Multifactorial and multiple component interventions for preventing falls in older people living in the community.

Abstract

Multifactorial fall prevention interventions are those where intervention components are tailored to each person's individual fall risk factor profile. Multiple component interventions provide the same components to everyone. The evidence on the effects of these interventions is inconclusive. This review updates one published on the Cochrane Library in 2018. To assess the effects of multifactorial and multiple component fall prevention interventions compared to usual care or attention control, exercise, and falls prevention advice or education in community-dwelling older people. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, ClinicalTrials.gov, the WHO ICTRP, and reference lists, without restrictions on language or full-text publication, on 16 May 2024. We included randomised controlled trials (RCTs) of community-dwelling older people (≥ 60 years) evaluating multifactorial or multiple component fall prevention interventions. We excluded quasi-randomised trials, stroke or Parkinson's disease populations, and comparisons with single active interventions other than exercise. Our critical outcomes were falls rate (falls per person-year), risk of falling (number of people sustaining one or more falls), and risk of recurrent falls (number of people sustaining two or more falls). We assessed risk of bias in the included studies using Cochrane's RoB 1 tool. We calculated rate ratios (RaR) and risk ratios (RR) with 95% confidence intervals (CIs). Where possible, outcomes were synthesised using random-effects meta-analysis and pooled with the generic inverse-variance method; otherwise, findings were narratively summarised. We assessed the certainty of evidence using the GRADE approach. This update includes 110 RCTs involving 48,919 older people. Risk of bias was mixed, and there was potential publication bias in a few comparisons. Multifactorial interventions versus usual care or attention control Multifactorial interventions may reduce falls rate (RaR 0.76, 95% CI 0.67 to 0.87; I² = 92%; 29 trials, 9442 participants; low-certainty evidence) and the risk of recurrent falls (RR 0.87, 95% CI 0.78 to 0.98; I² = 45%; 17 trials, 4826 participants; low-certainty evidence). They may have little or no effect on the risk of falling (RR 0.95, 95% CI 0.90 to 1.01; I² = 55%; 38 trials, 12,774 participants; low-certainty evidence). Multifactorial interventions versus exercise The evidence on falls rate and risk of falling is very uncertain (very low-certainty evidence). Risk of recurrent falls was not evaluated. Multifactorial interventions versus falls advice or education Multifactorial interventions provide no additional benefit and probably increase falls rate by a small amount (RaR 1.09, 95% CI 1.00 to 1.18; I² = 27%; 7 trials, 9901 participants; moderate-certainty evidence). They probably have little or no effect on the risk of falling (RR 0.99, 95% CI 0.93 to 1.05; I² = 0%; 7 trials, 8850 participants; moderate-certainty evidence) and recurrent falls (RR 0.99, 95% CI 0.89 to 1.10; I² = 0%; 3 trials, 7865 participants; moderate-certainty evidence). Multiple component interventions versus usual care or attention control Multiple component interventions may have little or no effect on falls rate (RaR 0.91, 95% CI 0.80 to 1.04; I² = 72%; 14 trials, 4026 participants; low-certainty evidence) and may reduce the risk of falling (RR 0.88, 95% CI 0.80 to 0.97; I² = 54%; 19 trials, 6925 participants; low-certainty evidence). We are uncertain if they reduce the risk of recurrent falls (very low-certainty evidence). Multiple component interventions versus exercise Multiple component interventions may have little or no effect on falls rate (RaR 0.91, 95% CI 0.80 to 1.04; I² = 54%; 8 trials, 2160 participants; low-certainty evidence) and recurrent falls (RR 0.97, 95% CI 0.69 to 1.35; I² = 21%; 5 trials, 874 participants; low-certainty evidence). They likely have little or no effect on the risk of falling (RR 0.97, 95% CI 0.90 to 1.05; I² = 0%; 10 trials, 2920 participants; moderate-certainty evidence). Multiple component interventions versus falls advice or education Multiple component interventions may have little or no effect on falls rate (RaR 0.96, 95% CI 0.85 to 1.08; I² = 75%; 7 trials, 9313 participants; low-certainty evidence) and risk of falling (RR 1.05, 95% CI 0.95 to 1.17; I² = 60%; 8 trials, 9355 participants; low-certainty evidence). They likely have little or no effect on recurrent falls (RR 0.93, 95% CI 0.83 to 1.05; I² = 18%; 6 trials, 8725 participants; moderate-certainty evidence). Adverse effects Adverse effects across all six comparisons were generally mild, indicating that both interventions were safe and well-tolerated. Multifactorial interventions may slightly reduce falls rate and the risk of recurrent falls, but may have little or no effect on the risk of falling, compared with usual care or attention control. When compared with exercise, their effects on falls rate and risk of falling are uncertain. Multifactorial interventions provide no additional benefit for falls rate and probably have little or no effect on the risk of falling and recurrent falls when compared with falls advice or education. Multiple component interventions may have little or no effect on falls rate compared with usual care or attention control, exercise, or falls advice or education. They may also have little or no effect on the risk of falling compared with usual care or attention control or falls advice or education, and on the risk of recurrent falls compared with exercise. Multiple component interventions probably have little or no effect on the risk of falling compared with exercise and on the risk of recurrent falls compared with falls advice or education. The effect on recurrent falls compared with usual care or attention control is very uncertain. The certainty of evidence for most comparisons was limited by risk of bias and statistical heterogeneity. NIHR Exeter Biomedical Research Centre, Dennis and Mireille Gillings Foundation, Bateman Family Charitable Trust, NIHR SPCR Post-doctoral fellowship. Not applicable.