Flu_tab

Canadian Task Force on Preventive Health Care

Recommendation Table

Preventive Health Care, 2005: Prevention of Falls in Long-Term Care Facilities

Prepared by M.A. Norris, BSc, PT, MHSc, MD, FRCPC, ABIM, R.E. Walton, MSc, C.J.S. Patterson, MD, FRCPC, J.W. Feightner, MD, MSc, FPCP, with the Canadian Task Force on Preventive Health Care

MANEUVER EFFECTIVENESS LEVEL OF EVIDENCE <REF> RECOMMENDATION

Interventions directed to the general population of LTC residents

Multifactorial screening and intervention program for all residents admitted to long-term care (LTC) facilities.
The most comprehensive intervention (Jensen, 2002) included multidisciplinary assessment and intervention to reduce environmental hazards, improve staff education, increase patient exercise, supply or repair aids, evaluate medication, hip protectors, post-fall problem-solving conferences and staff guidance for fall-prone residents. This program was successful in reducing falls and hip fractures in the resident population. Another multidisciplinary study (Becker, 2003) (which did not include post-fall conference or adjustments to medications) reduced the incidence density rate of falls but not fractures. Level I - fair <Jensen, 2002; Becker, 2003> The CTFPHC concludes that there is fair evidence to recommend that a multifactorial intervention program for long-term care residents prevents falls and reduces the rate of injurious falls and hip fractures. Residents should be assessed on admission and re-assessed after a fall (B Recommendation).

Interventions targeted to only the higher-risk residents of LTC

Structured multidisciplinary assessment in the immediate post-fall period (e.g., 7 days) Comprehensive assessment includes a detailed history, physical examination and environmental assessment, review of medications, laboratory work-up, ECG, and 24 hours of Holter monitoring, performed within 7 days of a fall. In one study (Kerse. 2004) that relied on existing and limited staff for assessment and implementation, there was an increase in falls in the intervention group compared to usual care. In one study (Rubenstein, 1990) there was a reduction in hospital admissions over one year but no reduction in number of falls. 90% of subjects who underwent post-fall assessment had at least one active problem identified. A comprehensive post-fall assessment and intervention directed specifically to cognitively impaired elderly (Shaw, 2003) did not produce a reduction in falls, injuries or hospitalizations. Level I - fair <Kerse, 2004; Rubenstein, 1990; Shaw, 2003> The CTFPHC concludes that there is insufficient evidence to recommend structured multidisciplinary programs that are targeted exclusively to those deemed at highest risk to reduce the risk of future falls* (I Recommendation).

Structured multidisciplinary assessment of residents deemed to be at high risk or who have a history of falling The interventions (Ray, 1997) included a comprehensive multidisciplinary structured individual assessment and safety recommendations for sub-optimal practices including wheelchair use, psychotropic drug use, transferring and ambulation. There was a reduction in recurrent falls (i.e., > 2 falls in follow-up) but no reduction in injuries. Level I - fair <Ray, 1997>

Selective interventions such as exercise or physical therapy

Interventions (e.g., physiotherapy or exercise programs) to reduce specific risk factors Studies lacked power to show effect on fall incidence but showed benefits in intermediate outcomes such as patient strength and reduced the need for assistive devices/wheelchairs. Level I - fair <Nowalk, 2001; Mulrow, 1994; Fiatarone, 1994; McMurdo, 2000> The CTFPHC concludes that there is insufficient evidence to recommend that exercise alone or in combination with other limited interventions is effective in preventing falls in LTC residents (I Recommendation).

* There is evidence that a comprehensive assessment done in a timely manner after a fall (e.g., within a week) can reduce future hospitalization (level I - fair, Rubenstein, 1990). Such assessments can detect recent changes in an individual's health or function, such as an acute or progressive illness, a need for evaluation of medications, increasing frailty, etc.

Link to Recommendation Statement

Link to Technical Report

Link to Selected References list of this review

Top of Page

CTFPHC Home Page

Reprinted in modified format by the Canadian Task Force on Preventive Health Care
with permission.
Original Copyright © 2000 Canadian Medical Association.
For any technical issues please contact: webmaster@ctfphc.org
Last modified: August 17, 2005

MANEUVER	EFFECTIVENESS	LEVEL OF EVIDENCE <REF>	RECOMMENDATION
*Interventions directed to the general population of LTC residents*
Multifactorial screening and intervention program for all residents admitted to long-term care (LTC) facilities.	The most comprehensive intervention (Jensen, 2002) included multidisciplinary assessment and intervention to reduce environmental hazards, improve staff education, increase patient exercise, supply or repair aids, evaluate medication, hip protectors, post-fall problem-solving conferences and staff guidance for fall-prone residents. This program was successful in reducing falls and hip fractures in the resident population. Another multidisciplinary study (Becker, 2003) (which did not include post-fall conference or adjustments to medications) reduced the incidence density rate of falls but not fractures.	Level I - fair <Jensen, 2002; Becker, 2003>	The CTFPHC concludes that there is fair evidence to recommend that a multifactorial intervention program for long-term care residents prevents falls and reduces the rate of injurious falls and hip fractures. Residents should be assessed on admission and re-assessed after a fall (B Recommendation).
Interventions targeted to only the higher-risk residents of LTC
Structured multidisciplinary assessment in the immediate post-fall period (e.g., 7 days)	Comprehensive assessment includes a detailed history, physical examination and environmental assessment, review of medications, laboratory work-up, ECG, and 24 hours of Holter monitoring, performed within 7 days of a fall. In one study (Kerse. 2004) that relied on existing and limited staff for assessment and implementation, there was an increase in falls in the intervention group compared to usual care. In one study (Rubenstein, 1990) there was a reduction in hospital admissions over one year but no reduction in number of falls. 90% of subjects who underwent post-fall assessment had at least one active problem identified. A comprehensive post-fall assessment and intervention directed specifically to cognitively impaired elderly (Shaw, 2003) did not produce a reduction in falls, injuries or hospitalizations.	Level I - fair <Kerse, 2004; Rubenstein, 1990; Shaw, 2003>	The CTFPHC concludes that there is insufficient evidence to recommend structured multidisciplinary programs that are targeted exclusively to those deemed at highest risk to reduce the risk of future falls* (I Recommendation).
Structured multidisciplinary assessment of residents deemed to be at high risk or who have a history of falling	The interventions (Ray, 1997) included a comprehensive multidisciplinary structured individual assessment and safety recommendations for sub-optimal practices including wheelchair use, psychotropic drug use, transferring and ambulation. There was a reduction in recurrent falls (i.e., > 2 falls in follow-up) but no reduction in injuries.	Level I - fair <Ray, 1997>
Selective interventions such as exercise or physical therapy
Interventions (e.g., physiotherapy or exercise programs) to reduce specific risk factors	Studies lacked power to show effect on fall incidence but showed benefits in intermediate outcomes such as patient strength and reduced the need for assistive devices/wheelchairs.	Level I - fair <Nowalk, 2001; Mulrow, 1994; Fiatarone, 1994; McMurdo, 2000>	The CTFPHC concludes that there is insufficient evidence to recommend that exercise alone or in combination with other limited interventions is effective in preventing falls in LTC residents (I Recommendation).
* There is evidence that a comprehensive assessment done in a timely manner after a fall (e.g., within a week) can reduce future hospitalization (level I - fair, Rubenstein, 1990). Such assessments can detect recent changes in an individual's health or function, such as an acute or progressive illness, a need for evaluation of medications, increasing frailty, etc.