How best to prevent falls in older people in care homes and hospitals remains unclear despite large body of evidence

Key message: In care facilities, amongst people with low levels of vitamin D, vitamin D supplementation reduces the rate of falls. Evidence on other strategies to prevent falls in hospitals and care facilities is inconclusive.

Falls by older people are common events that can have serious consequences and understanding how they can be prevented is really important.  The Cochrane Bone, Joint and Muscle Trauma Group published a large update to their review on strategies to prevent falls in older people living in the community in September and they have now followed this with an update to their review on interventions for preventing falls in older people in care facilities and hospitals. Around three times as many falls occur in people in nursing homes compared with those living in the community, at a rate of about 1.5 falls per bed per year.

The review includes 60 randomized controlled trials (20 trials with over 35,000 people in this update) with over 60,000 participants. Just over half the people studied were in care facilities and the rest in hospitals. Care facilities and hospitals were subdivided according to the level of care given. The studies tested a wide variety of interventions in many different types of care facilities in 15 countries. Interventions to prevent falls were compared with any other intervention, usual care or placebo.

What did they find?

  • Vitamin D in a dose of 700 to 1000 IU a day reduced the rate of falls in care facilities (5 trials, 4603 participants). Participants had low levels of vitamin D at baseline
  • Multifactorial approaches (offering two or more types of intervention, linked to each person’s risk profile) reduced the rate of falls in hospitals but the evidence for risk of falling was inconclusive. The effect in care homes is unclear
  • The results of the 13 trials testing exercise interventions were inconsistent

How good is the evidence?

Despite the large number of trials and participants included in the review, the authors consider that they do not provide robust evidence on the effectiveness of interventions for reducing falls. They note that:

  • Study quality was variable
  • Methods of ascertaining, recording, analysing and reporting falls varied widely
  • Not all studies met the standards of the extended CONSORT statement (which aims to improve the reporting of randomized controlled trials; you can find it here http://www.consort-statement.org/consort-statement/overview0/)
  • It was not possible to minimize bias by ‘blinding’ participants and treatment providers for exercise interventions
  • The level of care and case mix in each facility was often not defined
  • Multifactorial interventions vary widely and this review was unable to provide evidence regarding specific components of these programmes

At the start of the year, the Chief Medical Officer for England Professor Dame Sally Davis put a spotlight on the high levels of vitamin D deficiency amongst many people in the UK, and the residents of our care homes are at high risk for this both through age and lack of exposure to sunlight, quite aside from any dietary factors. The Department of Health recommends that this population should take a daily supplement containing 10 micrograms of vitamin D. It seems that its benefits may well include keeping them on their feet.

Links:

Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465. DOI:10.1002/14651858.CD005465.pub3

Cochrane summary and podcast of this review: http://summaries.cochrane.org/CD005465/interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals

Evidently Cochrane blog: Keeping the over-65s on their feet: new review evidence tells us how. 12th September 2012.

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub2.

Department of Health: Dangers of vitamin D deficiency highlighted http://www.dh.gov.uk/health/2012/02/vitamin-d/

Department of Health: Vitamin D – advice on supplements for at risk groups (PDF)http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132508.pdf

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