A Multifactorial Intervention to Reduce the Risk of ...

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Sep 29, 1994 - Article in New England Journal of Medicine · October 1994 ... Rehabilitation Services, Yale-New Haven Hospital, New Haven, Conn. (M.G.); ...

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A Multifactorial Intervention to Reduce the Risk of Falling among Elderly People Living in the Community Article in New England Journal of Medicine · October 1994 Impact Factor: 55.87 · DOI: 10.1056/NEJM199409293311301 · Source: PubMed

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Owned, published, and © copyrighted, 1994, by the MASSACHUSETTS MEDICAL SOCIETY Volume 331(13)

29 Sep 1994

pp 821-827

A Multifactorial Intervention To Reduce The Risk Of Falling Among Elderly People Living In The Community. [Original Articles] Tinetti, Mary E.; Baker, Dorothy I.; McAvay, Gail; Claus, Elizabeth B.; Garrett, Patricia; Gottschalk, Margaret; Koch, Marie L.; Trainor, Kathryn; Horwitz, Ralph I. From the Departments of Medicine (M.E.T., P.G., R.I.H.) and Epidemiology and Public Health (G.M., E.B.C., K.T.), Yale University School of Medicine, and the Yale University School of Nursing (D.I.B.), New Haven, Conn.; the Department of Rehabilitation Services, Yale-New Haven Hospital, New Haven, Conn. (M.G.); and the Department of Physical Therapy, Quinnipiac College, Hamden, Conn. (M.L.K.). Address reprint requests to Dr. Tinetti at 333 Cedar St., P.O. Box 208025, New Haven, CT 06520-8025. Supported by a grant (UO1 AG09087) from the National Institute on Aging. Dr. Tinetti was a Kaiser Family Foundation Faculty Scholar.

Abstract Background: Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors. Methods: We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects). Results: During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted incidence-rate ratio for falling in the intervention group as compared with the control group was 0.69 (95 percent confidence interval, 0.52 to 0.90). Among the subjects who had a particular risk factor at base line, a smaller percentage of those in the intervention group than of those in the control group still had the risk factor at the time of reassessment, as follows: at least four prescription medications, 63 percent versus 86 percent, P = 0.009; balance impairment, 21 percent versus 46 percent, P = 0.001; impairment in toilet-transfer skills, 49 percent versus 65 percent, P = 0.05; and gait impairment, 45 percent versus 62 percent, P = 0.07. Conclusions: The multiple-risk-factor intervention strategy resulted in a significant reduction in the risk of falling among elderly persons in the community. In addition, the proportion of persons who had the targeted risk factors for falling was reduced in the intervention group, as compared with the control group. Thus, risk-factor modification may partially explain the reduction in the risk of falling. (N Engl J Med 1994;331:821-7.)

Falling is a serious public health problem among elderly people because of its frequency, the morbidity associated with falls, and the cost of the necessary health care [1-3]. Approximately 30 percent of people over 65 years of age who live in the community fall each year [4-6]. Unintentional injury, which most often results from a fall, ranks as the sixth leading cause of death among people over 65 years of age [1]. The nonfatal results of falls include physical injury, [4,7] fear, [4] functional deterioration, [8-12] and institutionalization [8-11]. Although the total costs associated with falls are unknown, the yearly costs for acute care associated with fall-related fractures are estimated at $10 billion [1,2]. Several potentially modifiable risk factors for falling, such as muscle weakness, impairment in balance, and use of medications, have been identified [1,4-7]. Furthermore, the risk of falling increases with the number of risk factors present, [4,7] suggesting that a multifactorial strategy of risk-factor abatement may reduce the risk of falling. Uncontrolled studies have reported a potential effect of such interventions on the incidence of falls, [13,14] but preventive strategies have not proved effective in controlled trials to date [15-18]. These negative results could have occurred because the subjects were either at too high or too low a risk of falling to benefit or because the interventions were not intensive enough. Alternatively, falls may not be preventable among elderly persons. We conducted a controlled study of the effects of a program of multiple-risk-factor reduction on the incidence of falls among elderly people. The primary aim was to assess the effectiveness of the multifactorial targeted risk-abatement strategy in reducing the risk of falls among elderly persons in the community. A secondary aim was to determine whether the strategy was effective in altering the targeted risk factors themselves.

Methods Setting and Subjects The details of the study design and methods have been reported elsewhere and are summarized here [19]. The potential subjects were the 2522 enrollees of a health maintenance organization (HMO) in southern Connecticut who were at least 70 years of age. Sixteen of the 17 eligible physicians who cared for at least 100 of these enrollees agreed to participate. For reasons previously described, the 16 physicians were frequency-matched into four groups of 4 physicians each, on the basis of their high or low scores on two measures -- namely, the number of people at least 70 years of age among their patients (>150 vs. less/= 150) and the mean number of new prescriptions written per office visit ( greater/= 1 vs.

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