Handout for Evidence for Fall Prevention – Best Bets
David Greene, PhD, OTR/OTAC Fall 2007
What Works (from meta analyses, systematic reviews, articles found within these reports):
Where to search:
•Citations: OT Seeker (low in variability -of experience – same yield regardless of who’s doing the search)
•Abstracts: Ageline, OTCATS, OTDBASE (all low variability); OT Search (high variability though & subscription separate from AOTA membership!)
•Abstracts & full-text articles: Ageline, CINAHL & PsychINFO (all three very low in variability)
Interventions that work:
•Reduction in home hazards after hospitalization
•Multifactorial risk assessment with targeted management
•Discontinuation of psychotropic medication
•Specific balance or strength exercise programs (But not computerized balance in Wolf, et al. 1996 study!)
•Exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months
•Tai Chi 15 min twice daily at home for 4mo
•Individually tailored program of exercise. Physiotherapist visited 4× in first 2mo. Exercises 3× per wk, 30 min each, lower limb strength and balance plus encouraged walking outside 3×/wk
•For individuals with at least mild deficits in strength or balance: Strength training: upper and lower limb; 3 sessions per wk for 60 min. PLUS flexibility PLUS endurance training: stationary cycle 75% max. heart rate
Interventions with little to no support:
•Strengthening exercise/balance found to “work” but not always:
–NOT computerized balance (as described in Wolf, et al. 1996 study)!
–NOTExercise: 60 min, 3× per wk, 12mo. Stand-up, step-up, stretching and movement to music
–NOT Cognition/behavioral: health and safety curriculum to prevent falls, relaxation, video games.
–NOT Exercise/cognition: 2× per wk exercise, once per wk cognition
–NOT stand-up/step-up routine progressing to 4 sets of 10 repetitions. 60 min 3× per wk
–NOT individually tailored one-one physiotherapy sessions 3× per wk for 4mo, including range of motion, strength, balance, transfer and mobility. Each session 30-40 min
–NOT 60-min exercise sessions, twice weekly in 4 terms of 10-12wk. 4 sections per session: warm-up, conditioning (aerobic, strength, balance and flexibility), stretching and relaxation
–NOT 45 min weight-bearing exercise to music, 3× per wk for 3× 10wk terms for 2y (although worked for 18 months)
–NOT strength, endurance, mobility and balance training for 90 min, 3× per wk for 12wk
What works from Cochrane Collaboration systematic reviews:
•Exercise may prevent falls?????? (Carter – problem with measurement of dependent variables)
•Hospital-based fall prevention????? (Oliver – Compliance, costs, inconsistent study designs all a problem; no significant findings per study, but a possible pooled effect across studies)
•Multi disciplinary/factorial risk screening
•Risk screening (for individuals with a history of falls)
•Programs in nursing home settings
•Strength and balance programs?
•Home hazard evaluation and modification (for individuals with a history of falls)
•Tai Chi group
Interventions not supported in Cochrane:
- Group-Delivered Exercise
- Individual LE Strengthening
- Home Hazard Mod. w/ Medication suggestions
- Home Hazard Mod. w/ education packet on exercise and reducing falls
- Cognitive/Behavioral Approach Alone
- Hm. Haz. Mod. when no Hx of falling
- Brisk walking in older women with UE fracture
What works from CATs – critical appraisals (OTCATS.com):
•Home hazard assessment and modification/Risk awareness or advice
–But which one is more effective??
•Interdisciplinary/multifactorial assessment and intervention for those with a history of falls
–NOT if cognitive impairment/dementia was present!!
•multifactorial falls risk assessment and management program
–But which components?: Exercise effective – but which type of exercise?
–!!Environmental modification and education not necessarily effective!!
Final What Works:
Search with
•OTCATS, OTDBASE, AOTA Evidence-Based Practice Abstracts (for other than falls); Ageline, CINAHL & PsychINFO for full text
Intervene with
•Some programs using multifactorial and interdisciplinary risk assessment with reduction in home hazards and behavioral hazards (maybe most effective with a history of falling)
•Some programs for balance or strength exercise
•Tai Chi (certain programs)
•Individually tailored program of exercise (consult PT)
•Specific strength training WITH flexibility WITH endurance training
•The “Stepping on” program to improve mobility efficacy and protective behaviors
•Individually prescribed multidisciplinary evaluation and recommendations in residential settings
Final What Doesn’t:
•Strengthening program
•increase in safety devices and reduction in hazards (installed hand-rails, removed rugs, increased lighting, repaired floors) in a “one-time intervention
•decrease in internal risk factors including improved visual acuity, improved sit-to-stand time and improved knee flexion strength
•reducing risk factors: gait/balance training, medicine review, optometry and podiatry visits
•“low impact” individually prescribed fall risk management (individually prescribed: strength/balance training, ADL devices, caregiver instructions for supervision, medication review, accompany resident to toilet, ID as fall risk, vision/hearing eval & tx)
Three studies you can really use:
•Improve mobility efficacy and protective behaviors as in the “Stepping on” program – 7-sewssion course in hazard identification, adopting safety strategies, etc. (described in Appendix of Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487-1494, 2004)
•Reduce environmental hazards and behavioral hazards. There was no difference in strength in fall vs no-fall group; but no-fall group benefitted from hazard reduction, so hazard reduction seems more important than strengthening. (Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247-252, 2005)
•Individually prescribed multidisciplinary recommendations ( as per OT / Speech / PT / Nursing / Pharmacy / Social Services evals): scheduled toileting program, ambulate with CNA when restless, clear pathways/clutter, wc modifications and minimal unsupervised use of adaptive mobility aids, restraint-free alarms, role-relevant activities to visit/engage. (Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29-39, 2002)
Bibliography
•Tinetti, M (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348 (1 ), 42-49.
•Carter, N D; Kannus, P & Khan, K M. (2001).Exercise in the Prevention of Falls in Older People: A Systematic Literature Review Examining the Rationale and the Evidence. Sports Med 31 (6), 427-438.
•Lehtola, S; Hanninen L & Paatalo, M. (2000). The incidence of falls during a six-month exercise trial and four-month followup among home dwelling persons aged 70-75 years [Finnish]. Liikunta Tiede 6: 41-7.
•Campbell AJ, Roberton MC, Gardner MM, et al. (1997). Randomized controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal, 315, 1065-9.
•Campbell AJ, Roberton MC, Gardner MM, et al. (1999). Psychotropic medicine withdrawal and a home-based exercise program to prevent falls: a randomized controlled trial. Journal of the American Geriatric Society, 47, 850-3.
•Buchner DM, Cress ME, de Lauteur BJ, et al. (1997). The effect of strength and endurance training on gait, balance, fall risk and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 1997; 52 (4), M218-M24.
•Wolf SL, Barnhart MX, Kutner NG, et al. (1996). Reducing frailty and falls in older persons: an investigation of Tai-Chi and computerized training. J Am Geriatr Soc, 44:,489-97.
•Development of a common outcome data set for fall injury prevention trials: the prevention of Falls Network Europe consensus. (includes abstract) Lamb SE; Journal of the American Geriatrics Society, 2005 Sep; 53 (9): 1618-22. (journal article - tables/charts) PMID: 16137297 CINAHL AN: 2009084166
•Fall-prevention programs for the elderly: a Bayesian secondary meta-analysis. (includes abstract) Lucke JF; Canadian Journal of Nursing Research, 2004 Sep; 36 (3): 49-64. (journal article - equations & formulas, tables/charts) PMID: 15551662 CINAHL AN: 2005015262
•Trauma library in review. [Commentary on] A meta-analysis of fall prevention programs for the elderly. Strever T; Whalen E; Journal of Trauma Nursing, 2002 Jul-Sep; 9 (3): 84. (journal article - abstract, commentary) CINAHL AN: 2003064892
•A meta-analysis of fall prevention programs for the elderly: how effective are they? (includes abstract) Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1-8. (journal article - research, tables/charts) PMID: 11822564 CINAHL AN: 2002038264
•Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. (includes abstract) Carter ND; Sports Medicine, 2001; 31 (6): 427-38. (journal article - research, systematic review, tables/charts) PMID: 11394562 CINAHL AN: 2002022846
•Do hospital fall prevention programs work? A systematic review. (includes abstract) Oliver D; Journal of the American Geriatrics Society, 2000 Dec; 48 (12): 1679-89. (journal article - research, systematic review, tables/charts) PMID: 11129762 CINAHL AN: 2001029614
•Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. (2003). Interventions for preventing falls in the elderly. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000340. DOI: 10.1002/14651858.CD000340.
•Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., Roth, E. A., Shekelle, P. G. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal, 328, 680.
•Clemson, L.,Cumming, R. G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Gerontological Society, 52: 1487-1494, 2004
•Diener D D, & Mitchell J M. (2005). Impact of a multifactorial fall prevention program upon falls of older frail adults attending an adult health day care center. Topics in Geriatric Rehab, 21 (3), 247-252.
•Stevens, M., Holman, C. D., Benet, N., de Klerk, N. (2001). Preventing falls in older people: Outcome evaluation of a randomized controlled trial. Journal of the American Gerontological Society, 49: 1448-1455.
•Lord, S. R., Tiedemann, A., Chapman, K., Munro, B., Murray, S. M., Remed, D., & Sherington. C. (2005). The effect of an individualized fall prevention program for fall risk and falls in older people: A randomized controlled trial. Journal of the American Gerontological Society, 53: 1296-1304.
•Dyer, C. A. E., Taylor, G. J., Reed, M., Dyer, C. A., Robertson, D. R., & Harrington, R. (2004). Falls prevention in residential care homes: a ransomised controlled trial. Age and Aging, 33 (6): 596-602.
•Kerse, N., Butler, M., Robinson, E., & Todd, M. (2004). Fall prevention in residential care: A cluster, randomized, controlled trial. Journal of the American Gerontological Society, 52: 524-531.
•Eakman A M et al. (2002). Fall prevention in long-term care: An in-house interdisciplinary team approach. Topics in Geriatric Rehabilitation, 17 (3): 29-39.