Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether ...characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.
Update of a systematic review with random effects meta-analysis and meta-regression.
Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.
We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.
99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I
47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson's disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I
65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I
21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital.
Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.
Background: it is uncertain as to which measures of gait best predict those who are likely to fall. Our aim was to investigate the associations of gait and gait variability measures with incident ...falls risk.
Methods: individuals aged 60-86 years (n = 412) were randomly selected from the Tasmanian electoral roll. Average gait and gait variability measures were collected on a computerised walkway. Falls were recorded prospectively over 12 months. Log multinomial regression was used to estimate the relative risk of single and multiple falls associated with gait measures. Covariates included age, sex, sensorimotor and cognitive measures, mood and medications.
Results: in this population-based study greater intra-individual variability in step length and double-support phase were linearly associated with increased risk of multiple falls (P = 0.04). Non-linear associations with multiple falls were found for gait speed P = 0.002, cadence P = 0.004 and step time variability P = 0.03. None of the gait measures predicted risk of single falls.
Conclusion: there is an increased risk of multiple falls, but not single falls, in older people with poorer gait. Specific measures of gait and gait variability seem to confer this risk and may be amenable to interventions designed to reduce the risk of multiple falls in older people.
Abstract
Background
Healthcare professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier and furthermore, there is ...no consensus on which medications are considered as FRIDs despite several systematic reviews. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) and a deprescribing tool were developed by a European expert group.
Methods
STOPPFall was created by two facilitators based on evidence from recent meta-analyses and national fall prevention guidelines in Europe. Twenty-four panellists chose their level of agreement on a Likert scale with the items in the STOPPFall in three Delphi panel rounds. A threshold of 70% was selected for consensus a priori. The panellists were asked whether some agents are more fall-risk-increasing than others within the same pharmacological class. In an additional questionnaire, panellists were asked in which cases deprescribing of FRIDs should be considered and how it should be performed.
Results
The panellists agreed on 14 medication classes to be included in the STOPPFall. They were mostly psychotropic medications. The panellists indicated 18 differences between pharmacological subclasses with regard to fall-risk-increasing properties. Practical deprescribing guidance was developed for STOPPFall medication classes.
Conclusion
STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review. The effectiveness of these tools in falls prevention should be further evaluated in intervention studies.
Abstract
Background
Older people are at high risk of falls after hospital discharge. The study aimed to evaluate the effect of providing individualized falls prevention education in addition to usual ...care on falls rates in older people after hospital discharge compared to providing a social intervention in addition to usual care.
Methods
A randomized clinical trial at three hospitals in Western Australia: participants followed for 6 months after discharge. Baseline and outcomes measured by assessors masked to group allocation. Participants: aged 60 years and over, admitted for rehabilitation. Eligibility included: cognitively able to undertake education (Abbreviated mental test score >7/10). Intervention: tailored education comprising patient video and workbook, structured discussion and goal setting led by trained therapist. Main outcomes: falls in the 6 months after discharge; proportion of participants sustaining one or more falls.
Results
There were 382 (194 intervention; 188 control) participants (mean age 77.7 SD 8.7 years). There were 378 falls (fall rate per 1,000 patient-days, 5.9 intervention; 5.9 control) reported by 164 (42.9%) participants in the 6 months following hospital discharge; 188 (49.7%) of these falls were injurious. There were no significant differences in falls rates between intervention and control groups: (adjusted IRR, 1.09; 95% CI 0.78 to 1.52) or the proportion of participants who fell once or more (adjusted OR, 1.37; 95% CI 0.90 to 2.07).
Conclusions
Providing individualized falls prevention education prior to discharge did not reduce falls at home after discharge. Further research is warranted to investigate how to reduce falls during this high-risk transition period.
Objectives
To investigate the discriminative ability and diagnostic accuracy of the Timed Up and Go Test (TUG) as a clinical screening instrument for identifying older people at risk of falling.
...Design
Systematic literature review and meta‐analysis.
Setting and Participants
People aged 60 and older living independently or in institutional settings.
Measurements
Studies were identified with searches of the PubMed, EMBASE, CINAHL, and Cochrane CENTRAL data bases. Retrospective and prospective cohort studies comparing times to complete any version of the TUG of fallers and non‐fallers were included.
Results
Fifty‐three studies with 12,832 participants met the inclusion criteria. The pooled mean difference between fallers and non‐fallers depended on the functional status of the cohort investigated: 0.63 seconds (95% confidence (CI) = 0.14–1.12 seconds) for high‐functioning to 3.59 seconds (95% CI = 2.18–4.99 seconds) for those in institutional settings. The majority of studies did not retain TUG scores in multivariate analysis. Derived cut‐points varied greatly between studies, and with the exception of a few small studies, diagnostic accuracy was poor to moderate.
Conclusion
The findings suggest that the TUG is not useful for discriminating fallers from non‐fallers in healthy, high‐functioning older people but is of more value in less‐healthy, lower‐functioning older people. Overall, the predictive ability and diagnostic accuracy of the TUG are at best moderate. No cut‐point can be recommended. Quick, multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls.
Abstract
Background
The aim was to investigate the associations of sarcopenia as defined by European Working Group on Sarcopenia in Older People (EWGSOP) and Foundation for the National Institutes of ...Health (FNIH) Sarcopenia Project, and their underlying components, with the incidence of recurrent falling and fractures.
Methods
In 498 older men and women (mean age = 75.2 SD = 6.4) from the Longitudinal Aging Study Amsterdam (LASA), the sarcopenia components lean mass (DXA), handgrip strength (handheld dynamometer), and gait speed were measured. Data on falls (3-year follow-up) and fractures (10-year follow-up) were collected. Cox regression analyses were performed, adjusting for age, sex, and total body fat.
Results
Recurrent falling occurred in 130 persons and 60 persons experienced a fracture during follow-up. Participants who were identified as sarcopenic based on the FNIH definitions had a more than 2-fold increased risk to become a recurrent faller. There was no association between sarcopenia based on the EWGSOP definition and incidence of recurrent falling. When the sarcopenia components were examined individually, only a low grip strength was associated with incidence of recurrent falling, independent of a low lean mass or a slow gait speed. Sarcopenia according to both definitions was not associated with incident fractures, which may be caused by low statistical power.
Conclusion
Sarcopenia according to the FNIH definitions, but not according to the EWGSOP definition was associated with recurrent falling. When examining the individual components, only a low grip strength was independently associated with recurrent falling. No associations between sarcopenia with incidence of fractures were found.
Objective
To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall‐related fractures in community‐dwelling older persons.
Methods
MEDLINE, Embase, ...and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) evaluating the effectiveness of fall prevention interventions in community‐dwelling adults aged ≥65 years, from inception until February 27, 2019. Two large RCTs (published in 2020 after the search closed) were included in post hoc analyses. Pairwise meta‐analysis and network meta‐analysis (NMA) were conducted.
Results
NMA including 192 studies revealed that the following single interventions, compared with usual care, were associated with reductions in number of fallers: exercise (risk ratio RR 0.83; 95% confidence interval CI 0.77–0.89) and quality improvement strategies (e.g., patient education) (RR 0.90; 95% CI 0.83–0.98). Exercise as a single intervention was associated with a reduction in falls rate (RR 0.79; 95% CI 0.73–0.86). Common components of multiple interventions significantly associated with a reduction in number of fallers and falls rate were exercise, assistive technology, environmental assessment and modifications, quality improvement strategies, and basic falls risk assessment (e.g., medication review). Multifactorial interventions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80–0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89–1.01). The following single interventions, compared with usual care, were associated with reductions in number of fall‐related fractures: basic falls risk assessment (RR 0.60; 95% CI 0.39–0.94) and exercise (RR 0.62; 95% CI 0.42–0.90).
Conclusions
In keeping with Tricco et al. (2017), several single and multiple fall prevention interventions are associated with fewer falls. In addition to Tricco, we observe a benefit at the NMA‐level of some single interventions on preventing fall‐related fractures.
Background
At least one‐third of community‐dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these ...people. An up‐to‐date synthesis of the evidence is important given the major long‐term consequences associated with falls and fall‐related injuries
Objectives
To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community.
Search methods
We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies.
Selection criteria
We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.
Main results
We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster‐RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here.
Exercise (all types) versus control
Eighty‐one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high‐certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high‐certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not.
The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall‐related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low‐certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low‐certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low‐certainty evidence). Exercise may make little important difference to health‐related quality of life: conversion of the pooled result (standardised mean difference (SMD) ‐0.03, 95% CI ‐0.10 to 0.04; 3172 participants, 15 studies; low‐certainty evidence) to the EQ‐5D and SF‐36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales.
Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non‐serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups.
Different exercise types versus control
Different forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high‐certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high‐certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate‐certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate‐certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low‐certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high‐certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control.
Authors' conclusions
Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high‐certainty evidence). The effects of such exercise programmes are uncertain for other non‐falls outcomes. Where reported, adverse events were predominantly non‐serious.
Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.
PDF
