CRD summary

The review concluded that the evidence on interventions to reduce fall-related incidents in elderly residents of long-term care facilities was inconclusive. This conclusion should be considered with some caution due to the use of a basic synthesis which did not consider trial quality or other trial characteristics.

Authors' objectives

To evaluate the effectiveness and implementation of interventions to reduce falls and related incidents in elderly residents in long-term care settings.

Searching

Papers published before 2003 were identified from a previous review conducted by a different group of authors (see Other Publications of Related Interest). The previous search strategy was replicated for the period 2003 to April 2009. MEDLINE, EMBASE and CINAHL were searched for relevant papers. Search terms were reported. Bibliographies of included trials were searched manually. The authors did not report whether language restrictions were applied to the search.

Study selection

Randomised controlled trials (RCTs) that evaluated preventative interventions for falls in elderly, disabled (cognitive or physical) residents of long-term care settings and nursing homes were eligible for inclusion. The effect of the intervention had to be assessed.

Mean participant age (where stated) ranged from 80 to 89 years. Other participant characteristics varied widely. Interventions included fall risk assessments, recommendations/education, physical exercise/balance training, nutritional supplementation (calcium, vitamin D), provision of hip protectors, staff education and multifactorial interventions. Intervention duration (where stated) ranged from 11 weeks to eight months; intervention frequency (where stated) ranged from two days a week to every two hours on five days a week. More than half of the investigated programmes were multifactorial, half of them were multidisciplinary and most were tailored to the individual. Most programmes had the primary aim to prevent falls. The most frequently used comparator treatment was usual care. Other comparators included friendly visits, reminiscence therapy, calcium supplementation, provision of written health information, completion of fall records, placebo and no provision of hip protectors. Thirteen studies were conducted in nursing homes; other settings included residential care facilities, long-stay geriatric care and homes for the elderly.

Two reviewers assessed study eligibility. Disagreements were resolved in discussions until consensus was achieved or by referral to a third reviewer.

Assessment of study quality

The CONSORT Statement 2001 Checklist was used to assess the quality of reporting of the included RCTs.

The authors did not report how many reviewers assessed study quality.

Data extraction

Data on fall incidents were extracted independently by two reviewers. Statistical significance of results was recorded. No information was given how disagreements in data extraction were resolved.

Methods of synthesis

Studies were summarised by means of a narrative synthesis.

Results of the review

Twenty RCTs (23,646 participants, range 122 to 10,558) were included: eight from the previous review and 12 from the updated search. Follow-up ranged from three to 24 months. Compliance rates for implementation of the intervention ranged from low to good. The authors reported variable trial quality with regards to randomisation procedures (mostly cluster-randomised, few studies used individual randomisation). Blinding of participants and care staff was generally not possible. In general the design, conduct and analyses of the included RCTs were considered to be adequate. No further details on study quality results were reported.

Seven RCTs showed a significant positive effect of the intervention on fall rate (five RCTs), percentage of recurrent fallers (one RCT) and on both the fall rate and the percentage of participants who sustained fractures (one RCT).

Multifactor programmes: A comprehensive structured individual assessment with specific safety recommendations (one RCT), environmental and personal safety assessments and improvements (three RCTs), a multifaceted intervention that included education, environmental adaptation, balance and resistance training and provision of hip protectors (one RCT) and an intervention that combined fall risk evaluation with general and specific interventions (one RCT) had a statistically significant positive effect.

Single-factor interventions: Calcium plus vitamin D supplementation (one RCT), vitamin D supplementation (one RCT) and a review of medication (one RCT) showed statistically significant positive effects.

A programme that included a fall-risk assessment-tool, a warning sign for high fall risk and strategies to address identified risks (one RCT) showed a statistically significant adverse effect of the intervention on the fall rate.

Provision of hip protectors (three RCTs), physical exercise (four RCTs), drug prescriptions (one RCT) and vitamin D supplementation (two RCTs) did not have any statistically significant effect.

All studies provided possible reasons for reduced programme effectiveness: low compliance, inability to target most important risk factors, insufficient vigour of the intervention, lack of support from staff and limited resources.

Authors' conclusions

The authors concluded that the limited number of studies made the evidence was inconclusive, but multifactorial interventions seemed to be more likely to be beneficial than single interventions in long-term care populations.

CRD commentary

The review question and search strategy were clear. Population inclusion criteria were unclear as the term "elderly" was not defined. The authors report neither any language restrictions nor whether unpublished studies were sought, so there was a risk that studies may have been missed and biases introduced. The risk of reviewer bias was reduced by use of independent duplicate review processes for study selection and data extraction; whether the same processes were in place for quality assessment was unclear.

Use of a narrative synthesis instead of meta-analysis seemed appropriate due to heterogeneity between the included studies. However, by merely classifying and grouping studies as producing significant effects (or not) the synthesis took no account of effect size, study quality and sample size, which made the results difficult to interpret. An evaluation of study quality was made, but results for individual trials were not reported and so it was not possible to assess which studies provided the most reliable results.

The authors' conclusions had an element of caution, but the review's basic synthesis and the lack of study quality detail mean that a careful interpretation is warranted.

Implications of the review for practice and research

Practice: The authors recommended that practitioners develop interventions tailored to the specific setting when wishing to reduce falls in elderly long-term care residents. The authors further advised delivery of a multifactorial intervention by a multidisciplinary team, focused on good co-ordination, communication, compliance and continuity of the programme to ensure success.

Research: The authors stated that further research in the area was necessary, especially on implementation of interventions.

Funding

Not reported.

Bibliographic details

Neyens JC, van Haastregt JC, Dijcks BP, Martens M, van den Heuvel WJ, de Witte LP, Schols JM. Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: a systematic review of RCTs. Journal of the American Medical Directors Association 2011; 12(6): 410-425. [PubMed: 21450201]

Original Paper URL

http://www.jamda.com/article/S1525-8610(10)00248-3/abstract

Other publications of related interest

Gillespie LD, Gillespie, WJ, Robertson, MC et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2003; (4). CD000340 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000340.pub2/abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Accidental Falls /prevention & control; Aged; Female; Humans; Male; Program Evaluation; Randomized Controlled Trials as Topic; Residential Facilities; Safety Management /methods /organization & administration

AccessionNumber

12011004359

Database entry date

03/04/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.