In Ontario the Community Care Access Centre (CCAC) determines what services clients on the home care program receive. The current CCAC strategy is to decrease the volume of therapy services and put lower priority clients on a wait list in response to budget deficits. Therapy agencies have been advocating for increased therapy services to facilitate client independence. What is the evidence is to support Occupational Therapy/Physiotherapy (OT/PT) intervention for clients that are home bound, aged 65 years and over with a history of at least two falls in the past six months. The therapy intervention provided either by a PT or an OT may consist of falls prevention education and strategies and/or home safety assessment and related strategies and/or an exercise program. (Assignment 1 Jan 30, 2011 Gill C)
FOCUSSED CLINICAL QUESTION:
" Is therapy (PT/OT) intervention, consisting of either single or multiple components of therapy (falls prevention education, home safety, exercise program) for home bound clients aged 65 and over with a history of falls, efficacious in reducing falls and cost effective in reducing health care costs over the long term. than providing personal support?"*
* Italics and strike through indicate changes from the original question from Assignment 1
SUMMARY of Search and Key Findings of five best articles:
Research design and purpose
Strengths
Weaknesses
Conclusions
Systematic review;
to summarize the best evidence for effectiveness of interventions designed to reduce the incidence of falls in older people living in the community
- level 1a intervention review reviewing RCTs and quasi-randomised trials
-details of the electronic search included
-international (15 countries)
-111 trials with 55,303 participants
-although prospective daily calendars returned monthly for a year is the preferred method for recording falls some trials that retrospectively monitored or were not monitored continuously were also included
-Exercise interventions reduce risk and rate of falls
-interventions to improve home safety do not seem to be effective except in higher risk populations
-there is some evidence that falls prevention strategies can be cost saving{{36 Gillespie Lesley,D. 2009}}
Systematic Review;
to determine the effect of modifications to the home environment on the reduction of injuries, with the primary focus being interventions which reduce physical hazards in the home.
-level 1a
-29 RCTs
- details of the electronic search included
- multifactorial (education plus action) intervention included
-Most studies did not provide enough detail in their results to ascertain the mechanism of injuries,
- all age groups included (clinical question related to people 60 years and over)
- there is very little high-grade evidence that interventions to modify the home physical environment affect the likelihood of sustaining an injury in the home
{{37 Turner,Samantha 2006}}
Systematic review;
to assess the effectiveness of population-based intervention, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people
-level 2a
-prospective cohort
-details of the electronic search included
-Only 6 studies out of 35 met the inclusion criteria
-no RCTs
-lack of information about intervention
-a preliminary claim that the population-based approach to the prevention of fall-related is effective and can form the basis of public health practice{{38 McClure Roderick,J. 2005}}
Critical literature review;
to determine if OT education and functional training programs are effective in improving occupational performance and quality of life of older adults
-level 1
-both quantitative (RCT, before and after, cross over) and qualitative (ethnographic) evidence included
-evidence divided into two program groups (1.related to preventing functional decline and falls and 2. chronic illnesses)
-pretesting on a sample of ten to ensure consistency among reviewers
-description of specific OT interventions not well described and may be difficult to duplicate
- programs are effective in three areas (prevention of functional decline and falls, stroke and rheumatoid arthritis)
{{40 Wilkins,S. 2003}}
Meta-analysis;
to examine the effectiveness of interventions used for decreasing the fear of falling
-level 1a
-six studies (RCT) out of 101 met eligibility criteria (all six rated as high)
-957 participants
-details of search included
-mean weighted effect size (MWES) is.21(n=957,95%CI .068-.362)
-may be difficult to replicate since interventions only partly described
-small number of studies unable to generalize
-unable to detect publication bias ("file drawer problem")
-interventions are effective in reducing the fear of falling or increasing fall efficacy
- community and home based interventions rather than facility based have a significant effect
-best outcome after four months{{9 Dukyoo,Jung 2009}}
CLINICAL BOTTOM LINE: Grade A recommendation
There is good evidence (level 1a) supporting falls prevention and exercise intervention to benefit clients living in their own homes and limited evidence that falls prevention strategies can be cost saving during the trial period (short term), and may also be cost effective over the participants remaining lifetime (long term). There is evidence (level 1a) that supports community or home based interventions to decrease the fear of falling. There is a lack of good evidence to support home modification as an intervention for prevention of falls related injuries.
Limitation of this CAT: prior to March 13, 2011 this critically appraised topic has not yet been reviewed by a lecturer.
SEARCH STRATEGY:
Terms used to guide Search Strategy:
Patient/Client Group: Home bound 65year+ clients with a recent history of falls
Intervention (or Assessment): Occupational Therapy (OT) or Physical Therapy (PT) intervention "therapy intervention" (falls prevention education/strengthening/ balance exercises)
Comparison: therapy intervention versus PSW (personal support worker) visits/intervention
Outcome(s):decreased cost of long term PSW as evidenced by decreased visits and increased client independence as evidenced by the ability to stay at home (versus not being admitted to hospital/LTCF) (Assignment 1 Jan 30, 2011 Gill C)
Databases and sites searched
Search Terms
Limits used
Cochrane Collaboration
(advanced search)
Pubmed
CINAHL
Homemaker services, accidental falls, home care services, exercise therapy, homemaker services and occupational therapy
Accidental falls, Homemaker services, Home Care services, Home maker services, Physical therapy and Occupational Therapy
Accidental falls, health care costs, home health care
No limits
Eng, 65+,Human, RCT Meta analysis
2004-2010, 65+,
Eng, Human Academic journals
INCLUSION and EXCLUSION CRITERIA (of search)
Inclusion:
English language studies that were included were high level studies focusing on falls, falls prevention intervention and strategies in older adults, living in their own home or residences.
Exclusion:
Studies that focused on disease specific falls related studies (e.g. Parkinson's) or nutrition related intervention and older studies
RESULTS OF SEARCH
41 relevant studies were located and categorised as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 1998)
Table 1: Summary of Study Designs of Articles retrieved
Study Design/ Methodology of Articles Retrieved
Level
Number Located
Author (Year)
Systematic review
1a
1a
2a
4
Gillespie (2009)
( divided into 2 articles)
Turner(2006)
McClure (2005)
Protocol for RCT
1
1
Canning (2009)
Critical Literature Review
1
Wilkes (2003)
RCT and meta analysis
1(all 13 )
13
Ashburn (2006),Campbell (1999), Dukyoo(2009),
Gill (2002),Gitlin (2009),
Iliffe (2010),Logan(2010)
Luukinen(2007),
Robertson (2002), Robertson(2001),
Sherrington (2009) Tinetti(1994) and Ziden (2008)
RCT/Meta Analysis
1 (all 3)
3 (+ 3 repeats)
Burke ( 2010),Davidson (2005) and Petridou (2009)
Prospective cohort design
Retrospective study
RCT
Cross sectional study
Cross sectional study
Cross sectional study
2
2b
1
2
2
2
6
Bohl (2010),
Hendrie ( 2004)
Markle-Reid (2010),* Markle -Reid (2010)
Newton( 2006) and Sartini (2010)
Various levels (1-4), not dealt with in detail
14
Clemson (2004)(2010), Di Monaco (2008), Fletcher (2004), Fortinsky (2008),Gitlin (2006), Hedley (2010),Hendriks (2008), Huang (2004), Jansson (2004), Leclerc (2009), Lewis (2004), Smith (2008) and Wyman (2007)
BEST EVIDENCE
Gillespie Lesley, D., Robertson, M. C., Gillespie William, J., Lamb Sarah, E., Gates, S., Cumming Robert, G., & Rowe Brian, H. (2009). Interventions for preventing falls in older people living in the community. Chichester, UK: John Wiley & Sons, Ltd. doi:10.1002/14651858.CD007146.pub2; 10.1002/14651858.CD007146.pub2
Reasons for selecting this study were:
It is a level 1a intervention review (111 randomized controlled trials (RCT) with a total of 55, 303 participants)
The objective of the study was to summarize the best evidence for effectiveness of interventions designed to reduce the incidence of falls in older people living in the community and as such addressed the clinical question posed
The review focused on any intervention designed to reduce falls and the clinical question was interested in both single or multiple components of therapy
The primary outcomes were rate and numbers of falls, the secondary outcomes were the number of participants sustaining fall related fractures, adverse effects of the interventions and economic outcomes; these resonated with the clinical question.
SUMMARY OF BEST EVIDENCE
Table 2: Description and appraisal of "Interventions for preventing falls in older people living in the community" {{36 Gillespie Lesley,D. 2009}}
Objective of the Systematic Review: The objective of the study was to summarize the best evidence for effectiveness of interventions designed to reduce the incidence of falls in older people living in the community. (p. 30)
Study Design: Systematic Review (SR)
Search Strategy: The authors searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2008), CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1950-May 2008), EMBASE (1988-May 2008), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-May 2008), PsycINFO (1967-Sept 2007), and Allied and Complementary Medicine (AMED) (1985-to Sept 2007). Ongoing trials were identified by searching the UK National Research Register (NRR) Archive (to Sept 2007), Current Controlled Trials and the Australian New Zealand Clinical Trials Registry (all to May 2008). (p. 4)
This represents a comprehensive search strategy
Setting: Studies from 15 countries were reviewed. (p.6)
Participants: The 111 studies resulted in 55, 303 participants, both men and women. (p.7) Participants were recruited in a variety of ways from specialist, falls and geriatric clinics, state and private health care data bases, discharges from primary and tertiary settings and by advertisement and social organisations. (pp 6, 7)
Participants had a high likelihood of not having significant cognitive deficits based on exclusion criteria in the majority of the studies and the importance of getting informed consent. (p.7)
There was a mean age of more than 60 years. A history of falls was not an inclusion criterion for all studies but was for 52/111. (p.7)
Intervention Investigated
The review focused on interventions to prevent falls in older people. Studies included comparing with 'usual care' (defined as no change in usual care) or a placebo intervention (defined as an intervention such as a social visit or education that is not thought to reduce falls) or two types of falls prevention intervention. (p.4)
74 studies had a single intervention; exercise (43 studies), surgery (3 studies), medication (13 studies) fluid or nutrition therapy (1 study), psychological (1 study), environment/assistive technology (11 studies)* and knowledge/education interventions (2 studies). (pp 7-11)
There were 10 studies that described multiple interventions (i.e. two or more interventions);
Exercise and a variety of other interventions (nutritional, education, home safety, advice) (8 studies) (p11) and education and either access to a geriatric clinic or home safety and medication review (2 studies) (p11)
Finally there were 31 studies in the multifactorial interventions category; assessment and active intervention (10 studies) and assessment and referral or provision of information (21 studies) (p11)
*Some repetition of studies which accounts for 115 being counted although only 111 studies reviewed.
Both OT and PT provided the intervention in some of the studies but it is not clear in how many. The exercise programs were supervised in some way in the majority of cases. (pp.7, 8) The exercises were described as gait, balance, functional training, strengthening, flexibility, Tai Chi, dance, general physical activity, endurance and other. (p.15)
Outcome Measures
Primary outcomes were the rate of falls and number of fallers. Secondary outcomes were the number of participants sustaining fall related fractures, adverse effects of the intervention and the economic outcomes. (p.4)
Main Findings: Only results pertaining to the clinical question were included in the table.
Intervention
Rate Ratio (RaR)
↓rate of falls
Confidence Interval (CI)
Risk Ratio
(RR)
↓risk of falling
Confidence Interval
(CI)
Multiple-component (MC) group exercise
0.78
95% (0.71-0.86)
0.83
95% (0.72-0.97)
Tai Chi
0.63
95% (0.52-0.78)
0.65
95% (0.51-0.82)
individually prescribed MC home-based exercise
0.66
95%(0.53-082)
0.77
95% (0.61-0.97)
Assessment & multifactorial
intervention
0.75
95% (0.65-0.86)
n/a
n/a
Anti-slip shoe device in icy conditions
0.42
95% (0.22-0.78)
0.89
95%
home safety
0.90 (did not reduce)
95% (0.79-1.03)
Economic evaluation: Fifteen studies reviewed cost effectiveness of falls intervention. Eight studies reported comprehensive economic information but the ability to compare across studies was challenging. There was some limited evidence that falls prevention strategies may be cost effective.
Original Authors' Conclusions
"Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective".(p.2)
Critical Appraisal:
The SR addressed an appropriate and clearly focused question (p.1)
The description of the methodology was in-depth( pp.3-4)
There was a comprehensive and rigorous literature search (p.4-6, 23) and the authors sought out unpublished data and abstracts to enhance their search
Authors considered adequate sequence generation, allocation concealment and blinding (how randomization was described, how selection occurred and if participants and assessors were aware of the intervention being administered)in order to minimize bias (pp 4-5, 14)
Heterogeneity was assessed and set at P< 0.10 (pp.5-6) and planned subgroup analysis also used
Statistically high CI results
Summary/Conclusion:
This is a high quality SR, with large numbers of participants, in an international context, looking at multifactorial interventions, despite this very few recommendations brought forward, therefore further research is required.
IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH
The prevalence of falls and the impact on morbidity and mortality on community based elderly people warrants a multilevel approach. (p.3)
Clinicians working in the community with an elderly population, who are cognitively intact but have a fear of falling and or a history of falls, can be confident that they will have a positive impact on reducing the rate of falls and risk of falls by assessing and then implementing either a group or individual exercise program for their clients. The exercises should target balance, strength and flexibility and have more than one component. Since Tai Chi, a single component activity contains elements of balance and strength, clinicians can be reassured that recommending participation in Tai Chi is evidenced based. Except for a select group of high risk clients (e.g. visually impaired) home safety modifications do not seem to be effective.
Funders and health policy managers should note that there is some, although limited, evidence that falls prevention strategies can be cost saving if directed at the appropriate group.
Researchers in conjunction with clients, clinicians, funders and policy makers should design large quantitative and qualitative studies to determine specific parameters (e.g. frequency, intensity) for the different components of the noted beneficial interventions, and would also determine what the recommendations should be for the inconclusive interventions.
