Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20,000 participants

Key Points

1. Among community-dwelling older adults, multifactorial interventions may prevent falls and the evidence suggests that it may slightly reduce the risk of recurrent falls.
2. There may be little or no long-term benefit on other fall-related outcomes, such as fractures, falls requiring hospital admission or medical attention, or health-related quality of life.

BACKGROUND & OBJECTIVE

Falls are a major concern among older adults, healthcare providers, and public health officials. Therefore, it is important to be able to identify and address the multifactorial nature of falls (1). This requires healthcare providers to evaluate and address a minimum of two modifiable risk factors for falls (2). When studying the effect of these multifactorial interventions there are many challenges, including the heterogeneity of individualized multifactorial interventions. Therefore, the researchers of this study aimed to explore the heterogeneity in order to examine the effectiveness of multifactorial interventions for preventing falls in older people living in the community, and to focus on trials which provided longer term follow-up data (≥12 months).

Falls risk is influenced by a multitude of factors.

The results of this systematic review identified that multifactorial interventions do reduce the rate of falls, and slightly reduce the risk of people sustaining 1 or more falls.

METHODS

Search Strategy: MEDLINE, EMBASE, and CINAHL.

Study Selection: 2 reviewers independently screened titles and abstract of all potentially eligible studies. Studies were selected if they were a RCT that evaluated the effects of a multifactorial intervention designed to prevent falls or fall-related injuries in community dwelling older-adults (65+ years old), and the study had > 12 months’ follow-up.

Primary Outcome: rate of falls (i.e. number of falls per person-years)

Secondary Outcomes: risk of sustaining one or more falls, recurrent falls (defined as two or more falls in a specified time period), one or more fall-related fractures, a fall that required hospital admission, a fall that required medical attention or affected quality of life

Data Extraction and Risk of Bias: independently performed by two reviewers. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to classify the evidence as high, moderate, low, or very low.

RESULTS

Out of the initial 7,975 articles identified, 41 studies were included in the final qualitative and quantitative analyses (meta-analyses). See Table 1 for a summary of the results.

*A value of 1 indicates there is no difference in the risk rate between the multifactorial intervention group and the comparator intervention. A value less than 1 indicates a lower risk rate in the multifactorial intervention group, and a value greater than 1 indicates a higher risk rate in the multifactorial intervention group.

LIMITATIONS

The primary limitation of this study is the heterogeneity of the interventions included. The other limitation is that some of the RCTs that were included in this systematic review had limited power analysis, reporting of results, and reporting of adverse events.

CLINICAL IMPLICATIONS

The results of this systematic review identified that multifactorial interventions do reduce the rate of falls and slightly reduce the risk of people sustaining 1 or more falls. However, they make little to no difference when examining other fall-related outcomes (including fall-related fractures, falls requiring hospital admission or medical attention, or health-related quality of life). There is also some evidence that suggests that the effect on rate of falls may be smaller in the usual care plus non-tailored fall prevention (i.e. in either written, audio, or visual format) as opposed to usual care only.

Findings of this study confirm that the Cochrane Review of 2018 and NICE recommendations are appropriate. It is also important to note that if an individual is unable to provide multi-factorial interventions, studies have identified that usual care only may have better outcomes than providing usual care plus non-tailored falls prevention advice.

+STUDY REFERENCE

Hopewell S, Copsey B, Nicolson P, Adedire B, Boniface G, Lamb S (2019) Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants. Br J Sports Med. doi: 10.1136/bjsports-2019-100732. [Epub ahead of print]

SUPPORTING REFERENCE

1. Lastrucci V, Lorini C, Rinaldi G, Bonaccorsi G. Identification of fall predictors in the active elderly population from the routine medical records of general practitioners. Primary health care research & development. 2018 Mar;19(2):131-9.
2. Lamb SE, Becker C, Gillespie LD, et al. Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions. Trials 2011;12:125–25.
3. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2018;32.
4. Excellence NIfHaC. Falls in older people: assessing risk and prevention 2013 [CG161], 2016. Available: wwwniceorguk/guidance/cg161/chapter/1-recommendations.
5. Hopewell S, Copsey B, Nicolson P, Adedire B, Boniface G, Lamb S. Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants. British journal of sports medicine. 2019 Aug 21:bjsports-2019.