According to the World Health Organization (WHO), falls among older people are a major global public health challenge.1 Falls are the second leading cause of unintentional injury and death after road traffic injuries, with an estimated 424,000 fatal falls occurring each year throughout the world.1 In 2011–2012 in Australia, 96,385 people aged 65 and over were hospitalized for a fall-related injury.2 Overall one in every ten days spent in hospital by a person aged 65 and older in 2009–2010 was directly attributable to an injurious fall (1.3 million patient days over the year).2
Hospitalization in older adults, including those who are admitted for medical problems, rehabilitation and acute care, has been shown to be associated with clinically relevant decline in function and mobility.3,4 It is well documented that a significant proportion of older people are admitted to hospital with baseline vulnerability, which results in complicated admissions and long-term adverse hospitalization outcomes, including institutionalization and readmission.5-7 Injury or illness requiring hospitalization is an external stressor that initiates a cycle of decline that is observable in frailty scores at six months and one year after discharge.8,9 The period after discharge has also been shown to be associated with adverse events, including falls, social problems and medication errors, with up to 30% of older people experiencing an adverse event following hospital discharge.10 One study investigating falls and fall injuries found an increase in falls among older people in the post-hospital discharge setting compared with older people in the broader community population.11 Other studies have found that between 29 and 45% of older people fall in the period following discharge from medical, surgical and rehabilitation wards.12,13 One study examining the incidence of falls in older, recently hospitalized medical patients requiring post-discharge home care, found that falls were substantially increased during the first month after hospital discharge.10
A large number of interventions designed to provide discharge support for older people have been evaluated for their effectiveness for reducing adverse events, including falls following hospital discharge.14,15 Systematic reviews have found that there is only limited evidence that discharge interventions encompassing planning and social support have a positive impact on the physical status of patients after discharge.16,17 A recent systematic review also concluded that a structured discharge plan tailored to the individual patient may bring about a reduction in hospital length of stay and readmission rates and an increase in patient satisfaction, but the impact on health outcomes was uncertain.16 Interventions that specifically target falls prevention in the post-hospital discharge setting also show mixed results. For example, a large randomized controlled trial (RCT) found that providing home exercises to older people living in the community who had recently been discharged from hospital improved participants’ mobility, but increased the incidence of falls.17 An RCT that evaluated providing hospital patients with tailored falls prevention education demonstrated that the intervention reduced in-patient falls, but had no ongoing effect in the post-discharge period.11 In a factorial design study, combination interventions of extended physiotherapy reduced falls but not hospital admissions; though when high-dose cholecalciferol treatment was introduced, hospital admissions, but not falls rates, were reduced.18 In post-discharge populations, one systematic review synthesized the evidence for the efficacy of education interventions for reducing falls in hospital and post-discharge settings.19 This review suggested that education was an effective means of reducing falls and falls injuries in the hospital in-patient and post-hospital setting. However, other falls prevention interventions were not examined in this review unless provided in combination with education.
Large systematic reviews have been conducted to establish the evidence for effective falls interventions in the general community.20-25 For example, multiple systematic reviews have concluded there is an established evidence that exercise interventions, which contain a balance and strength component, can reduce both the risk and rate of falls.23-25 This included a large systematic review of 159 RCTs (79,193 participants), which examined the effectiveness of interventions designed to reduce the incidence of falls for older people in the community.24 However, these reviews did not specifically address the evidence for interventions evaluated in the post-discharge setting. In comparison, the lack of systematic evidence for the effectiveness of falls prevention interventions in the post-discharge setting shows there is a potential gap in evidence for guiding clinical care during the hospital-to-home transition period. This potentially impacts on older people who are vulnerable to falls, functional decline and readmission during this period.
A preliminary search of the literature in the JBI Database of Systematics Reviews and Implementation Reports, Cochrane Library, PubMed, CINAHL and PROSPERO found no recent systematic reviews either published or underway on the effectiveness of falls prevention interventions for the older population in the post-hospital discharge setting. The absence of synthesized best available evidence for single and multiple component falls interventions for older people in the post-discharge setting justifies this current review. The timing for this current systematic review is appropriate given the implications for clinical practice, as older people being discharged from hospital are at a higher risk of falls. It is important to summarize the best available evidence for falls prevention interventions that could be used for older people during the post-discharge period, and to also identify what further research regarding falls prevention is required to be undertaken in this population.
Types of participants
The review will consider studies that include people aged 60 years of age or older; studies where there are people who are less than 60 years will be included if the mean age of the group is over 60. Studies with older people who have been hospitalized in acute or rehabilitation wards and discharged to the community setting will be included.
Studies will be excluded if they are: conducted in a population of patients discharged from hospice/palliative care wards; residential care awaiting long-term placement or surgical wards (other than orthopedic); community-based studies that do not include post-hospitalized adults; or studies where participants attended hospital for an emergency department or outpatient service, but were not admitted.
Types of intervention(s)
The review will consider studies that evaluate falls prevention interventions, including but not limited to education (including one–one/group/written/telephone/e-health), exercises (home/group/outpatient), functional assistance as a falls prevention strategy, health professional home visits, medications either withdrawing or taking for falls prevention, multifactorial interventions including combinations of the above. The interventions must have been delivered in hospital or in the first month after discharge from hospital. Interventions that are delivered during the period of six months after hospital will be included as long as they commenced in hospital or during the first month after discharge from hospital.
The outcomes of these falls interventions will be compared but not limited to control conditions where there is no falls prevention intervention provided, where usual care is provided for the control group and the intervention group receives the falls prevention intervention in addition to usual care, or where one falls prevention intervention is compared with another falls prevention intervention.
Studies will only be included in this review if an outcome measure related to falls prevalence is used. Since the period of interest is the six months after patients are discharged from hospital, studies must measure the falls outcome within at least six months after discharge from hospital to be included. The outcomes must be measured before and after the investigated intervention. Outcome measures related to falls prevalence may include the rate of falls (expressed as the number of falls per 1000 person days) and the proportion of participants who became fallers (expressed as the percentage of participants who fell); the rates of injurious falls (expressed as the number of falls with injury per 1000 patient days) and the proportion of participants who had an injurious fall (expressed as the percentage of participants who sustained an injury as a result of a fall). Studies that measure falls rates as secondary outcome measures will be included if they provide data where the falls rate can be calculated.
Types of studies
The review will include any experimental study design that incorporates RCTs, controlled clinical trials and experimental studies where randomization has been used. In the absence of these methods, comparative studies without randomization, cohort and case-control studies will be considered for inclusion. Studies will be included if they have a repeated measures design and compare an intervention against standard treatment, no treatment or another intervention.
The review aims to find both published and unpublished studies. Studies written in English from 1990 to present will be considered. The start date 1990 was considered appropriate as research into falls prevention is considered a relatively recent field of research and other large systematic reviews investigating effective falls interventions include RCTs dated from 1990.19-25 A three-step search strategy will be used when undertaking this review. An initial limited search of MEDLINE (PubMed) and CINAHL Plus with full text (EBSCO) using initial keywords will be undertaken with the aim of identifying all possible keywords from the text, and words contained in the title and abstract of the retrieved literature. A second extensive search using all keywords identified and terms will then be carried out across all included databases. Third, the reference list of all identified literature will be searched for additional studies not previously identified during the first or second search.
The databases to be searched include the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, Embase, AMED and PsycINFO. The search for unpublished studies will include an electronic search of trials registers, TROVE, Current Controlled Trials (http://www.controlled-trials.com) and the National Institute of Health Clinical Database (http://www.clinicaltrials.gov). All studies identified during the database search will be retrieved and two independent reviewers will examine the title, abstract and description/MESH headings of the studies to ensure they the studies meet the inclusion criteria. If the two independent reviewers disagree on whether a study should be included, a third independent reviewer will be consulted until a consensus has been reached.
Assessment of methodological quality
Studies selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any discrepancies that arise between reviewers will be resolved by discussion or arbitration with a third reviewer if necessary.
Quantitative data will be extracted from the retrieved studies by two independent reviewers using the standardized data extraction tool from the JBI-MAStARI (Appendix II). The data extracted will include details about the interventions, populations, study methods and outcomes of significance to the review objective. Authors of primary studies will be contacted if necessary, to seek clarification or missing information.
Quantitative data will, wherever possible, be pooled in statistical meta-analysis using Rev-Man Review Manager.26 All results will be subject to double data entry. Statistical analysis will be carried out for primary outcomes wherever possible using the inverse variance method. All studies will be analyzed in terms of primary outcomes where data are available regardless of their settings or combinations of intervention. Heterogeneity will be assessed statistically using the standard χ2. Where data can be pooled, subgroup analyses will be explored based on grouping trials with comparable interventions. Risk ratios with 95% confidence intervals will be calculated for analysis. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data presentation, where appropriate.
This study is being conducted alongside a larger study evaluating the provision of tailored falls prevention education for older people after hospital discharge. The larger study is funded by an NHMRC (Australia) project grant App1078918. CN is a doctoral student who is supported by the project. SM and TH are supported by NHMRC Career Development Fellowships.
APPENDIX I: MAStARI appraisal instrument
APPENDIX II: MAStARI Data extraction instrument
2. Bradley C. Hospitalisations due to falls by older people, Australia 2009–10. Injury research and statistics series no 70 Cat no INJCAT 146 Canberra:AIHW 2013.
3. Ehlenbach WJ, Larson EB, Curtis JR, Hough CL. Physical function and disability after acute care and critical illness hospitalizations in a prospective cohort of older adults. J Am Geriatr Soc
2015; 63 10:2061–2069.
4. Heyland DK, Garland A, Bagshaw SM, Cook D, Rockwood K, Stelfox HT, et al. Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study. Intensive Care Med
2015; 41 11:1911–1920.
5. Gill TM, William CS, Tinetti ME. The combined effects of baseline vulnerability and acute hospital events on the development of functional dependence among community-living older persons. J Gerontol A Biol Sci Med Sci
1999; 54 7:M377–M383.
6. Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med
1996; 156 6:645–652.
7. Podrazik PM, Whelan CT. Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care. Med Clin North Am
2008; 92 2:387–406.
8. Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc
2008; 56 12:2171–2179.
9. Wong RY, Miller WC. Adverse outcomes following hospitalization in acutely ill older patients. BMC Geriatr
10. Mahoney JE, Palta M, Johnson J, Jalaluddin M, Gray S, Park S, Sager M. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med
2000; 160 18:2788–2795.
11. Hill AM, Hoffmann T, McPhail S, Beer C, Hill KD, Oliver D, et al. Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow-up to a randomized controlled trial. J Gerontol A Biol Sci Med Sci
2011; 66 9:1001–1012.
12. Davenport RD, Vaidean GD, Jones CB, Chandler AM, Kessler LA, Mion LC, et al. Falls following discharge after an in-hospital fall. BMC Geriatr
13. Mackintosh SF, Hill KD, Dodd KJ, Goldie PA, Culham EG. Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation. Arch Phys Med Rehabil
2006; 87 12:1583–1589.
14. Mistiaen P, Francke AL, Poot E. Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Serv Res
15. Carpenter GI, Demopoulos GR. Screening the elderly in the community: controlled trial of dependency surveillance using a questionnaire administered by volunteers. BMJ
1990; 300 6734:1253–1256.
16. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev
17. Sherrington C, Lord SR, Vogler CM, Close JC, Howard K, Dean CM, et al. A post-hospital home exercise program improved mobility but increased falls in older people: a randomised controlled trial. PLoS One
2014; 9 9:e104412.
18. Bischoff-Ferrari HA, Dawson-Hughes B, Platz A, Orav EJ, Stahelin HB, Willett WC, et al. Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture: a randomized controlled trial. Arch Intern Med
2010; 170 9:813–820.
19. Lee D-CA, Pritchard E, McDermott F, Haines TP. Falls prevention education for older adults during and after hospitalization: a systematic review and meta-analysis. Health Educ J
2014; 73 5:530–544.
20. Goodwin VA, Abbott RA, Whear R, Bethel A, Ukoumunne OC, Thompson-Coon J, et al. Multiple component interventions for preventing falls and fall-related injuries among older people: systematic review and meta-analysis. BMC Geriatr
21. Bunn F, Dickinson A, Barnett-Page E, McInnes E, Horton K. A systematic review of older people's perceptions of facilitators and barriers to participation in falls-prevention interventions. Ageing Soc
2008; 28 4:449–472.
22. Jang H, Clemson L, Lovarini M, Willis K, Lord SR, Sherrington C. Cultural influences on exercise participation and fall prevention: a systematic review and narrative synthesis. Disabil Rehabil
23. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc
2008; 56 12:2234–2243.
24. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev
25. Winter H, Watt K, Peel NM. Falls prevention interventions for community-dwelling older persons with cognitive impairment: a systematic review. Int Psychogeriatr
2013; 25 2:215–227.
26. Review Manager (RevMan) [Computer program]. Version 53. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014 [Cited 3 March 2016]. Available from: http://community-archive.cochrane.org/
. Accessed August 30, 2016.