BMJ  2007;334:53-54 (13 January), doi:10.1136/bmj.39084.388553.80

Editorials

Preventing falls in elderly people living in hospitals and care homes

Inconclusive evidence means uncertainty remains

Falls are common in elderly people living in institutions, and they often cause serious injuries such as hip fracture.^{1 2} The clinical and economic costs of such injuries are high,³ and numerous guidelines have been developed to reduce falls and related injuries. A variety of approaches have been used in different countries and it is not known whether these have been effective. Current literature suggests that some interventions may be effective, based on lower levels of evidence, and these have been combined into multifactorial interventions in many studies.⁴ In this week's BMJ a systematic review by Oliver and colleagues evaluates interventions to prevent falls and fractures in people living in hospitals and care homes.⁵

It is important to review the effectiveness of interventions in these settings as most studies of falls have been conducted in the community.⁶ People in institutional settings have different risk profiles to those living in the community because their activity is limited and they often have cognitive impairment. Also, interventions in institutions are often dependent on the involvement of staff rather than the individual. The most recent Cochrane systematic review⁶ and clinical guidelines on preventing falls^{7 8} consider prevention programmes in general and do not provide specific guidance for institutional settings.

The review by Oliver and colleagues provides limited evidence of the effectiveness of multifaceted interventions in hospitals (13 studies, relative risk 0.82, 95% confidence interval 0.68 to 0.99) and of hip protectors in care homes (11 studies, 0.67, 0.46 to 0.98). Only these two of the eight categories of intervention in the two settings showed some evidence of effectiveness; the others were inconclusive.

Part of the reason for the inconclusive results may have been the variety of interventions used in the studies, which ranged from exercise programmes to hip protectors. Institutional settings also varied between countries. These differences in approach are reflected in the heterogeneity of results.⁹

Interpretation of the review is complicated by differences in the outcomes measured: the percentage of people who fall, the total number of falls, the number of falls per participant, and falls as a time dependent variable. The best outcome measure is number of falls because interventions are probably better at preventing multiple falls in one person than reducing the overall number of people who fall. The meta-analyses in the review present data to support this.

Why did Oliver and colleagues examine dementia in the meta-regression? Dementia (or cognitive impairment) increases the risk of falls and fractures. The prevalence of dementia in elderly people in institutional care is high, and evidence is lacking that programmes aimed at preventing falls are effective in this group.¹⁰ The review shows that the presence of dementia does not influence the effectiveness of strategies to prevent falls and fractures in institutional settings. In addition, the review found no evidence that effectiveness is increased by improved adherence (www.rdg.ac.uk/ihs/bmj_falls.htm).

Interventions to prevent falls may paradoxically increase the risk of falls and injuries, or have other side effects, in elderly people in hospitals and care homes. These potential harms are not directly considered in the review, although they have been documented elsewhere. For example, one randomised controlled trial found that the rate of falls was increased in the intervention group (incidence rate ratio 1.34, 1.06 to 1.72).¹¹

It is not clear what effect these results should have on clinical practice. Although there is an emerging consensus that multifaceted interventions and exercise programmes prevent falls in community settings,¹² we cannot be confident that the same applies to preventing falls and fractures in hospitals and care homes.

Clinicians will need to apply the available evidence in the context of the institutional setting, local policies and guidelines, and available resources. Key interventions are those that are cornerstones of appropriate care for elderly people. These include adequate supervision, encouragement of supervised mobility and exercise, individually prescribed aids, a safe institutional environment, avoidance of psychotropic drugs where possible, and recognition of changes in health status that predispose to falls, such as delirium. The combination of these can be considered a multifactorial intervention. Researchers should use the available evidence to design focused studies that can answer the question of how to prevent falls in institutional care. Ideally a large multicentre study will examine a standardised multifactorial intervention (including the components outlined above) with falls and peripheral fractures as key outcomes. This should be a cluster randomised trial with hospital and residential care facility strata.⁹ Economic analyses will be required to guide implementation. Until further research is completed, uncertainty remains about the prevention of falls and fractures in hospitals and nursing care facilities.

¹ Rehabilitation Studies Unit, University of Sydney, Ryde, NSW 2112, Australia, ² University of Sydney, Hornsby, NSW 2077, Australia

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Competing interests: IDC and SK have been chief investigators in research studies of hip protectors that have received funding from the Australian National Health and Medical Research Council and other funding bodies. Several companies have provided hip protectors at reduced cost for some of these studies.

References

1. Kannus P, Sievänen H, Palvanen M, Järvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet 2005;366:1885-93.[CrossRef][ISI][Medline]
2. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ 2000;320:341-6.[Abstract/Free Full Text]
3. Stevens A, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290-5.[Abstract/Free Full Text]
4. Todd C, Skelton D. What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen: WHO Regional Office for Europe Health Evidence Network report, 2004. www.euro.who.int/document/E82552.pdf
5. Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007 doi: 10.1136/bmj.39049.706493.55[Abstract/Free Full Text]
6. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2003;(4):CD000340.
7. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Fall Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664-72.[CrossRef][ISI][Medline]
8. Royal College of Nursing. Clinical practice guideline for the assessment and prevention of falls in older people www.nice.org.uk/guidance/CG21/guidance/pdf/English
9. The Cochrane Collaboration. Glossary of terms in the Cochrane Collaboration. Version 4.2.5, May 2005. www.cochrane.org/resources/handbook/glossary.pdf
10. Shaw FE, Bond J, Richardson DA, Dawson P, Steen IN, McKeith IG, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003;326:73-9.[Abstract/Free Full Text]
11. Kerse N, Butler M, Robinson E, Todd M. Fall prevention in residential care: a cluster, randomized, controlled trial. J Am Geriatr Soc 2004;52:524-31.[CrossRef][ISI][Medline]
12. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004;328:680-6.[Abstract/Free Full Text]

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