Preventing Falls in Older Adults – Vitamin D combination is the best - JAMA Meta-analysis Nov 2017

Comparisons of Interventions for Preventing Falls in Older Adults – A Systematic Review and Meta-analysis

JAMA. 2017;318(17):1687-1699. doi:10.1001/jama.2017.15006

Andrea C. Tricco, PhD1,2; Sonia M. Thomas, MSc1; Areti Angeliki Veroniki, PhD1; et al Jemila S. Hamid, PhD1; Elise Cogo, ND1; Lisa Strifler, MSc1,3; Paul A. Khan, PhD1; Reid Robson, MSc1; Kathryn M. Sibley, PhD4,5; Heather MacDonald, MSc1; John J. Riva, DC6,7; Kednapa Thavorn, PhD1,8; Charlotte Wilson, MSc1; Jayna Holroyd-Leduc, MD9; Gillian D. Kerr, MD1; Fabio Feldman, PhD10; Sumit R. Majumdar, MD11; Susan B. Jaglal, PhD12; Wing Hui, MSc1; Sharon E. Straus, MD, MSc1,13

Key Points

• Question What types of fall-prevention programs may be effective for reducing injurious falls in older people?
• Findings In a network meta-analysis including 54 studies and 41 596 participants,
• exercise (odds ratio [OR], 0.51),
• combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30),
• combined exercise, and vision assessment and treatment (OR, 0.17), and
• combined clinic-level quality-improvement strategies, multifactorial assessment and treatment, calcium supplementation, and vitamin D supplementation (OR, 0.12) were significantly associated with reductions in injurious falls.
• Meaning The analysis identified combinations of interventions likely to be more effective than usual care for preventing injurious falls.

Importance Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.
Objective To assess the potential effectiveness of interventions for preventing falls.

Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.

Study Selection Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.

Data Extraction and Synthesis Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.

Main Outcomes and Measures Injurious falls and fall-related hospitalizations.

Results A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], −0.67 [95% CI, −1.10 to −0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, −1.79 [95% CI, −2.63 to −0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, −1.19 [95% CI, −2.04 to −0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, −2.08 [95% CI, −3.56 to −0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).

Conclusions and Relevance Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.