Research Review By Dr. Joshua Plener©


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Date Posted:

March 2022

Study Title:

Evaluation of Clinical Practice Guidelines on Fall Prevention and Management for Older Adults: A Systematic Review


Montero-Odasso, Kamkar, Pieruccini-Faria et al.

Author's Affiliations:

Schulich School of Medicine and Dentistry, Division of Geriatric Medicine, Department of Medicine, The University of Western Ontario, London, Ontario, Canada; Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, Ontario; Department of Epidemiology and Biostatistics, The University of Western Ontario

Publication Information:

JAMA Network Open 2021; 4(12): e2138911. doi:10.1001/jamanetworkopen.2021.38911

Background Information:

Approximately 30% of adults over 60 years of age or older fall each year (1-3). Older adults with greater frailty and living in nursing homes are more likely to fall, with consequences including fractures, mobility challenges, loss of independence and more (4, 5).

Clinical practice guidelines for fall prevention and management have been created by several organizations, which are typically based on systematic reviews and expert consensus (6, 7). Despite the large number of published reviews, there is little knowledge on the level of agreement among them.

This study aimed to systematically review existing clinical practice guidelines on fall prevention and management for older adults, identify common areas evaluated and the level of agreement, address fall risk stratification in each guideline to describe which assessments are recommended to inform the management across settings, and identify potential gaps that should be addressed through future clinical practice guidelines.

Pertinent Results:

11 414 records were identified, and after 6647 records were removed due to being duplicates, 4608 were excluded after title and abstract review, resulting in 159 full texts reviewed and assessed for eligibility. Of the 159 records, 144 were excluded, leaving 15 records for final analysis and data synthesis.

The AGREE-2 total scores across the guidelines had a mean of 80.1%. From the 15 guidelines that were analyzed, 198 recommendations were extracted.

The following topics were presented in more than 40% of the guidelines:
  • Risk stratification (graded as 1A)
  • Assessment tools (graded as 1A)
  • Fractures and osteoporosis management (graded as 1A)
  • Multifactorial interventions (graded as 1A)
  • Medication review (graded as 1A)
  • Exercise interventions (graded as 1A)
  • Vitamin D supplementation (graded as mixed)
  • Hip protectors (graded as underrepresented)
  • Vision modification (graded as 1B)
  • Environment modifications (graded as 1A)
  • Cognitive factors management (graded as mixed)
  • Physiotherapy referral (graded as 1A)
  • Falls education (graded as mixed)
  • Cardiovascular interventions (graded as 1B)
  • Footwear evaluation and interventions (graded as 1A)
Topic areas that were presented in less than 40% of the guidelines were: addressing the use of canes or walking aids, alcohol use, depression, urinary incontinence, hearing impairment, atypical blood glucose, social isolation, functional dependence as risk factors for falls, and staff education in nursing homes as part of interventions to prevent and manage falls.

Recommendations on vitamin D supplementation and education on falls prevention had low levels of agreement across 15 guidelines. 7 guidelines strongly recommended the use of vitamin D supplementation, 4 provided weak recommendations and 4 didn’t address the topic. This lack of consensus likely reflects the inconsistent nature of the evidence currently published and the impact that the setting, such as community versus residential or nursing home care may have (8-10). For education on falls prevention, 6 provided strong recommendations, 6 provided weak recommendations and 3 didn’t address the area.

Most guidelines strongly recommended risk stratification using “case finding” self-reported questions including fall history, fear of falling, and gait and balance difficulties, while reserving gait and balance testing for those who screen positive on these questions. Individuals who had either no falls or 1 non-injurious fall in the last year, with no impairment of balance and gait on examination, were considered low risk, with a reassessment recommended in 1-2 years. For individuals who screened positive for a fall history, guidelines stratified their risk by demographic factors or clinical characteristics such as using the Timed Up and Go test, Berg Balance Scale and Tinetti Performance-Oriented Mobility Assessment Tool, with the Timed Up and Go test being the most recommended in 6 of 15 guidelines. Only 2 guidelines recommended active interventions with follow-up care for low risk individuals, including education and exercises involving balance and lower limb strengthening.

Clinical Application & Conclusions:

This review nicely summarizes the recommendations made across clinical practice guidelines for fall prevention and management of older adults. This study demonstrated that some recommendations are rated strongly with high quality evidence while other recommendations have lower quality evidence or conflicting reports. One aspect that is noticeably underrepresented in clinical practice guidelines is the clinical applicability to the recommendations, as facilitators and/or barriers to the recommendations were only detailed in 3 of the guidelines. Future guidelines should assist in better addressing the challenges encountered for implementing these recommendations.

To summarize, this systematic review found high agreement across clinical practice guidelines, with strong recommendations for risk stratification, the use of specific tests for gait and balance assessments (if risk stratification indicates necessity), multifactorial interventions, medication review, physical exercise, vision and footwear intervention, physiotherapy referral, environment modification, management of osteoporosis and fracture risk, and cardiovascular interventions. Inconsistent recommendations on vitamin D supplementation and educational programs for fall prevention and management were noted, and recommendations on hip protectors and wearable technologies were often not included.

Study Methods:

The initial search for this study was conducted on April 2, 2020 and updated on July 1, 2021 including the following databases: MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos. Search terms pertaining to falls, clinical practice guidelines, management and prevention, and older adults were used, with no restrictions on date, language or setting.

The inclusion criteria for this review were as follows:
  • Published clinical practice guideline on falls prevention
  • The guideline had to have at least one of the following outcomes: fall reduction, prevention and management
  • The guideline had to be assessing the prevention or management of falls, categorized as consensus or evidence-based guidelines
  • The target population had to be older adults
Three independent reviewers selected records for full-text examination and appraised the quality of the guideline through the AGREE-2 tool. The AGREE-2 tool ranges from 0 to 100 with higher scores indicating higher quality. Furthermore, GRADE was utilized to reflect the strength of the recommendations with 1 representing a strong recommendation and 2 a weak recommendation, which was paired with the quality of the supporting evidence, with A representing high quality, B representing moderate quality, and C representing low quality.

Study Strengths / Weaknesses:

  • This was the first review to assess the consistency of the recommendations made by the clinical practice guidelines in this field.
  • This review had strong methodology.
  • All guidelines in this review were led by authors in developed countries. Therefore, this may demonstrate a lack of guidelines for fall prevention in many regions of the developing world.
  • A criticism of the included studies is the lack of attention to the clinical applicability of the recommendations, and greater attention should be placed on the resources, costs and implementation barriers.

Additional References:

  1. Muir SW, Berg K, Chesworth B, et al. Application of a fall screening algorithm stratified fall risk but missed preventive opportunities in community-dwelling older adults: a prospective study. J Geriatr Phys Ther 2010; 33(4): 165-172.
  2. Lamb SE, McCabe C, Becker C, et al. The optimal sequence and selection of screening test items to predict fall risk in older disabled women: the Women’s Health and Aging Study. J Gerontol A Biol Sci Med Sci 2008; 63(10): 1082-1088.
  3. TinettiME, SpeechleyM, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319(26): 1701-1707.
  4. Samper-Ternent R, Karmarkar A, Graham J, et al. Frailty as a predictor of falls in older Mexican Americans. J Aging Health 2012; 24(4): 641-653.
  5. Cameron EJ, Bowles SK, Marshall EG, et al. Falls and long-term care: a report from the care by design observational cohort study. BMC Fam Pract 2018; 19(1): 73.
  6. Institute for Quality and Efficiency in Health Care. What Are Clinical Practice Guidelines? Institute for Quality and Efficiency in Health Care; 2016.
  7. Guyatt GH, Oxman AD, Schünemann HJ, et al. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011; 64(4): 380-382.
  8. Murad MH, Elamin KB, Abu Elnour NO, et al. Clinical review: the effect of vitamin D on falls: a systematic review and meta-analysis. J Clin Endocrinol Metab 2011; 96(10): 2997-3006.
  9. Bischoff-Ferrari HA, Dawson-Hughes B, WillettWC, et al. Effect of vitamin D on falls: a meta-analysis. JAMA 2004; 291(16): 1999-2006.
  10. Smith LM, Gallagher JC, Suiter C. Medium doses of daily vitamin D decrease falls and higher doses of daily vitamin D3 increase falls: a randomized clinical trial. J Steroid Biochem Mol Biol 2017; 173: 317-322.

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