Prevention of falls in the elderly: A review

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1 483215SJP / M. K. Karlsson et al.short Title 2013 Scandinavian Journal of Public Health, 2013; 41: REVIEW ARTICLE Prevention of falls in the elderly: A review MAGNUS K. KARLSSON, THORD VONSCHEWELOV, CAROLINE KARLSSON, MARIA CÖSTER & BJÖRN E. ROSENGEN Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics and Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden Abstract Aims: Falls often result in soft tissue injuries, dislocations, fractures, longstanding pain and reduced quality of life. Therefore, fall preventive programmes have been developed. Methods: In this review, we evaluate programmes that in randomized controlled trials (RCT) have been shown with fall reducing effect. Results: Physical exercise that includes several training modalities, especially balance and strength training, is the only intervention programme that reduces both the number of fallers and the number of falls in community dwellers. Home hazards modification reduces the fall risk in communityliving elderly but has the best effects in high risk groups when the programme is led by occupational therapists. Vitamin D supplement in those with low levels of vitamin D, adjustment of psychotropic medication and modification of multipharmacy are drug-related programmes that reduce the fall risk. Anti-slip shoe devices in elderly who walk outdoors during icy conditions and multifaceted podiatry to patients with specific foot disability are interventions targeted at the lower extremities with a fall-reducing effect. First eye cataract surgery and pacemakers in patients with cardio-inhibitory carotid sinus hypersensitivity are surgical procedures with fall-reducing effect. Multifactorial standardized preventive programmes that include an exercise component and individually-designed subject-specific programmes also reduce the number of falls. Conclusions: Fall preventive interventions should be provided to elderly by a structured approach, especially to high risk groups, as to reduce the number of falls and fallers. Key Words: Elderly, epidemiology, falls, fractures, prevention, randomized controlled trials Epidemiology One third of community-dwellers aged >65 years and 60% of people in nursing and retirement homes fall each year, with women falling more often than men [1]. Falls are often followed by pain syndromes, functional limitations, dislocations, serious soft tissue injuries, fractures, immense health-care costs and high mortality [2]. Up to 15% of falls in patients living in the community [1] and 20% of falls in institutionalized patients [3] result in a significant injury. Up to 12% of all falls in the elderly are also followed by a fracture [4] and just below 1% in a hip fracture [1,3]. In addition, 23% of trauma related deaths in patients >65 years and 34% in those >85 years follow a fall [5]. Fall-related injuries therefore result in an enormous health care burden. In the US, during the year 2000, around 10,300 fatal and 2.6 million non-fatal but medically-treated fall-related injuries occurred in individuals >65 years [6]. Of all fall related injuries, fractures may provide the largest health care burden [7]. Fragility fractures, that is, fractures of the proximal humerus, distal forearm, vertebrae, pelvis, hip and the tibial condyles in elderly due to a low-energy trauma, share common features such as a higher incidence in women than in men and an exponential increase with advancing age [8]. The incidence of hip fractures has increased during the recent 50 years [9,10] even if there in many Western countries has been a decline in the incidence since the end of the former century [9,10]. But in spite of this trend break, the total number of hip fractures is still increasing due to changes in population demographics. As the proportion of elderly in the Correspondence: Magnus Karlsson, Department of Orthopedics, Skåne University Hospital, SE Malmö, Sweden. magnus.karlsson@med.lu.se (Accepted 26 February 2013) 2013 the Nordic Societies of Public Health DOI: /

2 future will grow even larger, the total number of fragility fractures will continue to rise [11], a fact that highlights the need of fall and fracture reducing interventions. Risk factors for falls Currently a variety of risk factors for falls have been identified. Falls are regarded as one of the single most important predictors for fractures, and few low energy-related fragility fractures occur without a fall [1,4]. Furthermore, falls become a more potent risk factor for fractures with advancing age [12]. As individuals with multiple risk factors are at especially high risk to sustain falls, it is clinically important to determine the number of risk factors in each patient [13]. By advocating such a structured approach, we ought to identify individuals suitable for fall preventive interventions. Risk factors for falls can be divided into two types, intrinsic risk factors such as old age, female gender, Caucasian ethnicity, postmenopausal status, tallness, low body mass, cognitive impairment, musculoskeletal diseases, chronic arthritis, gait and balance disorders, sensory impairments, postural hypotension, history of previous falls, use of certain medications such as benzodiazepines, sedative-hypnotic drugs, antidepressants, anti-hypertensive medication, antiarrhythmic drugs, diuretics and anti-seizure medications [1,3,4,8,14,15]. But there are also environmental risk factors that increase the fall risk, such as living in nursing home, an immobile lifestyle, malnutrition, loose rugs, slippery and uneven floors and outdoor surfaces, poor lighting, electrical cords, stools without handrails, unsuitable footwear, often referred to as extrinsic risk factors [1,3,4,8,16]. Extrinsic factors play a progressively smaller role for fall risk as age advances, largely because the intrinsic factors, such as chronic illnesses, get more important in this age group [16]. We must still however identify extrinsic risk factors in the old fall prone patient as 50% 80% of patients treated in emergency departments for a fall related injury report environmental home hazards as one of the causes of their fall [17]. Modification of risk factors for falls Risk factors for falls can also be divided into modifiable and non-modifiable. Non-modifiable risk factors can be used as a marker for future fall risk. Modifiable risk factors can be addressed by interventions and include most extrinsic risk factors, but also some of the intrinsic risk factors such as impaired neuromuscular function. Given the complexity of fall-related risk factors, intervention programmes Prevention of falls in the elderly: A review 443 should address as many risk factors as possible. To reach the highest cost effectiveness, prevention programmes ought to be focused on high risk groups and the preventive effort should include both intrinsic modifications and environmental changes [18,19]. Since having a history of falling is one of the strongest independent risk factor for future falls, it is especially important to include all elderly that have fallen in a structured assessment of fall risk. This has been successfully done in the PROFET study (Prevention of Falls in the Elderly Trial) in which a structured intervention programme reduced the fall risk by 70% in patients who had attended an emergency department with a fall [20]. That is, there is evidence for the effectiveness of addressing high risk individuals with fall preventive programmes. We identified studies through a structured search in PubMed from all years by using the terms: accidental falls, physical therapy, equipment, supplies, self-help devices, protective devices, environmental intervention, home modification, exercise, exercise therapy, physical education and training. From the identified studies we included those evaluating effects of interventions designed to reduce falls in older people, evaluated in RCTs, in individuals aged 60 years or more or if described as elderly, seniors or older individuals. The participants should be living in the community at home or in places of residence not providing residential health-related care. Trials that included younger participants, for example recruited on the basis of a medical condition such as a stroke or Parkinson s disease was included if the mean age minus one standard deviation was more than 60 years. References that evaluated interventions in nursing care facilities, that is in long-term institutions or facilities, or in hospitals are presented separately. In studies with participants living in different settings, participants were included if data were provided for subgroups based on setting. Intervention programmes were included if compared with usual care or placebo and studies that evaluated two types of fall-prevention interventions were also included. Finally, we went through the included studies and excluded those without the end point variables number of falls or number of participants sustaining at least one fall during follow up (fallers). Apart from these studies we also included recently-published structured reviews and Cochrane reviews within the field that summarized the outcome in published RCT [14,15,21 27]. We chose to present central studies reported in these Cochrane reviews in the figures, that is, the entire 159 RCT reported in the latest Cochrane review are not included in the figures. Finally, we also reviewed each article in the reference lists of each identified paper

3 444 M. K. Karlsson et al. Figure 1. Comparison of number of falls in community-living elderly exposed to intervention with different types of exercise interventions vs. controls reported in a variety of RCTs. fulfilling the above mentioned criteria to add further relevant RCTs. The meta-analyses calculations referred to in this article are in detail reported in the cited Cochrane reviews [14,15,21]. In summary, in the meta-analyses, data from different RCTs with comparable interventions and participant characteristics were pooled by use of generic inverse variance method. Calculated pooled rate ratios for total number of falls or risk ratios for being a faller with 95% confidence intervals were estimated through the fixed-effect model. Where there was substantial statistical heterogeneity, data were pooled using a random effect model [20]. Exercise interventions Physical training in community-living elderly reduces the risk of falling [14,15,18,26,28 54] (Figure 1).

4 This effect is most obvious in those who are most compliant with the training programme [39,55,56]. The most effective exercise modalities are multicomponent programmes that include balance and muscle strength training, followed by flexibility and endurance training [15]. The training should be performed often and with high frequency [18,49]. These programmes have been shown to be both the most effective and the most cost-effective fall preventive strategy in the elderly community living population [57 60], and the only intervention that reduces both the number of fallers and the fall rate [15,21]. All other interventions targeted at an unselected population have at best reduced only one of these two variables [15,21]. Supervised group exercise in community living elderly >60 years, where at least two different training components are included, decreases the rate of falls by 22% (relative risk [RR] 0.78, 95% CI 0.71, 0.86) (Figure 1) and the risk of falling by 17% (RR 0.83, 95% CI 0.72, 0.97). The beneficial effects are more prominent in high-risk individuals (Figure 1). Training classes in community-living elderly that include only gait, balance and/or functional training reduce the fall rate with 27% (RR 0.73, 95% CI 0.54, 0.98) (Figure 1) but not the number of fallers (RR 0.77, 95% CI 0.58, 1.03). Home-based individually designed exercise programmes with more than one exercise category is another strategy that in community-living elderly reduce the number of falls and then by 34% (RR 0.66, 95% CI 0.53, 0.82 (Figure 1) and the risk of falling by 23% (RR 0.77, 95% CI 0.61, 0.97) [15] But also single exercise modalities may be effective [61]. Tai Chi has been shown as one of the most effective training strategies, in one RCT shown to decrease the number of fallers by close to 50% [50] and in a meta-analyse that included unselected community living elderly the number of falls by 37% (RR 0.63, 95% CI 0.52, 0.78) (Figure 1) and the number of fallers by 35% (RR 0.65, 95% CI 0.51, 0.82). The beneficial effect is usually referred to the fact that Tai Chi includes both strength and balance training [61]. Only walking, often conducted as a single physical activity, does not reduce the fall risk in elderly community living individuals [15,26,62,63]. Neither seems selective muscle-strengthening training reduce the number of falls [26], even if this training modality has been included as one component in multicomponent exercise programmes with fall reducing effect [15, 31, 64]. The effect of physical training as a fall reducing strategy seems be less obvious in institutionalized individuals [14,65 71] (Suppl. 1). Supervised Prevention of falls in the elderly: A review 445 training in institutionalized patients >65 years reduced the risk of falling by 56% (RR 0.44, 95% CI 0.20, 0.97) (Suppl. 1), but subgroup analysis revealed that the effect was only found in individuals in subacute care hospitals and not in patients in general nursing care facilities [14] (Suppl. 1). It should also be noted that studies on gait, balance and coordination exercises that used a mechanical apparatus reduced the rate of falls by 55% (RR 0.45, 95% CI 0.24, 0.85) (Suppl. 1) also in individuals in nursing homes. That is, specific types of training and in specific patient groups seem to reduce the fall frequency also in elderly in nursing homes or other type of hospitals (Suppl. 1). Vitamin D interventions Vitamin D supplement, with or without calcium, in community living elderly did not reduce the number of falls (RR 0.95, 95% CI 0.80, 1.14) (Suppl. 2) or number of fallers (RR 0.96, 95% CI 0.92, 1.01) [15,21,72 76]. Neither did this intervention reduce the number of fallers in institutionalized elderly (RR 0.98, 95% CI 0.89, 1.09) even if the total number of falls was reduced by 28% (RR 0.72, 95% CI 0.55, 0.95) [14]. Adverse effects such as hypercalcaemia, renal disease and/or gastrointestinal effects were in the three trials that included data on adverse effects not increased in the intervention groups. In subgroup analysis that included pooled data of communitydwelling elderly, the rate of falls was reduced by 43% (RR 0.57, 95% CI 0.37, 0.89) (Suppl. 2) with supplement to elderly with low vitamin D levels at baseline, as was the risk of falling (RR 0.65, 95% CI 0.46, 0.91) [15,21,75,76]. In contrast, no fall-reduction was found when including participants with normal vitamin D levels at baseline (Suppl. 2). Furthermore, there was no fall-reductive effect in community dwellers with alfacalcidol (RR 1.08, 95% CI 0.75, 1.57) whereas those with calcitriol had a 36% reduction in number of falls (RR 0.64, 95% CI 0.49, 0.82) [15,21,77]). That is, vitamin D supplement may reduce the number of falls but probably only in those with low levels of vitamin D and maybe only with specific types of vitamin D drugs. Drug-targeted interventions Common problems in the elderly are multi-pharmacy and a combination of different drugs may produce an excess in fall rate. In contrast, a structured prescription modification programme with gradual withdrawal of psychotropic medication was in one RCT followed by reduced fall rate in community-dwellers

5 446 M. K. Karlsson et al. Figure 2. Comparison of number of falls in community-living elderly exposed to intervention with home hazard assessment followed by risk factor reduction vs. controls reported in a variety of RCTs. by 66% (RR 0.34, 95% CI 0.16, 0.73) (Figure 3) but not the number of fallers (RR 0.61, 95% CI 0.32, 1.17) [28]. Another RCT that included communitydwelling elderly reported that fall-preventive education for family physicians, feedback on prescribing practices, and financial rewards combined with selfassessment of medication followed by a subsequent medication review and modification of prescriptions reduced the risk of falling by 39% (RR 0.61, 95% CI 0.41, 0.91) [78] (Figure 3). Similar positive effects was found in a RCT that evaluated a prescribing modification programme by pharmacist in nursing care facilities or hospitals, an intervention that reduced the fall frequency by 38% (RR % CI 0.53, 0.72) [28]. Surgical interventions Specific surgical treatments in specific risk cohorts reduce the fall risk. A cardiac pacemaker in patients with cardio-inhibitory carotid sinus hypersensitivity was in one published RCT reported to reduce the

6 Prevention of falls in the elderly: A review 447 Figure 3. Comparison of number of falls in community-living elderly exposed to drug withdrawal, surgery and foot assessment vs. controls reported in a variety of RCTs. rate of falls by 58% (RR 0.42, 95% CI 0.23, 0.75) (Figure 3), but not the number of fallers [79 81]. Cataract surgery for the first eye was in another RCT found to reduce the rate of falls by 34% (RR 0.66, 95% CI 0.45, 0.95) (Figure 3), but not the number of fallers (RR 0.95, 95% CI 0.68, 1.33) [82]. It should also be noted that surgery for the second eye in people with cataract did not reduce the fall rate (RR 0.68, 95% CI 0.39, 1.17) [83] (Figure 3). Footwear interventions Type of footwear may influence the risk of falling [84]. The oldest individuals, mostly staying indoors, have the highest likelihood to fall inside their home. This risk is thus more associated with intrinsic risk factors, such as severe medical problems and poor functional ability [85]. Younger individuals are more prone to fall outdoors [85] and their falls are attributed not only to footwear properties but also to environmental factors such as temperature, snowfall and lighting [86]. In one RCT, anti-slip shoe devices reduced the rate of falls by 58% (RR 0.42, 95% CI 0.22, 0.78) (Figure 3) and minor-injurious falls by 87% (RR 0.13, 95% CI 0.03, 0.66) in elderly individuals but only during icy conditions [87]. Another RCT that evaluated the effect of multifaceted podiatry including foot and ankle exercise in patients with

7 448 M. K. Karlsson et al. disabling foot pain, found that this intervention reduced the fall risk by 36% (RR 0.64, 95% CI 0.45, 0.91) (Figure 3) but not the risk of falling compared to standard podiatry [88]. Anti-slip shoe device devices should therefore be recommended to ambulatory elderly who walk outdoors under icy conditions and multifaceted podiatry to patients with specific foot disability. Home hazard interventions Most falls that lead to fragility fractures occur indoors and this is even more pronounced in individuals >80 years [85]. Home hazard modification should therefore be focused at the oldest [24,46,87,89,90 93] but modification of home hazards in the general elderly population also reduces the number of falls (RR 0.81, 95% CI 0.68, 0.97) (Figure 2) and the number of fallers (RR 0.88, 95% CI 0.80, 0.96) [21,46,89 92,94,95]. The effect was most obvious when the programme was conducted by occupational therapists [89,92,94,96] (Figure 2). In addition, home hazards modification in individuals >75 years with visual impairment who were recommended to remove or change loose floor mats, paint the edges of steps, reduce glare, install grab bars and stair rails, remove clutter and improve lighting where needed, was followed by a 41% fall reduction (RR 0.59, 95% CI 0.42, 0.83) (Figure 2) and 24% reduction in the number of fallers (RR 0.76, 95% CI 0.62, 0.95) [15,21,92]. A subgroup analysis found that the home safety-programme significantly reduced the rate of falling in high risk individuals such as individuals with a history of falls or multiple risk factors, with a fall reduction of 44% (RR 0.56, 95% CI 0.42, 0.76) but not in the subgroup without increased fall risk (RR 0.92, 95% CI 0.80, 1.06) (Figure 2). The subgroup analysis also revealed that the intervention reduced the number of fallers in the highest risk subgroup by 22% (RR 0.78, 95% CI 0.64, 0.95) but not in the subgroup with normal risk (RR 0.90, 95% CI 0.80, 1.00) [15,21,97]. Home hazard assessment and modification of risk factors should therefore be provided to all elderly in society, but specifically to high risk individuals since the interventions are more effective in people at higher risk of falling. Generalized multifaceted interventions Physiological changes, diseases, drug intake, visual impairment, development of sarcopenia and other risk factors of falling are increasing with advancing age. These risk factors decrease the ability to compensate for a slip or disturbed balance during everyday activities [98]. Thus, falling can be regarded as a failure of a complex system of factors that all would benefit from specific interventions strategies [98]. One approach would be to prescribe general intervention programmes that include fixed combination of different components of intervention delivered to all participants independently of individual demands. Standard multiple intervention programmes would be easy to initiate and follow and similar programmes often include exercise, care planning, medical and/or diagnostic approaches, changes in physical environment, education programmes, calcium and vitamin D supplementation, medication review, removal of physical restraints [14,15,21,25,92,99 102] (Figure 4). Such standard programmes report a 31% fall reduction when using a combination of exercise, education and home safety interventions (RR 0.69, 95% CI 0.50, 0.96) [100], an 81% reduction with exercise plus nutritional supplementation with vitamin D and calcium in replete women (RR 0.19, 95% CI 0.05, 0.68) [102], a 24% reduction with an exercise component and home safety assessment (RR 0.76, 95% CI 0.60, 0.97) [95], a 27% reduction with exercise plus vision assessment (RR 0.73, 95% CI 0.59, 0.91) [95], a 23% reduction with exercise plus vision and home safety assessment (RR 0.67, 95% CI 0.51, 0.88) [95] and a 23% reduction when using an educational intervention combined with free access to a geriatric clinic assessments (RR 0.77, 95% CI 0.63, 0.94) [103] (Figure 4). Individualized multifactorial interventions Multifaceted individualized interventions would hypothetically be the ideal strategy to reduce the number of falls [14,15,21]. Each individual would in such a programme be evaluated for risk factors for falls and then, if found to be at high risk, referred to an individually-designed prevention programme with a specific combinations of interventions based on the individual assessment [15,17,20,21, ] (Figure 5). Individualized multifactorial interventions have been shown to reduce the rate of falls in community-dwelling older adults by 25% (RR 0.75, 95% CI 0.65, 0.86) (Figure 5) but not the number of individuals who fall (RR 0.95, 95% CI 0.88, 1.02) [15]. In hospital settings, these multifactorial interventions reduce rate of falls by 31% (RR 0.69, 95% CI 0.49, 0.96) and the risk of falling by 27% (RR 0.73, 95% CI 0.56, 0.96). No fall-reducing effect was however found when including only individuals in nursing home facilities (RR 0.82, 95% CI 0.68, 1.08), even if further sub-analysis revealed that multidisciplinary team approaches together with physical training in nursing homes reduced the rate of falling

8 Prevention of falls in the elderly: A review 449 Figure 4. Comparison of number of falls in community-living elderly exposed to intervention with generalized multifaceted interventions vs. controls reported in a variety of RCTs. by 40% (RR 0.60, 95% CI 0.5, 0.72) and the number of fallers by 15% (RR 0.85, 95% CI 0.77, 0.95) [14]. It should also be noted that all multiple intervention trials that reduced the fall risk included physical training as one component of the programme [14,15,21] (Figure 5). Interventions with no or deleterious effects No RCT has ever shown that assistive devices only, such as canes and walkers, reduce the number of falls or the number of fallers. These devices have however been used for centuries, are cheap and without any adverse effects. It is therefore reasonable to continue to recommend assistive devices to fall prone individuals. Clinicians can recommend interventions without support by RCT as long as they are aware of this shortcoming, since lower levels of evidence also provide us with valuable information. This is actually how we should use the evidence based system; absence of evidence is not the same as evidence of absence of effect. Furthermore, RCTs with multifaceted interventions that include assistance devices as one component have reduced the number of falls [14,21,25]. Oral nutritional supplementation, such as fluid or nutrition therapy, is another intervention that has not been proven in RCT to reduce the number of falls [116] and the same accounts for cognitive behavioral intervention [117]. Two RCTs have also reported that interventions that increase the knowledge about

9 450 M. K. Karlsson et al. Figure 5. Comparison of number of falls in community-living elderly exposed to intervention with individualized multifactorial interventions vs. controls reported in a variety of RCTs. fall-prevention in patients did not reduce the number of falls or number of fallers [93,118]. Intervention programmes may also increase the fall rate. Two RCTs have reported that intervention to improve vision with vision assessment, eye examination, new spectacles and/or ophthalmology treatment in conjunction mobility training and canes increased the fall rate by 57% (RR 1.57, 95% CI 1.19, 2.06) (Figure 2) and the risk to become a faller by 54% (RR 1.54, 95% CI 1.24, 1.91) [15,91,95]. Different combinations of exercise modalities in hospitalized individuals not tailored to each specific individual were in one RCT found to more than double the fall rate (RR 2.72, 95% CI 1.42, 5.19) [68] (Suppl. 1) and when using pooled data from several RCTs by 37% (RR 1.37, 95% CI 1.01, 1.85) [14] (Suppl. 1). This highlights the importance of drawing inferences for fall-preventive effect only in cohorts similar to the one originally evaluated. Beneficial effect found in one cohort may not apply to different populations. Cost benefits In one review there were eight RCTs that included economic evaluation as an outcome [15,21]. These studies infer that there is weak evidence that prevention strategies for fall reduction can be cost saving during the trial period but also during the rest of the lifespan of the participants. All reports also infer that

10 to obtain a maximum value for money, the prevention strategies with fall reducing effects, ought to be targeted at high risk subgroups of older people to reach to greatest cost-beneficial effects [15]. Conclusions Currently there is strong evidence that both the number of falls and the number of fallers can be reduced by structured intervention. Physical training reduces the number of falls in elderly communitydwelling individuals. The most effective approach includes multicomponent exercise programmes with strength and balance training and if possible also flexibility and endurance training. Exercise in supervised groups, home training, Tai Chi training and individualized programmes all reduce the number of falls. Exercise in institutionalized individuals, except for maybe persons in a sub-acute care hospital, seems less effective. Home hazard assessment with modification of risk factors is efficient for community-living elderly but with special beneficial effect found in high risk groups or if the programme was led by occupational therapists. Anti-slip shoe devices reduce the fall rate in elderly who walk outdoors during icy conditions. Multifaceted podiatry in patients with specific foot disabilities reduces the fall risk. Multifaceted generalized interventions and multifactorial individually-designed programme reduce the rate of falls in older people living in the community with the most beneficial effect in those at the highest risk of falls. These multifaceted interventions should include a physical training component. Vitamin D supplement reduces the number of falls, but only in those with low vitamin D levels. Ensuring that multi-medications are reviewed and adjusted reduce the number of falls, as do gradual withdrawal from drugs that improve sleep, reduce anxiety and depressive symptoms. First eye cataract surgery and pacemakers in patients with carotid sinus hypersensitivity are examples of surgery in specific risk cohorts that reduce the number of falls. In summary, there is today strong evidence for implementation of structured fall-preventive programmes in elderly to reduce the number of falls and fallers both in community-living elderly and in those staying in hospitals or nursing homes. Conflict of interest None declared. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. Prevention of falls in the elderly: A review 451 References [1] Tinetti ME, Speechley M and Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319: [2] Kannus P, Sievanen H, Palvanen M, et al. Prevention of falls and consequent injuries in elderly people. Lancet 2005;366: [3] Tinetti ME, Liu WL and Ginter SF. 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