1. Falls prevention for the elderly
- Author
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Dagmar Lühmann, Susanne Schramm, Martina Bremer, Katrin Balzer, and Heiner Raspe
- Subjects
sight ,economic evaluation ,visual acuity ,diagnosis ,fall prophylaxis ,eigene Häuslichkeit ,TECHNOLOGY ASSESSMENT, BIOMEDICAL ,Risikoabschätzung ,Sehschärfenprüfung ,falling consequences ,environment design ,accidents, home ,prevention ,randomisierte kontrollierte Studie ,RISK ASSESSMENT ,DIAGNOSTIK ,Motorik ,dose-response relationship, drug ,geriatric nursing home ,Vorsorge ,aged/*psychology ,Ältere ,lcsh:R723-726 ,ACCIDENTAL FALLS ,freiheitsentziehende Maßnahmen ,DIETARY SUPPLEMENTS ,Prophylaxe ,Visusprüfung ,HTA ,review literature as topic ,Health Technology Assessment ,Übersichtsliteratur ,HÜFTFRAKTUREN ,610 Medical sciences ,Medicine ,eyesight ,meta-analysis as topic ,adjustment of the living environment ,MOTOR SKILLS ,hip protectors ,lcsh:R855-855.5 ,Diagnose ,hip fracture ,RISK FACTORS ,customisation of the living environment ,multi-factorial programs ,geriatrisches Pflegeheim ,humans ,interventions ,Umweltgestaltung ,Senioren ,evidenzbasierte Medizin ,primäre Prävention ,randomisierte kontrollierte Studien ,Risikofaktoren ,lcsh:Medical technology ,motor activity/drug effects ,Risiko-vermeidendes Verhalten ,fall ,fall risk ,medical adjustment ,private domesticity ,eye test ,Medikationsanpassung ,Metaanalyse ,biomedical ,Hüftprotektoren ,dose-response relationship ,Article ,NAHRUNGSERGÄNZUNGSMITTEL ,aged ,multimodal programs ,DOSIS-WIRKUNGSBEZIEHUNG, ARZNEIMITTEL ,gutachterbasierte Medizin ,alte Menschen/*Psychologie ,motor activity ,Sturzfolgen ,technology assessment ,Krankenpflegeheime ,systematische Übersicht ,randomized controlled trial ,Kataraktchirurgie ,UNFALLBEDINGTE STÜRZE ,lcsh:Medical philosophy. Medical ethics ,PRIMARY PREVENTION ,Sehschärfe ,eyesight test ,Technologiefolgenabschätzung, biomedizinische ,EVIDENCE-BASED MEDICINE ,VITAMIN D/ADMINISTRATION & DOSAGE ,Sturz ,randomized controlled trials as topic ,nursing homes ,power of movement ,exercise program ,Vitamin D/administration & dosage ,FREEDOM ,Sturzprophylaxe ,systematic review ,Übungsprogramm ,HIP FRACTURES ,correction of the visual acuity ,home ,Hüftfraktur ,training program ,alte Menschen ,Interventionen ,motor function ,drug ,HUMANS ,motorische Aktivität/Arzneimittelwirkungen ,ACTIVITIES OF DAILY LIVING ,cataract surgery ,fall prevention ,Sturzgefährdung ,MOTORISCHE GESCHICKLICHKEIT ,multifaktorielle Programme ,Unfälle, Haushalts ,ddc: 610 ,prophylaxis ,RISK REDUCTION BEHAVIOR ,Seniorenheime ,EXERCISE/PHYSIOLOGY ,motorische Funktionen ,RCT ,EBM ,TECHNIKFOLGEN-ABSCHÄTZUNG, BIOMEDIZINISCHE ,systematisches Review ,accidents ,Fraktur ,ökonomische Evaluation ,Sturzrisiko ,Aktivitäten des täglichen Lebens ,Prävention ,elderly ,seniors ,Mensch ,HOMES FOR THE AGED ,Freiheit ,MOTORISCHE AKTIVITÄT ,Visuskorrektur ,GUTACHTENBASIERTE MEDIZIN ,fall-related injuries ,Sturzrisikofaktoren ,Vitamin D/Verabreichung & Dosierung ,Visus ,fracture ,fall risk factors ,stabilisierend ,falling danger ,sturzbedingte Verletzung ,freedom-depriving measures ,stabilized ,multimodale Programme ,Training, körperliches/Physiologie ,Anpassung der Wohnumgebung - Abstract
Background An ageing population, a growing prevalence of chronic diseases and limited financial resources for health care underpin the importance of prevention of disabling health disorders and care dependency in the elderly. A wide variety of measures is generally available for the prevention of falls and fall-related injuries. The spectrum ranges from diagnostic procedures for identifying individuals at risk of falling to complex interventions for the removal or reduction of identified risk factors. However, the clinical and economic effectiveness of the majority of recommended strategies for fall prevention is unclear. Against this background, the literature analyses in this HTA report aim to support decision-making for effective and efficient fall prevention. Research questions The pivotal research question addresses the effectiveness of single interventions and complex programmes for the prevention of falls and fall-related injuries. The target population are the elderly (> 60 years), living in their own housing or in long term care facilities. Further research questions refer to the cost-effectiveness of fall prevention measures, and their ethical, social and legal implications. Methods Systematic literature searches were performed in 31 databases covering the publication period from January 2003 to January 2010. While the effectiveness of interventions is solely assessed on the basis of randomised controlled trials (RCT), the assessment of the effectiveness of diagnostic procedures also considers prospective accuracy studies. In order to clarify social, ethical and legal aspects all studies deemed relevant with regard to content were taken into consideration, irrespective of their study design. Study selection and critical appraisal were conducted by two independent assessors. Due to clinical heterogeneity of the studies no meta-analyses were performed. Results Out of 12,000 references retrieved by literature searches, 184 meet the inclusion criteria. However, to a variable degree the validity of their results must be rated as compromised due to different biasing factors. In summary, it appears that the performance of tests or the application of parameters to identify individuals at risk of falling yields little or no clinically relevant information. Positive effects of exercise interventions may be expected in relatively young and healthy seniors, while studies indicate opposite effects in the fragile elderly. For this specific vulnerable population the modification of the housing environment shows protective effects. A low number of studies, low quality of studies or inconsistent results lead to the conclusion that the effectiveness of the following interventions has to be rated unclear yet: correction of vision disorders, modification of psychotropic medication, vitamin D supplementation, nutritional supplements, psychological interventions, education of nursing personnel, multiple and multifactorial programs as well as the application of hip protectors. For the context of the German health care system the economic evaluations of fall prevention retrieved by the literature searches yield very few useful results. Cost-effectiveness calculations of fall prevention are mostly based on weak effectiveness data as well as on epidemiological and cost data from foreign health care systems. Ethical analysis demonstrates ambivalent views of the target population concerning fall risk and the necessity of fall prevention. The willingness to take up preventive measures depends on a variety of personal factors, the quality of information, guidance and decision-making, the prevention program itself and social support. The analysis of papers regarding legal issues shows three main challenges: the uncertainty of which standard of care has to be expected with regard to fall prevention, the necessity to consider the specific conditions of every single case when measures for fall prevention are applied, and the difficulty to balance the rights to autonomous decision making and physical integrity. Discussion and conclusions The assessment of clinical effectiveness of interventions for fall prevention is complicated by inherent methodological problems (esp. absence of blinding) and meaningful clinical heterogeneity of available studies. Therefore meta-analyses are not appropriate, and single study results are difficult to interpret. Both problems also impair the informative value of economic analyses. With this background it has to be stated that current recommendations regarding fall prevention in the elderly are not fully supported by scientific evidence. In particular, for the generation of new recommendations the dependency of probable effects on specific characteristics of the target populations or care settings should be taken into consideration. This also applies to the variable factors influencing the willingness of the target population to take up and pursue preventive measures. In the planning of future studies equal weight should be placed on methodological rigour (freedom from biases) and transferability of results into routine care. Economic analyses require input of German data, either in form of a “piggy back study“ or in form of a modelling study that reflects the structures of the German health care system and is based on German epidemiological and cost data., GMS Health Technology Assessment; 8:Doc01; ISSN 1861-8863
- Published
- 2012