Interventions for preventing falls in older people living in the community

  • Comment
  • Review
  • Intervention

Authors


Abstract

Background

Approximately 30% of people over 65 years of age living in the community fall each year.

Objectives

To assess the effects of interventions to reduce the incidence of falls in older people living in the community.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).

Selection criteria

Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

Main results

We included 111 trials (55,303 participants).

Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).

Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.

Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. 

Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03; RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).

Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).

Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).

There is some evidence that falls prevention strategies can be cost saving.

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.

摘要

背景

避免社區老人跌倒的預防措施

平均每年有30%六十五歲以上的社區老人會發生跌倒的意外事故。

目標

為了評估各種減少社區老人跌倒發生率的預防措施其成效。

搜尋策略

我們搜尋了Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials等資料庫 (到2008五月為止)。

選擇標準

針對各種減少社區老人跌倒發生率的預防方式進行隨機試驗,初步的結果以跌倒發生率和併發的風險性作為評估依據。

資料收集與分析

兩位作者獨立針對各項試驗,評估其品質,並將資料彙整歸入適當的評估項目當中。

主要結論

我們總共蒐集111個試驗,總共55303位受試者。多元性的團體運動、太極拳、以及量身訂做的多元化居家運動都可以減少跌倒的發生率以及併發的風險。多元性的團體運動(rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97),太極拳(RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82),量身訂做的多元化居家運動(RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97)。評估以及各種預防跌倒措施可以減低其發生率(RaR 0.75, 95%CI 0.65 to 0.86),但無法減低其併發的風險。總體而言,維他命D的補充並不會減少跌倒的發生率(RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01),但對於有維他命D缺乏的病人,或許有所幫助。居家安全環境並不會減低跌倒的發生率(RaR 0.90, 95%CI 0.79 to 1.03; RR 0.89, 95%CI 0.80 to 1.00),但對於有嚴重視力障礙以及跌倒高風險族群,則有正面的效果。至於防滑鞋具在一些滑溜的環境下則可以減低跌倒的發生率(RaR 0.42, 95%CI 0.22 to 0.78)。 將精神科方面的藥物逐漸減量可以有效的減低跌倒發生的比例(RaR 0.34, 95%CI 0.16 to 0.73),但無法減少其併發的風險。臨床第一線照護醫師進行處方藥物的調整則可以大幅減低跌倒發生的危險性(RR 0.61, 95%CI 0.41 to 0.91)。在頸靜脈竇過度敏感的病人身上安裝心臟節律器可以減少跌倒發生的頻率(RaR 0.42, 95%CI 0.23 to 0.75),至於第一次進行眼部白內障手術的病人也可以有效減低跌倒發生率(RaR 0.66, 95%CI 0.45 to 0.95)。 目前為止仍有部分的證據顯示跌倒的預防是相當有效益的。

作者結論

運動可以減低跌倒的風險以及發生率。但我們需要更多研究來證明其他預防措施的成效,包括各項預防跌倒的處置,居家安全環境的建立,維他命D的補充,以及其他各種措施。

翻譯人

本摘要由臺灣大學附設醫院李奕辰翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

避免社區老人跌倒的預防措施: 隨著年紀增加,跌倒的機會也會隨之增加,原因包括平衡感的問題、視力障礙、以及失智。每年約有30%的人會發生跌倒。雖然有將近1/5的人跌倒之後需要醫療照護,但只有不到1/10的人會發生骨折。即便如此,對於跌倒的恐懼仍會使得老人家侷限自己的行動。我們當然無法完全避免跌倒的發生,但是對於時常跌倒的族群,我們仍舊可以盡量降低跌倒的比例。這次的研究主要在探討哪些方法可以有 效減少社區老人跌倒的比例,總共含括111個隨機對照試驗,共55303個受試者。運動計畫可以有效提升肌力、平衡感、柔軟度、以及肌耐力。包含兩個訓練項目以上的計畫可以有效減低跌倒發生率以及跌倒人數。至於參與有指導者的團體、太極拳、或是量身訂做的居家運動計畫都有同樣的效果。有許多計畫可以評估一個人跌倒的發生率以及風險,進而介入或轉介治療以減少危險性。這些計畫在有些試驗中被證明有效,有些則是沒有效果。但是目前的證據顯示,這些計畫仍具有一定的成效,可以減低社區老人的跌倒比例,但是相關的因素仍需要更多的實驗來證實。服用維他命D並不能減少跌倒發生的危險性,除了一些真正維他命D缺乏的病人之外,可能跟高血鈣、腸胃道障礙、以及腎功能障礙有關。對於居家環境安全的介入並不能有效減少跌倒比例,除了一些高危險族群之外,例如嚴重的視力障礙。但是防滑鞋具在滑溜的環境之下,則可以顯著減少跌倒的發生。除了一些高危險群病人,如嚴重視力障礙的老人家。但是防滑鞋具在滑溜的環境下則可以有效的減少跌倒比例。有一些藥物會增加跌倒的機會,因此檢視並調整所服用的藥物是有效的,同時可以逐步減少安眠藥、鎮靜劑以及抗憂鬱藥物的使用,都可以減少跌倒的機會。在第一隻眼睛發生白內障時進行白內障手術可以減少跌倒的機會。至於有頸動脈竇敏感的病人,因會會引起心率以及血壓改變,因此安裝心率調節器可以有效的減少跌倒的比例。

Resumen

Antecedentes

Intervenciones para la prevención de caídas en las personas de edad avanzada que residen en la comunidad

Aproximadamente, un 30% de las personas de más de 65 años de edad que residen en la comunidad sufren caídas cada año.

Objetivos

Evaluar los efectos de las intervenciones diseñadas para reducir la incidencia de caídas en las personas de edad avanzada que residen en la comunidad.

Estrategia de búsqueda

Se hicieron búsquedas en el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Lesiones Óseas, Articulares y Musculares (Cochrane Bone, Joint and Muscle Trauma Group), CENTRAL (The Cochrane Library 2008, número 2), MEDLINE, EMBASE, CINAHL y Current Controlled Trials (todas hasta mayo 2008).

Criterios de selección

Ensayos aleatorios de intervenciones diseñadas para reducir las caídas en las personas de edad avanzada que residen en viviendas comunitarias. Los resultados primarios fueron la tasa y el riesgo de caídas.

Obtención y análisis de los datos

Dos autores de la revisión evaluaron de forma independiente la calidad de los ensayos y extrajeron los datos. Se agruparon los datos cuando fue adecuado.

Resultados principales

Se incluyeron 111 ensayos (55 303 participantes).

Los ejercicios del grupo de componentes múltiples redujeron la tasa y el riesgo de caídas (cociente de tasas [CT] 0,78, IC del 95%: 0,71 a 0,86; cociente de riesgos [CR] 0,83, IC del 95%: 0,72 a 0,97), al igual que el Tai Chi (CT 0,63, IC del 95%: 0,52 a 0,78; CR 0,65, IC del 95%: 0,51 a 0,82) y los ejercicios domiciliarios de componentes múltiples prescritos de forma individual (CT 0,66, IC del 95%: 0,53 a 0,82; CR: 0,77; IC del 95%: 0,61 a 0,97).

La evaluación e intervención multifactorial redujo la tasa de caídas (CT 0,75; IC del 95%: 0,65 a 0,86), pero no el riesgo de caídas.

En términos generales, la vitamina D no redujo las caídas (CT 0,95, IC del 95%: 0,80 a 1,14; CR 0,96, IC del 95%: 0,92 a 1,01), pero puede hacerlo en personas con niveles inferiores de vitamina D.

En términos generales, las intervenciones de seguridad domiciliaria no redujeron las caídas (CT 0,90, IC del 95%: 0,79 a 1,03; RR 0,89, IC del 95%: 0,80 a 1,00), pero fueron eficaces en pacientes con deterioro visual grave y en otros con alto riesgo de caídas. Un dispositivo antideslizante para el calzado redujo las caídas en suelos cubiertos de hielo (CT 0,42; IC del 95%: 0,22 a 0,78).

El retiro gradual de los fármacos psicotrópicos redujo la tasa de caídas (CT 0,34; IC del 95%: 0,16 a 0,73), pero no el riesgo de caídas.Un programa de modificación de la prescripción para los médicos de atención primaria redujo significativamente el riesgo de caídas (CR 0,61; IC del 95%: 0,41 a 0,91).

La estimulación cardíaca con marcapasos redujo la tasa de caídas en las personas con hipersensibilidad del seno carotídeo (CT 0,42; IC del 95%: 0,23 a 0,75). La cirugía de cataratas para el primer ojo redujo la tasa de caídas (CT 0,66; IC del 95%: 0,45 a 0,95).

Existen algunas pruebas acerca de que las estrategias de prevención de caídas pueden reducir los costes.

Conclusiones de los autores

Las intervenciones de ejercicios reducen el riesgo y la tasa de caídas. Se necesita investigación para confirmar los contextos en los que la evaluación e intervención multifactorial, las intervenciones de seguridad en el hogar, la administración de suplementos de vitamina D y otras intervenciones son efectivas.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

Plain language summary

Interventions for preventing falls in older people living in the community

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall per year. Although one in five falls may require medical attention, less than one in 10 results in a fracture. Fear of falling can result in self-restricted activity levels. It may not be possible to prevent falls completely, but people who tend to fall frequently may be enabled to fall less often.

This review looked at which methods are effective for older people living in the community, and includes 111 randomised controlled trials, with a total of 55,303 participants.   

Exercise programmes may target strength, balance, flexibility, or endurance. Programmes that contain two or more of these components reduce rate of falls and number of people falling. Exercising in supervised groups, participating in Tai Chi, and carrying out individually prescribed exercise programmes at home are all effective. 

Multifactorial interventions assess an individual person’s risk of falling, and then carry out or arrange referral for treatment to reduce their risk. They have been shown in some studies to be effective, but have been ineffective in others. Overall current evidence shows that they do reduce rate of falls in older people living in the community. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  

Taking vitamin D supplements probably does not reduce falls, except in people who have a low level of vitamin D in the blood. These supplements may be associated with high levels of calcium in the blood, gastrointestinal discomfort, and kidney disorders. 

Interventions to improve home safety do not seem to be effective, except in people at high risk, for example with severe visual impairment. An anti-slip shoe device worn in icy conditions can reduce falls.

Some medications increase the risk of falling. Ensuring that medications are reviewed and adjusted may be effective in reducing falls. Gradual withdrawal from some types of drugs for improving sleep, reducing anxiety and treating depression has been shown to reduce falls.

Cataract surgery reduces falls in people having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which may result in changes in heart rate and blood pressure.

Ancillary