Key message: In care facilities, amongst people with low levels of vitamin D, vitamin D supplementation reduces the rate of falls. Evidence on other strategies to prevent falls in hospitals and care facilities is inconclusive.

Falls by older people are common events that can have serious consequences and understanding how they can be prevented is really important.  The Cochrane Bone, Joint and Muscle Trauma Group published a large update to their review on strategies to prevent falls in older people living in the community in September and they have now followed this with an update to their review on interventions for preventing falls in older people in care facilities and hospitals. Around three times as many falls occur in people in nursing homes compared with those living in the community, at a rateThe speed or frequency of occurrence of an event, usually expressed with respect to time. For instance, a mortality rate might be the number of deaths per year, per 100,000 people. of about 1.5 falls per bed per year.

The review includes 60 randomizedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group).   controlled trialsA trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’). (20 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. with over 35,000 people in this update) with over 60,000 participants. Just over half the people studied were in care facilities and the rest in hospitals. Care facilities and hospitals were subdivided according to the level of care given. The studies tested a wide variety of interventions in many different types of care facilities in 15 countries. Interventions to prevent falls were compared with any other interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include  a drug, surgery, exercise or counselling.  , usual care or placeboAn intervention that appears to be the same as that which is being assessed but does not have the active component. For example, a placebo could be a tablet made of sugar, compared with a tablet containing a medicine..

What did they find?

• Vitamin D in a dose of 700 to 1000 IU a day reduced the rateThe speed or frequency of occurrence of an event, usually expressed with respect to time. For instance, a mortality rate might be the number of deaths per year, per 100,000 people. of falls in care facilities (5 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., 4603 participants). Participants had low levels of vitamin D at baseline
• Multifactorial approaches (offering two or more types of interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include  a drug, surgery, exercise or counselling.  , linked to each person’s riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. profile) reduced the rateThe speed or frequency of occurrence of an event, usually expressed with respect to time. For instance, a mortality rate might be the number of deaths per year, per 100,000 people. of falls in hospitals but the evidence for riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of falling was inconclusive. The effect in care homes is unclear
• The results of the 13 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. testing exercise interventions were inconsistent

How good is the evidence?

Despite the large number of trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. and participants included in the review, the authors consider that they do not provide robust evidence on the effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. of interventions for reducing falls. They note that:

• StudyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. quality was variableA factor that differs among and between groups of people. Examples include people’s age, sex, depression score or smoking habits.  
• Methods of ascertaining, recording, analysing and reporting falls varied widely
• Not all studies met the standards of the extended CONSORT statement (which aims to improve the reporting of randomized controlled trials; you can find it here http://www.consort-statement.org/consort-statement/overview0/)
• It was not possible to minimize biasAny factor, recognised or not, that distorts the findings of a study. For example, reporting bias is a type of bias that occurs when researchers, or others (e.g. drug companies) choose not report or publish the results of a study, or do not provide full information about a study. by ‘blinding’ participants and treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. providers for exercise interventions
• The level of care and case mix in each facility was often not defined
• Multifactorial interventions vary widely and this review was unable to provide evidence regarding specific components of these programmes

At the start of the year, the Chief Medical Officer for England Professor Dame Sally Davis put a spotlight on the high levels of vitamin D deficiency amongst many people in the UK, and the residents of our care homes are at high riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. for this both through age and lack of exposure to sunlight, quite aside from any dietary factors. The Department of Health recommends that this populationThe group of people being studied. Populations may be defined by any characteristics e.g. where they live, age group, certain diseases. should take a daily supplement containing 10 micrograms of vitamin D. It seems that its benefits may well include keeping them on their feet.

Links:

Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2012, Issue 12. Art. No.: CD005465. DOI:10.1002/14651858.CD005465.pub3

Cochrane summary and podcast of this review: http://summaries.cochrane.org/CD005465/interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals

Evidently Cochrane blog: Keeping the over-65s on their feet: new review evidence tells us how. 12^th September 2012.

Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3.

Department of Health: Dangers of vitamin D deficiency highlighted http://www.dh.gov.uk/health/2012/02/vitamin-d/

Department of Health: Vitamin D – advice on supplements for at risk groups (PDF)http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132508.pdf

This page was last updated: 26 March 2014