As part of PCORI’s effort to investigate and fund useful, impactful research on critical patient-centered health and healthcare issues, we are asking the public to provide us with questions of personal importance regarding preventing injuries from falls in the elderly. We would like your input on which questions remain unanswered, which treatments should be compared, and which critical patient-centered outcomes should be addressed. Our objective is to identify those questions that, if answered, would provide patients, caregivers, and clinicians with the best information available to help them prevent falls among the elderly and the injuries that often result.
In the United States, with the current trend toward aging demographics, more people are living longer, often independently. However, falls are a significant risk factor for injuries that threaten that independence. In addition, people who have previously fallen have a significant risk of falling again. Clinicians are able to assess a patient’s risk factors for having a dangerous fall— these include assessments of current level of physical activity, prior history of falls, vision testing, and balance screening.
Patients, caregivers, and clinicians all want seniors to be able to avoid falls and resulting injuries, but there is uncertainty about the best prevention strategies. Some approaches include safety assessment in the home environment, strength and balance training, and improved vision interventions. It is unclear whether certain prevention strategies are more effective than others, however, and whether additional community-level outreach would be helpful. Strong evidence-based studies on treatment plans can guide patients and caregivers in making decisions that will maximize the impact of their prevention and treatment choices and health outcomes.
Between 30 to 40 percent of community-dwelling people aged 65 and older fall at least once per year. Falls represent the leading cause of fatal and nonfatal injuries among older adults.1 With the current trend toward aging demographics, some have estimated that the direct medical costs for fatal and nonfatal fall-related injuries among community-dwelling people aged 65 years and older could reach $55 billion by 2020.2
Adults aged 65 years and older who have previously fallen or suffered a hip fracture have a higher risk of falling again. Falls in older adults may be linked to injury or even death, but research suggests that the risk of falls may be reduced, perhaps dramatically. Physicians can assess a patient’s risk factors that may lead to a dangerous fall, such as level of physical activity and prior history of falls or previous fractures. From this assessment, patients with varying degrees of risk receive individualized plans aimed to lower their susceptibility to falls. This may include a combination of different types of exercises, such as balance, strength, endurance, and physical therapy, as well as vitamin D supplementation and environmental safety precautions.
Although studies suggest exercise therapies and vitamin D supplementation may improve health and reduce the risk of falling, it is unknown which combination of treatments is most effective and which patients would benefit most. A comparison between the effectiveness of exercise therapies and other clinical treatments in older adults may help doctors recommend preventative measures and targeted treatment for patients who have a history, or a high risk, of falling.
Other researchers have established that these interventions are effective, but the optimal regimens, frequency, and duration of prevention strategies remain understudied. Additional research is needed to confirm the context within which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective. For example, a Cochrane Review of 111 trials (55,303 participants) concluded that multiple-component group exercise, individually prescribed multiple-component home-based exercise, and Tai Chi resulted in reduced rates of falls, but it is unclear which patients would benefit most.7
Additional evidence underpinning the US Preventive Services Task Force recommendations regarding fall prevention in older adults comes from time-limited, randomized, controlled trials involving heterogeneous populations that participated in different combinations of balance, strength, endurance, or general exercise programs in various settings under the supervision of diverse groups of experts (e.g., physical therapists, nurses, and exercise physiologists).8 The trials provide general guidance, but no details as to how to construct or conduct a clinical exercise program.9
PCORI is interested in identifying research questions that evaluate important choices faced by patients and that have a good chance of providing evidence that can reduce uncertainty, support decision making, change practice, and improve patients’ health outcomes. PCORI views these gaps in the evidence base on strategies for preventing injuries from falls in the elderly as an area where we can contribute to improving health outcomes.
Research Areas of Interest
We have identified the following specific topic areas for falls prevention in the elderly as an area of potential research funding:
- Questions that compare different strategies for preventing falls, including exercise and balance training
- Questions that compare promising strategies among older adults at varying degrees of risk
- Questions that compare strategies to overcome patient-, provider-, or system-level barriers (e.g., language, culture, transportation, homelessness, unemployment, lack of family/caregiver support) and thereby reduce risks of falls and resulting injuries. Strategies may focus on different segments of at-risk populations, such as hospital inpatients, residents of nursing homes, and older people with osteopenia and osteoporosis
We ask you to submit your questions about preventing injuries from falls in older adults and help us define which critical questions in this topic area should be further explored.
About Our Workgroup Process
For each topic considered as part our accelerated process to develop targeted PCORI funding announcements, we will convene an ad hoc workgroup to provide input on research gaps in the current evidence base and critical near-term research questions that, if answered, will improve health. Consistent with our core value of inclusiveness, each workgroup is comprised of a diverse group of researchers, patients and other stakeholders. Each workgroup will meet once in the second quarter of 2013. Meetings will be accessible through audio-conference, webcast, or other forms of communication, and, through our website, any interested individual can contribute comments, suggestions, and input for up to two weeks before, during, and for two weeks after each meeting. Learn more about the workgroup selection process for preventing injuries from falls in the elderly.
Submit a Question or Comment
The question and comment period for this topic has now closed. PCORI staff will review all questions and comments received on this topic, as well as the deliberations of the ad hoc workgroup that met March 12, and recommend questions for our Board of Governors to consider approving as the basis of topic-specific PCORI Funding Announcements. We hope to release such announcements by mid-year.
We were very pleased to see how many people contributed to this process by viewing the webinar of our ad hoc workgroup’s proceedings or submitting questions or comments through our website or via email. In coming months, we will post a summary of the workgroup’s meeting as well as a full record of all of the questions we received. Stay up to date on this process, and all of PCORI’s activities, by signing up for our email alerts.
1. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science. 1996;41(5):733-746.
2. Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: A 3-year randomized controlled trial. Archives of Internal Medicine. 2006;166:424-430.
3. Michael YL, Lin JS, Whitlock EP, Gold R, Fu R, O’Connor EA, et al. Interventions to prevent falls in older adults: an updated systematic review. Evidence Synthesis No. 80. AHRQ Publication No. 11-05150-EF1. Rockville, MD: Agency for Healthcare Research and Quality, December 2010.
4. Chou WC, Tinetti ME, King MB, Irwin K, Fortinsky RH. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. J Gen Intern Med. 2006;21117-21122.
5. Fortinsky RH, Iannuzzi-Sucich M, Baker DI, Gottschalk M, King MB, Brown CJ, et al. Fall-risk assessment and management in clinical practice: Views from healthcare providers. J Am Geriatr Soc. 2004;521-522.
6.Tinetti ME, Gordon C, Sogolow E, Lapin P, Bradley EH. Fall-risk evaluation and management: Challenges in adopting geriatric care practices. Gerontologist. 2006;46717-46725.
7. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012, Issue 9.
8. Moyer VA. Prevention of falls in community dwelling older adults: US Preventive Services Task Force Recommendation Statement. Ann Int Med. 2012;157:197-204.
9. Tinetti ME, Brach JS. Fall prevention recommendations as a covered service. Ann Intern Med. 2012;157:213-214.
Posted Feb. 8, 2013