Structured Abstract
Please note: In 2003, the CTF updated its Grades of
Recommendations to include an "I Recommendation" for situations where
insufficient evidence exists to allow a recommendation to be made.
(Formerly, these situations were captured under a "C
Recommendation".) This change is not retroactive, and all
"C Recommendations" made prior to 2003 have not been
reevaluated in light of the new "I" recommendation grade. For a
discussion of these recommendation grades, please link to the 2003 article in
the Canadian Medical Association Journal here.
Prevention of Household and Recreational Injuries in the
Elderly
Prepared by R. Wayne Elford, MD, CCFP, FCFP, Professor
and Director of Research and Faculty Development, Department of Family
Medicine, University of Calgary, Alberta
These recommendations were finalized by the Task Force in June 1993
Contents
Objective
To make recommendations about the prevention of unintentional household
and recreational injuries (particularly falls and burns) among elderly
persons in Canada. This updates a 1979 report.
Burden
of Suffering
Injuries sustained in falls are a major cause of mortality and morbidity
in the elderly population. In 1988 there were 2,100 deaths due to falls.
Falls resulting in serious injury or death were much more frequent among
those aged 55 and over; 70% of fatal falls were among persons 75 years
and older. One percent of falls by individuals aged 65 and older result
in hip fracture. Fallers tend to be more physically and functionally impaired
with hip weakness, have poor balance and more medications predictive of
falls. Risk factors for falling include increased age, female sex, presence
of more than one disease, dementia, depression, acute illness, decreased
morbidity, confinement to the home, postural gait instability, gait disturbance,
sensory impairment, medications and possible dietary deficiencies.
Other causes of unintentional death among Canadian adults over age 65
include drowning (12 % of 429 drowning deaths in 1987), burns, scalds and
fire-related accidents (21% of 402 fire-related deaths in 1988), poisoning
(16% of 424 poisoning deaths in 1987), and suffocation (13% of 415 suffocation
deaths 1987).
Options
Public health education, legislation and environmental modification, individual
counselling. Multidisciplinary post-fall assessment and monitoring of patients
for medical impairment.
Outcomes
Outcomes included falls and fall-related mortality, hospitalizations and
hospital days (p915). Incidence and severity of fire and burn injuries
were also considered.
Evidence
MEDLINE was searched for the years 1981 to November 1991 using the major
MeSH heading "accidents" with subheadings "diagnosis", "economics", "epidemiology",
"law and jurisprudence", "mortality", "prevention and control", "standards
and trends" and not "aviation, occupational or traffic accidents". Other
data sources included Statistics Canada, Health and Welfare Canada, the
Insurance Bureau of Canada, the Poison Control Centre, supporting documents
from other recommending bodies and citations from identified references.
Recommendations were graded as:
|
A
|
Good evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
B
|
Fair evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
C
|
Poor evidence regarding inclusion or exclusion of the condition
in a PHE, but recommendations may be made on other grounds. |
|
D
|
Fair evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
|
E
|
Good evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
Quality of evidence was rated according to 5 levels:
|
I
|
Evidence from at least 1 properly randomized controlled
trial (RCT). |
|
II-1
|
Evidence from well-designed controlled trials without randomization. |
|
II-2
|
Evidence from well-designed cohort or case-control analytic
studies, preferably from more than 1 centre or research group. |
|
II-3
|
Evidence from comparisons between times or places with
or without the intervention. Dramatic results in uncontrolled experiments
could also be included here. |
|
III
|
Opinions of respected authorities, based on clinical experience,
descriptive studies or reports of expert committees. |
Values
The 13-member Task Force of experts in family medicine, geriatric medicine,
pediatrics, psychiatry and epidemiology used an evidence-based method for
evaluating the effectiveness of preventive health care interventions. Recommendations
were not based on cost-effectiveness of options. Patient preferences were
not discussed.
Background papers providing critical appraisal of the evidence and tentative
recommendations prepared by the chapter author were pre-circulated to the
members. Evidence for this topic was presented and deliberated upon in
1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993.
Consensus was reached on final recommendations.
Benefits,
Harms, and Costs
A 1989 review found no controlled trials on examining the effectiveness
for reducing falls of detecting disease, counselling about or changing
medications, promoting exercise, home visits to assess environmental hazards,
educating patients, physical therapy, and balance and gait training on
reducing falls.
An RCT evaluated the effectiveness of care given in a ‘Falls Clinic’
which provided coordinated care by a geriatrician, neurologist, cardiologist
and psychiatrist with resources in audiology, ophthalmology and podiatry
and home visits by occupational therapists. For 1 year, there were no falls
in 77% of patients. An RCT of post-fall assessment including physical examination
and environmental assessment by a nurse practitioner, laboratory tests
and 24-hour Holter monitoring reduced hospitalizations by 26% (p<0.05)
and hospital days by 52% (p<0.01), but did not significantly reduce
falls (9% reduction) or mortality (17% reduction) during 2 years of follow-up.
Evidence on individual counselling or public education about the use
of safety aids and the use of non-flammable fabrics and self-extinguishing
cigarettes is limited to expert opinion.
Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence
[I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations
in support of individual recommendations are identified in the guideline
text.
-
There is good evidence to support referral to a multidisciplinary post-fall
assessment team where the service is available [A,
I].
-
There is insufficient evidence to include or exclude (in the PHE) monitoring
patients for medical impairment (balance, medication, gait abnormalities)
[C, III].
-
There is fair evidence to implement legislation regarding use of safety
aids in hazardous areas such as stairs and bathrooms [B,
II-2], and insufficient evidence to include
or exclude (in the PHE) individual counselling regarding use of safety
aids [C, III].
-
There is insufficient evidence to implement public health education [C,
III], or to include or exclude (in the PHE) individual
counselling [C, III]
regarding the use of non-flammable fabrics and self-extinguishing cigarettes.
Validation
This report was externally peer-reviewed. Recommendations and background
papers were sent for external peer review. The 1989 U.S. Preventive Services
Task Force suggested that it would be prudent to provide counselling on
injury prevention measures. The National Institute on Aging provides recommendations
for primary care physicians based on expert opinion regarding routine assessment
for falls and appropriate interventions.
Sponsors
The Canadian Task Force on Preventive Health Care
developed this guideline with funding from Health Canada.
Selected
References
Source Document
Other
-
Canadian Task Force on the Periodic Health Examination: The Periodic Health
Examination. Can Med Assoc J. 1979;121:1193-1254.
Link to Full Text of this
review
Link to Summary Table of Recommendations of this review
Link to Selected References list of this review
Link to 1994 chapter:
Prevention of Household and Recreational Injuries in Children (<15 years of
age)
Link to 1994 chapter: Prevention
of Household and Recreational Injuries in Adults
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