An intervention designed to prevent serious fall injuries among older adults was less effective than researchers expected but did identify important ways for clinicians to help, including screening all older patients for fall risk and deprescribing certain medications when possible.
The study was conducted by Shalender Bhasin, MD, MBBS, from Brigham and Women’s Hospital, Harvard Medical School, in Boston, Massachusetts, and colleagues on behalf of the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial investigators and was published online July 8 in The New England Journal of Medicine.
Patients are often unaware of their increased risk until they have fallen for the first time, and they often underestimate how many of their risk factors can be improved, Bhasin told Medscape Medical News.
“Fall injuries are a very important cause of injury-related deaths among older adults, and these are preventable. Yet they are so difficult; for 30 years the rates of fall injuries have not declined,” he said.
Using a pragmatic, cluster-randomized trial, the researchers studied the clinical effectiveness of a “patient-centered intervention that combined elements of practice redesign (reconfiguration of workflow to improve quality of care) and an evidence-based, multifactorial, individually tailored intervention implemented by specially trained nurses in primary care settings,” the authors explain.
Participants in the intervention group worked with trained nurses (fall care managers) to identify their risk factors and determine which risks they wanted to modify. Participants in the control group received their typical care and a pamphlet with information on falls and were encouraged to talk with their primary care physicians (who received the results on risk factor screening) about fall prevention. Those in the intervention group also received the pamphlet.
Fall care managers evaluated patients’ home environments and in some cases visited the patient’s home, Bhasin said.
The researchers enrolled community-dwelling adults aged 70 years or older who were at higher risk for fall injuries from 86 primary care practices across 10 US healthcare systems. Half of the practices were randomly assigned to provide the intervention to their patients; the other half of the practices provided enhanced usual care.
The researchers defined patients with increased risk for fall injuries as those who had suffered a fall-related injury at least twice during the previous year or those whose difficulties with balance or walking made them fearful of falling. Serious fall injuries were defined as falls that cause a fracture (other than a thoracic or lumbar vertebral fracture), joint dislocation, a cut needing closure, or falls that resulted in hospital admission for a “head injury, sprain or strain, bruising or swelling, or other serious injury,” they explain.
Demographic and baseline characteristics were similar for both groups of patients (mean age, 80 years; 62.0% women); 38.9% had experienced a fall-related injury during the previous year, and 35.1% had suffered at least two falls during the previous year.
The researchers hypothesized that serious fall injuries would be 20% lower in the intervention group compared with the control group, but that was not the case.
The findings showed no significant difference between the intervention group (4.9 events per 100 person-years of follow-up) and the control group (5.3 events per 100 person-years of follow-up) for the rate of first adjudicated serious fall injury (hazard ratio [HR], 0.92; P = .25).
Results were similar in a practice-level analysis and a sensitivity analysis adjusted for participant-level covariates.
However, there was a difference in rates of first participant-reported fall injury, which was a secondary endpoint, at 25.6 events per 100 person-years of follow-up among participants in the intervention group vs 28.6 events among those in the control group (HR, 0.90; P = .004).
There were no significant differences between the groups for rates of all adjudicated serious fall injuries and all patient-reported fall injuries. Bone fractures and injuries resulting in hospitalization were the most frequent types of adjudicated serious fall injuries.
Rates of serious adverse events resulting in hospitalization were similar for the intervention group and the control group (32.8 vs 33.3 hospitalizations per 100 person-years of follow-up, respectively), as well as rates of death (3.3 deaths per 100 person-years of follow-up in both groups).
Simple Steps Can Help
“The most important thing clinicians can do is a quick screen for fall injury risk,” Bhasin told Medscape Medical News. The screening tool he uses consists of three questions and can be completed in less than a minute. Clinicians should share that information with patients, he continued.
“Just recognizing that they are at risk for falls, patients are much more motivated to take action,” Bhasin added.
The top three risk factors identified among trial participants were trouble with strength, gait, or balance; osteoporosis or vitamin D deficiency; and impaired vision. “The use of certain medications, postural hypotension, problems with feet or footwear, and home safety hazards were less commonly identified, and the use of certain medications was the least commonly prioritized,” the authors write.
It is vital that clinicians help patients implement changes, Bhasin said. He noted that many patients encounter barriers that prevent them from taking action, including transportation or insurance problems and lack of access to exercise programs in the community.
Deprescribing medications such as sleep medications and benzodiazepines is also a key piece of the puzzle, he added. “They’re pretty huge risks and yet it is so hard to get people off these medications.”
Future research will focus on how to improve the intervention’s effectiveness and also will test the strategy among those with cognitive impairments who have even higher risk for fall injuries, Bhasin said.
Falls Remain Common
A report published online July 9 in Morbidity and Mortality Weekly Report underscores the prevalence of fall-related injuries: In 2018, more than one quarter (27.5%) of adults aged 65 years or older said they had fallen at least once during the previous year (35.6 million falls), and 10.2% said they had experienced a fall-related injury (8.4 million fall-related injuries). The percentage of adults who reported a fall increased from 2012 to 2016, then decreased from 2016 to 2018.
Briana Moreland, MPH, from Synergy America, Inc, and the Division of Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), both in Atlanta, Georgia, and colleagues write that older adults and healthcare providers can work together to reduce fall risk.
“CDC created the Stopping Elderly Accidents, Deaths and Injuries (STEADI) initiative, which offers tools and resources for health care providers to screen their older patients for fall risk, assess modifiable fall risk factors, and to intervene with evidence-based fall prevention interventions (https://www.cdc.gov/steadi). These include medication management, vision screening, home modifications, referral to physical therapists who can address problems with gait, strength, and balance, and referral to effective community-based fall prevention programs,” Moreland and colleagues explain.
Bhasin has received grants from the National Institute on Aging (NIA) and Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study. He has received grants, personal fees, and nonfinancial support from AbbVie, grants from Transition Therapeutics, grants from Alivegen, grants from Metro International Biotechnology, and personal fees from OPKO, outside the submitted work. Latham has received grants from the NIA and PCORI during the conduct of the study and is co-owner of Lynx Health LLC. Peduzzi received grants and other compensation from NIA-PCORI during the conduct of the study. Reuben and Gill have disclosed no relevant financial relationships. The remaining authors report a variety of relevant financial relationships; a complete list is available on the journal’s website. The authors of the article in Morbidity and Mortality Weekly Report have disclosed no relevant financial relationships.
N Engl J Med. Published online July 8, 2020. Abstract
Morb Mortal Wkly Rep. Published online July 9, 2020. Full text
Troy Brown is an award-winning Medscape contributor with a special interest in infectious diseases, women’s health, and pediatrics.