Interventions to prevent falls in older adults in Primary Care: a systematic review

Dourado Júnior, Francisco Wellington; Moreira, Andréa Carvalho Araújo; Salles, Dafne Lopes; Silva, Maria Adelane Monteiro da

doi:10.37689/acta-ape/2022AR0225666

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Review Article • Acta Paul Enferm 35 • 2022 • https://doi.org/10.37689/acta-ape/2022AR0225666 copy

Interventions to prevent falls in older adults in Primary Care: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To identify effective interventions for preventing falls in older adults in the national and international literature, developed in primary health care settings, and categorize them based on the World Health Organization’s Report on Fall Prevention.

Methods

A systematic review registered in PROSPERO (CRD42020149529), conducted between 2019 and 2020, according to the PRISMA guidelines. Independent reviewers consulted MEDLINE®/PubMed®, Lilacs, Scopus, Cochrane, Web of Science, and Embase databases. The descriptors “elderly”, “elder”, “aged”, “aging”, “care”, “education”, “primary health”, “falls” and “prevention” were used for the database search, and were defined from the PICO strategy. The PEDro scale was used to evaluate the methodological quality of the selected studies. The results are presented in order to favor comparability among the studies included in this review and categorization regarding the profile of the publications and classification of the intervntions.

Results

Twenty eligible articles were identified, with 35% (n=8) classified as high methodological quality and 25% (n=5) as excellent quality. Among the investigated interventions, 55% (n=11) consisted of physical exercise programs, and 45% (n=9) were multicomponent, with a duration time between 3 weeks and 12 months, implemented by professionals from different disciplines. Such interventions had an impact on reducing falls and decreasing the fear of falling in older adults, as well as contributing to muscle strengthening, motor skills, and cognitive improvement.

Conclusion

The interventions identified proved to be effective in strengthening the musculoskeletal system, maintaining geriatric functionality, improving balance, and assessing the risk of falls to promote better management of these events.

Accidental falls; Aged; Health of the elderly; Primary Health Care

Authors	Country	Type of study	Sample	Professionals involved in the interventions	Duration of intervention (months)	Methodological quality PEDro scale (score)
Serra-Prat et al.⁽¹⁵15. Serra-Prat M, Sist X, Domenich R, Jurado L, Saiz A, Roces A, et al. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial. Age Ageing. 2017;46(3):401-7.⁾	Spain	RCT	CG: 92 IG: 80	Nurse, physical educator	12	10
Bustamante-Troncoso et al.⁽¹⁶16. Bustamante-Troncoso C, Herrera-López LM, Sánchez H, Pérez JC, Márquez-Doren F, Leiva S. [Effect of a multidimensional intervention for prevention of falls in the eldery]. Aten Primaria. 2020;52(10):722-30. Spanish.⁾	Chile	RCT	IG: 70 CG: 70	Nurse	5	8
Kuhirunyaratn et al.⁽¹⁷17. Kuhirunyaratn P, Prasomrak P, Jindawong B. Effects of a health education program on fall risk prevention among the urban elderly: a quasi-experimental study. Iran J Public Health. 2019;48(1):103-11.⁾	Thailand	Quasi-Experimental	IG: 108 CG: 108	Physicians, physical therapists	6	4
Shumway-Cook et al.⁽¹⁸18. Shumway-Cook A, Silver IF, LeMier M, York S, Cummings P, Koepsell TD. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2007;62(12):1420-7.⁾	United States	RCT	476	Nurse, physiotherapist health educators	12	8
Boongird et al.⁽¹⁹19. Boongird C, Keesukphan P, Phiphadthakusolkul S, Rattanasiri S, Thakkinstian A. Effects of a simple home-based exercise program on fall prevention in older adults: a 12-month primary care setting, randomized controlled trial. Geriatr Gerontol Int. 2017;17(11):2157-63.⁾	Thailand	RCT	IG: 219 CG: 220	Physician, nurse	12	8
Elley et al.⁽²⁰20. Elley CR, Robertson MC, Kerse NM, Garrett S, McKinlay E, Lawton B, et al. Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics. BMC Public Health. 2007;7:185.⁾	New Zealand	RCT	IG: 155 CG: 157	Nurse, physician	12	8
Saudi et al.⁽²¹21. Saudi RA, Nour-Eldein H, Waheed A, Abdulmajeed AA. Effect of a fall prevention program for elderly persons attending a rural family medicine center, Egypt. J Public Health. 2019;27(7):1-8.⁾	Egypt	Quasi-experimental, before-and-after	100	Nurse, physician, physiotherapist	12	4
Duckham et al.⁽²²22. Duckham RL, Masud T, Taylor R, Kendrick D, Carpenter H, Iliffe S, et al. Randomised controlled trial of the effectiveness of community group and home-based falls prevention exercise programmes on bone health in older people: the ProAct65+ bone study. Age Ageing. 2015;44(4):573-9.⁾	England	RCT	319	Physician, physical therapist, physical educator, nurse	6	10
Spice et al.⁽²³23. Spice CL, Morotti W, George S, Dent TH, Rose J, Harris S, et al. The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people. Age Ageing. 2009;38(1):33-40.⁾	England	RCT by cluster	IG: 354 CG: 162	Nurse, physician, physical educator, occupational therapist	12	9
Siegrist et al.⁽²⁴24. Siegrist M, Freiberger E, Geilhof B, Salb J, Hentschke C, Landendoerfer P, et al. Fall Prevention in a Primary Care Setting. Dtsch Arztebl Int. 2016;113(21):365-72.⁾	Germany	RCT	IG: 222 CG: 156	Physiotherapist, physician, physical educator	4	4
Li et al.⁽²⁵25. Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, et al. Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60(2):187-94.⁾	China	RCT	669	Physician, physical educator	6	4
Cristopoliski et al.⁽²⁶26. Cristopoliski F, Sarraf TA, Dezan VH, Provensi CL, Rodacki AL. Efeito transiente de exercícios de flexibilidade na articulação do quadril sobre a marcha de idosas. Rev Bras Med Esporte. 2008;14(2):139-44.⁾	Brazil	RCT	5	Physical educators	3	8
Silva et al.⁽²⁷27. Silva A, Almeida GJ, Cassilhas RC, Cohen M, Peccin MS, Tufik S. Equilíbrio, coordenação e agilidade de idosos submetidos à prática de exercícios físicos resistidos. Rev Bras Med Esporte. 2008;14(2):88-93.⁾	Brazil	CT	61	Physical educator, physical therapist	3	8
Gschwind et al.⁽²⁸28. Gschwind YJ, Eichberg S, Ejupi A, de Rosario H, Kroll M, Marston HR, et al. ICT-based system to predict and prevent falls (iStoppFalls): results from an international multicenter randomized controlled trial. Eur Rev Aging Phys Act. 2015;12:10.⁾	New Zealand	RCT	153	Physical educator, neuroscientists	6	10
Liu-Ambrose et al.⁽²⁹29. Liu-Ambrose T, Davis JC, Best JR, Dian L, Madden K, Cook W, et al. Effect of a home-based exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: a randomized clinical trial. JAMA. 2019;321(21):2092-100. Erratum in: JAMA. 2019;322(2):174.⁾	Canada	RCT	IG: 143 CG: 172	Physiotherapists	12	10
Li et al.⁽³⁰30. Li F, Harmer P, Fitzgerald K, Eckstrom E, Akers L, Chou LS, et al. Effectiveness of a therapeutic tai ji quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Intern Med. 2018;178(10):1301-10.⁾	China	RCT	Tai Chi Chuan: group 224 Multimodal intervention group:223 Usual care group: 223	Physiotherapist, physical educators	6	8
Van Ooijen et al.⁽³¹31. van Ooijen MW, Roerdink M, Trekop M, Janssen TW, Beek PJ. The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial. BMC Geriatr. 2016;16(1):215.⁾	Germany	RCT	IG: 48 CG: 24	Physiotherapist, physical educator	12	4
Freiberger et al.⁽³²32. Freiberger E, Blank WA, Salb J, Geilhof B, Hentschke C, Landendoerfer P, et al. Effects of a complex intervention on fall risk in the general practitioner setting: a cluster randomized controlled trial. Clin Interv Aging. 2013;8:1079-88.⁾	Germany	RCT	IG: 222 CG: 150	Physical educators	12	4
Nguyen et al.⁽³³33. Nguyen MH, Kruse A. A randomized controlled trial of Tai chi for balance, sleep quality and cognitive performance in elderly Vietnamese. Clin Interv Aging. 2012;7:185-90.⁾	Vietnam	RCT	IG: 56 CG: 56	Physical educator	6	4
Moura et al.⁽³⁴34. Moura M, Pedrosa M, Costa E, Bastos Filhos P, Sayão L, Sousa T. Efeitos de exercícios resistidos, de equilíbrio e alongamentos sobre a mobilidade funcional de idosas com baixa massa óssea. Rev Bras Ativ Fis Saúde. 2012;17(6):474-84.⁾	Brazil	RCT	IG: 18 CG: 18	Physiotherapist	4	4

Type of intervention	Authors	Characteristic of the intervention	Measured variables	Intervention effectiveness
Multi-component Intervention	Serra-Prat et al.⁽¹⁵15. Serra-Prat M, Sist X, Domenich R, Jurado L, Saiz A, Roces A, et al. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial. Age Ageing. 2017;46(3):401-7.⁾	Nutritional recommendations, physical activity program (aerobic, strengthening, balance and coordination activities), telephone follow-up	Prevalence of frailty	Effective in preventing frailty in community-dwelling pre-fragile older adults, with the CG showing a higher number of older adults (15.3%) who evolved to frailty, when compared to the IG (4.9%)
	Bustamante-Troncoso et al.⁽¹⁶16. Bustamante-Troncoso C, Herrera-López LM, Sánchez H, Pérez JC, Márquez-Doren F, Leiva S. [Effect of a multidimensional intervention for prevention of falls in the eldery]. Aten Primaria. 2020;52(10):722-30. Spanish.⁾	Home visit, health education, development of a management plan for fall risk factors, telephone follow-up	Self-perception of fall risk, presence of risk factors for falls, occurrence of falls	Effective in reducing the frequency of falls (IG with only 7.9% falls versus CG, with 27.7%); management of extrinsic risk factors (24% shoes; 21% walking and 36% presence of mobile objects)
	Kuhirunyaratn et al.⁽¹⁷17. Kuhirunyaratn P, Prasomrak P, Jindawong B. Effects of a health education program on fall risk prevention among the urban elderly: a quasi-experimental study. Iran J Public Health. 2019;48(1):103-11.⁾	Program included exchange of learning and experiences among participants, home exercises, group dialogue	Presence of risk factors for falls	Effective in improving balance (IG with 52.9% versus CG with 60.8%), decreasing use of medications among older adults
	Shumway-Cook et al.⁽¹⁸18. Shumway-Cook A, Silver IF, LeMier M, York S, Cummings P, Koepsell TD. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2007;62(12):1420-7.⁾	Exercise program , health education group for older community adults	Occurrence of falls in older adults	Effective in improving balance (IG with 75% showed good balance versus CG with 50%); mobility and physical strength’ dealing with the risk factors for falls
	Boongird et al.⁽¹⁹19. Boongird C, Keesukphan P, Phiphadthakusolkul S, Rattanasiri S, Thakkinstian A. Effects of a simple home-based exercise program on fall prevention in older adults: a 12-month primary care setting, randomized controlled trial. Geriatr Gerontol Int. 2017;17(11):2157-63.⁾	Exercise program, telephone follow-up	Occurrence of falls during the research period	Effective in reducing fear of falling (IG with rate of 24.7; CG with rate of 27); improvement in exercise adherence. The IG had a rate of 0.3 falls/person, while in the CG this rate increased to 0.4
	Elley et al.⁽²⁰20. Elley CR, Robertson MC, Kerse NM, Garrett S, McKinlay E, Lawton B, et al. Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics. BMC Public Health. 2007;7:185.⁾	Assessment of risk factors for falls, health education, review of medications used, prescription of vitamin D, specialized follow-up if needed	Occurrence of falls during the research period	Effective in reducing the risk factors for falls; self-management of older adults. A discrete difference was verified in the frequency of falls when comparing IG (67%) with CG (70%)
	Saudi et al.⁽²¹21. Saudi RA, Nour-Eldein H, Waheed A, Abdulmajeed AA. Effect of a fall prevention program for elderly persons attending a rural family medicine center, Egypt. J Public Health. 2019;27(7):1-8.⁾	Assessment of intrinsic and extrinsic risk factors for falls and assessment of the older adults’ bone capacity	Occurrence of falls during the study period and the functionality of the older adults	Effective in reducing the occurrence of falls when comparing the pre-test (63.4) and post-test (49.5); reducing recurrence of this event (pre: 40.8% versus post: 25.8%)
	Duckham et al.⁽²²22. Duckham RL, Masud T, Taylor R, Kendrick D, Carpenter H, Iliffe S, et al. Randomised controlled trial of the effectiveness of community group and home-based falls prevention exercise programmes on bone health in older people: the ProAct65+ bone study. Age Ageing. 2015;44(4):573-9.⁾	Strength and balance exercise program, home visits, telephone follow-up	Bone mineral density of participants, especially of femur	Effective in reducing the risk of falls and fractures, as it increased muscle strength and functionality of older adults, but did not improve bone density of participants
	Spice et al.⁽²³23. Spice CL, Morotti W, George S, Dent TH, Rose J, Harris S, et al. The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people. Age Ageing. 2009;38(1):33-40.⁾	Assessment of fall risk factors	Reduction in the number of falls and injuries caused by falls	Effective in reducing the risk factors for falls (IG: 75% of the older adults fell, compared to 84% in the CG)
Physical exercise programs	Siegrist et al.⁽²⁴24. Siegrist M, Freiberger E, Geilhof B, Salb J, Hentschke C, Landendoerfer P, et al. Fall Prevention in a Primary Care Setting. Dtsch Arztebl Int. 2016;113(21):365-72.⁾	Supervised exercise program, assessment of fall risk factors	Reduction in the occurrence of falls and injuries caused by falls	Effective in decreasing the occurrence of falls (IG: 291 falls; CG: 367 falls); reduction in injuries caused by these events
	Li et al.⁽²⁵25. Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, et al. Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60(2):187-94.⁾	Tai Chi Chuan training as exercise	Physical performance, functionality, fear of falling	Effective in decreasing risk factors for falls; improved balance; strengthened musclesl reduced fall occurrences (IG: 28%; CG: 46%)
	Cristopoliski et al.⁽²⁶26. Cristopoliski F, Sarraf TA, Dezan VH, Provensi CL, Rodacki AL. Efeito transiente de exercícios de flexibilidade na articulação do quadril sobre a marcha de idosas. Rev Bras Med Esporte. 2008;14(2):139-44.⁾	Program of stretching exercises, flexibility promotion	Improved gait, flexibility	Effective in improving gait performance; motor ability to move feet and hip joint angle by 3.9°
	Silva et al.⁽²⁷27. Silva A, Almeida GJ, Cassilhas RC, Cohen M, Peccin MS, Tufik S. Equilíbrio, coordenação e agilidade de idosos submetidos à prática de exercícios físicos resistidos. Rev Bras Med Esporte. 2008;14(2):88-93.⁾	Aerobic stretching, movement exercise program	Balance, coordination, agility	Effective in improving mean functional and motor performance of older adults (IG: 11.33; CG: 10.81)
	Gschwind et al.⁽²⁸28. Gschwind YJ, Eichberg S, Ejupi A, de Rosario H, Kroll M, Marston HR, et al. ICT-based system to predict and prevent falls (iStoppFalls): results from an international multicenter randomized controlled trial. Eur Rev Aging Phys Act. 2015;12:10.⁾	Exercise programs for muscle strengthening	Risk factors for falls, self-care, mobility, pain	Effective in reducing risk factors for falls (IG: only 6 falls; CG: 16); postural sway; stepping reaction; cognitive function
	Liu-Ambrose et al.⁽²⁹29. Liu-Ambrose T, Davis JC, Best JR, Dian L, Madden K, Cook W, et al. Effect of a home-based exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: a randomized clinical trial. JAMA. 2019;321(21):2092-100. Erratum in: JAMA. 2019;322(2):174.⁾	Exercise programs for muscle strengthening	Reduction in occurrence of falls during research period	Effective in reducing occurrence of falls (IG: 236 falls versus CG: 366 falls); injuries caused by such incidents
	Li et al.⁽³⁰30. Li F, Harmer P, Fitzgerald K, Eckstrom E, Akers L, Chou LS, et al. Effectiveness of a therapeutic tai ji quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Intern Med. 2018;178(10):1301-10.⁾	One group used a Tai Chi Chuan training program; the other used a multimodal physical exercise program	Occurrence of falls among older adults in the groups	Tai Chi Chuan was more effective in reducing fall occurrence (IG: 152 versus GC: 218) than multimodal exercises; it improved balance and flexibility of participants
	Van Ooijen et al.⁽³¹31. van Ooijen MW, Roerdink M, Trekop M, Janssen TW, Beek PJ. The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial. BMC Geriatr. 2016;16(1):215.⁾	Physical exercise program	Mobility, muscle strength	Effective in improving physical mobility; educing risk and occurrence of falls (IG: 0.59 falls/person versus CG: 0.63 falls/person)
	Freiberger et al.⁽³²32. Freiberger E, Blank WA, Salb J, Geilhof B, Hentschke C, Landendoerfer P, et al. Effects of a complex intervention on fall risk in the general practitioner setting: a cluster randomized controlled trial. Clin Interv Aging. 2013;8:1079-88.⁾	Exercise programs for muscle strengthening; body self-knowledge	Occurrence of falls during research period	Effective in reducing occurrence of falls in community-dwelling older adults (IG: 291 and CG: 397)
	Nguyen et al.⁽³³33. Nguyen MH, Kruse A. A randomized controlled trial of Tai chi for balance, sleep quality and cognitive performance in elderly Vietnamese. Clin Interv Aging. 2012;7:185-90.⁾	Tai Chi Chuan training as exercise	Sleep quality, risk of falls	Effective in improving balance; sleep quality; cognitive performance of older adults. In the falls risk assessment scale, a mean of 8.06 in IG and 9.48 in CG was identified.
	Moura et al.⁽³⁴34. Moura M, Pedrosa M, Costa E, Bastos Filhos P, Sayão L, Sousa T. Efeitos de exercícios resistidos, de equilíbrio e alongamentos sobre a mobilidade funcional de idosas com baixa massa óssea. Rev Bras Ativ Fis Saúde. 2012;17(6):474-84.⁾	Exercise programs for muscle strengthening; functionality	Functional capacity	Analysis found improvement in functional mobility test (CG: mean of 26.38 and in IG: mean of 24.57); walking test (IG: 4.41 versus CG: 4.22)

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[1] Corresponding author: Francisco Wellington Dourado Júnior E-mail: wjunior0599@gmail.com