Background
Falls for older people can be life-changing, or even life ending. In 2012, Falls cost medicare $31 billion and result in reduced quality of life in those who have them. The consequences of a fall can be dire, falls are can be a complication of many factors; aging, frailty, poor vision, poor balance, strength or other factors. Some of these are inevitable, like aging, or even poor vision, but the rest all all preventable, or can at least, the progression can be slowed.
I have personally been working in an older persons mental health ward and whilst none of the people are in there directly because of a fall, they are all at a high falls risk and that will limit their ability to go home, potentially sending them to an aged care home. I’ve seen great preliminary results by taking them through balance training and lower limb strength training, and they have been enjoying it too, but now it’s time to see what the evidence says works best.
This is my review of the paper: Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis by Tricco et al. (2017)
Methods
The authors conducted a systematic review and network meta-analysis, which is the highest level of evidence, systematically combing over the previous literature, ideally, capturing every study which is relevant and comparing the effects they found. A network meta-analysis also allows you to compare different interventions to each other, allowing you to determine which is ‘best.’
This study was prospectively registered and had a protocol which typically improves the quality as the authors determined what they would do before seeing the data, improving the validity of the findings. They included RCT’s with their primary outcomes being number of injurious falls and fall related hospitalizations. They searches published and unpublished literature and assessed the quality of studies using the Cochrane risk of bias tool.
When analyzing the data, they conducted random effects network meta-analysis, which essentially mean that they accounted for differences within the studies in their analysis.
Results:
In total, their search produced >10,000 results, leading to the inclusion of 300 studies, which is very large. The participants were on average between 74 and 84yrs old with a relatively even gender split.
They found that exercise halved the odds of having a fall (0.51 OR), with combined exercise and vision assessment and treatment being the more effective (OR 0.17) and the former + environmental assessment and modification resulting in an OR of 0.3 and finally the most effect treatment was combined clinic level quality improvement strategies, multifactorial assessment and treatment, calcium and vitamin D supplementation (OR 0.12).
Another finding was that exercise did not improve quality of life compared to usual care which is interesting.
Implications
So what does this all mean? It looks as though exercise very clearly reduces the risk of falling and having an injurious fall, but also that there are other factors which can be added to exercise to reduce the risk of falls even further, including a vision assessment and supplementation to improve bone mineral density.
So what am I going to do with this? Well I’m going to check what medications my patients are on, ensuring that, if they need to be, they are taking calcium and vit. D supplements, asking how their vision is, checking that they believe it is okay and if not, refer them to an optometrist.
What are the limitations of this study for me? well one major issue I have is that it doesn’t explain what types of exercises were undertaken in any of the trials, which limits how much I can change my exercise prescription based on this study, although it reinforces that simply exercising improves outcomes.
So where does this paper leave us? It leaves us knowing that this thing called “exercise” is effective, but it doesn’t explain what exercise helps, this will require a little more reading and another paper review, so stay tuned.
Candid thoughts
This is my first go writing up a review of a paper, I know this probably is a little all over the shop but it’s for me to practice more than anything, assisting in my endeavor to be a good, evidence based clinician.
Harrison Hansford 