Falls Prevention in Community-Dwelling Older Adults, Interventions --Adults 65 years or older


General

Grade: D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.

Specific Recommendations

The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

This recommendation applies to community-dwelling adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency.

Brief Risk Assessment

When determining to whom these recommendations apply, primary care clinicians can reasonably consider a small number of risk factors to identify older adults who are at increased risk for falls. Age is strongly related to risk for falls. Studies most commonly used a history of falls to identify increased risk for future falls; history of falls is generally considered together or sequentially with other key risk factors, particularly impairments in mobility, gait, and balance. A pragmatic approach to identifying persons at high risk for falls, consistent with the enrollment criteria for intervention trials, would be to assess for a history of falls or for problems in physical functioning and limited mobility. Clinicians could also use assessments of gait and mobility, such as the Timed Up and Go test.5-7

Interventions

Exercise Interventions

Effective exercise interventions include supervised individual and group classes and physical therapy, although most studies reviewed by the USPSTF included group exercise. Given the heterogeneity of interventions reviewed by the USPSTF, it is difficult to identify specific components of exercise that are particularly efficacious. The most common exercise component was gait, balance, and functional training (17 trials), followed by resistance training (13 trials), flexibility (8 trials), and endurance training (5 trials). Three studies included tai chi, and 5 studies included general physical activity. The most common frequency and duration for exercise interventions was 3 sessions per week for 12 months, although duration of exercise interventions ranged from 2 to 42 months.8 The 2008 US Department of Health and Human Services guidelines recommended that older adults get at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, as well as muscle-strengthening activities twice per week.9 It also recommended performing balance training on 3 or more days per week for older adults at risk for falls because of a recent fall or difficulty walking.9

Multifactorial Interventions

Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment. The initial assessment could include a multidisciplinary comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health. In studies, nursing staff usually performed the assessment, and a number of different professionals performed subsequent interventions, including nurses, clinicians, physical therapists, exercise instructors, occupational therapists, dieticians, or nutritionists. Intervention components vary based on the initial assessment and could include group or individual exercise, psychological interventions (cognitive behavioral therapy), nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists (eg, ophthalmologist, neurologist, or cardiologist). For additional details on multifactorial interventions reviewed by the USPSTF, please see the full evidence report.8, 10

Other Interventions

The following single interventions lack sufficient evidence for or against their use to prevent falls in community-dwelling older adults when offered alone and not in the context of a multifactorial intervention: environmental modification, medication management, psychological interventions, and combination interventions not customized to an individual risk profile.

Useful Resources

Fractures are an important injury associated with falls, and the USPSTF has issued 2 related recommendation statements on the prevention of fractures. The USPSTF recommends screening for osteoporosis in women 65 years or older and in younger women at increased risk.11 In its recommendation on vitamin D and calcium supplementation to prevent fractures, the USPSTF states that it found insufficient evidence on vitamin D or calcium supplementation to prevent fractures in men, premenopausal women at any dose, and in postmenopausal women at doses greater than 400 IU of vitamin D and greater than 1000 mg of calcium; the USPSTF recommends against supplementation with 400 IU or less of vitamin D or 1000 mg or less of calcium in postmenopausal women.12

The Centers for Disease Control and Prevention has published guidance on implementing community-based interventions to prevent falls.13


Rationale

Importance

Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States.1 In 2014, 28.7% of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment or restricted activity for a day or longer)2 and an estimated 33,000 deaths in 2015.1-4

Detection

Effective primary care interventions to prevent falls use various approaches to identify persons at increased risk. However, no instrument has been clearly identified as accurate and feasible for identifying older adults at increased risk for falls. Although many studies used a variety of risk factors functional tests, or both involving gait, balance, or mobility to identify study participants, history of falls was the most commonly used factor that consistently identified persons at high risk for falls.

Benefits of Early Intervention

The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls. The USPSTF found adequate evidence that multifactorial interventions have a small benefit in preventing falls in older adults at increased risk for falls. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults.

Harms of Early Intervention

Based on the noninvasive nature of most of the interventions, the low likelihood of serious harms, and the available information from studies reporting few serious harms, the USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate; evidence suggests that the harms of vitamin D supplementation at very high dosages may be moderate.

USPSTF Assessment

The USPSTF concludes with moderate certainty that exercise interventions provide a moderate net benefit in preventing falls in older adults at increased risk for falls.

The USPSTF concludes with moderate certainty that multifactorial interventions provide a small net benefit in preventing falls in older adults at increased risk for falls.

The USPSTF concludes with moderate certainty that vitamin D supplementation has no net benefit in preventing falls in older adults.


Others

Other Considerations Implementation Although the evidence does not support routinely performing an in-depth multifactorial risk assessment with comprehensive management in all older adults, there may be reasons for providing this service to certain patients. Important items in the patient's medical history could include the circumstances of prior falls and the presence of comorbid medical conditions. The American Geriatric Society (AGS) recommends multifactorial risk assessment with multicomponent interventions in older adults who have had 2 falls in the past year (1 fall if combined with gait or balance problems), have gait or balance problems, or present with an acute fall.14 According to the AGS, evaluation of balance and mobility, vision, and orthostatic or postural hypotension are effective components of multifactorial risk assessment with comprehensive management, as well as review of medication use and home environment.14 Follow-up and comprehensive management of identified risk factors are essential to the effectiveness of this strategy. The burden of falls on patients and the health care system is large. Reducing the incidence of falls would also improve the socialization and functioning of older adults who have previously fallen and fear falling again. Many other interventions could potentially be useful to prevent falls, but because of the heterogeneity in the target patient population, heterogeneity (ie, multiplicity) of predisposing factors, and their additive or synergistic nature, the effectiveness of other interventions is not known. However, many interventions with insufficient evidence to support their use to prevent falls have other arguments that support their use. Research Needs and Gaps Studies are needed on the clinical validation of primary care tools to identify older adults at increased risk for falls. More efficacy trials are needed on how the following interventions may help prevent falls if offered alone and not as part of multifactorial interventions: environmental modification, medication management, and psychological interventions. Additional research is needed on the effectiveness of interventions in different age groups, in particular adults older than 85 years. Additional research to identify effective components of exercise interventions would also be useful.   Recommendations of Others The National Institute on Aging outlines similar interventions for the prevention of falls: exercise for strength and balance, monitoring for environmental hazards, regular medical care to ensure optimized hearing and vision, and medication management.30 According to the AGS, detecting a history of falls is fundamental to a falls reduction program, and it recommends asking all older adults once a year about falls.14 The AGS further recommends that older persons who have experienced a fall should have their gait and balance assessed using one of the available evaluations; those who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial falls risk assessment that includes a focused medical history, physical examination, functional assessment, and an environmental assessment. The AGS also recommends the following interventions for falls prevention: adaptation or modification of home environment; withdrawal or minimization of psychoactive or other medications; management of postural hypotension; management of foot problems and footwear; exercise (particularly balance), strength, and gait training; and vitamin D supplementation of at least 800 IU per day for persons with vitamin D deficiency or who are at increased risk for falls. The AGS found insufficient evidence to recommend vision screening alone as a single intervention for falls prevention. The Centers for Disease Control and Prevention recommends STEADI, a coordinated approach to implementing the AGS clinical practice guidelines for falls prevention that consists of 3 core elements: screen to identify fall risk, assess modifiable risk factors, and intervene using effective clinical and community strategies to reduce the identified risk. Clinical strategies include but are not limited to physical therapy and medication management. Community strategies include but are not limited to evidence-based exercise programs and home modification.31 Similar to the 2012 USPSTF recommendation, the American Academy of Family Physicians recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. It does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks.32   Update of Previous Recommendation The USPSTF last issued a recommendation on interventions to prevent falls in older adults in 2012. At that time, consistent with the current recommendation statement, the USPSTF recommended exercise (B recommendation) and selectively offering multifactorial interventions (C recommendation) to prevent falls in community-dwelling older adults at increased risk for falls. At that time, the USPSTF also recommended vitamin D supplementation to prevent falls (B recommendation), based on previous evidence that found a reduction in the number of persons experiencing a fall. The current review excluded studies considered in the previous review that enrolled persons with vitamin D deficiency or insufficiency because, on further consideration, vitamin D supplementation in these examined additional fall-related outcomes, including incident falls (in addition to the number of persons experiencing a fall, which was considered in the previous review). With this revised scope of review, as well as newer evidence from trials reporting no benefit, the USPSTF found that vitamin D supplementation has no benefit in falls prevention in community-dwelling older adults not known to have vitamin D deficiency or insufficiency. Thus, the USPSTF now recommends against vitamin D supplementation for the prevention of falls in community-dwelling older adults.


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