Key messages
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Combined treatments that are tailored to someone’s risk factors (multifactorial approaches) may slightly reduce the number of falls and the chance of falling two or more times compared with no special falls prevention treatment (usual care). However, compared with exercise or falls education, the benefit becomes very small or disappears.
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Combined treatments where everyone receives the same treatment (multiple component approaches) may provide little or no additional benefit compared to usual care, exercise, or falls advice or education, except that they may reduce the chance of falling compared with usual care.
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More research is needed into why falls happen, when and where they are most likely to happen, and how to measure the effects of treatment.
How can we prevent falls in older people, and why is this important?
Falls are one of the most common causes of injury and death in older people worldwide. People may be at risk of falling for a number of reasons (their 'risk factors' for falling), such as previous falls, muscle weakness, and balance problems, as well as hazards in the environment and inappropriate footwear. Falls prevention treatments used include exercise, education, counselling, and medication review.
Multifactorial falls prevention approaches refer to combined treatments that are tailored to an individual's specific risk factors. In contrast, multiple component falls prevention approaches are standardised combinations of treatments. These treatments may be compared with no special falls prevention treatment (usual care), exercise, or falls prevention education (such as a leaflet).
What did we want to find out?
We wanted to know, in older people living in the community, whether multifactorial or multiple component falls prevention treatments:
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reduce the number of falls;
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reduce the chance of falling at least once and the chance of falling two or more times;
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cause any unwanted effects.
What did we do?
We searched for studies that compared multifactorial or multiple component falls prevention treatments to exercise, usual care, or falls prevention education. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 110 studies involving 48,919 older people. Of these:
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65 studies looked at multifactorial treatments;
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44 studies looked at multiple component treatments; and
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1 study looked at both types of treatments.
The studies were performed worldwide, mostly in Australia, the UK, and the USA. The average age of participants ranged from 62 to 85 years. Most studies included more women than men, and most lasted around 12 months.
Main results
Multifactorial falls prevention treatments:
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versus usual care may reduce the number of falls (29 studies, 9442 people) and the risk of falling two or more times (17 studies, 4826 people); and may have little or no effect on the risk of falling at least once (38 studies, 12,774 people).
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versus exercise may or may not make a difference to the number of falls and the risk of falling at least once – the evidence is very uncertain. No studies tested the risk of falling two or more times.
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versus falls advice or education provide no additional benefit and likely increase the number of falls by a small amount (7 studies, 9901 people). They probably have little or no effect on the risk of falling at least once (7 studies, 8850 people) and the risk of falling two or more times (3 studies, 7865 participants).
Multiple component falls prevention treatments:
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versus usual care may have little or no effect on the number of falls (14 studies, 4026 people) and may reduce the risk of falling at least once (19 studies, 6925 people). The evidence for the risk of falling two or more times is very uncertain.
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versus exercise may have little or no effect on the number of falls (8 studies, 2160 people) and the risk of falling two or more times (5 studies, 874 people). They likely have little or no effect on the risk of falling at least once (10 studies, 2920 people).
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versus falls advice or education may have little or no effect on the number of falls (7 studies, 9313 people) and the risk of falling at least once (8 studies, 9355 people). They likely have little or no effect on the risk of falling two or more times (6 studies, 8725 people).
Unwanted effects were generally mild.
What are the limitations of the evidence?
We have only moderate to very low confidence in the evidence because:
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the results varied across studies;
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in most studies, people likely knew which treatment they were receiving;
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not all studies measured everything we were interested in; and
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the benefits we found might be overestimated, because studies with smaller or negative results are less likely to be published.
How up to date is this review?
This review updates an earlier version from 2018. The evidence is current to May 2024.
อ่านบทคัดย่อฉบับเต็ม
บทนำ
Falls and fall-related injuries are common, particularly in those aged over 65, with around one-third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.
วัตถุประสงค์
To assess the effects of multifactorial and multiple component fall prevention interventions compared to usual care or attention control, exercise, and falls prevention advice or education in community-dwelling older people.
วิธีการสืบค้น
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, ClinicalTrials.gov, the WHO ICTRP, and reference lists, without restrictions on language or full-text publication, on 16 May 2024.
เกณฑ์การคัดเลือก
Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.
การรวบรวมและวิเคราะห์ข้อมูล
Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random-effects model. We used the GRADE approach to assess the quality of the evidence.
ผลการวิจัย
We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow-up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.
Forty-four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I2 not reported if = 0%).
Multifactorial interventions versus usual care or attention control
This comparison was made in 43 trials. Commonly-applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I2 = 88%; low-quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low-quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I2 = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I2 = 53%); fall-related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low-quality evidence that multifactorial interventions may reduce the risk of fall-related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health-related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I2 = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self-limiting musculoskeletal symptoms in total.
Multifactorial interventions versus exercise
Very low-quality evidence from one small trial of 51 recently-discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall-related outcomes were not assessed.
Multiple component interventions versus usual care or attention control
The 17 trials that make this comparison usually included exercise and another component, commonly education or home-hazard assessment. There is moderate-quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I2 = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low-quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low-quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall-related fractures (2 trials) or fall-related hospital admission (1 trial). There is low-quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health-related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I2 = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.
Multiple component interventions versus exercise
This comparison was tested in five trials. There is low-quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low-quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.
ข้อสรุปของผู้วิจัย
Multifactorial interventions may slightly reduce falls rate and the risk of recurrent falls, but may have little or no effect on the risk of falling, compared with usual care or attention control. When compared with exercise, their effects on falls rate and risk of falling are uncertain. Multifactorial interventions provide no additional benefit for falls rate and probably have little or no effect on the risk of falling and recurrent falls when compared with falls advice or education.
Multiple component interventions may have little or no effect on falls rate compared with usual care or attention control, exercise, or falls advice or education. They may also have little or no effect on the risk of falling compared with usual care or attention control or falls advice or education, and on the risk of recurrent falls compared with exercise. Multiple component interventions probably have little or no effect on the risk of falling compared with exercise and on the risk of recurrent falls compared with falls advice or education. The effect on recurrent falls compared with usual care or attention control is very uncertain.
The certainty of evidence for most comparisons was limited by risk of bias and statistical heterogeneity.
แหล่งทุน
NIHR Exeter Biomedical Research Centre, Dennis and Mireille Gillings Foundation, Bateman Family Charitable Trust, NIHR SPCR Post-doctoral fellowship.
การลงทะเบียน
Not applicable.
