What works to prevent falls in older adults dwelling in long term care facilities and hospitals an umbrella review of meta analyses of randomised controlled trials

What works to prevent falls in older adults dwelling in long term care facilities and hospitals?. What works to prevent falls in older adults dwelling in long term care facilities and ho

Maturitas

j ourna l h o me pa g e :w w w e l s e v i e r c o m / l o c a t e / m a t u r i t a s

Review

a Faculty of Education and Health, University of Greenwich, Southwood Site, Avery Hill Road, Eltham, London SE9 2UG, UK

b Competence Centre of Geriatrics and Aging Research Ulm/Alb-Donau, Zollernring 26, 89075 Ulm, Germany

c AGAPLESION Bethesda Clinic, Geriatrics Ulm University, Zollernring 26, 89073 Ulm, Germany

a r t i c l e i n f o

Article history:

Received 24 March 2015

Received in revised form 30 March 2015

Accepted 31 March 2015

Available online xxx

Keywords:

Falls prevention

Older adult

Long term care facilities

Exercise

Vitamin D supplementation

Hospitals

a b s t r a c t Preventingfallsinlongtermcarefacilities(LTCF)andhospitalsisaninternationalpriority.Many inter-ventionshavebeeninvestigatedandsummarisedinmeta-analyses(MA)andthereisaneedtosynthesise thetopofthehierarchyofevidenceinoneplace.ThereforeweconductedanumbrellareviewofMAof randomisedcontrolledtrials(RCTs)offallspreventioninterventionsLTCFandhospitals.Two indepen-dentreviewerssearchedmajorelectronicdatabasesfrominceptiontillOctober2014forMAcontaining

≥3RCTsinvestigatinganyinterventiontopreventfallsinLTCForhospitalsinolderadultsaged≥60 years.MethodologicalqualitywasassessedbytheAMSTARtoolanddatawerenarrativelysynthesised ThemethodologicalqualityoftheMAwasmoderatetohighacrossthe10includedMA.NineMAprovided dataforLTCFandonlytwoconsideredhospitalsettings.OnlyoneMAdefinedafallandtworeported adverseevents(althoughminor).Consistentevidencesuggeststhatmultifactorialinterventionsreduce falls(includingtherate,riskandoddsoffalling)inLTCFandhospitals.Inconsistentevidenceexistsfor exerciseandvitaminDassingleinterventionsinLTCF,whilstnoMAhasinvestigatedthisinhospitals

NoevidenceexistsforhipprotectorsandmedicationreviewonfallsinLTCF.Inconclusion,multifactorial interventionsappeartobethemosteffectiveinterventionstopreventfallsinLTCFandhospitalsettings ThisisnotwithoutlimitationsandmorehighqualityRCTsareneededinhospitalsettingsinparticular FutureRCTsandMAshouldclearlyreportadverseevents

©2015ElsevierIrelandLtd.Allrightsreserved

Contents

1 Introduction 00

2 Method 00

2.1 Eligibilitycriteria 00

2.2 Searchprocedure 00

2.3 Dataextractionandsynthesis 00

2.4 Methodologicalqualityassessment 00

3 Results 00

3.1 Descriptionofsearchresults 00

3.2 Descriptionofincludedmeta-analyses 00

4 Interventionsinlongtermcarefacilities 00

∗ Corresponding author Tel.: +44 2083313000; fax: +44 1604696126.

E-mail addresses: B.Stubbs@greenwich.ac.uk , brendonstubbs@hotmail.com (B Stubbs), simone.brefka@bethesda-ulm.de (S Brefka).

1 These authors contributed equally to this work.

http://dx.doi.org/10.1016/j.maturitas.2015.03.026

0378-5122/© 2015 Elsevier Ireland Ltd All rights reserved.

Please cite this article in press as: Stubbs B, et al What works to prevent falls in older adults dwelling in long term care facilities and hospitals? An umbrella review of meta-analyses of randomised controlled trials Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.026

ARTICLE IN PRESS

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MAT-6384; No of Pages 8

4.1 ExerciseinLTCF 00

4.2 VitaminDsupplementationinLTCF 00

4.3 OthersingleinterventionsinLTCF 00

4.4 MultifactorialinterventionsinLTCF 00

4.5 Interventionsinhospitals 00

5 Discussion 00

6 Strengthsandlimitations 00

Contributors 00

Competinginterests 00

Funding 00

Provenanceandpeerreview 00

AppendixA Supplementarydata 00

References 00

1 Introduction

Fallsrepresentasubstantialthreattotheageingglobal

popula-tion’squalityoflifeandremainaleadingcauseofmorbidityand

mortality[1–3].Fallsareparticularlyproblematicandcommonin

longtermcarefacilities(LTCF)andhospitals[4].Indeed,the

conse-quencesoffallingcanbeparticularlydevastatinginthesesettings

withhighratesofinjury,reducedqualityoflifeandevendeath[4]

Hipfracturesareofparticularconcernsinceofthosethat

experi-enceahipfracture1in5willdieandlessthanonethirdwillregain

theirpreviousleveloffunctioning[5,6].Thefinancialcostsoffalling

arealsoprofound.Forinstance,arecentstudydemonstratedthat

thecostofcarefollowingahipfractureis$40,000[7].Giventhe

aforementioned,itisunsurprisingthatmanynationaland

inter-nationalguidelineshavebeendevelopedseekingtopreventfalls

[1,8,9]

Inordertopreventfallsandthesecatastrophicconsequences,a

rangeofinterventionshavebeendevelopedand testedthrough

robust randomised controlled trials (RCTs) and subsequently

summarised in systematic reviews and meta-analyses Indeed,

conclusionsbasedonsystematicreviewsofRCTsareconsidered

thetopof thehierarchyof evidence[10].Despite thefact that

meta-analysesarethecornerstoneofevidencebasedmedicineand

consideredthe“goldstandard”,thereisanincreasingrealisation

thatevenaperfectmeta-analysiswithperfectdatacanonlyprovide

apartialoverviewofaninterventionavailabletoclinicians[12]

Whenoneconsidersthecomplexnatureoffallspreventionand

multitudeofinterventionsavailable,thisnotionbecomesevidently

clear.In addition,thereis a rising challengefor busyclinicians

tokeepontopoftheevidencebaseofanygiventopicand itis

notfeasiblefor clinicianstoreadmultipleindividualsystematic

reviews.Thereforethepopularityofumbrellareviews,or

system-aticreviewsofsystematicreviewshasincreasedastheseseekto

provideclinicians,policy-makersandresearchersthehighest

qual-ityinformationinoneplaceregardinganyparticularintervention

ConsideringthepreventionoffallsinLTCFandhospitals,a

num-berofinterventionshavebeenconsideredinsystematicreviewsto

date[4]

Given the aforementioned, we sought to conduct a

com-prehensiveumbrellareview of allsystematic reviewsincluding

meta-analysesofRCTsthatsoughttopreventfallsinolderadults

dwellinginLTCFofhospitalsettings

This umbrella review followed a predetermined published

protocol (PROSPERO registration http://www.crd.york.ac.uk/

2.1 Eligibilitycriteria Meta-analysesofRCTsthatinvestigatedanyinterventionthat soughttoreducefallsinolderadultsdwellinginLTCFordelivered

inhospitalswereincluded.Morespecifically,meta-analyseshadto meetthefollowingcriteria:

Population: Older adults (mean age≥60 years and above) dwellingin LTCFor hospitals.Studiesconductedin community dwellingolderadultswereexcluded.We alsoexcludedreviews focussingsolelyonspecialistpopulations(e.g.stroke,Parkinson’s disease,dementia)inordertoincreasehomogeneity

Interventions: Any intervention that sought to prevent falls (includingtherate,number,riskoroddsoffalling)

Outcomes:Ourprimaryoutcomewastheeffectofinterventions

ontherateoffallsand/orthenumberoffallers.Wedefinedafall

as‘anunexpectedeventinwhichtheparticipantscometorestonthe ground,floor,orlowerlevel’[14].Weconsideredanytypeoffalls, includingrecurrent(2>fallsoverthestudyperiod)andinjurious falls

Nolanguagerestrictionswereplaceduponthestudieswe con-sidered.Weonlyconsideredmeta-analysesthatwereinformedby

asystematicreviewoftheliterature.Inaddition,weonlyincluded meta-analyseswhentheycontainedatleast3RCTs.Whena meta-analysisreportedmultiplesubgroupandsensitivityanalysis,we reporttheprimaryeffectsizeforeachintervention.Ifwe encoun-teredmeta-analysesthatwereupdatesfrompreviousreviews(e.g updatedCochranereview),weonlyincludedthemostrecent meta-analysis.Ifweencounteredreviewsonsimilartopicsbutcontained differentsearchstrategies,inclusioncriteria,analysesandresults

weincludedbothreviews(decidedbythreeauthors).Ifwe encoun-teredmeta-analysesincludingsomecontrolledtrials,weincluded thepooled resultsbut only if RCTsaccounted for ≥50% of the includedstudies

2.2 Searchprocedure Two independent authors (BS, SB) conducted a systematic search of MEDLINE, EMBASE, CINAHL, AMED, BNI, PsycINFO, CochraneLibrary,PubMedandthePEDrodatabasesfrominception tillOctober2014.Athirdauthor(MD)wasavailableasamediator Thekeywordsusedinthesearcheswere‘falls’or‘fall*’or‘recurrent falls’or‘injuriousfall’or‘fallprevention’AND‘randomisedcontrol trial’or‘RCT’or‘systematicreview’or‘meta-analysis’AND‘older adult’or‘elderly’or‘age’AND‘intervention’or‘exercise’or‘vitamin

Dsupplementation’or ‘multifactorial’.Weconsideredthe refer-encelistsofallpotentiallyeligiblearticlesandofarecentumbrella reviewoffallsinterventionsincommunitydwellingolderadults [13]

2.3 Dataextractionandsynthesis

Twoindependentauthorsextracteddatafromeachstudy(BS,

SB)andathirdreviewerwasavailable(MD)throughout.Thedata

extractedfromeachstudyincluded:firstauthor,yearof

publica-tion,country,setting,aim,searchstrategy,eligibilitycriteria,type

offallinvestigating,fallsdefinitionused,detailsoffalls

interven-tion,numberof studiesandnumber ofparticipants,participant

demographics,mainresults,adverseevents,heterogeneity,

pub-licationbiasandconclusions.Withintheliterature,anumberof

differentstatisticalapproacheshavebeenemployedtoconsiderthe

effectivenessoffallsinterventions.Wedidnotplaceanyrestriction

onthetypeofanalysesandconsideredrateratios(RaR=rateoffalls

betweentheinterventionandcontrolgroups),riskratios/relative

risk(RR=comparesthenumberofpeoplewhohavefallenbetween

theinterventionandcontrolgroup)andoddsratios(OR=oddsof

havingafallduringthetrial)[4,15].Collectively,werefertothe

effectofinterventionson‘falls’butwhenreferringtoindividual

meta-analysesweutilisethemeasurementinthatstudy

2.4 Methodologicalqualityassessment

Twoindependentauthors(BS,SB)completedmethodological

qualityassessmentutilisingtheassessmentof multiple

system-aticreviewstool(AMSTAR[17]).TheAMSTARtoolconsistsof11

itemsthatareratedas‘met’, ‘unclear’or‘unmet’andscoresare

givenrangingfrom0(lowquality)to11(highestquality)[17,18]

AMSTARscoresaregradedashigh(8–11),medium(4–7)andlow

quality(0–3)[17–19]

3 Results

3.1 Descriptionofsearchresults

Usingthesearchstrategy,107fulltextswereconsideredand

97articleswereexcludedwithreasons(seeonlinesupplementary

file1forlistofallexcludedstudies).Withinthefinalsample,10

uniquemeta-analyseswereincludedreporting26pooledanalyses

[4,20–28].FulldetailsofthesearchresultsarepresentedinFig.1

3.2 Descriptionofincludedmeta-analyses

Fulldetailsoftheincludedmeta-analysesaresummarisedin

Table1.Inbrief,ninemeta-analysesprovideddataforfalls

inter-ventionsinLTCF[4,20–23,25–28]andtwocontaineddataforfall

prevention interventions in hospital settings [4,24] The

meta-analysescontainedbetween3[4,21]and15[23]individualRCTs

andbetween561([4];combinedexercises)and11,275[27]unique

participantsacrossthepooledanalyses.Onlyonemeta-analyses

definedafall[22]andonlytwoprovideddetailsofadverseevents

whichwereminor[24,27](seeTable1)

Overall, the methodological quality of the included

meta-analyseswasmoderatetohigh.Morespecificallyfourweregraded

ashighquality[4,21,22,25]andsixweregradedatmoderatequality

[20,23,24,26–28].Halfofthemeta-analysesdidnotformallyassess

heterogeneitywithastatisticaltestanddetailsofthosethatdidare

summariseinTable1[20,23–25,28,26]

4 Interventions in long term care facilities

4.1 ExerciseinLTCF

Fourmeta-analysesinvestigatedarangeofexercise

interven-tionsinLTCF[4,20,23,26].Fromthese3outof10pooledanalyses

fromtwometa-analyses[20,26]demonstratedasignificanteffect

onreducingfalls(includingtheodds,rateandriskoffalling).Briefly, Guoetal.[20]pooleddatafrom10RCTs(n=1262)investigatinga rangeofexerciseinterventionsandfoundasignificantreductionin theoddsoffallingintheinterventiongroup(OR0.79(0.64–0.98)) However,whentwotaichiRCTswereremovedtheresultbecame non-significant(OR0.84(0.63–1.11),N=8,n=917).Cameronetal [4]foundthatexercisehadnosignificanteffectonreducingtherate

offallsacrossfourpooledanalyses.Sherringtonetal.[23]pooled datafrom15RCTs(n=unclear)inLTCFandalsofoundthat exer-ciseinterventionhaveanon-significanteffect.Lastly,Silvaetal [26]pooleddatafrom14RCTsinthemostrecentmeta-analyses andfoundthatexercisesignificantlyreducedtheriskoffalling(RR 0.77(0.64–0.92),n=1292).Silvaetal.[26]conductedasubgroup analysesandfoundthatonlycombinedexercisesweresignificantly associated with a reduced in the risk of fallsin LTCF (RR 0.71 (0.55–0.90),N=9,n=885,I2=72.0%)

Insummary,inconsistentevidenceexistswithevidencefrom2 from3meta-analysesor3outof10pooledresultsdemonstrating thatexercisecanreducefalls.Therefore,thebenefitsofexerciseon reducingfallsinhospitalsandLTCFarenotconsistentlyevidentin theliteraturetodate.Thisisbasedprimarilyonmoderateandhigh qualityevidence

4.2 VitaminDsupplementationinLTCF Five meta-analyses investigated the influence of vitamin D supplementationonfalls[4,20,22,25,28].Thisincludedsixpooled analysesandonlyoneofthesedemonstratedasignificantreduction

intherateoffalls[4](RaR0.63(0.46–0.86),N=5,n=4603).Ofthe remainder,oneothermeta-analysesdemonstratedatrendtowards significance[22](RR0.90(0.80–1.01),N=5,n=1428)andtwo pool-ingsfromanothermeta-analysisdemonstratedanon-significant reductionin therisk offallingfromvitamin Dsupplementation withand withoutcalcium[28].Giventhis,thecurrentevidence doesnotsupportvitaminDsupplementationtoreducefallsinLTCF currently.Thisisbasedprimarilyonmoderateand highquality evidence

4.3 OthersingleinterventionsinLTCF

Inalargemeta-analysis,Santessoetal.[27]foundthathip pro-tectorswerenoteffectiveinreducingtherateoffallsamongolder adultsdwellinginLTCF(RaR1.02(0.90–1.16),N=16,n=11,275,

I2=92%).Guoetal.[20]investigatedtheinfluenceofnutritional supplementsontheoddsoffallingandfoundithasnosignificant effect(OR0.93(0.77–1.13),N=6,n=4934).Finally,Cameronetal [4]foundnoevidencetosuggestthatimplementingamedication reviewreducestherateoffallsinolderadultsdwellinginLTCF(RR 1.00(0.91–1.10),N=4,n=4857,I2=47%)

4.4 MultifactorialinterventionsinLTCF Twometa-analyses[4,21]investigatedtheinfluenceof multifac-torialinterventionsonfalls,whichinvolvesindividuallytailoring twoormoreinterventionstoanindividualfollowingarisk assess-ment.Bothmeta-analysesproducedoneresultdemonstratingthat multifactorialinterventionsreducefallsandoveralltwofromfour pooledanalysesdemonstratedasignificanteffectonreducingfalls Specifically,Choi and Hector[21] pooled datafrom three RCTs and found a largesignificant reduction in therisk of falls(RR 0.45 (0.38–0.53), n=1291, Cochran Qp<0.001) Cameronet al [4]investigatedmultifactorialinterventionsingreaterdepthand

in their subgroup analysesdemonstrated that thesewere only effectivewhenconductedinintermediateLTCFsettings(RaR0.64 (0.50–0.83),N=3,n=670,I2=33%).Bothofthesemeta-analyses were classified as high quality according to the AMSTAR In

Please cite this article in press as: Stubbs B, et al What works to prevent falls in older adults dwelling in long term care facilities and hospitals? An umbrella review of meta-analyses of randomised controlled trials Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.026

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Fig 1.PRISMA (2009) flow diagram for search strategy

summary,althoughsparse,thereisevidencetosuggestthat

mul-tifactorialinterventionsareeffectiveinreducingfallsinLTCF

AsummaryoftheinterventionstopreventfallsinLTCFare

pre-sentedinTable2

4.5 Interventionsinhospitals

Thereisconsistentevidencefromtwometa-analyses[4,24]that

multifactorialinterventionssignificantly reduceriskand rateof

fallinginhospitals.Specifically,Cameronetal.[4]foundfromfour

RCTsinvolving6478peoplethat therateoffalling was

signifi-cantlyreduced(RaR0.69(0.49–0.96),I2=59%).Coussementetal

[24]establishedthatindividuallytailoredmultifactorial

interven-tionsreducedtheriskoffalls(RR0.74(0.58–0.96),N=4,n=3514)

However,whentheauthorscombinedthemultifactorialRCTswith

singleinterventions,theyfoundnosignificanteffectontheriskof

falls(RR0.87(0.70–1.08),N=7,n=3894).Thus,althoughsparse,

thereisevidencethatmultifactorialinterventionsareeffectivein

reducingfalls(boththerateandrisk)inhospitalsettings.Thisis

baseduponmoderateandhighqualityevidence

5 Discussion

Toourknowledge,thisisthefirstattempttoidentify,appraise

andsummarisethehighesttierofevidenceoffallsprevention

inter-ventionsin LTCFand hospitals.Thereis conflictingand limited

evidenceformostoftheinterventionstodate,althoughthe

opti-malandmostconsistentevidencetopreventfallsinbothLTCFand

hospitalsaremultifactorialinterventions.Inbothofthesesettings

thereweremoderate/high qualitymeta-analysesdemonstrating thatmultifactorialinterventionsareeffectiveinreducingfalls,but theresultswerelimitedtoonlytwoMA.Surprisingly,onlyone

oftheincludedmeta-analysesdefinedafallwithinourumbrella review.Moreover,onlytwometa-analysesreportedadverseevents arisingfromtheinterventionswhichisconcerninggivenasthis informationisequallyimportanttopolicy-makersandclinicians

toaninterventionseffectiveness.However,fromthetwo meta-analysesthatdidreportadverseeventstheywereminorandthis lackofreportingcouldrepresentinadequatereportinginthe orig-inalRCTs

Fromthisumbrellareview,itispossibletorecommend mul-tifactorialinterventionsastheoptimalmethodtopreventfallsin LTCFandhospitals,althoughtheevidencebaseisstilllimited.No clearandconsistentevidenceexistsregardingexerciseorvitamin

Dsupplementation.Thisisincontrasttoanotherrecentumbrella reviewonfallsinterventionsincommunitydwellingolderadults whichfoundconsistentevidencethatexercisewaseffectiveasa singleinterventionwith13outof14pooledanalyses demonstrat-ingapositiveeffect[13].However,whilsttheevidenceisequivocal regarding exercisein LTCF,themost recentmeta-analyses [26] foundthatexerciseiseffectiveinreducingfallsinLTCFandthat

itis mosteffectivewhenappliedfor morethan6 monthswith

afrequencyof2–3timesaweek[26].Thus,inthecaseof exer-cise,thisinconsistencyinresultsfrommeta-analysesmaybedue

tothefactthatthequalityofresearchhasonlyimprovedrecently andthushigherweightingshouldbegiventothefindingsfrom Silvaetal.[26],sincetheyappear tohaveaddressed uncertain-tiesinpreviousmeta-analyses(e.g.[4,23]).Thesamecannotbe

Table 1

Summary of included studies.

Author

(Ref)

Country Intervention and control RCTs included

(n = participants)

Participants details and setting

Define a fall? Main results (95% CI) Heterogeneity Adverse events AMSTAR Conclusion

Gou et al.

(2013) [20]

Tai Exercise v control 10 (n = 1262) Older adults

without cognitive impairment

older adults in LTCF Pooled effect become

non-significant when exclude 2× tai chi results from analysis.

Nutritional supplements and vitamin D have no significant effect on falls.

Non tai chi exercise 8 (n = 917) Mean age 64.5 to

89.0.

OR 0.84 (0.63–1.11) Nutritional supplement v

control

Control groups received TAU or another intervention Choi and

Hector

(2012) [21]

US Multifactorial

interventions

3 (n = 1291) Mean age 79.2

years

No RR 0.45 (0.38–0.53) Q = 62.7,

p < 0001

interventions reduce falls in LTCF.

LTCF Cameron

et al.

(2012) [4]

AUS Exercise care facilities: 8 (n = 1844) Care facilities 84

years & 77%

women

No RaR 1.03 (0.81–1.31) I 2 = 70% NR 10 LT care facilities:

exercise does not reduce falls as a single intervention (including when separated into high and intermediate care).

High level care 4 (n = 625) Hospitals 79 years

58% women

RaR 1.29 (0.93–1.79) I 2 = 64%

Combination exercises 4 (n = 561) RaR 1.24 (0.84–1.83) I 2 = 73%

Medication review care facilities

does not reduce falls.

supplementation does significantly reduce falls.

Multifactorial interventions care facilities:

interventions only reduce falls in intermediate care but not high level care settings.

Hospitals: multifactorial interventions

multifactorial interventions significantly reduce falls in hospital settings.

Kalyani

et al.

(2010) [22]

US Vitamin D 5 (n = 1428) 80 years and above

in hospitals or LTCF

Yes RR 0.90 (0.80–1.01) I 2 = 0% NR 9 There was a trend for

vitamin D to reduce falls in hospitals and LTCF, but this was not significant.

Sherrington

et al.

(2011) [23]

Aus Exercise 15 (n = ?) Residential care,

LTCF.

Demographics not available.

falls in LTCF residents.

Table 1 (Continued)

Author

(Ref)

Country Intervention and control RCTs included

(n = participants)

Participants details and setting

Define a fall? Main results (95% CI) Heterogeneity Adverse events AMSTAR Conclusion

Coussement

et al.

(2008) [24]

Bel Hospital fall prevention

programmes

7 (n = 3894) 69–85 years No RR 0.87 (0.70–1.08) NR 4/8 RCTs

reporter adverse events All minor.

6 Pooling single and multifactorial interventions together had

no significant effect on falls.

Single interventions 3 (n = 380) Hospitals No pooled data

Multifactorial Interventions

interventions may reduce falls, but when this analysis was adjusted for clustering it was no longer significant.

Note-2 were CCT, not RCTs.

Murad

et al.

(2011) [25]

US Vitamin D 10 (n = ?, overall

sample)

76 years, 78%

female

reduce falls in people

in institutions.

LTCF.

Silva et al.

(2013) [26]

Aus Exercise pooled analysis 14 (n = 1292)

(9 RCTs combined exercise and 5 RCTs single)

68% female, 83.9 years

No RR 0.77 (0.64–0.92) I 2 = 72.1% NR 5 Exercise is effective in

reducing falls in LTCF It is most effective when combinations of exercises are used.

LTCF

Combined exercise interventions

Single exercise interventions

Santesso

et al.

(2014) [27]

Can Hip protectors 16 (n = 11,275)

Unclear how many RCTs were LTCF? 14

65 + years No RaR 1.02 (0.90–1.16) I 2 = 92% 5% experience

skin irritation

7 Hip protectors have

no significant effect

on falls in LTCF.

LTCF

Bolland

et al.

(2014) [28]

NZ Vitamin D with (N = 1) or

without calcium (N = 5)

6 (n = 2013) Mean age 83 to 89

years in RCTs, 73–100% females

in RCTs

significant effect on falls in

a traditional meta-analysis approach.

Vitamin D no calcium 5 (n = 1430) LTCF RR 0.92 (0.82–1.02) NR Key: NR, not reported; OR, odds ratio; CI, confidence interval; RR, risk ratio; RaR, rate ratio (rate of falls); LTCF, long term care facilities; RCT, randomised control trial; N, New Zealand; Can, Canada; US, United States; Aus, Australia;

Bel, Belgium; Tai, Taiwan.

Table 2

Summary overview of findings of meta-analysis reporting the falls prevention interventions in LTCF and hospital settings.

of MA

Number of pooled analysis

Number of MA’s (pooled analysis in brackets) [references]

Overall effect % (pooled)*

Comment

Reduces falls

Increases falls

Non-significant effect Single interventions

LTCF

regarding the influence of exercise

on falls.

reduce falls Combining with calcium does not appear to have altered the effect.

nutritional supplements do not reduce falls

medication review has no significant effect on falls

protectors do not reduce falls Multifactorial, combined and multicomponent interventions

LTCF

Multifactorial interventions 2 4 2 (2) [4,21] 1 (2) [4] 50% (2/4) Multifactorial interventions may

reduce falls in LTCF, this appears most promising in intermediate care settings.

Hospital

falls in hospital settings However, one MA result was not significant when adjusted for clustering.

single and multifactorial interventions had no significant effect on falls However, separated

in subgroup analyses multifactorial interventions reduced falls Key: MA, meta-analysis; *overall effect, number of supporting associations versus overall number (pooled); LTCF, long term care facilities.

saidforvitaminDsupplementationasthemeta-analysesresults

havebroadlybeenconsistentacrossallfivethatweincluded

How-ever,whilstuncertaintyexistsandvitaminDsupplementationis

notwithoutcontroversywithintheliterature(e.g.[28,29]),

sev-eralofthesedemonstratednon-significantreductioninfalls.For

instance,Kalyanietal.[22]andBollandetal.[28]foundresultsof

RR0.90(0.80–1.01),OR0.87(0.71–1.07)andRR0.92(0.82–1.02)

forvitaminDsupplementation.Thus,vitaminDsupplementation

mayproveusefulinLTCFtopreventfalls,butinitsownrightcannot

berecommendasaprimaryintervention.Wealsofoundno

meta-analysespoolingRCTsonexerciseandvitaminDsupplementation

specificallyinhospitalsettings

Thecomparativelackofresearchinvestigatingfallsprevention

strategiesinLTCFandhospitalsisclearlynotproportionatetothe

heightenedriskandconsequencesoffallsinthesesettings[30,31]

Surprisingly,despitefallsbeingaconsiderableissueinhospitals

[30,31],weonlyidentifiedtwosystematicreviewswitha

meta-analysisofRCTsinvestigatingtheeffectofinterventionstoprevent

falls.Clearlythedearthinhighqualityevidenceisconcerninggive

thegreatneedtopreventfallsinthesesettings.However,the

avail-able evidence is encouraging demonstrating that multifactorial

interventionsthatincludeindividualriskassessmentandtailored

interventionsare effective in preventingfalls in thesesettings

Whilstthereis apaucity ofresearchinvestigating fall

interven-tionsinLTCFandhospitals,onecomfortisthatthequalityofthe

includedmeta-analyseswasmoderateandhighqualityandoverall

itishigherthanintheotherumbrellareview[13]

6 Strengths and limitations

Ourumbrellareviewhasanumberofstrengths.Weconducteda comprehensivesearchincludingonlythehighestqualityevidence (meta-analysesofRCTs)andcondensedthisinoneplacetomake thisreadilyaccessibleforclinicians.Anotherstrengthisthatthe methodologicalqualityoftheincludedmeta-analyseswas moder-ateandhigh.Whilstthisisthefirstumbrellareviewofitskindin LTCFandhospitals,a numberoflimitationsshouldbe acknowl-edgedwhich are largelyreflected by limitationsin theoriginal studiesandpaucityofdata.First,therewerearelativesmallnumber

ofeligiblemeta-analyses,particularlyinhospitalsettings,although ironicallywefoundthemostpromisingandconsistentevidence Second,notallofthestudiesassessedheterogeneityandascanbe seenfromTable1,amongthosethatdidheterogeneitywaspresent

inanumberofpooledanalyses.Third,theincludedstudiesoften analysedtheeffectofinterventionsusingdifferentsummary meas-ures(e.g.RaR,RR,OR).Fourth,oftentheindividualmeta-analyses didnotpublishspecificdetailsregardingtheincludedstudies.Thus,

itwasnotalwayspossibletodetermineclinicalhomogeneity.Fifth, severalmeta-analysesmayhaveincludedsimilarstudiesintheir analysesandtheremayhavebeensomeoverlap.Also,itisunclear

ifthelackofadverseeventsreportedintheincludedmeta-analyses

isduetotheabsenceoftheseintheoriginalstudies.Inaddition, relyinguponsystematicreviewsmaymeanthatlandmarkprimary studies are not highlighted.Finally, we could not include sev-eralreviewsthatinvestigatedfallspreventioninterventionswith

Please cite this article in press as: Stubbs B, et al What works to prevent falls in older adults dwelling in long term care facilities and hospitals? An umbrella review of meta-analyses of randomised controlled trials Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.026

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meta-analysisinmixedsettingsthatdidnotprovidesubgroup

anal-ysisforolderadultsinLTCForhospitalsettings

Nevertheless,allowingforthesecaveatsourumbrellareviewis

afirstandprovideskeyevidencefromthehighesttierofthe

evi-dencehierarchyforfallspreventioninLTCFandhospitals.Whilst

theevidenceregardingthemosteffectiveinterventionsbeyond

multifactorialprogrammesareequivocal,itisevidentlyclearthat

futuresystematicreviewsmustcarefullyconsideranddocument

adverseeventsreportedinanyoftheincludedRCTstheyinclude

Althoughthisimportantoutcomeislikelylimitedbytheprimary

studies,policiesareoftenmadebaseduponsystematicreviewsof

interventions.Therefore,itisimportantthatauthorsof

interven-tionsadequatelyreportanyharmfulsideeffectsandclearlydefine

theiroutcomemeasuresinadvance

In conclusion, although sparse, somepromising evidence to

preventfallsinLTCFandhospitalslieswithmultifactorial

inter-ventions Currently, it is not possible to make any further

recommendationsbeyondthatwithregardtosingleinterventions

suchasexerciseatthelevelofmeta-analysesofRCTs.Thereisa

needforfutureRCTsandindeedmeta-analysestocarefullyrecord

adverseeventstoinformpolicyandclinicalpractice

Contributors

Allauthors helped acquire the data, BS, DD, MDwrote the

manuscriptandSBprovidedinput.Allauthorshaveapprovedthe

finalversion

Allauthorshavenocompetinginterests

Funding

Nofunding

Notcommissioned;externallypeerreviewed

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,athttp://dx.doi.org/10.1016/j.maturitas.2015 03.026

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