In 1960 Sheldon described the literature on falling as “meagre.”
w1
Now so much has been published on the topic that it is difficult to
make sense of the evidence and identify clear messages for policy and
practice. We know that more than 30% of people aged 65 or older living
in the community fall each year, many fall more than once, and the risk
of falling increases with age.
1,2
Although only 3-10% of these falls result in serious injury, they have
serious implications for healthcare resources. What do we know about how
to prevent falls?
Over 60 randomised controlled trials
of interventions to prevent falling have now been published.
This issue
contains a systematic review of interventions for the prevention of
falling (p 680).
3
Chang et al searched up to 2002 and include 40 trials; a further six
trials were identified after they had completed their analysis. A
Cochrane review, updated in July 2003 (for which the author is a
reviewer), contains 62 trials.
4
These two reviews reach broadly similar conclusions but differ in
detail. As well as covering a different time period, the inclusion
criteria and statistical methods used by Chang et al differ from those
used in the Cochrane review, which could account for some of the
variation in results.
Both reviews agree that
multifactorial risk assessment and management programmes are effective,
although it is not possible to say which components of the
multifactorial interventions are the most effective, according to Chang
et al. They also conclude that exercise programmes overall are
effective. The Cochrane review, on the other hand, splits exercise
programmes into individually targeted interventions and group
interventions. It concludes that individualised, home based programmes
of muscle strengthening, balance retraining, and walking, which target
people at higher risk, are effective.
5,6
w2 However, community based group exercise interventions have not been shown to reduce the number of persons falling,
3 although they may of course produce other health and social benefits.
Chang
et al report that environmental modification does not result in an
appreciable reduction in the risk of falling. However, the Cochrane
review contains additional evidence that shows that home assessment may
be effective for people with a history of falls in the previous year,
but this needs more research. Both reviews conclude that education alone
is not beneficial.
The Cochrane review also examined
interventions for targeting single risk factors. For example, the
gradual withdrawal of psychotropic medication seemed effective.
6
However, many participants who had successfully reduced their
consumption of psychotropic drugs in the trial returned later to prior
medication patterns. This remains a challenge.
The review by Chang et al contains only one trial evaluating interventions to reduce falls in hospital,
w3
whereas the Cochrane review contains four small randomised controlled
trials set in hospital rehabilitation or geriatric assessment wards.
Evidence that these interventions were effective is lacking. Haines et
al, in this issue, report on an intensive multicomponent trial in a
subacute hospital setting that achieved a 30% reduction in falls (p
676).
7 This will add to that body of knowledge, but further good quality research is needed in other hospital settings.
8
Overall,
it has been possible to achieve only modest reductions, usually less
than 35% in the number of people falling and in the number of falls,
even in the somewhat artificial settings of randomised controlled
trials. On the basis of these data, service providers should set
conservative and achievable targets. As many of the possible
interventions are labour intensive and expensive, we need to target
effective interventions at people who are most likely to benefit.
Targeting
effective interventions at people at higher risk so as to maximise the
impact on the number of falls makes sense. Tinetti has proposed an
algorithm based on evidence from randomised controlled trials and the
epidemiological literature.
9
She recommends that people of 75 years or older, or over 70 if they are
known to be at increased risk of falling, should be asked about falls
and balance or gait difficulties, and observed getting into and out of a
chair and walking. People with a history of two or more falls, or
balance or gait difficulties, should be assessed for predisposing and
precipitating factors, followed by interventions suggested by the
results of that assessment. People without balance or gait related
difficulties and a history of no more than one fall should be encouraged
to participate in an exercise programme that includes balance and
strength training. Oliver et al suggest a similar approach in hospital
settings.
10
The
impact of falling on the quality of people's lives should not be
forgotten in the current focus on risk management. Healthcare activities
ought also to address psychological issues such as fear of falling and
self imposed restriction of activity.
11
w4 w5 Healthcare professionals and carers should avoid
placing unnecessary restrictions on older peoples' activity, whether
imposed consciously or unconsciously.
12
We should reflect on the potential dangers associated with a risk
management culture, and continue to encourage measures to promote
autonomy and independence in older people.
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