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alls experienced by the elderly population are a major concern for the community, family members, and healthcare providers. Many factors, including polypharmacy, balance impairment, environmental hazards, and muscle weakness to name a few, put the elderly person at increased risk for falling. Additionally, it is thought that as the number of risk factors increases, the probability of a fall increases as well. While not all risk factors can be eliminated, it has been suggested that falls can be prevented. The Centers for Medicare and Medicaid Services (CMS) conducted a review of fall prevention literature as part of its Healthy Aging Project. To understand what falls prevention interventions would be most effective, CMS posed questions involving the effectiveness of fall prevention programs, the usefulness of education campaigns, which care settings are more effective at preventing falls, and others. Although CMS published this report several years ago, the findings of the report are still relevant, and the results can be applied to your practice, regardless of setting or discipline, today.
       The reviewers for the project divided falls intervention components into broad categories including the following:
• Exercise: This category included both general physical activities, such as walking or cycling, and specific physical activities, such as exercises for balance, strength, or gait.
• Multifactorial falls risk assessment and management program: A multifactorial falls risk assessment and management program will include a focused post-fall assessment or a risk factor screening for at-risk individuals followed by interventions for the risks discovered. This program should have three parts: 1) a questionnaire that will identify risk factors for falls (this questionnaire can be self-administered by the patient or administered by a caregiver); 2) a thorough medical evaluation, which should include an examination of vision, gait, balance, strength, postural vital signs, medication review, and cognitive and functional status; and 3) follow-up interventions, such as an exercise program, environmental modifications, and assistive devices.
• Education: This intervention category refers to educational materials, such as pamphlets or posters, designed to raise awareness among the elderly or caregivers at extended care facilities. One-on-one counseling about risk factors would also fall under this category.
• Assistive devices: This category includes assistive devices, such as walkers and canes.
• Medication review: During a medication review, the physician will review patient records for any adverse effects of medications, which may cause falls to occur. Calcium, vitamin D, and hormone replacement therapy may be used to increase muscle and bone strength, which in turn will help prevent falls.
• Environmental modification: Environmental modification is particularly applicable to the home care patient. Environmental modification starts with a visit from a caregiver during which the caregiver will look for hazards, such as poor lighting, sliding carpets, and slippery floors. Examples of modifications include installing grab bars and placing bath mats in the shower.
• Staff or facility: Modifications in the facility or within the staff structure may start with a visit from a falls prevention specialist. This specialist may recommend bed alarms, restraints, or patient reminder bracelets.
       For the report, CMS developed the following questions, which the researchers were to answer by conducting a literature search of randomized, controlled trials and controlled clinical trials. A brief summary of the researchers’ findings follows each question.
1. Are falls prevention programs effective? What are the key components that should be included in a falls prevention intervention? Are multifactorial approaches more effective than single intervention approaches? Based on the literature reviewed, the researchers concluded that falls prevention programs are effective at reducing the number of falls in the elderly. No evidence was found to support single component falls intervention programs, but a clear trend demonstrated the effectiveness of multifactorial falls risk assessment and management programs. Additionally, researchers found that multifactorial falls risk assessment and management programs appeared to be the most effective intervention. They found the most commonly assessed risks in the programs to be medication review, vision, environmental hazards, and orthostatic blood pressure. Exercise was found to be the next most effective intervention component. They did not find evidence to support the effectiveness of environmental modification or education as independent components. Similarly, the effectiveness of the independent components of assistive devices, medication review, and staff/organizational changes was not supported in the literature reviewed. Most interventions in the literature were multifactorial, thus it was not possible for the researchers to draw conclusions regarding the effectiveness of multiple component interventions versus single component interventions.
2. Are public information or education campaigns alone effective in reducing or preventing falls? The researchers found no literature to support the effectiveness of public information or education campaigns. Patient education within a multifactorial program did not show a substantial effect on falls prevention.
3. Which care settings/approaches have been more effective than others for the delivery of falls prevention interventions? Which providers should deliver this service? Successful falls prevention interventions were found across all settings of care, from patient homes to physician offices to nursing homes. Additionally, these interventions were successfully carried out by all disciplines of caregivers, including nurses, physical therapists, social workers, and interdisciplinary teams. No research demonstrated that one setting, approach, or provider was more effective than another.
4. What are the key issues in sustaining falls prevention programs? Research showed two key issues in sustaining falls prevention programs: insufficient funding and lack of available programs. In most of the studies reviewed, the programs were backed by research grants, and none were continued as regular programs. Research indicates that funding is needed to support components of falls prevention programs, such as supervised exercise programs and multifactorial fall risk assessments and management.
5. Cost effectiveness or cost savings: Do falls prevention interventions appear to reduce healthcare costs by reducing disease, physician office visits, hospitalizations, nursing home admissions, etc.? Though further research is needed and no definitive conclusion about cost effectiveness or cost savings could be reached through the literature reviewed, the literature does suggest that an effective intervention provided to high-risk patients has the potential to be cost effective or cost saving compared to current practice.
6. Should falls prevention programs be targeted toward high-risk individuals? Are there a few basic questions to identify these individuals? Can this be done through self identification? The literature suggests that risk factors for falls exist and can be identified through basic questions and physical examination. However, data do not support whether falls prevention interventions are more effective in high-risk patients versus low-risk patients.
7. Are there specific falls prevention exercises recommended for seniors? Data indicated that exercise is effective in preventing falls; however, the literature leaned toward the effectiveness of exercise in general, and no data supported the effectiveness of one exercise over another. The exercise components of the falls prevention programs in the literature reviewed included cardiovascular endurance, muscle strength, flexibility, and balance.
8. Are falls prevention programs acceptable to seniors? Researchers did not find concrete data to answer this question, but data does suggest that the amount of elderly that accept falls prevention programs is probably substantial.
       Fall prevention is an integral component of care of the elderly. Though there were limitations to this study, it is apparent that with a multifactorial falls prevention program in place, the incidence of falls is likely to decline.
       This article is based on the Executive Summary of the CMS Healthy Aging Initiative Evidence Report, “Falls Prevention Intervention in the Medicare Population,” which is available at http://www.cms.hhs.gov/healthyaging/FallsPI.asp.