Hard evidence to soften falls

Even frail and reluctant patients will reduce their risk of falls with the right exercise regime

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Almost counter-intuitively, older people could significantly cut their risk of falls if they become physically active, according to a major systematic review of all the available evidence on fall prevention strategies. 

Exercise alone reduced injurious falls by 12%, but combining it with vision testing and treatment shrunk the risk by 38%, the US review authors told The Medical Republic.

In the US, the annual incidence of falls among those aged over 85 is 82 per 100 people, and 36% of adults aged over-65 would have an injury-causing fall every two years, according to the study. Not only can this be devastating to the individual, it is costly to the healthcare system. 

The review found there was strong evidence for the effectiveness of these different strategies to prevent falls. And as the population greyed, the need to adopt evidence-based fall prevention measures became more urgent, the authors suggested.

In an accompanying editorial, Dr Eric Larson, geriatrician from the US Sanford Internal Medicine Clinic, said the analysis was “superbly” done and presented a “substantial amount of evidence” on the best way to prevent falls. 

What set this study of almost 300 randomised controlled trials and 160,000 participants apart from other analyses was that it uncovered actionable findings for clinicians and patients, rather than calling for more evidence, he said.    

The major recommendation is to encourage older patients to develop an exercise routine, particularly among those who are inactive out of habit or poor health. 

“Clinicians should focus on patients at highest risk for falls, but there is no reason not to encourage most older patients to exercise,” Dr Larson said. 

“It is better to increase exercise levels gradually rather than begin at too high a level, only to become discouraged and stop,” he said. “Walking, balance, and strength training are all valuable, but most important is to find an exercise that a person will do regularly so that it becomes a habit.”

Although he warned that when individuals initially went from a sedentary lifestyle to a more active one, their risk of falling increased. 

“Advising patients to start exercising slowly and carefully usually is effective, but for frail people, as well as those reluctant to initiate exercise, it may help to recommend personal trainers or physical therapists, especially when the risks are higher.”

The benefits of exercise were magnified when exercise was coupled with interventions that addressed other risk factors for falls, such as vision and bone health. 

Vision assessment was a key arena where GPs could be especially helpful. 

“Visual impairment among older patients is highly prevalent, usually has an insidious onset, and can easily escape detection, but most important, often can be corrected,” Dr Larson said. 

Research also indicated that fractures could be prevented by improving vitamin D and calcium intake among suitable patients, as could combining these with osteoporosis treatment. 

Even if the patient had already sustained a fall, interventions such as exercise in conjunction with safety improvements to their environment and multifactorial treatment appeared to make things safer and prevent future fractures. 

Hip protectors and orthotics were also found to be protective against injurious falls when combined with exercise. 

 JAMA 2017; online 7 November