Meta‐analysis of Multifactorial Interventions to Prevent Falls of Older Adults in Care Facilities

Field: Health Professions (Health Sciences)

To the Editor: In a recent issue of the Journal of the American Geriatrics Society, Vlaeyen et al.1 performed a meta-analysis of fall prevention programs in nursing homes, examining the number of falls, fallers, and recurrent fallers after single, multiple, and multifactorial interventions. The authors stated that one of the reasons why previous meta-analyses (e.g., Cameron et al.2) did not detect a reduction in the number of falls and fallers may have been because trials investigating groups of participants requiring different levels of assistance (high and intermediate) were combined and unclear descriptions of the care contexts (e.g., long-term care facilities, residential care facilities, nursing homes) were used to identify studies. Using a specific definition of a nursing home, as part of their inclusion criteria to select trials, Vlaeyen et al.1 found statistically significantly fewer falls and recurrent fallers when multifactorial intervention trials were combined in a meta-analysis. We became aware of the meta-analysis of Vlaeyen et al.1 while working on the Optimal Evidence-Based Non-drug Therapies in Older People (ONTOP) project. ONTOP is a work package of a European Union–funded FP 7 research project called Software ENgine for the Assessment & Optimization of drug and non-drug Therapy in Older peRsons (SENATOR).3 The aim of ONTOP is to undertake literature searches of systematic reviews of evidence-based nonpharmacological treatments of prevalent medical conditions affecting older people. In this case, electronic databases were searched for systematic reviews and meta-analyses of any nonpharmacological interventions to prevent falls of older people. An additional aspect that may explain the lack of conclusive evidence of fall prevention in care facilities, at least for multifactorial interventions, are the elements included in this latter approach used in the various trials. When the randomized controlled trials (RCTs) of multifactorial interventions in care facilities analyzed by Cameron et al.2 and Vlaeyen et al.1 were combined in a meta-analysis, neither statistically significantly fewer falls (rate ratio (RR) = 0.78, 95% confidence interval (CI) = 0.59–1.04; I2 = 83%, P < .001; 7 RCTs)4-10 nor number of fallers (RR = 0.93, 95% CI = 0.80–1.10; I2 = 83%, P < .001; 8 RCTs)4-8, 10-12 was found. An attempt was made to understand the reason for the substantial heterogeneity by extracting the information regarding the participant populations, the settings, and the components of those trials. When the components of the multifactorial interventions were examined, it was seen that two of the analyses7, 10 did not use exercise as part of their multifactorial program (Table 1). Moreover, one of the studies11 used exercise but not any physical environment (hazard assessment and modification) or assistive technology (e.g., walking aids, hearing and vision assessment and modification) interventions. Excluding those three studies, a sensitivity analysis of the trials revealed that the lower fall rate (RR = 0.61, 95% CI = 0.52–0.72; I2 = 6%, P = .37; 5 RCTs)4-6, 8, 9 and the number of fallers (RR = 0.82, 95% CI = 0.70–0.96; I2 = 66%, P = .02; 5 RCTs)4-6, 8, 12 were larger and became statistically significant. Moreover, the heterogeneity declined from 83% to 6% for fall rate and from 83% to 66% for number of fallers. These results suggest that, in addition to the participants and the setting in which fall prevention measures are implemented, exercise, physical environment, and assistive technology are fundamental elements of multifactorial interventions to reduce falls in older adults who are residents of care facilities. This work was supported by the European Union Seventh Framework program (FP7/2007–2013) under Grant Agreement 305930 (SENATOR). Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Rimland: study concept, data analysis, writing the letter. Dell'Aquila: data analysis, writing the letter. O'Mahony, Soiza, Cruz-Jentoft: writing the letter, critical comments. Abraha, Cherubini: study concept, data analysis, writing the letter, critical comments. Sponsor's Role: None.