Fall Prevention Programs Ineffective at Reducing Falls, Injuries in Older Patients

Sallie Lamb, DPhil

New research suggests fall prevention programs in older adults may not be having the effect clinicians and their patients had hoped.

Results from a 3-group, randomized trial with more than 9000 patients indicate fall prevention programs and multifactorial interventions did not result in fewer fractures than giving advice to patients through mail alone.

"Whilst this is a disappointing result, it shows that we must continue to invest in research and development to reduce fractures in older people. We need to think about the broader causes of fractures, and also understand more about what happens to cause falls,” said lead investigator Sallie Lamb, DPhil, a professor at the University of Exeter, in a statement.

With falls posing a significant risk to the immediate and long-term health of older individuals, Lamb and a team of colleagues from the UK designed a study with the hope of comparing the effectiveness of multiple fall prevention approaches. The 3-group, pragmatic, cluster-randomized, controlled trial was conducted across 63 general practices in England and enrolled patients from September 2010-June 2014.

Each of the 63 practices included in the trial randomly selected up to 400 patients and recruited them by mail to partake in an 18-month series of surveys related to aging. A total of 9803 patients aged 70 years or older were recruited for the study, of which 9802 had fracture data available at 18 months.

Of these, 3223 were assigned to advice by mail alone, 3279 were assigned to a falls-risk screening and targeted exercise intervention in addition to advice by mail, and 3301 were assigned to the falls-risk screening a targeted multifactorial prevention program in addition to advice by mail.

Patients assigned to the exercise intervention took part in the Otago Exercise Program, which investigators noted included at-home exercises at least twice a week and multiple sessions with physical therapists over a 6-month period. Those assigned to the multifactorial prevention program included undergoing assessments and linked treatments from a multidisciplinary team of care providers, including medication review, exercise, home modifications, and referrals to specialists such as opticians and podiatrists.

The primary outcome of the study was the rate of fractures per 100 person-years over 18 months. Secondary outcome measures of the study included falls, health-related quality of life, and frailty. As part of the secondary outcome analysis, investigates also performed a parallel economic evaluation.

In total, 89% of those selected for the exercise arm and 87% of those selected from the multifactorial arm completed 18-month questionnaires. Of these 5579 participants, 2153 (37%) were considered at increased risk for falls and invited to receive the intervention.

In adjusted analyses, results indicated there were no significant differences in fracture rates between the exercise and the mail alone group (RR, 1.20; 95% CI, 0.91-1.59; P=.19) or the multifactorial group and the mail alone group (RR, 1.30; 95% CI, 0.99-1.71; P=.06). In nested analysis with patients who were at an increased risk for falls, the fracture rate was 3.70 per 100 person-years in the exercise group, 5.12 per 100 person-years in the multifactorial group, and 4.28 per 100 person-years in the mail alone group. In cost and quality of life analyses, investigators found the exercise intervention was associated with small incenses in health-related quality of life and the lowest overall costs.

While investigators noted their disappointment in the implications of the results, they also pointed out this should not deter from recommending older patients to be more physically active.

"People completing the 6-month exercise program became stronger and their balance improved but that did not translate into a reduction in fractures in the long term,” said co-investigator Julie Bruce, PhD, a member of the Warwick Clinical Trials Unit at the University of Warwick, in the aforementioned statement. “The take home message is that we would encourage older people to do physical activity and keep mobile because of the health benefits."

This study, “Screening and Intervention to Prevent Falls and Fractures in Older People,” was published in the New England Journal of Medicine.