Preventing falls in high risk groups - An evidence update

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Falls are a major and increasing health problem that require urgent attention, says Cathie Sherrington, Professorial Research Fellow, The George Institute for Global Health and The University of Sydney. Leading up to the Australia and New Zealand Falls Prevention Society Conference, Cathie provides an update on falls prevention evidence and research.

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At least one in three people aged 65 years and older fall each year. These rates are higher in higher risk groups such as people with impaired vision, people with neurological problems, people who have recently been in hospital and older people who are frail. At least one in two people in these groups fall each year.
There have now been hundreds of randomised controlled trials testing the impact of fall prevention interventions. These are summarised in two systematic reviews published by the Cochrane Collaboration. Both reviews are freely available from any computer in Australia and the international author groups of both reviews include a number of Australian researchers.
The most recent review of fall prevention interventions in residential care facilities and hospitals included 60 randomised controlled trials and was led by Professor Ian Cameron; a rehabilitation medicine specialist from Sydney. The most recent review of fall prevention interventions in community settings included 159 randomised controlled trials and was led by Dr Leslie Gillespie; a nursing academic from New Zealand and is the most highly accessed Cochrane review. Both reviews can be accessed at the following address: http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance.html
The community Cochrane review shows that a range of interventions can prevent falls in community dwelling older people. Exercise as a single intervention has been the most investigated approach. Effective programs target balance, are ongoing and are undertaken more than once a week. Such programs are effective when delivered in a group or as a home exercise program taught by a health professional such as a physiotherapy or a trained nurse. Successful group programs include Tai Chi as well as exercise targeting balance and strength. Well-designed exercise programs have been found to prevent falls when delivered to the general community or when targeted to those at some increased risk of falls, such as with a mobility or balance problem.
Some important risk factors for falls are not modifiable by exercise interventions. Studies have found that interventions targeting some of these factors can prevent falls. Successful approaches have included: cataract extraction for those with cataract; occupational therapist home safety interventions for people with severe visual impairment; podiatry treatment including foot and ankle exercise for those with foot pain; medication management by general practitioners for those on multiple medications; and careful withdrawal of psychoactive medications.
A number of successful fall prevention programs have also involved assessment of risk factors among community dwelling older people and tailored delivery of required intervention strategies. As it is often difficult to deliver, multiple interventions programs that have ensured that the interventions are delivered have had greater impacts.
High quality evidence is not yet available to guide us in the prevention of falls in people with neurological impairments or in frail older people.
So although exercise has a range of benefits for everyone when we are seeking to prevent falls in high risk groups it is important to target intervention to particular risk factors. Yet the optimal way to deliver such interventions is not yet clear.
Falls are particularly common in  hospitals and residential care settings. The relevant Cochran review studies have found that multifaceted intervention programs can prevent falls in longer stay sub-acute settings, and that a patient education program delivered by a  trained nurse can prevent falls in  acute settings. However the impact  of other falls prevention interventions  in acute settings has not yet been  demonstrated by high quality studies.
In the residential care setting it is known that vitamin D supplementation can reduce the rate of falls. Exercise appears to prevent falls in intermediate level facilities (i.e., hostels) but does not appear to be an effective single intervention in nursing home settings. There is evidence from an individual study in a nursing home that a multi- disciplinary program including exercise prevented falls. Another promising intervention tested in an individual study involved regular mobilisation and toileting for people in nursing homes.
While we now have good evidence to guide a number of aspects of fall prevention practice there remain important gaps in our knowledge about how best to prevent falls, which can have devastating consequences for affected individuals and their families as well as straining health services.
The prevention of falls in high risk groups is one of the topics to be addressed at the upcoming Australia and New Zealand Falls Prevention Society Conference at Luna Park in Sydney 16-18 November 2014.
The Australia and New Zealand Falls Prevention Society Conference is held every two years. This year’s conference is the sixth held by the Society and will be at Luna Park in Sydney 16-18 November 2014. The 2016 conference will be in Melbourne and the venue for the 2018 conference will be announced at the Sydney Conference.

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References
1. Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, et al. (2012) Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews: CD005465.
2. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, et al. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews: CD007146.
3. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR (2011) Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 22: 78-83.

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Australia and New Zealand Falls Prevention Society conferences bring together researchers, clinicians and policy makers from a range of disciplinary backgrounds and are attended by people from around Australia and New Zealand as well as an increasing number of overseas visitors.
The 2014 conference will feature several invited international speakers. Prof Stephen Robinovitch from Canada will speak about his work videoing hundreds of falls in residential care to understand their causes. Prof Jeffrey Hausdorff from Israel will speak about his work in better understanding gait and balance impairments and their contribution to falls. Prof Chris Todd from the UK will talk about the Europe-wide falls prevention implementation network and Mr George Langlands from the Accident Compensation Corporation in New Zealand will talk about the unique approach to crowd sourcing solutions from the community used by the Corporation.
Australian experts will include Dr Anna Barker who will talk about falls prevention in hospitals, Prof Adrian Bauman about community wide approaches, Professor Henry Brodaty and Dr Morag Taylor about dementia, A/Prof Lesley Day about a Victoria-wide fall prevention initiatives, Dr Sabrina Pit about working with General Practitioners on medication management, Dr Jasmine Menant on footwear and glasses and Prof Cathie Sherrington about falls in high risk groups.
Pre-conference workshop will focus on the practical aspects of implementing successful fall prevention interventions in exercise, home safety, working with GPs and undertaking and interpreting falls prevention research.
Short papers submitted by conference attendees will cover a range of falls prevention research designs from biomechanical research to analysis of routinely collected health service data and large scale epidemiological studies, to systematic reviews and randomised trials. Papers will also outline state and national policy and program implementation as well as local implementation projects from around Australia and New Zealand.
More information is available here: www.anzfpconference.com.au

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Cathie Sherrington is a Professorial Research Fellow at The George Institute for Global Health and The University of Sydney. She leads the Ageing Research Group within the Institute’s Musculoskeletal Division. Prior to completing a PhD and Masters of Public health Cathie was a physiotherapist in aged care and rehabilitation settings.