Characteristics and Effectiveness of Fall

Prevention Programs in Nursing

Homes:

A Systematic Review and Meta-

Analysis of

Randomized Controlled Trials

J Am Geriatr Soc 2015; 63:211–221

Falls are an important problem in

RACFs >50% NH residents fall >once a year

Annual hip# rate 4%

12% incur a new fracture within 1 year

after a fall-related hip fracture, and

31% die as a result

Associated with fear and poor QoL

Falls prevention programs*

Single programs – single intervention directed at all residents

Multiple programs – more than one intervention provided to all residents

Multifactorial – more than one intervention targeted to individual risk profile

*Prevention of Falls Network Europe (ProFaNE)

Rationale for the present

review No conclusive evidence on

effectiveness of falls prevention

interventions in RACFs, except

vitamin D supplementation

Heterogeneity

Did not differentiate fallers vs.

recurrent fallers

Vague terminology to define the care

settings

Inclusion criteria

Conducted in a nursing home:“a residential facility that provides 24-hour-a-day

surveillance, personal care, and limited clinical

care for persons who are typically elderly and

infirm”

RCT/ cluster randomised RCT

Duration ≥ 6 months

Single, multiple or multifactorial

programs

Outcome measures: falls, fallers

and recurrent fallers number of falls

◦ RR= number of falls per resident year in

the intervention group/ number of falls per

resident year in the control group

number of fallers and recurrent fallers

◦ RR = proportion of (recurrent) fallers in

intervention group /proportion in control

group

Study Characteristics

13 studies

7 in Europe, 4 in the US, 2 in Australia/NZ

11 were cluster RCTs

22,915 patients (mean age 82-88 yrs)

Follow up 6- 17 months

Intervention type

◦ 6 single

◦ 1 multiple

◦ 6 multifactorial

Positive studies Pooled analysis Components of

intervention

No of Falls 2/12 multifactorial

36-45%

*one study effect

only significant in

cognitively

impaired

residents

10 studies

RR = 0.93, 95%

CI = 0.76–1.13

No effect

Group/ individual

exercise

Medication RV

Hip protectors

Mobility+envior

Ax

Staff training

No of fallers 2/7 multifactorial

25-30%

7 studies

RR = 0.97, 95%

CI = 0.84–1.11

No effect

As above

No of recurrent

fallers

1/4 multifactorial

44%

4 studies

RR = 0.79,

95% CI = 0.65–

0.97

21% reduction in

recurrent fallers

Group exercise

Medication RV

Mobility+envior

Ax Staff training

Pt education

Podiatry

Results

Intervention (number

of studies)

Pooled analysis Effect

Single

Intervention

Staff training &

education (2)

RR = 1.29

95% CI = 1.23–

1.36

more falls in the

intervention

group

Medication

reconciliation (2)

RR= 1.20

95% CI = 0.89–

1.61

trend towards

falls in interven

grp

Vitamin D suppl (1) No effect

Exercise program (1) No effect

Multiple

interventions

Low intensity

exercise+ continence

care (1)

No effect

Multifactorial

interventions

Exercise, Medication,

Orthostatic HypoT,

Environment, Hip

protectors, Vision,

Footwear; and goal

setting, reminders,

and feedback (6)

RR = 0.67,

95% CI = 0.55–

0.82

No of falls by

33%

RR = 0.79

95% CI = 0.65–

0.97

Recurrent

fallers by 21%

Results

Conclusions

Falls are multifactorial; therefore it’s

not surprising that single interventions

failed to show a beneficial effect

Single interventions can even be

harmful in RACF setting

Customized, multifactorial

interventions delivered by MDTs

reduce falls in RACFs

Are the interventions effective in

residents with dementia? There were fewer fallers in intervention

groups that had a greater prevalence of dementia

Each one-point increase in dementia prevalence category corresponded to a RR that was only 0.76 of its former size

No significant associations with dementia prevalence score were found for number of falls (RR = 0.95, 95% CI = 0.72–1.25) or number of recurrent fallers (RR = 1.42, 95% CI = 0.49–4.11).

What should be the composition

of a multifactorial intervention? Small number of studies did not allow

additional moderator analyses to

evaluate which

components/combinations of the

intervention programs were most

effective.

Limitations

Poor methodological quality of studies:

blinding difficult, loss of FU

Small number of studies eligible

“nursing home” definition is far from

satisfactory

Inconsistencies/ vague definitions in

reporting falls related outcomes

Some studies had FU <12 months

Cochrane Database Systematic

Review 2012 1. No evidence overall that exercise reduces falls in care

facilities, but may be more effective in less frail

residents. Of the exercise types, only balance training

using mechanical apparatus in intermediate level care

facilities was effective.

2. Results relating to medication review by pharmacists

are equivocal.

3. The prescription of vitamin D in care facilities is

effective in reducing falls.

4. There is currently no evidence of effect from

interventions targeting staff and the organisation of

care.

5. Some falls prevention programmes that target multiple

individual risk factors (classified as multifactorial

interventions) may be effective.

Cameron et al. Interventions for preventing falls in older people in care facilities and hospitals.

Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465. DOI:10.1002/14651858.CD005465.pub3.

RaR = Rate ratio (falls per person-year); RR= relative risk (no of fallers)

RaR 0.78 RR 0.89

RaR 1.03 RR 1.07

but not risk of falling