No Proof That Prevention Programs Reduce Falls in Elderly

There is limited proof that any of the multifaceted or individualized programs designed to prevent falls in the elderly both inside and outside the hospital setting are effective, according to a comprehensive literature review.

Additionally, an assessment of existing fall-prevention techniques "indicates that many of these interventions were designed using expert opinion or statistical trends and that there is no conclusive medical evidence that any of them qualifies as an evidence-based guideline," wrote Dr. Terry A. Clyburn and Dr. John A. Heydemann of the University of Texas, Houston. The only exception, they noted, are interventions that address delirium (J. Am. Acad. Orthop. Surg. 2011;19: 402-9).

Falls are the leading cause of fatal and nonfatal injuries to older people in the United States. Approximately one-third of people aged 65 years or older and half of those aged 80 years or older fall at least once annually, and 3%-20% of hospital inpatients fall at least once during their stay, according to the authors. Given those statistics, they wrote, "the [Centers for Disease Control and Prevention] estimates that the direct and indirect cost of all fall-related injuries, including hospitalization, payments for physician and other professional services, medical equipment, prescription drugs, changes to the home, and lost time from work and household duties will reach $54.9 billion by 2020."

Among the intrinsic risk factors that are linked to falls in the elderly are comorbidities (such as diabetes, Parkinson’s disease, osteoporosis, history of stroke, arthritis, peripheral sensory deficit, malnutrition, arrhythmia, and orthostatic hypotension) and functional disabilities (such as reduced strength, vertigo, visual impairment, inappropriate footwear, incontinence, and the use of certain high-risk medications), the authors noted. Extrinsic risk factors include environmental considerations, such as the condition of the floor, cluttered areas, throw rugs, poor lighting, the lack of or poorly placed grab rails, noncollapsing bed rails, and intravenous equipment, they wrote.

Because the Centers for Medicare and Medicaid Services has placed the financial burden for inpatient falls in particular on hospitals by denying reimbursements for fall-related injuries to those institutions that have not followed evidence-based fall-prevention guidelines, the authors sought to determine whether medical evidence exists to support the effectiveness of fall-prevention strategies. Toward this end, they reviewed the available literature related to fall-prevention modalities "that are considered to be modifiable and, therefore, effective in fall prevention." These include medical interventions such as delirium prevention, nutrition, medications, and vision/eye care, as well as physical interventions, including bed rails, electronic bed sensors, appropriate bed and toilet seat height, footwear, flooring, identification bracelets, bed trapeze, grab rails, room and floor lighting, scheduled toileting, access to call light, bedside commode, unobstructed environment, and exercise and balance training.

With respect to prevention programs that combine multiple individual modalities, "our review of the literature reveals no conclusive medical evidence that multifactorial prevention programs in the acute hospital setting are effective," the authors wrote.

In one randomized, controlled trial comprising nearly 4,000 hospitalized patients in elderly care wards, no differences were found in fall frequency, injurious falls, or fractures between patients who spent 25 hours per week receiving targeted prevention support (fall risk assessments, education, walking aids, eyewear, environmental modifications, increased supervision, physiotherapy, and medication review and adjustments) and those in the usual care condition (BMJ 2008;336: 758-60). The authors attributed the finding to the short median duration of patient stay, and noted that similar programs have demonstrated efficacy in long-term care settings.

Of the individual, in-hospital, fall-prevention measures, addressing delirium was the only one supported by statistically significant evidence, the authors wrote. Multiple studies demonstrated a strong correlation between falls and delirium, supporting the early identification and management of the confusional state in the hospital, they stated. Efficacy studies of the delirium protocols of HELP (Hospital Elder Life Program) intervention, which focus on orientation, therapeutic activities, early mobilization, vision and hearing, oral volume repletion, and sleep enhancement, have noted a reduction in the development of delirium and in falls associated with the intervention. In one study, 95% of medical staff working in 29 hospitals that use the program noted a decrease in falls (N. Engl. J. Med. 2009;360: 2930-3). Even so, the authors wrote, "the literature is not adequate to support its consideration as a medical evidence-based guideline."

One surprising finding noted by the authors was the fact that the rate of falls in the hospital was only slightly greater than the rate in the home. "I would have imagined that inpatients who were in unfamiliar surroundings, often post operative and in heavily medicated states would have had a significantly higher rate of falls," Dr. Clyburn said in an interview. Also unexpected, he said, was the fact that some of the multimodal fall-prevention efforts and some of the "high-tech" measures, including alarmed beds, were not more effective.

Education regarding the prevalence and nature of inpatient falls – as well as large, controlled trials to evaluate preventative measures – are warranted, the authors wrote. "We must also be aware of the potential risks of enacting measures to prevent falls that may be counterproductive to patient recovery," they stated.

Dr. Clyburn disclosed financial relationships with Nimbic Systems and ConforMIS. Dr. Heydemann disclosed a financial relationship with Merck.

There is limited proof that any of the multifaceted or individualized programs designed to prevent falls in the elderly both inside and outside the hospital setting are effective, according to a comprehensive literature review.

Additionally, an assessment of existing fall-prevention techniques "indicates that many of these interventions were designed using expert opinion or statistical trends and that there is no conclusive medical evidence that any of them qualifies as an evidence-based guideline," wrote Dr. Terry A. Clyburn and Dr. John A. Heydemann of the University of Texas, Houston. The only exception, they noted, are interventions that address delirium (J. Am. Acad. Orthop. Surg. 2011;19: 402-9).

Falls are the leading cause of fatal and nonfatal injuries to older people in the United States. Approximately one-third of people aged 65 years or older and half of those aged 80 years or older fall at least once annually, and 3%-20% of hospital inpatients fall at least once during their stay, according to the authors. Given those statistics, they wrote, "the [Centers for Disease Control and Prevention] estimates that the direct and indirect cost of all fall-related injuries, including hospitalization, payments for physician and other professional services, medical equipment, prescription drugs, changes to the home, and lost time from work and household duties will reach $54.9 billion by 2020."

Among the intrinsic risk factors that are linked to falls in the elderly are comorbidities (such as diabetes, Parkinson’s disease, osteoporosis, history of stroke, arthritis, peripheral sensory deficit, malnutrition, arrhythmia, and orthostatic hypotension) and functional disabilities (such as reduced strength, vertigo, visual impairment, inappropriate footwear, incontinence, and the use of certain high-risk medications), the authors noted. Extrinsic risk factors include environmental considerations, such as the condition of the floor, cluttered areas, throw rugs, poor lighting, the lack of or poorly placed grab rails, noncollapsing bed rails, and intravenous equipment, they wrote.

Because the Centers for Medicare and Medicaid Services has placed the financial burden for inpatient falls in particular on hospitals by denying reimbursements for fall-related injuries to those institutions that have not followed evidence-based fall-prevention guidelines, the authors sought to determine whether medical evidence exists to support the effectiveness of fall-prevention strategies. Toward this end, they reviewed the available literature related to fall-prevention modalities "that are considered to be modifiable and, therefore, effective in fall prevention." These include medical interventions such as delirium prevention, nutrition, medications, and vision/eye care, as well as physical interventions, including bed rails, electronic bed sensors, appropriate bed and toilet seat height, footwear, flooring, identification bracelets, bed trapeze, grab rails, room and floor lighting, scheduled toileting, access to call light, bedside commode, unobstructed environment, and exercise and balance training.

With respect to prevention programs that combine multiple individual modalities, "our review of the literature reveals no conclusive medical evidence that multifactorial prevention programs in the acute hospital setting are effective," the authors wrote.

In one randomized, controlled trial comprising nearly 4,000 hospitalized patients in elderly care wards, no differences were found in fall frequency, injurious falls, or fractures between patients who spent 25 hours per week receiving targeted prevention support (fall risk assessments, education, walking aids, eyewear, environmental modifications, increased supervision, physiotherapy, and medication review and adjustments) and those in the usual care condition (BMJ 2008;336: 758-60). The authors attributed the finding to the short median duration of patient stay, and noted that similar programs have demonstrated efficacy in long-term care settings.

Of the individual, in-hospital, fall-prevention measures, addressing delirium was the only one supported by statistically significant evidence, the authors wrote. Multiple studies demonstrated a strong correlation between falls and delirium, supporting the early identification and management of the confusional state in the hospital, they stated. Efficacy studies of the delirium protocols of HELP (Hospital Elder Life Program) intervention, which focus on orientation, therapeutic activities, early mobilization, vision and hearing, oral volume repletion, and sleep enhancement, have noted a reduction in the development of delirium and in falls associated with the intervention. In one study, 95% of medical staff working in 29 hospitals that use the program noted a decrease in falls (N. Engl. J. Med. 2009;360: 2930-3). Even so, the authors wrote, "the literature is not adequate to support its consideration as a medical evidence-based guideline."

One surprising finding noted by the authors was the fact that the rate of falls in the hospital was only slightly greater than the rate in the home. "I would have imagined that inpatients who were in unfamiliar surroundings, often post operative and in heavily medicated states would have had a significantly higher rate of falls," Dr. Clyburn said in an interview. Also unexpected, he said, was the fact that some of the multimodal fall-prevention efforts and some of the "high-tech" measures, including alarmed beds, were not more effective.

Education regarding the prevalence and nature of inpatient falls – as well as large, controlled trials to evaluate preventative measures – are warranted, the authors wrote. "We must also be aware of the potential risks of enacting measures to prevent falls that may be counterproductive to patient recovery," they stated.

Dr. Clyburn disclosed financial relationships with Nimbic Systems and ConforMIS. Dr. Heydemann disclosed a financial relationship with Merck.

There is limited proof that any of the multifaceted or individualized programs designed to prevent falls in the elderly both inside and outside the hospital setting are effective, according to a comprehensive literature review.

Additionally, an assessment of existing fall-prevention techniques "indicates that many of these interventions were designed using expert opinion or statistical trends and that there is no conclusive medical evidence that any of them qualifies as an evidence-based guideline," wrote Dr. Terry A. Clyburn and Dr. John A. Heydemann of the University of Texas, Houston. The only exception, they noted, are interventions that address delirium (J. Am. Acad. Orthop. Surg. 2011;19: 402-9).

Falls are the leading cause of fatal and nonfatal injuries to older people in the United States. Approximately one-third of people aged 65 years or older and half of those aged 80 years or older fall at least once annually, and 3%-20% of hospital inpatients fall at least once during their stay, according to the authors. Given those statistics, they wrote, "the [Centers for Disease Control and Prevention] estimates that the direct and indirect cost of all fall-related injuries, including hospitalization, payments for physician and other professional services, medical equipment, prescription drugs, changes to the home, and lost time from work and household duties will reach $54.9 billion by 2020."

Among the intrinsic risk factors that are linked to falls in the elderly are comorbidities (such as diabetes, Parkinson’s disease, osteoporosis, history of stroke, arthritis, peripheral sensory deficit, malnutrition, arrhythmia, and orthostatic hypotension) and functional disabilities (such as reduced strength, vertigo, visual impairment, inappropriate footwear, incontinence, and the use of certain high-risk medications), the authors noted. Extrinsic risk factors include environmental considerations, such as the condition of the floor, cluttered areas, throw rugs, poor lighting, the lack of or poorly placed grab rails, noncollapsing bed rails, and intravenous equipment, they wrote.

Because the Centers for Medicare and Medicaid Services has placed the financial burden for inpatient falls in particular on hospitals by denying reimbursements for fall-related injuries to those institutions that have not followed evidence-based fall-prevention guidelines, the authors sought to determine whether medical evidence exists to support the effectiveness of fall-prevention strategies. Toward this end, they reviewed the available literature related to fall-prevention modalities "that are considered to be modifiable and, therefore, effective in fall prevention." These include medical interventions such as delirium prevention, nutrition, medications, and vision/eye care, as well as physical interventions, including bed rails, electronic bed sensors, appropriate bed and toilet seat height, footwear, flooring, identification bracelets, bed trapeze, grab rails, room and floor lighting, scheduled toileting, access to call light, bedside commode, unobstructed environment, and exercise and balance training.

With respect to prevention programs that combine multiple individual modalities, "our review of the literature reveals no conclusive medical evidence that multifactorial prevention programs in the acute hospital setting are effective," the authors wrote.

In one randomized, controlled trial comprising nearly 4,000 hospitalized patients in elderly care wards, no differences were found in fall frequency, injurious falls, or fractures between patients who spent 25 hours per week receiving targeted prevention support (fall risk assessments, education, walking aids, eyewear, environmental modifications, increased supervision, physiotherapy, and medication review and adjustments) and those in the usual care condition (BMJ 2008;336: 758-60). The authors attributed the finding to the short median duration of patient stay, and noted that similar programs have demonstrated efficacy in long-term care settings.

Of the individual, in-hospital, fall-prevention measures, addressing delirium was the only one supported by statistically significant evidence, the authors wrote. Multiple studies demonstrated a strong correlation between falls and delirium, supporting the early identification and management of the confusional state in the hospital, they stated. Efficacy studies of the delirium protocols of HELP (Hospital Elder Life Program) intervention, which focus on orientation, therapeutic activities, early mobilization, vision and hearing, oral volume repletion, and sleep enhancement, have noted a reduction in the development of delirium and in falls associated with the intervention. In one study, 95% of medical staff working in 29 hospitals that use the program noted a decrease in falls (N. Engl. J. Med. 2009;360: 2930-3). Even so, the authors wrote, "the literature is not adequate to support its consideration as a medical evidence-based guideline."

One surprising finding noted by the authors was the fact that the rate of falls in the hospital was only slightly greater than the rate in the home. "I would have imagined that inpatients who were in unfamiliar surroundings, often post operative and in heavily medicated states would have had a significantly higher rate of falls," Dr. Clyburn said in an interview. Also unexpected, he said, was the fact that some of the multimodal fall-prevention efforts and some of the "high-tech" measures, including alarmed beds, were not more effective.

Education regarding the prevalence and nature of inpatient falls – as well as large, controlled trials to evaluate preventative measures – are warranted, the authors wrote. "We must also be aware of the potential risks of enacting measures to prevent falls that may be counterproductive to patient recovery," they stated.

Dr. Clyburn disclosed financial relationships with Nimbic Systems and ConforMIS. Dr. Heydemann disclosed a financial relationship with Merck.