falls prevention education for older adults during and ......or video or media or publication or...

Falls prevention education for older adults during and after hospitalization: A systematic

review and meta-analysis Supplementary materials on patient education for the

prevention of falls

May 2013

i

Contents Search string terms and limiters applied to databases........................................................................... 1

Keywords used and PICO model ............................................................................................................. 2

Subcategories of patient education intervention with or without other interventions during

hospitalization ......................................................................................................................................... 3

Subcategories of patient education intervention with or without other interventions post-

hospitalization ......................................................................................................................................... 6

Risk of bias assessment of included studies (based on the “Law tool”) ............................................... 10

Studies of hospitalized older adults (multifactorial falls prevention program that consisted of

patient educational component) ...................................................................................................... 10

Studies of hospitalized older adults (education intervention only).................................................. 12

Studies of post-hospitalized older adults (education intervention only) ......................................... 14

Studies of post-hospitalized older adults (multifactorial falls prevention program that consisted of


Calculation of effect size estimates of primary outcomes .................................................................... 18

Table of risk ratio, confidence interval and standard error of studies used for meta-analysis ............ 20







Forest plots of meta-analysis, subgroup meta-analysis and a priori meta-analysis ............................. 26

ii

Analysis 1.1 Proportion of patients who became fallers (all studies) ............................................... 26

Analysis 1.2 Subgroup meta-analysis of proportion of patients who became fallers (hospital setting)

.......................................................................................................................................................... 26

Analysis 1.3 Subgroup meta-analysis of proportion of patients who became fallers (post discharge

setting) .............................................................................................................................................. 27

Analysis 1.4 Proportion of patients who became fallers (studies with only cognitive intact

participants) ...................................................................................................................................... 27

Analysis 1.5 Proportion of patients who became fallers (studies with cognitive intact and impaired

participants) ...................................................................................................................................... 28

Analysis 1.6 Proportion of patients who became fallers (studies with only cognitive impaired

participants) ...................................................................................................................................... 28

Analysis 2.1 Rate of falls (all studies) ................................................................................................ 29

Analysis 2.2 Rate of falls (studies with only cognitive intact participants) ....................................... 29

Analysis 2.3 Rate of falls (studies with cognitive intact and impaired participants) ........................ 30

Analysis 2.4 Rate of falls (studies with only cognitive impaired participants) .................................. 30

Analysis 3.1 Rate of injurious fall (all studies) ................................................................................... 31

Analysis 3.2 Rate of injurious fall (studies with cognitive intact and impaired participants) ........... 31

Analysis 3.3 Rate of injurious fall (studies with only cognitive intact participants) ......................... 32

Analysis 4 Proportion of fallers with injury (all studies) ................................................................... 32

Analysis 5.1 Rate of hospital readmission due to falls (all studies) .................................................. 33

Analysis 5.2 Rate of hospital readmission due to falls (studies with only cognitive intact

participants) ...................................................................................................................................... 33

iii

Analysis 5.3 Rate of hospital readmission due to falls (studies with cognitive intact and impaired

participants) ...................................................................................................................................... 34

Analysis 6 Rate of emergency department presentations due to falls (all studies) ......................... 34

Citations of included studies in the review ........................................................................................... 35

Characteristics of included studies ....................................................................................................... 38







Characteristics of excluded studies....................................................................................................... 66

1

Search string terms and limiters applied to databases

(older adult OR older people OR older patient* OR aged OR elderly OR geriatric) AND (information

OR counselling OR consultation OR advice OR discuss* OR education OR pamphlet* OR brochure*

OR video OR media OR publication OR leaflet* OR internet) AND ( attitude* OR motivation OR

intention OR participat* OR program OR prevent* OR adherence OR change OR action OR health

beliefs OR awareness) AND (fall* OR fall* risk* OR accidental fall*) AND ( hospital* OR community

OR discharge OR transition OR post hospitali*ation)

Ovid MEDLINE limiters: English, human, aged 65

PsycINFO limiters: Human, English language, aged 65 years or older

CINAHL limiters: English language, aged 65+years, human and research articles

Scopus limiters: English, aged, humans and journal. Inverted commas were used for phrasing

health beliefs, fall* risk*, accidental fall and post hospitalisation.

Cochrane central register of control trials: No limiter

2

Keywords used and PICO model

Patient group terms Intervention terms

Outcome terms i)

Outcome terms ii)

Context

Older adult Older people Elderly Aged Geriatric Older patient*

Information Counselling Consultation Advice Discuss* Education Pamphlet* Brochure* Video Media Publication Leaflet* internet

Intention Attitude* Motivation Health beliefs Participat* Prevent* Program Adherence Change Action Awareness

Fall* Fall* risk* Accidental fall*

Hospital* Community Discharge Transition Post hospitali*ation

3

Subcategories of patient education intervention with or without other interventions during hospitalization

Studies of hospitalized older adults

1:1 education session

Group education program

Information leaflet/brochures/written information/posters

Counseling/ Advice

Video/ Media/ internet

Other non- educational interventions

Intensity of education as defined by review authors

Location of education intervention

Location of follow-up

Haines (2004)

** To patient: 4 half hour sessions twice weekly (fall prevention in hospital)

** Handbook (Nature of hospital falls and ways to prevent them) Falls risk alert card

** Intensive Hospital Hospital

Haines (2006)

** As above

** As above


Ang (2011) ** To patient+/-family: 30 minutes education (individual risk factors and fall reduction strategies)


Cumming (2008)

** To patient and family: (safe mobility on ward, use of gait aids, need for supervision)

** Brief Hospital Hospital

Dykes (2010)

** To patient: Tailored handouts to reduce individual fall risks


4

Tailored poster to reduce individual risk

Vassallo (2004)

** To patient: Specific safety advice on ward


Von R-Kruse

(2007) ** To patient and family: (individual falls risk and preventive measures, ADL training for carers)

** 5 page flyer to at risk patients and their family. (Explained risks, preventive measures, recommendations on safety, eye and footwear, ask for help, hydration and turn on light when getting out of bed at night) Risk alert sign


Healey (2004)

** To patient: Advice on footwear safety, change body position slowly(postural hypotension),use of nurse call button


Clarke (2012)

To patients: One education session of 15 to 30 minutes on fall risk factors and ways to prevent falls Knowledge test conducted after the session

Information leaflet given to patient

Intensive Hospital Hospital

Haines (2011)

** To patient: Variable no. of sessions as

** To patient: Written information (based on Health Belief Model)

** To patient: Video


5

needed (based on HBM)

(based on Health Belief Model)

Hill (2009)

** To patient: Written information (based on Health Belief Model)

** To patient: Video (based on Health Belief Model)

Brief Hospital Hospital

Hill€

(2011) ** (based on Health Belief Model, Haines 2011)

** Written information (based on Health Belief Model, Haines 2011)

** Video (based on Health Belief Model, Haines 2011)


Tzeng (2008)

** To patient: Brochure on falls prevention (No detail)

** To patient: Advice (No detail)

Brief Hospital Community

** Denotes intervention

€Falls after discharge from hospital: Is there a gap between older people’s knowledge about falls prevention strategies and the research evidence.

Intervention was applied in a previous RCT (Haines 2011)

6

Subcategories of patient education intervention with or without other interventions post-hospitalization

Studies of post hospitalized older adults

1:1 education session

Group education program

Information leaflet/brochure/booklet/written information/posters

Counseling/ Advice

Video/ Media/ internet

Other non-educational interventions

Intensity of education as defined by review authors

Location of education intervention

Location of follow- up

Hill‡




Intensive Hospital Community

Hill ≠




Intensive Hospital Hospital and community

Buri (1997)

** To patient: Two 20 minutes sessions on 2 days. (risk factors for falls, exercises, how to get up from floor, identify hazards,

** To patient: (content based on group education program)

Intensive Hospital Hospital and community

7

info on aids and help) Based on Cimprich And Hilton (1992)

Rucker (2006)

** To patient: Leaflet (reduction of environmental hazards and optimising physical health)

** To patient: 10 minutes telephone counselling (reinforce info in leaflet and to answer questions)

Brief Emergency department and community

community

Batchelor (2012)

** To patient: Booklet(A guide to preventing falls)

** To patient and carer about falls risk factors and risk minimization

** Brief Community Community

Close (1999)

** To patient: home safety and modification

** Brief Emergency department and community

Community

Banez (2008)

** To patient: 1 hour weekly of 12 week duration. Various topics (falls prevention, osteoporosis diet and community

** To Patient: Handouts based on weekly education

** To patient: Counselling on fall risk factors and other concern (unknown duration)

** Intensive Community Community

8

resources)

Lightbody (2002)

** To patient: Home safety and modification


McQueen (2003)

** To patient: 8 week program of hourly duration (various topics: diet, Osteoporosis, falls action planning, home safety, getting up from floor, community resources)

** Intensive Community Community

Nikolaus (2003)

** To patient: Use of technical and mobility aid

** To patient: falls risk, home safety and modification


Russell (2010)

** To patient: Hip protector, Footwear safety, vision check, home safety modification


Community

Whitehead (2003)

** To patient: Home safety and


community

9

modification

Wong (2010)

** To patient+/-family: Home safety modification, carer education

Brief Hospital and community

Community

‡ Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a randomised

controlled trail. Intervention was applied in a previous RCT (Haines 2011)

≠Factors associated with older patients’ engagement in exercise after hospital discharge. Intervention was applied in a previous RCT (Haines 2011)

** denotes intervention

10

Risk of bias assessment of included studies (based on the “Law tool”)

Studies of hospitalized older adults (multifactorial falls prevention program that consisted of patient educational

component)

Author (year)

Study Purpose Purpose was stated

Literature Background literature was reviewed

Design and Bias 1.Selection bias avoided 2.Measurement bias avoided 3.Intervention bias avoided

Sample 1.N 2.Sample was described 3.Sample size was justified

Outcomes 1.Measures were reliable 2.Measure were valid

Intervention 1.Intervention described in detail 2.Contamination was avoided 3.Co-intervention was avoided

Results 1.Results were reported in statistical significance 2.Analysis was appropriate 3.Clinical importance was reported 4.Drop-outs were reported

Conclusions and clinical implications Conclusions were appropriate given study methods and results

Score ( /18) Quality Rating 0-9=Low 10-14= Moderate 15-18= High

Haines (2004)

Yes Yes RCT 1. Yes 2. No 3. No

1. Yes 2. Yes 3. Yes

1.Yes 2.Yes

1. Yes 2. Unclear 3. Unclear

1. Yes 2. Yes 3. Yes 4. Yes

Yes 14 Moderate

Haines (2006)



1.Yes 2.Yes

1. Yes 2. No 3. No


Yes 14 Moderate

Ang (2011)

Yes Yes RCT 1. Yes 2. No


1.Yes 2.Yes


1.Yes 2.Yes 3.Yes

Yes 14 Moderate

11

3. Unclear 4. Yes Cumming (2008)

Yes Yes Cluster randomised trial

1. Yes 2. No 3. No


1. Yes 2. Yes

1. Yes 2. Yes 3. No

1. Yes 2. Yes 3. Yes 4. N/A

Yes 14/17 Moderate

Dykes (2010)

Yes Yes Clustered randomised trial 1.Yes 2.Unclear 3.Unclear


1. No 2. No

1. Yes 2. Yes 3. Unclear


Yes 12/17 Moderate

Vassallo (2004)

Yes Yes parallel design 1. Yes 2. Yes 3. Unclear


1. No 2. No

1. Yes 2. Yes 3. No


Yes 13/17 Moderate

Von R-Kruse (2007)

Yes Yes Before and after design 1.Yes 2.Unclear 3.No


1. Yes 2. Yes

1. Yes 2. N/A 3. No


Yes 12/17 Moderate

Healey (2004)

Yes Yes Clustered randomised trial

1. Yes 2. Yes 3. No


1. No 2. No

1. No 2. Yes 3. No

1. Yes 2. No 3. No 4. N/A

No 9/17 Low

12

Studies of hospitalized older adults (education intervention only)

Author (year)









Score ( /18) Quality rating 0-9=Low 10-14= Moderate 15-18= High

Clarke (2012)

Yes Yes Retrospective cohort

1. Unclear 2. Unclear 3. unclear


1. Yes 2. Yes



Yes 11/17 Moderate

Haines (2011)

Yes Yes RCT 1. Yes 2. Yes 3. No


1.Yes 2.Yes

1. Yes 2. Yes 3. No


Yes 16 High

Hill (2009)


1. Yes 2. Yes 3. unclear

1. Unclear 2. Unclear



Yes 12 Moderate

13

Hill €

(2011)

Yes Yes Cross sectional 1. N/A 2. Yes 3. N/A

1. Yes 2. Yes 3. N/A

1.Unclear 2.Unclear

1. N/A 2. N/A 3. N/A

1.N/A 2.Yes 3.Yes 4.N/A

Yes 8/10 Low

Tzeng (2008)

Yes Yes Cross sectional 1. Yes 2. Yes 3. N/A

1. Yes 2. Yes 3. No

1. Yes 2. Yes

1. N/A 2. N/A 3. N/A

1. Yes 2. Yes 3. Yes 4. No

No 11/14 Moderate

€Falls after discharge from hospital: Is there a gap between older people’s knowledge about falls prevention strategies and the research evidence

14

Studies of post-hospitalized older adults (education intervention only)

Author (year)










Hill‡

(2011)

Yes Yes Cohort 1. N/A 2. No 3. N/A


1.Yes 2.Yes

1. N/A 2. N/A 3. N/A

1.Yes 2.Yes 3.Yes 4.Yes

Yes 11/12 Moderate

Hill≠

(2011)

Yes Yes Cross sectional 1. N/A 2. Unclear 3. N/A



1. N/A 2. N/A 3. N/A

1.Yes 2.Yes 3.Yes 4.Yes

Yes 9/12 Low

Buri (1997)

Yes Yes Before and after 1. No 2. Yes 3. No

1. Yes 2. Yes 3. No

1. Unclear 2. unclear

1. Yes 2. N/A 3. No


Yes 11/17 Moderate

Rucker (2006)

Yes Yes Controlled pilot trial(quasi experimental)



1. Yes 2. Yes 3. No


Yes 14 Moderate

15

1. Yes 2. Yes 3. No

4. Yes

‡Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a randomised

controlled trail

≠ Factors associated with older patients’ engagement in exercise after hospital discharge

16

Studies of post-hospitalized older adults (multifactorial falls prevention program that consisted of patient

educational component)

Author (year)




Sample 1.N

2.Sample was described

3.Sample size was justified

Outcomes 1.Measures were reliable

2.Measure were valid





Batchelor (2012)

Yes Yes RCT 1. Yes 2. No 3. Unclear


1. Yes 2. Yes



Yes 13 Moderate

Close (1999)

Yes Yes RCT 1. Yes 2. No 3. unclear


1. No 2. No



Yes 13 Moderate

Banez (2008)

Yes Yes Before and after design

1. No

1. Yes 2. No 3. No

1. No 2. No

(falls

1. Yes 2. N/A 3. Unclear

1. No 2. Yes 3. Yes

Yes 8/17 Low

17

2. No 3. unclear

data) 4. Yes

Lightbody (2002)



1. No 2. No



Yes 13 Moderate

McQueen (2003)

Yes Yes Before and after design

1. Unclear 2. Unclear 3. Unclear

1. Yes 2. No 3. No

1. No 2. No

(falls data)

1. Yes 2. N/A 3. No

1. No 2. Yes 3. Yes 4. Yes

Yes 8/17 Low

Nikolaus (2003)



1. Yes 2. Yes



Unclear 14 Moderate

Russell (2010)



1. Yes 2. Yes



Yes 15 High

Whitehead (2003)



1. Yes 2. Yes

1. Unclear 2. Unclear 3. Unclear


Yes 12 Moderate

Wong (2010)

Yes Yes Cross sectional Design

1. Yes 2. No 3. No

1. No 2. No 3. Yes


1. Yes 2. Yes 3. No

1. Yes 2. Yes 3. Yes 4. No

No 9 Low

18

Calculation of effect size estimates of primary outcomes

For outcome i) The proportion of patients who became fallers and outcome iii) Proportion

of patients who had an injurious fall (relative to all patients)

STATA (version 12, college station TX) was used to calculate a relative risk.

An integer of one was added to each cell in the 2x2 contingency table if there was a

zero cell so as to obtain a finite odds ratio.

For studies that involved allocation of intervention and control conditions to hospital wards

rather than individual patients (eg. cluster randomised trials, parallel control group studies),

95% confidence interval of the ratio was adjusted before pooling using the approach of

White and Thomas (White and Thomas 2005)and the intra-cluster correlation coefficient

reported by Cumming (2008)study.

Adjustment of 95% confidence interval for clustering used in cluster randomised

trials

Step 1: To calculate design effect (DE) for the study:

DE= 1+ (n per cluster-1) x Intra cluster coefficient

Where n per cluster =

Intra cluster coefficient=0.014 from Cumming (2008)

Step 2: To calculate standard error (normal) for the study:

Standard error

(normal)=

19

Step 3: To calculate standard error (corrected) for studies:

Standard error (corrected) =Standard error (normal) x √

For outcome ii) Rate of falls, outcome iv) Rate of injurious falls, outcome v) Rate of hospital

readmission due to falls and outcome vi) Rate of emergency department presentations due

to falls

if hazard ratios or incidence rate ratio were not provided, an estimate of the relative

rate using the formula for calculating a relative risk (Altman and Deeks 2002)was

calculated where the number of fallers was replaced with the number of falls in each

group and the number of non-fallers with the number of patient days in each group.

Previous research has shown that this relative rate approach produced similar point

estimates to survival analysis and negative binomial analysis approaches, however

the relative rate approach produces 95% confidence intervals that are too narrow in

range (Haines and Hill 2011). To account for this, an inflation factor was determined

from two trials included in this review that had the same patient-level data that was

calculated from a negative binomial regression (Haines 2004 and 2011). An inflation

factor of 1.24 and 1.39 was required and therefore we decided to multiply the log

natural standard error of relevant estimates by 1.3 in order for its 95% confidence

intervals to be the same width as that from the negative binomial regression

generated incidence rate ratio. This improved the estimate for inclusion in the meta-

analysis (Haines and Hill 2011).These estimates were also inflated to account for the

intra-cluster correlation as described above if warranted by the study design.

20

Table of risk ratio, confidence interval and standard error of studies used for meta-analysis

Studies of hospitalized older adults (multifactorial falls prevention program that consisted of patient educational component) Study (year)

Proportion of fallers Rate of falls Proportion of fallers with injury Rate of injurious fall

RR (lnRR)

Lower range 95%CI (ln)

Upper range 95%CI (ln)

SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

Haines (2004) 0.78 (-0.2485)

0.56 (-0.5798)

1.06 (0.0583)

0.1628 0.7086Ω

(-0.3445)

0.55 (-0.5978)

0.91 (-0.0943)

0.1249Ω

0.7098£

(-0.3428)

0.3364a

(-1.0896)

1.4978a

(0.404)

0.3810a

Haines (2006) Subgroup of Haines 2004: cognitive intact participants only

1.59 (0.4637)

0.71 (-0.3425)

3.58 (1.2754)

0.4127 0.4526 (-0.7927)

0.16a

(-1.8326)

1.25a

(0.2231)

0.5200a

Haines (2006) Subgroup of Haines 2004: cognitive impaired participants only

1 (0)

0.43 (-0.8440)

2.34 (0.8502)

0.4322 0.6172 (-0.4826)

0.25a

(-1.3863)

1.54a

(0.4318)

0.4656a

Ang (2011)

0.29*

(-1.2379)

0.1*

(-2.3026)

0.89*

(-0.1165)

0.5577 0.30y

(-1.2040)

0.10y

(-2.3026) 0.91

y

(-0.0943)

0.5633 0.6013£

(-0.5086)

0.1441 (-1.9370)

2.5087 (0.9198))

0.7288

Cumming (2008)

1.0469£

(0.0459)

0.704¢

(-0.351)

1.557¢

(0.4428)

0.2025¢

0.96x

(-0.0408)

0.72x

(-0.33)

1.28x

(0.25)

0.1468 1.2002£

(0.1825)

0.6471¢

(-0.4352)

2.2260 ¢

(0.8002)

0.3152¢

1.12x

(0.1133)

0.71x

(-0.3425)

1.77x

(0.5710)

0.233

Dykes (2010)

0.7618£

(-0.2721)

0.1923¢

(-1.6486)

3.017¢

(1.1044¢)

0.7023¢

0.7536Ω

(-0.2829)

0.5752 (-0.553)

0.9873 (-0.0128)

0.1378Ω 1.1681

£

(0.1554)

0.01¢a

(-4.6746)

146.26¢a

(4.9854)

2.4644¢a

Vassallo (2004)

0.7027£

(-

0.3364¢

(-

1.4679¢

(0.3838)

0.3758¢

1.070£

(0.0676)

0.473¢a

(-0.7487)

2.4203¢a

(0.8839)

0.4165¢a

0.4889£

(-

0.1189¢

(-

2.0107¢

(0.6985)

0.7215¢

21

0.3528) 1.0894) 0.7156) 2.1297)

Von R-Kruse (2007)

0.7740 (-0.2562)

0.6827 (-0.3816)

0.8775 (-0.1307)

0.0640 0.82b

(-0.1985)

0.73 (-0.3147)

0.92 (-0.0834)

0.0590 0.84b

(-0.1744)

0.67 (-0.4005)

1.04 (0.0392)

0.1122

Healey (2004)

0.705 (-0.3496)

0.3021¢a

(-1.1969)

1.6449¢a

(0.4977)

0.4323¢a

1.352 (0.3016)

0.2253¢a

(-1.4904)

8.1141¢a

(2.0936)

0.9143¢a

RR rate ratio

ln log natural

CI confidence interval

SE standard error

ΩData supplied by trial author on contact

£rate ratio calculated by review author

*Adjusted rate ratio provided by trial author for age and gender (time to first fall)

yHazard ratio provided by trial author adjusted for age and gender

¢Corrected by review author for clustering using intracluster correlation coefficient 0.014 given in Cumming (2008) paper

xIRR adjusted for clustering, length of stay and previous falls by trial author

aAdjusted by inflation factor calculated by author

b Incidence rate ratio provided by trial author

22

Studies of hospitalized older adults (education intervention only) Study (year)


RR (lnRR)



SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

Haines (2011) 0.74 (-0.3011)

0.48 (-0.7340)

1.15 (0.1398)

0.2229 0.83 (-0.1863)

0.54 (-0.6162)

1.27 (0.2390)

0.2182 1.22 (0.1989)

0.69 (-0.3711)

2.20 (0.7885)

0.2958

Haines (2011) Subgroup: cognitive intact participants only

0.51 (-0.6733)

0.28 (-1.2730)

0.94 (-0.0619)

0.3090 0.43 (-0.8440)

0.24 (-1.4271)

0.78 (-0.2485)

0.3007 0.53 (-0.6349)

0.23 (-1.4697)

1.22 (0.1989)

0.4256

Haines (2011) Subgroup: cognitive impaired participants only

1.38 (0.3221)

0.70 (-0.3567)

2.75 (1.0116)

0.3490 1.48 (0.3920)

0.86 (-0.1508)

2.53 (0.9282)

0.2753 2.63 (0.9670)

1.19 (0.1740)

5.84 (1.7647)

0.0444

Clarke (2012)

0.2842£

(-1.2581)

0.0063£

(-5.0672)

2.1938£

(0.7856)

1.4931£ 0.4630

£

(-0.7700)

0.0097£

(-4.6356)

4.2534£

(1.4477)

1.5519£

£rate ratio calculated by review author (one added to all cells in 2x2 table due to zero odds ratio, Clarke 2012)

23

Studies of post-hospitalized older adults (education intervention only) Study (year)


RR (lnRR)



SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

RR (lnRR)



SE ln

Hill ‡ (2011) 1.34

b(0.2927)

0.76(-0.2744)

2.37(0.8629) 0.2901 1.18b

(0.1655)

0.71 (-0.3425)

1.96 (0.6729)

0.2590 1.00b

(0)

0.6 (-0.5108)

1.66 (0.5068)

0.2596

Rucker (2006)

4.3¥

(1.4586) 0.9 (-0.1054)

19.8 (2.9857)

0.7885

Study (year)

Rate of hospital readmissions due to falls Rate of emergency department presentations due to falls

RR (ln)



SE ln

RR (ln)



SE ln

Hill ‡

(2011) 0.5

b

(-0.6931)

0.2 (-1.6094)

1.28 (0.2469)

0.4735

‡Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a randomized controlled trial

¥ OR adjusted for study sites, white race and previous fracture provided by trial author

b IRR Complete program vs control provided by trial author

24

Studies of post-hospitalized older adults (multifactorial falls prevention program that consisted of patient educational

component) Study (year)

Proportion of fallers Rate of falls Proportions of fallers with injury Rate of injurious fall

RR (ln)



SE ln

RR (ln)



SE ln

RR (ln)



SE ln

RR (ln)



SE ln

Batchelor (2012)

0.83 (-0.1863)

0.6 (-0.5108)

1.14 (0.1310)

0.1637 1.1b

(0.0953)

0.63 (-0.4620)

1.90 (0.6419)

0.2816 1.57b

(0.4511)

0.73 (-0.3147)

3.4 (1.2238)

0.3925

Close (1999)

0.39ϕ

(-0.9416)

0.23 (-1.4697)

0.6 (-0.5108)

0.2446

Lightbody (2002)

0.9469£

(-0.0546)

0.6377

(-0.4499

1.4060 (0.3407)

0.2017 0.8246£§

(-0.1929)

0.6119 a

(-0.4912)

1.111a

(0.1054)

0.1522a

McQueen (2003)

0.1667£

(-1.7916)

0.0314a

(-3.6769)

1.0982a

(0.0937)

0.9619a

Nikolaus (2003)

0.69b

(-0.3711)

0.51 (-0.6733)

0.97 (-0.0305)

0.1640 0.8499£

(-0.1627)

0.6321a

(-0.4587)

1.1423a

(0.1331)

0.1509a

Russell (2010)

1.11 (0.1044)

0.95 (-0.0513)

1.31 (0.2700)

0.0820 0.87Đ

(-0.1393)

0.65 (-0.4308)

1.17 (0.1570)

0.1499 1.08Ɵ

(0.0770)

0.78 (-0.2485)

1.48 (0.3920)

0.1634

Whitehead (2003)

1.7ʄ

(0.5306)

0.7 (-0.3567)

4.4 (1.4816)

0.4689

Study (year)

Rate of hospital readmissions due to falls Rate of emergency department presentations due to falls

RR (ln)



SE ln

RR (ln)



SE ln

Close (1999)

0.61ϕ

(-0.4943) 0.35

(-1.050)

1.05 (0.0488)

0.2803

Lightbody (2002)

0.8£

(-0.2231) 0.2037a

3.1424a

(1.145)

0.6980a

0.7414£

(-0.2992)

0.4322a

(-0.8388)

1.27a

(0.239a)

0.2753a

25

(-1.5912)

Russell (2010)

2.33z

(0.8459)

0.71 (-0.3425)

7.67 (2.0373)

0.6071 1.03 (0.0296)

0.68 (-0.3857)

1.54 (0.4318)

0.2085

zAdjusted rate ratio for medical conditions, balance, independence of activity of daily living, cognitive status, balance, age, site of recruitment and English speaking provided

by trail author

ϕ Odds ratio adjusted for Barthel and AMT score, previous falls provided by trial author

£ Rate ratio calculated by review author

§ Rate ratio calculated by review author from diary record of falls

Đ Adjusted rate ratio for previous falls, English speaking, balance and independence of activity of daily living provided by trail author

Ɵ Adjusted rate ratio for previous falls and balance provided by trial author

ʄ Odds ratio provided by trial author

aAdjusted by inflation factor calculated by author

bIncidence rate ratio provided by trial author

26

Forest plots of meta-analysis, subgroup meta-analysis and a priori

meta-analysis Appendix

Analysis 1.1 Proportion of patients who became fallers (all studies)

Analysis 1.2 Subgroup meta-analysis of proportion of patients who became

fallers (hospital setting)

NOTE: Weights are from random effects analysis

Overall (I-squared = 52.3%, p = 0.014)

Batchelor

Haines

Whitehead

Ang

Dykes

Von R-Kruse

Vassallo

Haines

Rucker

Cumming

Russell

Clarke

study

Lightbody

2012

2004

2003

2011

2010

2007

2004

2011

2006

2008

2010

2012

year

2002

0.88 (0.75, 1.04)

0.83 (0.60, 1.14)

0.78 (0.57, 1.07)

1.70 (0.68, 4.26)

0.29 (0.10, 0.87)

0.76 (0.19, 3.02)

0.77 (0.68, 0.88)

0.70 (0.34, 1.47)

0.74 (0.48, 1.15)

4.30 (0.92, 20.17)

1.05 (0.70, 1.56)

1.11 (0.95, 1.30)

0.28 (0.02, 5.30)

ES (95% CI)

0.95 (0.64, 1.41)

100.00

11.83

11.89

2.79

2.05

1.34

19.11

4.05

8.55

1.08

9.55

17.84

0.31

Weight

9.60

%

0.88 (0.75, 1.04)

0.83 (0.60, 1.14)

0.78 (0.57, 1.07)

1.70 (0.68, 4.26)

0.29 (0.10, 0.87)

0.76 (0.19, 3.02)

0.77 (0.68, 0.88)

0.70 (0.34, 1.47)

0.74 (0.48, 1.15)

4.30 (0.92, 20.17)

1.05 (0.70, 1.56)

1.11 (0.95, 1.30)

0.28 (0.02, 5.30)

ES (95% CI)

0.95 (0.64, 1.41)

100.00

11.83

11.89

2.79

2.05

1.34

19.11

4.05

8.55

1.08

9.55

17.84

0.31

Weight

9.60

%

favours intervention favours control 1.1 10



Clarke

Haines

Vassallo

Ang

Von R-Kruse

Cumming

study

Haines

Dykes

2012

2011

2004

2011

2007

2008

year

2004

2010

0.78 (0.70, 0.87)

0.28 (0.02, 5.30)

0.74 (0.48, 1.15)

0.70 (0.34, 1.47)

0.29 (0.10, 0.87)

0.77 (0.68, 0.88)

1.05 (0.70, 1.56)

ES (95% CI)

0.78 (0.57, 1.07)

0.76 (0.19, 3.02)

100.00

0.13

5.94

%

2.09

0.95

71.98

7.19

Weight

11.13

0.60

0.78 (0.70, 0.87)

0.28 (0.02, 5.30)

0.74 (0.48, 1.15)

0.70 (0.34, 1.47)

0.29 (0.10, 0.87)

0.77 (0.68, 0.88)

1.05 (0.70, 1.56)

ES (95% CI)

0.78 (0.57, 1.07)

0.76 (0.19, 3.02)

100.00

0.13

5.94

%

2.09

0.95

71.98

7.19

Weight

11.13

0.60


27

Analysis 1.3 Subgroup meta-analysis of proportion of patients who became

fallers (post discharge setting)

Analysis 1.4 Proportion of patients who became fallers (studies with only

cognitive intact participants)



Batchelor

Russell

Lightbody

study

Hill

Whitehead

Rucker

2012

2010

2002

year

2011

2003

2006

1.07 (0.87, 1.33)

0.83 (0.60, 1.14)

1.11 (0.95, 1.30)

0.95 (0.64, 1.41)

ES (95% CI)

1.34 (0.76, 2.37)

1.70 (0.68, 4.26)

4.30 (0.92, 20.17)

100.00

23.71

40.43

18.44

Weight

10.87

%

4.76

1.79

1.07 (0.87, 1.33)

0.83 (0.60, 1.14)

1.11 (0.95, 1.30)

0.95 (0.64, 1.41)

ES (95% CI)

1.34 (0.76, 2.37)

1.70 (0.68, 4.26)

4.30 (0.92, 20.17)

100.00

23.71

40.43

18.44

Weight

10.87

%

4.76

1.79




study

Haines

Rucker

Haines

Whitehead

Lightbody

year

2011

2006

2006

2003

2002

1.15 (0.67, 1.97)

ES (95% CI)

0.51 (0.28, 0.93)

4.30 (0.92, 20.17)

1.59 (0.71, 3.57)

1.70 (0.68, 4.26)

0.95 (0.64, 1.41)

100.00

Weight

24.32

9.13

19.67

17.45

29.43

%

1.15 (0.67, 1.97)

ES (95% CI)

0.51 (0.28, 0.93)

4.30 (0.92, 20.17)

1.59 (0.71, 3.57)

1.70 (0.68, 4.26)

0.95 (0.64, 1.41)

100.00

Weight

24.32

9.13

19.67

17.45

29.43

%


28

Analysis 1.5 Proportion of patients who became fallers (studies with

cognitive intact and impaired participants)

Analysis 1.6 Proportion of patients who became fallers (studies with only

cognitive impaired participants)



Ang

Haines

Cumming

Dykes

Haines

study

Vassallo

Clarke

Von R-Kruse

Russell

Batchelor

2011

2004

2008

2010

2011

year

2004

2012

2007

2010

2012

0.84 (0.71, 1.00)

0.29 (0.10, 0.87)

0.78 (0.57, 1.07)

1.05 (0.70, 1.56)

0.76 (0.19, 3.02)

0.74 (0.48, 1.15)

ES (95% CI)

0.70 (0.34, 1.47)

0.28 (0.02, 5.30)

0.77 (0.68, 0.88)

1.11 (0.95, 1.30)

0.83 (0.60, 1.14)

100.00

2.15

13.54

10.66

%

1.40

9.46

Weight

4.32

0.32

23.24

21.44

13.47

0.84 (0.71, 1.00)

0.29 (0.10, 0.87)

0.78 (0.57, 1.07)

1.05 (0.70, 1.56)

0.76 (0.19, 3.02)

0.74 (0.48, 1.15)

ES (95% CI)

0.70 (0.34, 1.47)

0.28 (0.02, 5.30)

0.77 (0.68, 0.88)

1.11 (0.95, 1.30)

0.83 (0.60, 1.14)

100.00

2.15

13.54

10.66

%

1.40

9.46

Weight

4.32

0.32

23.24

21.44

13.47




Haines

Haines

study

2011

2006

year

1.22 (0.71, 2.07)

1.38 (0.70, 2.73)

1.00 (0.43, 2.33)

ES (95% CI)

100.00

60.53

39.47

%

Weight

1.22 (0.71, 2.07)

1.38 (0.70, 2.73)

1.00 (0.43, 2.33)

ES (95% CI)

100.00

60.53

39.47

%

Weight


29

Analysis 2.1 Rate of falls (all studies)

Analysis 2.2 Rate of falls (studies with only cognitive intact participants)



Vassallo

Ang

Dykes

Lightbody

Haines

Healey

study

Close

Batchelor

Russell

Von R-Kruse

Haines

Nikolaus

Cumming

McQueen

2004

2011

2010

2002

2011

2004

year

1999

2012

2010

2007

2004

2003

2008

2003

0.77 (0.69, 0.87)

1.07 (0.47, 2.42)

0.30 (0.10, 0.90)

0.75 (0.58, 0.99)

0.82 (0.61, 1.11)

0.83 (0.54, 1.27)

0.70 (0.30, 1.64)

ES (95% CI)

0.39 (0.24, 0.63)

1.10 (0.63, 1.91)

0.87 (0.65, 1.17)

0.82 (0.73, 0.92)

0.71 (0.55, 0.91)

0.69 (0.50, 0.95)

0.96 (0.72, 1.28)

0.17 (0.03, 1.10)

100.00

1.91

1.08

10.71

9.53

5.79

1.79

Weight

4.84

3.83

9.71

19.89

11.91

8.67

9.96

0.38

%

0.77 (0.69, 0.87)

1.07 (0.47, 2.42)

0.30 (0.10, 0.90)

0.75 (0.58, 0.99)

0.82 (0.61, 1.11)

0.83 (0.54, 1.27)

0.70 (0.30, 1.64)

ES (95% CI)

0.39 (0.24, 0.63)

1.10 (0.63, 1.91)

0.87 (0.65, 1.17)

0.82 (0.73, 0.92)

0.71 (0.55, 0.91)

0.69 (0.50, 0.95)

0.96 (0.72, 1.28)

0.17 (0.03, 1.10)

100.00

1.91

1.08

10.71

9.53

5.79

1.79

Weight

4.84

3.83

9.71

19.89

11.91

8.67

9.96

0.38

%




McQueen

Haines

study

Haines

Nikolaus

Close

Lightbody

2003

2011

year

2006

2003

1999

2002

0.56 (0.40, 0.77)

0.17 (0.03, 1.10)

0.43 (0.24, 0.78)

ES (95% CI)

0.45 (0.16, 1.25)

0.69 (0.50, 0.95)

0.39 (0.24, 0.63)

0.82 (0.61, 1.11)

100.00

2.72

16.25

Weight

7.84

%

26.17

19.88

27.15

0.56 (0.40, 0.77)

0.17 (0.03, 1.10)

0.43 (0.24, 0.78)

ES (95% CI)

0.45 (0.16, 1.25)

0.69 (0.50, 0.95)

0.39 (0.24, 0.63)

0.82 (0.61, 1.11)

100.00

2.72

16.25

Weight

7.84

%

26.17

19.88

27.15


30

Analysis 2.3 Rate of falls (studies with cognitive intact and impaired

participants)

Analysis 2.4 Rate of falls (studies with only cognitive impaired participants)



Haines

Dykes

Von R-Kruse

Cumming

Russell

Haines

study

Healey

Ang

Batchelor

Vassallo

2011

2010

2007

2008

2010

2004

year

2004

2011

2012

2004

0.82 (0.75, 0.89)

0.83 (0.54, 1.27)

0.75 (0.58, 0.99)

0.82 (0.73, 0.92)

0.96 (0.72, 1.28)

0.87 (0.65, 1.17)

0.71 (0.55, 0.91)

ES (95% CI)

0.70 (0.30, 1.64)

0.30 (0.10, 0.90)

1.10 (0.63, 1.91)

1.07 (0.47, 2.42)

100.00

3.87

9.70

52.91

8.55

8.20

11.81

Weight

%

0.99

0.58

2.32

1.06

0.82 (0.75, 0.89)

0.83 (0.54, 1.27)

0.75 (0.58, 0.99)

0.82 (0.73, 0.92)

0.96 (0.72, 1.28)

0.87 (0.65, 1.17)

0.71 (0.55, 0.91)

ES (95% CI)

0.70 (0.30, 1.64)

0.30 (0.10, 0.90)

1.10 (0.63, 1.91)

1.07 (0.47, 2.42)

100.00

3.87

9.70

52.91

8.55

8.20

11.81

Weight

%

0.99

0.58

2.32

1.06




study

Haines

Haines

year

2006

2011

1.04 (0.45, 2.41)

ES (95% CI)

0.62 (0.25, 1.54)

1.48 (0.86, 2.54)

100.00

Weight

%

40.78

59.22

1.04 (0.45, 2.41)

ES (95% CI)

0.62 (0.25, 1.54)

1.48 (0.86, 2.54)

100.00

Weight

%

40.78

59.22


31

Analysis 3.1 Rate of injurious fall (all studies)

Analysis 3.2 Rate of injurious fall (studies with cognitive intact and

impaired participants)



Russell

Healey

Batchelor

Dykes

Haines

Cumming

Haines

Nikolaus

study

Von R-Kruse

2010

2004

2012

2010

2011

2008

2004

2003

year

2007

0.94 (0.82, 1.08)

1.08 (0.78, 1.49)

1.35 (0.23, 8.11)

1.57 (0.73, 3.39)

1.17 (0.01, 146.28)

1.22 (0.68, 2.18)

1.12 (0.71, 1.77)

0.71 (0.34, 1.50)

0.85 (0.63, 1.14)

ES (95% CI)

0.84 (0.67, 1.05)

100.00

%

18.23

0.58

3.16

0.08

5.56

8.96

3.35

21.38

Weight

38.69

0.94 (0.82, 1.08)

1.08 (0.78, 1.49)

1.35 (0.23, 8.11)

1.57 (0.73, 3.39)

1.17 (0.01, 146.28)

1.22 (0.68, 2.18)

1.12 (0.71, 1.77)

0.71 (0.34, 1.50)

0.85 (0.63, 1.14)

ES (95% CI)

0.84 (0.67, 1.05)

100.00

%

18.23

0.58

3.16

0.08

5.56

8.96

3.35

21.38

Weight

38.69




Russell

Batchelor

Haines

Cumming

Haines

Von R-Kruse

Healey

Dykes

study

2010

2012

2011

2008

2004

2007

2004

2010

year

0.97 (0.83, 1.13)

1.08 (0.78, 1.49)

1.57 (0.73, 3.39)

1.22 (0.68, 2.18)

1.12 (0.71, 1.77)

0.71 (0.34, 1.50)

0.84 (0.67, 1.05)

1.35 (0.23, 8.11)

1.17 (0.01, 146.28)

ES (95% CI)

100.00

23.19

4.02

7.08

11.40

4.27

49.21

0.74

0.10

Weight

%

0.97 (0.83, 1.13)

1.08 (0.78, 1.49)

1.57 (0.73, 3.39)

1.22 (0.68, 2.18)

1.12 (0.71, 1.77)

0.71 (0.34, 1.50)

0.84 (0.67, 1.05)

1.35 (0.23, 8.11)

1.17 (0.01, 146.28)

ES (95% CI)

100.00

23.19

4.02

7.08

11.40

4.27

49.21

0.74

0.10

Weight

%


32

Analysis 3.3 Rate of injurious fall (studies with only cognitive intact

participants)

Analysis 4 Proportion of fallers with injury (all studies)



study

Nikolaus

Haines

year

2003

2011

0.79 (0.57, 1.10)

ES (95% CI)

0.85 (0.63, 1.14)

0.53 (0.23, 1.22)

100.00

Weight

85.51

%

14.49

0.79 (0.57, 1.10)

ES (95% CI)

0.85 (0.63, 1.14)

0.53 (0.23, 1.22)

100.00

Weight

85.51

%

14.49




Vassallo

study

Clarke

Ang

Cumming

2004

year

2012

2011

2008

0.94 (0.56, 1.59)

0.49 (0.12, 2.01)

ES (95% CI)

0.46 (0.02, 9.70)

0.60 (0.14, 2.51)

1.20 (0.65, 2.23)

100.00

13.45

Weight

%

2.91

13.18

70.46

0.94 (0.56, 1.59)

0.49 (0.12, 2.01)

ES (95% CI)

0.46 (0.02, 9.70)

0.60 (0.14, 2.51)

1.20 (0.65, 2.23)

100.00

13.45

Weight

%

2.91

13.18

70.46


33

Analysis 5.1 Rate of hospital readmission due to falls (all studies)

Analysis 5.2 Rate of hospital readmission due to falls (studies with only

cognitive intact participants)



study

Lightbody

Hill

Russell

Close

year

2002

2011

2010

1999

0.77 (0.43, 1.37)

ES (95% CI)

0.80 (0.20, 3.14)

0.50 (0.20, 1.26)

2.33 (0.71, 7.66)

0.61 (0.35, 1.06)

100.00

Weight

14.40

25.10

17.83

42.67

%

0.77 (0.43, 1.37)

ES (95% CI)

0.80 (0.20, 3.14)

0.50 (0.20, 1.26)

2.33 (0.71, 7.66)

0.61 (0.35, 1.06)

100.00

Weight

14.40

25.10

17.83

42.67

%




Close

Lightbody

study

1999

2002

year

0.63 (0.38, 1.05)

0.61 (0.35, 1.06)

0.80 (0.20, 3.14)

ES (95% CI)

100.00

%

86.11

13.89

Weight

0.63 (0.38, 1.05)

0.61 (0.35, 1.06)

0.80 (0.20, 3.14)

ES (95% CI)

100.00

%

86.11

13.89

Weight


34

Analysis 5.3 Rate of hospital readmission due to falls (studies with

cognitive intact and impaired participants)

Analysis 6 Rate of emergency department presentations due to falls (all

studies)



Hill

study

Russell

2011

year

2010

1.03 (0.23, 4.64)

0.50 (0.20, 1.26)

ES (95% CI)

2.33 (0.71, 7.66)

100.00

53.05

%

Weight

46.95

1.03 (0.23, 4.64)

0.50 (0.20, 1.26)

ES (95% CI)

2.33 (0.71, 7.66)

100.00

53.05

%

Weight

46.95

favours intervention favours control

1.1 10



study

Lightbody

Russell

year

2002

2010

0.91 (0.66, 1.27)

ES (95% CI)

0.74 (0.43, 1.27)

1.03 (0.68, 1.55)

100.00

%

Weight

36.45

63.55

0.91 (0.66, 1.27)

ES (95% CI)

0.74 (0.43, 1.27)

1.03 (0.68, 1.55)

100.00

%

Weight

36.45

63.55


35

Citations of included studies in the review

Studies Title and reference

Ang, E., S. Z. Mordiffi, et al. (2011) "Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial." Journal of Advanced Nursing 67(9): 1984-1992.

Banez, C., S. Tully, et al. (2008)

"Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults." Journal of the American Geriatrics Society 56(8): 1549-1555.

Batchelor, F. A., K. D. Hill, et al. (2012) "Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial." Archives of Physical Medicine & Rehabilitation 93(9): 1648-1655.

Buri, H. (1997) "A group programme to prevent falls in elderly hospital patients." British Journal of Therapy & Rehabilitation 4(10): 550.

Clarke, H. D., V. L. Timm, et al. (2012) "Preoperative patient education reduces in-hospital falls after total knee arthroplasty." Clinical Orthopaedics & Related Research 470(1): 244-249.

Close, J., M. Ellis, et al. (1999) "Prevention of falls in the elderly trial (PROFET): a randomised controlled trial." Lancet 353(9147): 93-97.

Cumming, R. G., C. Sherrington, et al. (2008) "Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital." Bmj 336(7647): 758-760.

Dykes, P. C., D. L. Carroll, et al. (2010) "Fall prevention in acute care hospitals: a randomized trial." JAMA: Journal of the American Medical Association 304(17): 1912-1918.

Haines, T. P., K. L. Bennell, et al. (2004) "Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial." Bmj 328(7441): 676.

Haines, T. P., A. M. Hill, et al. (2011) "Patient education to prevent falls among older hospital inpatients: A randomized controlled trial." Archives of internal medicine 171(6): 516-524.

Haines, T. P., K. D. Hill, et al. (2006) "Patient education to prevent falls in subacute care." Clinical Rehabilitation 20(11): 970-979.

Healey, F., A. Monro, et al. (2004) "Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial." Age and ageing 33(4): 390-395.

≠Hill, A.-M., T. Hoffmann, et al. (2011) "Factors Associated With Older Patients'

36

Engagement in Exercise After Hospital Discharge." Archives of Physical Medicine & Rehabilitation 92(9): 1395-1403.

€Hill, A. M., T. Hoffmann, et al. (2011) "Falls After Discharge From Hospital: Is There a Gap Between Older Peoples’ Knowledge About Falls Prevention Strategies and the Research Evidence?" The Gerontologist 51(5): 653-662.

‡ Hill, A. M., T. Hoffmann, et al. (2011) "Evaluation of the Sustained Effect of Inpatient Falls Prevention Education and Predictors of Falls After Hospital Discharge--Follow-up to a Randomized Controlled Trial." Journals of Gerontology Series A: Biological Sciences & Medical Sciences 66(9): 1001-1012.

Hill, A. M., S. McPhail, et al. (2009) "A randomized trial comparing digital video disc with written delivery of falls prevention education for older patients in hospital." Journal of the American Geriatrics Society 57(8): 1458-1463.

Lightbody, E., C. Watkins, et al. (2002) "Evaluation of a nurse-led falls prevention programme versus usual care: a randomized controlled trial." Age & Ageing 31(3): 203-210.

McQueen, J. M. (2003) "Fall management and prevention: a day hospital perspective." British Journal of Therapy & Rehabilitation 10(3): 115-121.

Nikolaus, T. and M. Bach (2003) "Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the Randomized Falls-HIT Trial." Journal of the American Geriatrics Society 51(3): 300-305.

Rucker, D., B. H. Rowe, et al. (2006) "Educational intervention to reduce falls and fear of falling in patients after fragility fracture: results of a controlled pilot study." Preventive Medicine 42(4): 316-319.

Russell, M. A., K. D. Hill, et al. (2010) "A randomized controlled trial of a multifactorial falls prevention intervention for older fallers presenting to emergency departments." Journal of the American Geriatrics Society 58(12): 2265-2274.

Tzeng, H. and C. Yin (2009) "Perspectives of recently discharged patients on hospital fall-prevention programs." Journal of nursing care quality 24(1): 42-49.

Vassallo, M., R. Vignaraja, et al. (2004) "The Effect of Changing Practice on Fall Prevention in a Rehabilitative Hospital: The Hospital Injury Prevention Study." Journal of the American Geriatrics Society 52(3): 335-339.

von Renteln-Kruse, W. and T. Krause (2007)

"Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention." Journal of the American Geriatrics Society 55(12): 2068-2074.

Whitehead, C., R. Wundke, et al. (2003) "Evidence-based clinical practice in falls

37

prevention: a randomised controlled trial of a falls prevention service." Australian Health Review 26(3): 88-97.

Wong, E. L. Y., J. Woo, et al. (2011) "Determinants of participation in a fall assessment and prevention programme among elderly fallers in Hong Kong: Prospective cohort study." Journal of Advanced Nursing 67(4): 763-773.

38

Characteristics of included studies

Studies of hospitalized older adults (multifactorial falls prevention program that consisted of patient educational

component)

Haines (2004)

Title Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial Methods RCT Setting Subacute wards from a metropolitan hospital in Melbourne, Australia Participants 626 patients :310 interevntion,316 control

Inclusion: All patients admitted to the hospital from March to December 2002 and deemed appropriate to receive fall prevention intervention after administration of local fall risk assessment tool Mean age=80 Female=67% MMSEa (intervention)=23, (control)=23 No withdrawal Diagnosis: Stroke, orthopaedic, geriatric management, other impairments

Intervention Intervention group received a targeted fall prevention programme which consisted of falls risk alert card with information brochure, exercise programme, individual education programme (twice weekly of 30 minutes duration) and hip protectors in addition to usual care Participants in intervention group (n) who received: falls risk alert card=151 Exercise program=64 (attendance n=595) Education program=114 (attendance n=473) Hip protector=89 (57% wore it for ≥12 hours, 25% refused to wear it at all) Control group received usual care only

Outcome Primary outcome of interest :

Falls rate ( /1000 patient days) Control vs intervention=16.1 vs 11.2 p=0.045

Fallers Control vs intervention=71 vs 54 RR=0.78 (95%CI=0.56-1.06)

No. of falls with injury

39

Control vs intervention=32 vs 23 p=0.20 aMMSE Mini mental state examination( /30) >23 regarded as cognitively intact

Haines (2006)

Title Patient education to prevent falls in subacute care Methods Randomised controlled trial (subgroup analysis) and post intervention 5 point Likert survey Setting Metropolitan subacute/aged rehabilitation hospital, Melbourne, Australia Participants 226 patients: 115 (intervention), 111 (control)

Exclusion criteria: Patients with low risk of falls, severe communication and learning impairments Inclusion: Participants were subgroup of a randomised controlled trail investigating a targeted multi intervention fall prevention programme Median age:82 (interquartile range 75-88) 66% male Diagnosis: orthopaedic, stroke, geriatric management No participant withdrew from trial

Interventions One to one education session, twice weekly with occupational therapist at patient’s bed side Duration of each session ranged from 15 to 35 minutes. Median of 4 sessions were provided Information booklet was provided which contained the education materials Intervention group may also receive fall risk alert card or exercise program or hip protector or a combination of 2 or more of these. Control group received usual care only

Outcome Primary outcome of interest:

Falls rate ( /1000 patient days) for any participant recommended for education intervention Control vs intervention= 16 vs 8.2 p value=0.007

% fallers Control vs intervention=21 vs 18 RR 1.21 (95%CI 0.68-2.14)

Secondary outcome of interest: % of behavioural changes reported in post intervention survey (64/115 surveys returned)

Increased awareness of fall risks=11%

40

Increase awareness of fall (be careful)=44%

Action to reduce falls: Use of protective equipment=13% Ask for help=17% Follow staff instruction=8% Plan ahead=11% Avoid risky activities=20%

Notes Significant lower incidence of falls in intervention group compared to control group:

With education alone or education with other interventions

For cognitive intact patients whose MMSE>23

For cognitive impaired patients whose MMSE≤23

Ang (2011)

Title Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial

Methods RCT Setting Acute care hospital in Singapore Participants 1822 patients : n=910 (intervention) ; n=912 (control)

Inclusion: Participants admitted to the medical wards who were ≥21 years and scored ≥5 Hendrich II fall risk model Mean age of participants=70 Female%=52 (intervention);48 (control) No loss to follow up or withdrawal

Intervention Intervention group received 30 minutes of education about fall risk factors and prevention strategies as part of a multifactorial fall prevention program in addition to usual care Control group received usual care only

Outcome Primary outcome of interest

% fallers in intervention group versus control group =0.4% vs 1.5% Relative risk=0.29(95%CI 0.1-0.89) p=0.031 adjusted for age and gender

No. of fallers with injury

41

3/4 fallers(intervention) vs 5/14 (control) Notes Education was also given to family of participants who were confused or delirious

Cumming (2008)

Title Cluster randomised trail of a targeted multifactorial intervention to prevent falls among older people in hospital Methods Clustered randomised trail Setting 24 acute and rehabilitation elderly care wards in 12 hospitals in Sydney, Australia Participants n=3999 patients

Intervention n=1907, 12 wards Control n=1952, 12 wards Inclusion: all admissions to the study wards from October 2003 to October 2006 mean age=79 years Female=59% Median length of hospital stay=7 days No drop outs of wards or patients

Intervention Intervention wards: Falls risk assessment Targeted risk factor intervention which may include: education (patient/family/staff), gait aid provision, eyewear, modification to bedside environment, medication change, management of confusion and foot problem, patient alarm Supervised group or individual exercises, practised safe mobility within ward environment, education to patient/staff/family re safe mobility and supervision requirement Control wards: No trial intervention


Falls rate ( /1000patient days): Intervention wards=9.26; control wards=9.2 (p=0.96) Incidence rate ratio (ratio of fall rate in intervention ward to control ward): All wards (unadjusted)= 1.02(0.70-1.49) p=0.92 All wards (adjusted for previous falls and length of stay)= 0.96(0.72-1.28) p=0.78

Rate of injurious fall Intervention vs control IRR= 1.12 (95%CI 0.71-1.77)

42

Dykes (2010)

Title Fall prevention in acute care hospitals Methods Cluster randomised study Setting 8 medical wards of 4 urban hospitals in Boston, US Participants n=10264

Intervention n=5160, 4 wards Control n=5104, 4 wards Inclusion: all admissions to the study wards from Jan 2009 to June 2009 Mean age≥65 years Female=55% Median length of stay=3 No drop outs of wards or patients

Intervention Intervention wards: Falls prevention tool kit using health information technology Tool kit consisted of falls risk assessment, computer generated tailored falls prevention intervention which consisted of a bed poster, a patient education handout and a plan of care Control wards: Generic high risk for falls sign used at bedside, generic education and handout, care plan and falls risk assessment in manual or electronic record


Falls rate( /1000 patient days) Intervention=3.15 (95% CI 2.54-3.9) vs control=4.18 (95% CI 3.45-5.06) p=0.04

No. of fallers Intervention vs control=67 vs 87 p=0.02

No. of injurious falls Intervention vs control=14 vs 12 p=0.64

Notes Fewer falls in intervention wards overall but results were only significant for patients over 65 years Non significant result for repeated falls and falls with injury between the intervention wards and control wards

43

Vassallo (2004)

Title The effect of changing practice on fall prevention in a rehabilitative hospital: The hospital injury prevention study Methods Quasi experimental design Setting 3 geriatric wards of a community rehabilitation hospital Participants n=825 patients

Intervention ward: n=275 Control ward 1 n=275, control ward 2 n=275 Inclusion: All patients admitted to the study wards Exclusion: None Mean age=82 Female=64%

Intervention Intervention: Fall risk assessment and case conference, medication review, environmental review and safety assessment. Development and implementation of a falls prevention plan. Advice re maintaining safety on ward Control: Usual care Mean length of hospital stay=21 (intervention ward), 27 (control wards)


% fallers (intervention vs control)=16.2 vs 22.9 p=0.038

No. of falls (intervention vs control)=71 vs 163 p=0.048

Fallers with injury (intervention vs control)=4.7% vs 9.3% p=0.035 Notes Non significant fewer recurrent fallers 5.5% vs 7.2% p=0.52

Benefit of intervention did not remain significant after adjusting for length of patient stay for all of the above.

Von R-Kruse (2007)

Title Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisplinary team based fall-prevention intervention

44

Methods Prospective cohort with historical control (pre and post intervention study) Setting 5 geriatric wards (acute care and early rehabilitation) of a hospital in Hamburg, Germany Participants Historical control n=4272

Intervention n=2981 Mean age =80 years Female=69% Mean length of stay=20 days Inclusion: All patients that were admitted to the study wards from Jan 2003 to Nov 2004 (served as control, before intervention) and Dec2004 to March 2006 (after introduction of intervention) Exclusion: None

Intervention Falls risk assessment, weekly team discussion of at risk patients, increased assistance and monitoring of patients with frequently toileting needs, use of commode at night for patients with poor transfer, provision of gait aid immediately, individual and caregiver education by team members or nurses about falls risk, preventive measures and behaviour change. Caregivers were encouraged to participate in therapy sessions. Discharge home visits were conducted to selected cases. All at risk patients received a 5 page flyer which explained typical risks and risky situations, preventive measures in hospital, recommendation such as corrective eyewear, proper footwear, call for help if feeling unsafe to transfer, hip protector use etc. This was in addition to usual care.


No. of falls (before vs after intervention)=893 vs 468 Incidence risk ratio=0.82 (95%CI 0.73-0.92) p<0.001

Falls rate ( /1000 patients days) before vs after=10 vs 8.2 (p<0.001)

No. of injurious falls (before vs after)=240 vs 129 IRR 0.84 (95%CI 0.67-1.04) p=0.1 Notes Significant reduction in the risk of falling 0.77 (95%CI 0.68-0.88) p<0.001

Healey (2004)

Title Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial Methods Clustered randomised trial Setting 8 elderly care wards (acute, rehabilitation and speciality wards) of a general hospital in UK Participants n= 3386 patients

Intervention n= 749 (6 months after intervention), n=776 (6 months before intervention) Control n=905 (6 months after intervention), n=956 (6 months before introduction) Inclusion: All patients who were admitted to the study wards in a 12 month period

45

Exclusion: None Mean age=81 years Female=60%

Intervention Intervention wards: Pre-printed care plan comprised of a falls risk factor screen and related intervention which included medication review, referral to physiotherapist or optometrist, advice on mobility and footwear, environmental safety, education about use of nurse call bell, lowered bed height, use of bed rails, increased monitoring of high risk patients and urine test Control wards: Usual care


Falls rate Intervention vs control RR=0.705 (95%CI 0.55-0.90) p=0.006

Injurious falls rate Intervention vs control RR=1.35 (95%CI 0.8-2.28) p=0.26

46

Studies of hospitalized older adults (education intervention only)

Clarke (2012)

Title Preoperative patient education reduces in-hospital falls after total knee arthroplasty Methods Retrospective cohort study Setting Outpatient setting of a hospital within 2 weeks before elective knee surgery and in-patient hospital setting after surgery in Phoenix,

USA Participation 244 patients: n=72(education group),n=172(control group)

All patients underwent total knee arthroplasty with one surgeon in March 2009 received preoperative education program for fall prevention after surgery. Patients of another surgeon did not receive education program. Mean age of education group=70.2 years; control group=70.3 years Female (education group)= 64% Female (control group)=56%

Intervention Education group received one 15 to 30 minutes 1:1 education by a nurse within 2 weeks before knee surgery, education pamphlet and an oral test for knowledge gained Control group received no education


No. of fallers Education group vs control group: 0/72 vs 7/172 (p=0.03)

No. of fallers with injury Education group vs control group: 0 vs 4/7

Haines (2011)

Title Patient education to prevent falls among older hospital inpatients Methods 3-group randomized control trial Setting Acute and subacute wards of 2 general hospitals in Brisbane and Perth, Australia Participants 1206 patients: 401(intervention, complete program), 424 (intervention, materials only), 381 (control)

Inclusion: Patients >60 years who were admitted to subacute wards; patients > 60 years who were admitted to acute wards and expected to stay more than 3 days Mean age: 75 years Female=53%

47

Diagnosis: Stroke, orthopaedic, pulmonary, geriatric management, other >73% of participants had intact cognition (SPMSQb≥8) n=388 (complete program intervention, 13 withdrawn) n=409 (material only intervention, 15 withdrawn) n=381 (control, no withdrawal)

Intervention Complete program: written information, video and 1:1 follow up with physiotherapist provided to patients at their bedside (2-3 one to one sessions) Material only program: written information and video without 1:1 follow up Control: No intervention All groups received usual ward based care


Fall rate ( /1000 patient days) No significant difference in rate of falls between groups Complete group=7.63; material group=8.61; control=9.27 Incidence rate ratio (95% CI): Complete group versus control 0.83(0.54-1.27) p=0.39 Material group versus control 0.91 (0.61-1.36) P=0.65

Complete program versus material only 0.91 (0.58-1.42) p=0.63

Rate of injurious falls Incidence rate ratio (95% CI): Complete group versus control 1.22(0.69-2.2) p=0.49 Material group versus control 1.21(0.67-2.17) p=0.53

Complete program versus material only 0.99 (0.56-1.76) p=0.99 Secondary outcome of interest:

Participation in fall prevention strategies Intention to change behaviour to prevent falls 273/280 patients in complete program identified 700 goals to behaviour modification versus 31/299 patients in material program which identified 75 goals

Notes Significant difference in rate of fall among cognitive intact patients: Complete program versus material only 4.01/1000 patient days versus 8.18/1000 patient days (adjusted hazard ratio 0.51; 95%CI 0.28-0.93) Complete group versus control

48

4.01/1000 patient days versus 8.72/1000 patient days (adjusted hazard ratio 0.43; 95% 0.24-0.78) Lower trend of rate of injurious fall in cognitive intact patients who received complete program vs control group

bSPMSQ Short portable mental status questionnaire ≥8 regarded as cognitively intact

Hill (2009)

Title A randomized trial comparing digital video disc with written delivery of falls prevention education for older patients in hospital Methods 2 group randomised control trial with quasi experimental control group Setting Acute and subacute wards of 2 hospitals in Brisbane and Perth of Australia Participants 222 patients : intervention (51, DVD) ; intervention (49, workbook) ; control (122)

Exclusion: Patients<60 years old, MMSE<24/30, previously participated in the study, medically unstable, had severe hearing or visual deficits No withdrawal from each group Mean age=77 years Female=56%

Intervention Intervention groups: DVD or workbook of identical content received at bedside Control group: No education

Measurement Pre intervention survey of self perceived risk of falls in a 5 point Likert scale (item 1 of 21 questions in a survey) Outcome Secondary outcome of interest:

Perception of fall risk No significant difference between intervention groups in self perceived risk of falls post intervention p=0.7 Significant difference within DVD group in self perceived risk of falls after intervention p=0.04 No significant difference within workbook group in self perceived risk of falls after intervention p=0.18

Knowledge Significant difference in knowledge of falls in intervention groups combined compared to control p<0.001

Self efficacy DVD group was more confident and motivated to attempt fall prevention strategies in the hospital post intervention compared to workbook group p=0.03

Notes Almost all intervention participants could identify a fall prevention strategy. DVD group participants were more likely to nominate a secondary strategy than workbook group participants (odds ratio 3.28, 95%CI 1.16-9.26, p=0.02)

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Hill (2011)

Title Falls after discharge from hospital: Is there a gap between older people’s knowledge about falls prevention strategies and the research evidence

Methods Survey Setting A general hospital in Perth, Australia Participants Inclusion:333 patients of a RCT* who were within 48 hours of discharge from hospital

n=120 (group 1 received material* only), n=116 (group 2 received complete program*), n=97 (control) All group received usual care. Mean age=79.2 Female= 61.6% Diagnosis: stroke, orthopaedic, pulmonary, cardiac, geriatric management, other surgical/medical SPMSQ<8=26% GDS^≤ 4=60% No withdrawal

Intervention N/A Outcome Secondary outcome of interest:

Knowledge of fall prevention 3% of 333 patients suggested doing physical exercise to reduce risk of fall Subgroup analysis of group 1 and 2 combined versus control group showed identification of 71% compared to 29% fall prevention strategies

Notes Participants with cognitive impairments (26%) gave responses similar to non cognitively impaired participants but result from RCT* showed they did not benefit from education

*Refer to Haines 2011

^GDS Geriatric depression scale >4 indicated depressive symptoms

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Tzeng (2008)

Title Perspectives of recently discharged patients on hospital fall prevention programs Methods Post intervention/cross sectional survey Setting Home care agency of the affiliated hospital Participants n=91 participants

Inclusion: 30 days post discharged from the affiliated hospital, medicare patients, ≥65 years, absence of communication difficulties Mean age =77 years Female=49.5% No report of withdrawal

Intervention Fall prevention advice from hospital staff and information brochure Outcome Secondary outcome of interest:

Perceived benefit 43% received advice or education. Participant who fell in hospital perceived the advice/education to be more useful than those who did not fall.

Notes Leaving a brochure without explanation was perceived by patients to be insufficient

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Studies of post-hospitalized older adults (education intervention only)

Hill (2011)

Title Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a randomised controlled trail

Methods Prospective cohort study Setting Pre hospital discharge and 6 month post discharge follow up of patients from a general hospital in Perth, Australia Participants 343 patients of a RCT study*

Inclusion: Participants >60 years old and previously enrolled in the RCT n=343 (n=120 received complete program*; n=123 received material* only; n=100 control. All groups received usual care) Lost to follow up, death, withdrawal at 1/2/3/4/5/6 month post discharge, n=9/7/3/7/8/4 Mean age=79.4 Female=61.2% SPMSQ<8=26% GDS<4=60%

Intervention N/A Measurement Admission measurements: Medical diagnosis, visual impairment, history of falls in 6 months prior to admission

Pre discharge measurements: Discharge destination, length of stay in hospital, fell during inpatient stay, mobility status, SPMSQ, GDS^, EQ5D#


Fall rate ( /1000 patient days) in the 6 months following discharge Complete group=4.4; material group=5.36; control=3.62 (no significant difference) Incidence rate ratio, 95%CI, p value: Complete group versus control=1.18,0.71-1.96,0.51 Material group versus control=1.48,0.95-2.30,0.08 Complete group versus material group=0.80,0.54-1.19,0.28

Fallers(%) Incidence rate ratio, 95%CI, p value: Complete group vs control=1.34, 0.76-2.37,0.32 Material group vs control=2.12,1,21-3.70,0.009

Rates of hospital readmission due to falls ( /1000 person days) Complete=0.37; material=0.54; control=0.86 (no significant difference) Incidence rate ratio, 95%CI, p value:

52

Complete group versus control=0.5,0.2-1.28,0.15 Material group versus control=0.96,0.43-2.17,0.93 Complete group versus material=0.52,0.21-1.28,0.16

Rates of injurious falls( /1000 person days) Complete=2.2; material=2.92; control=2.18 (no significant difference) Incidence rate ratio, 95%CI, p value: Complete group versus control=1, 0.6-1.66,1 Material group versus control=1.36,0.8-2.3,0.25 Complete group versus material=0.74,0.47-1.17,0.2

Notes Depressive mood at discharge is an independent risk factor for falls after discharge

*Refer to Haines 2011

^GDS Geriatric depression scale >4 indicates depressive symptoms

#EQ5D Health related quality of life

Hill (2011)

Title Factors associated with older patients’ engagement in exercise after hospital discharge Methods Survey (pre hospital discharge face to face survey and 6 months post discharge telephone survey) Setting Post discharge in patients’ home setting from a general hospital in Perth, Australia Participants Inclusion: 343 patients of a RCT*

Mean age : 79.4 Female=61.2% GDS (mean± SD)=4.3±2.8 SPMSQ>8 (252patients, 78%) (2/3 of patients received inpatient education in the RCT to reduce their risk of falls whilst in hospital) 333 patients completed the pre discharge survey (10 patients discharged earlier than expected) 305 patients completed the 6 months post discharge survey (27 patients died, 4 patients withdrew, 7 patients lost to follow up)

Intervention N/A

53

Measurement Pre discharge survey of 1 item in 5 point likert scale about the perception of risk of fall post discharge Outcome Secondary outcome of interest :

Perception of falls and falls risk Perceived risk of harm from fall 40% disagreed they personally will sustain a serious injury from fall

Perceived risk of serious injury from fall at discharge 0.72 (0.60–.87), .001

Uptake of fall prevention strategies(exercise): 36% participants at 6 months post discharge engaged in exercise

Facilitators of engaging in exercise (OR, 95%CI, p value): Living with partner 1.76 (1.11–2.79), .02

Cue to action Health professional recommended exercise 2.90 (1.71–4.92), <0.001

Notes No significant association between mood or cognition with engagement of exercise

*Refer to Haines(2011)

Buri(1997)

Title A group programme to prevent falls in elderly hospital patients Methods 2 group quasi experimental pre and post test Setting 2 trauma orthopaedic wards of a hospital in Britain and follow up after discharge Participants n=37

Inclusion:≥65 years, admission to trauma orthopaedic wards due to a fall, abbreviated mental test score≥8∟, Barthel ADL index≥12∩, Sheffield Screening test≥16≈

Exclusion: Nursing home or residential patients were excluded Mean age=79.5 Female% unknown

Intervention Group A (n=17) received group education program and booklet ; group B (n=20) received booklet only. Group A or B at any one time of 4 weeks duration. Intervention was given to both groups whilst as an inpatient Group education program consisted of two 20 minutes sessions on consecutive days

Measurement Knowledge questionnaire and attitude/behaviour questionnaire were administered to group A and B pre intervention

54

Knowledge questionnaire were repeated after intervention and 24 hours later to test recall Attitude/behaviour questionnaire were sent to patients 1 month after discharge 76% returned post discharge survey

Outcome Secondary outcome of interest:

Knowledge: No significant difference in number of patients with very good knowledge comparing group A and B after intervention(χ2=2.01,df=1) Significant difference in number of patients with very good knowledge in group A compared to group B 24 hours after intervention(χ2=9.75,p<0.01) Group B showed a decrease in knowledge after intervention

Behavioural change: Both groups had made some home safety modifications 1 month after discharge but had no change to their attitude in risk taking.

∟Abbreviated mental test score<8 indicated cognitive impairment

∩Barthel ADL index<12 indicated functional dependence

≈Sheffield Screening test<16 indicated evidence of dysphasia

Rucker (2006)

Title Educational intervention to reduce falls and fear of falling in patients after fragility fracture :results of a controlled pilot study Methods Controlled pilot study Setting 2 emergency departments of a health care service in Alberta, Canada

Participants n=102 patients Intervention group n=66 Control group n=67 Inclusion: aged ≥50 years with closed fracture of distal forearm and who could be discharged home Exclusion: hospital admission, those lived outside the area, lived in a long term care facility, non English speaking or could not give consent Mean age=67 years Female= 80% No withdrawal or lost to follow up at 3 month evaluation

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Intervention Intervention group : Printed educational leaflets and telephone counselling (average duration of 10 min) within a week post discharge which focussed on evidence based falls prevention information Control group: Educational leaflets and similar duration of telephone counselling but focussed on osteoporosis

Outcome Primary outcome of interest :

% fallers (intervention vs control)=17 vs 5 adjusted odds ratio=4.3 (95%CI 0.9-20) p=0.059 Notes Increase in fear of falling in intervention group vs control group= 43% vs 53% adjusted p value=0.55

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Studies of post-hospitalized older adults (multifactorial falls prevention program that consisted of patient

educational component)

Batchelor (2012)

Title Effects of a Multifactorial Falls Prevention Program for People with Stroke Returning Home After Rehabilitation: A Randomized Controlled Trial

Methods Randomized controlled trial Setting Nine health services in Melbourne and Adelaide, Australia and post discharge into the community Participants Control group n=85

Intervention group n=81 Inclusion: People with stroke ≥ 45years, discharged home after rehabilitation and had high risk of falls* Exclusion: Those discharged to residential care facilities or with homes more than 100 kilometers from study sites were ineligible. Mean age= 71 Female=37%

Intervention Intervention group: Multifactorial individually tailored falls prevention program consisting of individualized home exercise program, falls risk minimization strategies based on general and stroke-specific risk factors identified in the baseline assessment, education (written and verbal) for participant and carer about identified falls risk factors and risk minimization, injury risk minimization strategies for those at high risk of fracture (based on delayed walking after stroke, previous diagnosis of osteoporosis), a falls prevention booklet, “A Guide to Preventing Falls.” Control group: Falls prevention booklet All participants received usual care

Outcome Primary outcome of interest: Rate of falls IRR (intervention vs control) = 1.10 (.63–1.90) Rate of injurious falls IRR(intervention vs control)= 1.57 (.73–3.4) Loss to follow up at 12 months: control=10, intervention=14

* fallen during hospital admission or had a Step Test 13 worse leg score of less than 7, or a Berg Balance Scale14 score of less than 49

Close (1999)

Title Prevention of falls in the elderly trial (PROFET): a randomised controlled trial Methods RCT Setting Accident and emergency department and local community of hospital in UK

57

Participants n=397 patients (intervention n=184, control n=213) Inclusion: Aged≥65years, presented to accident and emergency due to a fall and lived in the local community from Dec 1995 to June 1996 Exclusion: patients with cognitive impairment of AMTΨ<7, lived outside the community of the hospital and people with poor English Female=68% Mean age=78 years Withdrawal n=50 (control), n=43(intervention)

Intervention Intervention: Medical assessment and referral if required, occupational therapy home assessment, advice and education about home safety and modification Control: No assessment, advice or education

Outcome Primary outcome of interest: Lower risk of falling in the intervention vs control group OR 0.39 (95%CI 0.23-0.6) adjusted for previous fall, AMT and Barthel score Lower risk of hospital admission in intervention vs control OR 0.61 (95%CI 0.35-1.05) adjusted for AMT and Barthel score

Notes Lower risk of recurrent falling in the intervention vs control group OR 0.33(95%CI 0.16-0.68) Barthel score was significantly higher in the 12 month follow up period in the intervention group compared to the control group

ΨAbbreviated mental test<7 regarded as cognitively impaired

Banez (2008)

Title Development, implementation, and evaluation of an interprofessional falls prevention program for older adults Methods Within group pre-post test,pilot study Setting Out-patient clinic at a Toronto hospital and a nearby retirement home in Canada Participants n=41(22 attended program delivered in hospital ; 19 attended program delivered in retirement home)

Inclusion: ≥65 years, community dwelling or living in the specified retirement home and had one or more falls in the previous year before the program Exclusion: score ≤24 in MMSE and could not give consent or followed multilevel command or retained information from education sessions; too frail to participate in exercise program; medically unstable or could not complete initial assessment Participants who underwent the program in the hospital were recruited from general internal medicine, family medicine and emergency department of the hospital, community agencies and family physicians. Participants who underwent the program in retirement home were recruited by director of nursing care in the retirement home.

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Mean age:≥65 years 63% female Mean MMSE=27.4, 80% lived alone, 57% completed high school, 22 lived in own home, 19 lived in the retirement home n=30 completed 3 month follow up; n=25 completed 6 month follow up

Intervention 12 week program consisted of an initial interdisciplinary falls risk assessment, 1 hour weekly group education program,1 hour group balance and strengthening exercise class and individual counselling to address individual’s fall risk factors. Handout of information for each session was given.

Measurement Fall or near fall was recorded each week prior to the session. Participants were evaluated using the same outcome measures at 3 and 6 months ie. Time up and go(TUG), Morse fall Scale(Morse), the falls efficacy scale (FES) and the Berg Balance Scale(BERG). Further falls were recorded. Post program satisfaction survey was conducted


% fallers Pre program fallers=100% 6 month evaluation: 78% no fall or fewer falls; 11% same number of falls;11% more falls

Notes Unknown number of post discharge patients who were recruited in the study

Lightbody (2002)

Title Evaluation of a nurse led falls prevention programme versus usual care: a randomized controlled trial Methods RCT Setting Accident and emergency department of a hospital in Liverpool, UK Participants n=348 (intervention n=171,control n=177)

Inclusion:≥65 years admitted to accident and emergency department due to a fall between July and December 1997 Exclusion: Faller who was admitted subsequently to the ward as a result, lived in institutional care, lived out of the area, refused or unable to give consent Median age=75 years Female=77% intervention group and 72% control group Control group: 10 withdrew,7 died and 1 lost to follow up Intervention group: 2 withdrew,11 died and 3 lost to follow up

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Intervention Intervention: Home visit by falls nurse 2-4 weeks post fall and risk factors for falls were checked using a falls checklist. Patients were given advice and education about home safety and simple modifications were made. Referrals were made to family, community services, social services and/or primary care team for further risk factor reduction Control: Usual care

Measurement Diary to record on a daily basis for falls, consequent injury and subsequent place of treatment for 6 months Outcome Primary outcome of interest

No. of falls: Intervention vs control=89 vs 145 (p=0.65)

% fallers: Intervention vs control=23% vs 25% (p=0.89)

Hospital readmission due to new fall:

Accident and emergency Intervention vs control=43 vs 58 (p=0.82)

Hospital admission Intervention vs control=8 vs 10 (p=0.87)

Notes Intervention group was significantly more independent (p<0.04) and more mobile(p<0.02) at 6 month follow up Trend of fewer falls and less falls related hospital admissions and bed days in the intervention group

McQueen (2003)

Title Fall management and prevention :a day hospital perspective Methods Pre and post design and focus group, a pilot study Setting Day hospital in rural UK Participants n=13 ( participants were post discharge from hospital, current attendees of the day hospital or referral from local GP

Inclusion: ≥24 in MMSE, mobile with or without gait aid, one fall in the last 12 months, expressed fear of falling or being less able after a fall Exclusion: Lived in residential care facility Mean age=78 years Female=82%

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n=2 did not complete the program Intervention Once weekly of 8 week program which consisted of:

exercise class, home safety discussions, education on osteoporosis and diet, fall action planning, getting up from floor, social and recreational activities designed to improve balance and promote social interaction, home safety assessment and advice, supply and installation of aids to promote independence. Information was given at the end of the program on local group/facilities to encourage an active lifestyle

Measurement Pre and post elderly mobility scale and confidence rating (in house)scale, video recording of participants’ gait, balance, transfers and reaction times No. of falls experienced in the 6 month before the program. Focus group at end of program. Interviews at 6 months post program to record no. of falls since completion of the program


No. of falls 6 months before the program vs 6 months after the program=18 vs 3 (no statistical analysis)

No. of hospital readmissions 1/9 participant was readmitted to hospital due to a fall

Secondary outcome of interest: Qualitative data from focus group

Uptake of falls prevention strategies/activities Modification of home environment to safety recommendations Engagement in exercise

Joined local elderly activity group after program

Perceived benefits: Increased confidence in moving around the house Increased confidence in walking outdoors Increased confidence of coping with falls Adoption of an active lifestyle Increased functional independence Establishment of social relationship with program participants

Notes Unknown no. of post discharge participants after 3 recruits were excluded (minimum n=2)

81% of participants engaged in exercise after the program

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Nikolaus (2003)

Title Preventing falls in community dwelling frail older people using a home intervention team (HIT): results from the randomised falls HIT trial

Methods RCT Setting Geriatric clinic of a university hospital in southern Germany and patients’ homes Participants n=360 (intervention n=181, control n=179)

Inclusion: Older patients who were referred by GP or admitted from emergency wards of departments of internal medicine, neurology and surgery; lived at home prior to admission, had multiple chronic conditions or functional decline, could be discharged back to home Exclusion: Those who had terminal illness or severe cognitive decline, lived >15 km from the hospital Mean age=81.5 years Female=73% n= 41 (intervention group) and n=40 (control group) not followed at 12 months

Intervention Intervention group: Comprehensive geriatric assessment and post discharge follow up home visit which consisted of information about possible falls risk at home and advice on home safety modifications Control group: Comprehensive geriatric assessment with recommendation followed by usual care


No. of falls (intervention vs control)=163 vs 204 Incidence risk ratio=0.69 (95%CI=0.51-0.97) p=0.032

No. of fallers with injury (intervention vs control)=14 vs 16 trend only Secondary outcome of interest:

Uptake of falls prevention strategies/activities Compliance rate of at least one home modification= 76%

Notes Proportion of frequent fallers ≥2 falls did not differ significantly between intervention and control group Intervention had significant effect on reducing falls in patients who had past history of frequent falls(≥ 2 falls) but not significant in those who had no fall or 1 fall Compliance ranged from 33% to 83% at 12 month follow up with different types of home safety recommendations advised

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Russell (2010)

Title A randomized controlled trial of a multifactorial falls prevention intervention for older fallers presenting to emergency departments Methods RCT Setting 7 emergency departments of Melbourne, Australia Participants n=712 patients (Intervention n=351,control n=361)

Inclusion: ≥60 years living in the community who presented to emergency department after a fall and discharged home, patient with cognitive impairment were included if they had a carer who gave consent to participation Exclusion: Those who were unable to follow simple instructions, unable to walk independently indoors (with or without a gait aid) and refused consent Mean age≥60 years Female=70% Total withdrawal/deceased at 1 and 12 month follow up n=31 (intervention), n=31 (control)

Intervention Intervention: Referrals to targeted multifactorial falls prevention program in the community, health promotion recommendations and standard care Control: Standard care, a letter informing the individual’s risk of falls based on FROP-COM¢ falls risk and advice to see their family physician


% fallers Intervention vs control=51 vs 46, RR=1.11 (95%CI 0.95-1.31) non significant

Rate of falls Intervention vs control=2.77 vs 4.24 RR=0.87 (95%CI 0.65-1.17) non significant

Rate of injurious fall Intervention vs control=1.07 vs 1.01 RR=1.08 (95%CI 0.78-1.48) non significant

Rate of hospital readmission due to falls Intervention vs control= 1.99 vs 1.2, adjusted rate ratio=2.33 (95%CI 0.71-7.67) non significant

Rate of falls related ED visits Intervention vs control=0.18 vs 0.18, adjusted rate ratio=1.03(95%CI 0.68-1.54) non significant

Secondary outcome of interest:

Uptake of falls prevention strategies or activities >65% compliance to occupational and physiotherapy referral

≈30% compliance to health promotion recommendation eg. Consult optometrist, change footwear, making home safety improvement

¢FROP-COM falls risk assessment (score of 0-60,≥25 regarded as high risk of falls)

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Whitehead (2003)

Title Evidence-bases clinical practice in falls prevention: a randomised controlled trial of s falls prevention service Methods RCT Setting Emergency department of a general hospital in Adelaide, South Australia Participants n= 140 patients (n=70 intervention, n=70 control)

Inclusion: Aged≥65 years who presented to emergency department because of a fall in August 1999 to January 2000, lived in the community or low level care facility Exclusion: People who lived in nursing homes, had cognitive impairment, lived outside the local community, had terminal illness and those with limited English Mean age=78 years Female=71% Living in community=97%, living in low level care=3% Lost to follow up= 5 in control group, 12 in intervention group

Intervention Intervention group: Fall risk assessment and referral to general practitioner for action. Recommended strategies suggested to GP were based on the individual risk factors for falls for that patient which included review of medication, occupational therapy home assessment, advice on home safety and modification, participation in exercise program, interdisciplinary assessment at falls and balance clinic and assessment of osteoporosis risk of those who had a fracture. Research nurse referred patients to services when asked by them. Control group: Standard care from general practitioners


% fallers (intervention vs control): OR=1.7, 95%CI=0.7-4.4 p=0.244 Secondary outcome of interest:

Uptake of falls prevention strategies (intervention vs control): OR=12.3 95%CI 4.2-35.9 p<0.001

Cues to action: GP or health professional advice increased uptake of falls prevention strategies Notes Data set was too small to separate out each individual strategy for likelihood of uptake

Unknown no. of patients who received advice

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Wong (2010)

Title Determinants of participation in a fall assessment and preventive programme along elderly fallers in Hong Kong Methods Survey and focus group, baseline interviews Setting Accident and emergency department of a hospital in Hong Kong Participants n= 1194 patients

Inclusion : All patients aged ≥60 years who were admitted to accident and emergency department of the study hospital due to a fall between August 2006 and August 2007 Mean age= 79 years Female=70% 13 participants were recruited from exercise class for focus group 94% response rate at 1 year telephone survey

Intervention Patients were invited to attend falls prevention program which consisted of falls assessment post discharge. Patients were referred to Intervention based on assessment findings. Intervention include exercise class, out patient rehabilitation in a geriatric day hospital (multidisciplinary involvement of approximately 4 weeks duration), geriatrician consultation to manage medical risk factors for falls within 4 weeks of discharge, ophthalmology referral, home safety assessment and modification, aid or hip protector prescription, social worker referral to provide patient and carer counselling or education

Outcome Secondary outcome of interest: 68% of 1194 patients attended falls prevention program

Barriers 24% refusers declined due to poor health such as limited mobility, mental and communication problem 6% refusers declined due to unavailability of their carers to accompany them Older age was associated with reduced participation (OR=0.96, 95%CI 0.95-0.98) Lower education was associated with reduced participation (OR=2.07, 95%CI (1.2-3.57)

Perception of falls and fall risk 44% refusers thought there was no need to attend the program as they have recovered from the fall Significant association with perceptions: Fall was preventable and participation (OR=3.47, 95%CI 1.59-7.56) Fall injury was reversible and participation (OR=1.73, 95%CI 1.06-2.82)

Facilitators/benefits Safe outside environment and participation (OR=3.15, 95%CI 1.9-5.23) Absence of chronic diseases (OR=9.6, 95%CI 5.16-16.45)

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Need for assistive aid for walking (OR=1.43, 95%CI 1.07-1.9) Improved score in geriatric depression scale (p<0.001) and reduction of no. of falls(p<0.001) Improved balance, self confidence in ADL’s, fewer falls and greater happiness were benefits expressed by participants

Notes Unknown no. of participants in each intervention and received patient counselling or education

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Characteristics of excluded studies Study Reason for exclusion

Abreu (1998) Participants were not hospitalized or post hospital discharge patients Assantachai (2002) Participants were not hospitalized or post hospital discharge patients Barrett (2004) Letter to the editor Barat (2012) Participants were not hospitalized or post hospital discharge patients Brandis (2001) Participants were not hospitalized or post hospital discharge patients Bright (2005) Practice paper Carpenter (2010) Review paper Cathrine(2011) Participants were not hospitalized or post hospital discharge patients Chang(2011) Participants were not hospitalized or post hospital discharge patients Chase (2012) Review paper Cheal (2001) Participants were not hospitalized or post hospital discharge patients Ciaschini (2009) Participants were not hospitalized or post hospital discharge patients Clemson(2004) Participants were not hospitalized or post hospital discharge patients Clouten(2005) Participants were not hospitalized or post hospital discharge patients Costello (2008) Review paper De Groot (2011) Participants were not hospitalized or post hospital discharge patients Dempsey (2003) Paper focussed in nursing practice change Dickinson(2011) Participants were not hospitalized or post hospital discharge patients Elliot (2012) Participants were not hospitalized or post hospital discharge patients Evron (2009) Participants were not hospitalized or post hospital discharge patients Forkan (2006) Participants were not hospitalized or post hospital discharge patients Gillespie (2009) Review paper(Interventions for preventing falls in older people living in

the community) Gillespie (2009) Review paper(WITHDRAWN: Interventions for preventing falls in elderly

people) Gopaul (2012) Participants were not hospitalized or post hospital discharge patients Gray-Vickrey(1984) Practice paper Grahn (2006) Participants were not hospitalized or post hospital discharge patients Hagedorn(2010) Participants were not hospitalized or post hospital discharge patients Haines (2009) Exercise program only. No patient education Hakim (2003) Participants were not hospitalized or post hospital discharge patients Hakim (2007) Participants were not hospitalized or post hospital discharge patients Hakim (2001) Participants were not hospitalized or post hospital discharge patients Hastings (2005) Review paper Hedley (2010) Participants were not hospitalized or post hospital discharge patients Hill (2009) No intervention Hornbrook (1994) Participants were not hospitalized or post hospital discharge patients Huang (2010) Participants were not hospitalized or post hospital discharge patients Hutton (2009) Participants were not hospitalized or post hospital discharge patients Jeske (2006) Unknown age of patients John-leader (2008) Participants were not hospitalized or post hospital discharge patients Kerse (2005) Participants were not hospitalized or post hospital discharge patients Koestner (2009) Participants were not hospitalized or post hospital discharge patients Laforest (2009) Participants were not hospitalized or post hospital discharge patients Lambert (2001) Participants were not hospitalized or post hospital discharge patients Lancaster (2007) Unknown age of patients from hospitals that participated in the study

Larsson (2010) Participants were not hospitalized or post hospital discharge patients

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Lins (2011) Participants were not hospitalized or post hospital discharge patients Maddock (2005) Participants were not hospitalized or post hospital discharge patients Marks (2004) Review paper McClure (2005) Review paper McMahon (2011) Review paper Michael (2010) Review paper Mitchell (2006) Participants were not hospitalized or post hospital discharge patients Ness (2003) Participants were not hospitalized or post hospital discharge patients Nyman (2011) Review paper Oliver (2000) Review paper Peel (2000) Participants were not hospitalized or post hospital discharge patients Perula (2012) Participants were not hospitalized or post hospital discharge patients Petridou (2009) Review paper Reinsch (1992) Participants were not hospitalized or post hospital discharge patients Ryan (1996) Participants were not hospitalized or post hospital discharge patients Schepens (2011) Participants were not hospitalized or post hospital discharge patients Schoenfelder (1997) Participants were not hospitalized or post hospital discharge patients Shah (2006) Participants were not hospitalized or post hospital discharge patients Shumway-cook (2007) Participants were not hospitalized or post hospital discharge patients Simpson (2003) No intervention Walker (2011) Participants were not hospitalized or post hospital discharge patients Sjosten (2007) Participants were not hospitalized or post hospital discharge patients Stackpool (2006) Participants were not hospitalized or post hospital discharge patients Steinberg (2000) Participants were not hospitalized or post hospital discharge patients Stern (2009) Review paper Stevens (2001) Participants were not hospitalized or post hospital discharge patients Sweeney (2003) Participants were not hospitalized or post hospital discharge patients Sze (2005) Participants were not hospitalized or post hospital discharge patients Tinetti (1993) Participants were not hospitalized or post hospital discharge patients Tse (2011) Participants were not hospitalized or post hospital discharge patients Vernon (2008) Participants were not hospitalized or post hospital discharge patients Walker (2011) Participants were not hospitalized or post hospital discharge patients Wijhuizen (2007) Participants were not hospitalized or post hospital discharge patients Wu (2010) Participants were not hospitalized or post hospital discharge patients Wyman (2007) Participants were not hospitalized or post hospital discharge patients Yates (2001) Participants were not hospitalized or post hospital discharge patients

falls prevention education for older adults during and ......or video or media or publication or...

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