Are there any effective interventions for preventing falls in older people with mental health problems?

Falls are estimated to cost the NHS more than £2.3 billion per year (College of Optometrists, 2011) and are associated with significant morbidity and mortality. This fact alone should be giving us the drive to look for ways to prevent falls in healthcare settings.

A systematic review recently published in BMC Nursing (Bunn et al, 2014) is the first of its kind to evaluate the effectiveness of interventions aimed at preventing falls among older people with any form of mental illness, not just those with dementia or cognitive impairment.

The aim of this study from Bunn et al is honourable. Existing big reviews focus solely on preventing falls in older people in hospital settings, or just those with dementia or other forms of cognitive impairment (Oliver et al, 207), but this research group set out to find the interventions that could benefit those with any form of mental health problem in any setting.

This review looked for trials including older people with all kinds of mental health conditions

Methods

The researchers undertook a comprehensive literature search for both published and unpublished studies, English language, from any healthcare setting, which evaluated any intervention(s) aimed at reducing or preventing falls in people aged 60 or over, with any diagnosis of mental illness. There were no date restrictions. The two key outcomes examined were:

Number of people sustaining at least one fall (‘fallers’)
Total number of falls

21 studies met the inclusion criteria, 17 of which were randomised controlled trials and the remaining 4 uncontrolled trials.

Results

The authors stated their intention to address interventions preventing AND managing falls, although their results focused on prevention strategies only.

The interventions they identified varied widely, including physical activity, risk assessment, environmental modification, staff training, increased supervision, patient education and sensory interventions. Individual studies were not pooled in a meta-analysis because they were too varied, so a narrative analysis was provided instead.

Results were categorised according to location (nursing/residential care, hospital and community) as well as intervention type (single or multifactorial).

5 studies found a statistically significant reduction in the number of ‘fallers’ (2 of which were uncontrolled trials), interventions ranged from exercise and supervision to staff training
8 studies found a statistically significant reduction in the rate or total number of falls (2 of which were also uncontrolled), including interventions such as environmental adjustments, person-centred care, sensory stimulation, staff training and exercise
Of note, 4 studies found a non-significant increase in falls with the intervention given, which were all different

However, due to the diversity of interventions studied and the variety in quality of the studies, no overwhelming evidence to be drawn in favour of any of the individual interventions.

There were no outright winners in terms of interventions that prevent or manage falls

Limitations

There were several problems with the quality of the individual studies:

7 of the studies did not specifically define a fall, leaving the results open to interpretation
1 study included syncopal falls (related to fainting or passing out)
1 study only included falls that needed medical attention

Less than half of the studies had a specific mental health focus. Although they all included patients with mental health problems, studies without a specific mental health focus were included as long as at least half of their participants had mental health problems.

For those identified as having mental health problems, the majority had dementia, other cognitive impairment or depression, so actually the aim to identify successful interventions relevant to other mental health problems was not met.

Looking at the review overall, the inclusion of both controlled and uncontrolled trials may have introduced a large element of bias.

The review included randomised and non-randomised studies, which makes the findings less reliable

Conclusions

The authors state:

Although the evidence from this review is not robust, it does challenge the American Geriatrics Society and British Geriatrics Society guideline (Martin, 2010) which states that there is insufficient evidence to support any recommendation to reduce fall risk for older people with cognitive impairment.

However, the strengths lie in the few individual studies of good quality that were included, not in the results drawn from the systematic review and there were no studies found that looked purely at mental health hospital settings, so results cannot be applied specifically to those with mental health problems.

The National Patient Safety Agency (NPSA) states:

Approaches to preventing falls must be individualised, as each patient is affected differently by the interplay between a range of risk factors.

Their report from 2007 indicates that using multifactorial interventions is an effective way to reduce the number of patient falls (Healy et al, 2007), including:

Reviewing medication associated with a risk of falling

Detecting and treating causes of delirium, cardiovascular illness, incontinence or urgency and eyesight problems (i.e. all those conditions that increase risk of falling)
Providing safe footwear
Physiotherapy, exercise and walking aids
Consideration of the environmental layout

The NPSA acknowledges that it is uncertain if these interventions are as effective for those with cognitive impairment as for other people.

The latest NICE guidance (NICE, 2013), in addition to the above considerations, recommend also routinely asking older people about their falls history and then tailoring any interventions specifically to the patient, depending on their risk factors.

With regard to this systematic review, the researchers looked at a clearly focused question and comprehensively assessed the quality of each study, but their inclusion criteria could have been stricter and they were limited by the number of good quality, comparable studies.

This work has not identified any robust evidence to recommend specific interventions. Multifactorial interventions may be effective, but this must be refined. There is a need for better quality studies examining single interventions to determine what is actually effective at reducing falls in older people with mental health problems.

In the meantime, don’t let the poor quality evidence trip you up: find the shoe that fits your patient and tailor your approach.