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Exercise alone, intervention combinations lower risk for injurious falls

Compared with usual care, exercise alone and various combinations of interventions were associated with lower risk for falls leading to injury, according to findings recently published in JAMA.

“The key elements of an effective fall-prevention program remain unclear, which has hampered implementation of effective interventions,” Andrea C. Tricco, PhD, of the Li Ka Shing Knowledge Institute at Saint Michael’s Hospital in Toronto, and colleagues wrote. “Furthermore, a network meta-analysis ranking all available fall-prevention interventions and their combinations has not been conducted.”

Researchers conducted a systematic review of 283 randomized clinical trials with 159,910 participants. The mean age of the participants was 78.1 years, and 74% were women. The network meta-analysis included 54 randomized clinical trials and 41,596 participants.

Interventions reviewed were vision, podiatry and multifactorial assessments and treatments; vitamin D supplementation; surgery; social engagement; quality improvement strategies; osteoporosis medications; floor modifications; exercise; environmental assessment and modification; electromagnetic field therapy and whole-body vibration; diet modification; devices; cognitive behavioral therapy; calcium supplementation; and basic falls risk assessment. Quality improvement strategies centered on increasing use of research in practice, and were classified at patient, clinic and clinician and health system levels, according to researchers.

Primary outcomes were numbers of injurious falls and fall-related hospitalizations. Secondary outcomes were costs such as those related to the health care system, number of fallers, number of fall-related ED visits, number of fall-related physician visits, number of fractures, number of intervention-related harms such as muscle soreness from exercise, quality of life, and rates of falls. Potential comparators were placebo, other fall-prevention interventions and usual care, which researchers said was defined as what clinicians provided to their patients for fall prevention in each study.

Tricco and colleagues found that with 97% likelihood, combined exercise and vision assessment and treatment appeared to be the most effective intervention to reduce injurious falls (OR = 0.17; 95% CI, 0.07-0.38; absolute risk difference, –1.79%; 95% CI, –2.63 to –0.96).

According to researchers, other interventions linked to a reduced risk for injurious falls compared to usual care, included:

• calcium supplementation, vitamin D supplementation, combined clinic-level quality improvement strategies, multifactorial assessment and treatment (OR = 0.12; 95% CI, 0.03-0.55; absolute risk difference, –2.08; 95% CI, –3.56 to –0.6);
• combined exercise, vision assessment and treatment, and environmental
• assessment and modification (OR = 0.3; 95% CI, 0.13–0.7; absolute risk difference, –1.19%; 95% CI, –2.04 to –0.35); and

• exercise (OR = 0.51; 95% CI, 0.33-0.79; absolute risk difference, 0.67; 95% CI, –1.1 to –0.24).

In addition, Tricco and colleagues found that pairwise meta-analyses for fall-related hospitalizations showed no significant link between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care.

Researchers wrote that their findings suggest strategies to prevent falls cannot be one size fits all.

“Choice of fall-prevention intervention may depend on patient and caregiver values and preferences. ... The results indicate the need for a tailored approach.”

In a related editorial, Eric B. Larson, MD, MPH, wrote that Tricco and colleagues’ findings could serve as a “catalyst for change” in getting more Medicare recipients to utilize existing interventions to prevent falls.

“[This systematic review] provides evidence that knowledge and practices to reduce fall risk among older persons are available, especially by promoting regular and safe exercise,” he wrote. “Using advances from implementation science could help minimize delay in creating sustained system- and community-wide programs to prevent falls. Direct-to-consumer campaigns may be useful to increase awareness about potentially devastating consequences of falls and ways to prevent them. Clinicians and health care systems should evaluate how best to deliver interventions to reduce falls among their patients and increase efforts to achieve effective fall prevention among older persons.” – by Janel Miller

Disclosures: Larson reports no relevant financial disclosures. Tricco reports receiving grants from Tier 2 Canada Research Chair in Knowledge Synthesis Grant. Please see the study for all authors relevant financial disclosures.