Evidence profile: risk of falls

Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity

Evidence profile: risk of falls

Scoping question:

Do interventions to prevent falls produce any benefit or harm for older people at risk of falls?

The full ICOPE guidelines and complete set of evidence

profiles are available at:

who.int/publications/i/item/9789241550109

Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression. Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved

WHO/MCA/17.06.04

https://www.who.int/publications/i/item/9789241550109

Evidence profile: risk of falls

ICOPE guidelines – World Health Organization

Contents

Background .......................................................................................................................................................................................................................... 1

Part 1: Evidence review ....................................................................................................................................................................................................... 2

Scoping question in PICO format (population, intervention, comparison, outcome) ............................................................................................................ 2 Search strategy ...................................................................................................................................................................................................................... 3 List of systematic reviews identified by the search process .................................................................................................................................................. 3 PICO table .............................................................................................................................................................................................................................. 4 Narrative description of the studies that went into analysis .................................................................................................................................................. 5 GRADE table 1: Medication review or withdrawal versus control for older people living in the community ......................................................................... 6 GRADE table 2: Environment (home safety and aids for personal mobility) versus control for older people living in the community: subgroup analysis by risk of falling at baseline .................................................................................................................................................................................................... 7 GRADE table 3: Home safety intervention versus control for older people living in the community: subgroup analysis by delivery personnel ................. 8 GRADE table 4: Multifactorial intervention versus control for older people living in the community .................................................................................... 9 GRADE table 5: Multifactorial intervention versus control for older people living in the community: subgroup analysis by risk of falling at baseline ...... 10 GRADE table 6: Multifactorial intervention versus control for older people living in the community: subgroup analysis by intensity of intervention ........ 11 GRADE table 7: Exercise intervention versus control for older people living in the community ......................................................................................... 12 GRADE table 8: Group exercise intervention versus control in older people living in the community: subgroup analysis by risk of falling at baseline ... 15 GRADE table 9: Group t’ai chi exercise versus control in older people living in the community: subgroup analysis by risk of falling at baseline ............ 16

Part 2: From evidence to recommendations ................................................................................................................................................................... 17

Summary of evidence .......................................................................................................................................................................................................... 17 Evidence-to-recommendations table ................................................................................................................................................................................... 20

Guideline development group recommendations and remarks ................................................................................................................................... 24

References .......................................................................................................................................................................................................................... 26

Annex 1: Search strategy .................................................................................................................................................................................................. 28

Annex 2: PRISMA 2009 flow diagram for intervention to prevention falls in community-dwelling older people ................................................... 29

© World Health Organization 2017

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

https://creativecommons.org/licenses/by-nc-sa/3.0/igo

1 Evidence profile: risk of falls


Background

In older people, falls are the most prominent external cause of

unintentional injury. Research suggests that one third of

community-dwelling people aged over 65 years fall each year and

almost half of them experience recurrent falls (1–10). Incidents of

falls by older people are strongly associated with hospitalization,

severe functional decline, care dependency and premature

admission to institutional care (11). Nearly 15% of falls result in

non-fatal injuries (12), ranging from minor bruises and wrist

lacerations to hip fractures (4, 5, 13). More importantly,

23–40% of injury-related deaths in older people are attributable to

falls (9, 14).

The risk factors for falls are complex and multifactorial in nature.

Evidence from longitudinal studies suggests strong interactions

among multiple risk factors, such as age, sex, previous history of

falls, chronic diseases and environmental factors (4, 10, 14).

Medical conditions that increase the risk of falls include: orthostatic

hypotension (6, 8, 10, 15), musculoskeletal disease (3, 5, 16),

visual impairment (7, 17, 18), low systolic blood pressure, stroke,

cognitive impairments, Parkinson’s disease, gait disorders, balance

disorders and sensory impairments (3, 4, 7, 10, 14). Medications in

general, and polypharmacy in particular, increase the risk of falls in

older people (19).

In recent years, there has been an increasing level of research and

policy interest in the public health impact of falls. The effectiveness

of single and complex programmes for the prevention of falls and

fall-related injuries was extensively tested among older people at

risk of falls (20). Most intervention studies were carried out in

community settings; a few were undertaken in hospitals and

residential care settings (13). In this document, the evidence for

fall-prevention interventions undertaken for community-dwelling

older people at risk of falls has been summarized to inform the

recommendations provided in the full ICOPE guidelines available

at who.int/ageing/publications/guidelines-icope.

http://who.int/ageing/publications/guidelines-icope



Part 1: Evidence review

Scoping question in PICO format (population,

intervention, comparison, outcome)

Population

Older people 60 years of age and older (both male and female) at

risk of falls

Interventions

• Multicomponent exercise programme/strength training

• Falls risk assessment by the physiotherapist to develop

individualized falls and injury prevention

• Individually tailored exercises

• Medication review

• Withdrawal of psychotropic medication

• Multifactorial interventions with comprehensive geriatric

assessment

• Environmental modification for home safety

• Assistive technology (walking aid, hearing aid, personal alarm

system)

• Footwear assessment

• Insertion of a pacemaker (carotid sinus hypersensitivity)

Comparison

• Usual care or standard care

• Placebo or no active intervention

• Waiting list control

• Active control intervention

Outcome

• Critical: rate of falls

Setting

• Primary care/community



Search strategy

The search for systematic reviews was conducted on 10 October

2015 in Ovid MEDLINE, Embase and the Cochrane Library using

comprehensive search terms (Annex 1). Details of the number

studies retrieved and included are presented in Annex 2.

List of systematic reviews identified by the

search process

Included in GRADE1 tables (6):

— Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates

S, Clemson LM, Lamb SE. Interventions for preventing falls in older

people living in the community. Cochrane Database Syst Rev.

2012;(9):CD007146. Publication status and date: Edited (no change

to conclusions), published in Issue 4, 2015.

_______________________________

1 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http://gradeworkinggroup.org

http://gradeworkinggroup.org/



PICO table

Intervention/comparison Outcomes Systematic review used

for GRADE

Explanation

1 Compared with no

intervention (or an

intervention not expected to

reduce falls), fall-prevention

interventions included:

• exercise

• t’ai chi

• multifactorial programmes

• home safety interventions

• cognitive behavioural

intervention

• prevention education

• anti-slip shoe device

• vision treatment

• pacemaker for carotid

hypersensitivity

• reduced psychotropics

• vitamin D

supplementation.

Risk of falls. Gillespie LD, Robertson MC,

Gillespie WJ, Sherrington C, Gates

S, Clemson LM, Lamb SE.

Interventions for preventing falls in

older people living in the

community. Cochrane Database

Syst Rev. 2012;(9):CD007146. (6)

Systematic review relevant to the

area.



Narrative description of the studies that went into

analysis

Gillespie et al. (2012) is a Cochrane systematic review of

interventions designed to reduce the incidence of falls in older

people living in the community (6). The search for clinical trials was

conducted in the Cochrane Bone, Joint and Muscle Trauma Group

Specialized Register (February 2012), CENTRAL (The Cochrane

Library 2012, Issue 3), MEDLINE (1946 to March 2012), Embase

(1947 to March 2012), CINAHL (1982 to February 2012) and online

trial registers. Only randomized controlled trials (RCTs) of

interventions to reduce falls in community-dwelling older people

were included. The review included 159 trials with 79 193

participants. Most trials compared a fall-prevention intervention

with no intervention or an intervention not expected to reduce falls.

The most common interventions tested were exercise as a single

intervention (59 trials) and multifactorial programmes (40 trials).

Sixty-two per cent (99/159) of the trials were at low risk of selection

bias for sequence generation, 60% for attrition bias for the outcome

of falls (66/110), 73% (96/131) for attrition bias for fallers, and

38% (60/159) for selection bias due to allocation concealment. The

review found no evidence of effect for cognitive behavioural

interventions or interventions aiming to improve knowledge about

falls prevention alone. Limited evidence was reported in the review

for an anti-slip shoe device, and for interventions to treat vision

problems. Pacemaker insertion reduced falls in very selected

populations of older people with carotid hypersensitivity, and

reduction of psychotropic medication also reduced falls but the

sustainability of the effect was questioned. The authors concluded

that group and home-based exercise programmes and home

safety interventions reduce the rate of falls and the risk of falling;

that multifactorial assessment and intervention programmes reduce

the rate of falls but not the risk of falling; and that t’ai chi reduces

the risk of falling. Overall, vitamin D supplementation does not

appear to reduce falls but may be effective in people who have

lower vitamin D levels before treatment.



GRADE table 1: Medication review or withdrawal versus control for older people

living in the community

Author: WHO systematic review team

Date: November 2015

Question: What is the effectiveness of medication review or withdrawal versus control for

preventing falls in older people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM,

Lamb SE. Interventions for preventing falls in older people living in the community.

Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date:

Edited (no change to conclusions), published in Issue 4, 2015.

Quality assessment Number of patients Effect

Quality Importance

Number of

studies Design

Risk of

bias Inconsistency Indirectness Imprecision

Other

considerations

Medication

withdrawal Control

Relative

(95% CI)

Rate of falls: psychotropic medication withdrawal vs control (follow-up 14 weeks)

1 randomized

trials

serious a no serious

inconsistency

no serious

indirectness

serious b none 48

45

RR: 0.34 (0.16 to

0.73)

LOW

CRITICAL

Rate of falls: medication review and modification vs usual care (follow-up 12 months)

1 randomized

trials

serious c no serious

inconsistency

no serious

indirectness

serious b none 93

93

RR: 1.01 (0.81 to

1.25)

LOW

CRITICAL

RR: rate ratio a Risk of bias: downgraded once as information on incomplete data was not adequately described. b Imprecision: downgraded once as sample size was small (smaller than 200). c Risk of bias: downgraded once as allocation concealment was unclear.



GRADE table 2: Environment (home safety and aids for personal mobility) versus

control for older people living in the community: subgroup analysis

by risk of falling at baseline


Date: November 2015

Question: What is the effectiveness of home safety intervention versus control for preventing falls

in older people living in the community (subgroup analysis by risk of falling at

baseline)?

Setting: Community



Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited

(no change to conclusions), published in Issue 4, 2015.


Quality Importance

Number of

studies Design Risk of bias Inconsistency Indirectness Imprecision

Other

considerations

Home safety

intervention Control

Relative

(95% CI)

Rate of falls: selected for higher risk of falling (follow-up 14–52 weeks)

3 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 429

422

RR: 0.62

(0.5 to 0.77)

MODERATE

CRITICAL

Rate of falls: not selected for higher risk of falling (follow-up 12–18 months)

3 randomized

trials

serious b no serious

inconsistency

no serious

indirectness

no serious

imprecision

none 1377

1980

RR: 0.94

(0.84 to 1.05)

MODERATE

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as allocation concealment and procedure for masking outcome assessor was unclear in two included

trials. Further, information of incomplete data for falls outcome was not clearly described in one of the included trial. b Risk of bias: Downgraded once as allocation concealment was unclear for one of the included trials and information on incomplete

data was not clearly described in the other two trials.



GRADE table 3: Home safety intervention versus control for older people living in

the community: subgroup analysis by delivery personnel


Date: November 2015

Question: What is the effectiveness of home safety intervention versus control (subgroup analysis

by delivery personnel) for preventing falls in older people living in the community?

Setting: Community



Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited

(no change to conclusions), published in Issue 4, 2015.


Quality Importance

Number of


Other

considerations

Home safety


Relative

(95% CI)

Rate of falls: home safety intervention (occupational therapy [OT] delivered by an occupational therapist) vs control

4 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 728

715 RR: 0.69

(0.55 to 0.86)

MODERATE

CRITICAL

Rate of falls: home safety intervention (not OT) vs control (follow-up 6–18 months)

4 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 1234

1841

RR: 0.91

(0.75 to 1.11)

MODERATE

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was not concealed in two trials. b Risk of bias: Downgraded once as analysis was not performed on the principle of intention to treat in two trials and allocation concealment

was unclear in the other two trials.



GRADE table 4: Multifactorial intervention versus control for older people living in the community


Date: November 2015

Question: What is the effectiveness of multifactorial intervention versus control or usual care for preventing

falls in older people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

Interventions for preventing falls in older people living in the community. Cochrane Database

Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions),

published in Issue 4, 2015.


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Multifactorial

intervention

Control or

usual care

Relative

(95% CI)

Rate of falls

19 randomized

trials

serious a serious b no serious

indirectness

no serious

imprecision

none 4833

4670

RR: 0.76 (0.67 to

0.86

)

LOW

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in five included trials and procedure for masking outcome assessor

was unclear in nine included trials. b Inconsistency: Downgraded once as considerable heterogeneity was observed in the meta analysis for the estimate (Tau2 = 0.06;

Chi2 = 116.96, df = 18 [P < 0.00001]; I2 = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity.



GRADE table 5: Multifactorial intervention versus control for older people living in the

community: subgroup analysis by risk of falling at baseline


Date: November 2015

Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by

risk of falling at baseline) for preventing falls in older people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb

SE. Interventions for preventing falls in older people living in the community. Cochrane

Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to

conclusions), published in Issue 4, 2015.


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Multifactorial


Relative

(95% CI)

Rate of falls: selected for higher risk of falling

17 randomized

trials


indirectness

no serious

imprecision

none 3041

2913

RR 0.77

(0.66 to 0.90)

LOW

CRITICAL

Rate of falls: not selected for higher risk of falling

2 randomized

trials

serious c serious d no serious

indirectness

no serious

imprecision

none 1792 1757 RR 0.57

(0.23 to 1.38)

LOW

CRITICAL

CI: confidence interval; RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in eight included trials and procedure for masking outcome assessor

was unclear in nine trials. b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 104.40, df = 16 [P <

0.00001]; I² = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment and procedure for masking outcome assessor were unclear in one of the

trials. Randomization method was unclear in the other trial. d Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.36; Chi² = 7.54, df = 1 [P = 0.006];

I² = 87%). No subgroup analysis was performed and we were not able to explain the heterogeneity.



GRADE table 6: Multifactorial intervention versus control for older people living in the

community: subgroup analysis by intensity of intervention


Date: November 2015

Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by

intensity of intervention) for preventing falls in older people living in the community?

Setting: Community






Quality Importance

Number of


Other

considerations

Multifactorial


Relative

(95% CI)

Rate of falls: assessment and active intervention (follow-up 6–24 months)

11 randomized

trials


indirectness

no serious

imprecision

none 3178 3160 RR: 0.74

(0.61 to 0.89)

LOW

CRITICAL

Rate of falls: assessment and referral or provision of information

9 randomized

trials

serious c serious d no serious

indirectness

no serious

imprecision

none 1665 1711 RR: 0.82

(0.71 to 0.95)

LOW

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in nine included trials and procedure for masking outcome assessor was unclear in five trials. b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 97.46, df = 10 [P < 0.00001]; I² = 90%). No

subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in five trials. d Inconsistency: Downgraded once as moderate heterogeneity was observed in the analysis (Tau² = 0.03; Chi² = 18.02, df = 8 [P = 0.02]; I² = 56%). No subgroup

analysis was performed and we were not able to explain the heterogeneity.



GRADE table 7: Exercise intervention versus control for older people living in

the community


Date: November 2015

Question: What is the effectiveness of exercise versus control for preventing falls in older

people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson

LM, Lamb SE. Interventions for preventing falls in older persons living in the

community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication

status and date: Edited (no change to conclusions), published in Issue 4, 2015.


Quality Importance

Number of


Other

considerations Exercise Control

Relative

(95% CI)

Rate of falls: group exercise: multiple categories of exercise vs control (follow-up 3.5–36 months)

16 randomized

trials


indirectness

no serious

imprecision

none 1853

1769

RR: 0.71

(0.63 to 0.82)

LOW

CRITICAL

Rate of falls: individual exercise at home: multiple categories of exercise vs control (follow-up 6–24 months)

7 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 469

482

RR: 0.68

(0.58 to 0.8)

MODERATE

CRITICAL

(continued

next page)



Rate of falls: individual exercise: LiFE (balance and strength training in daily life activities) vs control (follow-up 12 months)

1 randomized

trials

serious d no serious

inconsistency

no serious

indirectness

serious e none 18

16

RR: 0.21

(0.06 to 0.71)

LOW

CRITICAL

Rate of falls: group exercise: t’ai chi vs control (follow-up 5.5–12 months)

5 randomized

trials

serious f serious g no serious

indirectness

no serious

imprecision

none 797

766

RR: 0.72

(0.52 to 1)

LOW

CRITICAL

Rate of falls: group exercise: gait, balance or functional training vs control (follow-up 5.5–24 months)

4 randomized

trials

serious h no serious

inconsistency

no serious

indirectness

no serious

imprecision

none 258

261

RR: 0.72

(0.55 to 0.94)

MODERATE

CRITICAL

Rate of falls: individual exercise: balance training vs control (follow-up 8 months)

1 randomized

trials

serious i no serious

inconsistency

no serious

indirectness

serious e none 64

64

RR: 1.19

(0.77 to 1.82)

LOW

CRITICAL

Rate of falls: group exercise: strength/resistance training vs control (follow-up 5.5 months)

1 randomized

trials

serious j no serious

inconsistency

no serious

indirectness

serious e none 32

32

RR: 1.8

(0.84 to 3.87)

LOW

CRITICAL

(continued

next page)



Rate of falls: individual exercise at home: resistance training vs control (follow-up 6 months)

1 randomized

trials

no serious risk

of bias

no serious

inconsistency

no serious

indirectness

serious k none 112

110

RR: 0.95

(0.77 to 1.18)

MODERATE

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was unclear in seven included trials and allocation

concealment was unclear in 12 included trials. Outcome assessor was not masked in nine trials. b Inconsistency: Downgraded once as moderate heterogeneity was observed for the estimate (Tau² = 0.03; Chi² = 29.11, df =

15 [P = 0.02]; I² = 48%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as allocation concealment was unclear in four included trials. d Risk of bias: Downgraded once as procedure for masking outcome assessor and management of incomplete data was

unclear in the trial. e Imprecision: Downgraded once as sample size was small (less than 200). f Risk of bias: Downgraded once as allocation concealment was unclear in four trials. g Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau² = 0.10; Chi² = 14.38, df

= 4 [P = 0.006]; I² = 72%). No subgroup analysis was performed and we were not able to explain the heterogeneity. h Risk of bias: Downgraded once as allocation concealment method was unclear in all included trials. i Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor were

unclear in the trial. j Risk of bias: Downgraded once as method of allocation concealment, masking of outcome assessor, and management of

incomplete data were unclear in the trial. k Imprecision: Downgraded once as sample size was small (n=222).



GRADE table 8: Group exercise intervention versus control in older people living in the



Date: November 2015

Question: What is the effectiveness of group exercise (multiple categories of exercise) versus control

(subgroup analysis by risk of falling at baseline) for preventing falls in older people living in

the community?

Setting: Community






Quality Importance

Number of

studies Design

Risk of


Other

considerations

Group

exercise:

multiple

categories of

exercise

Control Relative

(95% CI)

Rate of falls: selected for higher risk of falling (follow-up 3–24 months)

9 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 652

609

RR: 0.70

(0.58 to 0.85)

MODERATE

CRITICAL

Rate of falls: not selected for higher risk of falling (follow-up 4.6–30 months)

7 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 1201

1160

RR: 0.72

(0.58 to 0.9)

MODERATE

CRITICAL

RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was unclear in five included trials and allocation concealment was unclear in seven trials. B Risk of bias: Downgraded once as allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in four trials.



GRADE table 9: Group t’ai chi exercise versus control in older people living in the



Date: November 2015

Question: What is the effectiveness of group t’ai chi exercise versus control (subgroup analysis by risk of

falling at baseline) for preventing falls in older people living in the community?

Setting: Community

Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

Interventions for preventing falls in older people living in the community. Cochrane Database Syst

Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions),

published in Issue 4, 2015.


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Group

exercise:

t’ai chi

Control Relative

(95% CI)

Rate of falls: selected for higher risk of falling at baseline (follow-up 11–12 months)

2 randomized

trials


indirectness

no serious

imprecision

none 283

272

RR: 0.95

(0.62 to 1.46)

LOW

CRITICAL

Rate of falls: not selected for higher risk of falling at baseline (follow-up 5.5–12 months)

3 randomized

trials


inconsistency

no serious

indirectness

no serious

imprecision

none 514

494

RR: 0.59

(0.45 to 0.76)

MODERATE

CRITICAL

RR: risk ratio a Risk of bias: Downgraded once as allocation concealment was unclear in one of the trials. b Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.07; Chi2 = 3.30, df = 1 [P = 0.07]; I2 = 70%) c Risk of bias: Downgraded once as allocation concealment was unclear in three of the included trials.



Part 2: From evidence to recommendations

Summary of evidence

Intervention Effect size

Medication withdrawal or review vs control

Psychotropic medication withdrawal vs control

GRADE table 1, Gillespie et al. (6)

Rate ratio: 0.34 (0.16 to 0.73);

Favours experiment

Quality of evidence: LOW

Medication review and modification vs usual care


Rate ratio: 1.01 (0.81 to 1.25);


Environment (home safety and aids for personal mobility)

Home safety intervention vs control:

subgroup analysis by risk of falling at baseline


Rate ratio: 0.62 (0.5 to 0.77); 3 trials

Favours experiment

Quality of evidence: MODERATE

Home safety intervention vs control:

subgroup analysis (not selected for higher risk of falling)




Home safety intervention (occupational therapy) vs control



Favours experiment


Home safety intervention (not occupational therapy) vs control




(continued next page)



Multifactorial intervention

Multifactorial intervention vs control or usual care


Rate ratio: 0.76 (0.67 to 0.86);

Favours experiment


Multifactorial intervention vs control:

subgroup analysis (selected for higher risk of falling)


Rate ratio: 0.77 (0.66 to 0.90);

Favours experiment


Multifactorial intervention vs control:



Rate ratio: 0.57 (0.23 to 1.38);


Multifactorial intervention: assessment and active intervention


Rate ratio: 0.74 (0.61 to 0.89);

Favours experiment


Multifactorial intervention: assessment and referral or provision of information


Rate ratio: 0.82 (0.71 to 0.95);

Favours experiment


Exercise intervention

Group exercise (multiple categories vs control)


Rate ratio: 0.71 (0.63 to 0.82);

Favours experiment


Group exercise at risk of falls (multiple categories vs control)


Rate ratio: 0.70 (0.58 to 0.85);

Favours experiment





Individual exercise at home (multiple categories vs control)


Rate ratio: 0.68 (0.58 to 0.80);

Favours experiment


Individual exercise (balance and strength vs control)


Rate ratio : 0.21 (0.06 to 0.71);

Favours experiment


Group exercise (t’ai chi vs control)


Rate ratio: 0.72 (0.52 to 1.00);

Favours experiment


Group exercise (gait, balance or functional training vs control)


Rate ratio: 0.72 (0.55 to 0.94);

Favours experiment


Individual exercise (balance training vs control)


Rate ratio: 1.19 (0.77 to 1.82)


Group exercise (strength/resistance training vs control)


Rate ratio: 1.8 (0.84 to 3.87)


Individual exercise at home (resistance training vs control)


Rate ratio: 0.95 (0.77 to 1.18)


Group exercise (multiple categories of exercise vs control):



Rate ratio: 0.7 (0.58 to 0.85)

Favours experiment





Group exercise (multiple categories of exercise vs control):



Rate ratio: 0.72 (0.58 to 0.9)

Favours experiment


Group exercise: t’ai chi vs control:



Rate ratio: 0.95 (0.62 to 1.46)


Group exercise: t’ai chi vs control:



Rate ratio: 0.59 (0.45 to 0.76)

Favours experiment


Evidence-to-recommendations table

Problem Explanation

Is the problem a priority?

Yes No Uncertain

✓

Falls are the leading cause of injury in older people aged 65 years and over. Between 30% and

40% of community-dwelling adults aged 65 years or older fall at least once per year. Therefore,

prevention of falls in older people at risk of falling is important.

Benefits and harms Explanation

Do the desirable effects outweigh the

undesirable effects?

Yes No Uncertain

✓

Fifty-nine trials (which included 13 264 randomized participants) tested the effect of exercise on

falls in older people. Trials were based on multimodal exercise interventions and combined two or

more of the following components: (a) gait, balance and functional training; (b) strength and

resistance training; (c) flexibility; (d) t’ai chi; (e) general physical activity; and (f) endurance. The

interventions were delivered in groups or individually.

Moderate-quality evidence suggests that multimodal exercise, delivered in groups or individually,




(continued from previous page)



Yes No Uncertain

✓

reduces the occurrence of falls in older people at risk of falls. Sixteen trials (3622 participants)

examined the effectiveness of multi-component group exercise interventions. The mean age of

the participants ranged from 69 to 88 years, and the mean age in 94% of the trials was over 70

years. All reviewed trials were from high-income countries. Duration of follow-up ranged from 3.5

to 36 months. Overall, the intervention achieved a statistically significant reduction in the rate of

falls (Rate ratio: 0.71, 95% CI: 0.63 to 0.82). Eight trials delivered individual exercise

interventions at the participants’ homes. The mean age of the participants ranged from 74.7 to

84.1 years, and the mean age in the majority of trials was over 80 years. The duration of the trials

ranged from 7.5 to 24 months. Overall, home-based interventions achieved a statistically

significant reduction in the rate of falls (Rate ratio: 0.68, 95% CI: 0.58 to 0.80). One trial, which

examined balance and strength training included in daily life activities, showed a statistically

significant reduction in the rate of falls (Rate ratio: 0.21, 95% CI: 0.06 to 0.71).

There is limited moderate-quality evidence that t’ai chi training may reduce the risk of falls in older

people. However, the benefit of t’ai chi exercise (in terms of reduction in the rate of falls) was

experienced by the subgroup who were not selected for a higher risk of falling, while there was no

effect in the group selected for a higher risk of falling. Thus, t’ai chi training seems to be more

effective in people who are not at high risk of falling.

Adequate low-quality evidence suggests that multifactorial interventions reduce the rate of falls in

older people at risk of falls. Nineteen reviewed trials investigated the benefit of multifactorial

interventions (assessment and referral or provision of active interventions). The mean age of the

participants ranged from 73.1 to 80.6 years and the proportion of women participants in the trials

ranged from 49% to 100%. Only one study originated from a middle-income country (Thailand),

while the other 18 trials were conducted in high-income countries, mainly Australia, Canada,

China, Denmark, Finland, the Netherlands, the Province of Taiwan, the United Kingdom of Great

Britain and Northern Ireland and the United States of America. Multifactorial interventions

integrating assessments with individualized interventions, usually involving a multidisciplinary

team, were effective in reducing the rate of falls in older people at risk of falls (Rate ratio: 0.77,

CI: 0.67 to 0.86).




(continued from previous page)



Yes No Uncertain

✓

There is limited moderate-quality evidence to suggest that home safety assessment and tailored

interventions reduce the rate of falls in older people at risk of falls. Six RCTs (4208 participants)

investigated the effectiveness of home safety interventions to reduce the rate of falls and the risk

of falling. The mean age of the trial participants was more than 75 years. The follow-up period

ranged from 3 to 18 months. Overall, home safety assessments and modification interventions

were effective in reducing the rate of falls (Rate of falls: 0.62, 95% CI: 0.5 to 0.77). Furthermore,

in a post hoc analysis, home safety interventions delivered by an occupational therapist were

more effective than interventions delivered by other health care professionals.

There is very limited low-quality evidence suggesting that medication reviews and modification or

withdrawal of medication reduce the risk of falls in older people. The results of one trial showed

that withdrawal of psychotropic medication was effective in reducing the rate of falls (Rate ratio:

0.34, 95% CI: 0.16 to 0.73). In another study, an educational programme for general practitioners

on medical review and treatment modification was found to be ineffective in reducing rate of falls.

Values and preferences/

acceptability

Explanation

Is there important uncertainty or variability about how much people value the options?

Major variability

Minor variability

Uncertain

✓

Fall is an important clinical outcome, which is also considered to be important by older people themselves and their family members and caregivers.

Is the option acceptable to key stakeholders?

Major variability

Minor variability

Uncertain

✓

The guideline development group strongly believes that recommendations for fall prevention will be valued by health care providers and acceptable to stakeholders (older people and those closet to them).




Feasibility/resource use Explanation

How large are the resource requirements?

Major Minor Uncertain

✓

Fall-preventions interventions are resource intensive. However, health benefits gained from the

recommendation are likely to outweigh the burden of resources required for implementation.

Intervention costs can be reduced through task shifting, engaging family members, and

administering the intervention in groups.

Is the option feasible to implement?

Yes No Uncertain

✓

Multifactorial interventions may be difficult to implement as they may require the involvement of

multiple service providers. In some countries, delivering exercise in groups might be difficult.

However, exercise delivered at home to individuals might be an alternative.

Some trials (those on exercise and home safety) have utilized non-specialized health care

professionals to deliver fall-prevention interventions. Drawing on this experience, the guideline

development group believes that it would be feasible to implement their recommendations in both

high- and low-resource health care settings.

Equity Explanation

Would the option improve equity in

health?

Yes No Uncertain

✓

The guideline development group strongly believes that all recommendations for prevention of

falls will increase equity in health.



Guideline development group recommendations and remarks

Recommendations

Medication review and withdrawal (of unnecessary or harmful medication) can be

recommended for older people at risk of falls.

Quality of the evidence: Low

Strength of the recommendation: Conditional

Multimodal exercise (balance, strength, flexibility and functional training) should be

recommended for older people at risk of falls.

Quality of the evidence: Moderate

Strength of the recommendation: Strong

Following a specialist’s assessment, home modifications to remove environmental hazards

that could cause falls should be recommended for older people at risk of falls.

Quality of the evidence: Moderate

Strength of the recommendation: Strong

Multifactorial interventions integrating assessment with individually tailored interventions

can be recommended to reduce the risk and incidence of falls among older people.

Quality of the evidence: Low

Strength of the recommendation: Conditional




Remarks

• Effective primary health care interventions for falls use various approaches to identify people at

increased risk.

• No evidence-based instrument to accurately identify older adults who are at increased risk for

falling exists.

• The majority of trials were conducted in high-income countries. Further research in low- and

middle-income countries is needed to understand the feasibility of implementing fall-prevention

interventions in low-resource health care settings.

• There is a pressing need to standardize assessments of the risk of falls to identify high-risk

older people. Currently, the history of falls is the most common factor used in the majority of

trials; a small proportion of trials used additional risk factors to select patients.

• Vision care for older people at risk of falls should not be restricted to cataract surgery.

• Due to their high heterogeneity, multifactorial interventions were rated as low quality. This is

largely due to differences in the intervention components included and the risk factors targeted

for reducing falls. Future research should unpack multifactorial interventions and report

treatment effect by subgroup of intervention components.



References

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7. Publications and resources. In: Home and Recreational Safety [website]. Atlanta (GA): United States Centers for Disease Control and Prevention (CDC); 2017 (http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html, accessed 13 June 2017).

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9. Järvinen TL, Sievänen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008;336(7636):124–6. doi:10.1136/bmj.39428.470752.AD.

10. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporosis International. 2013;24(3):747–62. doi:10.1007/s00198-012-2256-7.

11. Lee WK, Kong KA, Park H. Effect of preexisting musculoskeletal diseases on the 1-year incidence of fall-related injuries. J Prev Med Public Health. 2012:45(5);283–90. doi:10.3961/jpmph.2012.45.5.283.

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14. Health Quality Ontario. Prevention of falls and fall-related injuries in community-dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser. 2008;8(2):1–78.

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16. Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L. Prognostic validity of the Timed Up-and Go Test, a modified Get-Up-and-Go Test, staff’s global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008;37(4);442–8. doi:10.1093/ageing/afn101.

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Annex 1: Search strategy

MEDLINE database 1946 to 2015 (search date: 9 October 2015)

1. Accidental Falls/

2. (fall$ or faller$ or fallen).tw.

3. or/1-2

4. exp Aged/

5. (senior$ or elder$ or older).tw.

6. or/4-5

7. and/3,6

8. randomized controlled trial.pt.

9. controlled clinical trial.pt.

10. randomized.ab.

11. placebo.ab.

12. ((clinical or controlled or comparative or placebo or

prospective$ or randomi#ed) adj3 (trial or study)).tw.

(random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$

or order$)).tw

13. trial.ab.

14. groups.ab.

15. or/8-14

16. humans.sh.

17. 15 and 16

18. and/7,17

19. limit 18 to systematic reviews

Embase database 1946 to 2015 (search date: 9 October 2015)

1. Falling/

2. (fall$ or fallers).tw.

3. or/1-2

4. exp Aged/

5. (elderly or senior$ or older).tw.

6. or/4-5

7. and/3,6

8. exp Randomized Controlled trial/

9. exp Double Blind Procedure/

10. exp Single Blind Procedure/

11. exp Crossover Procedure/

12. or/8-11

13. ((clinical or controlled or comparative or placebo or

prospective$ or randomi#ed) adj3 (trial or study)).tw.

14. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$

or order$)).tw.

15. ((single or double or triple) adj7 (blind$ or mask$)).tw.

16. (crossover adj1 trial).tw.

17. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or

experiment$ or intervention$ or treatment$ or therap$ or

control$ or group$)).tw.

18. or/13-17

19. or/12,18

20. Animal/ not Human/

21. 19 not 20

22. and/7,21

23. limit 22 to systematic reviews


Annex 2: PRISMA2 2009 flow diagram for intervention to prevention

falls in community-dwelling older people

2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA). For more information: http://www.prisma-statement.org

Records identified through database (Embase

and MEDLINE) searching (n = 374)

Scre

en

ed

Elig

ible

In

clu

de

d

Iden

tified

Full-text articles excluded, with reasons (n = 1):

• Target population not community dwellers

Records excluded

(n = 372)

Records after duplicates removed

(n = 374)

Records screened

(n = 374)

Full-text articles assessed for eligibility

(n = 2)

Studies included in qualitative synthesis

(n = 1)

Studies included in quantitative synthesis

(meta-analysis) (n = 1)

WHO/MCA/17.06.04


http://www.prisma-statement.org/

Documents

Evidence profile: risk of falls