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Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity
Evidence profile: risk of falls
Scoping question:
Do interventions to prevent falls produce any benefit or harm for older people at risk of falls?
The full ICOPE guidelines and complete set of evidence
profiles are available at:
who.int/publications/i/item/9789241550109
Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression. Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved
WHO/MCA/17.06.04
Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Contents
Background .......................................................................................................................................................................................................................... 1
Part 1: Evidence review ....................................................................................................................................................................................................... 2
Scoping question in PICO format (population, intervention, comparison, outcome) ............................................................................................................ 2 Search strategy ...................................................................................................................................................................................................................... 3 List of systematic reviews identified by the search process .................................................................................................................................................. 3 PICO table .............................................................................................................................................................................................................................. 4 Narrative description of the studies that went into analysis .................................................................................................................................................. 5 GRADE table 1: Medication review or withdrawal versus control for older people living in the community ......................................................................... 6 GRADE table 2: Environment (home safety and aids for personal mobility) versus control for older people living in the community: subgroup analysis by risk of falling at baseline .................................................................................................................................................................................................... 7 GRADE table 3: Home safety intervention versus control for older people living in the community: subgroup analysis by delivery personnel ................. 8 GRADE table 4: Multifactorial intervention versus control for older people living in the community .................................................................................... 9 GRADE table 5: Multifactorial intervention versus control for older people living in the community: subgroup analysis by risk of falling at baseline ...... 10 GRADE table 6: Multifactorial intervention versus control for older people living in the community: subgroup analysis by intensity of intervention ........ 11 GRADE table 7: Exercise intervention versus control for older people living in the community ......................................................................................... 12 GRADE table 8: Group exercise intervention versus control in older people living in the community: subgroup analysis by risk of falling at baseline ... 15 GRADE table 9: Group t’ai chi exercise versus control in older people living in the community: subgroup analysis by risk of falling at baseline ............ 16
Part 2: From evidence to recommendations ................................................................................................................................................................... 17
Summary of evidence .......................................................................................................................................................................................................... 17 Evidence-to-recommendations table ................................................................................................................................................................................... 20
Guideline development group recommendations and remarks ................................................................................................................................... 24
References .......................................................................................................................................................................................................................... 26
Annex 1: Search strategy .................................................................................................................................................................................................. 28
Annex 2: PRISMA 2009 flow diagram for intervention to prevention falls in community-dwelling older people ................................................... 29
© World Health Organization 2017
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo)
1 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Background
In older people, falls are the most prominent external cause of
unintentional injury. Research suggests that one third of
community-dwelling people aged over 65 years fall each year and
almost half of them experience recurrent falls (1–10). Incidents of
falls by older people are strongly associated with hospitalization,
severe functional decline, care dependency and premature
admission to institutional care (11). Nearly 15% of falls result in
non-fatal injuries (12), ranging from minor bruises and wrist
lacerations to hip fractures (4, 5, 13). More importantly,
23–40% of injury-related deaths in older people are attributable to
falls (9, 14).
The risk factors for falls are complex and multifactorial in nature.
Evidence from longitudinal studies suggests strong interactions
among multiple risk factors, such as age, sex, previous history of
falls, chronic diseases and environmental factors (4, 10, 14).
Medical conditions that increase the risk of falls include: orthostatic
hypotension (6, 8, 10, 15), musculoskeletal disease (3, 5, 16),
visual impairment (7, 17, 18), low systolic blood pressure, stroke,
cognitive impairments, Parkinson’s disease, gait disorders, balance
disorders and sensory impairments (3, 4, 7, 10, 14). Medications in
general, and polypharmacy in particular, increase the risk of falls in
older people (19).
In recent years, there has been an increasing level of research and
policy interest in the public health impact of falls. The effectiveness
of single and complex programmes for the prevention of falls and
fall-related injuries was extensively tested among older people at
risk of falls (20). Most intervention studies were carried out in
community settings; a few were undertaken in hospitals and
residential care settings (13). In this document, the evidence for
fall-prevention interventions undertaken for community-dwelling
older people at risk of falls has been summarized to inform the
recommendations provided in the full ICOPE guidelines available
at who.int/ageing/publications/guidelines-icope.
2 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Part 1: Evidence review
Scoping question in PICO format (population,
intervention, comparison, outcome)
Population
Older people 60 years of age and older (both male and female) at
risk of falls
Interventions
• Multicomponent exercise programme/strength training
• Falls risk assessment by the physiotherapist to develop
individualized falls and injury prevention
• Individually tailored exercises
• Medication review
• Withdrawal of psychotropic medication
• Multifactorial interventions with comprehensive geriatric
assessment
• Environmental modification for home safety
• Assistive technology (walking aid, hearing aid, personal alarm
system)
• Footwear assessment
• Insertion of a pacemaker (carotid sinus hypersensitivity)
Comparison
• Usual care or standard care
• Placebo or no active intervention
• Waiting list control
• Active control intervention
Outcome
• Critical: rate of falls
Setting
• Primary care/community
3 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Search strategy
The search for systematic reviews was conducted on 10 October
2015 in Ovid MEDLINE, Embase and the Cochrane Library using
comprehensive search terms (Annex 1). Details of the number
studies retrieved and included are presented in Annex 2.
List of systematic reviews identified by the
search process
Included in GRADE1 tables (6):
— Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates
S, Clemson LM, Lamb SE. Interventions for preventing falls in older
people living in the community. Cochrane Database Syst Rev.
2012;(9):CD007146. Publication status and date: Edited (no change
to conclusions), published in Issue 4, 2015.
_______________________________
1 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http://gradeworkinggroup.org
4 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
PICO table
Intervention/comparison Outcomes Systematic review used
for GRADE
Explanation
1 Compared with no
intervention (or an
intervention not expected to
reduce falls), fall-prevention
interventions included:
• exercise
• t’ai chi
• multifactorial programmes
• home safety interventions
• cognitive behavioural
intervention
• prevention education
• anti-slip shoe device
• vision treatment
• pacemaker for carotid
hypersensitivity
• reduced psychotropics
• vitamin D
supplementation.
Risk of falls. Gillespie LD, Robertson MC,
Gillespie WJ, Sherrington C, Gates
S, Clemson LM, Lamb SE.
Interventions for preventing falls in
older people living in the
community. Cochrane Database
Syst Rev. 2012;(9):CD007146. (6)
Systematic review relevant to the
area.
5 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Narrative description of the studies that went into
analysis
Gillespie et al. (2012) is a Cochrane systematic review of
interventions designed to reduce the incidence of falls in older
people living in the community (6). The search for clinical trials was
conducted in the Cochrane Bone, Joint and Muscle Trauma Group
Specialized Register (February 2012), CENTRAL (The Cochrane
Library 2012, Issue 3), MEDLINE (1946 to March 2012), Embase
(1947 to March 2012), CINAHL (1982 to February 2012) and online
trial registers. Only randomized controlled trials (RCTs) of
interventions to reduce falls in community-dwelling older people
were included. The review included 159 trials with 79 193
participants. Most trials compared a fall-prevention intervention
with no intervention or an intervention not expected to reduce falls.
The most common interventions tested were exercise as a single
intervention (59 trials) and multifactorial programmes (40 trials).
Sixty-two per cent (99/159) of the trials were at low risk of selection
bias for sequence generation, 60% for attrition bias for the outcome
of falls (66/110), 73% (96/131) for attrition bias for fallers, and
38% (60/159) for selection bias due to allocation concealment. The
review found no evidence of effect for cognitive behavioural
interventions or interventions aiming to improve knowledge about
falls prevention alone. Limited evidence was reported in the review
for an anti-slip shoe device, and for interventions to treat vision
problems. Pacemaker insertion reduced falls in very selected
populations of older people with carotid hypersensitivity, and
reduction of psychotropic medication also reduced falls but the
sustainability of the effect was questioned. The authors concluded
that group and home-based exercise programmes and home
safety interventions reduce the rate of falls and the risk of falling;
that multifactorial assessment and intervention programmes reduce
the rate of falls but not the risk of falling; and that t’ai chi reduces
the risk of falling. Overall, vitamin D supplementation does not
appear to reduce falls but may be effective in people who have
lower vitamin D levels before treatment.
6 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 1: Medication review or withdrawal versus control for older people
living in the community
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of medication review or withdrawal versus control for
preventing falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM,
Lamb SE. Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date:
Edited (no change to conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design
Risk of
bias Inconsistency Indirectness Imprecision
Other
considerations
Medication
withdrawal Control
Relative
(95% CI)
Rate of falls: psychotropic medication withdrawal vs control (follow-up 14 weeks)
1 randomized
trials
serious a no serious
inconsistency
no serious
indirectness
serious b none 48
45
RR: 0.34 (0.16 to
0.73)
LOW
CRITICAL
Rate of falls: medication review and modification vs usual care (follow-up 12 months)
1 randomized
trials
serious c no serious
inconsistency
no serious
indirectness
serious b none 93
93
RR: 1.01 (0.81 to
1.25)
LOW
CRITICAL
RR: rate ratio a Risk of bias: downgraded once as information on incomplete data was not adequately described. b Imprecision: downgraded once as sample size was small (smaller than 200). c Risk of bias: downgraded once as allocation concealment was unclear.
7 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 2: Environment (home safety and aids for personal mobility) versus
control for older people living in the community: subgroup analysis
by risk of falling at baseline
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of home safety intervention versus control for preventing falls
in older people living in the community (subgroup analysis by risk of falling at
baseline)?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM,
Lamb SE. Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited
(no change to conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design Risk of bias Inconsistency Indirectness Imprecision
Other
considerations
Home safety
intervention Control
Relative
(95% CI)
Rate of falls: selected for higher risk of falling (follow-up 14–52 weeks)
3 randomized
trials
serious a no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 429
422
RR: 0.62
(0.5 to 0.77)
MODERATE
CRITICAL
Rate of falls: not selected for higher risk of falling (follow-up 12–18 months)
3 randomized
trials
serious b no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 1377
1980
RR: 0.94
(0.84 to 1.05)
MODERATE
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as allocation concealment and procedure for masking outcome assessor was unclear in two included
trials. Further, information of incomplete data for falls outcome was not clearly described in one of the included trial. b Risk of bias: Downgraded once as allocation concealment was unclear for one of the included trials and information on incomplete
data was not clearly described in the other two trials.
8 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 3: Home safety intervention versus control for older people living in
the community: subgroup analysis by delivery personnel
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of home safety intervention versus control (subgroup analysis
by delivery personnel) for preventing falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM,
Lamb SE. Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited
(no change to conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design Risk of bias Inconsistency Indirectness Imprecision
Other
considerations
Home safety
intervention Control
Relative
(95% CI)
Rate of falls: home safety intervention (occupational therapy [OT] delivered by an occupational therapist) vs control
4 randomized
trials
serious a no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 728
715 RR: 0.69
(0.55 to 0.86)
MODERATE
CRITICAL
Rate of falls: home safety intervention (not OT) vs control (follow-up 6–18 months)
4 randomized
trials
serious b no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 1234
1841
RR: 0.91
(0.75 to 1.11)
MODERATE
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was not concealed in two trials. b Risk of bias: Downgraded once as analysis was not performed on the principle of intention to treat in two trials and allocation concealment
was unclear in the other two trials.
9 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 4: Multifactorial intervention versus control for older people living in the community
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of multifactorial intervention versus control or usual care for preventing
falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.
Interventions for preventing falls in older people living in the community. Cochrane Database
Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions),
published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design
Risk of
bias Inconsistency Indirectness Imprecision
Other
considerations
Multifactorial
intervention
Control or
usual care
Relative
(95% CI)
Rate of falls
19 randomized
trials
serious a serious b no serious
indirectness
no serious
imprecision
none 4833
4670
RR: 0.76 (0.67 to
0.86
)
LOW
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in five included trials and procedure for masking outcome assessor
was unclear in nine included trials. b Inconsistency: Downgraded once as considerable heterogeneity was observed in the meta analysis for the estimate (Tau2 = 0.06;
Chi2 = 116.96, df = 18 [P < 0.00001]; I2 = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity.
10 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 5: Multifactorial intervention versus control for older people living in the
community: subgroup analysis by risk of falling at baseline
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by
risk of falling at baseline) for preventing falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb
SE. Interventions for preventing falls in older people living in the community. Cochrane
Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to
conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design
Risk of
bias Inconsistency Indirectness Imprecision
Other
considerations
Multifactorial
intervention Control
Relative
(95% CI)
Rate of falls: selected for higher risk of falling
17 randomized
trials
serious a serious b no serious
indirectness
no serious
imprecision
none 3041
2913
RR 0.77
(0.66 to 0.90)
LOW
CRITICAL
Rate of falls: not selected for higher risk of falling
2 randomized
trials
serious c serious d no serious
indirectness
no serious
imprecision
none 1792 1757 RR 0.57
(0.23 to 1.38)
LOW
CRITICAL
CI: confidence interval; RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in eight included trials and procedure for masking outcome assessor
was unclear in nine trials. b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 104.40, df = 16 [P <
0.00001]; I² = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment and procedure for masking outcome assessor were unclear in one of the
trials. Randomization method was unclear in the other trial. d Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.36; Chi² = 7.54, df = 1 [P = 0.006];
I² = 87%). No subgroup analysis was performed and we were not able to explain the heterogeneity.
11 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 6: Multifactorial intervention versus control for older people living in the
community: subgroup analysis by intensity of intervention
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of multifactorial intervention versus control (subgroup analysis by
intensity of intervention) for preventing falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb
SE. Interventions for preventing falls in older people living in the community. Cochrane
Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to
conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design Risk of bias Inconsistency Indirectness Imprecision
Other
considerations
Multifactorial
intervention Control
Relative
(95% CI)
Rate of falls: assessment and active intervention (follow-up 6–24 months)
11 randomized
trials
serious a serious b no serious
indirectness
no serious
imprecision
none 3178 3160 RR: 0.74
(0.61 to 0.89)
LOW
CRITICAL
Rate of falls: assessment and referral or provision of information
9 randomized
trials
serious c serious d no serious
indirectness
no serious
imprecision
none 1665 1711 RR: 0.82
(0.71 to 0.95)
LOW
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in nine included trials and procedure for masking outcome assessor was unclear in five trials. b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau² = 0.08; Chi² = 97.46, df = 10 [P < 0.00001]; I² = 90%). No
subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in five trials. d Inconsistency: Downgraded once as moderate heterogeneity was observed in the analysis (Tau² = 0.03; Chi² = 18.02, df = 8 [P = 0.02]; I² = 56%). No subgroup
analysis was performed and we were not able to explain the heterogeneity.
12 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 7: Exercise intervention versus control for older people living in
the community
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of exercise versus control for preventing falls in older
people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson
LM, Lamb SE. Interventions for preventing falls in older persons living in the
community. Cochrane Database Syst Rev. 2012;(9):CD007146. Publication
status and date: Edited (no change to conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design Risk of bias Inconsistency Indirectness Imprecision
Other
considerations Exercise Control
Relative
(95% CI)
Rate of falls: group exercise: multiple categories of exercise vs control (follow-up 3.5–36 months)
16 randomized
trials
serious a serious b no serious
indirectness
no serious
imprecision
none 1853
1769
RR: 0.71
(0.63 to 0.82)
LOW
CRITICAL
Rate of falls: individual exercise at home: multiple categories of exercise vs control (follow-up 6–24 months)
7 randomized
trials
serious c no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 469
482
RR: 0.68
(0.58 to 0.8)
MODERATE
CRITICAL
(continued
next page)
13 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Rate of falls: individual exercise: LiFE (balance and strength training in daily life activities) vs control (follow-up 12 months)
1 randomized
trials
serious d no serious
inconsistency
no serious
indirectness
serious e none 18
16
RR: 0.21
(0.06 to 0.71)
LOW
CRITICAL
Rate of falls: group exercise: t’ai chi vs control (follow-up 5.5–12 months)
5 randomized
trials
serious f serious g no serious
indirectness
no serious
imprecision
none 797
766
RR: 0.72
(0.52 to 1)
LOW
CRITICAL
Rate of falls: group exercise: gait, balance or functional training vs control (follow-up 5.5–24 months)
4 randomized
trials
serious h no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 258
261
RR: 0.72
(0.55 to 0.94)
MODERATE
CRITICAL
Rate of falls: individual exercise: balance training vs control (follow-up 8 months)
1 randomized
trials
serious i no serious
inconsistency
no serious
indirectness
serious e none 64
64
RR: 1.19
(0.77 to 1.82)
LOW
CRITICAL
Rate of falls: group exercise: strength/resistance training vs control (follow-up 5.5 months)
1 randomized
trials
serious j no serious
inconsistency
no serious
indirectness
serious e none 32
32
RR: 1.8
(0.84 to 3.87)
LOW
CRITICAL
(continued
next page)
14 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Rate of falls: individual exercise at home: resistance training vs control (follow-up 6 months)
1 randomized
trials
no serious risk
of bias
no serious
inconsistency
no serious
indirectness
serious k none 112
110
RR: 0.95
(0.77 to 1.18)
MODERATE
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was unclear in seven included trials and allocation
concealment was unclear in 12 included trials. Outcome assessor was not masked in nine trials. b Inconsistency: Downgraded once as moderate heterogeneity was observed for the estimate (Tau² = 0.03; Chi² = 29.11, df =
15 [P = 0.02]; I² = 48%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as allocation concealment was unclear in four included trials. d Risk of bias: Downgraded once as procedure for masking outcome assessor and management of incomplete data was
unclear in the trial. e Imprecision: Downgraded once as sample size was small (less than 200). f Risk of bias: Downgraded once as allocation concealment was unclear in four trials. g Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau² = 0.10; Chi² = 14.38, df
= 4 [P = 0.006]; I² = 72%). No subgroup analysis was performed and we were not able to explain the heterogeneity. h Risk of bias: Downgraded once as allocation concealment method was unclear in all included trials. i Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor were
unclear in the trial. j Risk of bias: Downgraded once as method of allocation concealment, masking of outcome assessor, and management of
incomplete data were unclear in the trial. k Imprecision: Downgraded once as sample size was small (n=222).
15 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 8: Group exercise intervention versus control in older people living in the
community: subgroup analysis by risk of falling at baseline
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of group exercise (multiple categories of exercise) versus control
(subgroup analysis by risk of falling at baseline) for preventing falls in older people living in
the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb
SE. Interventions for preventing falls in older people living in the community. Cochrane
Database Syst Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to
conclusions), published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design
Risk of
bias Inconsistency Indirectness Imprecision
Other
considerations
Group
exercise:
multiple
categories of
exercise
Control Relative
(95% CI)
Rate of falls: selected for higher risk of falling (follow-up 3–24 months)
9 randomized
trials
serious a no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 652
609
RR: 0.70
(0.58 to 0.85)
MODERATE
CRITICAL
Rate of falls: not selected for higher risk of falling (follow-up 4.6–30 months)
7 randomized
trials
serious b no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 1201
1160
RR: 0.72
(0.58 to 0.9)
MODERATE
CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was unclear in five included trials and allocation concealment was unclear in seven trials. B Risk of bias: Downgraded once as allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in four trials.
16 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
GRADE table 9: Group t’ai chi exercise versus control in older people living in the
community: subgroup analysis by risk of falling at baseline
Author: WHO systematic review team
Date: November 2015
Question: What is the effectiveness of group t’ai chi exercise versus control (subgroup analysis by risk of
falling at baseline) for preventing falls in older people living in the community?
Setting: Community
Bibliography: (6) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.
Interventions for preventing falls in older people living in the community. Cochrane Database Syst
Rev. 2012;(9):CD007146. Publication status and date: Edited (no change to conclusions),
published in Issue 4, 2015.
Quality assessment Number of patients Effect
Quality Importance
Number of
studies Design
Risk of
bias Inconsistency Indirectness Imprecision
Other
considerations
Group
exercise:
t’ai chi
Control Relative
(95% CI)
Rate of falls: selected for higher risk of falling at baseline (follow-up 11–12 months)
2 randomized
trials
serious a serious b no serious
indirectness
no serious
imprecision
none 283
272
RR: 0.95
(0.62 to 1.46)
LOW
CRITICAL
Rate of falls: not selected for higher risk of falling at baseline (follow-up 5.5–12 months)
3 randomized
trials
serious c no serious
inconsistency
no serious
indirectness
no serious
imprecision
none 514
494
RR: 0.59
(0.45 to 0.76)
MODERATE
CRITICAL
RR: risk ratio a Risk of bias: Downgraded once as allocation concealment was unclear in one of the trials. b Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.07; Chi2 = 3.30, df = 1 [P = 0.07]; I2 = 70%) c Risk of bias: Downgraded once as allocation concealment was unclear in three of the included trials.
17 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Part 2: From evidence to recommendations
Summary of evidence
Intervention Effect size
Medication withdrawal or review vs control
Psychotropic medication withdrawal vs control
GRADE table 1, Gillespie et al. (6)
Rate ratio: 0.34 (0.16 to 0.73);
Favours experiment
Quality of evidence: LOW
Medication review and modification vs usual care
GRADE table 1, Gillespie et al. (6)
Rate ratio: 1.01 (0.81 to 1.25);
Quality of evidence: LOW
Environment (home safety and aids for personal mobility)
Home safety intervention vs control:
subgroup analysis by risk of falling at baseline
GRADE table 2, Gillespie et al. (6)
Rate ratio: 0.62 (0.5 to 0.77); 3 trials
Favours experiment
Quality of evidence: MODERATE
Home safety intervention vs control:
subgroup analysis (not selected for higher risk of falling)
GRADE table 2, Gillespie et al. (6)
Rate ratio: 0.94 (0.84 to 1.05); 3 trials
Quality of evidence: MODERATE
Home safety intervention (occupational therapy) vs control
GRADE table 3, Gillespie et al. (6)
Rate ratio: 0.69 (0.55 to 0.86); 4 trials
Favours experiment
Quality of evidence: MODERATE
Home safety intervention (not occupational therapy) vs control
GRADE table 3, Gillespie et al. (6)
Rate ratio: 0.91 (0.75 to 1.11); 4 trials
Quality of evidence: MODERATE
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18 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Multifactorial intervention
Multifactorial intervention vs control or usual care
GRADE table 4, Gillespie et al. (6)
Rate ratio: 0.76 (0.67 to 0.86);
Favours experiment
Quality of evidence: LOW
Multifactorial intervention vs control:
subgroup analysis (selected for higher risk of falling)
GRADE table 4, Gillespie et al. (6)
Rate ratio: 0.77 (0.66 to 0.90);
Favours experiment
Quality of evidence: LOW
Multifactorial intervention vs control:
subgroup analysis (not selected for higher risk of falling)
GRADE table 5, Gillespie et al. (6)
Rate ratio: 0.57 (0.23 to 1.38);
Quality of evidence: LOW
Multifactorial intervention: assessment and active intervention
GRADE table 6, Gillespie et al. (6)
Rate ratio: 0.74 (0.61 to 0.89);
Favours experiment
Quality of evidence: LOW
Multifactorial intervention: assessment and referral or provision of information
GRADE table 6, Gillespie et al. (6)
Rate ratio: 0.82 (0.71 to 0.95);
Favours experiment
Quality of evidence: LOW
Exercise intervention
Group exercise (multiple categories vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 0.71 (0.63 to 0.82);
Favours experiment
Quality of evidence: LOW
Group exercise at risk of falls (multiple categories vs control)
GRADE table 8, Gillespie et al. (6)
Rate ratio: 0.70 (0.58 to 0.85);
Favours experiment
Quality of evidence: MODERATE
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19 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Individual exercise at home (multiple categories vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 0.68 (0.58 to 0.80);
Favours experiment
Quality of evidence: MODERATE
Individual exercise (balance and strength vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio : 0.21 (0.06 to 0.71);
Favours experiment
Quality of evidence: LOW
Group exercise (t’ai chi vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 0.72 (0.52 to 1.00);
Favours experiment
Quality of evidence: LOW
Group exercise (gait, balance or functional training vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 0.72 (0.55 to 0.94);
Favours experiment
Quality of evidence: MODERATE
Individual exercise (balance training vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 1.19 (0.77 to 1.82)
Quality of evidence: LOW
Group exercise (strength/resistance training vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 1.8 (0.84 to 3.87)
Quality of evidence: LOW
Individual exercise at home (resistance training vs control)
GRADE table 7, Gillespie et al. (6)
Rate ratio: 0.95 (0.77 to 1.18)
Quality of evidence: MODERATE
Group exercise (multiple categories of exercise vs control):
subgroup analysis (selected for higher risk of falling)
GRADE table 8, Gillespie et al. (6)
Rate ratio: 0.7 (0.58 to 0.85)
Favours experiment
Quality of evidence: MODERATE
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20 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Group exercise (multiple categories of exercise vs control):
subgroup analysis (not selected for higher risk of falling)
GRADE table 8, Gillespie et al. (6)
Rate ratio: 0.72 (0.58 to 0.9)
Favours experiment
Quality of evidence: MODERATE
Group exercise: t’ai chi vs control:
subgroup analysis (selected for higher risk of falling)
GRADE table 9, Gillespie et al. (6)
Rate ratio: 0.95 (0.62 to 1.46)
Quality of evidence: LOW
Group exercise: t’ai chi vs control:
subgroup analysis (not selected for higher risk of falling)
GRADE table 9, Gillespie et al. (6)
Rate ratio: 0.59 (0.45 to 0.76)
Favours experiment
Quality of evidence: MODERATE
Evidence-to-recommendations table
Problem Explanation
Is the problem a priority?
Yes No Uncertain
✓
Falls are the leading cause of injury in older people aged 65 years and over. Between 30% and
40% of community-dwelling adults aged 65 years or older fall at least once per year. Therefore,
prevention of falls in older people at risk of falling is important.
Benefits and harms Explanation
Do the desirable effects outweigh the
undesirable effects?
Yes No Uncertain
✓
Fifty-nine trials (which included 13 264 randomized participants) tested the effect of exercise on
falls in older people. Trials were based on multimodal exercise interventions and combined two or
more of the following components: (a) gait, balance and functional training; (b) strength and
resistance training; (c) flexibility; (d) t’ai chi; (e) general physical activity; and (f) endurance. The
interventions were delivered in groups or individually.
Moderate-quality evidence suggests that multimodal exercise, delivered in groups or individually,
(continued next page)
21 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
(continued from previous page)
Do the desirable effects outweigh the
undesirable effects?
Yes No Uncertain
✓
reduces the occurrence of falls in older people at risk of falls. Sixteen trials (3622 participants)
examined the effectiveness of multi-component group exercise interventions. The mean age of
the participants ranged from 69 to 88 years, and the mean age in 94% of the trials was over 70
years. All reviewed trials were from high-income countries. Duration of follow-up ranged from 3.5
to 36 months. Overall, the intervention achieved a statistically significant reduction in the rate of
falls (Rate ratio: 0.71, 95% CI: 0.63 to 0.82). Eight trials delivered individual exercise
interventions at the participants’ homes. The mean age of the participants ranged from 74.7 to
84.1 years, and the mean age in the majority of trials was over 80 years. The duration of the trials
ranged from 7.5 to 24 months. Overall, home-based interventions achieved a statistically
significant reduction in the rate of falls (Rate ratio: 0.68, 95% CI: 0.58 to 0.80). One trial, which
examined balance and strength training included in daily life activities, showed a statistically
significant reduction in the rate of falls (Rate ratio: 0.21, 95% CI: 0.06 to 0.71).
There is limited moderate-quality evidence that t’ai chi training may reduce the risk of falls in older
people. However, the benefit of t’ai chi exercise (in terms of reduction in the rate of falls) was
experienced by the subgroup who were not selected for a higher risk of falling, while there was no
effect in the group selected for a higher risk of falling. Thus, t’ai chi training seems to be more
effective in people who are not at high risk of falling.
Adequate low-quality evidence suggests that multifactorial interventions reduce the rate of falls in
older people at risk of falls. Nineteen reviewed trials investigated the benefit of multifactorial
interventions (assessment and referral or provision of active interventions). The mean age of the
participants ranged from 73.1 to 80.6 years and the proportion of women participants in the trials
ranged from 49% to 100%. Only one study originated from a middle-income country (Thailand),
while the other 18 trials were conducted in high-income countries, mainly Australia, Canada,
China, Denmark, Finland, the Netherlands, the Province of Taiwan, the United Kingdom of Great
Britain and Northern Ireland and the United States of America. Multifactorial interventions
integrating assessments with individualized interventions, usually involving a multidisciplinary
team, were effective in reducing the rate of falls in older people at risk of falls (Rate ratio: 0.77,
CI: 0.67 to 0.86).
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22 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
(continued from previous page)
Do the desirable effects outweigh the
undesirable effects?
Yes No Uncertain
✓
There is limited moderate-quality evidence to suggest that home safety assessment and tailored
interventions reduce the rate of falls in older people at risk of falls. Six RCTs (4208 participants)
investigated the effectiveness of home safety interventions to reduce the rate of falls and the risk
of falling. The mean age of the trial participants was more than 75 years. The follow-up period
ranged from 3 to 18 months. Overall, home safety assessments and modification interventions
were effective in reducing the rate of falls (Rate of falls: 0.62, 95% CI: 0.5 to 0.77). Furthermore,
in a post hoc analysis, home safety interventions delivered by an occupational therapist were
more effective than interventions delivered by other health care professionals.
There is very limited low-quality evidence suggesting that medication reviews and modification or
withdrawal of medication reduce the risk of falls in older people. The results of one trial showed
that withdrawal of psychotropic medication was effective in reducing the rate of falls (Rate ratio:
0.34, 95% CI: 0.16 to 0.73). In another study, an educational programme for general practitioners
on medical review and treatment modification was found to be ineffective in reducing rate of falls.
Values and preferences/
acceptability
Explanation
Is there important uncertainty or variability about how much people value the options?
Major variability
Minor variability
Uncertain
✓
Fall is an important clinical outcome, which is also considered to be important by older people themselves and their family members and caregivers.
Is the option acceptable to key stakeholders?
Major variability
Minor variability
Uncertain
✓
The guideline development group strongly believes that recommendations for fall prevention will be valued by health care providers and acceptable to stakeholders (older people and those closet to them).
(continued next page)
23 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Feasibility/resource use Explanation
How large are the resource requirements?
Major Minor Uncertain
✓
Fall-preventions interventions are resource intensive. However, health benefits gained from the
recommendation are likely to outweigh the burden of resources required for implementation.
Intervention costs can be reduced through task shifting, engaging family members, and
administering the intervention in groups.
Is the option feasible to implement?
Yes No Uncertain
✓
Multifactorial interventions may be difficult to implement as they may require the involvement of
multiple service providers. In some countries, delivering exercise in groups might be difficult.
However, exercise delivered at home to individuals might be an alternative.
Some trials (those on exercise and home safety) have utilized non-specialized health care
professionals to deliver fall-prevention interventions. Drawing on this experience, the guideline
development group believes that it would be feasible to implement their recommendations in both
high- and low-resource health care settings.
Equity Explanation
Would the option improve equity in
health?
Yes No Uncertain
✓
The guideline development group strongly believes that all recommendations for prevention of
falls will increase equity in health.
24 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Guideline development group recommendations and remarks
Recommendations
Medication review and withdrawal (of unnecessary or harmful medication) can be
recommended for older people at risk of falls.
Quality of the evidence: Low
Strength of the recommendation: Conditional
Multimodal exercise (balance, strength, flexibility and functional training) should be
recommended for older people at risk of falls.
Quality of the evidence: Moderate
Strength of the recommendation: Strong
Following a specialist’s assessment, home modifications to remove environmental hazards
that could cause falls should be recommended for older people at risk of falls.
Quality of the evidence: Moderate
Strength of the recommendation: Strong
Multifactorial interventions integrating assessment with individually tailored interventions
can be recommended to reduce the risk and incidence of falls among older people.
Quality of the evidence: Low
Strength of the recommendation: Conditional
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25 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
Remarks
• Effective primary health care interventions for falls use various approaches to identify people at
increased risk.
• No evidence-based instrument to accurately identify older adults who are at increased risk for
falling exists.
• The majority of trials were conducted in high-income countries. Further research in low- and
middle-income countries is needed to understand the feasibility of implementing fall-prevention
interventions in low-resource health care settings.
• There is a pressing need to standardize assessments of the risk of falls to identify high-risk
older people. Currently, the history of falls is the most common factor used in the majority of
trials; a small proportion of trials used additional risk factors to select patients.
• Vision care for older people at risk of falls should not be restricted to cataract surgery.
• Due to their high heterogeneity, multifactorial interventions were rated as low quality. This is
largely due to differences in the intervention components included and the risk factors targeted
for reducing falls. Future research should unpack multifactorial interventions and report
treatment effect by subgroup of intervention components.
26 Evidence profile: risk of falls
ICOPE guidelines – World Health Organization
References
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2. Beauchet O, Fantino V, Allali G, Muir SW, Monter-Odasso M, Annweiler C. Timed Up and Go Test and risk of falls in older adults: a systematic review. J Nutr Health Aging. 2011;15(10);933–8. doi:10.1007/s12603-011-0062-0.
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16. Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L. Prognostic validity of the Timed Up-and Go Test, a modified Get-Up-and-Go Test, staff’s global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008;37(4);442–8. doi:10.1093/ageing/afn101.
17. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1);148–57. doi:10.1111/j.1532-5415.2010.03234.x.
18. Patino CM, McKean-Cowdin R, Azen SP, Allison JC, Choudhury F, Varma R; Los Angeles Latino Eye Study Group. Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology. 2010;117(2);199–206. doi:10.1016/j.ophtha.2009.06.063.
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27 Evidence profile: risk of falls
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20. Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, Lord SR. Discriminative ability and predictive validity of the Timed Up and Go Test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013;61(2);202–8. doi:10.1111/jgs.12106.
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28 Evidence profile: risk of falls
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Annex 1: Search strategy
MEDLINE database 1946 to 2015 (search date: 9 October 2015)
1. Accidental Falls/
2. (fall$ or faller$ or fallen).tw.
3. or/1-2
4. exp Aged/
5. (senior$ or elder$ or older).tw.
6. or/4-5
7. and/3,6
8. randomized controlled trial.pt.
9. controlled clinical trial.pt.
10. randomized.ab.
11. placebo.ab.
12. ((clinical or controlled or comparative or placebo or
prospective$ or randomi#ed) adj3 (trial or study)).tw.
(random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$
or order$)).tw
13. trial.ab.
14. groups.ab.
15. or/8-14
16. humans.sh.
17. 15 and 16
18. and/7,17
19. limit 18 to systematic reviews
Embase database 1946 to 2015 (search date: 9 October 2015)
1. Falling/
2. (fall$ or fallers).tw.
3. or/1-2
4. exp Aged/
5. (elderly or senior$ or older).tw.
6. or/4-5
7. and/3,6
8. exp Randomized Controlled trial/
9. exp Double Blind Procedure/
10. exp Single Blind Procedure/
11. exp Crossover Procedure/
12. or/8-11
13. ((clinical or controlled or comparative or placebo or
prospective$ or randomi#ed) adj3 (trial or study)).tw.
14. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$
or order$)).tw.
15. ((single or double or triple) adj7 (blind$ or mask$)).tw.
16. (crossover adj1 trial).tw.
17. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or
experiment$ or intervention$ or treatment$ or therap$ or
control$ or group$)).tw.
18. or/13-17
19. or/12,18
20. Animal/ not Human/
21. 19 not 20
22. and/7,21
23. limit 22 to systematic reviews
29 Evidence profile: risk of falls
Annex 2: PRISMA2 2009 flow diagram for intervention to prevention
falls in community-dwelling older people
2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA). For more information: http://www.prisma-statement.org
Records identified through database (Embase
and MEDLINE) searching (n = 374)
Scre
en
ed
Elig
ible
In
clu
de
d
Iden
tified
Full-text articles excluded, with reasons (n = 1):
• Target population not community dwellers
Records excluded
(n = 372)
Records after duplicates removed
(n = 374)
Records screened
(n = 374)
Full-text articles assessed for eligibility
(n = 2)
Studies included in qualitative synthesis
(n = 1)
Studies included in quantitative synthesis
(meta-analysis) (n = 1)
WHO/MCA/17.06.04
ICOPE guidelines – World Health Organization