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Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Published articles

Recommended evidence-based resources: Systematic reviews, clinical guidelines and toolkits

Contents

  • Introduction
  • Recommendations
  • Cochrane Reviews
  • 10 Topics in reducing harm from falls
  • Clinical guidelines and standards for reducing harm from falls
  • Toolkits and guides for implementation
    • for clinicians
    • for patients/consumers
    • for organisations
  • Recent literature of interest (Feb 2017–Feb 2018)
    • New Zealand studies
    • Randomised controlled trials
    • Identifying older people at risk of falling
    • The older person’s environment
    • Keeping active is crucial
    • Medication optimisation
    • Implementing what works
    • Cost-effectiveness
    • Looking to the future
  • References

2018 Evidence base Contents

Introduction

This page includes:

  • a collection of high-level evidence on reducing harm from falls
  • evidence, and an overview, of the Health Quality & Safety Commission’s 10 Topics in reducing harm from falls. These contain more detailed information by topic, which will be updated approximately every three years, and are intended as professional development exercises
  • recent literature of interest relevant to anyone working to reduce harm from falls, which will be updated annually.

This page will be updated annually. Please contact us if there is a readily available resource you’d like us to consider including.

Recommendations

The information in this page supports the following high-level recommendations.

  • Perform a multifactorial assessment for an older person’s risk of falling, ideally including assessment for:
    • frailty
    • cognitive impairment.
  • Implement an individualised care plan to address identified risk factors (including safe environment and appropriate referrals).
  • Perform an orthogeriatrician assessment for patients who have fractured their hip.
  • Perform a physiotherapy assessment for patients who have fractured their hip.
  • Supervised and supported balance, strength and gait training is effective for prevention of falls.
  • Combine planned, evidence-based falls prevention programmes with fracture liaison services using partnerships of key providers.

Cochrane Reviews

Comprehensive geriatric assessment for older people admitted to a surgical service (eg, for hip fracture) improves outcomes (NEW 2018):

Comprehensive geriatric assessment for older people admitted to hospital improves outcomes (NEW 2017):

Exercise for reducing fear of falling in older people living in the community (2014):

Hip protectors for preventing hip fractures in older people (2014):

 Preventing falls in older people living in the community (2012):

Preventing falls in older people in aged residential care and hospitals (2012):

10 Topics in reducing harm from falls

The 10 Topics resources (overview below) were updated in August 2017 (peer-reviewed by a panel of experts). They will be updated approximately every three years (or more often if major new evidence is published).

Topic 1

The impact of falls on the health of older persons is substantial, and needs to be addressed through a systematic and integrated approach (see Topic 1).

  • Jones S, Blake S, Hamblin R, et al. 2016. Reducing harm from falls. New Zealand Medical Journal 129(1446): 89–103.

Topic 2

All older people should be asked about falls to identify those at risk who then need a multifactorial risk assessment (see Topic 2).

Topic 3

All older people screening positive when asked about falls should have a multifactorial risk assessment (see Topic 3).

Topic 4

An individualised care plan addressing identified risk factors should be implemented for any older person at risk of falling (see Topic 4). 

In the community
In hospitals and long-term care facilities

Topic 5

Falls can be prevented by making the environment safer – whether the older person is in care, at home, or out and about (see Topic 5).

Topic 6

Every fall is an opportunity for assessment, individualised care planning and system improvement to prevent further falls (see Topic 6).

Topic 7

Osteoporosis risk assessment and management are important in any fragility fracture, along with guideline-based care for hip fracture (see Topic 7).

Topic 8

A medicine optimisation review is recommended, including review for inappropriate polypharmacy and falls-risk-increasing drugs (see Topic 8).

Topic 9

Balance and strength exercises prevent falls (See Topic 9).

Topic 10

Falls prevention requires an integrated multidisciplinary system-wide approach (see Topic 10).

Clinical guidelines and standards

Toolkits and guides

For clinicians
For patients/consumers
For organisations

Recent literature of interest (Feb 2017–Feb 2018)

The links above provide evidence for the key messages in the 10 Topics based on systematic reviews, guidelines, meta-analyses, umbrella reviews or health technology assessments.

Below we outline new evidence published in the last 12 months, which includes:

  • important risk factors to consider
  • some more nuanced guidance on antihypertensive use
  • confirmation that vitamin D does not reduce falls or fractures in healthy older people
  • evidence for widening our current use of bisphosphonates
  • some cost-effectiveness analyses of interventions for reducing harm from falls in the New Zealand context.
New Zealand studies

New Zealand studies published in the last year detail the incidence of falls in care facilities, the need for fracture liaison services to manage patients with fragility fractures, and the importance of medication optimisation review to reduce harm from falls.

A snapshot of key care indicators across 276 residents in 13 nursing care facilities estimated that 13 percent of residents in New Zealand nursing home facilities had a fall in the previous 30 days, that those between 75–84 years had proportionately more falls, and that 55 percent had a fall-related physical injury (Carryer et al 2017).

An Auckland hospital study showed that over 1,500 patients presented with fragility fracture in a one-year period; 82 percent of these required admission to hospital for an average of 20 days. Yet, only 24 percent of these patients received a potent bisphosphonate during their admission or in the following year (Braatvedt et al 2017). This is important given the cost-effectiveness of oral bisphosphonates (see the analysis from NICE below) for patients with even a low fracture risk. The authors conclude that fracture liaison services are urgently needed.

In a study of drug burden and its association with falls in New Zealand, data from interRAI assessments was matched to the national dispensing database. Results showed that a drug burden index (DBI – which measures the cumulative burden of certain medications) of greater than 3 was associated with increased falls, thereby confirming the importance of medication optimisation review (see Topic 8) in our local context (Jamieson et al 2018).

Randomised controlled trials

The large, double-blind, placebo-controlled ViDA trial showed that high-dose bolus vitamin D supplementation of 100,000 IU colecalciferol monthly did not prevent falls or fractures in a healthy adult population (Khaw et al 2017). This is consistent with the 10 Topics advice to reserve vitamin D supplementation for those likely to be deficient in vitamin D (see Topic 4).

These findings have been confirmed in a meta-analysis of randomised controlled trials published in the Journal of the American Medical Association (JAMA), which found that calcium, vitamin D or the two combined, are not associated with a lower risk of fractures among community-dwelling older adults (Zhao et al 2017).

A randomised control trial in the UK compared a screening programme using the FRAX tool with usual care. Of 6,233 women randomised to the screening group, 898 women were identified for treatment with osteoporosis medication. Over a five-year period, those in this intervention sub-group had 28 percent fewer hip fractures (Shepstone et al 2018).

In a study of falls where the person was not admitted to hospital, participants were given proactive assistance by emergency services to prioritise interventions that addressed their personal risk factors for falling and, if necessary, included referrals for exercise, home safety assessment, to a pharmacist, optometrist or aged care clinic. The 39 participants who reported full adherence experienced half the number of falls of non-adherers over 12 months. The Attitudes to Falls-Related Interventions Scale at baseline predicted those most likely to adhere to the advice (Mikolaizak et al 2017).

Identifying older people at risk of falling

The 10 Topics recommend an individualised falls risk assessment for older people in order to identify modifiable risk factors that can then be addressed. Risk prediction tools are not recommended. This recommendation is supported by a meta-analysis showing generally poor predictive validity of these tools (Park 2018).

A systematic review to identify the risk factors for falls confirmed 50 risk factors, including 12 that were not listed in the NANDA-I nursing diagnosis ‘risk for falls’ category (Sousa et al 2016). The full list of 50 risk factors can be found here . Many of these are modifiable with a multifactorial care plan.

More specifically, a large study of 7,233 people aged over 65 in the US investigated the relationship between falls risk and symptoms of depression. Results showed that the risk of falls increased following an increase in depressive symptoms, however, this increased risk may be due to psychiatric medication use (Hoffman et al 2017).

Additionally, experiencing a fall was associated with higher social exclusion and increased loneliness in a population of 7,808 German people (Hajek and König 2017).

Assessment of depression, loneliness and medication should continue to be important components of a falls risk assessment.

For those with cognitive impairment, additional risk factors for falls identified in a systematic review include: verbally disruptive and attention-seeking behaviour, visual perception problems and caregiver burden (Fernando et al 2017).

It also appears that poor sleep quality can increase risk for falls (Prato et al 2017) as can an increased number of insomnia symptoms and the use of sleep medication (Chen et al 2017).

Orthostatic hypotension is a known risk for falls. A study of 4,846 UK inpatients revealed that only 16 percent had a lying and standing blood pressure recorded within 48 hours of admission. The Royal College of Physicians has produced standardised and pragmatic guidance for how and when to measure standing and lying blood pressure (O’Riordan et al 2017).

Finally, there is an association between falling and risk of motor vehicle accidents. If an older person has fallen, it may be prudent to assess what can be done to minimise risk when driving (Scott et al 2017).

The older person’s environment

Topic 5 explains the importance of assessing an older person’s environment. It is important to remember that an older person’s environment extends beyond their home, and when it comes to policy and environmental modifications, reducing harm from falls is everyone’s business. A study of 384 participants, of which 69 had a fear of falling, revealed that drainage ditches and broken pavements were associated with greater likelihood of fear of falling. On the other hand, low traffic speeds reduced the likelihood of fear (Lee et al 2017).

Topic 5 details an observational study of 278 falls in New Zealand, which suggests that safety flooring can reduce harm. A new review of literature on compliant flooring now shows that 11 out of 14 studies reported some reduction in injury from falls on compliant flooring compared with usual flooring. Furthermore, the review found no clear evidence of an increased rate of falling with compliant flooring. Compliant flooring may be cost-effective, but can create some increased demands for health care workers (Lachance et al 2017).

Keeping active is crucial

Topic 9 emphasises the importance of the right kind of physical activity to help reduce harm from falls and suggests Tai Chi probably prevents falls. Recent evidence from two meta-analyses of randomised control trials (Huang et al 2017; Lomas-Vega et al 2017) indicates that Tai Chi is effective for preventing falls in older adults, and reducing the number of fallers by 20 percent and the rate of falls by over 30 percent. The authors conclude that Yang-style Tai Chi is probably more effective than Sun-style Tai Chi, and the effect is greater with more frequent exercise.

Medication optimisation

In a series of systematic reviews and meta-analyses published in 2018, a group from the University of Amsterdam examined fall risk increasing drugs (FRIDs). The following medicines were associated with falls: opioids, anti-epileptics, antipsychotics, benzodiazepines, loop diuretics and polypharmacy. Proton pump inhibitors may be associated with falls but no meta-analysis was performed. Beta-blockers as a class were associated with a decrease in falls (de Vries et al 2018, Seppala et al 2018a, 2018b).

The analysis of beta-blocker use is complicated by the fact that meta-analysis shows selective beta-blockers don’t appear to be associated with falls, but non-selective beta-blockers are associated with falls (Ham et al 2017).

Although polypharmacy is associated with falls, it may be that the use of just two or more FRIDs is a risk factor, as was found in an observational study of 202 patients aged over 65 years (Zia et al 2017).

Furthermore, one study of 252 patients has found that the use of FRIDs was increased one month after a fall-related fracture (Beunza-Sola et al 2018). This finding underscores the importance of medication optimisation review, especially when a fracture has occurred.

Some blood pressure medicines have previously been associated with an increased risk of falls (see Topic 8).

However, analysis of the 5,236 patients in the REGARDS stroke study showed that indicators of frailty, including low body mass index, cognitive impairment, depressive symptoms, exhaustion, impaired mobility and history of falls, were associated with increased risk of falling, but that blood pressure and number of antihypertensive medicines being taken were not (Bromfield et al 2017).

Additionally, the above meta-analysis of cardiovascular medicines and risk of falling (de Vries et al 2018) showed no association with falls for all antihypertensives except loop diuretics, which increased risk, and beta-blockers, which decreased risk.

Furthermore, a systematic review and meta-analysis aimed to determine the effect of acute or chronic use of antihypertensives on falls. Data pooled from 26 studies showed no difference in the hazard ratio or odds ratio for falls with chronic antihypertensive use. However, analysis of five studies showed an increased risk of falls in the first 24 hours following blood pressure medication initiation, change or dose adjustment. For diuretics only, this effect lasted up to 21 days (Kahlaee et al 2017).

This recent evidence suggests that diuretics should be used cautiously, and the first 24 hours of antihypertensive use or adjustment is a key period for increased risk of falling.

The important consideration, which requires critical thinking and clinical judgement, is to evaluate the risks and benefits of various antihypertensives for each individual patient, bearing in mind that treating older patients to blood pressure guideline targets does not appear to increase the risk of falls (Weiss et al 2017).

Implementing what works

There are many aspects of care planning for falls that we know work, and some that don’t. We can aim to implement evidence-based interventions where possible.

A systematic review of barriers and facilitators to fall prevention strategies in residential care facilities identified good communication and equipment availability as the most important facilitators. Barriers to fall prevention included: staffing issues, limited knowledge and skills, and poor communication. These facilitators (and others cited in the paper) need to be leveraged and the barriers overcome to reduce harm from falls (Vlaeyen et al 2017).

As an example of practice to reduce harm from falls in hospitals that appeared to get frontline buy-in, a Tennessee academic medical centre managed to reduce harmful falls by 47 percent by implementing a multiple component programme that included ‘plan–do–study–act’ (PDSA) cycles. This approach used a multidisciplinary quality improvement team with executive leadership support. However, and critically, ownership and advancement of the PDSA cycles, and specific interventions themselves, remained at the unit level. The programme also instigated unit-based falls champions, staff and patient/family education, a targeted toileting focus on purposeful rounds, shift leader rounding, physical environment assessment, patient proximity to staff and data transparency (France et al 2017).

A recent systematic review and network meta-analysis published in JAMA concluded that exercise alone (odds ratio [OR], 0.51) or various combinations of interventions can reduce harm from falls. These combinations include:

  • combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30)
  • combined exercise, and vision assessment and treatment (OR, 0.17)
  • combined clinic-level quality-improvement strategies, multifactorial assessment and treatment, calcium supplementation, and vitamin D supplementation (OR, 0.12) (Tricco et al 2017).

As noted above the calcium and vitamin D may play little role in the final combination.

Consistent with this evidence is an Australian cohort study of 196 patients with cataracts of both eyes having first-eye cataract surgery. The study reported a 33 percent reduction in falls per person year pre-op to post-op (Palagyi et al 2017).

Expedited cataract surgery coupled with exercise may be a useful intervention to reduce harm from falls.

A selection of other recent published descriptions of implementing falls interventions include:

Finally, a qualitative study of 20 patients with cognitive impairment and their relatives mirrored findings in the general older population. It emphasised that clinicians must present interventions with understanding and respect, identify and address goals that patients and relatives value, and focus on maintaining independence and preserving quality of life, while supporting a positive self-image for patients and their relatives (Peach et al 2017). We must seek to enable safe independence and not just tell older people they cannot do activities that pose a risk.

Cost-effectiveness

The University of Otago, Wellington, Burden of Disease Epidemiology, Equity and Cost-effectiveness Programme (BODE3) provides an interactive league table  demonstrating the relative effectiveness and cost-effectiveness of exercise programmes (Deverall 2018) and home safety assessment and modifications (Wilson et al 2017) for reducing harm from falls.

These results suggest that home safety assessment and modifications are cost-saving for certain high-risk populations at a district health board level. Also, that an in-home strength and balance exercise programme for all New Zealanders aged over 65 years is cost-effective at NZ$6,900 per year of quality life gained. Other cost-effectiveness analyses are presented in the BODE3 league table.

NICE performed a cost-effectiveness analysis on the use of bisphosphonates  for preventing fractures. Results show that oral bisphosphonates are cost-effective at a threshold of £20,000 (NZ$38,200) per year of quality life gained, provided there is a 1 percent or greater 10-year probability of osteoporotic fragility fracture. Fracture probability can be assessed using the FRAX tool .

It is interesting to note that analysis of the three osteoporotic fractures in men study cohorts shows a history of falling predicts the risk of incident osteoporotic fracture independently of FRAX probability, with or without bone mineral density measurement (Harvey et al 2018). This emphasises the importance of taking a falls history.

Looking to the future

The 10 Topics explain the recommended falls multifactorial risk assessment and individualised care planning process. Recommendations in the 10 Topics are based on robust evidence of what works to reduce harm from falls. However, new innovations are being devised almost daily, and descriptions of some promising recent findings have been published in the last year.

For example, one study evaluated bed sensor pads that sent an alert to nursing staff on mobile devices when inpatients attempted to get out of bed. Results showed that in 246 bed-days, the average time from a bed exit attempt to assistance from staff was 46 seconds, and no bed falls occurred (Balaguera et al 2017).

Finally, Newcastle University in the UK has developed a massive open online course (MOOC) for education about falls. The course is called ‘Ageing Well: Falls’ and is hosted by online education provider Future Learn . In the first year 1,442 people took the course, and 56 percent completed it. Those who completed it felt more confident about managing falls risk. The designers of the course conclude that older people are interested in using the internet to learn about how to manage their health (Frith 2017).

References

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  2. Beunza-Sola M, Hidalgo-Ovejero ÁM, Martí-Ayerdi J, Sánchez-Hernández JG, Menéndez-García M, García-Mata S. 2018. Study of fall risk-increasing drugs in elderly patients before and after a bone fracture. Postgrad Med J 94(1108): 76–80.
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Published: 27 Oct 2021 Modified: 21 Nov 2024