Intended for healthcare professionals

Rapid response to:

Clinical Review

Fall assessment in older people

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5153 (Published 14 September 2011) Cite this as: BMJ 2011;343:d5153

Rapid Response:

No new evidence to drag fall assessment out of bed!

Dear Editor.

We read with interest the clinical review by Close and Lord (1) on fall assessment in the elderly, but are surprised about the methods used and the conclusions drawn by the authors.

First, the authors use a very limited part of the existing evidence that seem to be chosen as it is in line with the authors' pre-defined conclusions. We are astonished about the neglect of the bulk of evidence demonstrating that fall risk assessment and screening is as good as tossing a coin and therefore without clinical relevance and most likely a waste of resources. A proper evidence-based systematic review surely would have led to different conclusions.

The authors acknowledge that useful assessment instruments need to show good predictive and discriminatory characteristics and argue that there are instruments that "have acceptably high accuracy in predicting those who will or will not fall". We wonder how the authors come to their conclusions and where they set the threshold for accuracy. Again a limited part of the evidence is presented to the readers consisting mostly of original validation studies that naturally show higher diagnostic accuracy compared to further replication studies in different populations (2, 3). An own systematic review and a recently conducted HTA report (4) impressively confirmed what had already been acknowledge by Gates et al. (5) for community dwelling elderly and by Oliver for hospitals patients i.e. that it is "time to put [fall risk prediction tools] to bed!" (6).

We seriously challenge the authors' statement that "several approaches" linking assessment and interventions have been shown to be effective. Surely the results of the Cochrane reviews on fall prevention (7, 8) are far from showing a consistent picture. Also, considering the Cochrane reviewers' conclusion that there has to be more research on what might be effective under what circumstances (7), the generalisability of the study results seems disputable. Apart from methodological challenges inherent to the Cochrane reviews, e.g. pooling data in spite of pronounced clinical heterogeneity, most importantly fall assessment and intervention programmes failed to show effectiveness on the most relevant clinical endpoint, i.e. fall-related injuries.

Finally, the authors surprisingly fail to acknowledge the available direct evidence for the absence of effectiveness of fall assessment tools. We have shown in a randomised controlled trial that using a fall risk assessment tool in nursing homes had no effect on falls and fall-related injuries (9).

In conclusion, the authors may be convinced that fall risk assessment is a good thing to do, but have failed to acknowledge the striking evidence for the limited accuracy and the lack of effectiveness of existing tools as well as the weak evidence for multifaceted interventions comprising assessment and interventions.

References

1. Close J, Lord S. Fall assessment in older people. BMJ 2011;343:d5153.

2. Justice A, Covinsky K, Berlin J. Assessing the generalizability of prognostic information. Annals of Internal Medicine 1999;130:515-24.

3. Koepke S, Meyer G. The Tinetti test - Babylon in geriatric assessment. Z Gerontol Geriatr 2006;39:288-91.

4. Balzer K, Bremer M, Luehmann D, Raspe H. Fall prevention in the elderly: current evidence and challenges for further research. Fourth European Nursing Congress. Older Persons: the Future of Care. Rotterdam, 04.-07.10.2010. J Clin Nurs 2010;19:25-6.

5. Gates S, Smith L, Fisher J, Lamb S. Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults. J Rehabil Res Dev 2008;45:1105-16.

6. Oliver D. Falls risk-prediction tools for hospital inpatients. Time to put them to bed? Age Ageing 2008;37:248-50.

7. Gillespie L, Robertson M, Gillespie W, Lamb S, Gates S, Cumming R, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2008;2:CD007146.

8. Cameron I, Murray G, Gillespie L, Robertson M, Hill K, Cumming R, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;1:CD005465.

9. Meyer G, Koepke S, Haastert B, Muehlhauser I. Comparison of a fall risk assessment tool with nurses' judgement alone: a cluster-randomised controlled trial. Age Ageing. 2009;38:417-23.

Competing interests: None declared

Competing interests:

18 September 2011
Sascha Koepke
Professor
Katrin Balzer, Research Fellow, and Gabriele Meyer, Professor
Nursing Research Group, Institute of Social Medicine, University of Luebeck, Luebeck, Germany (SK&KB