Libro

RESEARCH
Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis
S Gates, principal research fellow,1 S E Lamb, director and professor of rehabilitation,1,3 J D Fisher, senior research fellow,2 M W Cooke, professor of emergency medicine,2 Y H Carter, dean2
1 WarwickClinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL 2 Warwick Medical School, University of Warwick 3 Kadoorie Critical Care Research Centre, University of Oxford Correspondence to: S Gates s.gates@warwick.ac.uk

doi:10.1136/bmj.39412.525243.BE

ABSTRACT Objective To evaluate the effectiveness of multifactorial assessment and intervention programmes to preventfalls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. Design Systematic review of randomised and quasirandomised controlled trials, and meta-analysis. Data sources Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews.Review methods Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. Data extraction Outcomes were number of fallers, fall related injuries, fall rate,death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. Results 19 studies, of variable methodological quality, were included. The combined risk ratio for thenumber of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations,populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral. Conclusions Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallersor fall related injuries is limited. Data were insufficient to assess fall and injury rates.

INTRODUCTION Falls are a major health problem for older adults, through both immediate effects such as fractures and head injuries and longer terms problems such as disability, fear of falling, and loss of independence.1 Prevention of falls and injuries has been a major focus of research, stimulated byageing populations and by growing awareness of the mortality and morbidity resulting from falls. Earlier reviews of randomised controlled trials of fall prevention interventions concluded that several types of intervention are effective, including training in strength and balance, modification of hazards at home, and withdrawal of psychotropic drugs.2 Multifactorial risk assessment of fallsfollowed by targeting of interventions to an individual’s risk factors is an attractive strategy as it could reduce several components of fall risk and would be expected to lead to greater reductions in falls than dealing with risk factors in isolation. Earlier reviews suggested that this type of intervention may be among the most effective,2 3 and it is recommended as a primary treatment strategy in...