Comparisons of Interventions for Preventing Falls in Older Adults

Note from IGS President, Dr. Diarmuid O' Shea:

The inaugural contribution to this ejournal is from Dr Grainne Ni Mhaillie a consultant Geriatrician with Dr Sanjyoth Reddy Yeruva in Sligo University Hospital and is on “Comparisons of Interventions for Preventing Falls in Older Adults”.  The editorial comment is provided by Dr Paul McElwaine, Consultant Physician and Geriatrician at Tallaght University Hospital.  I look forward to seeing how this new IGS initiative evolves under the guidance and leadership of our Digital Editorial lead Dr Shane O Hanlon and our new Editorial Board.

We are interested in any additional comments you have about this paper and initiatives and resources that your local services are accessing or using to improve the care delivered to people who have had a fall or fractures.   We look forward to you sharing any tips, hints or informed comments you may have and that you can post on the topic of “Falls”.

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Comparisons of Interventions for Preventing Falls in Older Adults
Dr S R Yeruva, Dr G O Malley

A Systematic Review and Meta-analysis
Andrea C. Tricco, PhD; Sonia M. Thomas, MSc; Areti Angeliki Veroniki, PhD; et al
JAMA. 2017;318(17):1687-1699. doi:10.1001/jama.2017.15006

Introduction

Falls continue to be a significant challenge with an ageing population and increase in attributable risk factors in older people.  How we best reduce the risk of and prevent falls is still a challenge.  This recently published article helps provide positive advice with regard to falls prevention strategies.   

Summary

What are the key components of an effective falls prevention programme? There has been a multitude of single intervention studies exploring mechanisms to prevent falls in older adults. In this paper, the authors carried out a complex network meta-analysis to explore the efficacy of both single and multi-component interventions to prevent falls. The authors included 283 RCTs involving 159910 participants (mean age, 78.1yrs; 74% women) in the systematic review.  The study included all types of RCTs examining fall-prevention interventions for adults aged 65 years or older in all settings.  Comparators were usual care, other fall-prevention interventions, and placebo. The primary outcome measured was the number of injurious falls and fall-related hospitalizations. Secondary outcomes included fractures, healthcare usage and quality of life measures. Baseline characteristics were similar between the control and intervention groups in many of the studies, but a high proportion had unclear risk of bias for allocation and selective outcome reporting.

A network meta-analysis for primary outcome of injurious falls included 54 RCTs (41,596 participants) with 39 interventions plus usual care. The following four single and combined interventions were associated with lower risk for injurious falls, compared with usual care:


1.    Exercise, such as walking and balance training (odds ratio, 0.51)
2.    Exercise combined with vision assessment and treatment (OR, 0.17)
3.    Exercise combined with vision assessment and treatment and environmental assessment and home modifications (0.30)
4.    Clinic-based quality-improvement strategies (combined with multifactorial assessment and treatment (e.g., comprehensive geriatric assessment) and vitamin D and calcium supplementation (OR, 0.12)

The network meta-analysis for the secondary outcome of fracture included 86,491 participants and examined 43 interventions plus usual care. Of these, only 1 intervention (combined osteoporosis treatment (eg, bisphosphonates), calcium supplementation, and vitamin D supplementation) was associated with a lower risk of fractures relative to usual care (OR, 0.22). 

Commentary

Management of falls poses a huge challenge in everyday practice. Presenting a network meta-analysis at journal club in an understandable format is also difficult, as an enormous amount of falls interventions are simultaneously compared. However, network meta-analysis may provide evidence that is useful for clinical decision-making, because it allows comparisons of interventions that may not have been directly compared in head-to-head trials. At our discussion, we felt this paper did provide useful insights from both an individual patient and organisational perspective. While efforts at reducing falls are focused on patients in the hospital setting, this study emphasises the importance of a coordinated approach to reviewing patients in community and in their home. The study also emphasises the importance of a multifactorial approach. 

From an individual perspective, the combination of exercise and vision assessment and treatment was the intervention most strongly associated with reduction in injurious falls. However, among previous fallers, subgroup analyses showed that the combination of exercise and multi-factorial assessment and treatment was associated with an increased risk of injurious falls. Exercise may increase fall risk in some individuals because they become more mobile as their strength improve; patients can be made aware of this situation and advised accordingly.  However, any cautionary advice must be balanced with the need to improve mobility and avoid deconditioning. 

Take Home Messages

Our take home message is that evidence supports exercise and a multi-disciplinary, coordinated individualised approach to preventing injurious falls. However, it raises the question as to the type of exercise to recommend. It emphasises the importance of the proactive treatment of osteoporosis to prevent the one of the most problematic consequences of falls which is fractures.

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Editorial Comment – Dr Paul McElwaine

This is one of the types of articles that lends itself to generating informed discussion and debate at our Journal Clubs around the country.  
As a comprehensive systematic review it is a welcome publication to inform the discussion on how best to manage falls prevention.  The fact that journals such as JAMA are publishing these reviews gives weight to the rising importance that falls and falls prevention now holds in the medical community, and highlights the importance of interdisciplinary teams and community teams playing an active role in falls assessment and prevention.

The authors identify that exercise alone or in combination with other interventions has benefit over usual care.  Exercise is likely to become a more prescriptive part of how we manage both primary and secondary preventive strategies in a number of conditions including falls.  The findings are presented with the caveat that in some patient groups the increase in activity may have an effect of increasing the falls rate, as there are more opportunities to fall with changes from a sedentary state.  Thus highlighting the importance of patient centred and individualised assessment and intervention in falls prevention.  
The paper highlights that a number of interventions have potential benefit, and perhaps would argue that in the absence of all the elements of care, implementation of some of these interventions in a more pragmatic way, may change established behaviours and promote more practical evidence of effectiveness.

The combination of exercise and vision assessment and treatment as being the intervention with the strongest association of reducing injurious falls certainly will change my practice, in particular in developing pathways for patients to access specialist care e.g. surgical ophthalmology.

Weaknesses are evident in this paper.  For example cost effectiveness as a secondary outcome was unanalysed due to inconsistency in the few studies reporting this measure and perhaps more importantly for hospital based physicians, few studies were conducted in the acute care setting.

This comprehensive review does demonstrate that any effective strategy requires knowledge of successful interventions which are tailored to an individual patient’s needs.  The greater challenge is in how to provide individualised care to a patient in an increasingly heterogeneous and complex group of people.

Learning Points

•    Promoting and highlighting the need for regular and safe exercise in all patients, but in particular those at risk of falls should be a daily routine in practice.
•    Assessment and treatment of vision related problems is important, potentially reduces injurious falls and should be a prominent part of a falls prevention strategy.
•    The choice of intervention which is most likely to be effective needs to reflect the values and preferences of the patient.