Evidence profile: risk of falls

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Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity

Evidence profile:

risk of falls

Scoping question:

Do interventions to prevent falls produce any benefit or harm for older people at risk of falls?

The full ICOPE guidelines and complete set of evidence profiles are available at:

who.int/publications/i/item/9789241550109

Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression.

Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved

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Background

In older people, falls are the most prominent external cause of unintentional injury. Research suggests that one third of

community-dwelling people aged over 65 years fall each year and almost half of them experience recurrent falls (1–10). Incidents of falls by older people are strongly associated with hospitalization, severe functional decline, care dependency and premature admission to institutional care (11). Nearly 15% of falls result in non-fatal injuries (12), ranging from minor bruises and wrist lacerations to hip fractures (4, 5, 13). More importantly,

23–40% of injury-related deaths in older people are attributable to falls (9, 14).

The risk factors for falls are complex and multifactorial in nature.

Evidence from longitudinal studies suggests strong interactions among multiple risk factors, such as age, sex, previous history of falls, chronic diseases and environmental factors (4, 10, 14).

Medical conditions that increase the risk of falls include: orthostatic

hypotension (6, 8, 10, 15), musculoskeletal disease (3, 5, 16), visual impairment (7, 17, 18), low systolic blood pressure, stroke, cognitive impairments, Parkinson’s disease, gait disorders, balance disorders and sensory impairments (3, 4, 7, 10, 14). Medications in general, and polypharmacy in particular, increase the risk of falls in older people (19).

In recent years, there has been an increasing level of research and policy interest in the public health impact of falls. The effectiveness of single and complex programmes for the prevention of falls and fall-related injuries was extensively tested among older people at risk of falls (20). Most intervention studies were carried out in community settings; a few were undertaken in hospitals and residential care settings (13). In this document, the evidence for fall-prevention interventions undertaken for community-dwelling older people at risk of falls has been summarized to inform the recommendations provided in the full ICOPE guidelines available at who.int/ageing/publications/guidelines-icope.

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Part 1: Evidence review

Scoping question in PICO format (population, intervention, comparison, outcome)

Population

Older people 60 years of age and older (both male and female) at risk of falls

Interventions

• Multicomponent exercise programme/strength training

• Falls risk assessment by the physiotherapist to develop individualized falls and injury prevention

• Individually tailored exercises

• Medication review

• Withdrawal of psychotropic medication

• Multifactorial interventions with comprehensive geriatric assessment

• Environmental modification for home safety

• Assistive technology (walking aid, hearing aid, personal alarm system)

• Footwear assessment

• Insertion of a pacemaker (carotid sinus hypersensitivity)

Comparison

• Usual care or standard care

• Placebo or no active intervention

• Waiting list control

• Active control intervention

Outcome

• Critical: rate of falls Setting

• Primary care/community

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Search strategy

The search for systematic reviews was conducted on 10 October 2015 in Ovid MEDLINE, Embase and the Cochrane Library using comprehensive search terms (Annex 1). Details of the number studies retrieved and included are presented in Annex 2.

List of systematic reviews identified by the search process

Included in GRADE¹ tables (6):

— Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev.

2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

_______________________________

1 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http://gradeworkinggroup.org

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PICO table

Intervention/comparison Outcomes Systematic review used for GRADE

Explanation

1 Compared with no intervention (or an

intervention not expected to reduce falls), fall-prevention interventions included:

• exercise

• t’ai chi

• multifactorial programmes

• home safety interventions

• cognitive behavioural intervention

• prevention education

• anti-slip shoe device

• vision treatment

• pacemaker for carotid hypersensitivity

• reduced psychotropics

• vitamin D

supplementation.

Risk of falls. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

Interventions for preventing falls in older people living in the

community. Cochrane Database Syst Rev. 2012;(9):CD007146. (6)

Systematic review relevant to the area.

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Narrative description of the studies that went into analysis

Gillespie et al. (2012) is a Cochrane systematic review of interventions designed to reduce the incidence of falls in older people living in the community (6). The search for clinical trials was conducted in the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), Embase (1947 to March 2012), CINAHL (1982 to February 2012) and online trial registers. Only randomized controlled trials (RCTs) of

interventions to reduce falls in community-dwelling older people were included. The review included 159 trials with 79 193 participants. Most trials compared a fall-prevention intervention with no intervention or an intervention not expected to reduce falls.

The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials).

Sixty-two per cent (99/159) of the trials were at low risk of selection bias for sequence generation, 60% for attrition bias for the outcome

of falls (66/110), 73% (96/131) for attrition bias for fallers, and 38% (60/159) for selection bias due to allocation concealment. The review found no evidence of effect for cognitive behavioural

interventions or interventions aiming to improve knowledge about falls prevention alone. Limited evidence was reported in the review for an anti-slip shoe device, and for interventions to treat vision problems. Pacemaker insertion reduced falls in very selected populations of older people with carotid hypersensitivity, and reduction of psychotropic medication also reduced falls but the sustainability of the effect was questioned. The authors concluded that group and home-based exercise programmes and home safety interventions reduce the rate of falls and the risk of falling;

that multifactorial assessment and intervention programmes reduce the rate of falls but not the risk of falling; and that t’ai chi reduces the risk of falling. Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

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GRADE table 1: Medication review or withdrawal versus control for older people living in the community

Author: WHO systematic review team

Date: November 2015

Question: What is the effectiveness of medication review or withdrawal versus control for preventing falls in older people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community.

Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date:

Edited (no change to conclusions), published in Issue 4, 2015.

Quality assessment Number of patients Effect

Quality Importance Number of

studies Design Risk of

bias Inconsistency Indirectness Imprecision Other considerations

Medication

withdrawal Control Relative (95% CI) Rate of falls: psychotropic medication withdrawal vs control (follow-up 14 weeks)

1 randomized trials

serious ^a no serious inconsistency

no serious indirectness

serious ^b none 48 45 RR: 0.34 (0.16 to

0.73)

  

LOW CRITICAL

Rate of falls: medication review and modification vs usual care (follow-up 12 months) 1 randomized

trials

serious ^c no serious inconsistency

serious ^b none 93 93 RR: 1.01 (0.81 to

1.25)

  

LOW CRITICAL

RR: rate ratio

a Risk of bias: downgraded once as information on incomplete data was not adequately described.

b Imprecision: downgraded once as sample size was small (smaller than 200).

c Risk of bias: downgraded once as allocation concealment was unclear.

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GRADE table 2: Environment (home safety and aids for personal mobility) versus control for older people living in the community: subgroup analysis by risk of falling at baseline

Question: What is the effectiveness of home safety intervention versus control for preventing falls in older people living in the community (subgroup analysis by risk of falling at

baseline)?

Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Home safety

intervention Control Relative (95% CI) Rate of falls: selected for higher risk of falling (follow-up 14–52 weeks)

3 randomized trials

no serious imprecision

none 429 422 RR: 0.62

(0.5 to 0.77)

 MODERATE

CRITICAL

Rate of falls: not selected for higher risk of falling (follow-up 12–18 months)

3 randomized trials

serious ^b no serious inconsistency

none 1377 1980 RR: 0.94

(0.84 to 1.05)

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as allocation concealment and procedure for masking outcome assessor was unclear in two included trials. Further, information of incomplete data for falls outcome was not clearly described in one of the included trial.

b Risk of bias: Downgraded once as allocation concealment was unclear for one of the included trials and information on incomplete data was not clearly described in the other two trials.

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GRADE table 3: Home safety intervention versus control for older people living in the community: subgroup analysis by delivery personnel

Question: What is the effectiveness of home safety intervention versus control (subgroup analysis by delivery personnel) for preventing falls in older people living in the community?

Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Home safety

intervention Control Relative (95% CI) Rate of falls: home safety intervention (occupational therapy [OT] delivered by an occupational therapist) vs control

4 randomized trials

none 728 715 RR: 0.69

(0.55 to 0.86)

CRITICAL

Rate of falls: home safety intervention (not OT) vs control (follow-up 6–18 months)

4 randomized trials

none 1234 1841 RR: 0.91

(0.75 to 1.11)

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as method of random allocation was not concealed in two trials.

b Risk of bias: Downgraded once as analysis was not performed on the principle of intention to treat in two trials and allocation concealment was unclear in the other two trials.

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GRADE table 4: Multifactorial intervention versus control for older people living in the community

Question: What is the effectiveness of multifactorial intervention versus control or usual care for preventing falls in older people living in the community?

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

Multifactorial intervention

Control or usual care

Relative (95% CI) Rate of falls

19 randomized trials

serious ^a serious ^b no serious indirectness

none 4833 4670 RR: 0.76 (0.67 to

0.86 )



LOW

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as allocation concealment was unclear in five included trials and procedure for masking outcome assessor was unclear in nine included trials.

b Inconsistency: Downgraded once as considerable heterogeneity was observed in the meta analysis for the estimate (Tau² = 0.06;

Chi² = 116.96, df = 18 [P < 0.00001]; I²= 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

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GRADE table 5: Multifactorial intervention versus control for older people living in the community: subgroup analysis by risk of falling at baseline

Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by risk of falling at baseline) for preventing falls in older people living in the community?

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

Multifactorial

intervention Control Relative (95% CI) Rate of falls: selected for higher risk of falling

none 3041 2913 RR 0.77

(0.66 to 0.90)



LOW

CRITICAL

Rate of falls: not selected for higher risk of falling 2 randomized

trials

serious ^c serious ^d no serious indirectness

none 1792 1757 RR 0.57

(0.23 to 1.38)



LOW

CRITICAL

CI: confidence interval; RR: rate ratio

a Risk of bias: Downgraded once as allocation concealment was unclear in eight included trials and procedure for masking outcome assessor was unclear in nine trials.

b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 104.40, df = 16 [P <

0.00001]; I² = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

c Risk of bias: Downgraded once as method of allocation concealment and procedure for masking outcome assessor were unclear in one of the trials. Randomization method was unclear in the other trial.

d Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.36; Chi² = 7.54, df = 1 [P = 0.006];

I² = 87%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

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GRADE table 6: Multifactorial intervention versus control for older people living in the community: subgroup analysis by intensity of intervention

Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by intensity of intervention) for preventing falls in older people living in the community?

studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Multifactorial

intervention Control Relative (95% CI) Rate of falls: assessment and active intervention (follow-up 6–24 months)

none 3178 3160 RR: 0.74

(0.61 to 0.89)



LOW

CRITICAL

Rate of falls: assessment and referral or provision of information

9 randomized

trials

serious ^c serious ^d no serious indirectness

none 1665 1711 RR: 0.82

(0.71 to 0.95)



LOW

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as allocation concealment was unclear in nine included trials and procedure for masking outcome assessor was unclear in five trials.

b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 97.46, df = 10 [P < 0.00001]; I² = 90%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

c Risk of bias: Downgraded once as method of allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in five trials.

d Inconsistency: Downgraded once as moderate heterogeneity was observed in the analysis (Tau² = 0.03; Chi² = 18.02, df = 8 [P = 0.02]; I² = 56%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

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GRADE table 7: Exercise intervention versus control for older people living in the community

Question: What is the effectiveness of exercise versus control for preventing falls in older people living in the community?

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older persons living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2015.

studies Design Risk of bias Inconsistency Indirectness Imprecision Other

considerations Exercise Control Relative (95% CI) Rate of falls: group exercise: multiple categories of exercise vs control (follow-up 3.5–36 months)

none 1853 1769 RR: 0.71

(0.63 to 0.82)



LOW

CRITICAL

Rate of falls: individual exercise at home: multiple categories of exercise vs control (follow-up 6–24 months)

7 randomized trials

none 469 482 RR: 0.68

(0.58 to 0.8)

CRITICAL

(continued next page)

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Rate of falls: individual exercise: LiFE (balance and strength training in daily life activities) vs control (follow-up 12 months) 1 randomized

trials

serious ^d no serious inconsistency

serious ^e none 18 16 RR: 0.21

(0.06 to 0.71)



LOW

CRITICAL

Rate of falls: group exercise: t’ai chi vs control (follow-up 5.5–12 months)

5 randomized trials

serious ^f serious ^g no serious indirectness

none 797 766 RR: 0.72

(0.52 to 1)



LOW

CRITICAL

Rate of falls: group exercise: gait, balance or functional training vs control (follow-up 5.5–24 months)

4 randomized trials

serious ^h no serious inconsistency

none 258 261 RR: 0.72

(0.55 to 0.94)

CRITICAL

Rate of falls: individual exercise: balance training vs control (follow-up 8 months) 1 randomized

trials

serious ⁱ no serious inconsistency

(0.77 to 1.82)



LOW

CRITICAL

Rate of falls: group exercise: strength/resistance training vs control (follow-up 5.5 months) 1 randomized

trials

serious ^j no serious inconsistency

(0.84 to 3.87)



LOW

CRITICAL

(continued next page)

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Rate of falls: individual exercise at home: resistance training vs control (follow-up 6 months) 1 randomized

trials

no serious risk of bias

no serious inconsistency

serious ^k none 112 110 RR: 0.95

(0.77 to 1.18)

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as method of random allocation was unclear in seven included trials and allocation concealment was unclear in 12 included trials. Outcome assessor was not masked in nine trials.

b Inconsistency: Downgraded once as moderate heterogeneity was observed for the estimate (Tau² = 0.03; Chi² = 29.11, df = 15 [P = 0.02]; I² = 48%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

c Risk of bias: Downgraded once as allocation concealment was unclear in four included trials.

d Risk of bias: Downgraded once as procedure for masking outcome assessor and management of incomplete data was unclear in the trial.

e Imprecision: Downgraded once as sample size was small (less than 200).

f Risk of bias: Downgraded once as allocation concealment was unclear in four trials.

g Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau² = 0.10; Chi² = 14.38, df

= 4 [P = 0.006]; I² = 72%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

h Risk of bias: Downgraded once as allocation concealment method was unclear in all included trials.

i Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor were unclear in the trial.

j Risk of bias: Downgraded once as method of allocation concealment, masking of outcome assessor, and management of incomplete data were unclear in the trial.

k Imprecision: Downgraded once as sample size was small (n=222).

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GRADE table 8: Group exercise intervention versus control in older people living in the community: subgroup analysis by risk of falling at baseline

Question: What is the effectiveness of group exercise (multiple categories of exercise) versus control (subgroup analysis by risk of falling at baseline) for preventing falls in older people living in the community?

bias Inconsistency Indirectness Imprecision Other considerations

Group exercise:

multiple categories of

exercise

Control Relative (95% CI)

Rate of falls: selected for higher risk of falling (follow-up 3–24 months)

9 randomized trials

none 652 609 RR: 0.70

(0.58 to 0.85)

CRITICAL

Rate of falls: not selected for higher risk of falling (follow-up 4.6–30 months)

7 randomized trials

none 1201 1160 RR: 0.72

(0.58 to 0.9)

CRITICAL

RR: rate ratio

a Risk of bias: Downgraded once as method of random allocation was unclear in five included trials and allocation concealment was unclear in seven trials.

B Risk of bias: Downgraded once as allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in four trials.

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GRADE table 9: Group t’ai chi exercise versus control in older people living in the community: subgroup analysis by risk of falling at baseline

Question: What is the effectiveness of group t’ai chi exercise versus control (subgroup analysis by risk of falling at baseline) for preventing falls in older people living in the community?

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions),

published in Issue 4, 2015.

Group exercise:

t’ai chi

Control Relative (95% CI)

Rate of falls: selected for higher risk of falling at baseline (follow-up 11–12 months)

2 randomized trials

none 283 272 RR: 0.95

(0.62 to 1.46)



LOW

CRITICAL

Rate of falls: not selected for higher risk of falling at baseline (follow-up 5.5–12 months)

3 randomized trials

none 514 494 RR: 0.59

(0.45 to 0.76)

CRITICAL

RR: risk ratio

a Risk of bias: Downgraded once as allocation concealment was unclear in one of the trials.

b Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau² = 0.07; Chi² = 3.30, df = 1 [P = 0.07]; I² = 70%)

c Risk of bias: Downgraded once as allocation concealment was unclear in three of the included trials.

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Part 2: From evidence to recommendations

Summary of evidence

Intervention Effect size

Medication withdrawal or review vs control Psychotropic medication withdrawal vs control GRADE table 1, Gillespie et al. (6)

Rate ratio: 0.34 (0.16 to 0.73);

Favours experiment Quality of evidence: LOW Medication review and modification vs usual care

GRADE table 1, Gillespie et al. (6)

Rate ratio: 1.01 (0.81 to 1.25);

Quality of evidence: LOW

Environment (home safety and aids for personal mobility) Home safety intervention vs control:

subgroup analysis by risk of falling at baseline GRADE table 2, Gillespie et al. (6)

Rate ratio: 0.62 (0.5 to 0.77); 3 trials Favours experiment

Quality of evidence: MODERATE Home safety intervention vs control:

subgroup analysis (not selected for higher risk of falling) GRADE table 2, Gillespie et al. (6)

Rate ratio: 0.94 (0.84 to 1.05); 3 trials Quality of evidence: MODERATE

Home safety intervention (occupational therapy) vs control GRADE table 3, Gillespie et al. (6)

Rate ratio: 0.69 (0.55 to 0.86); 4 trials Favours experiment

Quality of evidence: MODERATE Home safety intervention (not occupational therapy) vs control

Rate ratio: 0.91 (0.75 to 1.11); 4 trials Quality of evidence: MODERATE

(continued next page)

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Multifactorial intervention

Multifactorial intervention vs control or usual care GRADE table 4, Gillespie et al. (6)

Rate ratio: 0.76 (0.67 to 0.86);

Favours experiment Quality of evidence: LOW Multifactorial intervention vs control:

subgroup analysis (selected for higher risk of falling) GRADE table 4, Gillespie et al. (6)

Rate ratio: 0.77 (0.66 to 0.90);

Favours experiment Quality of evidence: LOW Multifactorial intervention vs control:

Rate ratio: 0.57 (0.23 to 1.38);

Quality of evidence: LOW

Multifactorial intervention: assessment and active intervention GRADE table 6, Gillespie et al. (6)

Rate ratio: 0.74 (0.61 to 0.89);

Favours experiment Quality of evidence: LOW Multifactorial intervention: assessment and referral or provision of information

Rate ratio: 0.82 (0.71 to 0.95);

Favours experiment Quality of evidence: LOW Exercise intervention

Group exercise (multiple categories vs control) GRADE table 7, Gillespie et al. (6)

Rate ratio: 0.71 (0.63 to 0.82);

Favours experiment Quality of evidence: LOW Group exercise at risk of falls (multiple categories vs control)

Rate ratio: 0.70 (0.58 to 0.85);

Favours experiment

Quality of evidence: MODERATE

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Individual exercise at home (multiple categories vs control) GRADE table 7, Gillespie et al. (6)

Rate ratio: 0.68 (0.58 to 0.80);

Favours experiment

Quality of evidence: MODERATE Individual exercise (balance and strength vs control)

Rate ratio : 0.21 (0.06 to 0.71);

Favours experiment Quality of evidence: LOW Group exercise (t’ai chi vs control)

Rate ratio: 0.72 (0.52 to 1.00);

Favours experiment Quality of evidence: LOW Group exercise (gait, balance or functional training vs control)

Rate ratio: 0.72 (0.55 to 0.94);

Favours experiment

Quality of evidence: MODERATE Individual exercise (balance training vs control)

Rate ratio: 1.19 (0.77 to 1.82) Quality of evidence: LOW

Group exercise (strength/resistance training vs control) GRADE table 7, Gillespie et al. (6)

Individual exercise at home (resistance training vs control) GRADE table 7, Gillespie et al. (6)

Rate ratio: 0.95 (0.77 to 1.18) Quality of evidence: MODERATE

Group exercise (multiple categories of exercise vs control):

Rate ratio: 0.7 (0.58 to 0.85) Favours experiment

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Group exercise (multiple categories of exercise vs control):

Quality of evidence: MODERATE Group exercise: t’ai chi vs control:

Group exercise: t’ai chi vs control:

Evidence-to-recommendations table

Problem Explanation

Is the problem a priority?

Yes No Uncertain

✓

Falls are the leading cause of injury in older people aged 65 years and over. Between 30% and 40% of community-dwelling adults aged 65 years or older fall at least once per year. Therefore, prevention of falls in older people at risk of falling is important.

Benefits and harms Explanation

Do the desirable effects outweigh the undesirable effects?

Yes No Uncertain

✓

Fifty-nine trials (which included 13 264 randomized participants) tested the effect of exercise on falls in older people. Trials were based on multimodal exercise interventions and combined two or more of the following components: (a) gait, balance and functional training; (b) strength and resistance training; (c) flexibility; (d) t’ai chi; (e) general physical activity; and (f) endurance. The interventions were delivered in groups or individually.

Moderate-quality evidence suggests that multimodal exercise, delivered in groups or individually, (continued next page)

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(continued from previous page) Do the desirable effects outweigh the undesirable effects?

Yes No Uncertain

✓

reduces the occurrence of falls in older people at risk of falls. Sixteen trials (3622 participants) examined the effectiveness of multi-component group exercise interventions. The mean age of the participants ranged from 69 to 88 years, and the mean age in 94% of the trials was over 70 years. All reviewed trials were from high-income countries. Duration of follow-up ranged from 3.5 to 36 months. Overall, the intervention achieved a statistically significant reduction in the rate of falls (Rate ratio: 0.71, 95% CI: 0.63 to 0.82). Eight trials delivered individual exercise

interventions at the participants’ homes. The mean age of the participants ranged from 74.7 to 84.1 years, and the mean age in the majority of trials was over 80 years. The duration of the trials ranged from 7.5 to 24 months. Overall, home-based interventions achieved a statistically

significant reduction in the rate of falls (Rate ratio: 0.68, 95% CI: 0.58 to 0.80). One trial, which examined balance and strength training included in daily life activities, showed a statistically significant reduction in the rate of falls (Rate ratio: 0.21, 95% CI: 0.06 to 0.71).

There is limited moderate-quality evidence that t’ai chi training may reduce the risk of falls in older people. However, the benefit of t’ai chi exercise (in terms of reduction in the rate of falls) was experienced by the subgroup who were not selected for a higher risk of falling, while there was no effect in the group selected for a higher risk of falling. Thus, t’ai chi training seems to be more effective in people who are not at high risk of falling.

Adequate low-quality evidence suggests that multifactorial interventions reduce the rate of falls in older people at risk of falls. Nineteen reviewed trials investigated the benefit of multifactorial interventions (assessment and referral or provision of active interventions). The mean age of the participants ranged from 73.1 to 80.6 years and the proportion of women participants in the trials ranged from 49% to 100%. Only one study originated from a middle-income country (Thailand), while the other 18 trials were conducted in high-income countries, mainly Australia, Canada, China, Denmark, Finland, the Netherlands, the Province of Taiwan, the United Kingdom of Great Britain and Northern Ireland and the United States of America. Multifactorial interventions

integrating assessments with individualized interventions, usually involving a multidisciplinary team, were effective in reducing the rate of falls in older people at risk of falls (Rate ratio: 0.77, CI: 0.67 to 0.86).

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(continued from previous page) Do the desirable effects outweigh the undesirable effects?

Yes No Uncertain

✓

There is limited moderate-quality evidence to suggest that home safety assessment and tailored interventions reduce the rate of falls in older people at risk of falls. Six RCTs (4208 participants) investigated the effectiveness of home safety interventions to reduce the rate of falls and the risk of falling. The mean age of the trial participants was more than 75 years. The follow-up period ranged from 3 to 18 months. Overall, home safety assessments and modification interventions were effective in reducing the rate of falls (Rate of falls: 0.62, 95% CI: 0.5 to 0.77). Furthermore, in a post hoc analysis, home safety interventions delivered by an occupational therapist were more effective than interventions delivered by other health care professionals.

There is very limited low-quality evidence suggesting that medication reviews and modification or withdrawal of medication reduce the risk of falls in older people. The results of one trial showed that withdrawal of psychotropic medication was effective in reducing the rate of falls (Rate ratio:

0.34, 95% CI: 0.16 to 0.73). In another study, an educational programme for general practitioners on medical review and treatment modification was found to be ineffective in reducing rate of falls.

Values and preferences/

acceptability

Explanation

Is there important uncertainty or variability about how much people value the options?

Major variability

Minor variability

Uncertain

✓

Fall is an important clinical outcome, which is also considered to be important by older people themselves and their family members and caregivers.

Is the option acceptable to key stakeholders?

Major variability

Minor variability

Uncertain

✓

The guideline development group strongly believes that recommendations for fall prevention will be valued by health care providers and acceptable to stakeholders (older people and those closet to them).

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Feasibility/resource use Explanation

How large are the resource requirements?

Major Minor Uncertain

✓

Fall-preventions interventions are resource intensive. However, health benefits gained from the recommendation are likely to outweigh the burden of resources required for implementation.

Intervention costs can be reduced through task shifting, engaging family members, and administering the intervention in groups.

Is the option feasible to implement?

Yes No Uncertain

✓

Multifactorial interventions may be difficult to implement as they may require the involvement of multiple service providers. In some countries, delivering exercise in groups might be difficult.

However, exercise delivered at home to individuals might be an alternative.

Some trials (those on exercise and home safety) have utilized non-specialized health care professionals to deliver fall-prevention interventions. Drawing on this experience, the guideline development group believes that it would be feasible to implement their recommendations in both high- and low-resource health care settings.

Equity Explanation

Would the option improve equity in health?

Yes No Uncertain

✓

The guideline development group strongly believes that all recommendations for prevention of falls will increase equity in health.

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Guideline development group recommendations and remarks

Recommendations

Medication review and withdrawal (of unnecessary or harmful medication) can be recommended for older people at risk of falls.

Quality of the evidence: Low

Strength of the recommendation: Conditional

Multimodal exercise (balance, strength, flexibility and functional training) should be recommended for older people at risk of falls.

Quality of the evidence: Moderate Strength of the recommendation: Strong

Following a specialist’s assessment, home modifications to remove environmental hazards that could cause falls should be recommended for older people at risk of falls.

Quality of the evidence: Moderate Strength of the recommendation: Strong

Multifactorial interventions integrating assessment with individually tailored interventions can be recommended to reduce the risk and incidence of falls among older people.

Quality of the evidence: Low

Strength of the recommendation: Conditional

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Remarks

• Effective primary health care interventions for falls use various approaches to identify people at increased risk.

• No evidence-based instrument to accurately identify older adults who are at increased risk for falling exists.

• The majority of trials were conducted in high-income countries. Further research in low- and middle-income countries is needed to understand the feasibility of implementing fall-prevention interventions in low-resource health care settings.

• There is a pressing need to standardize assessments of the risk of falls to identify high-risk older people. Currently, the history of falls is the most common factor used in the majority of trials; a small proportion of trials used additional risk factors to select patients.

• Vision care for older people at risk of falls should not be restricted to cataract surgery.

• Due to their high heterogeneity, multifactorial interventions were rated as low quality. This is largely due to differences in the intervention components included and the risk factors targeted for reducing falls. Future research should unpack multifactorial interventions and report

treatment effect by subgroup of intervention components.

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doi:10.1007/s12603-011-0062-0.

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2012;(12):CD005465.

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2010;24(9);1437–46. doi:10.1038/eye.2010.60.

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2012;(9):CD007146.

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(http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html, accessed 13 June 2017).

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doi:10.1093/ageing/afn101.

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2011;59(1);148–57. doi:10.1111/j.1532-5415.2010.03234.x.

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Annex 1: Search strategy

MEDLINE database 1946 to 2015 (search date: 9 October 2015) 1. Accidental Falls/

2. (fall$ or faller$ or fallen).tw.

3. or/1-2 4. exp Aged/

5. (senior$ or elder$ or older).tw.

6. or/4-5 7. and/3,6

8. randomized controlled trial.pt.

9. controlled clinical trial.pt.

10. randomized.ab.

11. placebo.ab.

12. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.

(random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$

or order$)).tw 13. trial.ab.

14. groups.ab.

15. or/8-14 16. humans.sh.

17. 15 and 16 18. and/7,17

19. limit 18 to systematic reviews

Embase database 1946 to 2015 (search date: 9 October 2015) 1. Falling/

2. (fall$ or fallers).tw.

3. or/1-2 4. exp Aged/

5. (elderly or senior$ or older).tw.

6. or/4-5 7. and/3,6

8. exp Randomized Controlled trial/

9. exp Double Blind Procedure/

10. exp Single Blind Procedure/

11. exp Crossover Procedure/

12. or/8-11

13. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.

14. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$

or order$)).tw.

15. ((single or double or triple) adj7 (blind$ or mask$)).tw.

16. (crossover adj1 trial).tw.

17. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.

18. or/13-17 19. or/12,18

20. Animal/ not Human/

21. 19 not 20 22. and/7,21

23. limit 22 to systematic reviews

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Annex 2: PRISMA

²

2009 flow diagram for intervention to prevention falls in community-dwelling older people

2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For more information: http://www.prisma-statement.org

Records identified through database (Embase and MEDLINE) searching (n = 374)

ScreenedEligibleIncludedIdentified

Full-text articles excluded, with reasons (n = 1):

•Target population not community dwellers Records excluded

(n = 372) Records after duplicates removed

(n = 374)

Records screened (n = 374)

Full-text articles assessed for eligibility (n = 2)

Studies included in qualitative synthesis (n = 1)

Studies included in quantitative synthesis (meta-analysis) (n = 1)

WHO/MCA/17.06.04

Evidence profile: risk of falls

Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity