REVIEW QUESTION: What are the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals?

Nursing Implications

Falls by older people in residential or nursing care facilities and hospitals are common events that are associated with considerable morbidity and mortality. The incidence of falls in nursing homes is reported to be about three times that in the community and is often caused by a combination of various risk factors. Interventions may target risk factors in participants or staff with the aim of improving clinical practice or the organization of care. This systematic review summarized the current evidence on fall prevention in care facilities and hospitals, as falls are common in these settings (Cameron et al., 2012). This information is useful to nurses and other health care professionals and policy makers in improving care of older patients.

Study Characteristics

This review included 60 randomized controlled trials with a total of 60,345 participants. Forty-three trials were carried out in care facilities and 17 trials were in hospitals. All trials were carried out in developed countries, with most carried out in Australia (12 trials) and the United States (13 trials).

This review included older people (aged 65 years or older) in care facilities or hospitals. The mean age of participants was 84 years in care facilities and 79 years in hospitals. Most of the participants were women (77% and 58% in care facilities and hospitals, respectively), and four trials included women only.

Authors grouped interventions, using the fall-prevention classification system (taxonomy) developed by the Prevention of Falls Network Europe (ProFaNE) into single interventions (including any kinds of exercises, medication [drug target] interventions, vitamin D supplementation, environment/assistive technology, social environment, staff training, communication aids, service model change, knowledge interventions, and other single interventions), and multiple and multifactorial interventions. In care facilities, 32 trials tested the effect of a single intervention, one trial tested a multiple intervention and nine trials tested a multifactorial intervention. In hospitals, 14 trials tested the effect of a single intervention and three trials tested a multifactorial intervention.

The quality of studies included in this review varied. Detection bias was the most likely source of bias, with 62% (37/60) trials rated at high risk because of lack of blinding of outcome assessors. Methods for allocation concealment were judged at low risk of bias in 43% (26/60) of trials. Only 2% of trials were rated at a high risk of bias in random sequence generation, with 67% (40/60) of trials at low risk of bias in random sequence generation.

Summary of Key Evidence

The primary outcomes of the review were the rate of falls and the number of fallers, and secondary outcomes were the number of participants sustaining fall-related fractures, complications of the interventions, and economic outcomes. Meta-analysis was undertaken where possible and results were presented according to setting (care facility or hospital) and according the intervention (single, multiple, or multifactorial).

Care Facilities: Single Intervention

Thirteen trials involved exercises as a single intervention. Overall, pooled data from eight studies showed no reduction in the rate of falls. Pooled data from eight studies showed no significant difference in risk of falling. Subgroup analysis suggested that exercise might reduce falls in people in intermediate-level facilities and increase falls in facilities providing high levels of nursing care. Subgroup analysis by type of exercise found that balance training using mechanical apparatus reduced the rate of falls (rate ratio [RaR] 0.45, 95% CI [0.24, 0.85]; two studies, 54 participants), but had no effect on the risk of falling.

Vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI [0.46, 0.86]; five trials, 4,603 participants), but not risk of falling.

Other single interventions that did not give a significant reduction in fall rate included the use of a wireless position-monitoring device; staff training and education programs; changes to service models, such as the use of a falls risk assessment tool; sunlight exposure, lavender patches, and multisensory stimulation.

Care Facilities, Multiple Interventions

No multiple intervention was indicated to be effective.

Care Facilities, Multifactorial Interventions

Nine trials examined, multifactorial interventions in care facilities. Data from seven trials favored the interventions over usual care in the reduction of fall rate and risk of falling; however, these data were not statistically significant.

Hospital, Single Intervention

Two trials investigated additional physiotherapy (supervised exercises) in rehabilitation wards. There was no significant reduction in rate of falls; however, a significant reduction in risk of falling was seen (RR 0.36, 95% CI [0.14, 0.93]; two trials, 83 participants).

In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI [1.88, 115.35]) and potentially increased the risk of falling (RR 8.33, 95% CI [0.95, 73.37]).

One trial (1,822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI [0.11, 0.74]).

Other interventions that were included but were not found to have a significant effect were vitamin D supplementation; an identification bracelet for high-risk patients; bed exit alarms; implementation of fall-prevention guidelines; and service model changes such as the use of a computer-based fall-prevention tool kit.

Hospital, Multifactorial Interventions

Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI [0.49, 0.96]; 4 trials, 6,478 participants) and risk of falling (RR 0.71, 95% CI [0.46, 1.09]; 3 trials, 4,824 participants), although the evidence for risk of falling was inconclusive. One trial indicated that multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced the rate of falls (RaR 0.38, 95% CI [0.19, 0.74]; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI [0.20, 0.83]).

Economic Evaluations

No conclusions can be drawn from the nine trials reporting economic outcomes.

Best Practice Recommendations

In care facilities, vitamin D supplementation is effective in reducing the rate of falls. There was some evidence that balance training using mechanical apparatus was effective. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.

In hospitals, providing additional physiotherapy in subacute wards may reduce the risk of falling. Increasing patients' awareness of their falls risk and teaching risk-reduction strategies may reduce risk of falling in the acute setting. Multifactorial programs for patients who have longer lengths of stay are effective, but no recommendations can be made regarding any particular component of these programs.

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