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      Evaluation of Implementing a Home-Based Fall Prevention Program among Community-Dwelling Older Adults

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          Abstract

          We aimed to describe and evaluate the implementation of a home-based exercise program among community-dwelling adults aged ≥65 years. In an observational study, the twelve-week program was implemented in a community setting. The implementation plan consisted of dialogues with healthcare professionals and older adults, development of an implementation protocol, recruitment of participants, program implementation, and implementation evaluation. The dialogues consisted of a Delphi survey among healthcare professionals, and of individual and group meetings among older adults. The implementation of the program was evaluated using the framework model RE-AIM. In the dialogues with healthcare professionals and older adults, it was found that negative consequences of a fall and positive effects of preventing a fall should be emphasized to older adults, in order to get them engaged in fall prevention activities. A total of 450 older adults enrolled in the study, of which 238 started the program. The process evaluation showed that the majority of older adults were recruited by a community nurse. Also, a good collaboration between the research team and the local primary healthcare providers was accomplished, which was important in the recruitment. Future fall prevention studies may use this information in order to translate an intervention in a research project into a community-based program.

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          Multifactorial and multiple component interventions for preventing falls in older people living in the community

          Falls and fall‐related injuries are common, particularly in those aged over 65, with around one‐third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people. To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017. Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention. Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random‐effects model. We used the GRADE approach to assess the quality of the evidence. We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow‐up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains. Forty‐four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I 2 not reported if = 0%). Multifactorial interventions versus usual care or attention control This comparison was made in 43 trials. Commonly‐applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I 2 = 88%; low‐quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low‐quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I 2 = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I 2 = 53%); fall‐related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low‐quality evidence that multifactorial interventions may reduce the risk of fall‐related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health‐related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I 2 = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self‐limiting musculoskeletal symptoms in total. Multifactorial interventions versus exercise Very low‐quality evidence from one small trial of 51 recently‐discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall‐related outcomes were not assessed. Multiple component interventions versus usual care or attention control The 17 trials that make this comparison usually included exercise and another component, commonly education or home‐hazard assessment. There is moderate‐quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I 2 = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low‐quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low‐quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall‐related fractures (2 trials) or fall‐related hospital admission (1 trial). There is low‐quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health‐related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I 2 = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two. Multiple component interventions versus exercise This comparison was tested in five trials. There is low‐quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low‐quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported. Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall‐related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control. Review question To assess whether fall‐prevention strategies which target two or more risk factors for falls (multifactorial interventions) or fixed combinations of interventions (multiple component interventions) are effective in preventing falls in older people living in the community. Background As people age they are more likely to fall. Although most fall‐related injuries are minor, they can cause significant pain and discomfort, affect a person's confidence and lead to a loss of independence. Some falls can cause serious long‐term health problems. A combination of factors increases the risk of falls with ageing, such as weak muscles, stiff joints, hearing problems, changes in sight, side effects of medications, tiredness or confusion. Poor lighting, slippery or uneven surfaces, and issues with poor footwear can also increase the risk of falling. Different interventions have been developed to help prevent falls in older people. They may involve a single type of intervention, such as exercise to increase muscle strength, or combinations of interventions, such as exercise and adjustment of a person's medication. A combination of two or more components can be delivered as either a multifactorial intervention based on an assessment of a person's risk factors for falling or as a multiple component intervention where the same combination of interventions is provided to all participants. Search date We searched the healthcare literature for reports of randomised controlled trials relevant to this review up to 12 June 2017. Study characteristics We included 62 randomised trials involving 19,935 older participants. Most trials included more women than men; the average ages in the trials ranged from 62 to 85 years. Trials compared the interventions to an inactive control group receiving usual care (no change in usual activities) or a matched level of attention (such as social visits) or to an active control group receiving an exercise programme. Key results We identified 43 trials that compared a multifactorial intervention with an inactive control. Multifactorial interventions led to some reduction in the rate at which people fall compared with the inactive control group, but the quality of evidence was low because of large differences in how studies were conducted. There may be little or no difference in the number of people who experienced one or more falls (fallers), recurrent falls, fall‐related fractures, or experienced a fall requiring hospital admission or medical attention. Multifactorial interventions may make little difference to people's health‐related quality of life. There was very limited evidence on adverse events related to the intervention; all 12 reported musculoskeletal complaints such as back pain were minor. We did not find enough evidence to determine the effects of multifactorial interventions compared with exercise as this was only assessed in one small trial. We identified 18 trials assessing the effects of multiple component interventions. Seventeen compared the intervention with an inactive control group and five compared the intervention with exercise. Seventeen of the trials included exercise in the intervention and another component, often education on falls prevention or home safety assessment. There was limited evidence on adverse events related to the intervention; all six reported events were minor. Multiple component interventions probably reduce the rate at which people fall and the number of fallers compared with the inactive control group. They may also reduce the number of people who experienced recurrent falls. The evidence was not enough to determine their effects on fall‐related fractures or hospital admission. Multiple component interventions may make little or no difference to the risk of a fall requiring medical attention. However, they may slightly improve a person's health‐related quality of life. Trials comparing multiple component interventions with exercise showed there may be little or no difference in the rate at which people fall and the number of fallers, but not enough evidence to determine the effects on hospital admission. Other falls outcomes were not reported. Quality of the evidence We rated the quality of the available evidence as of low or very low quality. This means that we have limited confidence about the results where the evidence is low quality, but are uncertain where the evidence is of very low quality.
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            Falls prevention over 2 years: a randomized controlled trial in women 80 years and older.

            after 1 year, a home-based programme of strength and balance retraining exercises was effective in reducing falls and injuries in women aged 80 years and older. The exercise programme had been individually prescribed by a physiotherapist during the first 2 months of a randomized controlled trial. we aimed to assess the effectiveness of the programme over 2 years. women from both the control group and the exercise group completing a 1-year trial (213 out of the original 233) were invited to continue for a further year. falls and compliance to the exercise programme were monitored for 2 years. 81 (74%) in the control group and 71 (69%) in the exercise group agreed to continue in the study. After 2 years, the rate of falls remained significantly lower in the exercise group than in the control group. The relative hazard for all falls for the exercise group was 0.69 (95% confidence interval 0.49-0.97). The relative hazard for a fall resulting in a moderate or severe injury was 0.63 (95% confidence interval 0.42-0.95). Those complying with the exercise programme at 2 years had a higher level of physical activity at baseline, were more likely to have reported falling in the year before the study and had remained more confident in the first year about not falling compared with the rest of the exercise group. falls and injuries can be reduced by an individually tailored exercise programme in the home. For those who keep exercising, the benefit continues over a 2-year period.
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              International comparison of cost of falls in older adults living in the community: a systematic review.

              Our objective was to determine international estimates of the economic burden of falls in older people living in the community. Our systematic review emphasized the need for a consensus on methodology for cost of falls studies to enable more accurate comparisons and subgroup-specific estimates among different countries. The purpose of this study was to determine international estimates of the economic burden of falls in older people living in the community. This is a systematic review of peer-reviewed journal articles reporting estimates for the cost of falls in people aged > or =60 years living in the community. We searched for papers published between 1945 and December 2008 in MEDLINE, PUBMED, EMBASE, CINAHL, Cochrane Collaboration, and NHS EED databases that identified cost of falls in older adults. We extracted the cost of falls in the reported currency and converted them to US dollars at 2008 prices, cost items measured, perspective, time horizon, and sensitivity analysis. We assessed the quality of the studies using a selection of questions from Drummond's checklist. Seventeen studies met our inclusion criteria. Studies varied with respect to viewpoint of the analysis, definition of falls, identification of important and relevant cost items, and time horizon. Only two studies reported a sensitivity analysis and only four studies identified the viewpoint of their economic analysis. In the USA, non-fatal and fatal falls cost US $23.3 billion (2008 prices) annually and US $1.6 billion in the UK. The economic cost of falls is likely greater than policy makers appreciate. The mean cost of falls was dependent on the denominator used and ranged from US $3,476 per faller to US $10,749 per injurious fall and US $26,483 per fall requiring hospitalization. A consensus on methodology for cost of falls studies would enable more accurate comparisons and subgroup-specific estimates among different countries.
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                Author and article information

                Journal
                Int J Environ Res Public Health
                Int J Environ Res Public Health
                ijerph
                International Journal of Environmental Research and Public Health
                MDPI
                1661-7827
                1660-4601
                26 March 2019
                March 2019
                : 16
                : 6
                : 1079
                Affiliations
                [1 ]Department of Public Health, University Medical Center Rotterdam, Erasmus MC, 3000 CA Rotterdam, The Netherlands; v.erasmus@ 123456erasmusmc.nl (V.E.); l.barmentloo@ 123456erasmusmc.nl (L.M.B.); a.burdorf@ 123456erasmusmc.nl (A.B.); s.polinder@ 123456erasmusmc.nl (S.P.)
                [2 ]GENERO Foundation, 3001 AE Rotterdam, The Netherlands; dsmilde@ 123456xs4all.nl
                [3 ]Department of Geriatric Medicine, Radboud University Medical Center, 6525 GC Nijmegen, The Netherlands; yvonne.schoon@ 123456radboudumc.nl
                [4 ]Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam, University of Amsterdam. UMC, Amsterdam Public Health Research Institute, 1105 AZ Amsterdam, The Netherlands; n.vandervelde@ 123456amc.uva.nl
                Author notes
                [* ]Correspondence: b.olij@ 123456erasmusmc.nl
                Author information
                https://orcid.org/0000-0001-6701-3226
                Article
                ijerph-16-01079
                10.3390/ijerph16061079
                6466172
                30917558
                389d4dcc-32b9-4a0d-8662-89b82fefc296
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 08 February 2019
                : 20 March 2019
                Categories
                Article

                Public health
                accidental falls,aged,prevention and control,exercise,independent living,implementation science

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