interventions reduce injury, improve quality of life, reduce disability, or reduce mortality in older adults specifically identified as high risk for falls?
KQ2: Do primary care interventions used alone or in combination in community-dwelling older adults reduce risk or rate of falls or fallers?
KQ2a: Do these interventions reduce falls in older adults specifically identified as high risk for falls?
KQ2b: Are there positive outcomes other than reduced falls, and related morbidity and mortality, that result from primary care fall interventions?
KQ3: What are the adverse effects associated with interventions to reduce falls?
KQ4: How are high-risk older adults identified for primary care fall interventions?


This review addresses KQs 2 and 3. KQ = key question.
* Multifactorial assessment and management includes multifactor risk assessment, comprehensive geriatric assessment, and ≥2 of the following screenings for fall risk: vision, gait, mobility, strength, medication review, cognitive impairment, orthostatic hypotension, and environmental risks. Single clinical treatment (with or without screening) includes vision correction, medication optimization or adjustment, assistive device prescription, pharmacologic or nutritional interventions, treatment of orthostatic hypotension, urinary incontinence, and hip protectors. Clinical education or behavioral counseling includes exercise, fall risk reduction, and a home-hazard checklist. Home-hazard modification includes identifying and removing potential fall hazards, adding grab bars and handrails, and modifying the environment to improve mobility and safety. Exercise or physical therapy includes physical exercise, mobility and gait training, muscle strengthening, balance training, and training for recurrent fallers.

Appendix Figure 2. Summary of evidence search and selection.

Appendix Figure 2. Summary of evidence search and selection. Go to [D] Text Description for details.

[D]. Select for Text Description.

Appendix Figure 2 is a flow chart that summarizes the search and selection of evidence. There were 3,423 citations identified by the search. Of these, 3,003 citations were excluded after abstract review. An additional 218 articles reviewed from outside sources were added, and the resulting 638 full-text articles were assessed for eligibility by key question. Some articles may have been included for more than one key question and more than one intervention. Of the 266 articles reviewed for key question 1, 225 were excluded. Reasons for exclusion were: relevance (n=97); setting (n=24); population (n=17); quality (n=18); study design (n=24); outcomes (n=26); covered by another systematic evidence review (n=1); and data reported in another article (n=18). 41 articles representing 38 different studies were deemed eligible for inclusion. Of these 38 studies, 14 were included in the qualitative synthesis for multifactorial assessment and management, 12 were included in the qualitative synthesis for single clinical treatment, 1 was included in the qualitative synthesis for clinical education/behavioral counseling, 1 was included in the qualitative synthesis for home hazard modification, and 11 were included in the qualitative synthesis for exercise/physical therapy. Of the 390 articles reviewed for key questions 2 and 4, 329 were excluded. Reasons for exclusion were: relevance (n=112); setting (n=35); population (n=27); quality (n=23); study design (n=58); outcomes (n=29); covered by another systematic evidence review (n=2); and data reported in another article (n=43). 61 articles representing 54 different studies were deemed eligible for inclusion. Of these 54 studies, 19 were included in the qualitative synthesis for multifactorial assessment and management, 17 were included in the qualitative synthesis for single clinical treatment, 1 was included in the qualitative synthesis for clinical education/behavioral counseling, 3 were included in the qualitative synthesis for home hazard modification, and 18 were included in the qualitative synthesis for exercise/physical therapy. Of the 84 articles reviewed for key question 3, 35 were excluded. Reasons for exclusion were: relevance (n=5); population (n=2); quality (n=2); study design (n=18); outcomes (n=7); and data reported in another article (n=2). 49 articles representing 48 different studies and 1 meta-analysis were deemed eligible for inclusion.

Articles may have been included for more than 1 KQ and more than 1 intervention. KQ = key question; PT = physical therapy; SER = systematic evidence review.

Appendix Table 1. Intervention Category Definitions

Multifactorial assessment and management Multifactorial assessment and management interventions include a clinical assessment of ≥2 domains of functioning, generally supplemented by assessment of falls-related or general geriatric risk factors or conditions, with assessment results used as a basis for remedial management. In this review, multifactorial risk assessments may have been a comprehensive geriatric assessment or a falls-focused assessment, generally including ≥2 of the following screenings: vision, gait, mobility, strength, medication review, cognitive impairment, orthostatic hypotension, and environmental risks. Management approaches were categorized as comprehensive (treatments and education to comprehensively address risks, conditions, or functional limitations identified through the assessment) or noncomprehensive (less comprehensive interventions that provided only referral or provided treatment of selected risks, conditions, or functional limitations).
Single clinical treatment Single clinical treatment protocols were defined as those with or without screening to identify persons needing treatment for a single fall-related risk factor, including vision correction, medication optimization or adjustment, assistive device prescription, pharmacologic or nutritional interventions, treatment of orthostatic hypotension, urinary incontinence, and hip protectors.
Clinical education or counseling Education or behavioral counseling included interventions delivered by primary care clinicians and related health care staff to assist patients in adopting, changing, or maintaining behaviors related to fall risk; interventions include exercise, fall risk reduction, or a home-hazard checklist.
Home-hazard modification Home visits to identify and remove potential fall hazards, add grab bars and handrails, or otherwise modify the environment to improve mobility and safety.
Exercise or physical therapy Organized programs for individuals or small groups that are part of a health care setting or widely available for referral in most communities, including physical exercise, mobility and gait training, muscle strengthening, balance training, and training for recurrent fallers. Programs may be home-based or be delivered in a community setting.

Appendix Table 2. Effectiveness of Multifactorial Assessment and Management Interventions to Prevent Falls in Older Adults

Study, Year (Reference) Setting Participants Intervention Fallers, n (%)
Randomly Assigned, n Mean Age, y Women, % History of Falling, %
Ciaschini et al, 200937 Canada IG: 101
CG: 100
IG: 72
CG: 71
IG: 91
CG: 96
NR IG: assessment with PT, OT, education, and referrals
CG: usual care
IG: 26 (26)
CG: 17 (17)
Close et al, 199931 United Kingdom IG: 184
CG: 213
IG: 77
CG: 79
IG: 68
CG: 67
IG: 64
CG: 66
IG: assessment with CM
CG: usual care
IG: 59 (32)
CG: 111 (52)
Coleman et al, 1999 25 United States IG: 96
CG: 73
IG: 77
CG: 77
IG: 48
CG: 49
IG: 44
CG: 49
IG: assessment and management in chronic care clinics
CG: usual care
IG: 42 (44)
CG: 28 (38)
Davison et al, 200526 United Kingdom IG: 159
CG: 154
IG: 77
CG: 77
IG: 73
CG: 72
100 IG: assessment with CM, including home-hazard modification
CG: usual care
IG: 95 (66)
CG: 103 (69)
Dyer et al, 200439 United Kingdom IG: 102
CG: 94
IG: 87
CG: 87
IG: 79
CG: 77
NR IG: assessment with feedback to PCP, referrals for eye and foot care, and
exercise training
CG: assessment only
IG: 56 (55)
CG: 51 (54)
Elley et al, 200827 New Zealand IG: 155
CG: 157
IG: 80
CG: 81
IG: 68
CG: 70
100 IG: assessment with referrals and home exercise training
CG: social visit
IG: 106 (68)
CG: 98 (62
Hendriks et al, 200828 The Netherlands IG: 166
CG: 167
IG: 75
CG: 75
IG: 67
CG: 70
100 IG: assessment with feedback to PCP and patient
CG: usual care
IG: 55 (46)
CG: 61 (47)
Hogan et al, 200132 Canada IG: 79
CG: 84
IG: 77.4
CG: 77.9
IG: 70
CG: 74
100 IG: assessment with referrals for services and exercise training
CG: home visit with leisure assessment
IG: 54 (72)
CG: 61 (79)
Lightbody et al, 200233 United Kingdom IG: 171
CG: 177
IG: 75
CG: 75
IG: 79
CG: 84
IG: 77
CG: 72
IG: assessment with referrals and simple home-hazard modification
CG: usual care
IG: 39 (25)
CG: 41 (26)
Lord et al, 200535 Australia IG (CM): 210
IG (NCM): 206
CG: 204
 
IG (CM): 80
IG (NCM): 81
CG: 80
IG (CM): 67
IG (NCM): 62
CG: 69
NR IG (CM): assessment with individualized management and exercise training
IG (NCM): assessment with referral
CG: wait-list control
IG (CM): 93 (46)
IG (NCM): 94 (49)
CG: 90 (45)
Newbury et al, 200129 Australia IG: 50
CG: 50
IG: 79
CG: 80
IG: 66
CG: 60
NR IG: complete geriatric health assessment with feedback to PCP
CG: usual care
IG: 12 (27)
CG: 17 (39)
Peri et al, 200840 New Zealand IG: 73
CG: 76
IG: 87
CG: 85
IG: 85
CG: 83
NR IG: assessment with feedback to PCP and tailored physical activity plan for
patient
CG: usual care
IG: 31 (42)
CG: 43 (57)
Salminen et al, 200938 Finland IG: 293
CG: 298
IG: 73
CG: 73
IG: 86
CG: 82
100 IG: assessment with medication management, education, vision referral,
and exercise training
CG: social visit with fall prevention written material
IG: 140 (48)
CG: 131 (44)
Shumway-Cook et al, 200736 United States IG: 226
CG: 227
76 IG: 77
CG: 76
NR IG: assessment with feedback to PCP, education, and exercise training
CG: fall prevention written material
IG: 124 (55)
CG: 130 (57)
Spice et al, 200924 United Kingdom IG (CM): 213
CG: 162
IG: 81
CG: 83
IG: 71
CG: 76
100 IG: assessment with comprehensive management in multidisciplinary clinic
CG: assessment only
IG: 158 (75)
CG: 133 (84)
Tinetti et al, 199430 United States IG: 153
CG: 148
IG: 78
CG: 78
IG: 69
CG: 69
IG: 41
CG: 44
IG: assessment with comprehensive management including home-hazard modification
CG: social visits only
IG: 52 (35)
CG: 68 (47)
Van Haastregt et al, 200034 The Netherlands IG: 159
CG: 157
IG: 77
CG: 73
IG: 65
CG: 63
IG: 38
CG: 36
IG: assessment with referrals and simple home-hazard modification
CG: usual care
IG: 63 (50)
CG: 53 (44)
Vind et al, 200941 Denmark IG: 196
CG: 196
IG: 74
CG: 75
IG: 73
CG: 75
100 IG: assessment with comprehensive management in geriatric clinic and through referrals
CG: usual care
IG: 110 (56)
CG: 101 (52)
Wagner et al, 199423 United States IG: 635
CG: 607
IG: 73
CG: 73
IG: 60
CG: 59
IG: 35
CG: 33
IG: assessment with feedback to PCP, exercise training, and follow-up telephone calls
CG: usual care
IG: 175 (28)
CG: 223 (37)

CG = control group; CM = comprehensive management; IG = intervention group; NCM = noncomprehensive management; NR = not reported; OT = occupational therapy; PCP = primary care provider; PT = physical therapy.

Appendix Table 3. Effectiveness of Exercise or Physical Therapy Interventions to Prevent Falls in Older Adults

Study, Year (Reference) Setting Participants Intervention Fallers, n (%)
Randomly Assigned, n Mean Age, y Women, % History of Falling, %
Ashburn et al, 200743 United Kingdom IG: 70
CG: 72
IG: 73
CG: 72
IG: 46
CG: 33
100 IG: ST and balance training
CG: usual care
IG: 46 (73)
CG: 49 (78)
Barnett et al, 200344 Australia IG: 83
CG: 80
IG: 74
CG: 75
IG: 69
CG: 64
IG: 43
CG: 41
IG: ST, ET, physical therapy, and education
CG: fall prevention written material
IG: 27 (36)
CG: 37 (50)
Buchner et al, 199745 United States IG (ET): 25
IG (ST): 25
IG (ET + ST): 25
CG: 30
IG (ET): 75
IG (ST): 74
IG (ET + ST): 75
CG: 75
IG (ET): 52
IG (ST): 52
IG (ET + ST): 52
CG: 50
IG (ET): 20
IG (ST): 16
IG (ET + ST): 28
CG: 23
IG (ET): ET
IG (ST): resistance training
IG (ET + ST): ET and ST
CG: usual care
IGs combined:
32 (42)
CG: 18 (60)
Campbell et al, 199746 New Zealand IG: 116
CG: 117
IG: 84
CG: 84
100 IG: 41
CG: 47
IG: ST, balance training, walking, and social visits
CG: social visits only
IG: 53 (46)
CG: 62 (53)
Campbell et al, 199947 New Zealand IG1: 21
IG2: 24
CG: 24
IG1: 73
IG2: 76
CG: 75
IG1: 71
IG2: 79
CG: 79
IG1: 10
IG2: 54
CG: 33
IG: ST, balance training, walking, with or without medication management
CG: medication management only
Reported rates only
Campbell et al, 200548 New Zealand IG (EX): 97
CG: 96
IG (EX): 83
CG: 84
IG (EX): 74
CG: 70
IG (EX): 42
CG: 50
IG (EX): ST and balance training, walking
CG: social visits
IG (ST): 47 (48)
CG: 59 (61)
Day et al, 200249 Australia IG (EX): 135
CG: 137
76.1 59.8 NR IG: ST and balance and flexibility training
CG: usual care
IG: 76 (56)
CG: 87 (64)
Green et al, 200250 United Kingdom IG: 85
CG: 85
IG: 72
CG: 74
IG: 42
CG: 46
NR IG: physical therapy
CG: usual care
IG: 30 (35)
CG: 23 (27)
Kronhed et al, 200960 Sweden IG: 31
CG: 34
IG: 72
CG: 71
100 IG: 19
CG: 44
IG: ST and balance training
CG: usual care
Reported rates only
Li et al, 200551 United States IG: 125
CG: 131
IG: 77
CG: 78
IG: 70
CG: 70
IG: 42
CG: 31
IG: tai chi
CG: stretching and relaxation classes
IG: 27 (28)
CG: 43 (46)
Logghe et al, 200952 The Netherlands IG: 138
CG: 131
IG: 78
CG: 77
IG: 70
CG: 73
IG: 64
CG: 60
IG: tai chi and education
CG: education only
IG: 58 (42)
CG: 59 (45)
Lord et al, 199553 Australia IG: 100
CG: 97
IG: 72
CG: 72
100 IG: 28
CG: 29
IG: ST, ET, and flexibility and coordination training
CG: NR
IG: 26 (35)
CG: 33 (35)
Luukinen et al, 200754 Finland IG: 243
CG: 243
IG: 88
CG: 88
IG: 78
CG: 80
NR IG: walking, standing exercises to improve strength and balance
CG: usual care
IG: 126 (58)
CG: 136 (62)
Morgan et al, 200455 United States IG: 119
CG: 110
IG: 81
CG: 80
IG: 72
CG: 69
IG: 39
CG: 33
IG: ST, balance and flexibility training, walking
CG: usual care
IG: 34 (29)
CG: 34 (31)
Robertson et al, 200156 New Zealand IG: 121
CG: 119
IG: 81
CG: 80
IG: 68
CG: 67
IG: 36
CG: 38
IG: ST, balance training, and walking
CG: usual care
Reported rates only
Rubenstein et al, 2000 57 United States IG: 31
CG: 28
IG: 76
CG: 74
0 IG: 48
CG: 64
IG: ST, ET, and balance training
CG: usual care
IG: 12 (39)
CG: 9 (32)
Voukelatos et al, 200758 Australia IG: 353
CG: 349
IG: 69
CG: 69
IG: 85
CG: 83
IG: 381
CG: 36
IG: tai chi
CG: wait-list control
IG: 71 (21)
CG: 81 (24)
Wolf et al, 199659 United States IG: 72
CG: 64
IG: 77
CG: 75
IG: 81
CG: 84
IG: 42
CG: 34
IG: tai chi
CG: general education classes (not fall prevention)
Reported rates only

CG = control group; ET = endurance training; EX = exercise; IG = intervention group; NR = not reported; ST = strength training.

Appendix Table 4. Effectiveness of Single Clinical Treatment Interventions to Prevent Falls in Older Adults

Study, Year (Reference) Setting Participants Intervention Fallers, n (%)
Randomly Assigned, n Mean Age, y Women, % History of Falling, %
Bischoff-Ferrari et al, 200663 United States IG: 219
CG: 226
IG: 71
CG: 71
IG: 55
CG: 55
NR IG: vitamin D
CG: placebo
IG: 107 (49)
CG: 124 (55)
Dhesi et al, 200464 United Kingdom IG: 70
CG: 69
IG: 77
CG: 77
IG: 76
CG: 80
100 IG: vitamin D
CG: placebo
IG: 11 (16)
CG: 14 (20)
Dukas et al, 200465 Switzerland IG: 193
CG: 187
IG: 75
CG: 75
51 NR IG: vitamin D
CG: placebo
IG: 40 (21)
CG: 46 (25)
Gallagher et al, 200166 United States IG: 123
CG: 123
IG: 72
CG: 71
100 NR IG: vitamin D, dietary advice
CG: placebo, dietary advice
IG: 59 (48)
CG: 77 (63)
Kärkkäinen et al, 201071 Finland IG: 287
CG: 306
IG: 67
CG: 67
100 NR IG: vitamin D
CG: no supplementation
IG: 179 (62)
CG: 205 (67)
Pfeifer et al, 200067 Germany IG: 74
CG: 74
IG: 75
CG: 75
100 NR IG: vitamin D and calcium
CG: calcium only
IG: 11 (16)
CG: 19 (28
Pfeifer et al, 200968 Austria and
Germany
IG: 121
CG: 121
IG: 76
CG: 77
IG: 74
CG: 75
NR IG: vitamin D and calcium
CG: calcium only
IG: 49 (40)
CG: 75 (63)
Porthouse et al, 200569 United Kingdom IG: 1321
CG: 1993
IG: 77
CG: 77
100 IG: 34
CG: 44
IG: vitamin D and calcium, education
CG: education only
Reported rates only
Prince et al, 200870 Australia IG: 151
CG: 151
IG: 77
CG: 77
100 100 IG: vitamin D and calcium
CG: calcium only
IG: 80 (53)
CG: 95 (63)
Cumming et al, 200772 Australia IG: 309
CG: 3071
IG: 81
CG: 80
IG: 67
CG: 68
NR IG: vision correction
CG: usual care
IG: 201 (65)
CG: 153 (50)
Day et al, 200249 Australia IG: 139
CG: 137
76.1 59.8 NR IG: vision correction
CG: wait-list control
IG: 84 (60)
CG: 87 (64)
Foss et al, 200673 United Kingdom IG: 120
CG: 119
IG: 79
CG: 45
100 IG: 48
CG: 80
IG: expedited cataract surgery
CG: routine wait for cataract surgery
IG: 48 (40
CG: 41 (34)
Harwood et al, 200574 United Kingdom IG: 154
CG: 152
IG: 79
CG: 47
100 IG: 51
CG: 78
IG: expedited cataract surgery
CG: routine wait for cataract surgery
IG: 76 (49)
CG: 69 (45)
Campbell et al, 199947 New Zealand IG: 24
CG: 24
IG: 75
CG: 75
IG: 75
CG: 79
IG: 46
CG: 33
IG: withdrawal of treatment with psychotropic medication
CG: usual care
Reported rates only

CG = control group; IG = intervention group; NR = not reported.

Appendix Table 5. Effectiveness of Home-Hazard Modification Interventions to Prevent Falls in Older Adults

Study, Year (Reference) Setting Participants Intervention Fallers, n (%)
Randomly Assigned, n Mean Age, y Women, % History of Falling, %
Campbell et al, 200548 New Zealand IG: 100
CG: 96
IG: 83
CG: 84
IG: 66
CG: 70
IG: 45
CG: 50
IG: home-hazard modification
CG: social visits only
IG: 36 (36)
CG: 59 (61)
Day et al, 200249 Australia IG: 136
CG: 137
76 59.8 NR IG: home-hazard modification
CG: usual care
IG: 78 (57)
CG: 87 (64)
Stevens et al, 200175 Australia IG: 635
CG: 1244
IG: 76
CG: 76
IG: 54
CG: 52
IG: 26
CG: 27
IG: home-hazard modification and education
CG: education alone
Odds ratio, 0.97 (95% CI, 0.74-1.28)

CG = control group; IG = intervention group; NR = not reported.

Appendix Table 6. Effectiveness of Clinical Education or Behavioral Counseling Interventions to Prevent Falls in Older Adults

Study, Year (Reference) Setting Participants Intervention Fallers, n (%)
Randomly Assigned, n Mean Age, y Women, % History of Falling,
(≥2 Falls) %
Clemson et al, 200476 Australia IG: 157
CG: 153
IG: 78
CG: 78
IG: 74
CG: 74
IG: 48
CG: 49
IG: seven 2-h sessions weekly, plus home visit and booster session
CG: up to 2 social visits
IG: 82 (52)
CG: 89 (58)

CG = control group; IG = intervention group; NR = not reported.

Current as of: December 2010

Internet Citation: Final Evidence Summary: Falls Prevention in Older Adults: Counseling and Preventive Medication. U.S. Preventive Services Task Force. September 2016.
https://www.uspreventiveservicestaskforce.org/Page/Document/final-evidence-summary24/falls-prevention-in-older-adults-counseling-and-preventive-medication

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