Gillespie Lesley D, Robertson M Clare, Gillespie William J, Sherrington Catherine, Gates Simon, Clemson Lindy M, Lamb Sarah E
Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Cochrane Database Syst Rev. 2012 Sep 12;2012(9):CD007146. doi: 10.1002/14651858.CD007146.pub3.
Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.
To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.
Randomised trials of interventions to reduce falls in community-dwelling older people.
Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.
We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.
AUTHORS' CONCLUSIONS: Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.
社区中65岁以上的老年人每年约有30%会跌倒。这是对2009年首次发表的Cochrane系统评价的更新。
评估旨在降低社区居住老年人跌倒发生率的干预措施的效果。
我们检索了Cochrane骨、关节和肌肉创伤组专业注册库（2012年2月）、CENTRAL（Cochrane图书馆2012年第3期）、MEDLINE（1946年至2012年3月）、EMBASE（1947年至2012年3月）、CINAHL（1982年至2012年2月）以及在线试验注册库。
针对社区居住老年人减少跌倒的干预措施的随机试验。
两位综述作者独立评估偏倚风险并提取数据。我们使用率比（RaR）和95%置信区间（CI）来比较干预组和对照组之间的跌倒率（例如每人每年的跌倒次数）。对于跌倒风险，我们根据每组中跌倒的人数（跌倒者）使用风险比（RR）和95%CI。我们在适当的情况下合并数据。
我们纳入了159项试验，共79193名参与者。大多数试验将预防跌倒干预措施与无干预措施或预期不会减少跌倒的干预措施进行了比较。测试的最常见干预措施是单一运动干预（59项试验）和多因素方案（40项试验）。62%（99/159）的试验在序列产生方面偏倚风险较低，60%在跌倒的失访偏倚方面（66/110），73%在跌倒者的失访偏倚方面（96/131），而只有38%（60/159）在分配隐藏方面。多组分团体运动显著降低了跌倒率（RaR 0.71，95%CI 0.63至0.82；16项试验；3622名参与者）和跌倒风险（RR 0.85，95%CI 0.76至0.96；22项试验；5333名参与者），多组分家庭运动也有同样效果（RaR 0.68，95%CI 0.58至0.80；7项试验；951名参与者和RR 0.78，95%CI 0.64至0.94；6项试验；714名参与者）。对于太极拳，跌倒率的降低接近统计学显著水平（RaR 0.72，95%CI 0.52至1.00；5项试验；1563名参与者），但太极拳确实显著降低了跌倒风险（RR 0.71，95%CI 0.57至0.87；6项试验；1625名参与者）。多因素干预措施，包括个体风险评估，降低了跌倒率（RaR 0.76，95%CI 0.67至0.86；19项试验；9503名参与者），但没有降低跌倒风险（RR 0.93，95%CI 0.86至1.02；34项试验；13617名参与者）。总体而言，维生素D没有降低跌倒率（RaR 1.00，95%CI 0.90至1.11；7项试验；9324名参与者）或跌倒风险（RR 0.96，95%CI 0.89至1.03；13项试验；26747名参与者），但可能对治疗前维生素D水平较低的人有效。家庭安全评估和改善干预措施在降低跌倒率（RR 0.81，95%CI 0.68至0.97；6项试验；4
