Falls can be prevented

Summarized by Robert W. Griffith, MD
February 26, 1999 (Reviewed: January 21, 2005)

Introduction

Falls are common and costly in the elderly - 8% of people over 70 attend emergency rooms each year for fall-related injuries, and of these, over 30% are admitted to hospital. The present article describes the results of a randomized controlled trial to assess the benefits of a structured interdisciplinary approach in dealing with elderly patients who have had falls.

Method

Participants included patients with falls aged 65 and over who attended the accident and emergency department of a London, UK hospital over a 6-month period. Patients who had cognitive impairment or who didn't speak English were excluded. After discharge home (from the emergency room or hospital) patients were contacted by phone and/or letter, to collect baseline data. These consisted of details of the fall, any previous falls, concurrent disorders, drug history, cognitive assessment and socio-demographic information. Enrolled patients were assigned randomly to receive intervention - detailed medical and occupational-therapy assessment, with referral to relevant services if indicated - or no assessment, as the control strategy. All participants were given a "falls diary" to record further falls.

In the intervention group, the medical assessment comprised a comprehensive physical examination, with detailed evaluation of postural hypotension, visual acuity, balance, cognition, affect and prescription drug intake. Studies to detect the carotid sinus syndrome were done if the cause of the fall was unclear. The medical assessment resulted in assigning a primary cause of the fall, and addressing any identified risk factors. If necessary, patients were referred to other services, and potential fall-inducing drugs were discussed with the family physician.

After the medical assessment, an occupational therapist visited the patient at home. Functional independence (using the Barthel index) and environmental hazards were evaluated. Advice on fall avoidance in the home was given, and minor modifications made if appropriate (e.g. removal of loose rugs, installation of handrails).

A postal questionnaire was sent to all participants every 4 months for 1 year, as follow-up. This inquired about further falls and fall-related injuries, with details of medical care. After 1 year, patients were classified as dead, institutionalized, lost to follow-up or still in the study. The two groups were compared with regard to the number of falls, serious injury (fracture or joint dislocation), and ability to go out alone.

Results

Over 1000 consecutive patients were considered for inclusion in this study. About 30% of these were ineligible, 20% could not be contacted, and 13% refused consent. About 20% of the almost 400 patients entering the study did not complete it. This left 163 intervention patients and 141 control patients in the 12-month follow-up analysis.

In the intervention group, a total of 152 medical assessments revealed a wide variety of potentially relevant conditions: poor balance (72%), poor depth vision (62%), visual impairment (59%), cataracts (35%), cognitive impairment (34%), decreased leg strength (28%), peripheral neuropathy (20%), depression (18%), and cardiovascular/circulatory disorder (17%). The primary causes assigned to the index fall were hazard outside the home (29%), hazard in the home (19%), cardiovascular condition (17%), falls on ice (7%), and prescribed drugs (1.3%). There were referrals to a hospital service, day-care facility, optician or family physician in all but 16% of cases.

The follow-up analysis showed significantly fewer falls in the intervention group (183 falls in 141 patients) compared with the control group (510 falls in 163 patients, p=0.002). After adjustment for baseline Barthel and cognition test scores, the risk of falling was significantly reduced in the intervention group (odds ratio 0.39 with 95% CI, 0.23-0.66), as was the risks of recurrent falls (odds ratio 0.33 with 95% CI, 0.16-0.68).

The mean change in functional ability (Barthel score) compared with baseline for the two groups showed a significant difference between the groups (p=0.017) and a significant change in scores over time (p<0.0001), both in favor of intervention.

Comment

Previous studies have already demonstrated the benefits of intervention in preventing further falls in elderly fall patients. The authors feel that this study examined a more routine, structured approach, which is probably economical - they indicate that a cost-benefit analysis is being undertaken. The variety of risk factors discovered at the medical assessment emphasizes the importance of being able to ensure patient-specific assistance in prevention. While primary prevention - steps to avoid the occurrence of first falls - is obviously important, the population studied here, having experienced a fall requiring emergency room care, is probably much more responsive to assistance in fall prevention.

Source

• Prevention of falls in the elderly trial (PROFET): a randomized controlled trial J Close , M  Ellis , R  Hooper , Lancet , 1999, vol. 353, pp. 93--97

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