A Cochrane review [Abstract] 1 included 60 trials with a total of 60 345 subjects. Forty-three trials (n=30 373) were carried out in care facilities and 17 (n=29 972) in hospitals. The mean age of participants was 84 years (77% women) in care facilities and 79 years (58% women) in hospitals. Overall, there was no difference between intervention and control groups in rate of falls (rate ratio (RaR) 1.03, 95% CI 0.81 to 1.31; 8 trials, n=1844) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, n=1887). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care. In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, n=4603), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, n=5186). For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, n=2876) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, n=2632) suggested possible benefits, but this evidence was not conclusive. In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, n=54) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, n=83). In one trial in a subacute ward (n=54), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37). One trial (n=1822) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74). Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, n=6478) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, n=4824), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, n=199) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings.
Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment and blinding) and by inconsistency (heterogeneity in interventions and variability in results across studies).
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