Schulich School of Medicine and Dentistry, Division of Geriatric Medicine, Department of Medicine, The University of Western Ontario, London, Ontario, Canada.
Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, Ontario, Canada.
JAMA Netw Open. 2021 Dec 1;4(12):e2138911. doi: 10.1001/jamanetworkopen.2021.38911.
With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have been developed. A systematic evaluation of the recommendations and agreement level is lacking.
To perform a systematic review of clinical practice guidelines for falls prevention and management for adults 60 years or older in all settings (eg, community, acute care, and nursing homes), evaluate agreement in recommendations, and identify potential gaps.
A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical Subject Headings search terms were related to falls, clinical practice guidelines, management and prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three independent reviewers selected records for full-text examination if they followed evidence- and consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation scores, and agreement across topic areas was assessed using the Fleiss κ statistic.
Of 11 414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean [SD], 80.1% [5.6%]), although individual quality domain scores for clinical applicability (mean [SD], 63.4% [11.4%]) and stakeholder (clinicians, patients, or caregivers) involvement (mean [SD], 76.3% [9.0%]) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (≥11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations.
This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders.
随着全球人口老龄化，跌倒和与跌倒相关的伤害无处不在，已经为 60 岁及以上人群制定了几项预防和管理跌倒的临床实践指南。缺乏对这些建议的系统评估和一致性水平的评估。
对所有环境（如社区、急性护理和养老院）中预防和管理 60 岁及以上成年人跌倒的临床实践指南进行系统评价，评估建议的一致性，并确定潜在差距。
按照系统评价和荟萃分析报告的首选项目声明方法，对老年人跌倒预防和管理的临床实践指南进行了系统评价（更新于 2021 年 7 月 1 日），使用了 MEDLINE、PubMed、PsycINFO、Embase、CINAHL、 Cochrane 图书馆、PEDro 和 Epistemonikos 数据库。医学主题词搜索词与跌倒、临床实践指南、管理和预防以及老年人有关，不限制纳入日期、语言或环境。如果遵循基于证据和共识的流程，并且使用评估研究和评估指南 II（AGREE-II）标准评估指南的质量，三位独立评审员会选择记录进行全文检查。使用推荐、评估、开发和评估等级（Grades of Recommendation, Assessment, Development, and Evaluation）评估建议的强度，并使用 Fleiss κ 统计评估跨主题领域的一致性。
在确定的 11414 条记录中，有 159 条经过全面审查并符合入选标准，其中 15 条被纳入。所有 15 项选定的指南均具有较高的 AGREE-II 总分（平均[标准差]，80.1%[5.6%]），尽管个别临床适用性（平均[标准差]，63.4%[11.4%]）和利益相关者（临床医生、患者或护理人员）参与（平均[标准差]，76.3%[9.0%]）的质量领域得分较低。在筛选了 4767 篇摘要后，共识别出 198 条建议，涵盖了 15 条指南中的 16 个主题领域。在对 4767 篇摘要进行筛选后，共识别出 198 条建议，涵盖了 15 条指南中的 16 个主题领域。在对 4767 篇摘要进行筛选后，共识别出 198 条建议，涵盖了 15 条指南中的 16 个主题领域。大多数（≥11）指南强烈建议进行风险分层、步态和平衡评估测试、骨折和骨质疏松症管理、多因素干预、药物审查、运动促进、环境修改、视力和鞋类矫正、转介物理治疗和心血管干预。在维生素 D 补充、解决认知因素和跌倒预防教育方面，建议的强度不一致。关于使用臀部保护器和数字技术或可穿戴设备的建议通常缺失。在审议过程中，没有一个检查过的指南包括患者或护理人员小组。
本系统评价发现，目前针对老年人跌倒预防和管理的临床实践指南在多个领域具有高度一致性，在这些领域提出了强有力的建议，而其他领域则没有达到这一共识或涵盖范围。未来的指南应解决其建议的临床适用性，并纳入患者和其他利益相关者的观点。
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