Recommended evidence-based resources: Systematic reviews, clinical guidelines and toolkits

Contents

 

Introduction

This page includes:

  • a collection of high-level evidence on reducing harm from falls
  • evidence and an overview of the Health Quality & Safety Commission’s 10 Topics on reducing harm from falls. These contain more detailed information by topic, which will be updated approximately every three years, and are intended as professional development exercises
  • recent literature of interest relevant to anyone working to reduce harm from falls, which will be updated annually.

The resources provided are intended to describe interventions to be undertaken, and exclude inconclusive and negative findings.

This page will be updated annually. Please contact us if there is a readily available resource you’d like us to include.

 

Recommendations

The information in this page supports the following high-level recommendations.

  • Perform a multifactorial assessment for an older person’s risk of falling, ideally including assessment for:
    • frailty
    • cognitive impairment.
  • Implement an individualised care plan to address identified risk factors (including safe environment and appropriate referrals).
  • Perform an orthogeriatrician assessment for patients who have fractured their hip.
  • Perform a physiotherapy assessment for patients who have fractured their hip.
  • Supervised and supported balance, strength and gait training is effective for prevention of falls.
  • Combine planned, evidence-based falls prevention programmes with fracture liaison services using partnerships of key providers.

 

Cochrane Reviews

Preventing falls in older people living in the community (2012):

Preventing falls in older people in aged residential care and hospitals (2012):

Exercise for reducing fear of falling in older people living in the community (2014):

Hip protectors for preventing hip fractures in older people (2014):

 

10 topics in reducing harm from falls 

These 10 Topics resources (overview below) have been updated in August 2017 (peer-reviewed by a panel of experts) and will be updated approximately every three years (or more frequently if major new evidence is published).

Click here if you are looking for the original suite of archived 2013–15 resources

Topic 1

The impact of falls on the health of older persons is substantial, and needs to be addressed through a systematic and integrated approach (see Falls Topic 1).

Topic 2 All older people should be asked about falls to identify those at risk who then need, a multifactorial risk assessment (see Falls Topic 2).
Topic 3

All older people screening positive when asked about falls should have a multifactorial risk assessment (see Falls Topic 3).

Topic 4

An individualised care plan addressing identified risk factors should be implemented for any older person at risk of falling (see Falls Topic 4). 

In the community

In hospitals and long-term care facilities
Topic 5

Falls can be prevented by making the environment safer – whether the older person is in care, at home, or out and about (see Falls Topic 5).

Topic 6

Every fall is an opportunity for assessment, individualised care planning and system improvement to prevent further falls (see Falls Topic 6).

Topic 7

Osteoporosis risk assessment and management are important in any fragility fracture, along with guideline-based care for hip fracture (see Falls Topic 7).

Topic 8

A medicine use review is recommended, including review for inappropriate polypharmacy and falls-risk-increasing drugs (see Falls Topic 8).

Topic 9

Balance and strength exercises prevent falls (See Falls Topic 9).

Topic 10

Falls prevention requires an integrated multidisciplinary system-wide approach (see Falls Topic 10).

 

Clinical guidelines and standards

 

Toolkits and guides 

For clinicians
For patients/consumers
For organisations

 

Recent literature of interest

The links provided above summarise the key messages from over 200 new resources reviewed at the level of systematic review, guideline, meta-analysis, umbrella review or health technology assessment. This means approximately one new high-level piece of evidence is being published per week in this field. The rate of relevant primary studies appears to be four or more per day. Below we survey some important literature that has emerged recently. 

New Zealand studies

The Ministry of Health published a new Healthy Ageing Strategy in 2016. This calls on hospitals to improve falls reduction strategies by using data to identify those at risk, and also reducing harm from falls by improving the quality of care for those admitted due to falls and fractures (Associate Minister of Health 2016).

The New Zealand Medical Journal published an article in Dec 2016 that summarises the success of the Health Quality & Safety Commission’s three-year programme of work for reducing harm from falls. The data shows that a targeted measurement framework and national action strategy led to a nationwide reduction in hip fractures and associated costs resulting from in-hospital falls, from 12 per 100,000 admissions to eight per 100,000 admissions (Jones et al 2016).

The results of the Home Injury Prevention Intervention Study are now published in the BMJ. This was a randomised controlled trial of 842 households in Taranaki showing that a modification package including handrails, grab rails, outside lighting, edging for outside steps, and slip-resistant surfacing was effective in reducing falls by 26 percent per year (Keall et al 2015). Home modification also appears to be very cost-effective in a recent modeling study (Pega et al 2016).

The results of the ViDA study are expected soon. This is a study of 5000 people in Auckland, who were given monthly vitamin D supplements at a dose of 100,000 IU cholecalciferol. This evidence will contribute to our knowledge of the effect of vitamin D supplementation in a healthy middle aged and older ambulatory population. 

Randomised controlled trials

The ProAct65+ study was a cluster randomised controlled trial of 1256 community dwelling people over 65 in the UK. Frequent fallers, and those with unstable conditions were excluded. The interventions were either the Fitness and Mobility Exercise Programme (FaME) or the Otago Exercise Programme (OEP). The interventions lasted 24 weeks with two years’ follow-up. FaME programme participants experienced a 26 percent reduction in all falls, and OEP participants a 24 percent reduction. However, only the FaME reduction was statistically significant (Gawler et al 2016). 

We know that exercise programmes prevent falls in the community, but it’s still unclear which components of ward care do so. The 6-PACK study was a cluster randomised controlled trial evaluating the effect of the 6-PACK ward bundle. This consists of ‘falls alert’ signs, supervision of patients in the bathroom, ensuring patients’ walking aids are within reach, a toileting regimen, use of a low bed, and use of a bed/chair alarm. There was no difference in the rate of falls in intervention wards in comparison to usual care (Barker et al 2016).

Identifying older people at risk of falling

Recent efforts to identify those who might benefit from falls prevention interventions have focused on tests and metrics, identifying frailty, the use of routinely collected health data, multidisciplinary clinics, and emergency services. 

A ‘state of the art review’ in the BMJ gives succinct guidance for assessing who is at risk of falling in the community and choosing interventions to manage risks (Viera et al 2016). 

In a reminder of the importance of multifactorial risk assessment, a 2017 review emphasises that no single test/measure is enough to predict risk. The Berg Balance Scale score (≤ 50 points), Timed Up and Go times (≥ 12 seconds), and five times sit-to-stand times (≥ 12) seconds are currently the most evidence-supported functional measures to determine individual risk of future falls (Lusardi et al 2017).

The first systematic review of studies examining frailty as a predictor of falls in the community pooled results from 11 studies incorporating 68,723 individuals. This showed that frailty (assessed using a variety of methods) predicts an increased risk of falls and underscores the need to assess for frailty and provide individualised falls prevention interventions for frail older people (Kojima 2015). 

Innovative use of routinely collected electronic health record data could provide enhanced clinical decision support for identifying those at risk of falls. One study shows how pertinent clinical narrative elements suggesting fall risk can be identified, throughout various parts of the medical record (ie, structured, semi-structured and free text) and extracted (Baus et al 2016). 

Another study implemented a novel multidisciplinary, multifactorial falls, syncope, and dizziness service model. This helped identify cases through proactive, primary care-based screening of individual case notes of individuals aged ≥ 60. Screening looked for individual fall risk factors. Through such screening and a Comprehensive Geriatric Assessment Plus (Plus being falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials (Parry et al 2016).

At-scene interventions can be delivered by emergency services. In a study of fallers who called 9-1-1 emergency medical technicians delivered at-scene advice to contact a local multifactorial fall prevention program. Six percent of fallers reported having made an appointment (vs 3 percent of the comparison group). The potential health impact could be substantial (Phelan et al 2016).

Keeping active is crucial

An accelerometer study showed that older adults have long periods of sedentary time with minimal activity after hip fracture and we should encourage these people to sit less and move more (Fleig et al 2016). Also, orthogeriatrician involvement in hip fracture in-patient care is associated with reduction in mortality (Neuburger et al 2016).

A meta-analyses of seven randomised controlled trials (660 participants) concludes that stepping interventions are highly effective for preventing falls. The rate of falls and number of fallers were significantly reduced by approximately 50 percent (Okubo et al 2016).

A 2017 review of the health impact of sarcopenia (muscle loss) emphasises that muscle loss is associated with increased falls, and mortality. The importance of exercise, in particular resistance training, not only for preventing falls, is brought home by this recent research (Beaudart et al 2017).

Medications

A New Zealand study demonstrated the association between potentially inappropriate medications (PIMs) and falls, and also polypharmcy (more than five medications) and falls in New Zealand health data sets (Narayan and Nishtala 2015). 

However, importantly, this kind of study can’t tell us if these associations are causal. It may be that people who are likely to fall also happen to be on particular medications. For example, there is ongoing controversy about the relationship between antidepressants and falls (do depressed people fall, or do antidepressants make people fall?) (Gebara et al 2015). 

This line of reasoning is borne out by evidence suggesting that the evidence for cross-sectional medication use review for reducing falls is inconclusive (Huiskes et al 2017). Again, it is important to intervene in personalised fashion to help prevent falls in older people. 

That said, the American Psychiatric Association gives clear guidance that before considering antipsychotics in older patients with dementia, a thorough assessment of the potential risks and benefits should be considered. Also, non-emergency antipsychotic medication should only be used in these cases when symptoms are severe, are dangerous, and/or cause significant distress to the patient. This is at least in part because of the reported risk of falls and orthopedic injuries (Agency for Healthcare Research and Quality 2016). 

Implementation of what is currently known

It’s all very well to have research evidence describing what works to prevent falls. But this knowledge must be implemented to be effective. A UK study of 62 mental health trusts revealed that most falls policies mentioned unvalidated tools. Also, the falls risk assessment tools from only four facilities met the National Institute for Clinical Excellence guidelines on multifactorial assessment to prevent falls (Narayanan et al 2016). This is a timely reminder to check policy is up-to-date with the evidence. 

Looking to the future

One indication of the critical importance of preventing harm from falls comes from a recent modeling study. The researchers modeled the future demographic transition in Bavaria. Their results suggest that in order to limit the increase of fractures between 2014 and 2025 to only 10 percent, fall-prevention-exercise participation rates need to be 25 percent and bisphosphonate treatment rates 41 percent, whereas to hold the 2025 rates flat at 2014 rates will require 43 percent participation in fall-prevention-exercises, and is not achievable using oral bisphosphonates (Benzinger et al 2016).

A 2017 systematic review concluded that long-term exercise programmes reduce falls in older people with cognitive impairment (Lewis et al 2017). Therefore, cognitive impairment should not be seen as a barrier to strength and balance exercise programmes, provided adequate supervision is available.

Finally, the International Osteoporosis Foundation has identified 10 ‘gaps in bone care’ (Harvey and McCloskey 2016).

Gap 1: Secondary fracture prevention

Gap 2: Osteoporosis induced by medicines

Gap 3: Diseases associated with osteoporosis

Gap 4: Primary fracture prevention for individuals at high risk of fracture

Gap 5: The importance of staying on treatment

Gap 6: Public awareness of osteoporosis and fracture risk

Gap 7: Public awareness of benefits versus risks of osteoporosis treatment

Gap 8: Access and reimbursement for osteoporosis assessment and treatment

Gap 9: Prioritisation of fragility fracture prevention in national policy

Gap 10: The burden of osteoporosis in the developing world.

 

References

Agency for Healthcare Research and Quality. 2016. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Agency for Healthcare Research and Quality.

Associate Minister of Health. 2016. Healthy Ageing Strategy. Wellington: Ministry of Health.

Barker AL, Morello RT, Wolfe R, et al. 2016. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. British Medical Journal 352: h6781.

Baus A, Zullig K, Long D, et al. 2016. Developing methods of repurposing electronic health record data for identification of older adults at risk of unintentional falls. Perspectives in health information management 13. URL: https://http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832126/.

Beaudart C, Zaaria M, Pasleau F, et al. 2017. Health Outcomes of Sarcopenia: A Systematic Review and Meta-Analysis. PLoS ONE [Electronic Resource] 12(1): e0169548.

Benzinger P, Becker C, Todd C, et al. 2016. The impact of preventive measures on the burden of femoral fractures–a modelling approach to estimating the impact of fall prevention exercises and oral bisphosphonate treatment for the years 2014 and 2025. BMC Geriatrics 16(75): DOI: 10.1186/s12877-016-0247-9.

Fleig L, McAllister MM, Brasher P, et al. 2016. Sedentary behavior and physical activity patterns in older adults after hip fracture: a call to action. Journal of aging and physical activity 24(1): 79–84.

Gawler S, Skelton DA, Dinan-Young S, et al. 2016. Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial. Archives of Gerontology & Geriatrics 67: 46–54.

Gebara MA, Lipsey KL, Karp JF, et al. 2015. Cause or effect? Selective serotonin reuptake inhibitors and falls in older adults: A systematic review. American Journal of Geriatric Psychiatry 23(10): 1016–28.

Harvey N, McCloskey E. 2016. Gaps and Solutions in Bone Health: A Global Framework for Improvement. Nyon: International Osteoperosis Foundation.

Huiskes VJ, Burger DM, van den Ende CH, et al. 2017. Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials. BMC Family Practice 18(5): doi:  10.1186/s12875-016-0577-x.

Jones S, Blake S, Hamblin R, et al. 2016. Reducing harm from falls. New Zealand Medical Journal 129(1446): 89–103.

Keall MD, Pierse N, Howden-Chapman P, et al. 2015. Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: a cluster-randomised controlled trial. The Lancet 385(9964): 231–8.

Kojima G. 2015. Frailty as a predictor of future falls among community-dwelling older people: A systematic review and meta-analysis. Journal of the American Medical Directors Association 16(12): 1027–33.

Lewis M, Peiris CL, Shields N. 2017. Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review. Journal of Physiotherapy 63(1): 23–9.

Lusardi MM, Fritz S, Middleton A, et al. 2017. Determining risk of falls in community dwelling older adults: A systematic review and meta-analysis using posttest probability. Journal of Geriatric Physical Therapy 40(1): 1–36.

Narayan SW, Nishtala PS. 2015. Associations of potentially inappropriate medicine use with fall-related hospitalisations and primary care visits in older New Zealanders: a population-level study using the updated 2012 Beers Criteria. Drugs-real world outcomes 2(2): 137–41.

Narayanan V, Dickinson A, Victor C, et al. 2016. Falls screening and assessment tools used in acute mental health settings: a review of policies in England and Wales. Physiotherapy 102(2): 178–83.

Neuburger J, Currie C, Wakeman R, et al. 2016. Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England. Age and Ageing 46(2): 187–92.

Okubo Y, Schoene D, Lord SR. 2016. Step training improves reaction time, gait and balance and reduces falls in older people: a systematic review and meta-analysis. British Journal of Sports Medicine 51(7): 586–93.

Parry SW, Hill H, Lawson J, et al. 2016. A novel approach to proactive primary care–based case finding and multidisciplinary management of falls, syncope, and dizziness in a one‐stop service: preliminary results. Journal of the American Geriatrics Society 64(11): 2368–73.

Pega F, Kvizhinadze G, Blakely T, et al. 2016. Home safety assessment and modification to reduce injurious falls in community-dwelling older adults: cost-utility and equity analysis. Injury Prevention 22(6): 420–6.

Phelan EA, Herbert J, Fahrenbruch C, et al. 2016. Coordinating care for falls via emergency responders: a feasibility study of a brief at-scene intervention. Frontiers in Public Health 4(266).

Viera E, Palmer R, Chaves P. 2016. Prevention of falls in older people living in the community. BMJ 353: i1419.

Last updated 21/03/2018