Evidence
Alert

Advice by mail is as effective as targeted interventions at preventing fall-related injuries in older people

A booklet containing advice on falls prevention reduced fractures as effectively as more intensive interventions. In a large study, the booklet was sent to older people by post. This advice alone prevented as many fractures as an exercise programme, or as multiple assessments by a range of professionals, the study found.  

Falls and fall-related injuries, including fractures, are common and a serious health problem for older people. Falls can cause pain and injury, distress, loss of confidence and independence, or death. They are estimated to cost the NHS more than £2.3 billion per year. 

The current approach to preventing falls in people at high risk is a multi-pronged assessment.  All risk factors for falls are considered – everything from blood pressure to failing eyesight or medications. Suitable preventive measures are then offered. Before this study, it was not known how effective this approach is.

The Prevention of Fall Injury Trial (Pre-FIT) included more than 9,000 people over 70 years old living in the community. Over a period of 18 months, the study found that the three approaches (advice alone, exercises, multiple assessments) were similarly effective in reducing fractures. The exercise programme was linked with small gains in health-related quality of life, which made it the most cost-effective approach.

These findings are being considered by the National Institute for Health and Care Excellence (NICE), which is updating its current guidelines on how best to prevent injuries from falls.

Further information on prevention of falls is available on the NHS website.

What’s the issue?

As people get older, they are more likely to fall. One in three (30%) people aged 65 and older – and half of those over 80 – fall at least once a year. Falls can lead to injuries, including fractures. Reducing falls and fractures is important for maintaining the health, wellbeing and independence of older people.

Risk factors for having a fall and the severity of an injury include bone health, frailty and low weight. Older people with low bone mineral density (osteoporosis) are more likely to fracture a bone when they fall.  

Current NICE guidelines state that people over 65 who are at an increased risk of falling should be considered for an individualised falls prevention programme. This includes components such as an eye test, a review of medications, and an assessment of their balance and of falling hazards at home. 

The costs of this measure, and whether it reduces fractures and improves quality of life, were unknown. Pre-FIT set out to address the considerable uncertainty over the effectiveness of current strategies– and the value of targeting interventions to higher-risk groups. 

What’s new?

Almost 10,000 people with an average age of 78 were recruited from 63 general practices across England. Practices were randomly assigned to one of three groups.

    • Advice: 3,223 people received advice by mail only. 
    • Exercise: 3,279 people received advice by mail, plus screening to identify those at high risk. The high risk group was offered an exercise programme (supervised home exercises to improve strength and balance, and recreational walking). 
    • Falls prevention: 3,301 people received advice by mail, plus screening. Those at high risk were offered a falls prevention programme (assessments by a range of professionals, tailored interventions that could include strength and balance training, a medication review, home modifications and referrals to other medical specialists). 

The three groups were compared in this study but many people at high risk did not take up invitations to the exercise or falls prevention programmes. About one in three (1,000 people in each group), were high risk and were invited. But 350 people did not attend exercise sessions and 439 did not attend the falls prevention programme.  

The study found that people in the exercise or falls prevention groups had a similar risk of a fracture in the 18 months of the study, compared with those in the group receiving advice only. This was the main outcome of the trial.

In other, secondary outcomes, neither the exercise nor falls prevention interventions reduced risk of falling compared to advice alone. Quality of life was marginally best for the exercise intervention but differences between the groups were slight. 

An economic analysis of the programme looked at the NHS costs for a year of good health (cost/QALY) with each of the three approaches. The falls prevention programme (£3,941) was slightly less cost-effective than the other two approaches. Exercise was most likely to improve quality of life and was therefore slightly more cost-effective (£3,720) than advice alone (£3,737). 

Why is this important?

These findings suggest that targeted programmes of exercise or fall prevention are no more effective than advice by mail at reducing fractures. Quality of life was slightly improved in the exercise group but differences seen in this trial were slight. Despite the resources offered in the falls prevention group, a health economic analysis showed that reductions in NHS costs were marginal.

Many NHS service providers are currently screening older people and offering fall prevention programmes to those at increased risk of falling. These strategies may now need to be reconsidered to ensure they are cost-effective and provide benefits for older people.

It remains possible that the exercise and fall prevention programmes could provide benefits that were not measured in this study. Exercise could have improved muscle strength, for example. It is also possible that the interventions reduced minor injuries which did not include a fracture. These injuries are poorly recorded in England and were not included in the study. 

The authors saw small improvements in health-related quality of life in the exercise group. These improvements might also be linked with reduced pain and improved mobility.

What’s next?

NICE clinical guidelines on preventing falls are currently being updated and should include the findings from this study. Further research is now needed into the development of more effective interventions that can prevent fall-related injuries fractures in older people.

This trial found that the interventions were not effective when delivered routinely in this way by the NHS. But it could be, for example, that more prolonged or intense exercise could reduce falls. In addition, many people in this study did not take up the offer of intervention. Future studies should examine how to encourage people at high risk of a serious fracture, to accept an intervention programme.

You may be interested to read

This NIHR Alert is based on: Lamb S, and others. Screening and Intervention to Prevent Falls and Fractures in Older People. The New England Journal of Medicine 2020;383:19 

Age UK has produced advice on keeping active and reducing the risk of falling in Staying Steady leaflet

National Institute for Health and Care Excellence (NICE), 2013. Guideline [CG161] on Falls in older people: assessing risk and prevention.

The National Falls Prevention Coordination Group (NFPCG) and Public Health England advice at: Falls and fracture consensus statement and resource pack plus updated NFPCG evidence briefing on multifactorial falls-prevention interventions. 

A good practice guide from the British Geriatrics Society: Comprehensive Geriatric Assessment (CGA) in Primary Care Settings: Patients at risk of falls and fractures.  

 

Funding: This study was supported by a grant from the NIHR Health Technology Assessment Programme

Conflicts of Interest: Two authors have received fees from pharmaceutical companies unrelated to this study. 

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study authors

These results question the assumption that preventing falls prevents fractures. The findings show that we have to do different things to prevent fractures. We could implement a medication pathway that targets osteoporosis (weak bones which are more likely to break). Or we need to make fall prevention interventions, particularly exercise, more potent and more capable of dealing with situations where people sustain injuries.

A lot more research is now needed to improve outcomes for both falls prevention and fractures. We can’t just sit and think the problem has been solved.

Sallie Lamb, Associate Dean for Research and Mireille Gillings Professor of Health Innovation, University of Exeter 

Clinician 

The authors of this paper are to be congratulated in performing a trial with sufficient power to assess if fractures can be prevented by falls reducing interventions embedded through existing NHS services.

It is important that the wrong conclusions are not reached. This trial does not mean that exercise or falls prevention programmes do not work. But in this specific context, delivered via the NHS, they did not result in a reduction in falls and fractures.

There are several potential reasons for this. For example, not everyone offered the interventions accepted. The exercise may not have been intense enough or done for long enough. The falls prevention programme may not have been comprehensive enough. This trial shows that current NHS services are not set up to provide the structure needed to deliver these interventions successfully. These services need to be improved.

There is a marked variability across the UK in the provision of falls prevention services. The results of this study should therefore not be used to justify decommissioning well-established falls services where the interventions are delivered in line with previous successful evidence-based falls prevention.

Further research is needed to assess if enhanced, evidence-based services would be cost-effective. It is likely that they would cost more, but if sufficient falls, fractures and other injuries are prevented leading to reduced hospital admissions, overall cost savings could potentially be achieved.

Tahir Masud, Consultant Physician and Honorary Professor of Geriatric Medicine, Nottingham University Hospitals NHS Trust 

Physiotherapist 

As a physiotherapist dealing with patients from remote areas, this research has given me confidence that providing individual advice is essential and as effective as targeted intervention in reducing the risk of falls and fractures in the elderly. It is especially important for people who do not have access to appropriate healthcare facilities in their vicinity. All elderly people need to receive a printed booklet of individual advice. General awareness through banners or optional leaflets are not sufficient.

Healthcare centres may need to set up fall-screening for older people, either at their home, at the centre or via a teleconsultation. Healthcare staff may need training in such screening and advice dissemination, in addition to targeted exercises, that could prevent elderly people from falling. Also, they need to consider how to encourage older people to continue with the specific advice or exercise therapy.

At a policy level, a combination of bone health improvement and fall prevention services can be the way ahead.

Priyanka Aggarwal, Physiotherapist, India 

Member of the public 

These findings are disappointing and mean that health and social care professionals need to look again at how they prevent falls. It is clear that no one size fits all and mail cannot be the sole solution in 2021.

For myself, I will continue doing exercises. I will ensure I have a high intake of calorific foods to maintain my strength and energy. Hydration is key for older people, as is checking blood pressure and the ability to swallow. You need to look holistically at a patient.

I believe the solutions are there if we look a little bit harder. Working with people who care for older people might give insights. They often have tips that might suggest interventions that would better serve patients.

Chandrika Kaviraj, Public contributor, London