Falls prevention education for older adults
during and after hospitalization: A systematic
review and meta-analysis
[Type the document subtitle]
Den-Ching Angel Lee
3/1/2013
Contents
Search string terms and limiters applied to databases........................................................................... 2
Calculation of effect size estimates of primary outcomes...................................................................... 3
Table of risk ratio, confidence interval and standard error of studies used for meta-analysis .............. 5
Forest plots of meta-analysis, subgroup meta-analysis and a priori meta-analysis ............................. 12
Characteristics of included studies ....................................................................................................... 21
Characteristics of excluded studies....................................................................................................... 47
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
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 =
𝑛 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠
𝑛 𝑜𝑓 𝑐𝑙𝑢𝑠𝑡𝑒𝑟𝑠 𝑜𝑟 𝑤𝑎𝑟𝑑𝑠
Intra cluster coefficient=0.014 from Cumming (2008)
 Step 2: To calculate standard error (normal) for the study:
Standard error
(normal)=
𝑅𝑎𝑛𝑔𝑒 𝑜𝑓 𝑛𝑎𝑡𝑢𝑟𝑎𝑙 𝑙𝑜𝑔𝑎𝑟𝑖𝑡ℎ𝑚 𝑜𝑓 95% 𝑐𝑜𝑛𝑓𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙𝑠
3.92
 Step 3: To calculate standard error (corrected) for studies:
Standard error (corrected) =Standard error (normal) x √𝐷𝐸

For outcome ii) Rate of falls, outcome iv) Rate of injurious falls, outcome v) Rate of hospital
admission 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
3
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 metaanalysis (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.
4
Table of risk ratio, confidence interval and standard error of studies used for meta-analysis
Table 6.1 Studies of hospitalized older adults (Targeted multifactorial fall prevention programme that consisted of educational component)
Study
(year)
Fallers
RR
(lnRR)
Haines
(2004)
Haines
(2006)
Subgroup
of Haines
2004:
cognitive
intact
participant
s only
Haines
(2006)
Subgroup
of Haines
2004:
cognitive
impaired
participant
s only
Ang
(2011)
Lower
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
0.78
(0.2485)
0.56
(0.5798
)
1.06
(0.0583)
0.1628
1.59
(0.4637
)
0.71
(0.3425
)
3.58
(1.2754)
0.4127
1
(0)
0.43
(0.8440
)
2.34
(0.8502)
0.4322
0.29*
(-
0.1*
(-
0.89*
(-
0.5577
Rate of falls
RR
Lower
(lnRR)
range
95%CI
(ln)
0.7086
Ω
(0.3445)
0.4526
(0.7927)
0.6172
(0.4826)
0.30y
(-
Upper
range
95%CI
(ln)
SE ln
0.55
(0.5978)
0.91
(0.0943)
0.1249Ω
a
0.16
(1.8326)
a
1.25
(0.2231)
a
0.5200
0.25
a
1.54
a
(1.3863)
(0.4318
)
0.10y
(2.3026)
0.91y
(-
Fallers with injury
RR
Lower
(lnRR)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
Rate of injurious fall
RR
Lower
Upper
(lnRR)
range
range
95%CI
95%CI
(ln)
(ln)
0.7098
£
(0.3428)
a
0.4656
0.5633
0.6013
£
0.1441
(1.9370
2.5087
(0.9198)
)
0.7288
0.3364a
(1.0896)
1.4978a
(0.404)
SE ln
0.3810a
Cumming
(2008)
1.2379)
2.3026
)
0.1165)
1.0469
0.704¢
(0.351)
1.557¢
(0.4428)
0.7618
0.1923
£
¢
3.017¢
(0.2721)
0.7027
(1.6486
)
0.3364
£
¢
(0.3528)
(1.0894
)
0.6827
(0.3816
)
£
(0.0459
)
Dykes
(2010)
Vassallo
(2004)
Von RKruse
(2007)
0.7740
(0.2562)
(1.1044¢
1.2040)
0.96x
(0.0408)
0.72x
(-0.33)
0.7023
0.7536
¢
Ω
0.5752
(-0.553)
0.2025
¢
(0.2829)
)
1.4679¢
(0.3838)
0.8775
(0.1307)
0.0943)
0.3758
¢
0.0640
Healey
(2004)
1.28x
(0.25)
0.1468
0.9873
(0.0128)
0.1378Ω
)
£
¢
(0.1825
)
(0.4352
)
0.6471
2.2260 ¢
(0.8002)
0.3152
¢
1.12x
(0.1133
)
0.71x
(0.3425)
1.77x
(0.5710)
0.233
1.1681
0.01¢a
(4.6746)
146.26¢
2.4644¢
a
a
£
(0.1554
)
0.473¢a
(0.7487)
2.4203¢
0.4165¢
a
a
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
0.705
(0.3496)
0.3021¢
1.6449¢
0.4323¢
0.2253¢
8.1141¢
0.9143¢
a
a
a
a
a
a
(1.1969)
(0.4977)
1.352
(0.3016
)
(1.4904)
(2.0936)
(0.8839)
ln log natural
CI confidence interval
SE standard error
supplied by trial author on contact
6
0.4889
0.1189
£
¢
(0.7156)
(2.1297
)
2.0107¢
(0.6985)
(4.9854)
1.070£
(0.0676
)
RR rate ratio
ΩData
(0.5086)
1.2002
0.7215¢
£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
xIRR
adjusted for clustering, length of stay and previous falls by trial author
aAdjusted
b
by review author for clustering using intracluster correlation coefficient 0.014 given in Cumming (2008) paper
by inflation factor calculated by author
Incidence rate ratio provided by trial author
7
Table 6.2 Studies of hospitalized older adults (education intervention only)
Study
(year)
Fallers
RR
(lnRR)
Haines
(2011)
Haines
(2011)
Subgroup:
cognitive
intact
participants
only
Haines
(2011)
Subgroup:
cognitive
impaired
participants
only
Clarke
(2012)
£rate
Lower
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
0.74
(0.3011)
0.51
(0.6733)
0.48
(0.7340)
0.28
(1.2730)
1.15
(0.1398)
0.2229
0.94
(0.0619)
0.3090
1.38
(0.3221)
0.70
(0.3567)
2.75
(1.0116)
0.3490
0.2842£
(1.2581)
0.0063£
(5.0672)
2.1938£
(0.7856)
1.4931£
Rate of falls
RR
Lower
(lnRR)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
Fallers with injury
RR
Lower
(lnRR)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
Rate of injurious fall
RR
Lower
Upper
(lnRR)
range
range
95%CI
95%CI
(ln)
(ln)
0.83
(0.1863)
0.43
(0.8440)
0.54
(0.6162)
0.24
(1.4271)
1.27
(0.2390)
0.2182
1.22
(0.1989)
0.78
(0.2485)
0.3007
1.48
(0.3920)
0.86
(0.1508)
2.53
(0.9282)
0.2753
0.4630£
(0.7700)
0.0097£
(4.6356)
4.2534£
(1.4477)
ratio calculated by review author (one added to all cells in 2x2 table due to zero odds ratio, Clarke 2012)
8
1.5519£
SE ln
2.20
(0.7885)
0.2958
0.53
(0.6349)
0.69
(0.3711)
0.23
(1.4697)
1.22
(0.1989)
0.4256
2.63
(0.9670)
1.19
(0.1740)
5.84
(1.7647)
0.0444
Table 6.3 Studies of post hospitalized older adults (education intervention only)
Study
(year)
Hill ‡
(2011)
Rucker
(2006)
Fallers
RR
(lnRR)
1.34b(0.2927)
4.3¥(1.4586)
Lower
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
0.76(0.2744)
2.37(0.8629)
0.2901
0.9
(0.1054)
19.8
(2.9857)
0.7885
Rate of falls
RR
Lower
(lnRR)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
1.18b
(0.1655)
1.96
(0.6729)
0.2590
0.71
(0.3425)
Study
(year)
Rate of hospital admissions
RR
Lower range 95%CI
(ln)
(ln)
Upper range 95%CI
(ln)
SE ln
Hill ‡
(2011)
0.5b
(-0.6931)
1.28
(0.2469)
0.4735
0.2
(-1.6094)
‡Evaluation
Fallers with injury
RR
Lower
Upper
(lnRR) range
range
95%CI
95%CI
(ln)
(ln)
SE
ln
Rate of injurious fall
RR
Lower
Upper
(lnRR) range
range
95%CI
95%CI
(ln)
(ln)
1.00b
(0)
0.6
(0.5108)
1.66
(0.5068)
Rate of accident and emergency admissions
RR
Lower range 95%CI
Upper range 95%CI
(ln)
(ln)
(ln)
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
9
SE ln
0.2596
SE ln
Table 6.4 Studies of post hospitalized older adults (Multifactorial falls prevention program that consisted of education component)
Study
(year)
Fallers
RR
(ln)
Rate of falls
RR
Lower
(ln)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
Batchelor
(2012)
0.83
(0.1863)
1.1b
(0.0953)
0.63
(-0.4620)
1.90
(0.6419)
0.2816
0.39ϕ
(0.9416)
0.23
(-1.4697)
0.6
(-0.5108)
0.2446
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)
0.87Đ
(0.1393)
0.65
(-0.4308)
1.17
(0.1570)
Lower
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
0.6
(-0.5108)
1.14
(0.1310)
0.1637
Close
(1999)
Lightbody
(2002)
0.9469£
(0.0546)
0.6377
1.4060
(0.3407)
0.2017
(-0.4499
Russell
(2010)
1.11
(0.1044)
0.95
(-0.0513)
1.31
(0.2700)
0.0820
Whitehead
(2003)
1.7ʄ
(0.5306)
0.7
(-0.3567)
4.4
(1.4816)
0.4689
Study
(year)
Rate of hospital admissions
RR
Lower range
(ln)
95%CI
(ln)
Upper range
95%CI
(ln)
SE ln
Fallers with injury
RR Lower
Upper
(ln) range
range
95%CI
95%CI
(ln)
(ln)
Rate of injurious fall
RR
Lower
(ln)
range
95%CI
(ln)
Upper
range
95%CI
(ln)
SE ln
1.57b
(0.4511)
0.73
(-0.3147)
3.4
(1.2238)
0.3925
0.1640
0.8499£
(0.1627)
0.6321a
(-0.4587)
1.1423a
(0.1331)
0.1509a
0.1499
1.08Ɵ
(0.0770)
0.78
(-0.2485)
1.48
(0.3920)
0.1634
SE
ln
Rate of accident and emergency admissions
RR
Lower range
Upper range 95%CI
(ln)
95%CI
(ln)
(ln)
10
SE ln
Close
(1999)
0.61ϕ
(-0.4943)
Lightbody
(2002)
0.8£
(-0.2231)
Russell
(2010)
2.33z
0.35
1.05
(0.0488)
0.2803
(-1.050)
(0.8459)
0.2037a
3.1424a
(1.145)
0.6980a
(-1.5912)
0.71
(-0.3425)
7.67
(2.0373)
0.6071
0.7414£
(-0.2992)
0.4322a
(-0.8388)
1.27a
1.03
(0.0296)
0.68
(-0.3857)
1.54
(0.4318)
0.2753a
(0.239a)
zAdjusted
0.2085
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
11
Forest plots of meta-analysis, subgroup meta-analysis and a priori
meta-analysis
Appendix 1.
Analysis 1.1 Proportion of patients who became fallers (all studies)
study
year
Lightbody
2002
Whitehead
2003
Vassallo
2004
Haines
2004
Rucker
2006
Von R-Kruse 2007
Cumming
2008
Dykes
2010
Russell
2010
Haines
2011
Ang
2011
Batchelor
2012
Clarke
2012
Overall (I-squared = 52.3%, p = 0.014)
ES (95% CI)
%
Weight
0.95 (0.64, 1.41)
1.70 (0.68, 4.26)
0.70 (0.34, 1.47)
0.78 (0.57, 1.07)
4.30 (0.92, 20.17)
0.77 (0.68, 0.88)
1.05 (0.70, 1.56)
0.76 (0.19, 3.02)
1.11 (0.95, 1.30)
0.74 (0.48, 1.15)
0.29 (0.10, 0.87)
0.83 (0.60, 1.14)
0.28 (0.02, 5.30)
0.88 (0.75, 1.04)
9.60
2.79
4.05
11.89
1.08
19.11
9.55
1.34
17.84
8.55
2.05
11.83
0.31
100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
Analysis 1.2 Subgroup meta-analysis of proportion of patients who became fallers (hospital setting)
%
study
year
ES (95% CI)
Weight
Haines
2004
0.78 (0.57, 1.07) 11.13
Vassallo
2004
0.70 (0.34, 1.47) 2.09
Von R-Kruse 2007
0.77 (0.68, 0.88) 71.98
Cumming
2008
1.05 (0.70, 1.56) 7.19
Dykes
2010
0.76 (0.19, 3.02) 0.60
Haines
2011
0.74 (0.48, 1.15) 5.94
Ang
2011
0.29 (0.10, 0.87) 0.95
Clarke
2012
0.28 (0.02, 5.30) 0.13
Overall (I-squared = 0.0%, p = 0.555)
0.78 (0.70, 0.87) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
Analysis 1.3 Subgroup meta-analysis of proportion of patients who became fallers (post discharge
setting)
%
study
year
ES (95% CI)
Weight
Lightbody
2002
0.95 (0.64, 1.41)
18.44
Whitehead
2003
1.70 (0.68, 4.26)
4.76
Rucker
2006
4.30 (0.92, 20.17)
1.79
Russell
2010
1.11 (0.95, 1.30)
40.43
Hill
2011
1.34 (0.76, 2.37)
10.87
Batchelor
2012
0.83 (0.60, 1.14)
23.71
1.07 (0.87, 1.33)
100.00
Overall (I-squared = 34.8%, p = 0.176)
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
Analysis 1.4 Proportion of patients who became fallers (studies with only cognitive intact
participants)
%
study
year
ES (95% CI)
Weight
Lightbody 2002
0.95 (0.64, 1.41) 29.43
Whitehead 2003
1.70 (0.68, 4.26) 17.45
Rucker
2006
4.30 (0.92, 20.17) 9.13
Haines
2006
1.59 (0.71, 3.57) 19.67
Haines
2011
0.51 (0.28, 0.93) 24.32
Overall (I-squared = 62.9%, p = 0.029)
1.15 (0.67, 1.97) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
13
Analysis 1.5 Proportion of patients who became fallers (studies with cognitive intact and impaired
participants)
study
year
ES (95% CI)
Vassallo
2004
Haines
2004
Von R-Kruse 2007
Cumming
2008
Dykes
2010
Russell
2010
Haines
2011
Ang
2011
Batchelor
2012
Clarke
2012
Overall (I-squared = 52.3%, p = 0.027)
%
Weight
0.70 (0.34, 1.47)4.32
0.78 (0.57, 1.07)13.54
0.77 (0.68, 0.88)23.24
1.05 (0.70, 1.56)10.66
0.76 (0.19, 3.02)1.40
1.11 (0.95, 1.30)21.44
0.74 (0.48, 1.15)9.46
0.29 (0.10, 0.87)2.15
0.83 (0.60, 1.14)13.47
0.28 (0.02, 5.30)0.32
0.84 (0.71, 1.00)100.00
NOTE: Weights are from random effects analysis
.1
1
favours intervention
10
favours control
Analysis 1.6 Proportion of patients who became fallers (studies with only cognitive impaired
participants)
%
study
year
ES (95% CI)
Weight
Haines 2006
1.00 (0.43, 2.33) 39.47
Haines 2011
1.38 (0.70, 2.73) 60.53
Overall (I-squared = 0.0%, p = 0.562)
1.22 (0.71, 2.07) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
favours control
14
10
Analysis 2.1 Rate of falls (all studies)
study
year
Close
1999
Lightbody
2002
Nikolaus
2003
McQueen
2003
Vassallo
2004
Healey
2004
Haines
2004
Von R-Kruse 2007
Cumming
2008
Dykes
2010
Russell
2010
Haines
2011
Ang
2011
Batchelor
2012
Overall (I-squared = 35.5%, p = 0.092)
ES (95% CI)
%
Weight
0.39 (0.24, 0.63)
0.82 (0.61, 1.11)
0.69 (0.50, 0.95)
0.17 (0.03, 1.10)
1.07 (0.47, 2.42)
0.70 (0.30, 1.64)
0.71 (0.55, 0.91)
0.82 (0.73, 0.92)
0.96 (0.72, 1.28)
0.75 (0.58, 0.99)
0.87 (0.65, 1.17)
0.83 (0.54, 1.27)
0.30 (0.10, 0.90)
1.10 (0.63, 1.91)
0.77 (0.69, 0.87)
4.84
9.53
8.67
0.38
1.91
1.79
11.91
19.89
9.96
10.71
9.71
5.79
1.08
3.83
100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
Analysis 2.2 Rate of falls (studies with only cognitive intact participants)
%
study
year
ES (95% CI)
Close
1999
0.39 (0.24, 0.63)19.88
Lightbody 2002
0.82 (0.61, 1.11)27.15
Nikolaus 2003
0.69 (0.50, 0.95)26.17
McQueen 2003
0.17 (0.03, 1.10)2.72
Haines
2006
0.45 (0.16, 1.25)7.84
Haines
2011
0.43 (0.24, 0.78)16.25
Overall (I-squared = 55.4%, p = 0.047)
Weight
0.56 (0.40, 0.77)100.00
NOTE: Weights are from random effects analysis
.1
1
favours intervention
10
favours control
15
Analysis 2.3 Rate of falls (studies with cognitive intact and impaired participants)
%
study
year
ES (95% CI)
Vassallo
2004
1.07 (0.47, 2.42) 1.06
Healey
2004
0.70 (0.30, 1.64) 0.99
Haines
2004
0.71 (0.55, 0.91) 11.81
Von R-Kruse 2007
0.82 (0.73, 0.92) 52.91
Cumming
2008
0.96 (0.72, 1.28) 8.55
Dykes
Russell
2010
2010
0.75 (0.58, 0.99) 9.70
0.87 (0.65, 1.17) 8.20
Haines
2011
0.83 (0.54, 1.27) 3.87
Ang
2011
0.30 (0.10, 0.90) 0.58
Batchelor
2012
1.10 (0.63, 1.91) 2.32
Overall (I-squared = 0.0%, p = 0.549)
Weight
0.82 (0.75, 0.89) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
favours control
10
Analysis 2.4 Rate of falls (studies with only cognitive impaired participants)
%
study
year
ES (95% CI)
Haines
2006
0.62 (0.25, 1.54) 40.78
Haines
2011
1.48 (0.86, 2.54) 59.22
Overall (I-squared = 61.8%, p = 0.106)
1.04 (0.45, 2.41) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
Weight
1
16
favours control
10
Analysis 3.1 Rate of injurious fall (all studies)
%
study
year
ES (95% CI)
Weight
Nikolaus
2003
0.85 (0.63, 1.14)
21.38
Healey
2004
1.35 (0.23, 8.11)
0.58
Haines
2004
0.71 (0.34, 1.50)
3.35
Von R-Kruse
2007
0.84 (0.67, 1.05)
38.69
Cumming
2008
1.12 (0.71, 1.77)
8.96
Dykes
2010
1.17 (0.01, 146.28)
0.08
Russell
2010
1.08 (0.78, 1.49)
18.23
Haines
2011
1.22 (0.68, 2.18)
5.56
Batchelor
2012
1.57 (0.73, 3.39)
3.16
0.94 (0.82, 1.08)
100.00
Overall (I-squared = 0.0%, p = 0.655)
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
Analysis 3.2 Rate of injurious fall (studies with cognitive intact and impaired participants)
%
study
year
ES (95% CI)
Weight
Healey
2004
1.35 (0.23, 8.11)
0.74
Haines
2004
0.71 (0.34, 1.50)
4.27
Von R-Kruse 2007
0.84 (0.67, 1.05)
49.21
Cumming
2008
1.12 (0.71, 1.77)
11.40
Dykes
2010
1.17 (0.01, 146.28) 0.10
Russell
2010
1.08 (0.78, 1.49)
23.19
Haines
2011
1.22 (0.68, 2.18)
7.08
Batchelor
2012
1.57 (0.73, 3.39)
4.02
0.97 (0.83, 1.13)
100.00
Overall (I-squared = 0.0%, p = 0.615)
NOTE: Weights are from random effects analysis
.1
favours intervention
1
10
favours control
17
Analysis 3.3 Rate of injurious fall (studies with only cognitive intact participants)
%
study
year
ES (95% CI)
Weight
Nikolaus 2003
0.85 (0.63, 1.14) 85.51
Haines
0.53 (0.23, 1.22) 14.49
2011
Overall (I-squared = 8.6%, p = 0.296)
0.79 (0.57, 1.10) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
favours control
10
Analysis 4 Proportion of fallers with injury (all studies)
%
study
year
ES (95% CI)
Vassallo
2004
0.49 (0.12, 2.01) 13.45
Cumming 2008
1.20 (0.65, 2.23) 70.46
Ang
2011
0.60 (0.14, 2.51) 13.18
Clarke
2012
0.46 (0.02, 9.70) 2.91
Overall (I-squared = 0.0%, p = 0.571)
0.94 (0.56, 1.59) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
Weight
1
10
favours control
18
Analysis 5.1 Rate of hospital readmission due to falls (all studies)
%
study
year
ES (95% CI)
Close
1999
0.61 (0.35, 1.06) 42.67
Lightbody 2002
0.80 (0.20, 3.14) 14.40
Russell
2010
2.33 (0.71, 7.66) 17.83
Hill
2011
0.50 (0.20, 1.26) 25.10
Overall (I-squared = 36.2%, p = 0.195)
Weight
0.77 (0.43, 1.37) 100.00
NOTE: Weights are from random effects analysis
.1
1
favours intervention
10
favours control
Analysis 5.2 Rate of hospital readmission due to falls (studies with only cognitive intact participants)
%
study
year
ES (95% CI)
Close
1999
0.61 (0.35, 1.06) 86.11
Lightbody 2002
0.80 (0.20, 3.14) 13.89
Overall (I-squared = 0.0%, p = 0.718)
0.63 (0.38, 1.05) 100.00
NOTE: Weights are from random effects analysis
.1
favours intervention
1
19
favours control
10
Weight
Analysis 5.3 Rate of hospital readmission due to falls (studies with cognitive intact and impaired
participants)
%
study
year
ES (95% CI)
Weight
Russell
2010
2.33 (0.71, 7.66)
46.95
Hill
2011
0.50 (0.20, 1.26)
53.05
1.03 (0.23, 4.64)
100.00
Overall (I-squared = 75.0%, p = 0.046)
NOTE: Weights are from random effects analysis
.1
1
favours intervention
10
favours control
Analysis 6 Rate of emergency department presentation due to falls (all studies)
%
study
year
ES (95% CI)
Weight
Lightbody
2002
0.74 (0.43, 1.27)
36.45
Russell
2010
1.03 (0.68, 1.55)
63.55
0.91 (0.66, 1.27)
100.00
Overall (I-squared = 0.0%, p = 0.341)
NOTE: Weights are from random effects analysis
.1
1
10
favours intervention
favours control
20
Characteristics of included studies
Studies of hospitalized older adults (Targeted multifactorial fall prevention programme that consisted of educational component)
Haines (2004)
Title
Methods
Setting
Participants
Intervention
Outcome
Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial
RCT
Subacute wards from a metropolitan hospital in Melbourne, Australia
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 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
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
Control vs intervention=32 vs 23 p=0.20
21
a
MMSE Mini mental state examination( /30) >23 regarded as cognitively intact
Haines (2006)
Title
Methods
Setting
Participants
Interventions
Outcome
Patient education to prevent falls in subacute care
Randomised controlled trial (subgroup analysis) and post intervention 5 point Likert survey
Metropolitan subacute/aged rehabilitation hospital, Melbourne, Australia
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
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
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%
 Increase awareness of fall (be careful)=44%
22

Notes
Ang (2011)
Title
Methods
Setting
Participants
Intervention
Outcome
Action to reduce falls:
Use of protective equipment=13%
Ask for help=17%
Follow staff instruction=8%
Plan ahead=11%
Avoid risky activities=20%
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
Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized
controlled trial
RCT
Acute care hospital in Singapore
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 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
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
3/4 fallers(intervention) vs 5/14 (control)
23
Notes
Cumming (2008)
Title
Methods
Setting
Participants
Intervention
Outcome
Education was also given to family of participants who were confused or delirious
Cluster randomised trail of a targeted multifactorial intervention to prevent falls among older people in hospital
Clustered randomised trail
24 acute and rehabilitation elderly care wards in 12 hospitals in Sydney, Australia
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 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
Primary outcome of interest
 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)
24
Dykes (2010)
Title
Methods
Setting
Participants
Intervention
Outcome
Notes
Fall prevention in acute care hospitals
Cluster randomised study
8 medical wards of 4 urban hospitals in Boston, US
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 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
Primary outcome of interest
 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
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
25
Vassallo (2004)
Title
Methods
Setting
Participants
Intervention
Outcome
Notes
Von R-Kruse
(2007)
Title
Methods
Setting
The effect of changing practice on fall prevention in a rehabilitative hospital: The hospital injury prevention study
Quasi experimental design
3 geriatric wards of a community rehabilitation hospital
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:
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)
Primary outcome of interest
 % 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
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.
Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisplinary team based fall-prevention
intervention
Prospective cohort with historical control (pre and post intervention study)
5 geriatric wards (acute care and early rehabilitation) of a hospital in Hamburg, Germany
26
Participants
Intervention
Outcome
Notes
Healey (2004)
Title
Methods
Setting
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
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.
Primary outcome of interest
 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
Significant reduction in the risk of falling 0.77 (95%CI 0.68-0.88) p<0.001
Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial
Clustered randomised trial
8 elderly care wards (acute, rehabilitation and speciality wards) of a general hospital in UK
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
Exclusion: None
Mean age=81 years
27
Intervention
Outcome
Female=60%
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
Primary outcome of interest:
 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
Studies of hospitalized older adults (Education intervention only)
Clarke (2012)
Title
Methods
Setting
Participation
Intervention
Outcome
Preoperative patient education reduces in-hospital falls after total knee arthroplasty
Retrospective cohort study
Outpatient setting of a hospital within 2 weeks before elective knee surgery and in-patient hospital setting after surgery in Phoenix,
USA
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%
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
Primary outcome of interest:
28
 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
Methods
Setting
Participants
Intervention
Outcome
Patient education to prevent falls among older hospital inpatients
3-group randomized control trial
Acute and subacute wards of 2 general hospitals in Brisbane and Perth, Australia
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%
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)
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
Primary outcome of interest:
 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
29
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
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
b
SPMSQ Short portable mental status questionnaire ≥8 regarded as cognitively intact
Hill (2009)
Title
Methods
Setting
Participants
Intervention
A randomized trial comparing digital video disc with written delivery of falls prevention education for older patients in hospital
2 group randomised control trial with quasi experimental control group
Acute and subacute wards of 2 hospitals in Brisbane and Perth of Australia
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 groups: DVD or workbook of identical content received at bedside
Control group: No education
30
Measurement
Outcome
Notes
Hill€ (2011)
Title
Methods
Setting
Participants
Pre intervention survey of self perceived risk of falls in a 5 point Likert scale (item 1 of 21 questions in a survey)
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
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)
Falls after discharge from hospital: Is there a gap between older people’s knowledge about falls prevention strategies and the
research evidence
Survey
A general hospital in Perth, Australia
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%
31
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
Tzeng (2008)
Title
Methods
Setting
Participants
Intervention
Outcome
Notes
Perspectives of recently discharged patients on hospital fall prevention programs
Post intervention/cross sectional survey
Home care agency of the affiliated hospital
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
Fall prevention advice from hospital staff and information brochure
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.
Leaving a brochure without explanation was perceived by patients to be insufficient
32
Studies of post hospitalized older adults (education intervention only)
Hill (2011) ‡
Title
Methods
Setting
Participants
Intervention
Measurement
Outcome
Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a
randomised controlled trail
Prospective cohort study
Pre hospital discharge and 6 month post discharge follow up of patients from a general hospital in Perth, Australia
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%
N/A
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#
Primary outcome of interest:
 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)
33
Complete=0.37; material=0.54; control=0.86 (no significant difference)
Incidence rate ratio, 95%CI, p value:
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
Methods
Setting
Participants
Factors associated with older patients’ engagement in exercise after hospital discharge
Survey (pre hospital discharge face to face survey and 6 months post discharge telephone survey)
Post discharge in patients’ home setting from a general hospital in Perth, Australia
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)
34
305 patients completed the 6 months post discharge survey (27 patients died, 4 patients withdrew, 7 patients lost to follow up)
Intervention
N/A
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
Methods
Setting
Participants
Intervention
A group programme to prevent falls in elderly hospital patients
2 group quasi experimental pre and post test
2 trauma orthopaedic wards of a hospital in Britain and follow up after discharge
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
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
35
Measurement
Knowledge questionnaire and attitude/behaviour questionnaire were administered to group A and B pre intervention
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
Methods
Setting
Participants
Educational intervention to reduce falls and fear of falling in patients after fragility fracture :results of a controlled pilot study
Controlled pilot study
2 emergency departments of a health care service in Alberta, Canada
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
36
Intervention
Outcome
Notes
Female= 80%
No withdrawal or lost to follow up at 3 month evaluation
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
Primary outcome of interest :
 % fallers (intervention vs control)=17 vs 5 adjusted odds ratio=4.3 (95%CI 0.9-20) p=0.059
Increase in fear of falling in intervention group vs control group= 43% vs 53% adjusted p value=0.55
Studies of post hospitalized older adults (Multifactorial fall prevention program that consisted of education component)
Batchelor (2012)
Title
Methods
Setting
Participants
Intervention
Effects of a Multifactorial Falls Prevention Program for People with Stroke Returning Home After Rehabilitation: A
Randomized Controlled Trial
Randomized controlled trial
Nine health services in Melbourne and Adelaide, Australia and post discharge into the community
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 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
37
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
Methods
Setting
Participants
Prevention of falls in the elderly trial (PROFET): a randomised controlled trial
RCT
Accident and emergency department and local community of hospital in UK
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
Ψ
Abbreviated mental test<7 regarded as cognitively impaired
38
Banez (2008)
Title
Methods
Setting
Participants
Development, implementation, and evaluation of an interprofessional falls prevention program for older adults
Within group pre-post test,pilot study
Out-patient clinic at a Toronto hospital and a nearby retirement home in Canada
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.
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
Primary outcome of interest:
 % fallers
Pre program fallers=100%
6 month evaluation: 78% no fall or fewer falls; 11% same number of falls;11% more falls
Unknown number of post discharge patients who were recruited in the study
Outcome
Notes
39
Lightbody (2002)
Title
Methods
Setting
Participants
Intervention
Measurement
Outcome
Notes
Evaluation of a nurse led falls prevention programme versus usual care: a randomized controlled trial
RCT
Accident and emergency department of a hospital in Liverpool, UK
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
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
Diary to record on a daily basis for falls, consequent injury and subsequent place of treatment for 6 months
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)
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
40
McQueen (2003)
Title
Methods
Setting
Participants
Intervention
Measurement
Outcome
Fall management and prevention :a day hospital perspective
Pre and post design and focus group, a pilot study
Day hospital in rural UK
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%
n=2 did not complete the program
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
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
Primary outcome of interest:
 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
41

Notes
Nikolaus (2003)
Title
Methods
Setting
Participants
Intervention
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
Unknown no. of post discharge participants after 3 recruits were excluded (minimum n=2)
81% of participants engaged in exercise after the program
Preventing falls in community dwelling frail older people using a home intervention team (HIT): results from the randomised falls HIT
trial
RCT
Geriatric clinic of a university hospital in southern Germany and patients’ homes
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 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:
42
Outcome
Notes
Russell (2010)
Title
Methods
Setting
Participants
Intervention
Outcome
Comprehensive geriatric assessment with recommendation followed by usual care
Primary outcome of interest:
 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%
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
A randomized controlled trial of a multifactorial falls prevention intervention for older fallers presenting to emergency departments
RCT
7 emergency departments of Melbourne, Australia
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: 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
Primary outcome of interest:
 % fallers
Intervention vs control=51 vs 46, RR=1.11 (95%CI 0.95-1.31) non significant
43

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)
Whitehead (2003)
Title
Methods
Setting
Participants
Intervention
Evidence-bases clinical practice in falls prevention: a randomised controlled trial of s falls prevention service
RCT
Emergency department of a general hospital in Adelaide, South Australia
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 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.
44
Control group:
Standard care from general practitioners
Outcome
Notes
Wong (2010)
Title
Methods
Setting
Participants
Intervention
Outcome
Primary outcome of interest:
 % 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
Data set was too small to separate out each individual strategy for likelihood of uptake
Unknown no. of patients who received advice
Determinants of participation in a fall assessment and preventive programme along elderly fallers in Hong Kong
Survey and focus group, baseline interviews
Accident and emergency department of a hospital in Hong Kong
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
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
Secondary outcome of interest:
45
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)

Notes
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)
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
Unknown no. of participants in each intervention and received patient counselling or education
46
Characteristics of excluded studies
Study
Abreu (1998)
Assantachai (2002)
Barrett (2004)
Barat (2012)
Brandis (2001)
Bright (2005)
Carpenter (2010)
Cathrine(2011)
Chang(2011)
Chase (2012)
Cheal (2001)
Ciaschini (2009)
Clemson(2004)
Clouten(2005)
Costello (2008)
De Groot (2011)
Dempsey (2003)
Dickinson(2011)
Elliot (2012)
Evron (2009)
Forkan (2006)
Gillespie (2009)
Gopaul (2012)
Gray-Vickrey(1984)
Grahn (2006)
Hagedorn(2010)
Haines (2009)
Hakim (2003)
Hakim (2007)
Hakim (2001)
Hastings (2005)
Hedley (2010)
Hill (2009)
Hornbrook (1994)
Huang (2010)
Hutton (2009)
Jeske (2006)
John-leader (2008)
Kerse (2005)
Koestner (2009)
Laforest (2009)
Lambert (2001)
Lancaster (2007)
Reason for exclusion
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Letter to the editor
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Practice paper
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Participants were not hospitalized or post hospital discharge patients
Paper focussed in nursing practice change
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper(Interventions for preventing falls in older people living in
the community)
Review paper(WITHDRAWN: Interventions for preventing falls in elderly
people)
Participants were not hospitalized or post hospital discharge patients
Practice paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Exercise program only. No patient education
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Participants were not hospitalized or post hospital discharge patients
No intervention
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Unknown age of patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Unknown age of patients from hospitals that participated in the study
Larsson (2010)
Participants were not hospitalized or post hospital discharge patients
Gillespie (2009)
47
Lins (2011)
Maddock (2005)
Marks (2004)
McClure (2005)
McMahon (2011)
Michael (2010)
Mitchell (2006)
Ness (2003)
Nyman (2011)
Oliver (2000)
Peel (2000)
Perula (2012)
Petridou (2009)
Reinsch (1992)
Ryan (1996)
Schepens (2011)
Schoenfelder (1997)
Shah (2006)
Shumway-cook (2007)
Simpson (2003)
Walker (2011)
Sjosten (2007)
Stackpool (2006)
Steinberg (2000)
Stern (2009)
Stevens (2001)
Sweeney (2003)
Sze (2005)
Tinetti (1993)
Tse (2011)
Vernon (2008)
Walker (2011)
Wijhuizen (2007)
Wu (2010)
Wyman (2007)
Yates (2001)
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Review paper
Review paper
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
No intervention
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Review paper
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
Participants were not hospitalized or post hospital discharge patients
48