Interventions to Prevent Falls in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]

Excerpt

Background: Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States.

Purpose: To systematically review evidence on the effectiveness of interventions to prevent falls in community-dwelling older adults.

Data Sources: We searched MEDLINE, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Clinical Trials for relevant English-language literature published between January 1, 2016, and May 8, 2023. Additionally, we re-evaluated all studies included in the 2018 review. We supplemented our searches with suggestions from experts and articles identified through news and table-of-contents alerts. We conducted ongoing surveillance through March 22, 2024, to identify any major studies published in the interim.

Study Selection: Two investigators independently reviewed identified abstracts and full-text articles against a set of a priori inclusion and quality criteria.

Data Analysis: One investigator abstracted data into an evidence table and a second investigator checked these data. When we had an adequate number of studies, we conducted random-effects meta-analyses with a Knapp-Hartung adjustment to estimate the effect of fall prevention interventions on falls, falls-related morbidity, and all-cause mortality.

Results: We included 83 fair- to good-quality randomized, controlled trials (RCTs) (n=48,839) examining the effectiveness of fall prevention interventions in older adults. Most of the included studies examined the effectiveness of multifactorial (k=28, n=27,784) and exercise (k=37, n=16,117) interventions. The remaining studies examined environment (k=6, n=4,162), exercise plus environment (k=3, n=935), exercise plus education (k=4, n=1,047), medication review/modification (k=4, n=1,052), psychological (k=3, n=9279), and education interventions (k=1, n=310). Based on a pooled analysis, multifactorial interventions were associated with a statistically significant reduction in the number of falls (20 RCTs, n=22,115; incidence rate ratio (IRR), 0.84 [95% CI, 0.74 to 0.95]; I²=85.0%), but not a statistically significant reduction in the number of people with a fall (26 RCTs, n=23,626; relative risk (RR), 0.96 [95% CI, 0.91 to 1.02]; I²=48.2%; k=26). Multifactorial interventions also showed no statistically significant association with the number of falls resulting in injury and people with a fall resulting in injury. Exercise interventions were associated with statistically significant reductions in the number of falls (29 RCTs, n=14,475; IRR, 0.85 [95% CI, 0.75 to 0.96]; I²=82.7%), the number of people with a fall (25 RCTs, n=13,384; RR, 0.92 [95% CI, 0.87 to 0.98]; I²=24.3%), the number of falls resulting in injury (12 RCTs, n=3,984; IRR, 0.84 [95% CI, 0.74 to 0.95]; I²=14.6%), but not the number of people with a fall resulting in injury (9 RCTs, n=3,924; RR, 0.90 [95% CI, 0.79 to 1.02]; I²=26.7%). Environment interventions were not statistically significantly associated with the number of falls and the number of people with a fall. Results from the other interventions did not show a consistent beneficial relationship with falls or fall-related morbidity. No interventions had a statistically significant association with all-cause mortality. Harms were poorly reported, but were usually rare, minor, and associated with exercise components of the interventions.

Limitations: The precision and generalizability of the body of literature for any single intervention type is limited by the marked heterogeneity of population characteristics, including baseline falls risk, and wide variation in intervention protocols. No specific effective exercise or multifactorial protocol has been widely replicated in larger population trials. Limited literature exists for falls prevention interventions in community-dwelling individuals with mild dementia. There are limited trials examining multifactorial and exercise interventions’ effectiveness on outcomes beyond falls and fall injuries like hospitalizations, institutionalizations, and mortality or the overall effectiveness of environmental interventions, medication review, and psychological interventions.

Conclusions: The current evidence base demonstrates that exercise is associated with fewer falls, fewer people with a fall, and a reduced number of injurious falls in average- and increased-risk community-dwelling older adults. Multifactorial interventions appear to reduce falls but not people with a fall or injuries; trials are clinically and statistically heterogeneous. Other single falls prevention interventions, including environmental modification, medication review/modification, education, and psychological interventions as well as falls interventions with multiple components like exercise plus education and exercise plus environment have either few trials showing no statistically significant effect or a few trials reporting inconclusive results.