Medical Domain

Falls Prevention Literature Review

Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2005;60:1157-1162.
Variable Studied: Medical resident risk factors.
Setting-Situation: Long-Term care facility.
Sample Size: N=139. Mean age = 88 (sd=7), range 70-105 years old; 97% Caucasian; 84% female. Inclusion criteria: age ≥60 years, ability to rise from seated position.
Study Design: Prospective cohort. Risk factors: clinical diagnoses, medication use, orthostatic changes in blood pressure, gait or balance, cognitive/mental status, general well-being, activities of daily living (ADLs), affect/behavior, range of motion, ambulation, communication. Outcome: fall incidence rate.
Results: Fall incidence rate: 49 participants (35%) experienced a fall; with diabetes, 78% fell, and without diabetes, 30% fell (p<.001). Increased risk of falls: diabetes-adjusted hazard ratio 4.0 (95% confidence interval [CI] 1.96-8.28); gait and balance-adjusted hazard ratio 5.26 (95% CI 1.26-22.02).
Conclusions: Diabetes mellitus is an independent fall risk factor among elderly nursing home residents. Gait and balance were the only other risk factors independently associated with increased risk of falls.

Maurer MS, Choen S, Cheng H. The degree and timing of orthostatic blood pressure changes in relation to falls in nursing home residents. Journal of the American Medical Directors Association 2004 Jul-Aug;5(4):233-238.
Variable Studied: Medical resident risk factors.
Setting-Situation: Long term care facility.
Sample Size: N=111 residents. Mean age = 88 (sd=7) years.
Study Design: Observational study. Risk factors: orthostatic blood pressure changes during active standing for up to 3 minutes with a real-time continuous, noninvasive beat-to-beat blood pressure device. Outcome: falls.
Results: Forty-six residents (41%) fell. The standard definition of orthostatic hypotension (OH) was not predictive of subsequent falls (hazard ratio 1.03 at 1 minute and 1.32 at 3 minutes, p>.05). Measures of orthostatic blood pressure changes were also not associated with a significant increase in risk for subsequent falls, including declines in blood pressure within the first minute of standing.
Conclusions: Standard definition of OH was not an independent predictor of falls in frail nursing home residents. A one-time measure for presence of postural hypotension using beat-to-beat tonometry was not predictive of falls. Timing and degree of orthostatic changes in blood pressure do not significantly enhance risk prediction for falls.

Young Y, Myers AH, Provenzano G. Factors associated with time to first hip fracture. Journal of Aging and Health 2001;13(4):511-526.
Variable Studied: Medical resident risk factors.
Setting-Situation: Data from Longitudinal Study on Aging.
Sample Size: N=7,527; 334 participants sustained a first hip fracture between 1984 and 1991.
Study Design: Prospective multicohort Longitudinal Study on Aging (LSOA). Risk factors: older age, female, Caucasian, history of falls, insufficient exercise, infrequent church attendance (proxy for activity level), hospitalization in year before study, and low body mass index. Outcomes: first hip fracture ever and time to first hip fracture.
Results: The time to first hip fracture was inversely related to the number of risk factors involved.
Conclusions: As the number of risk factors increases, the estimated time to fracture becomes shorter; thus, the window of opportunity for prevention is smaller. To reduce the incidence of first hip fracture and to prolong the time to first fracture, interventions should focus on modifiable risk factors identified: increasing exercise, increasing outside-the-home activities, and improving or maintaining body mass index.

Chandler JM, Zimmerman SI, Girman CJ, et al. Low bone mineral density and risk of fracture in white female nursing home residents. JAMA 2000;284(8):972-977.
Variable Studied: Medical resident risk factors; low bone mineral density.
Setting-Situation: 47 randomly selected nursing homes in Maryland.
Sample Size: N=1,427 white female nursing home residents; age = 65+.
Study Design: Prospective cohort study. Baseline data collected April 1995 to June 1997, with 18 months of followup. Risk factors: low bone mineral density (BMD). Outcome: fractures.
Results: A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in nursing home sample (p <.001) and the two factors increased synergistically (p =.06) to further increase fracture risk. Compared with women whose BMD was higher than median (0.296 g/cm2), those whose BMD was lower than median had an unadjusted hazard ratio (HR) for risk of fracture of 2.1 (95% confidence interval [CI] = 1.5-2.8); women who were independent in transfer had an HR of 1.6 (CI = 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below median had a more than threefold increase in fracture risk compared with those with higher BMD (unadjusted HR, 3.1; CI = 2.2-4.4). Among residents dependent in transfer, those with BMD below median had 60% increase in fracture risk (unadjusted HR, 1.6; CI = 1.1-2.3). Adjustment for covariates did not alter BMD-fracture relationship.
Conclusions: Low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents.

Gloth FM III, Gundberg CM, Hollis BW, et al. Vitamin D deficiency in homebound elderly persons. JAMA 1995;274(21):1683-1686.
Variable Studied: Medical resident risk factors; vitamin D deficiency.
Setting-Situation: Homebound elderly persons.
Sample Size: N=244 participants; age ≥65 years; Group 1: N=116 residents (85 women and 31 men) confined indoors for at least 6 months.; Group 2: N=128 healthy ambulatory participants from the Baltimore Longitudinal Study on Aging.
Study Design: Cohort analytic study. Risk factors: vitamin D deficiency and other resident characteristics. Measures: assessed vitamin D deficiency in homebound and nonhomebound residents; homebound, community-dwelling elderly persons; sunlight-deprived elderly nursing home residents; and healthy ambulatory elderly persons. Outcome: vitamin D status.
Results: In sunlight-deprived subjects overall, mean 25- hydroxyvitamin D3 concentration (OH)D level was 30 nmol/L (12 ng/mL) and mean 1,25-(OH) 2D level was 52 pmol/L (20 pg/mL). In sunlight-deprived subjects, 54% of community dwellers and 38% of nursing home residents had serum levels of 25-OHD below 25 nmol/L (10 ng/mL) (normal range, 25 to 137 nmol/L [10 to 55 ng/mL]). A significant inverse relationship existed between 25-OHD (i.e., Log [25-OHD]) and PTH when they were analyzed together (r=-0.42; R2=0.18; p<.001) and for each cohort separately. All other parameters measured, except ionized calcium, differed significantly from the Baltimore Longitudinal Study Group means. Mean (SD) daily intake of vitamin D (121 [132] IU) and calcium (583 [322] mg) were below recommended dietary allowance only in community-dwelling homebound population. Mean vitamin D binding protein level in sunlight-deprived subgroup was in normal range.
Conclusions: The study suggests that despite a relatively high degree of vitamin supplementation in the United States, homebound elderly persons are likely to suffer from vitamin D deficiency.

Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. British Medical Journal Oct. 2009;339(11):b3692.
Variable Studied: Medical resident risk factors; vitamin D.
Setting-Situation: Eight randomized controlled trials.
Sample Size: N=2,426. Mean age = 65+.
Study Design:Meta-analysis of randomized controlled trials. Risk factors: vitamin D. Outcome: falls.
Results: Heterogeneity among trials was observed for dose of vitamin D (700-1,000 IU/day versus 200-600 IU/day; p=0.02) and achieved 25-hydroxyvitamin D3 concentration (OH)D level of <60 nmol/L versus ≥60 nmol/L; p=0.005). High-dose supplemental vitamin D reduced fall risk by 19% (pooled relative risk (RR) 0.81, 95% CI 0.71 to 0.92; n=1,921 from seven trials), whereas achieved serum 25(OH)D concentrations of 60 nmol/L or more resulted in a 23% fall reduction (pooled RR 0.77, 95% CI 0.65 to 0.90). Falls were not notably reduced by low-dose supplemental vitamin D (pooled RR 1.10, 95% CI 0.89 to 1.35; n=505 from two trials) or by achieved serum 25-(OH)D concentrations of less than 60 nmol/L (pooled RR 1.35, 95% CI 0.98 to 1.84). Two randomized controlled trials (n=624) of active forms of vitamin D met the inclusion criteria. Active forms of vitamin D reduced fall risk by 22% (pooled RR 0.78, 95% CI 0.64 to 0.94).
Conclusions: Supplemental vitamin D in a dose of 700-1,000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D. Doses of supplemental vitamin D of less than 700 IU or serum 25-(OH) D concentrations of less than 60 nmol/L may not reduce the risk of falling among older individuals.

Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. Journal of the American Geriatric Society 1999;47(1):40-50.
Variable Studied: Medical treatment risk factors; cardiac and analgesic drugs.
Setting-Situation: Systematic evaluation of cardiac or analgesic drug use and any fall in people age 60 years and older.
Sample Size: N=29 studies. None were randomized controlled trials.
Study Design: Fixed-effects meta-analysis of English-language articles in MEDLINE® (1966-March 1996) indexed under "accidents" or "accidental falls" and "aged" or "age factors." Risk factors: cardiac and analgesic drugs. Outcome: falls.
Results: For one or more falls, the pooled odds ratio (OR) (95% confidence interval [CI] was 1.08 (1.02-1.16) for diuretic use, 1.06 (0.97-1.16) for thiazide diuretics, 0.90 (0.73-1.12) for loop diuretics, 0.93 (0.77-1.11) for beta-blockers, 1.16 (0.87-1.55) for centrally acting antihypertensives, 1.20 (0.92-1.58) for angiotensin-converting enzyme inhibitors, 0.94 (0.77-1.14) for calcium channel blockers, 1.13 (0.95-1.36) for nitrates, 1.59 (1.02-2.48) for type Ia antiarrhythmics, and 1.22 (1.05-1.42) for digoxin use. For analgesic drugs, the pooled OR was 0.97 (0.78-1.20) for narcotic use, 1.09 (0.88-1.34) for nonnarcotic analgesic use, 1.16 (0.97-1.38) for nonsteroidal anti-inflammatory drug use, and 1.12 (0.80-1.57) for aspirin use. In studies of the relationship between psychotropic, cardiac, or analgesic drugs and falls, subjects reporting the use of more than three or four medications of any type were at increased risk of recurrent falls.
Conclusions: Digoxin, type IA antiarrhythmic, and diuretic use are associated weakly with falls in older adults. Older adults taking more than three or four medications were at increased risk of recurrent falls. No associations were found for other classes of cardiac or analgesic drugs studied.

Broe KE, Chen TC, Weinberg J, et al. A higher dose of vitamin D reduces the risk of falls in nursing home residents: a randomized multiple-dose study. Journal of the American Geriatric Society 2007;55(2):234-239.
Variable Studied: Medical treatment to reduce risk; vitamin D supplement.
Setting-Situation: 725 bed long-term care facility.
Sample Size: N=124 nursing home residents (mean age 89).
Study Design: Secondary data analysis of a previously conducted randomized controlled trial. Risk factors: vitamin D levels and other resident characteristics. Intervention: one of four vitamin D supplement doses (200 IU, 400 IU, 600 IU, 800 IU) daily for 5 months. Control: placebo. Outcome: falls.
Results: Over the 5-month study period, the proportion of participants with falls was 44% in placebo group (11/25), 58% (15/26) in 200 IU group, 60% (15/25) in 400 IU group, 60% (15/25) in 600 IU group, and 22% (5/23) in 800 IU group. Participants in 800 IU group had a 72% lower adjusted-incidence ratio of falls than those taking placebo over the 5 months (rate ratio=0.28; 95% CI=0.11-0.75).
Conclusions: Nursing home residents in the highest vitamin D group (800 IU) had a lower number of fallers and a lower incidence rate of falls over 5 months than those taking lower doses. Adequate vitamin D supplementation in elderly nursing home residents could reduce the number of falls experienced by this high-risk group.

Burleigh E, McColl J, Potter J. Does vitamin D stop inpatients falling? A randomized controlled trial. Age and Ageing 2007; 36(5):507-513.
Variable Studied: Medical treatments to reduce risk; vitamin D and calcium supplement.
Setting-Situation: Geriatric medical unit.
Sample Size: N=205 acute admits >65 years; median age=84 years; median length of stay=30 days.
Study Design:Randomized, double blind, controlled study. Risk factors: vitamin D level. Intervention: daily vitamin D 800 IU plus calcium 1200 mg. Control: daily calcium 1200 mg. Outcome: falls.
Results: Effects of vitamin D and calcium in falls prevention: median study drug adherence=88%, with no significant differences between study groups in adherence. There were fewer fallers in the vitamin D cohort but this did not reach statistical significance.
Conclusions: In a population of geriatric hospital inpatients, vitamin D did not reduce the number of fallers. Routine vitamin D supplementation cannot be recommended to reduce falls in this group in the hospital.

Dhesi JK, Jackson SH, Bearne LM, et al. Vitamin D supplementation improves neuromuscular function in older people who fall. Age and Ageing 2004;33(6):589-595.
Variable Studied: Medical treatment to reduce risk; vitamin D supplement.
Setting-Situation: Falls clinic (taking referrals from general practitioners and accident and emergency department).
Sample Size: N=139 ambulatory subjects (≥65 yrs) with a history of falls and 25-hydroxyvitamin D (25 OHD) ≤12 µg/L.
Study Design: Randomized, double-blind, placebo-controlled study. Risk factors: vitamin D level. Intervention: single intramuscular injection of 600,000 IU ergocalciferol. Control:
placebo injection with no ergocalciferol. Outcomes: neuromuscular function, including biochemistry, postural sway, choice reaction time (CRT), aggregate functional performance time (AFPT), quadriceps.
Results: Baseline characteristics were comparable between intervention and control groups; 25 OHD in treatment group increased significantly at 6 months. AFPT deteriorated in control group and improved in the intervention group, representing a significant difference between groups (+6.6 s versus -2.0 s, t = 2.80, p<0.05). Similar changes were observed for CRT (-0.06 s versus +0.41 s, t = -2.52, p<0.01) and postural sway (+0.0025 versus -0.0138, t = 2.35, p<0.02). There was no significant difference in muscle strength between groups. A significant correlation between change in AFPT and change in 25 OHD levels was observed (r=0.19, p=0.03). There was no significant difference in number of falls (0.39 versus 0.24, t = 1.08, p=0.28) or fallers (14 versus 11, p=0.52) between the placebo and intervention groups, respectively.
Conclusions: Vitamin D supplementation, in fallers with vitamin D insufficiency, has a significant beneficial effect on functional performance, reaction time, and balance, but not on muscle strength. This suggests that vitamin D supplementation improves neuromuscular or neuro-protective function, which may in part explain the mechanism whereby vitamin D reduces falls and fractures.

Current as of February 2010
Internet Citation: Medical Domain: Falls Prevention Literature Review. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspxlitrev/fallspxlitrev1.html