Secondary_Prevention_of_Falls_in_Older_People

Review Article Secondary Prevention of Falls in Older People: A Systematic Review Chin-Ying Chen 1, Arminee Kazanjian 2, Martha Donnelly 3 Although several systematic reviews have been reported on fall prevention for older people, there is no review on secondary prevention of falls for older people. Our objective is to assess the effectiveness of intervention programs on secondary prevention of falls in older people. The study design is a systematic review of published controlled clinical designed studies for older people with a history of falls. We used keyword searches of MEDLINE, CINAHL, and EMBASE from 1996 to March 2002. Only English literatures were reviewed. Studies were reviewed if they met the following criteria: (1) randomized controlled trials (RCT); (2) participants were aged 65 years or older; (3) participants had history of falls; (4) secondary prevention of falls was an aim of the study. A total of 5 RCT met the criteria. Two multifactorial targeted intervention programs showed significant reduction of the risk of falling and /or recurrent falling. One multifactorial targeted intervention program revealed the tendency of reduction for subjects with recent recurrent falls ( exercise program as a single intervention was not effective. There is no evidence of exercise as a single intervention for secondary prevention of falls in older people. Occupational therapy home assessment is effective in the subgroup with history of falls, but further study is indicated for the widespread implementation as an individual fall prevention strategy. Several well-designed studies have shown the effectiveness of multifactorial targeted intervention. The tendency of effectiveness by multifactorial targeted intervention in subjects with recent recurrent falls need further study. (Tw Fam Med Res 2005; 3: 49-64) Key words: accidental falls, aged, review literature 2 falls). One occupational therapy intervention was effective in the subgroup with history of falls, one 1 2 3 Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Health Care and Epidemiology, The University of British Columbia, Vancouver, Canada Division of Community Geriatrics, Department of Family Practice, The University of British Columbia, Vancouver, Canada Received: December 21, 2004; Accepted: August 15, 2005. Correspondence to: Dr. Chin-Ying Chen, Department of Family Medicine, National Taiwan University Hospital, 7, Chung-Shan S. Road, Taipei 100, Taiwan, R.O.C. Tw Fam Med Res 2005 Vol.3 No.2, 3 49 Chen CY et al INTRODUCTION A fall is defined as unintentionally Canada. [7] Males have a higher mortality rate due to falls, especially at older ages, and that the mortality rate for both sexes due to falls increases dramatically beyond the age of 80 years [7]. In addition, compared with older people who do not fall, those who fall have more functional decline and are at increased risk for subsequent institutionalization [1]. Older people who have had an injurious fall are significantly more likely to use health care services in the following years [8] . For some seniors, an injurious fall may be the "last straw" or the precipitating event that causes family members to arrange for formal home care or institutionalization [7]. Most of the research in the area of falls in the elderly in 1980s had the goal of identifying the risk factors related to falls. During the 1990s and in the current decade studies of the effectiveness of fall prevention programs have become more common. Fall prevention programs are usually a primary prevention for healthy seniors or a heterogeneous group. A practice guide for the prevention of falls among seniors living in the community was recently published by Health Canada in September 2001. However, our study will focus on the secondary prevention of falls. Secondary prevention of falls is important because those who had a history of falls are at higher risk of subsequent falls than those who never had falls. We hope to present the best available coming to the ground or some lower level and other than as a consequence of sustaining a violent b l o w, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure by the Kellogg International Working Group in 1987 . Statistics show that incidence of falls differs significantly from a Poisson distribution. This implies that causal processes are involved in falls and that they are not merely random events . E a c h y e a r, a p p r o x i m a t e l y 3 0 % o f community-dwelling persons over the age 65 a n d 5 0 % o f t h o s e o v e r 8 0 y e a r s f a l l [2,3]. About half of those who fall do so more than once. In a prospective study of 325 community-dwelling persons who had fallen in the previous year, Nevitt et al [4] found that 57% experienced at least one fall in a 12month follow-up period and 31% had two or more falls. An estimated 5% of falls among community-dwelling elderly result in a fracture, and less than 1% in a hip fracture . [5] More than 90% of hip fractures are associated with falls. Hip fractures are the leading fall-related injury that results in hospitalization, which is often expensive . [6] A recent national study found that falls are the second leading cause of hospitalization among women age 65+, and fifth leading cause among men in this age group in 50 2005 Secondary Prevention of Falls in Older People information for the effectiveness of interventions designed to reduce the incidence of recurrent falls in older people with a history of falls. inclusion and exclusion criteria, g e n e r a l i s a b i l i t y, f o r m s o f i n t e r v e n t i o n , measure of outcomes, number lost to follow up, evidence of intervention effects, adverse effects. METHODS RESULTS Search strategy Three computerized databases were accessed in April 2002 for relevant Englishwritten articles. Medline, CINAHL and EMBASE were searched using Ovid. The databases were searched within the following periods: Medline (1996 to March 2002), EMBASE (1996 to April 2002), CINAHL (1996 to April 2002). Keywords for searching included falls/accidental falls/pc, meta-analysis, review literature, meta analysis, o v e r v i e w, systematic a p p r a i s a l , s y s t e m a t i c r e v i e w, c r i t i c a l appraisal, critical review, clinical trial. The database search revealed a total of 173 articles. Selection criteria Studies were reviewed if they met the following criteria: (a) randomized controlled trials; (b) participants were aged 65 years or older; (c) participants had a history of falls; (d) secondary prevention of falls was an aim of the study. The following factors were considered in each study: study design, eligible population, population agreeing to be randomized, age distribution, setting, Five randomized controlled trials meeting the inclusion criteria were identified and reviewed. Although one randomized controlled trial [9] didn't recruit all of the participants with a history of falls, it was included because stratified block randomization was applied according to one or more versus zero falls in the past year. Table 1 gives the study aims, sample, interventions used, intervention compliance, and intervention effects based on the review of the studies. In one of the 5 articles, the occupational-therapy assessment was a single intervention, and in 3 studies the occupational therapy assessment was provided with other interventions in a multifactorial or dual approaches. Medical assessment was provided in two of the 3 multifactorial or dual approached studies. In one of the 5 articles, exercise was a single i n t e r v e n t i o n , a n d i n t h e o t h e r s t u d y, t h e exercise was included as a referred program. Because of the great variability of intervention design among the five RCTs, we can only summarize the studies descriptively. Tw Fam Med Res 2005 Vol.3 No.2, 3 51 52 Chen CY et al Table 1. Summary of randomized controlled trials on secondary prevention of falls in older people Intermediate and other effect Effects on falls and fall injuries No The mean proportion of recurrent fallers in intervention facility (43.8%)was 19.1% (95% CI: 2.4% -35.8%) lower than that for control facility (54.1%) (p=0.03). The intervention reduced the risks of at least one hospital admission by 39% (odds ratio: 0.61, CI: 0.35-1.05) after adjustment for baseline Barthel & abbreviated mental (AMT) scores Articles, study aims, case Interventions Program compliance number, duration, analysis Ray et al (1997) Intervention group: The implementation of Fall intervention in nursing Multifactorial intervention safety recommendation is home residents age ≥65 by a team of physician, 63%in intervention group with a history of fall psychiatrist, geriin three months n=482, 1 year psychiatric nurse, nurse, ITT analysis and occupational therapist. Control group: No activity Close et al (1999) Intervention group: Assessment rate in the Fall intervention on elderly Medical assessment and intervention group: 83% age ≥65 who presented to occupational therapist medical and 99.3% emergency department home assessment with occupational therapist with a fall referral to relevant service home assessment rate n=391, 1 year if indicated The implementation of ITT analysis Control group: usual care safety recommendation is not reported. 2005 Cumming et al. (1999) Fall intervention in elderly age ≥65 who discharged from selected wards. n=530 (total),stratified on with/without a history of falls (n=206/324); 1 year ITT analysis Intervention group: 1-hour occupational therapist home assessment with specific recommendation. The occupational modification is funded. Control group: no active intervention Home visit rate: 64% in No intervention group Compliance with occupational modification: 19% to 75% on different recommendation At 1 year, the intervention reduced the risk of falls by 61% (odds ratio:0.39. CI: 0.23-0.6) after adjustment for differences in Barthel & AMT. The intervention reduced the risk of recurrent falling by 67% (odds ratio: 0.33, CI:0.16-0.68) Among people with a history of falls, the intervention reduced the proportion of people falling during follow-up by 36% (RR=0.64, 95% CI: 0.50-0.83, p=0.001) The intervention was not effective among people with no history of falls Tw Fam Med Res 2005 Vol.3 No.2, 3 Articles, study aims, case number, duration, analysis Hogan et al(2001) Fall intervention on community-dwelling elderly age ≥65 with ≥1 fall in past 3 months n=163, 1 year ITT analysis Intervention group 1-2 hrs in-home assessment by a team of specialist in Geriatric Medicine, 2 nurses, 2 OT and 1 PT Control group: usual care Interventions Program compliance Hauer et al (2001) Fall intervention in older women age ≥75 in acute care or inpatient rehabilitation with a history of injurious falls n=57, 3- month intervention Not mention in ITT analysis Intervention group: resistance training, progressive functional balance training for 3 months Control group: placebo activity Intermediate and other effect Effects on falls and fall injuries Complete rate: No No significant reduction in 85.3% (66/79) in intervention group for the intervention group and cumulative number of falls 86.9% (73/84) in usual (p=0.34), having one or care group more falls (p=0.30) or the Compliance to mean number of falls recommendation was not (p=0.43) reported Post-hoc subgroup analysis: subjects with more than 2 falls in past 3 months in the intervention group were less likely to fall (p=0.046) Adherence to intervention: Muscle strength: and At 6-month, the incidence 85.4±27.8% in functional performance of falls equivalent to a intervention group; 84± improved at the end and 3 15% non-significant 29.3% in control group month after the reduction of secondary intervention (p