Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Contents lists available at ScienceDirect
Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh
9
How can you prevent falls and subsequent fractures? Jacqueline C.T. Close, MBBS, MD, FRACP, FRACP * Neuroscience Research Australia and Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
a b s t r a c t Keywords: Falls Injury Older people Community Hospital Care facility
Over the years, a number of strategies have been investigated to prevent falls in older people in a number of settings. Over 200 randomised controlled trials now exist, and the challenge for the discerning clinician is to read and interpret the existing literature so as to be able to implement effective strategies, targeting the right individual with the right intervention. This chapter reviews the current literature and attempts to simplify what has become an enormously complex area. Interventions are reviewed in three main settings – community, hospital and care facilities and based on the type of approach – single, multiple or multifactorial interventions. It also considers the reality in which we practise and provides some ‘best bets’ to consider at this point in time. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction A wealth of literature has emerged over the last three decades, which has greatly enhanced our understanding of the important contributors to risk of falls and fall-related injury in older people. Equally, a number of clinical trials of varying quality have been published, providing evidence of effective approaches to preventing falls with the first effective study published in 1994 [1]. What has also become apparent is the complexity of the evidence upon which our practice is shaped with enormous challenges faced by those expected to implement research in knowing which intervention is likely to be most effective in which population.
* Tel.: þ61 2 93991055; fax: þ61 2 93991204. E-mail address: [email protected]. 1521-6942/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.berh.2013.12.001
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
A fall is an important event for an older person and should not simply be viewed as a surrogate marker of fracture risk. Most falls do not result in a fracture or serious injury, yet the functional consequences of a fall can be sufficient to necessitate hospitalisation and a period of restorative care. Data from New South Wales, Australia show that 17% of older people presenting to an emergency department do so as a result of a fall and of these, approximately 50% are admitted [2]. Of those admitted, 60% have not sustained a fracture. There are also data that highlight the increasing rates of non-fracture fallrelated hospitalisations (Fig. 1) – something that pharmacological agents for osteoporosis will not address. This chapter focusses on intervention and attempts to unravel the complex literature in a way that is helpful to clinicians working in this area. Consideration is given to the challenges associated with systematisation of models of care, addressing both bone health and falls risk. Of course, interventions are only successful in real life if they are demonstrated to be effective for and accepted by the intended recipients. Awareness of the preferences and priorities of older people as well as the ability to motivate, educate and negotiate are important and often under-recognised aspects of successful implementation in this area. Screening and assessment Screening offers the opportunity to identify a population potentially at risk of falls so as to streamline referrals to services and more effectively manage within limited resources. Whatever tool is used, it needs to be simple and quick to administer, but have adequate specificity and sensitivity to be fit for purpose. The Timed Up and Go Test (TUG) [3] has frequently been recommended as a screening tool but a recent systematic review [4], which included 53 studies and 12,832 participants, found that the TUG is not useful for discriminating between fallers and non-fallers, particularly when applied to a healthy, high-functioning population (Fig. 2). The article concludes that the predictive ability and diagnostic accuracy are at best moderate and that no cut-point could be recommended. The current American Geriatrics Society/British Geriatrics Society (AGS/BGS) clinical practice guideline [5] provides simple advice on opportunistic screening with three simple questions used to identify people requiring further assessment and intervention. The patient:
Fig. 1. Fall-related fracture and non-fracture injury hospitalisations, projected to 2020/21. NSW, Australia. Data from the NSW Admitted Patient Data Collection.
J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
823
Fig. 2. Results from a systematic review of the usefulness of the timed up and go test on discriminating between fallers and nonfallers.
1. has had two or more falls in the prior 12 months, 2. presents with an acute fall and 3. has difficulty with walking or balance. In some populations, the value of screening is questionable and this includes people living in residential and nursing-care facilities where approximately 50% of residents will fall annually. However, limited resources may necessitate a more focussed assessment linked to intervention, and in such cases, a screening tool may be useful in this setting. A recently published paper by Whitney et al. [6] provides a simple tool that quantifies the probability of a resident falling over a 6-month period (Care Home Falls Risk Screen – Fig. 3). The tool can also assist in guiding the approach to intervention. Intervention in the community setting The majority of older people live in the community setting, and preventing falls in this population is important in relation to maintaining function and independence. It is in this setting where most is to be gained from implementation and systematisation of effective models of care, but it is also the setting that is associated with most complexity in terms of interpretation of the literature and developing a clear understanding of which intervention should be targeted at which population. The most recent Cochrane review of interventions to prevent falls in the community setting includes 159 trials and 79,193 participants and presents a comprehensive high-quality review of the literature in this area. [7] Exercise Exercise has been the single most tested approach to falls prevention, and overall the evidence is supportive of exercise as a falls’ prevention strategy both as a single intervention and as part of a multifactorial intervention in the community setting. However, care is needed when interpreting the literature, as the type of exercise is important and not all populations will benefit from exercise with the potential of increasing falls in some. In a systematic review by Sherrington et al., designed to tease out the key components of an effective exercise intervention, three factors appear critical to success: 1) exercise that challenges balance (movement of centre of mass and reducing the base of support and need for upper limb support), 2) exercise undertaken for approximately 2 h a week over 6 months and 3) exercise that does not include walking as part of the programme. Table 1 highlights the effects of the various combinations of these factors with the most effective programmes offering a high-dose, highbalance challenge and no walking as part of the programme and producing a 42% reduction in rate of falls. However, programmes with a low-dose, low-balance challenge and including a walking programme produce a significant 20% increase in rate of falls.
J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Fig. 3. The care home falls risk screen.
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
825
Table 1 Effects of walking, challenging balance and dose of exercise on risk of falls in older people.
High dose þ walking High dose no walking Low dose þ walking Low dose no walking
High balance challenge rate ratio (95% CIs)
Low balance challenge rate ratio (95% CIs)
0.76 0.58 0.95 0.72
0.96 0.73 1.20 0.91
(0.66–0.88) (0.48–0.69) (0.78–1.16) (0.60–0.87)
(0.80–1.16) (0.60–0.88) (1.00–1.44) (0.79–1.05)
The bolded text reflect the approaches to exercise that have the greatest effect size both in terms of reducing falls but also increasing risk of falls.
The Cochrane review [7] also provides evidence to support exercise in the prevention of falls. A total of 59 trials were identified in the latest update which tested exercise as a single intervention and a further 40 included exercise as part of a multifactorial intervention. Both group- and home-based multicomponent exercise can reduce the rate and risk of falls. Importantly, the data also point to exercise as an effective strategy in reducing the risk of fall-related fractures (relative risk (RR) 0.34, 95% confidence interval (95% CI) 0.18–0.63; six trials; 810 participants). Emerging research suggests that not all populations stand to benefit from exercise as a single intervention. A study recently completed in Sydney, Australia [8] looked at the impact of an individualised 12-month strength and balance, home-based exercise programme on 340 participants (mean age 81.2 years, standard deviation (SD) 8.0) recently discharged from hospital. The target population represents a frailer end of the spectrum as most participants came from geriatric medicine services. The intervention group had a higher fall rate (1.0 per person, SD 1.23) than that of the control group (0.73 falls per person, SD 1.22) and this difference was statistically significant (incidence-rate ratio (IRR) 1.43, 95%CI 1.07–1.93). Interventions targeting vision Visual impairment is an established risk factor for falls [9,10] as is the use of bifocal and multifocal glasses [11] (Fig. 4). In cases where the cause of visual impairment is related to cataract formation, the first cataract extraction, leading to an average corrected binocular acuity improvement of 0.25 logMAR (logarithm of the minimum angle of resolution) units, has been shown to reduce the risk of falls [12]. In cases where cataracts are bilateral, the removal of the second cataract does not confer any additional benefit in terms of falls risk reduction, but does of course have benefits in terms of enhanced vision and quality of life [13]. The substitution of bifocal or multifocal glasses for single-lens glasses has been shown to reduce the rate of outdoor falls in people regularly undertaking outdoor activities as measured using the Adelaide Activities Profile [14]. However, a significant increase in outdoor falls occurred in those who rarely went out, which again highlights the need to carefully consider which intervention is appropriate for which population [15]. A separate visual intervention study targeting frail older people and undertaking detailed vision assessment linked to intervention showed that it was not only ineffective but also increased falls (rate ratio (RaR) 1.57 95%CI 1.20–2.05) and fractures (RR 1.74, 95%CI 0.97–3.11) [16]. Medication and medication management Medication management involves ensuring that people are prescribed and able to take medications that are appropriate for their clinical condition(s) and are also not taking medications causing harm or for which there is no longer a clinical indication. Medication review linked with clinical education, feedback on prescribing practice and financial reward for general practitioners (GPs) has been shown to improve prescribing practice and reduce risk of falling (RR 0.61, 95%CI 0.41–0.91) [17]. The financial rewards were in the form of incentive payments for completing medication review checklists and reimbursement for time with the pharmacist. However, simply sending recommendations to a GP following medication review by a pharmacist or a nurse has not been shown to be effective [18,19].
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Fig. 4. Street scene showing the effect of bifocal glasses on the visual resolution of a standard street scene.
The evidence linking psychotropic medications with falls and injury is substantial [20–22] and over the years, we have seen a change in clinician attitude and practice regarding use of drugs, such as sedative/hypnotics. One relatively small trial (93 participants) has shown the benefits of gradual withdrawal of psychotropic medications on the rate of falls (RaR 0.34, 95%CI 0.16–0.73) [23]. However, there were challenges with this study in terms of both recruitment of willing participants and reinstitution of withdrawn medications after conclusion of the study period. This study highlights the importance of not initiating a psychotropic medication in the first place unless there is a clear clinical indication and the benefits and risks of prescribing are considered. Whilst it is important to stop medications that increase the risk of falls and for which there is no clear clinical benefit, it is also important to encourage people to take medications from which they stand to benefit. There are fairly robust data that support a range of pharmacological agents in the treatment of osteoporosis and this is beyond the scope of this chapter. The exception is vitamin D. This vitamin is essential for bone health, but there is evidence of direct benefit of vitamin D on muscle function, reaction time and overall falls risk in people with low levels of vitamin D [24–26]. The Cochrane review of vitamin D in community-dwelling older people did not show an overall benefit of vitamin D in relation to reducing falls rate (RaR 1.00, 95%CI 0.90–1.11; seven trials; 9324 participants) or risk (RR 0.96, 95%CI 0.89–1.03; 13 trials; 26,747 participants), although a subgroup analysis does support the use of vitamin D in people with lower levels of vitamin D (the level is not defined but consensus would suggest levels 50%, falls were significantly reduced (IRR 0.52; 95%CI 0.31– 0.88) [45]. Olfactory stimulation Armed with some evidence of the benefits of lavender olfactory stimulation in reducing anxiety and agitation in people with behavioural and psychological symptoms of dementia (BPSD), Sakamoto et al. assessed the impact on falls of a lavender patch placed on the inner aspect of clothing near the participants’ neck over a 1-year period [46]. All participants were residents in care facilities and the mean Mini–Mental State Examination (MMSE) score was 15. There was a significant reduction in both the number of fallers (hazard ratio (HR) 0.57, 95%CI 0.34–0.95) and rate of falls (IRR 0.51, 95%CI 0.30–0.88) in the intervention group. There was also a significant reduction between baseline and 1-year followup in the Cohen-Mansfield Agitation Inventory in the intervention group, which was not seen in the control group. Whilst these results are promising, they need to be replicated. If supported by further research including the premise that the effect is through reducing anxiety and agitation, then this could be a cheap and effective intervention in care facilities and also for people living in the community with BPSD. Multiple and multifactorial interventions A number of studies over the years have looked at the potential benefits of multiple or multifactorial intervention of falls in care facilities. Again, as with many of the areas already covered in this chapter, it is challenging to tease out what might work in this population. There is marked heterogeneity in the multifactorial interventions making it difficult to pool the data and derive clinically meaningful outcomes. When looking at multiple interventions applied to all, a simple programme consisting of supervised exercise, regular toileting and promoting fluid intake and adequate hydration showed results trending but not reaching statistical significance in both rate (RaR 0.62, 95%CI 0.38–1.01) and risk (RR 0.62, 95%CI 0.36–1.05) of falls [47]. Multifactorial interventions may also have a role in preventing falls in care facilities, but the evidence as it stands is insufficient to be able to advise with any degree of certainty what the important or key aspects of success are. Subgroup analysis undertaken in the
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Cochrane review exploring heterogeneity by considering level of care and cognitive status failed to shed light on factors associated with success [40].
What does not work in care facilities? As with the community setting, it is important to consider what has been tested and not shown to have any benefit. Single interventions targeting the environment, staff education and the introduction of a risk assessment tool have not been shown to be effective [40]. A low-intensity multifactorial intervention study undertaken in Auckland, New Zealand actually showed an increase in the incidence of falls in the intervention group (IRR 1.34, 95%CI 1.06–1.72) [48]. Reasons put forward for this increase include taking staff away from direct resident care/supervision or the possibility that increasing the physical activity levels of residents had the unintended consequence, through increased exposure to risk, of increasing falls. Moving out of the research setting and into real life When examining the trials that inform our practice, we see that numerous interventions have been tested in various populations with some degree of success. The effectiveness of the intervention is determined by a number of factors including the quality of the study design, sample size, quality of the intervention, adherence to the intervention, accuracy of follow-up data and the quality of the analysis. Inclusion/exclusion criteria for clinical trials do not always reflect how older people currently access or move within health services, and one is left trying to figure out which intervention(s) is (are) likely to be most effective for the person sitting in the clinic or which population should be targeted first to meet the goals of a local falls plan or policy. What the literature does tell us is that there is no single approach to intervention that will prevent falls in all populations and that some interventions can be effective in one population and harmful in another. Knowledge of the literature and the ability to collate and synthesise relevant information and turn it into a plan for an older person are critical to effective intervention. Equally, the views of the older person should be sought as effectiveness is dependent on uptake and adherence. For some individuals, who require more than one intervention, it may be necessary to prioritise strategies in negotiation with the older person. The reality of course is that our approach to falls prevention is rarely systematic and is more likely to be opportunistic and linked to a policy or plan, funding opportunity or financial incentive or an interested person/group of individuals. Whilst we strive for integrated pathways of care that identify at-risk populations and direct them to the right level of intervention based on assessment, the current situation internationally is rather more piecemeal and rarely systematised. Best bets at this point in time Having summarised the evidence and highlighted the complexity and challenge of applying the right intervention to the right person or population, this section provides some ‘best bets’ for aspects to focus on at this point in time.
Best bets for the community setting Exercise challenging balance and strength is likely to be an effective approach to an unselected community-dwelling population, but caution is required in the frailer end of the spectrum. Getting older people to exercise in an effective and sustainable manner is a challenge despite multiple health and social benefits. Vitamin D is a cheap intervention with high rates of compliance likely. It should be targeted at those with vitamin D insufficiency/deficiency (
Contents lists available at ScienceDirect
Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh
9
How can you prevent falls and subsequent fractures? Jacqueline C.T. Close, MBBS, MD, FRACP, FRACP * Neuroscience Research Australia and Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
a b s t r a c t Keywords: Falls Injury Older people Community Hospital Care facility
Over the years, a number of strategies have been investigated to prevent falls in older people in a number of settings. Over 200 randomised controlled trials now exist, and the challenge for the discerning clinician is to read and interpret the existing literature so as to be able to implement effective strategies, targeting the right individual with the right intervention. This chapter reviews the current literature and attempts to simplify what has become an enormously complex area. Interventions are reviewed in three main settings – community, hospital and care facilities and based on the type of approach – single, multiple or multifactorial interventions. It also considers the reality in which we practise and provides some ‘best bets’ to consider at this point in time. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction A wealth of literature has emerged over the last three decades, which has greatly enhanced our understanding of the important contributors to risk of falls and fall-related injury in older people. Equally, a number of clinical trials of varying quality have been published, providing evidence of effective approaches to preventing falls with the first effective study published in 1994 [1]. What has also become apparent is the complexity of the evidence upon which our practice is shaped with enormous challenges faced by those expected to implement research in knowing which intervention is likely to be most effective in which population.
* Tel.: þ61 2 93991055; fax: þ61 2 93991204. E-mail address: [email protected]. 1521-6942/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.berh.2013.12.001
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
A fall is an important event for an older person and should not simply be viewed as a surrogate marker of fracture risk. Most falls do not result in a fracture or serious injury, yet the functional consequences of a fall can be sufficient to necessitate hospitalisation and a period of restorative care. Data from New South Wales, Australia show that 17% of older people presenting to an emergency department do so as a result of a fall and of these, approximately 50% are admitted [2]. Of those admitted, 60% have not sustained a fracture. There are also data that highlight the increasing rates of non-fracture fallrelated hospitalisations (Fig. 1) – something that pharmacological agents for osteoporosis will not address. This chapter focusses on intervention and attempts to unravel the complex literature in a way that is helpful to clinicians working in this area. Consideration is given to the challenges associated with systematisation of models of care, addressing both bone health and falls risk. Of course, interventions are only successful in real life if they are demonstrated to be effective for and accepted by the intended recipients. Awareness of the preferences and priorities of older people as well as the ability to motivate, educate and negotiate are important and often under-recognised aspects of successful implementation in this area. Screening and assessment Screening offers the opportunity to identify a population potentially at risk of falls so as to streamline referrals to services and more effectively manage within limited resources. Whatever tool is used, it needs to be simple and quick to administer, but have adequate specificity and sensitivity to be fit for purpose. The Timed Up and Go Test (TUG) [3] has frequently been recommended as a screening tool but a recent systematic review [4], which included 53 studies and 12,832 participants, found that the TUG is not useful for discriminating between fallers and non-fallers, particularly when applied to a healthy, high-functioning population (Fig. 2). The article concludes that the predictive ability and diagnostic accuracy are at best moderate and that no cut-point could be recommended. The current American Geriatrics Society/British Geriatrics Society (AGS/BGS) clinical practice guideline [5] provides simple advice on opportunistic screening with three simple questions used to identify people requiring further assessment and intervention. The patient:
Fig. 1. Fall-related fracture and non-fracture injury hospitalisations, projected to 2020/21. NSW, Australia. Data from the NSW Admitted Patient Data Collection.
J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
823
Fig. 2. Results from a systematic review of the usefulness of the timed up and go test on discriminating between fallers and nonfallers.
1. has had two or more falls in the prior 12 months, 2. presents with an acute fall and 3. has difficulty with walking or balance. In some populations, the value of screening is questionable and this includes people living in residential and nursing-care facilities where approximately 50% of residents will fall annually. However, limited resources may necessitate a more focussed assessment linked to intervention, and in such cases, a screening tool may be useful in this setting. A recently published paper by Whitney et al. [6] provides a simple tool that quantifies the probability of a resident falling over a 6-month period (Care Home Falls Risk Screen – Fig. 3). The tool can also assist in guiding the approach to intervention. Intervention in the community setting The majority of older people live in the community setting, and preventing falls in this population is important in relation to maintaining function and independence. It is in this setting where most is to be gained from implementation and systematisation of effective models of care, but it is also the setting that is associated with most complexity in terms of interpretation of the literature and developing a clear understanding of which intervention should be targeted at which population. The most recent Cochrane review of interventions to prevent falls in the community setting includes 159 trials and 79,193 participants and presents a comprehensive high-quality review of the literature in this area. [7] Exercise Exercise has been the single most tested approach to falls prevention, and overall the evidence is supportive of exercise as a falls’ prevention strategy both as a single intervention and as part of a multifactorial intervention in the community setting. However, care is needed when interpreting the literature, as the type of exercise is important and not all populations will benefit from exercise with the potential of increasing falls in some. In a systematic review by Sherrington et al., designed to tease out the key components of an effective exercise intervention, three factors appear critical to success: 1) exercise that challenges balance (movement of centre of mass and reducing the base of support and need for upper limb support), 2) exercise undertaken for approximately 2 h a week over 6 months and 3) exercise that does not include walking as part of the programme. Table 1 highlights the effects of the various combinations of these factors with the most effective programmes offering a high-dose, highbalance challenge and no walking as part of the programme and producing a 42% reduction in rate of falls. However, programmes with a low-dose, low-balance challenge and including a walking programme produce a significant 20% increase in rate of falls.
J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Fig. 3. The care home falls risk screen.
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
825
Table 1 Effects of walking, challenging balance and dose of exercise on risk of falls in older people.
High dose þ walking High dose no walking Low dose þ walking Low dose no walking
High balance challenge rate ratio (95% CIs)
Low balance challenge rate ratio (95% CIs)
0.76 0.58 0.95 0.72
0.96 0.73 1.20 0.91
(0.66–0.88) (0.48–0.69) (0.78–1.16) (0.60–0.87)
(0.80–1.16) (0.60–0.88) (1.00–1.44) (0.79–1.05)
The bolded text reflect the approaches to exercise that have the greatest effect size both in terms of reducing falls but also increasing risk of falls.
The Cochrane review [7] also provides evidence to support exercise in the prevention of falls. A total of 59 trials were identified in the latest update which tested exercise as a single intervention and a further 40 included exercise as part of a multifactorial intervention. Both group- and home-based multicomponent exercise can reduce the rate and risk of falls. Importantly, the data also point to exercise as an effective strategy in reducing the risk of fall-related fractures (relative risk (RR) 0.34, 95% confidence interval (95% CI) 0.18–0.63; six trials; 810 participants). Emerging research suggests that not all populations stand to benefit from exercise as a single intervention. A study recently completed in Sydney, Australia [8] looked at the impact of an individualised 12-month strength and balance, home-based exercise programme on 340 participants (mean age 81.2 years, standard deviation (SD) 8.0) recently discharged from hospital. The target population represents a frailer end of the spectrum as most participants came from geriatric medicine services. The intervention group had a higher fall rate (1.0 per person, SD 1.23) than that of the control group (0.73 falls per person, SD 1.22) and this difference was statistically significant (incidence-rate ratio (IRR) 1.43, 95%CI 1.07–1.93). Interventions targeting vision Visual impairment is an established risk factor for falls [9,10] as is the use of bifocal and multifocal glasses [11] (Fig. 4). In cases where the cause of visual impairment is related to cataract formation, the first cataract extraction, leading to an average corrected binocular acuity improvement of 0.25 logMAR (logarithm of the minimum angle of resolution) units, has been shown to reduce the risk of falls [12]. In cases where cataracts are bilateral, the removal of the second cataract does not confer any additional benefit in terms of falls risk reduction, but does of course have benefits in terms of enhanced vision and quality of life [13]. The substitution of bifocal or multifocal glasses for single-lens glasses has been shown to reduce the rate of outdoor falls in people regularly undertaking outdoor activities as measured using the Adelaide Activities Profile [14]. However, a significant increase in outdoor falls occurred in those who rarely went out, which again highlights the need to carefully consider which intervention is appropriate for which population [15]. A separate visual intervention study targeting frail older people and undertaking detailed vision assessment linked to intervention showed that it was not only ineffective but also increased falls (rate ratio (RaR) 1.57 95%CI 1.20–2.05) and fractures (RR 1.74, 95%CI 0.97–3.11) [16]. Medication and medication management Medication management involves ensuring that people are prescribed and able to take medications that are appropriate for their clinical condition(s) and are also not taking medications causing harm or for which there is no longer a clinical indication. Medication review linked with clinical education, feedback on prescribing practice and financial reward for general practitioners (GPs) has been shown to improve prescribing practice and reduce risk of falling (RR 0.61, 95%CI 0.41–0.91) [17]. The financial rewards were in the form of incentive payments for completing medication review checklists and reimbursement for time with the pharmacist. However, simply sending recommendations to a GP following medication review by a pharmacist or a nurse has not been shown to be effective [18,19].
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J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Fig. 4. Street scene showing the effect of bifocal glasses on the visual resolution of a standard street scene.
The evidence linking psychotropic medications with falls and injury is substantial [20–22] and over the years, we have seen a change in clinician attitude and practice regarding use of drugs, such as sedative/hypnotics. One relatively small trial (93 participants) has shown the benefits of gradual withdrawal of psychotropic medications on the rate of falls (RaR 0.34, 95%CI 0.16–0.73) [23]. However, there were challenges with this study in terms of both recruitment of willing participants and reinstitution of withdrawn medications after conclusion of the study period. This study highlights the importance of not initiating a psychotropic medication in the first place unless there is a clear clinical indication and the benefits and risks of prescribing are considered. Whilst it is important to stop medications that increase the risk of falls and for which there is no clear clinical benefit, it is also important to encourage people to take medications from which they stand to benefit. There are fairly robust data that support a range of pharmacological agents in the treatment of osteoporosis and this is beyond the scope of this chapter. The exception is vitamin D. This vitamin is essential for bone health, but there is evidence of direct benefit of vitamin D on muscle function, reaction time and overall falls risk in people with low levels of vitamin D [24–26]. The Cochrane review of vitamin D in community-dwelling older people did not show an overall benefit of vitamin D in relation to reducing falls rate (RaR 1.00, 95%CI 0.90–1.11; seven trials; 9324 participants) or risk (RR 0.96, 95%CI 0.89–1.03; 13 trials; 26,747 participants), although a subgroup analysis does support the use of vitamin D in people with lower levels of vitamin D (the level is not defined but consensus would suggest levels 50%, falls were significantly reduced (IRR 0.52; 95%CI 0.31– 0.88) [45]. Olfactory stimulation Armed with some evidence of the benefits of lavender olfactory stimulation in reducing anxiety and agitation in people with behavioural and psychological symptoms of dementia (BPSD), Sakamoto et al. assessed the impact on falls of a lavender patch placed on the inner aspect of clothing near the participants’ neck over a 1-year period [46]. All participants were residents in care facilities and the mean Mini–Mental State Examination (MMSE) score was 15. There was a significant reduction in both the number of fallers (hazard ratio (HR) 0.57, 95%CI 0.34–0.95) and rate of falls (IRR 0.51, 95%CI 0.30–0.88) in the intervention group. There was also a significant reduction between baseline and 1-year followup in the Cohen-Mansfield Agitation Inventory in the intervention group, which was not seen in the control group. Whilst these results are promising, they need to be replicated. If supported by further research including the premise that the effect is through reducing anxiety and agitation, then this could be a cheap and effective intervention in care facilities and also for people living in the community with BPSD. Multiple and multifactorial interventions A number of studies over the years have looked at the potential benefits of multiple or multifactorial intervention of falls in care facilities. Again, as with many of the areas already covered in this chapter, it is challenging to tease out what might work in this population. There is marked heterogeneity in the multifactorial interventions making it difficult to pool the data and derive clinically meaningful outcomes. When looking at multiple interventions applied to all, a simple programme consisting of supervised exercise, regular toileting and promoting fluid intake and adequate hydration showed results trending but not reaching statistical significance in both rate (RaR 0.62, 95%CI 0.38–1.01) and risk (RR 0.62, 95%CI 0.36–1.05) of falls [47]. Multifactorial interventions may also have a role in preventing falls in care facilities, but the evidence as it stands is insufficient to be able to advise with any degree of certainty what the important or key aspects of success are. Subgroup analysis undertaken in the
830
J.C.T. Close / Best Practice & Research Clinical Rheumatology 27 (2013) 821–834
Cochrane review exploring heterogeneity by considering level of care and cognitive status failed to shed light on factors associated with success [40].
What does not work in care facilities? As with the community setting, it is important to consider what has been tested and not shown to have any benefit. Single interventions targeting the environment, staff education and the introduction of a risk assessment tool have not been shown to be effective [40]. A low-intensity multifactorial intervention study undertaken in Auckland, New Zealand actually showed an increase in the incidence of falls in the intervention group (IRR 1.34, 95%CI 1.06–1.72) [48]. Reasons put forward for this increase include taking staff away from direct resident care/supervision or the possibility that increasing the physical activity levels of residents had the unintended consequence, through increased exposure to risk, of increasing falls. Moving out of the research setting and into real life When examining the trials that inform our practice, we see that numerous interventions have been tested in various populations with some degree of success. The effectiveness of the intervention is determined by a number of factors including the quality of the study design, sample size, quality of the intervention, adherence to the intervention, accuracy of follow-up data and the quality of the analysis. Inclusion/exclusion criteria for clinical trials do not always reflect how older people currently access or move within health services, and one is left trying to figure out which intervention(s) is (are) likely to be most effective for the person sitting in the clinic or which population should be targeted first to meet the goals of a local falls plan or policy. What the literature does tell us is that there is no single approach to intervention that will prevent falls in all populations and that some interventions can be effective in one population and harmful in another. Knowledge of the literature and the ability to collate and synthesise relevant information and turn it into a plan for an older person are critical to effective intervention. Equally, the views of the older person should be sought as effectiveness is dependent on uptake and adherence. For some individuals, who require more than one intervention, it may be necessary to prioritise strategies in negotiation with the older person. The reality of course is that our approach to falls prevention is rarely systematic and is more likely to be opportunistic and linked to a policy or plan, funding opportunity or financial incentive or an interested person/group of individuals. Whilst we strive for integrated pathways of care that identify at-risk populations and direct them to the right level of intervention based on assessment, the current situation internationally is rather more piecemeal and rarely systematised. Best bets at this point in time Having summarised the evidence and highlighted the complexity and challenge of applying the right intervention to the right person or population, this section provides some ‘best bets’ for aspects to focus on at this point in time.
Best bets for the community setting Exercise challenging balance and strength is likely to be an effective approach to an unselected community-dwelling population, but caution is required in the frailer end of the spectrum. Getting older people to exercise in an effective and sustainable manner is a challenge despite multiple health and social benefits. Vitamin D is a cheap intervention with high rates of compliance likely. It should be targeted at those with vitamin D insufficiency/deficiency (
