Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis

Abstract

Importance: Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.

Objective: To assess the potential effectiveness of interventions for preventing falls.

Data sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.

Study selection: Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.

Data extraction and synthesis: Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.

Main outcomes and measures: Injurious falls and fall-related hospitalizations.

Results: A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).

Conclusions and relevance: Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Figure 1.. Study Flow From Literature Search

RCT indicates randomized clinical trial. ^aIf multiple publications reported data from the same trial (eg, reporting results at 1-year vs 2-year follow-up), the first was identified as the primary publication and any additional publications were referred to as companion reports to avoid double counting data from the same trial.

Figure 2.. Network Geometry for Injurious Falls

Network geometry for 54 randomized clinical trials (41 596 patients). Each treatment node indicates an intervention and is weighted according to the number of patients who received the particular intervention. Each edge (line connecting the nodes) is weighted according to the number of studies and directly compares the treatments it connects. See Table 1 for expansions of treatment abbreviations. The coding guide, which provides a description of each intervention component, can be found in eTable 1 of the Supplement.

Figure 3.. Network Geometry for Fallers

Network geometry for 158 randomized clinical trials (107 300 patients). Each treatment node indicates an intervention and is weighted according to the number of patients who received the particular intervention. Each edge (line connecting the nodes) is weighted according to the number of studies and directly compares the treatments it connects. See Table 1 for expansions of treatment abbreviations. The coding guide, which provides a description of each intervention component, can be found in eTable 1 of the Supplement.

Figure 4.. Network Geometry for Fractures and Hip Fractures

A, Network geometry for 68 randomized clinical trials (86 491 patients). B, Network geometry for 39 randomized clinical trials (52 281 patients). Each treatment node indicates an intervention and is weighted according to the number of patients who received the particular intervention. Each edge (line connecting the nodes) is weighted according to the number of studies and directly compares the treatments it connects. See Table 1 for expansions of treatment abbreviations. The coding guide, which provides a description of each intervention component, can be found in eTable 1 of the Supplement.