Preventing falls in elderly people

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.¹²