Multicomponent fall prevention programs no more effective than mailed information alone

Mailed advice combined with an exercise-based intervention or a multifactorial program aimed at preventing falls in the elderly appeared no more effective at reducing fractures than advice by mail alone, according to a new English trial.

Researchers performed a pragmatic, three-group, cluster-randomized controlled trial to determine the effect of adding risk screening for falls and targeted interventions (multifactorial fall prevention or exercise for those at increased fall risk) to advice by mail for elderly patients. The exercise intervention included progressive home exercises for strength and balance performed at least twice a week along with a recreational walking program. Those assigned to this group received a minimum of seven sessions from a physical therapist over a six-month period, at least four of which were required to be in person. In the multifactorial intervention, participants received home environment interviews and comprehensive assessment from nurses, general practitioners, and geriatricians. The study's primary outcome was rate of fractures per 100 person-years over 18 months. The results were published by the New England Journal of Medicine on Nov. 5.

A random sample of 9,803 people ages 70 years or older from 63 general practices in England were included in the study. Mean age was 78 years, and 53% were women. Overall, 3,223 were assigned to receive advice by mail alone, 3,279 were assigned to fall-risk screening and targeted exercise plus advice by mail, and 3,301 were assigned to fall-risk screening and targeted multifactorial fall prevention plus advice by mail. Those in the latter two groups received a fall-risk screening questionnaire, which was completed by 2,925 of 3,279 participants (89%) in the exercise group and 2,854 of 3,301 participants (87%) in the multifactorial fall prevention group. Of these 5,779 participants, 2,153 (37%) were considered to be at increased fall risk and invited to receive the intervention. Fracture data were available for all but one of the 9,803 study participants.

Over 18 months, screening and targeted intervention were not associated with lower fracture rates. The most fractures occurred among the multifactorial group and the fewest occurred in the group that only received advice by mail. Compared with advice by mail alone, the rate ratio for fracture was 1.20 (95% CI, 0.91 to 1.59; P=0.19) with exercise and 1.30 (95% CI, 0.99 to 1.71; P=0.06) with multifactorial fall prevention. In a nested analysis of the 4,192 participants at increased risk for falls, the fracture rate was 3.70 per 100 person-years in the exercise group, 5.12 per 100 person-years in the multifactorial fall-prevention group, and 4.28 per 100 person-years in the mail-only group. Small improvements in health-related quality of life and the lowest overall costs were associated with the exercise strategy. One episode of angina, one fall during a multifactorial fall-prevention assessment, and one hip fracture occurred during the trial.

The researchers measured falls mainly by retrospective reporting via survey and did not collect data on minor injuries, among other limitations. “When applied in pragmatic settings, screening by mail followed by a targeted exercise intervention or multifactorial approach for prevention of falls did not result in a lower rate of fractures than advice by mail alone,” they concluded. They noted that future studies “should include interventions with better long-term adherence among persons at greatest risk for a fracture.”