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Clinical Guidelines |

Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force FREE

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
[+] Article and Author Information

From Drexel University School of Public Health, Philadelphia, Pennsylvania, and Kaiser Permanente Center for Health Research and Oregon Health & Science University, Portland, Oregon.


Acknowledgment: The authors thank Sarah Zuber, Tracy Beil, Kevin Lutz, and Debra Burch for their assistance with manuscript preparation.

Grant Support: By the AHRQ (contract HHSA-290-2007-10057-I).

Potential Conflicts of Interest: Drs. Michael, Whitlock, Lin, Fu, and O'Connor: Grant (money to institution): AHRQ. Payment for writing or reviewing the manuscript (money to institution): AHRQ. Drs. Michael, Whitlock, Lin, and O'Connor: Support for travel to meetings for the study or other purposes (money to institution): AHRQ. Drs. Michael and Lin: Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Dr. Gold: Grant (money to institution): AHRQ. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0104.

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: Dr. Michael: Epidemiology and Biostatistics, Drexel University School of Public Health, 1505 Race Street, 6th Floor, MS 1033, Philadelphia, PA 19102.

Drs. Whitlock, Lin, O'Connor, and Gold: Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227-1098.

Dr. Fu: Department of Public Health and Preventive Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code CB 669, Portland, OR 97239-3098.

Author Contributions: Conception and design: Y.L. Michael, E.P. Whitlock, J.S. Lin, E.A. O'Connor.

Analysis and interpretation of the data: Y.L. Michael, E.P. Whitlock, J.S. Lin, R. Fu, E.A. O'Connor, R. Gold.

Drafting of the article: Y.L. Michael, E.P. Whitlock, R. Fu, E.A. O'Connor.

Critical revision for important intellectual content: Y.L. Michael, E.P. Whitlock, J.S. Lin.

Final approval of the article: Y.L. Michael, E.A. O'Connor.

Statistical expertise: R. Fu, E.A. O'Connor.

Obtaining of funding: E.P. Whitlock.

Administrative, technical, or logistic support: E.A. O'Connor.

Collection and assembly of data: Y.L. Michael, J.S. Lin, R. Gold.


Ann Intern Med. 2010;153(12):815-825. doi:10.7326/0003-4819-153-12-201012210-00008
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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.

Limitations: 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.

Editor's Note: As part of the U.S. Preventive Services Task Force's (USPSTF) ongoing commitment to clarity about its work and methods, the USPSTF is inviting public comment on all draft recommendation statements. The USPSTF's draft recommendation statement on primary care–relevant interventions to prevent falling in older adults will soon be available for public comment atwww.uspreventiveservicestaskforce.org/tfcomment.htm. As a result, the recommendation on primary care–relevant interventions to prevent falling in older adults does not appear with this accompanying background review. Once finalized, the recommendation statement will reflect any changes made based on the public comments received. A summary of these changes will be included in a new section of the final recommendation statement.

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) (13). Between 30% and 40% of community-dwelling persons 65 years or older fall at least once per year (45). 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 (1113). 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.

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).

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Appendix Figure 1.
Key questions.

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.

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Table Jump PlaceholderAppendix Table 1.  Intervention Category Definitions
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 (1718). 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.

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Appendix Figure 2.
Summary of evidence search and selection.

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.

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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 (2021).

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

The 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.

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 review (16) 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 (18). Details of each included study are summarized in Appendix Tables 2, 3, 4, 5, and 6. The Table shows a summary of evidence by intervention category.

Table Jump PlaceholderAppendix Table 2.  Effectiveness of Multifactorial Assessment and Management Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 3.  Effectiveness of Exercise or Physical Therapy Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 4.  Effectiveness of Single Clinical Treatment Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 5.  Effectiveness of Home-Hazard Modification Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 6.  Effectiveness of Clinical Education or Behavioral Counseling Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderTable.  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 (2341). 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.

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

CG = control group; IG = intervention group.

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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 (4360). 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 (5052, 5860) 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, 5354, 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.

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

CG = control group; IG = intervention group.

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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 (4360); in addition, 2 additional fair-quality trials (496 participants) were identified in our harms search (6162). 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) (6371). Five of the trials included only women (6667, 6971); the proportion of women in the other trials ranged from 51% to 80% (6365, 68). Five trials were conducted in populations defined as high risk because of recent falls or vitamin D deficiency (64, 6770). The remaining 4 studies used populations that were unselected except for age 65 years or older (63, 6566, 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, 6668).

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, 6771). The control groups ranged from no intervention (69, 71) to placebo (6366) or calcium supplements only (6768, 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.

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

CG = control group; IG = intervention group.

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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 (6566, 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, 7274). 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 (7374). 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 (2325, 3132, 3741).

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) (4849, 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 (2325, 3031, 3338, 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.

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, 7779), 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 (7980). 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 (8283), 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 (7778, 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 (6566, 68, 71); these data were generally protective. One large null study (85) 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.

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Figures

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Appendix Figure 1.
Key questions.

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.

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Appendix Figure 2.
Summary of evidence search and selection.

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.

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

CG = control group; IG = intervention group.

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

CG = control group; IG = intervention group.

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

CG = control group; IG = intervention group.

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Tables

Table Jump PlaceholderAppendix Table 1.  Intervention Category Definitions
Table Jump PlaceholderAppendix Table 2.  Effectiveness of Multifactorial Assessment and Management Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 3.  Effectiveness of Exercise or Physical Therapy Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 4.  Effectiveness of Single Clinical Treatment Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 5.  Effectiveness of Home-Hazard Modification Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderAppendix Table 6.  Effectiveness of Clinical Education or Behavioral Counseling Interventions to Prevent Falls in Older Adults
Table Jump PlaceholderTable.  Summary of Evidence, by Intervention Category

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