Update on falls prevention for community-dwelling older adults: review of single and multifactorial intervention programs.

INTRODUCTION

As the average age of the current U.S. population continues to rise, so does the incidence of fall-related injuries and deaths. More than one-third of adults aged 65 years and older fall each year [1-2], and half of these individuals experience multiple falls [3-4]. The Centers for Disease Control and Prevention report that falls are the leading cause of injury-related deaths in individuals 65 years and older [5]. Twenty to thirty percent of seniors who fall suffer moderate to severe injuries, which in turn increase the risk of premature death [6]. In 2002, more than 1.8 million people were treated in hospital emergency rooms for fall-related injuries [5]. Twenty percent of all older adults who fracture a hip die within a year [7], and twenty-five percent of all fallers are in nursing homes within a year [8]. Costs for the 2.6 million medically treated nonfatal fall-related injuries in 2000 were $19 billion and for fatal injuries $0.2 billion [9]. These costs are estimated to increase to $240 billion by 2040 [10].

A variety of fall prevention programs targeting community-dwelling elderly adults have been established and critically evaluated. These prevention programs vary widely in their approach. Some have used single interventions such as health and risk assessment with referral to other healthcare practitioners to optimize health, polypharmacy assessment with medication management, home hazard assessment with modifications, individual or group exercise programs, or vision assessment with correction. Other programs have used a combination of some or all of the aforementioned interventions in a multifactorial approach.

Approaches to retrospective reviews of fall prevention programs have also varied because of the diverse nature of the programs. Some reviews targeted single intervention approaches [11-12], while others have assessed both single intervention and multifactorial programs [13-14]. Because of additional published research, the clinician may benefit from an updated review that assesses both types of fall prevention programs. On the basis of critical analyses of the current research, essential components of both single intervention and multifactorial approaches to falls prevention will be discussed and summarized in user-friendly tables. Key points and general guidelines for clinical practice will also be presented.

METHODS

Studies were identified by searching the electronic databases PubMed, Medline, Proquest, CINAHL, Cochrane Controlled Trials, Science Citation Index, and ERIC for citations between 1996 and 2007. In addition, through snowballing, citations from identified publications were hand-checked to find additional studies. Key search terms included fall$, elder$, community dwelling, aged, older, intervention, exercise program, prevent$, program$, injur$, home, hazard, residence, and any combination of these words. Study subjects in publications had to meet the following inclusion criteria to be included in this review: 60 years or older, ambulatory with or without an assistive device, and community dwelling. Prevention programs could offer single or multifactorial interventions. Outcomes of interest were number of falls and/or number of fallers or rate of falls. Falls were defined as "unintentionally coming to rest on the ground, floor, or other lower level" [15]. Studies reporting only intermediate outcome measures such as balance, strength, and self-efficacy were excluded from the analysis. Excluded also were studies that targeted nursing homes, hospitals, or supervised living environments, such as assisted living facilities, or those that were meta-analyses or follow-up studies of previously published primary research. In addition, studies that targeted individuals with identified disabilities (e.g., vestibular dysfunction, neurological dysfunction, cognitive impairment, cardiac pacing dysfunction) were excluded from this review.

The initial broad inclusion criteria were met by 781 studies. On the basis of the exclusion criteria, this number was reduced to 522. Two reviewers independently assessed the abstracts. Study quality was assessed using Sackett's criteria for level of evidence [16]. Only randomized controlled trials (RCTs) were chosen for this review. Whenever the two reviewers disagreed regarding appropriateness of an article, a dialogue ensued until consensus was met. Studies were grouped according to the following types of intervention programs: home hazard assessment with modification only, exercise and/or physical therapy only, and programs that offered multifactorial intervention programs.

MULTIFACTORIAL INTERVENTION PROGRAMS

Twelve multifactorial intervention studies met our described criteria. Participants included community-dwelling ambulatory adults over the age of 60, resulting in 4,251 participants. Comorbidities were described in four studies [17-20] and included stroke, arthritis, previous fractures, cardiovascular disorders, peripheral neuropathy, diabetes mellitus, depression, incontinence, and visual impairments. Recruitment methods varied and included individuals presenting to a hospital emergency room following a fall [20-22], health insurance database [17], residential database [23], voter registration database [24], flyers [18], senior centers and meal sites [25], health professional referrals [25-26], local media advertising [18,24], and referrals from general medical practices using a screening process [18-19,27]. The multifactorial programs included the following intervention strategies: health and fall risk assessment with referral to other healthcare practitioners who could address specific needs of the patient, medication assessment with education and/ or modifications, vision assessment with appropriate health practitioner referral and/or correction, home visit assessment with education and/or modifications of hazards, client education on fall risk factors, diet and exercise guidelines for healthy aging, exercise and balance training programs, and psychotropic medication withdrawal.

Studies included in the analysis of multifactorial prevention programs are found in Table 1. A comparison of specific intervention programs used in each multifactorial approach appears in Table 2.

Six studies employed a health and fall risk factor assessment with appropriate health practitioner referral as part of the multifactorial approach [18,20-21,25-26,28]. Of these studies, changes made to the participant's plan of care and subsequent follow-up and adherence based on referrals were evident in only two studies [25,28]. All six studies used multiple intervention strategies in addition to the comprehensive health assessment. Most programs offered five different intervention strategies. Three of the six studies demonstrated a significant decrease in falls outcomes in the intervention group [18,20-21]. Although Lightbody and colleagues reported fewer falls in the intervention group, the results were not significant [28]. However, the intervention group was significantly more functionally independent and mobile posttreatment than the control group. Increased mobility posttreatment may increase the opportunities for falls and related injuries and has been reported by other authors [29-30].

Eight of the twelve multifactorial prevention studies employed a review of the participants' medications with education [18,20-22,25-28], and one additional study used psychotropic medication withdrawal in a factorial design [19]. All nine of these investigations employed multiple intervention strategies in addition to medication assessment with modifications. Three study groups [18,25, 27] reported changes in medication based on study recommendations. Clemson et al. stated that subjects in the intervention group reported no changes in their medication regime based on study recommendations; however, subjects in the intervention group were less likely to start taking a new psychotropic medication than the control group [18]. Van Haastregt and colleagues reported a 46 percent adherence to recommendations made during the course of the study; however, this represented all changes made (home modifications, exercise, medication changes) [27]. Mahoney et al. reported adherence rates of 51 to 67 percent regarding medication changes at 1-year follow-up [25].

Of the nine studies that addressed the issue of polypharmacy, four demonstrated a significant decrease in the number of falls or fallers compared with the control group [18-21]. The remaining five studies with no effect on the measured outcome had a number of limitations [22,25-28]. These limitations included a high dropout rate [27], reduced power associated with sample size [28], a limited follow-up period (3 months) [22], and poor adherence for referrals to other healthcare professionals [25].

Campbell and colleagues conducted a study with a rigorous randomized factorial design [19]. In their study, psychotropic medications (associated with an increased risk of falls [31]) were withdrawn. Additionally, exercise was used as an intervention strategy. Individuals in the medication withdrawal group, exercise alone group, and combination group demonstrated a significant decrease in the number of falls compared with the control group. Despite the positive results, the authors reported a 45 percent dropout rate due to complaints of "not sleeping." In addition, 47 percent of individuals taking the placebo during the course of the study had restarted their psychotropic medications within a month of study completion.

Vision assessment was conducted as part of the comprehensive health assessment [20-21] or as an additional arm of the study in 7 of the 12 multifactorial investigations. All studies using vision assessment and correction also included other intervention strategies. Close and colleagues reported that 18 percent of subjects were referred to a vision specialist; however, no adherence or treatment information was presented [20]. Nor did Davison et al. report health practitioner referral rates or adherence data as a result of their vision assessment [21]. The most comprehensive adherence data were reported by Day and colleagues [24]. Ninety-six percent of subjects needing a referral to a vision specialist complied with the recommendations, which resulted in twenty-seven percent of the subjects requiring new glasses or other treatment. Other authors reported significant differences in visual acuity in the intervention group upon following study recommendations [17] and greater compliance in follow-up based on study recommendations [18].

Four of the seven studies that included vision assessment and correction demonstrated positive results [18,20-21,24]. Of the remaining three studies that found no effect, limitations in sample size were noted in two [17,28]. Lord and colleagues suggest that inadequate screening may have resulted in a sample with fall rates only slightly higher than the general population of similarly aged individuals, thus reducing the number of high-risk fallers who may have benefited from the program [17].

The effect of a home visit with education and/or home modifications as part of the multifactorial intervention was investigated in nine studies [18,20-25,27-28]. Participants in these studies received between one and five home visits within a year. Educational information regarding environmental hazards in and around the home was included in all programs. Additionally, all nine prevention programs included at least one other intervention strategy. Four of the programs demonstrated an improvement in fall outcomes in the treatment group [18,20-21,24], and five found no effect [22-23,25,27-28]. Only four of the studies reported some data relating to specific home modifications made as a result of study recommendations [18,23-24,27]. In six of the studies, clinicians actually made modifications in the home during the assessment [20-21,23-24,27-28].

An educational program was a frequent intervention arm used in a multifactorial approach. The educational program was delivered in a group setting [18,26], in individual sessions [17,20,22-23,27], or by brochure [23] and included information regarding fall-related risk factors, environmental hazards, medication management, coping with visual loss, and importance of visual screening and community safety. No measure of knowledge postintervention was reported in six of the eight studies [17-18,20,22,25,27]. Only Huang and Acton noted a significant difference in knowledge following an individualized educational session on fall-related risk factors compared with the comparison group who received a brochure [23]. One study also included additional information relating to healthy diet and exercise [22].

Five studies incorporated an exercise and/or balance training component in the multifactorial intervention program [17-19,24-25]. The programs varied in nature and incorporated flexibility activities, generalized strengthening exercises, balance and gait training, and a walking program. Three of the five studies offered group exercise programs ranging from 7 to 52 weeks and most encouraged a home exercise component. Of the five programs using exercise and/or balance training as an intervention, three demonstrated positive results [18-19,24]. Adherence to the program recommendations was documented in all programs and varied widely. Mahoney et al. reported poor adherence to follow-up referral for physical therapy [25]. A third of the subjects refused recommended physical therapy, stating concerns regarding travel, cost, and disbelief in its efficacy.

Comparisons between multifactorial programs are challenging as none of the programs utilized the same intervention strategies. Additionally, only two studies used a factorial design [19,24], making definitive support of the component intervention strategies impossible. The studies with strong factorial designs that were randomized and included a true control group had a positive effect on falls outcomes [19,24]. These studies included a combination of psychotropic medication withdrawal plus exercise and a combination of exercise, vision correction, and home hazard management. However, for Campbell et al.'s study, a high dropout rate and an inability to determine the resultant sample size may limit its generalizability [19].

Limitations in recording data (e.g., specific referrals, adherence to recommendations) and high attrition rates have been noted both in programs that demonstrated significant improvement in fall outcomes and in those with no effect. Three studies with no treatment effect may have been limited by the length of time until follow-up [22-23,28]. Additionally, sample size and power may have been the limiting factors in two studies with no effect [17,28].

EXERCISE AS SINGLE INTERVENTION APPROACH

Tinetti has suggested that some studies using a single or multifactorial intervention approach to falls prevention may have found no treatment effect because of design limitations [32]. That is, recruited subjects were at either too high or too low a risk for falls to benefit from the intervention and/or the treatment lacked sufficient intensity to effect changes in fall-related outcomes. Consequently, the trend in falls prevention research is to target those individuals who would most likely benefit from the intervention. In this review of prevention programs that use a separate exercise intervention arm, 5 of the 10 studies targeted individuals at high risk for falls [19,33-36]. Fall risk factors identified in previous epidemiologic studies and frequently used as inclusion criteria included muscle weakness, history of falls, gait deficits, balance deficits, use of an assistive device, visual deficits, arthritis, impaired activities of daily living (ADL), depression, cognitive impairment, use of psychotropic medication, and an age of 80 years or older [31,37].

Ten intervention studies that used some form of exercise as a separate intervention arm met the criteria for inclusion in this review (Table 3). Participants in these studies included community-dwelling ambulatory individuals over the age of 60, resulting in 2,443 participants. Recruitment methods varied and included individuals with identified fall risk factors from general practices [19,34-35], individuals with identified fall risk factors who previously received physical therapy [34], individuals with fall risk factors from a health maintenance organization [36], individuals selected via a voter registration database [24], individuals classified as "frail older adults" recently discharged from a hospital [38], individuals with identified fall risk factors from the Department of Veterans Affairs [33], individuals from a previous longitudinal study of elderly individuals [39], and individuals responding to flyers at an independent-living community for older adults [40].

For ease of analysis, we identified and grouped components of the exercise programs as follows: exercise to improve strength, exercise to improve balance, and exercise to improve endurance and/or aerobic capacity. All 10 studies included some type of identified strengthening program except the Atlanta Frailty and Injuries Cooperative Studies of Intervention Techniques (FICSIT) study [40]. Tai chi was chosen by this group as a balance training strategy. However, research has demonstrated significant strength gains with its use [41-42], thus tai chi may be considered both a balance and strengthening program.

Although some authors attempted to describe the exercise and balance programs, most of the descriptions lacked sufficient detail to enable replication of the exercise program. Of the 10 studies that used some form of exercise as a separate intervention strategy, half used a group-based exercise program and half had the subjects exercise at home. Four of the studies using a group-based exercise regime required the subjects to supplement the group program with an independent home exercise program. Six of the ten studies tailored the exercise program to meet the individual needs of each subject [19,35-36,38,40,43]; however, guidelines for progressing the subject were inadequate in all but two studies [36,38]. Both of these studies describe the use of one repetition maximum (1RM) (the maximum weight that can be lifted once while maintaining good form) [44] as a criterion for determining initial resistance for exercise. Latham et al. also used this guideline to progress the intensity of their subjects' quadriceps strengthening program [38]. The use of 1RM to guide exercise prescription and progression is well documented in physical therapy and exercise-related literature [45-46]. Table 4 illustrates the different components of each exercise regimen.

The exercise programs to improve strength were diverse in nature. Variations included targeted muscle groups (e.g., upper and lower limb, lower limb only, quadriceps only); use of resistance (cuff weights, rubber resistance bands, isokinetic machinery); and frequency, intensity, duration, and progression of exercise. The duration of the exercise programs varied from a minimum of 10 weeks to a maximum of 1 year.

Eight programs used a balance (re)training component; of these eight, four provided some general description. Three studies used some form of tai chi [34,39-40]. Other balance interventions mentioned were one-legged standing exercises, tandem walking, weight-shifting, positional changes during ADL, dancing, toe and heel walking, bending to pick up objects, walking over obstacles, turning, and stair climbing. The Atlanta FICSIT group also used a computerized balance training system.

An endurance or aerobic element was a component of the exercise program in six studies. Walking was the most frequently used approach (five studies). A stationary bicycle and treadmill walking were also used as training approaches. Duration of these aerobic activities was not well documented. Additionally, the use of target heart rates to determine an appropriate training level to induce true aerobic change was only reported in one study [36]. No mention was made of using ratings of perceived exertion as a rudimentary guideline for aerobic training and/ or progression [47]. Rubenstein and colleagues described some guidelines for use and progression on the stationary bicycle (e.g., 5 min at 30 W progression up to 15 min at 80 W); however, target heart rates were not reported [33]. Frequency of the aerobic activity varied between two [19,43] and three times a week [33,36,39]. These guidelines appear to loosely coincide with current literature that states improvement in aerobic capacity requires a minimum of 20 minutes of cardiovascular exercise [48], 3 to 5 days per week [45]. One study met once weekly and used a home exercise program to supplement the exercise regime; however, expectations for the frequency of the home program were not noted [34]. Compliance, a significant factor in any exercise program, was documented in some fashion in all 10 studies and varied from 42 to 91 percent of subjects still participating regularly in their exercise regimen at the completion of the study.

Limitations regarding specific description of exercise frequency, intensity, duration, and progression make study comparisons difficult. Nevertheless, 9 out of the 10 studies in this review demonstrated a positive effect of exercise on fall-related outcomes. Seven studies offered at least two out of three of the exercise components (strengthening, balance training, aerobic/endurance training). The study by Latham and colleagues was designed to address the effectiveness of strengthening only one muscle group (quadriceps) without any balance or conditioning component [38]. Latham et al. found no effect of a quadriceps muscle strengthening program on fall-related outcomes.

The Seattle FICSIT group used a single exercise strategy (strengthening only or endurance training only) and a combination strategy (strengthening and endurance training) in their design [36]. The aggregate data of all of the exercise groups (all three arms) were compared with the control group (no exercise). The results demonstrated a positive effect of exercise on fall-related outcomes. Separate exercise strategies (strength vs endurance training) were not analyzed.

Rubenstein's group [33] chose to look at falls sustained per hour of activity level based on previous evidence that suggests an increase in activity level for the very old can result in more falls because of an increased exposure to environmental hazards [49]. Rubenstein and colleagues found no significant difference in the absolute number of falls between the exercise and control groups following the intervention program; however, the fall rate based on activity level demonstrated a significant difference.

In summary, evidence suggests that a sustainable exercise program alone can decrease the number of falls and fall risk for a targeted group of older individuals. Programs that have been effective in this targeted population use at least two out of three exercise components: strengthening, balance training, and aerobic/endurance training. The strengthening program can involve a variety of devices (e.g., cuff weights, dumbbells, resistive bands, isokinetic machinery) and can be administered in a group session or individually at home. Multiple muscle groups need to be targeted in the lower limb during the strengthening program. Balance (re)training can use a variety of techniques. Tai chi appears to have both a strengthening effect in addition to producing changes in balance. Other effective balance training techniques include a combination of practicing weight shifting, sit-to-stand activities, tandem walking, one-legged standing, and toe and heel walking. In one study, a computerized balance training program was not effective in reducing fall-related outcomes. The aerobic or conditioning program can be as simple as community walking three times a week for 30 minutes or can employ treadmill walking or bicycle ergometry. The minimum duration of an effective fall prevention comprehensive exercise program appears to be 12 weeks.

HOME HAZARD ASSESSMENT WITH MODIFICATIONS AS SINGLE INTERVENTION APPROACH

Studies using home hazard assessment with modifications as a separate intervention arm were identified using the aforementioned criteria. Abstracts were independently assessed, resulting in four RCTs (Table 5). Participants in these four studies included community-dwelling ambulatory individuals over the age of 60, resulting in 2,687 participants. Subject recruitment varied and included individuals from recent hospital inpatients [50-52], outpatient clinics and day hospitals [50], and a voter database crossed with a telephone directory [53]. Of these four studies, only one study specifically recruited subjects at high risk for falls (history of previous falls) [52].

All home hazard assessments were conducted in the subject's home by a combination of one or more of the following: physical therapist (PT), occupational therapist (OT), nurse, physiatrist, or ergotherapist. Nikolaus and Bach also used a comprehensive geriatric assessment in addition to the home hazard assessment as part of the screening [51]. An educational component specific to falls prevention in the home was incorporated in all studies. Topics included removing, modifying, or living with current environmental hazards; safe footwear; and the use of technical and mobility aids. The length of follow-up after the home assessment for all four studies was 1 year.

The study team carried out modifications in the home, based on the assessment with additional modifications made by the subjects and their families. Simple modifications included moving furniture, removing loose carpets, moving electrical cords, using nonskid bath mats, and adding night-lights. More extensive modifications included installing grab bars, repairing damaged floors, and adding step rails. Adherence to recommendations was documented in three studies [50-51,53]. Adherence to recommendations 1 year following the home assessment ranged from 19 to 82 percent. Study descriptions are found in Table 6.

Two of the four studies demonstrated a significant improvement in falls outcomes using a home assessment with modifications [50-51]. However, in both of these studies, a reduction in falls was specific to a subgroup of individuals at high risk for falling: individuals with a previous fall history. This finding is consistent with previous studies [32,54-55] that suggest that a targeted high-risk group is more likely to benefit from a falls prevention program. In contrast, Stevens et al. also looked at a subgroup of frequent fallers and found no difference in the fall rate of frequent fallers compared with the whole group following the intervention [53]. These study results may in part depend on the clinician performing the home assessment. Cumming and colleagues address this issue in their findings [50].

Cumming et al. found a significant difference in the number of falls in the home following a home assessment with hazard modifications; however, they also noted that falls were decreased away from home [50]. They concluded the reduction in falls in the intervention group could not be attributed to the home hazard modifications alone. Instead, they suggested the reduction in falls might also depend on the individual conducting the assessment, in this case the OT. They concluded the OT may have addressed the subject's general functional limitations by providing specific strategies that resulted in an overall improvement in safety regardless of the environment, hence the improvement in number of falls away from home. This may also be the case in the study by Nikolaus and Bach [51]. A two-member team, a nurse or a PT with an OT, performed the home assessment. Both the OT and PT are trained to evaluate home hazards, suggest modifications, and suggest strategies to address the subjects' functional limitations. Cumming et al. suggest the success of the home hazard assessment may in part depend on the individual doing the assessing.

The research conducted by Pardessus and colleagues failed to find an effect on fall-related outcomes [52]. Whether an OT participated in the home hazard assessment in this study is unclear; however, an OT was available to offer advice on how to address hazards in the home. Although these authors found no detectable improvement in fall outcomes, the subjects' level of functional autonomy did improve. However, improving an older person's activity level has been associated with an increase in fall risk as they spend less time sitting [29,56-57]. This may explain some of the study findings. Additionally, the population was small (n = 60), which limits the study's power.

Previous review studies found inconclusive evidence that home hazard assessment with modifications produced a reduction in falls or fall-related injuries in elderly individuals [11,13]. Limitations in study designs were cited; the majority of the studies reviewed used a multifactorial intervention approach without the use of a factorial design. Thus, analysis of the individual intervention effect was not possible. In this current review, only studies using home hazard assessment with modification as a separate intervention arm were analyzed. Some benefits were noted in a targeted group of older individuals with a fall history. Additional benefits may be gained if an OT or a PT performs the assessment.

SUMMARY OF FINDINGS

Two rigorous reviews of multifactorial prevention trials concluded community-based multidisciplinary health and risk assessment programs with targeted treatment strategies were effective in reducing the number of falls sustained by community-dwelling older adults [13-14]. These authors also stated that multifactorial programs were effective for both an unselected population of older people and a population of older people with a history of falls or known fall-risk factors. These findings appear to differ from the current review, which found less than half of the programs that offered multifactorial health and risk assessment in conjunction with various targeted treatment strategies were successful. One possible reason for the disparity is the addition of new studies to the current review [18,21,25,28]. Of the additional studies reviewed, only two demonstrated a significant reduction in fall-related outcomes [18,21]. Moreover, these subjects were targeted individuals with a history of falls. In the two studies with no effect on falls outcomes [25,28], subjects were drawn from a nontargeted population of elderly individuals. Of the remaining multifactorial programs in this review, three demonstrated a positive effect on falls outcomes. Two of these studies had particularly strong factorial designs that resulted in positive findings related to interventions such as psychotropic medication withdrawal alone [19]; exercise alone [19,24]; medication withdrawal and exercise [19]; exercise and vision correction; exercise and home hazard management; and exercise, vision correction, and home hazard management [24]. Hence, multifactorial falls prevention programs that offer no comprehensive health and risk assessment should at least include a review of medications and vision assessment with appropriate health practitioner referral, in addition to an exercise program and home hazard assessment.

An additional factor to consider when comparing the outcomes of fall prevention programs is the method used to document the fall itself. It has been reported that older individuals do not recall falls that occurred during specific time periods and that more frequent reporting of falls (daily if feasible) is optimal [58]. Although most of the studies in the current review used daily self-report calendars, which have excellent compliance rates [59], accuracy (underreporting or overreporting falls) remains difficult to ascertain [24,58]. Hence, some of the variation in outcomes between individual studies and comprehensive reviews may be due to variations and inaccuracies in fall data collection. Tables 7-9 describe the data collection methods for studies included in this review. Studies were grouped based on their design: multifactorial programs, exercise as a separate intervention arm, and home hazard assessment as a separate intervention.

The effectiveness of exercise alone as a falls prevention intervention is clearly supported in this review and previous meta-analyses [12-14,60]. The current review suggests additional guidelines and parameters to use while designing the exercise program in order to ensure maximum benefits. The most effective programs incorporate at least two different types of exercise (strengthening, balance training, endurance training); are group based or individually administered; and are conducted at least three times per week for 30 minutes, for a minimum of 12 weeks.

Home hazard assessment and modification as a separate intervention arm may be beneficial in a targeted group of elderly adults at high risk for falls. The expertise of an OT or PT during the home hazard assessment may provide additional benefits.

KEY POINTS

* Multifactorial falls prevention programs appear to be more effective for individuals with a previous history of falls.

* Medication and vision assessment with appropriate health practitioner referral should be included as part of a falls screening examination.

* Exercise alone is effective in reducing the number of falls. It should include a comprehensive program combining strengthening, balance, and/or endurance training for a minimum of 12 weeks.

* Home hazard assessment with modifications may be beneficial in reducing falls, especially in a targeted group of individuals. Additional benefits may be obtained if an OT or a PT conducts the assessment.

ACKNOWLEDGMENTS

This material was unfunded at the time of manuscript preparation.

The authors have declared that no competing interests exist.

Submitted for publication October 18, 2007. Accepted in revised form August 4, 2008.

REFERENCES

[1.] Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: A 1-year prospective study. Arch Phys Med Rehabil. 2001;82(8):1050-56. [PMID: 11494184]

[2.] Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18(2):141-58. [PMID: 12180240]

[3.] Teno J, Kiel DP, Mor V. Multiple stumbles: A risk factor for falls in community-dwelling elderly. A prospective study. J Am Geriatr Soc. 1990;38(12):1321-25. [PMID: 2254571]

[4.] Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7. [PMID: 3205267]

[5.] WISQARS [homepage on the Internet]. Atlanta (GA): Centers for Disease Control and Prevention; c2008 [updated 2008 Oct 27; cited 2007 Oct 1]. Available from: http:// www.cdc.gov/ncipc/wisqars

[6.] Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health. 1992;82(7):1020-23. [PMID: 1609903]

[7.] Lu-Yao GL, Baron JA, Barrett JA, Fisher ES. Treatment and survival among elderly Americans with hip fractures: A population-based study. Am J Public Health. 1994;84(8): 1287-91. [PMID: 8059887]

[8.] Dunn JE, Furner SE, Miles TP. Do falls predict institutionalization in older persons? An analysis of data from the Longitudinal Study of Aging. J Aging Health. 1993;5(2): 194-207. [PMID: 10125444]

[9.] Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290-95. [PMID: 17018668]

[10.] Schneider EL, Guralnik JM. The aging of America. Impact on health care costs. JAMA. 1990;263(17):2335-40. [PMID: 2109105]

[11.] Lyons RA, John A, Brophy S, Jones SJ, Johansen A, Kemp A, Lannon S, Patterson J, Rolfe B, Sander LV, Weightman A. Modification of the home environment for the reduction of injuries. Cochrane Database Syst Rev. 2006;(4):CD003600. [PMID: 17054179]

[12.] Gardner MM, Robertson MC, Campbell AJ. Exercise in preventing falls and fall related injuries in older people: A review of randomised controlled trials. Br J Sports Med. 2000;34(1):7-17. [PMID: 10690444]

[13.] Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. BMJ. 2004;328(7441):680-87. [PMID: 15031239]

[14.] Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4): CD000340. [PMID: 14583918]

[15.] Buchner DM, Hornbrook MC, Kutner NG, Tinetti ME, Ory MG, Mulrow CD, Schechtman KB, Gerety MB, Fiatarone MA, Wolf SL, et al. Development of the common data base for the FICSIT trials. J Am Geriatr Soc. 1993;41(3): 297-308. [PMID: 8440854]

[16.] Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine-How to practice and teach EBM. 2nd ed. New York (NY): Churchill Livingstone; 2000.

[17.] Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM, Gerontology M, Ther GR, Sherrington C. The effect of an individualized fall prevention program on fall risk and falls in older people: A randomized, controlled trial. J Am Geriatr Soc. 2005;53(8):1296-1304. [PMID: 16078954]

[18.] Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. J Am Geriatr Soc. 2004;52(9):1487-94. [PMID: 15341550]

[19.] Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: A randomized, controlled trial. J Am Geriatr Soc. 1999;47(7):850-53. [PMID: 10404930]

[20.] Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): A randomised controlled trial. Lancet. 1999;353(9147):93-97. [PMID: 10023893]

[21.] Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention--A randomised controlled trial. Age Ageing. 2005;34(2):162-68. [PMID: 15716246]

[22.] Kingston P, Jones M, Lally F, Crome P. Older people and falls:

A randomized controlled trial of a health visitor (HV) intervention. Rev Clin Gerontol. 2001;11(3):209-14.

[23.] Huang TT, Acton GJ. Effectiveness of home visit falls prevention strategy for Taiwanese community-dwelling elders: Randomized trial. Public Health Nurs. 2004;21(3): 247-56. [PMID: 15144369]

[24.] Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ. 2002;325(7356): 128. [PMID: 12130606]

[25.] Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S, Schwalbe A. Kenosha County falls prevention study: A randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention. J Am Geriatr Soc. 2007;55(4):489-98. [PMID: 17397425]

[26.] Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care clinics: A randomized controlled trial of a new model of primary care for frail older adults. J Am Geriatr Soc. 1999;47(7):775-83. [PMID: 10404919]

[27.] van Haastregt JC, Diederiks JP, Van Rossum E, De Witte LP, Voorhoeve PM, Crebolder HF. Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: Randomised controlled trial. BMJ. 2000;321(7267):994-98. [PMID: 11039967]

[28.] Lightbody E, Watkins C, Leathley M, Sharma A, Lye M. Evaluation of a nurse-led falls prevention programme versus usual care: A randomized controlled trial. Age Ageing. 2002;31(3):203-10. [PMID: 12006310]

[29.] Speechley M, Tinetti M. Falls and injuries in frail and vigorous community elderly persons. J Am Geriatr Soc. 1991; 39(1):46-52. [PMID: 1987256]

[30.] O'Loughlin J, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137(3): 342-54. [PMID: 8452142]

[31.] Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47(1):30-39. [PMID: 9920227]

[32.] Tinetti ME. Prevention of falls and fall injuries in elderly persons: A research agenda. Prev Med. 1994;23(5):756-62. [PMID: 7845954]

[33.] Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO, Pietruszka FM, Robbins AS. Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men. J Gerontol A Biol Sci Med Sci. 2000; 55(6):M317-21. [PMID: 10843351]

[34.] Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: A randomised controlled trial. Age Ageing. 2003;32(4):407-14. [PMID: 12851185]

[35.] Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ. 1997;315(7115):1065-69. [PMID: 9366737]

[36.] Buchner DM, Cress ME, De Lateur BJ, Esselman PC, Margherita AJ, Price R, Wagner EH. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci. 1997;52(4):M218-24. [PMID: 9224433]

[37.] Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001;49(5):664-72. [PMID: 11380764]

[38.] Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID; Fitness Collaborative Group. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: The Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc. 2003;51(3):291-99. [PMID: 12588571]

[39.] Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled trial of exercise intervention for the prevention of falls in community-dwelling elderly Japanese women. J Bone Miner Metab. 2004;22(6):602-11. [PMID: 15490272]

[40.] Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and injuries: Cooperative studies of intervention techniques. J Am Geriatr Soc. 1996; 44(5):489-97. [PMID: 8617895]

[41.] Choi JH, Moon JS, Song R. Effects of Sun-style Tai Chi exercise on physical fitness and fall prevention in fall-prone older adults. J Adv Nurs. 2005;51(2):150-57. [PMID: 15963186]

[42.] Tsang WW, Hui-Chan CW. Comparison of muscle torque, balance, and confidence in older tai chi and healthy adults. Med Sci Sports Exerc. 2005;37(2):280-89. [PMID: 15692325]

[43.] Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. BMJ. 2001;322(7288):697-701. [PMID: 11264206]

[44.] McArdle WD, Katch FI, Katch VL. Exercise physiology: Energy, nutrition, and human performance. 5th ed. Philadelphia (PA): Lippincott, Williams & Wilkins; 2001.

[45.] American College of Sports Medicine (ACSM). ACSM's guidelines for exercise testing and prescription. 7th ed. Philadelphia (PA): Lippincott, Williams & Wilkins; 2006.

[46.] Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. 5th ed. Philadelphia (PA): F. A. Davis; 2007.

[47.] Borg G. Psychological basis of physical exertion. Med Sci Sports Exerc. 1982;14(5):377-81.

[48.] American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc. 1998;30(6):975-91. [PMID: 9624661]

[49.] Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442-51. [PMID: 8053619]

[50.] Cumming RG, Thomas M, Szonyi G, Salkeld G, O'Neill E, Westbury C, Frampton G. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. J Am Geriatr Soc. 1999;47(12):1397-1402. [PMID: 10591231]

[51.] Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): Results from the randomized falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305. [PMID: 12588572]

[52.] Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A, Dewailly P. Benefits of home visits for falls and autonomy in the elderly: A randomized trial study. Am J Phys Med Rehabil. 2002;81(4):247-52. [PMID: 11953541]

[53.] Stevens M, Holman CD, Bennet N. Preventing falls in older people: Impact of an intervention to reduce environmental hazards in the home. J Am Geriatr Soc. 2001; 49(11): 1442-47. [PMID: 11890581]

[54.] Tinetti M, McAvay G, Claus E. Does multiple risk factor reduction explain the reduction in fall rate in the Yale FIC-SIT trial? Frailty and injuries: Cooperative studies of intervention techniques. Am J Epidemiol. 1996;144(4):389-99. [PMID: 8712196]

[55.] Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: A metaanalysis of individual-level data. J Am Geriatr Soc. 2002; 50(5):905-11. [PMID: 12028179]

[56.] Studenski S, Duncan PW, Chandler J, Samsa G, Prescott B, Hogue C, Bearon LB. Predicting falls: The role of mobility and nonphysical factors. J Am Geriatr Soc. 1994;42(3): 297-302. [PMID: 8120315]

[57.] Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26(3):189-93. [PMID: 9223714]

[58.] Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988;36(7):613-16. [PMID: 3385114]

[59.] Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA. 1989;261(18):2663-68. [PMID: 2709546]

[60.] Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and injuries: Cooperative studies of intervention techniques. JAMA. 1995;273(17):1341-47. [PMID: 7715058]

Ellen Costello, PT, PhD; (1) * Joan E. Edelstein, MA, PT, FISPO, CPed (2)

(1) Program in Physical Therapy, The George Washington University, Washington, DC; (2) Program in Physical Therapy, College of Physicians and Surgeons, Columbia University, New York, NY

Abbreviations: 1RM = one repetition maximum, ADL = activities of daily living, FICSIT = Frailty and Injuries Cooperative Studies of Intervention Techniques (study), OT = occupational therapist, PT = physical therapist, RCT = randomized controlled trial.

* Address all correspondence to Ellen Costello, PT, PhD; Program in Physical Therapy, The George Washington University, 900 23rd St, NW, Washington, DC 20037; 202994-0056; fax: 202-994-8400. Email: hspexc@gwumc.edu DOI: 10.1682/JRRD.2007.10.0169

Table 1.
Studies included in analysis of multifactorial falls prevention
programs.

 Population
 Losses
 Study Study Type Age (yr) Sample Size (%)

Campbell et al., RCT, double >65 N = 93 23
1999 [1] blind,
 factorial
 design

Clemson et al., RCT, block >70 N = 310 8
2004 [2] design

Close et al., RCT >65 N = 397 23
1999 [3]

Coleman et al., RCT, cluster >65 N = 169 33
1999 [4] design

Davison et al., RCT >65 N = 313 10
2005 [5]

Day et al., RCT, factorial >70 N = 1,107 1.5 (442
2002 [6] design subjects
 chosen for
 posttest)

Huang & Acton, Randomized, >65 N = 120 6
2004 [7] no true
 control

Kingston et al., RCT >65 * N = 109 16
2001 [8]

Lightbody RCT >65 N = 368 10
et al., 2002
[9]

Lord et al., RCT, 3-group >75 N = 620 6.7
2005 [10] design

Mahoney et al., RCT >65 N = 349 19
2007 [11]

van Haastregt RCT >70 N = 316 26
et al., 2000
[12]

 Resultant Measured
 Study Sample Size Outcome

Campbell et al., Unable to No. falls
1999 [1] determine in 11 mo

Clemson et al., n exp = 147, No. falls in
2004 [2] n control = 138 12 mo

Close et al., n exp = 141, No. falls
1999 [3] n control = 163 in 12 mo;
 No. fallers
 in 12 mo

Coleman et al., n exp = 62, % fallers
1999 [4] n control = 51 in 12 mo;
 % fallers
 in 24 mo

Davison et al., n exp = 141, No. falls
2005 [5] n control = 141 in 12 mo;
 No. fallers
 in 12 mo

Day et al., n exp = 395, % subjects
2002 [6] n control = 47 with = 1 fall
 in 18 mo

Huang & Acton, n exp = 55, No. falls
2004 [7] n comparison = in 2 mo
 58

Kingston et al., n exp = 51, % fallers
2001 [8] n control = 41 in 3 mo

Lightbody n exp = 155, No. falls
et al., 2002 n control = 159 in 6 mo;
[9] No. fallers
 in 6 mo

Lord et al., n all exp = 381, No. falls
2005 [10] n control = 197 in 12 mo

Mahoney et al., n exp = 139, Falls rate
2007 [11] n control = 143 in 12 mo

van Haastregt n exp = 120, No. subjects
et al., 2000 n control = 115 with = 1 fall
[12] in 12 mo

 Control Outcome Exp Outcome

 No. No. No. No.
 Study Falls Fallers Falls Fallers

Campbell et al., 29 -- 15, 17, 18 --
1999 [1]

Clemson et al., 255 -- 179 --
2004 [2]

Close et al., 510 111 183 59
1999 [3]

Coleman et al., -- 37.9%; -- 43.5%;
1999 [4] 35.60% 43.50%

Davison et al., 617 102 387 94
2005 [5]

Day et al., -- 63.50% -- 54.50%
2002 [6] (mean for
 all groups)

Huang & Acton, 4 -- 0 --
2004 [7]

Kingston et al., -- 2% -- 2%
2001 [8]

Lightbody 145 39 89 35
et al., 2002
[9]

Lord et al., 175 -- Exp 1 = --
2005 [10] 183,
 Exp 2 =
 152

Mahoney et al., 2.31/yr -- 1.88/yr --
2007 [11]

van Haastregt -- 57 -- 60
et al., 2000
[12]

 Direction
 Study of Effect

Campbell et al., +Medication withdrawal,
1999 [1] +exercise, +medication
 withdrawal & exercise

Clemson et al., +
2004 [2]

Close et al., +
1999 [3]

Coleman et al., No effect
1999 [4]

Davison et al., +
2005 [5]

Day et al., +Exercise; +exercise &
2002 [6] vision correction;
 +exercise & home
 hazard management;
 +exercise, vision
 correction, & home
 hazard management

Huang & Acton, No effect
2004 [7]

Kingston et al., No effect
2001 [8]

Lightbody No effect
et al., 2002
[9]

Lord et al., No effect
2005 [10]

Mahoney et al., No effect
2007 [11]

van Haastregt No effect
et al., 2000
[12]

* Females only.

(1.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(2.) Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The
effectiveness of a community-based program for reducing the incidence
of falls in the elderly: A randomized trial. J Am Geriatr Soc.
2004;52(9):1487-94. [PMID: 15341550]

(3.) Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C.
Prevention of falls in the elderly trial (PROFET): A randomised
controlled trial. Lancet. 1999;353(9147):93-97. [PMID: 10023893]

(4.) Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care
clinics: A randomized controlled trial of new model of primary care
for frail older adults. J Am Geriatr Soc. 1999;47(7):775-83. [PMID:
10404919]

(5.) Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with
recurrent falls attending Accident & Emergency benefit from
multifactorial intervention--A randomised controlled trial. Age
Ageing. 2005;34(2):162-68. [PMID: 15716246]

(6.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(7.) Huang TT, Acton GJ. Effectiveness of home visit falls prevention
strategy for Taiwanese community-dwelling elders: Randomized trial.
Public Health Nurs. 2004;21(3):247-56. [PMID: 15144369]

(8.) Kingston P, Jones M, Lally F, Crome P. Older people and falls: A
randomized controlled trial of a health visitor (HV) intervention. Rev
Clin Gerontol. 2001;11(3):209-14.

(9.) Lightbody E, Watkins C, Leathley M, Sharma A, Lye M. Evaluation
of a nurse-led falls prevention programme versus usual care: A
randomized controlled trial. Age Ageing. 2002;31(3):203-10. [PMID:
12006310]

(10.) Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM, Gerontology
M, Ther GR, Sherrington C. The effect of an individualized fall
prevention program on fall risk and falls in older people: A
randomized, controlled trial. J Am Geriatr Soc. 2005;53(8):1296-1304.
[PMID: 16078954]

(11.) Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S,
Schwalbe A. Kenosha County falls prevention study: A randomized,
controlled trial of an intermediate-intensity, community-based
multifactorial falls intervention. J Am Geriatr Soc.
2007;55(4):489-98. [PMID: 17397425]

(12.) van Haastregt JC, Diederiks JP, Van Rossum E, De Witte LP,
Voorhoeve PM, Crebolder HF. Effects of a programme of multifactorial
home visits on falls and mobility impairments in elderly people at
risk: Randomised controlled trial. BMJ. 2000;321(7267):994-98. [PMID:
11039967]

Exp = experiment(al), RCT = randomized controlled trial.

Table 2.
Interventions used in multifactorial prevention programs.

 Medication
 Ass.
 w/Education
 Health & (Incl. Vision Ass.
 Risk Factor Medication (Incl.
 Ass. w/ Modification Correction
 Study Referral [X]) [X])

Campbell et al., 1999 [1] -- -- --
Clemson et al., 2004 [2] X X X
Close et al., 1999 [3] X [X] X
Coleman et al., 1999 [4] X X --
Davison et al., 2005 [5] X X X
Day et al., 2002 [6] -- -- [X]
Huang & Acton, 2004 [7] -- -- --
Kingston et al., 2001 [8] -- X --
Lightbody et al., 2002 [9] X X X
Lord et al., 2005 [10] -- -- X
Mahoney et al., 2007 [11] X X X
van Haastregt et al.,
 2000 [12] -- X --

 Home Visit:
 Environmental
 Ass. w/ Education
 Education Regarding Fall
 (Incl. Risk Factors
 Home (Incl. Diet &
 Study Modifications Exercise [X])

 [X])
Campbell et al., 1999 [1] -- --
Clemson et al., 2004 [2] X X
Close et al., 1999 [3] [X] X
Coleman et al., 1999 [4] -- [X]
Davison et al., 2005 [5] [X] --
Day et al., 2002 [6] [X] --
Huang & Acton, 2004 [7] [X] X
Kingston et al., 2001 [8] X [X]
Lightbody et al., 2002 [9] [X] X
Lord et al., 2005 [10] -- X
Mahoney et al., 2007 [11] X --
van Haastregt et al.,
 2000 [12] [X] X

 Medication
 Exercise & Withdrawal
 Balance (Psychotropic
 Study Training Only)

Campbell et al., 1999 [1] X X
Clemson et al., 2004 [2] X --
Close et al., 1999 [3] -- --
Coleman et al., 1999 [4] -- --
Davison et al., 2005 [5] -- --
Day et al., 2002 [6] X --
Huang & Acton, 2004 [7] -- --
Kingston et al., 2001 [8] -- --
Lightbody et al., 2002 [9] -- --
Lord et al., 2005 [10] X --
Mahoney et al., 2007 [11] X --
van Haastregt et al.,
 2000 [12] -- --

(1.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(2.) Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The
effectiveness of a community-based program for reducing the incidence
of falls in the elderly: A randomized trial. J Am Geriatr Soc.
2004;52(9):1487-94. [PMID: 15341550]

(3.) Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C.
Prevention of falls in the elderly trial (PROFET): A randomised
controlled trial. Lancet. 1999;353(9147):93-97. [PMID: 10023893]

(4.) Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care
clinics: A randomized controlled trial of a new model of primary care
for frail older adults. J Am Geriatr Soc. 1999;47(7):775-83. [PMID:
10404919]

(5.) Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with
recurrent falls attending Accident & Emergency benefit from
multifactorial intervention--A randomised controlled trial. Age
Ageing. 2005;34(2):162-68. [PMID: 15716246]

(6.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(7.) Huang TT, Acton GJ. Effectiveness of home visit falls prevention
strategy for Taiwanese community-dwelling elders: Randomized trial.
Public Health Nurs. 2004;21(3):247-56. [PMID: 15144369]

(8.) Kingston P, Jones M, Lally F, Crome P. Older people and falls: A
randomized controlled trial of a health visitor (HV) intervention. Rev
Clin Gerontol. 2001;11(3):209-14.

(9.) Lightbody E, Watkins C, Leathley M, Sharma A, Lye M. Evaluation
of a nurse-led falls prevention programme versus usual care: A
randomized controlled trial. Age Ageing. 2002;31(3):203-10. [PMID:
12006310]

(10.) Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM, Gerontology
M, Ther GR, Sherrington C. The effect of an individualized fall
prevention program on fall risk and falls in older people: A
randomized, controlled trial. J Am Geriatr Soc. 2005;53(8):1296-1304.
[PMID: 16078954]

(11.) Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S,
Schwalbe A. Kenosha County falls prevention study: A randomized,
controlled trial of an intermediate-intensity, community-based
multifactorial falls intervention. J Am Geriatr Soc.
2007;55(4):489-98. [PMID: 17397425]

(12.) van Haastregt JC, Diederiks JP, Van Rossum E, De Witte LP,
Voorhoeve PM, Crebolder HF. Effects of a programme of multifactorial
home visits on falls and mobility impairments in elderly people at
risk: Randomised controlled trial. BMJ. 2000;321(7267):994-98. [PMID:
11039967]

Ass. = assessment, Incl. = including, w/ = with.

Table 3.
Studies using exercise as separate intervention arm.

 Study Sample Losses
Study Type Age (yr) Size (%)

Barnett et RCT, >65 N = 163 8
al., 2003 [1] matched
 block
 design

Buchner et RCT, 4 Between N = 105 14
al., 1997 [2] groups 68-85

Campbell et RCT >80* N = 233 9
al., 1997 [3]

Campbell et RCT, >65 N = 93 23
al., 1999 [4] double
 blind,
 factorial
 design

Day et al., RCT, full >70 N = 1,107 1.5 (only
2002 [5] factorial 442
 design subjects
 chosen for
 posttest)

Latham et RCT, >65 N = 243 17
al., 2003 [6] stratified
 block 2 x
 2 factorial
 design

Robertson et RCT >75* N = 240 12
al., 2001 [7]

Rubenstein RCT, >70 ([dagger]) N = 59 7
et al., 2000 block
[8] design

Suzuki et RCT >73 ([dagger]) N = 52 15
al., 2004 [9]

Wolf et al., RCT >70 N = 200 20
1996 [10]

 Resultant Measured
Study Sample Size Outcome

Barnett et n exp = 76, No. fallers
al., 2003 [1] n control = 74 in 12 mo

Buchner et n endurance = % fallers
al., 1997 [2] 19, n strength = in 12 mo
 20, n endurance
 & strength = 22,
 n control = 29

Campbell et n exp = 103, No. falls
al., 1997 [3] in 12 mo

Campbell et Unable to No. falls
al., 1999 [4] determine in 11 mo

Day et al., n all exp = 395, % subjects
2002 [5] n control = 47 with [greater
 than or equal
 to] 1 fall
 in 18 mo

Latham et n exercise = 112, No. fallers
al., 2003 [6] n Vit D = 108, in 6 mo
 n placebo = 114,
 n control = 110

Robertson et n exp = 113, No. falls
al., 2001 [7] n control = 98 in 12 mo

Rubenstein n exp = 28, No. falls
et al., 2000 n control = 27 in 3 mo,
[8] fallrate/100h
 of activity

Suzuki et n exp = 22, No. falls
al., 2004 [9] n control = 22 in 20 mo;
 No. fallers
 in 8 and
 20 mo

Wolf et al., n tai chi = 61, n No. falls
1996 [10] CBT = 53, in 7 mo
 n control = 54

 Control Outcome

Study No. No. Fall
 Falls Fallers Rate
Barnett et
al., 2003 [1] -- 37 --

Buchner et
al., 1997 [2] -- 60% --

Campbell et
al., 1997 [3] 152 -- --

Campbell et
al., 1999 [4] 29 -- --

Day et al.,
2002 [5] -- 63.5% --

Latham et
al., 2003 [6] -- Placebo = --
 60,
 Social
 control =
 64
Robertson et
al., 2001 [7] 109 -- --

Rubenstein
et al., 2000 14 -- 16.2
[8]

Suzuki et
al., 2004 [9] 17 8 mo = 9, --
 20 mo =
 12

Wolf et al.,
1996 [10] 77 -- --

 Exp Outcome

Study No. No. Fall Direction
 Falls Fallers Rate of Effect
Barnett et
al., 2003 [1] -- 27 -- +

Buchner et
al., 1997 [2] -- 42% for all -- +
 3 exercise
 groups
 combined

Campbell et
al., 1997 [3] 88 -- -- +

Campbell et
al., 1999 [4] 15, 7, 18 -- -- +Medication
 exercise
Day et al.,
2002 [5] -- 54.5% (mean -- +Exercise,
 for all groups) +exercise &

Latham et
al., 2003 [6] -- Exercise = 60, -- No effect
 Vitamin D =
 80

Robertson et
al., 2001 [7] 80 -- -- +

Rubenstein
et al., 2000 13 -- 6.0 +For fall rate
[8]

Suzuki et
al., 2004 [9] 6 8 mo = 3, -- +For No.
 20 mo = 3 fallers in

Wolf et al.,
1996 [10] 56, 76 -- -- +For tai chi

* Females only.

([dagger]) Males only.

(1.) Barnett A, Smith B, Lord SR, Williams M, Baumand A.
Community-based group exercise improves balance and reduces falls in
at-risk older people: A randomised controlled trial. Age Ageing.
2003;32(4):407-14. [PMID: 12851185]

(2.) Buchner DM, Cress ME, De Lateur BJ, Esselman PC, Margherita AJ,
Price R, Wagner EH. The effect of strength and endurance training on
gait, balance, fall risk, and health services use in community-living
older adults. J Gerontol A Biol Sci Med Sci. 1997;52(4):M218-24.
[PMID: 9224433]

(3.) Campbell AJ, Robertson MC, Gardner MM,
Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a
general practice programme of home based exercise to prevent falls in
elderly women. BMJ. 1997;315(7115):1065-69. [PMID: 9366737]

(4.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(5.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(6.) Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID;
Fitness Collaborative Group. A randomized, controlled trial of
quadriceps resistance exercise and vitamin D in frail older people:
The Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am
Geriatr Soc. 2003;51(3):291-99. [PMID: 12588571]

(7.) Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness
and economic evaluation of a nurse delivered home exercise programme
to prevent falls. 1: Randomised controlled trial. BMJ.
2001;322(7388):697-701. [PMID: 11264206]

(8.) Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO,
Pietruszka FM, Robbins AS. Effects of a group exercise program on
strength, mobility, and falls among fall-prone elderly men. J Gerontol
A Biol Sci Med Sci. 2000;55(6):M317-21. [PMID: 10843351] Studies using
exercise as separate intervention arm.

(9.) Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled
trial of exercise intervention for the prevention of falls in
community-dwelling elderly Japanese women. J Bone Miner Metab.
2004;22(6):602-11. [PMID: 15490272]

(10.) Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T.
Reducing frailty and falls in older persons: An investigation of Tai
Chi and computerized balance training. Atlanta FICSIT Group. Frailty
and injuries: Cooperative studies of intervention techniques. J Am
Geriatr Soc. 1996;44(5):489-97. [PMID: 8617895

CBT = computerized balance training, exp = experiment(al), RCT =
randomized controlled trial.

Table 4.
Components of each exercise program.

 Individually
 Study Tailored Personnel Setting

Barnett et al., No Designed by PT, Group based
2003 [1] administered by with HEP
 exercise
 instructor

Buchner et al., Yes Unclear who Home based
1997 [2] designed &
 administered

Campbell et al., Yes Designed & Home based
1997 [3] administered by
 PT

Campbell et al., Yes Designed & Home based
1999 [4] administered by
 PT

Day et al., No Designed by PT, Group based
2002 [5] unclear who with HEP
 administered

Latham et al., Yes Designed and Exercise started
2003 [6] administered by as inpatient &
 PT continued in
 home with PT

Robertson et al., Yes Designed & Home based
2001 [7] administered by
 RN

Rubenstein et al., No Administered by Group based
2000 [8] exercise
 physiology
 graduate
 students

Suzuki et al., No Not reported Group based
2004 [9] with HEP

Wolf et al., 1996 Yes Credentials not Group based and
[10] reported HEP (tai chi),
 individual
 sessions at
 facility (CBT)

 Strengthening Aerobic/Endurance
 Study Program Training

Barnett et al., UL + LL using Walking & fast
2003 [1] resistance bands walking

Buchner et al., Cybex isokinetic Stationary bicycle
1997 [2] resistance for UL for UL & LL at
 & LL 75% heart rate
 reserve (30-35 min/
 session)

Campbell et al., Moderate intensity Walking 3 x/wk
1997 [3] with weights for LL

Campbell et al., Not detailed; no. Walking
1999 [4] of exercise reps &
 no. of ankle weights
 increased with
 subsequent visits

Day et al., LL strengthening None offered
2002 [5] not detailed

Latham et al., Resistance exercise No
2003 [6] using ankle cuff
 weights; 60%-80%
 1RM quadriceps
 only

Robertson et al., Graduated cuff Walking 2x/wk
2001 [7] weights

Rubenstein et al., LL strengthening Bicycle (5 min at
2000 [8] with weights 30 W progress to
 15 min at 80 W),
 treadmill & indoor
 walking (5 min
 progress to 15 min)

Suzuki et al., LL AROM with No
2004 [9] light weights &
 resistance bands

Wolf et al., 1996 No No
[10]

 Study Balance Training Time Frame

Barnett et al., Modified tai chi & 1 h/wk for 12 mo
2003 [1] functional activities (maximum of 37
 (sit to stand, weight classes)
 shift with reaching,
 dance steps,
 throwing ball)

Buchner et al., None offered 1 h/3 x wk for
1997 [2] 24-26 wk

Campbell et al., Toe & heel walking, PT visit 4 x in first
1997 [3] walking backwards, 2 mo; HEP 30 min
 sideways & turning, exercise 3 x/wk +
 stepping over walk outside home
 objects, bending & 3 x/wk for 12 mo
 picking up objects,
 stair climbing

Campbell et al., Not detailed PT visit 4 x in first
1999 [4] 2 mo; HEP 30 min
 exercise 3 x/wk +
 walk outside 2 x/
 wk x 11 mo

Day et al., Not detailed 1 h exercise class/
2002 [5] wk x 15 wk & HEP

Latham et al., No 3 x/wk x 10 wk
2003 [6]

Robertson et al., Not detailed 5 home visits by RN
2001 [7] at wk 1, 2, 4, 8, &
 24; HEP 3 x/wk x
 12 mo

Rubenstein et al., Not detailed 90 min 3 x/wk x
2000 [8] 12 wk

Suzuki et al., Weight shifting, one- 10 1 h sessions
2004 [9] legged standing, tai every other wk
 chi supplemented by
 HEP (3 x/wk for
 30 min) for 6 mo

Wolf et al., 1996 Tai chi, CBT Tai chi: 2 x/wk x
[10] 15 wk + home
 practice; CBT: 1 x/
 wk x 15 wk

 Study Compliance

Barnett et al., Median No. classes
2003 [1] attended 23/37; 91%
 in exercise group
 still performing
 HEP; 1 x weekly

Buchner et al., 95% of all
1997 [2] scheduled sessions
 were attended by
 those who did not
 drop out

Campbell et al., 42% still
1997 [3] participating
 [greater than or
 equal to] x 3 per
 week

Campbell et al., 63% still exercising
1999 [4] 3 x/wk & 72% still
 walking at least 2 x
 wk at end of study

Day et al., Mean No. sessions
2002 [5] attended = 10; mean
 no. home exercise
 sessions = 9/mo

Latham et al., 82% of sessions
2003 [6] attended

Robertson et al., Yes
2001 [7]

Rubenstein et al., Up to 91% of
2000 [8] sessions attended

Suzuki et al., Mean rate of group
2004 [9] attendance 75.3%

Wolf et al., 1996 Yes, but adherence
[10] to home program
 not monitored

(1.) Barnett A, Smith B, Lord SR, Williams M, Baumand A.
Community-based group exercise improves balance and reduces falls in
at-risk older people: A randomised controlled trial. Age Ageing.
2003;32(4):407-14. [PMID: 12851185]

(2.) Buchner DM, Cress ME, De Lateur BJ, Esselman PC, Margherita AJ,
Price R, Wagner EH. The effect of strength and endurance training on
gait, balance, fall risk, and health services use in community-living
older adults. J Gerontol A Biol Sci Med Sci. 1997;52(4):M218-24.
[PMID: 9224433]

(3.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW,
Buchner DM. Randomised controlled trial of a general practice
programme of home based exercise to prevent falls in elderly women.
BMJ. 1997;315(7115):1065-69. [PMID: 9366737]

(4. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(5.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(6.) Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID;
Fitness Collaborative Group. A randomized, controlled trial of
quadriceps resistance exercise and vitamin D in frail older people:
The Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am
Geriatr Soc. 2003;51(3):291-99. [PMID: 12588571]

(7.) Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness
and economic evaluation of a nurse delivered home exercise programme
to prevent falls. 1: Randomised controlled trial. BMJ.
2001;322(7388):697-701. [PMID: 11264206]

(8.) Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO,
Pietruszka FM, Robbins AS. Effects of a group exercise program on
strength, mobility, and falls among fall-prone elderly men. J Gerontol
A Biol Sci Med Sci. 2000;55(6):M317-21. [PMID: 10843351]

(9.) Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled
trial of exercise intervention for the prevention of falls in
community-dwelling elderly Japanese women. J Bone Miner Metab.
2004;22(6):602-11. [PMID: 15490272]

(10.) Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T.
Reducing frailty and falls in older persons: An investigation of Tai
Chi and computerized balance training. Atlanta FICSIT Group. Frailty
and injuries: Cooperative studies of intervention techniques. J Am
Geriatr Soc. 1996;44(5):489-97. [PMID: 8617895]

1RM = one repetition maximum, AROM = active range of motion, CBT =
computerized balance training, HEP = home exercise program, LL = lower
limb, PT = physical therapist,

RN = registered nurse, UL = upper limb.

Table 5.
Studies using home hazard assessment with modifications as separate
intervention.

 Population Community-
 Dwelling Elderly
 Type of
 Study Study Limitations N Losses (%)

Cumming et RCT, >65 yr 530 22
al., 1999 [1] stratified
 block

Nikolaus and RCT No age 360 23
Bach, 2003 [2] exclusion
 noted; mean
 age = 81

Pardessus et RCT >65 yr 60 No losses
al., 2002 [3]

Stevens RCT, >70 yr 1,737 * 14
et al., cluster
2001 [4] design
 with 2:1
 ratio of
 control to
 exp

 Resultant Measured
 Study Sample Size Outcome

Cumming et n exp = 208, No. falls in
al., 1999 [1] n control = 205 12 mo

Nikolaus and n exp = 140, No. falls in
Bach, 2003 [2] n control = 139 12 mo

Pardessus et n exp = 30, No. fallers
al., 2002 [3] n control = 30 in 12 mo

Stevens n exp = 534, No. falls in
et al., n control = 1,091 12 mo
2001 [4]

 Control Outcome

 Study No. Falls No. Fallers Fall Rate

Cumming et 324 -- --
al., 1999 [1]

Nikolaus and 204 -- --
Bach, 2003 [2]

Pardessus et -- 15 --
al., 2002 [3]

Stevens -- -- 17.15
et al., person-yr
2001 [4]

 Exp Outcome
 Direction of
 Study No. Falls No. Fallers Fall Rate Effect

Cumming et 226 -- -- +Only For
al., 1999 [1] those with

Nikolaus and 163 -- -- +Only For
Bach, 2003 [2] frail older

Pardessus et -- 13 -- No effect
al., 2002 [3]

Stevens -- -- 18.12 No effect
et al., person-yr
2001 [4]

* 51 subjects chosen randomly for follow-up home hazard assessment.

(1.) Cumming RG, Thomas M, Szonyi G, Salkeld G, O'Neill E, Westbury C,
Frampton G. Home visits by an occupational therapist for assessment
and modification of environmental hazards: A randomized trial of falls
prevention. J Am Geriatr Soc. 1999;47(12):1397-1402. [PMID: 10591231]

(2.) Nikolaus T, Bach M. Preventing falls in community-dwelling frail
older people using a home intervention team (HIT): Results from the
randomized falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305.
[PMID: 12588572]

(3.) Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A,
Dewailly P. Benefits of home visits for falls and autonomy in the
elderly: A randomized trial study. Am J Phys Med Rehabil.
2002;81(4):247-52. [PMID: 11953541]

(4.) Stevens M, Holman CD, Bennet N. Preventing falls in older people:
Impact of an intervention to reduce environmental hazards in the home.
J Am Geriatr Soc. 2001;49(11):1442-47. [PMID: 11890581]

Exp = experiment(al), RCT = randomized controlled trial.

Table 6.
Components of home hazard assessment programs.

 Home Hazard
 Study Assessment Personnel Education

Cumming et al., OT; 1 h home visit with Advice on footwear &
1999 [1] supervision of instruction on how to
 recommended home complete tasks safely in
 modifications, including home.
 further home visits.

Nikolaus & Bach, RN or PT with OT; Advice on fall risks &
2003 [2] comprehensive geriatric possible changes in
 assessment & minimum of home; instruction in use
 2 follow-up home visits of technical & mobility
 by home intervention aids.
 team.

Pardessus et al., Physiatrist & Advice on how to live
2002 [3] ergotherapist; unclear more safely with hazards
 if OT involved. that could not be
 removed.

Stevens et al., RN. Pamphlet emphasizing
2001 [4] general fall hazard
 reduction & methods to
 reduce identified home
 hazards.

 Adherence to
 Study Types of Modifications Recommendations

Cumming et al., Removal of mats/rugs, Compliance at 12 mo
1999 [1] change footwear, use of ranged from 19%-75%.
 nonslip bath mat,
 behavioral changes, use
 of night-light, add rail
 to external stairs, move
 electrical cord.

Nikolaus & Bach, Assistance in ordering Compliance at 12 mo
2003 [2] equipment & making 0.757 for maintaining 1
 modifications, removal chang
 of
 mats/rugs/obstructions
 in walkways, use of
 assistive devices
 (rollator, grab bars,
 shower seat, call bell),
 use of night-light,
 elevation of bed, use of
 nonslip bath mat.

Pardessus et al., Simple modifications None noted.
2002 [3] such as removal of loose
 carpets, moving
 obstacles/furniture; OT
 provided advice on how
 to live more safely if
 obstacles could not be
 removed.

Stevens et al., Installation of free Maintained significant
2001 [4] safety devices (grab reduction in 4 out of 5
 rails), removal of most prevalent home
 obstacles, removal or hazards.
 stabilization of
 rugs/mats, repair
 damaged flooring,
 improve height of
 chairs, improve
 lighting, wear safer
 shoes, use of nonslip
 tape.

(1.) Cumming RG, Thomas M, Szonyi G, Salkeld G, O'Neill E, Westbury C,
Frampton G. Home visits by an occupational therapist for assessment
and modification of environmental hazards: A randomized trial of falls
prevention. J Am Geriatr Soc. 1999;47(12):1397-1402. [PMID: 10591231]

(2.) Nikolaus T, Bach M. Preventing falls in community-dwelling frail
older people using a home intervention team (HIT): Results from the
randomized falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305.
[PMID: 12588572]

(3.) Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A,
Dewailly P. Benefits of home visits for falls and autonomy in the
elderly: A randomized trial study. Am J Phys Med Rehabil.
2002;81(4):247-52. [PMID: 11953541]

(4.) Stevens M, Holman CD, Bennet N. Preventing falls in older people:
Impact of an intervention to reduce environmental hazards in the home.
J Am Geriatr Soc. 2001;49(11):1442-47. [PMID: 11890581]

OT = occupational therapist, PT = physical therapist, RN = registered
nurse.

Table 7.
Fall data collection method: Exercise as separate intervention.

Study Method for Collecting Fall Data

Barnett et al., Postal surveys sent to subjects at end of each
2003 [1] calendar month. If not returned, further contact
 was made by telephone.

Buchner et al., Self-report monthly postcards reporting
1997 [2] occurrence of falls. Additionally, if subjects
 had a fall, they were asked to inform study staff
 by mail immediately. Subjects not returning
 postcards were telephoned.

Campbell et al., Daily self-report by participants using prepaid
1997 [3] monthly postcard calendars. Participants
 contacted by telephone if postcards not returned.

Campbell et al., Daily self-report by participants using
1999 [4] return-addressed, postage-paid, tear-off monthly
 postcards. Participants were contacted by
 telephone if postcard was not returned. When
 subject reported fall, research assistant
 telephoned subject to determine circumstances and
 injuries, if any, related to fall.

Day et al., Daily self-report using monthly postcard calendar
2002 [5] system. Telephone call by research assistant if
 no postcard returned within 5 days. When fall was
 reported, research assistant telephoned to
 determine circumstances.

Latham et al., Daily self-report diary using customized
2003 [6] calendar. Subjects received weekly reminders from
 physical therapist to complete diary for 10
 weeks; received reminder telephone calls
 periodically. Details of each fall were
 investigated at 3- and 6-month home visits.

Robertson et al., Self-report using preaddressed prepaid postcard
2001 [7] monthly calendars. If fall occurred, research
 assistant telephoned subjects to determine
 circumstances and injuries, if any, related to
 fall.

Rubenstein et al., Questioned subjects every 2 weeks either by
2000 [8] telephone (controls) or in exercise class for 12
 weeks.

Suzuki et al., By interview 8 and 20 months after intervention.
2004 [9]

Wolf et al., Self-report monthly calendar with fall
1996 [10] information or by monthly telephone calls from
 staff. If fall was reported, staff telephoned
 subject to verify.

(1.) Barnett A, Smith B, Lord SR, Williams M, Baumand A.
Community-based group exercise improves balance and reduces falls in
at-risk older people: A randomised controlled trial. Age Ageing.
2003;32(4):407-14. [PMID: 12851185]

(2.) Buchner DM, Cress ME, De Lateur BJ, Esselman PC, Margherita AJ,
Price R, Wagner EH. The effect of strength and endurance training on
gait, balance, fall risk, and health services use in community-living
older adults. J Gerontol A Biol Sci Med Sci. 1997;52(4):M218-24.
[PMID: 9224433]

(3.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW,
Buchner DM. Randomised controlled trial of a general practice
programme of home based exercise to prevent falls in elderly women.
BMJ. 1997;315(7115):1065-69. [PMID: 9366737]

(4.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(5.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(6.) Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID;
Fitness Collaborative Group. A randomized, controlled trial of
quadriceps resistance exercise and vitamin D in frail older people:
The Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am
Geriatr Soc. 2003;51(3):291-99. [PMID: 12588571]

(7.) Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness
and economic evaluation of a nurse delivered home exercise programme
to prevent falls. 1: Randomised controlled trial. BMJ.
2001;322(7388):697-701. [PMID: 11264206]

(8.) Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO,
Pietruszka FM, Robbins AS. Effects of a group exercise program on
strength, mobility, and falls among fall-prone elderly men. J Gerontol
A Biol Sci Med Sci. 2000;55(6):M317-21. [PMID: 10843351]

(9.) Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled
trial of exercise intervention for the prevention of falls in
community- dwelling elderly Japanese women. J Bone Miner Metab.
2004;22(6):602-11. [PMID: 15490272]

(10.) Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T.
Reducing frailty and falls in older persons: An investigation of Tai
Chi and computerized balance training. Atlanta FICSIT Group. Frailty
and injuries: Cooperative studies of intervention techniques. J Am
Geriatr Soc. 1996;44(5):489-97. [PMID: 8617895]

Table 8.
Fall data collection method: Home hazard assessment as separate
intervention.

 Study Method for Collecting Fall Data

Cumming et al., Daily self-report using preaddressed prepaid
1999 [1] monthly calendars. Recorded "F" if they fell and
 "N" if they did not. Follow-up telephone call if
 no calendar received and if fall had occurred to
 determine circumstances and injuries if any.

Nikolaus and Bach, Self-report diary and monthly telephone calls to
2003 [2] obtain information on falls, fall-related
 injuries, and their circumstances.

Pardessus et al., Telephone contact every month for 6 months and at
2002 [3] 12 months.

Stevens et al., Daily self-report using preaddressed prepaid
2001 [4] monthly calendars. Follow-up telephone interview
 if fall was reported to determine circumstances
 and injuries if any.

(1.) Cumming RG, Thomas M, Szonyi G, Salkeld G, O'Neill E, Westbury C,
Frampton G. Home visits by an occupational therapist for assessment
and modification of environmental hazards: A randomized trial of falls
prevention. J Am Geriatr Soc. 1999;47(12):1397-1402. [PMID: 10591231]

(2.) Nikolaus T, Bach M. Preventing falls in community-dwelling frail
older people using a home intervention team (HIT): Results from the
randomized falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305.
[PMID: 12588572]

(3.) Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A,
Dewailly P. Benefits of home visits for falls and autonomy in the
elderly: A randomized trial study. Am J Phys Med Rehabil.
2002;81(4):247-52. [PMID: 11953541]

(4.) Stevens M, Holman CD, Bennet N. Preventing falls in older people:
Impact of an intervention to reduce environmental hazards in the home.
J Am Geriatr Soc. 2001;49(11):1442-47. [PMID: 11890581]

Table 9.
Fall data collection method: Multifactorial prevention program.

Study Method for Collecting Fall Data

Campbell et al., Daily self-report by participants using
1999 [1] return-addressed, postage-paid, tear-off monthly
 postcards. Participants were contacted by
 telephone if postcard was not returned. When
 subject reported fall, research assistant
 telephoned subject to determine circumstances and
 injuries, if any, related to fall.

Clemson et al., Self-report falls schedule with monthly tear-off
2004 [2] postcard calendar. Subjects recorded "N" on each
 day that they did not fall and "F" if they fell.
 If fall was recorded, research assis- tant
 telephoned to ascertain whether fall met study
 definition. If calendar not returned in 2 weeks
 at end of month, research assistant telephoned
 subject.

Close et al., Follow-up data were collected every 4 months for
1999 [3] 1 year by postal questionnaire. Requested
 information included subsequent falls,
 fall-related injury, and details of doctor and
 hospital visits or admissions and degree of
 function.

Coleman et al., Self-report using health status survey at 12 and
1999 [4] 24 months. Detailed questions relating to fall
 not included.

Davison et al., Self-report using fall diary with 4 weekly cards
2005 [5] per diary returned every 4 weeks over 12 months.
 Telephone call prompting to maximize compliance.
 Subjects were asked to detail frequency and
 circumstances of each fall.

Day et al., Daily self-report of falls using monthly postcard
2002 [6] calendar system. Telephone call by research
 assistant if no postcard returned within 5 days.
 When fall was reported, research assistant
 telephoned to determine circumstances.

Huang & Acton, Self-report using fall record checklist with
2004 [7] calendar for subject to circle date of fall and
 note seriousness of fall. Checklist returned
 every 2 months for 4 months.

Kingston et al., Data collection method not detailed.
2001 [8] Differentiated between falls indoors and falls
 outdoors.

Lightbody et al., Self-report using daily diary for 6 months with
2002 [9] follow-up postal questionnaire that asked about
 total number of falls.

Lord et al., Self-report using monthly fall calendars. When
2005 [10] fall occurred, specific details about fall
 injuries were obtained from telephone interviews.
 If falls calendars were not returned at end of
 each month, prompting by telephone.

Mahoney et al., Self-report and caregiver assist, if necessary,
2007 [11] using 12 monthly falls diaries and calendars. If
 calendars not returned, research assistant called
 to prompt. When fall was reported, research
 assistant telephoned to determined circumstances
 and injuries if any.

van Haastregt Self-report using a weekly diary.
et al., 2000 [12]

(1.) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
Psychotropic medication withdrawal and a home-based exercise program
to prevent falls: A randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-53. [PMID: 10404930]

(2.) Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The
effectiveness of a community-based program for reducing the incidence
of falls in the elderly: A randomized trial. J Am Geriatr Soc.
2004;52(9):1487-94. [PMID: 15341550]

(3.) Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C.
Prevention of falls in the elderly trial (PROFET): A randomised
controlled trial. Lancet. 1999;353(9147):93-97. [PMID: 10023893]

(4.) Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care
clinics: A randomized controlled trial of a new model of primary care
for frail older adults. J Am Geriatr Soc. 1999;47(7):775-83. [PMID:
10404919]

(5.) Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with
recurrent falls attending Accident & Emergency benefit from
multifactorial intervention--A randomised controlled trial. Age
Ageing. 2005;34(2):162-68. [PMID: 15716246]

(6.) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S.
Randomised factorial trial of falls prevention among older people
living in their own homes. BMJ. 2002;325(7356):128. [PMID: 12130606]

(7.) Huang TT, Acton GJ. Effectiveness of home visit falls prevention
strategy for Taiwanese community-dwelling elders: Randomized trial.
Public Health Nurs. 2004;21(3):247-56. [PMID: 15144369]

(8.) Kingston P, Jones M, Lally F, Crome P. Older people and falls: A
randomized controlled trial of a health visitor (HV) intervention. Rev
Clin Gerontol. 2001;11(3):209-14.

(9.) Lightbody E, Watkins C, Leathley M, Sharma A, Lye M. Evaluation
of a nurse-led falls prevention programme versus usual care: A
randomized controlled trial. Age Ageing. 2002;31(3):203-10. [PMID:
12006310]

(10.) Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM, Gerontology
M, Ther GR, Sherrington C. The effect of an individualized fall
prevention program on fall risk and falls in older people: A
randomized, controlled trial. J Am Geriatr Soc. 2005;53(8):1296-1304.
[PMID: 16078954]

(11.) Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S,
Schwalbe A. Kenosha County falls prevention study: A randomized,
controlled trial of an intermediate-intensity, community-based
multifactorial falls intervention. J Am Geriatr Soc.
2007;55(4):489-98. [PMID: 17397425]

(12.) van Haastregt JC, Diederiks JP, Van Rossum E, De Witte LP,
Voorhoeve PM, Crebolder HF. Effects of a programme of multifactorial
home visits on falls and mobility impairments in elderly people at
risk: Randomised controlled trial. BMJ. 2000;321(7267):994-98. [PMID:
11039967]

Article Details

Printer friendly Cite/link Email Feedback
Author:	Costello, Ellen; Edelstein, Joan E.
Publication:	Journal of Rehabilitation Research & Development
Article Type:	Report
Geographic Code:	1USA
Date:	Oct 1, 2008
Words:	13747
Previous Article:	Balance control in hemiparetic stroke patients: main tools for evaluation.
Next Article:	Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults.
Topics:	Accidental falls Physiological aspects Prevention Research Aged Injuries Physiological aspects Elderly Injuries Physiological aspects Exercise Health aspects Exercise for the aged Injuries Physiological aspects Falls (Accidents) Physiological aspects Prevention Research Wellness programs Health aspects Usage

Related Articles

Review of intrinsic factors related to fall risk in individuals with visual impairments.

Preventing falls among older adults: no "one size suits all" intervention strategy.

The perceptions of physical activity in an elderly population at risk of falling: a focus group study.

Multidisciplinary assessment of elderly people with a history of multiple falls reduces the risk of further falls.